[
    {
        "Introduction": "hello and welcome to chapter 37 patients with special challenges this is of the emergency care and transportation of the sick and injured 12th edition\nlive at home or outside the hospital setting children who are born prematurely and have associated respiratory problems there's also infants or small children with congenital heart disease in patients with neurologic disease or patients with congenital or acquired diseases resulting in altered body function that requires medical assistance for breathing eating urination or bowel function there's also patients with sensory defects such as hearing or visual impairments or geriatric patients with chronic diseases requiring visitation from home health care service people who live at home depend upon mechanical ventilation intravenous pumps or other devices do not allow yourself to be distracted by the noise and mechanics of the medical equipment focus your needs to remain on the patient and follow the abcs if the emergency is the result of mechanical failure use equipment on the ambulance or the families to go back",
        "National EMS Education Standard Competencies": "after you complete this chapter and the related coursework you will understand the special needs of patients with developmental sensory and physical disabilities you will understand the unique anatomy and physiology and the assessment and treatment needed for these patients the special care considerations for patients who relay on medical technology assistance are also discussed as are considerations for the management of obese patients today more people with chronic diseases",
        "Intellectual Disability": "okay so let's first talk about intellectual disability developmental disability and this refers to a group of conditions that may impair development in the areas of physical ability learning language development skills or behavioral coping skills intellectual disability is a subset of developmental disability where patients have significant limitations in both intellectual functioning and skills needed for daily living diagnosis is made before age 18 and it ranges from mild to profound level of care and support varies possible causes are genetic factors congenital factors there could have been some complication at birth or malnutrition perhaps environmental factors prenatal drug or alcohol use or traumatic brain injury for possible poisoning rely on patients and family members for information patients with intellectual disabilities are susceptible to the same diseases as any patients",
        "Autism Spectrum Disorder": "so let's talk about autism in the autism spectrum disorder intellectual disability characterized by deficience in social communication and interactions along with restrictive repetitive patterns of behaviors interests and activities often they have abnormal sensory responses so may not feel heat or cold or pain as others do and they may respond to pain by laughing or humming singing or removing clothes they may also have an increased sensitivity to noise or physical stimulation so keep the environment calm and minimize stimulation three to four times more common in males than females and in those who have an older sibling with the same condition demonstration of examination techniques on a trusted individual may comfort that patient use short direct and simple phrases when communicating and allow extra time for the patient to process the communication if possible",
        "Down Syndrome": "next we're going to talk about down syndrome this is characterized by a genetic chromosomal defect defect that can occur during fetal development resulting in mild to severe intellectual impairment known risk factors are increased maternal age and a family history are known risk factors for this condition physical abnormalities they're going to have a round head with a flak ops occipit and large protruding tongue slanted wide eyes and folded skin on either side of their nose covering the inner corners of their eyes short wide hands and small face and features they're at an increased risk for medical complications such as leukemia congenital heart defects sensory endocrine muscular skeletal dental gastrointestinal and neurological complications an innovation may be difficult due to the large tongues and small oral and nasal cavities mass ventilations can also be challenging and the jaw thrust maneuver or nasopharyngeal airway may be necessary judgment of seizures is the same as for any other patient with seizures and approximately 15 percent of patients with down syndrome so a large amount the first two areas where the vertebrae meet is unstable this places them at an increased risk of complications when they have trauma",
        "Patient Interaction": "so patient interaction action approach the patient calm friendly watching for signs of increased anxiety or fear fear have the member of your team hold back slightly until you establish rapport with the patient introduce the team members explain what they're going to do and move slowly but deliberately explaining beforehand what you are going to do and make sure you are at the eye level with the patient do your best to sue the patient's discomfort as you work through your assessment and provide treatment",
        "Brain Injury": "brain injury so patients with a prior brain injury may be difficult to assess and treat take the time to speak with the patient and the family to establish what is considered normal for the patient treat the patient with respect use his or her name explain the procedures and reassure the patient throughout the process",
        "Visual Impairment": "and then there's sensory disabilities first we'll start with visual impairment so possible causes are congenital disease injury or degeneration of the optic nerve or nerve pathways the degree of visual impairment may range from partial to total some patients lose their peripheral or central vision and some can distinguish between light from dark um or shapes visual impairments may too be difficult to recognize so look for signs that the patient is visually impaired such as a cane or service animal patient interaction so make yourself known when you enter the room introduce yourself and your team retrieve any visual aids and give them to your patient to make the interaction more comfortable a visually impaired patient may feel vulnerable especially during the chaos of a crash scene so tell the patient um the patient may have learned to use other senses such as hearing touch and smell to compensate for the loss of sight tell the patient what is happening identify noises and describe the situation and surroundings especially if you must move the patient transport consideration so a patient may use a cane or walker and you should make sure that we take that with us a service animal can remain with the patient and will provide reassurance for the patient and prevent delays and transport however in some cases you may need to arrange for care or accompaniment of the animal an ambulatory patient may be led by a light touch on the arm or an elbow or the patient may rest his hand on his or her shoulder ask the patient which method they prefer to use patients should be gently guided but never pulled or pushed and obstacles need to be communicated in advance",
        "Hearing Impairment": "and then there's the hearing impaired so hearing impairment may range from slight hearing to total deafness most common forms of hearing loss are sensor neuro deafness which is nerve damage and then there's conductive hearing loss which is a faulty tremendous transmission of the sound waves clues that a person could be hearing a peer paired would be presence of hearing aids or poor pronunciation of words or failure to respond to your presence or questions",
        "Communication With Hearing Impaired Patient": "communication you're going to assist the patient with finding and inserting hearing aids if needed or face the patient when you communicate because they can lip read okay do not exaggerate your lip movements though and do not look away position yourself approximately 18 inches directly in front of the patient do not speak louder and try lowering the pitch of your voice you could learn american sign language or provide a paper and a pencil only one person should be asking questions to avoid confusing the patient the figure on this slide shows terms in sign language related to illness injury hurt and help okay so um the first one is sick the second one you're gonna see is hurt and then help",
        "Hearing Aids": "all right so hearing aids they're devices that make sound louder you could have a behind the ear type a conventional type and in the canal or completely in the canal type and in the ear type or an implantable option are also available the device should fit snugly if whistling occurs the hearing aid might may not be um in far enough so this this slide just shows the different types of hearing aids",
        "Cerebral Palsy": "physical disabilities so the first one we're going to talk about is cerebral palsy this is a group of disorders characterized by poorly controlled body movement result of damage to the developing fetal brain while in utero and oxygen deprivation to the brain or perhaps a traumatic brain injury at birth or infections such as meningitis during early childhood they range mild to severe so poor posture controlled movements of the limbs visual or hearing impairments difficulty communicating epilepsy intellectual disabilities or unsteady gait which may necessitate wheelchair or walker\nimportant consideration so observe the airway closely do not assume that the patient have an intellectual disability limbs are often underdeveloped or are prone to injury and patients who have the ability to walk may have a gait an unsteady gait and are prone to falls had the patient to ensure his or her comfort never force a patient's extremities into any positions however possible take walkers and wheelchairs along during transport and be prepared for seizure and keep suctioning available",
        "Spina Bifida": "next we're going to talk about spina bifida and this is a birth defect caused by incomplete closure of the spinal column during embryonic or fetal development the spinal cord is exposed and an opening can be closed surgically but often leaves spinal and neurologic damage associated congenital conditions are hydrocephalus partial or for pleurolysis of the lower extremities loss of bowel or bladder control or extremity latex allergies ask the patient or caregivers how to best move them before you transport them",
        "Paralysis": "and then you could also have patients who have paralysis so that's an inability to voluntarily move one or more body parts it could possibly be from a stroke trauma or birth defect patients may have normal sensation or hyper an increased sensitivity facial paralysis may also cause communication challenges and diaphragm may not function correctly requiring the use of a ventilator patients may have specialized equipment such as urinary catheters or tracheotomy tubes colostomy bags or feeding tubes patients may have difficulty swallowing creating the need for suctioning ask the parents or caregivers the best way to move them before you transport",
        "Bariatric Patients": "these patients as well and then you have bariatric patients and this is an obesity and it's a condition in which the person has an excessive amount of body fat the result of an imbalance between calories consumed and calories used its causes of obesity are not fully understood and it may be attributed to a low metabolic metabolic rate or genetic predisposition severe or morbid obesity so the terms obese is used when someone with 30 or more of his or her ideal body weight so that's 30 or more severe obesity is when a person is two to three times over the ideal body weight quality of life may be negatively affected and associated health problems include mobility difficulties diabetes high blood pressure heart disease or stroke",
        "Interaction with Patients with Obesity": "interaction with patients with this with obesity so patients may be embarrassed of their condition if transport is necessary plan early for extra help or specialized equipment send a member of your team to find the easiest and safest exit and also the risk of dropping the patient or injuring a team member by trying to lift too much weight is a possibility the patient with dignity and respect at all times and ask your patient how is the best way to move them avoid lifting the patient with only one limb which would risk injury or over-tax joints coordination and communication are big issues so all moves um by all team members should be talked about and communicated prior to lifting to prevent significant soft tissue injury or deep vein thrombosis look for pinch and pressure points from equipment become familiar with types of specialized equipment and resources which will be available large patients may have difficulty breathing if placed in a supine position so plan egress routes to accommodate large patients equipment and lifting crew members notify the receiving hospital early",
        "Tracheostomy Tubes": "patients with medical technology assistance okay so the first one we're going to talk about is the tracheostomy tube so a tracheal stoma provides a pathway between the surface of the neck and the trachea it can be temporary or permanent for patients who depend on home ventilators require frequent suctioning and have chronic pulmonary medical conditions because it is foreign to the respiratory tract the body reacts by building up secretions on or around the tube\ntubes are prone to becoming obstructed by mucus plugs or foreign bodies use the dope mnemonic so the dope mnemonic helps to recognize causes of his obstruction d stands for displacement dislodged or damaged tube o stands for obstruction of the tube such as with blood or secretions or mucus or vomit the p is the pneumothorax and e is equipment failure such as some type of kinking or ventilator malfunction or and maybe empty oxygen supply\ncommon problems are bleeding or air leaking around the tube the tube can become loose or dislodged or the infection around the opening of the tube you could have an infection so what are we going to do for these patients suction the patient in the position of comfort insert the suction catheter no more than one to two inches do not suction for more than 10 minutes do not force the suction catheter into the cannula oxygenate before and after the procedure and call for advanced life support",
        "Home Oxygen": "so people who are on home oxygen two types of oxygen delivery devices so there's oxygen from a gas cylinder or um an oxygen tank or there's oxygen from an oxygen concentrator so compressed oxygen cylinders do not require electricity the leader flow is limited only by the regulator and the amount of gas in the cylinder they're heavy and bulky and can be difficult to transport and it will eventually run out and patients need to coordinate pickup and delivery of new cylinders home oxygen concentrator however it takes ambient air and scrubs out the nitrogen from the atmospheric air and leaves behind almost 100 oxygen it can provide an unlimited supply of oxygen as long as it's functioning from a reliable source of electricity usually able to supply one to three liters and the patient must have a backup of compressed gas cylinders in case there is a power failure ask the patient on home oxygen why they're on it and how long they have been on it and what is their baseline home oxygen requirement so what is the patient's baseline oxygen saturation meaning if they're normally on two liters or three liters",
        "Mechanical Ventilators": "and then medical mechanical ventilators so these are used when patients cannot breathe without assistance and possible causes are congenital defects chronic lung disease traumatic brain injuries or muscular dystrophy or a disease process that weakens the ability to breathe and requires permanent trach and mechanical ventilator if the ventilator malfunctions remove the patient from the ventilator apply a tracheostomy collar or you could use a face mask over the stoma if you do not have a trach collar patients requiring assisted ventilation throughout transport um so the patient's caregivers will know how the ventilator works that's a picture of the ventilator",
        "Apnea Monitors": "and then you have apnea monitors and these are used for children for infants who are premature or have some type of gastro gastro reflex disease or have a family member of a sudden infant death syndrome who who have already had sids or have experienced an apparent life-threatening event they're usually used for two weeks to two months after birth to monitor the respiratory system the monitor sounds an alarm if the infant experiences some type of low heart rate or low respiratory rate it's attached with electrodes to a belt around the infant's chest and stomach and it provides a pulse ox reading that will assist you in assessing the patient's respiratory status if possible bring that apnea monitor to the receiving facility with the patient",
        "Internal Cardiac Pacemakers": "and then you have internal cardiac pacemakers so it's a device implanted under the skin to regulate the heart a pacemaker may also include an aed to monitor the rhythm never place d-fib pads or pacing pads over the implanted device gather information about the cardiac pacemaker when you obtain the patient's history some patients will have a pacemaker identification card in their wallets containing information about the device",
        "Left Ventricular Assist Devices": "and then there are left ventricular assist devices and this is a mechanical device that takes over the function of one or both heart ventricles typically used to bridge between heart transplant while the donor of the heart is being located or maybe a permanent solution for patients who do not qualify for a heart transplant a left ventricular assist device or lvad is most common and all vads are more common in adults okay so may be difficult to palpate a pulse in patients who use an lvad assess perfusion by noting the level of consciousness skin color temperature moisture and blood pressure there are risks to these and its excessive bleeding can follow spike could follow surgery also infection or blood clots a cure or acute heart failure if you encounter a patient with a vad call the number for the patient support team contact medical control and follow protocols if the device is alarm is sounding check the connections and be sure the batteries are fully charged and notify advanced life support",
        "External Defibrillator Vest": "an external defib vice so this is a vest with a built-in monitoring with electrodes and defeb pads which is worn by patient under his or her clothing it's attached to a monitor that provides alerts and prompts voice prompts when it recognizes a dangerous rhythm and before it delivers a shock so if the patient's in cardiac arrest the vest should remain in place while you're performing cpr unless it interferes with compressions any patients who's wearing a device that has already delivered a shock should be transported to the hospital for further evaluation",
        "Central Venous Catheter": "and then there's central venous catheters so this is a cath that has a tip placed in the vena cava to provide venous access used for many types of home care patients and including cardi chemotherapy or long-term antibiotic drug therapy total nutrition so tpn or hemodianolysis were often located in the chest upper arm or subcliffic area and so the figure on the slide shows the central venous catheter common problems with this is you could have broken lines or an infection clotted lines or bleeding around the line from the tubing attached to the line then you could have a gastro gastrotomy tube and this is sometimes referred to as a gastric tube or a g-tube it's placed into the stomach for patients who cannot ingest foods fluids or medication by mouth may be inserted through the nose or mouth into the stomach or it may be placed surgically directly into the stomach through the abdominal wall and so this figure on the slide shows a gastronomy tube and a child",
        "Gastrostomy Tubes": "okay so it may become dislodged during a patient's normal daily activity immediately stop the flow of any fluids okay so assess the signs and symptoms of bleeding in the stomach and so if there's any abnormal abdomen discomfort or nausea vomiting especially coffee ground emesis or blood in the emesis patients may be at an increased risk of aspiration so always have suctioning readily available and patients with difficulty breathing should be transported while sitting or laying on the right side with the hell head elevated 30 percent diabetic patients who receive insulin and gastric tube feedings may become hypoglycemic quickly unless the tube is dysfunctional dislodge or partially dislodged continue the feeding tube and transport the pump with you",
        "Shunts": "and then there's shunts for patients with chronic neurologic conditions and these are tubes that drain excessive cerebral fluid from the ventricles of the brain to keep pressure from building up during assessment you will likely feel a device beneath the skin on the side of the head behind the ear and it's a fluid reservoir it should alert you to the possibility that the patient have an underlying shunt there are types there's a ventricular peritoneum shine and this drains excess fluid from the ventricles of the brain into the abdomen and then there's a ventricle atrium shunt and this drains excess fluid from the ventricles of the brain into the right atrium of the heart it can become blocked or infected and chances changes of mental status and respiratory arrest may occur infections may occur within the first two months after the insertion you might hear a high pitch crying or bulging fontanelles in infants perhaps a headache projectile vomiting altered mental status irritability or fever and nausea difficulty with coordination or walking blurred vision seizures redness along the shunt track or bradycardia or heart dysrhythmias",
        "Vagus Nerve Stimulators": "and then you could see patients with vagal nerve stimula stimulators and these are for treatment used for seizures that are not controlled with medication so what it does is it stimulates the vagal nerve at predetermined intervals to prevent seizure activity they're used in conjunction with medications to reduce the frequency of seizures and they're located under the patient's skin and is about the size of a silver dollar",
        "Colostomies, lleostomies, and Urostomies": "and then you can have colostomies ileostomies or urostomies and so what of these are our surgical procedure that creates an opening between small and large intestines at the surface of the body it allows for elimination of waste products into clear external bags or pouches which is then emptied or changed frequently you want to assess for signs and symptoms of dehydration if the patient has been complaining of diarrhea and vomiting area around the stoma is prone to infection so signs of infection include warmness or redness around the stoma or tenderness on palpation over the colostomy site okay urostomy is a surgical procedure that connects the urinary system to the surface of the skin that allows urine to drain from a stoma in the abdomen wall so contact medical control or follow local protocols to care for patients with a colostomy ileostomy or urostomy bag",
        "Patient Assessment Guidelines": "okay so patient assessment are guidelines so interaction with the caregiver of an adult or child with special needs is important part of the patient assessment process they become experts on caring for the patient determine the patient's baseline mental status before assessment so ask what is different today",
        "Home Care": "when it comes to home care home care occurs within the patient's home environment so this represents a spectrum of special care uh healthcare op um population so you could have infants older adults or patients with chronic chronic illnesses or patients with developmental disabilities also services such as delivering meals or house cleaning laundry yard maintenance and physical therapy and also personal care such as bathing in wound care ems may be called to residents by the home health care provider so what you want to do is obtain health care status and history from the home care provider",
        "Hospice Care and Terminally Ill Patients": "then you could also have calls with hospice care and terminally ill patients okay so terminally ill patients may require hospice at a hospice facility or at a home with diseases such as cancer heart and lung failure and stage alzheimer's or aids most patients have completed do not resuscitated orders when they're on hospice okay so they may have medical orders for that scope of treatment basically it's comfort care and this means it's palliative care and that is only pain medicines and it improves the patient's quality of life before the patient dies and allows for the patient to be home with family and friends follow your local protocols the patients with wishes and legal documents such as the dnr order if the patient is at home the care you give will have a lasting impact on the family so show compassion understanding and sensitivity ascertain the family's wishes about having the patients remain in the home or having the patient transmitted to the hospital transported to the hospital and follow local protocols for handling the death of the patient",
        "Poverty and Homelessness": "you will also special situations you'll run into is poverty and homelessness so people who live in poverty are unable to provide all of their basic needs such as housing food health care child care health insurance and medication disease prevention strategies such as dental care nutrition and exercise are likely absent which leads to increased probability of disease when it comes to the homeless population people with mental illness and prior brain trauma victims of domestic abuse or persons with addiction behaviors or impoverished families your job is to provide emergency care and transport to the appropriate facility all healthcare facilities must provide assessment and treat treatment regardless of the patient's ability to pay you can be an advocate and become familiar with the social services resources within your community",
        "Review": "okay so that concludes chapter 37 of the patients with special challenges lecture next we're going to see what we've learned so which of the following is a development disorder characterized by impaired meant of social interaction okay and we know that this is autism so autism is a developmentally disability characterized by impairment of social interaction known risk factors for down syndrome include so smoking traumatic brain injury increased maternal age or lack of vitamin b and we know it's increased maternal age which of the following may be difficult to perform on a patient with down syndrome and we know it's innovation because of their abnormal their large tongues and the small oral and nasal cavities most patients with a disease also have hydrocephalus and so we know that patients usually with a shunt and that's spina bifida what does the dope mnemonic help you recognize so we know that this is some type of airway obstruction when talking about patients who have some type of event or stoma what device is placed directly into the stomach to feed patients that's a g tube a gastronomy tube okay what do vagal nerve stimulators do and they do help seizures from occurring keep them and they're also an alternative treatment to medicine bagel nerve syndrome stimulators an important part of the assessment process for a patient with special needs what should you do we know we're going to interact with the caregiver and also the patient but what is important um so we're interacting with the caregiver what improves a patient's quality of life shortly before death and that's hospice care it's palliative care the emergency medical treatment and active labor act states and we didn't really discuss this so let's see it's b and so we we know all patients must be treeless oh retreat treated regardless of the ability to pay and so that's the emergency medical treatment and active labor act okay thank you for joining us this evening with patience uh for the chapter 37 patients with special challenges lecture if you enjoyed this lecture go ahead and subscribe to the channel we're going to put out the remaining chapters of the 12th edition"
    },
    {
        "Introduction": "hello class and welcome to chapter 1 ems systems of emergency care and transportation of the sick and injured 12th edition",
        "National EMS Education Standard Competencies": "after you complete this chapter in the related coursework you will understand the origins and present day structure of the emergency medical care delivery system the emergency medical technicians roles responsibilities and relationships to the emergency medical services system as well as emt's role in the quality improvement process is going to be explained and other levels of ems providers are described the foundations necessary for being a competent efficient caring and ethical emt are presented the interrelationships of the national highway traffic safety administration's 14 components of the ems system per the ems agenda for the future are outlined also we will describe an emt's impact on research data collection and evidence-based decision-making as well as the emt's responsibilities as a student and a practitioner we're going to talk about ems systems and the history roles and responsibilities quality improvement and patient safety\nand also research and public health so",
        "Introduction to EMT Course": "this text is the primary research for the emt course it discusses what will be expected of you during the course and what requirements you will have to meet to be licensed or certified as an emt in most states you will learn the differences between first aid training a department of transportation emr training course and the training courses for an emt a emt and paramedic you also talk about how ems is a system and in chapter one this chapter one discusses the system's key components so let's talk about ems as a system it consists of teams of healthcare professionals and provides emergency care and transportation and is governed by state laws after you successfully complete this course you should be able to take either the national registry of emt's exam or your state's certification exam so after you pass the certification exam you are eligible to apply for state licensure licensure is the process by which the state ensures the applicant's competency in an examination setting this allows the states to manage who can function as a healthcare provider in most states there are four training and licensure levels there is the emr the emt and the aemt and then there's the paramedic okay so now let's discuss the differences in those four so an emr is an emergency medical responder and they have very basic training they provide care before the ambulance arrives and they may also assist with the ambulance these are people such as law enforcement officers are trained as emr and then an emt and an emt of course uh has the basic training in life support so basic life support and this includes an automatic external defibrillation so aeds airway adjuncts and assisting with certain medications then there's the aemt and they have training in specific aspects of advanced life support including they have iv iv access therapy and administration of a limited number of emergency medicines and then the paramedic and they have extensive advanced life support training it includes endotracheal innovation emergency pharmacology cardiac monitoring and other advanced assessment and treatment skills so the emt course includes four types of learning activities there will be reading assignments step-by-step demonstrations summary skill sheets and case presentations and scenarios",
        "EMT Training: Focus and Requirements": "emt training is focus and requirements so emts are the backbone of the ems system in the united states they provide emergency care to the sick and injured",
        "Licensure Requirements": "there's licensure requirements and so requirements do differ from states of state but generally the requirements to be licensed and employed as an emt are you need to have a high school diploma or equivalent proof of immunization against certain communicable diseases you need to successfully complete a background check and drug screening and have a valid driver's license you must also have successful completion of a recognized healthcare provider basic life support cardiopulmonary resuscitation course successful completion of a state-approved emt course successful completion of a state recognized written exam you must successfully complete a state recognized practical exam demonstrate mental and physical abilities necessary to safely and properly perform all these tasks and functions described in the defined role of an emt and you must be compliant with other state local and employer provisions\nokay so let's talk a little bit about the americans with disabilities act and it'll also be known as the ada act of 1990 this protects people who have a disability from being denied access to programs and services that are provided by state or local governments it prohibits employers from failing to provide full and equal employment to the disabled now title 1 protects emts with disabilities who are seeking gainful employment under many circumstances employers with a certain number of employees are required to adjust process is so that the candidate with a disability can be considered for the position and modify the work environment or how the job is normally performed and as a licensure requirement there is also personal background uh in information in accordance with state criminal requirements so states have various requirements prohibiting individuals who have committed either misdemeanors or felony felonies from becoming ems providers",
        "Overview of the EMS System": "okay so let's do an overview of the ems system but first we need to talk about the history origins of ems include volunteer ambulances in world war 1 field care in world war ii and field medic and rapid helicopter evacuation in the korean conflict as recently as 1960s and early 1970s emergency ambulance service and care varied widely in the united states ems as we know it today originated in 1966 with the publication of accidental death and disability the neglected disease of modern society more commonly known as the white paper now emergency services act in 1973 created funding sources and programs to develop improved systems of pre-hospital emergency care the dot or department of transportation published the first emt training curriculum in early 1970's the american academy of orthopedic surgeons prepared and published the first emt book in 1971. now efforts are underway to standardize levels of ems education nationally in late 1970s the dot developed a recommended national standard curriculum during the 1980s many areas enhanced the emt national standard curriculum by adding emts with advanced levels of training who could provide key components of advanced life support care and advanced life support procedures in the 1990s the national highway traffic safety administration or nhtsa developed the ems agency for future a document with a plan to standardize the levels of ems education and providers and in 19 or 2019 nhtsa revised the ems agenda for the future and published ems agenda for 2050 levels of field training okay so there's the federal level and at this federal level the national ems scope of practice model provides guidelines for ems skills this document provides overarching guidelines for the minimum skill level of an ems provider should be able to perform at the state level there is laws that regulate ems provider operations and then at the local level you have the medical director which provides daily oversight and support to ems personnel now this is a slide and it illustrates the hierarchies of that ems scope of practice model you see the medical direction which is day-to-day the state ems offices and then the national ems scope of practice public basic life support and immediate aid millions of lay people are trained in bls cpr and there's also aeds or automated external defibrillators and those are used by lay people",
        "Emergency Medical Responders": "and then there's the emergency medical responders or emrs like we talked about earlier those are the law enforcement sometimes firefighters park rangers ski patrollers emr training provides these individuals with the skill necessary to initiate immediate care and assist emts upon arrival the course focuses on providing immediate bls and urgent care with limited equipment and then emt the course you're in so the emt course requires about 150 to 200 hours the emt possesses the knowledge and skills to provide basic emergency care the emt together with any other emts who have responded assumes responsibility for the assessment care packaging and transport of the patient",
        "Advanced Emergency Medical Technicians": "advanced emergency medical conditions technicians so this is an aemt the aemt course adds knowledge and skill in specific aspects of advanced life support including iv therapy advanced airway adjuncts and administration of limited number of medicines",
        "Paramedics": "then there are the paramedics this is an extensive course of training course hours range from 1 000 to more than 1300 hours divided between classroom and internship training courses may be offered within the context of an associate's or bachelor's degree college program training requires a wide range of advanced life support skills",
        "Components of the EMS System": "so then let's talk about the components of the ems system the ems agenda 2050 it outlines five components of the ems system the five components are comprehensive quality and convenient care evidence-based clinical care efficient well-rounded care preventative care and comprehensive and easily accessible patient records",
        "Public Access": "public access so easy access to help in an emergency is essential the 911 system is the public safety asset access point an emergency medical dispatch or emd system has been developed to assist dispatchers in providing callers with vital medical instructions until ems personnel arrives so mobile apps have also allowed lay people trained in cpr to be alerted of a cardiac arrest in the area and the location of the nearest public aed",
        "Human Resources": "human resources so human resources as a component of ems it focuses on the people who deliver the care the ems agenda 2015 encourages the creation of an environment where talented people want to work and turn their passion into a rewarding career then medical direction a physician is a medical director and he authorizes emts to provide medical care in the field the medical director is an ongoing working liaison between the medical community hospitals and the emts in service so appropriate care is described in standing orders and protocols now protocols are described in a comprehensive guide and this tells the emt's scope of practice and standing orders are part of protocols and designate what the emt is required to do for a specific",
        "Medical Direction": "complaint or condition providers are not required to consult medical direction before implementing standing orders medical control can be offline or online and so medical control offline is indirect and that is the standing orders or training or supervision what we just spoke about online though is a direct order and this is a physician's directions and given over the phone or a radio and that is considered online medical control",
        "Legislation and Regulation": "next component is the legislation and regulation so although each ems system medical direction and training program has latitude training protocols and practices must follow state legislation rules regulations and guidelines a senior ems official is usually in charge of necessary administrative tax such as scheduling personnel budgets purchasing and vehicle maintenance and the daily operations of ambulances and crews okay so integration of health care",
        "Integration of Health Services": "services so pre-hospital care should be continued in the emergency department to ensure that the patient receives comprehensive continuity of care then there's the mobile integrated health care so method it's a method of delivering",
        "Mobile Integrated Health Care": "healthcare that utilizes the pre-hospital spectrum and mobile integrated healthcare is otherwise known as mih and it's evolved with the goal to facilitate improved access to health care at an affordable price in the mih model health care is provided within the community rather than at a hospi a physician's hospice office or hospital by an integrated team of health care professionals this branch of healthcare is using the evolution of additional training levels for ems providers this includes community paramedicine in which an experienced paramedic receives advanced training to equip them to provide services within the community in addition to the patient care services a paramedic would typically provide services providing the community paramedics with and they can perform health evaluations they can monitor chronic illnesses and conditions or conditions they can obtain lab samples and also administer immunizations",
        "Information Systems": "and then the the next component we're going to talk about is the information systems and this is the commuter computer systems which are used to document patient care they are electronically stored information and can be used to improve care",
        "Evaluation": "then evaluation so the medical director is responsible for maintaining quality control within the ems system and they it's adapting a just culture so this promotes a learning culture that holds employees accountable for behavioral choices by balancing fairness and accountability okay so the next thing we're going to",
        "Continuous Quality Improvement": "talk about is a continuous quality improvement and this you'll hear it called cqi within this component there reviews and performs audits of the ems system to identify areas of improvement and or assign remedial training minimizing errors is the goal and it uses a plan do study act cycle",
        "Patient Safety": "patient safety so to minimize medical errors that occur as a result of rules-based failure a knowledge-based failure or a skills-based feral or any combination of these three this requires the efforts of both the ems agency and ems personnel",
        "System Finance": "next we're going to talk about the system finance aspect of the ems system and so a finance system it varies depending on which organization is involved and so personnel may be paid they can be volunteer or a mix of paid and volunteers so emts may be asked to gather insurance information from patients secure signatures on documents such as hipaa notifications obtained written permission from patients to bill their health insurance company in 2020 the centers for medicare and medicaid services or cms implemented a pilot program called emergency triage treat and transport et3 et3 strives to reimburse ems systems for providing the right patient care at the right time set up a payment model for patient transport to alternative destinations such as an urgent care center or doctor's office or on scene treat with no transport",
        "Education Systems": "next we're going to talk about the education systems so ems instructors are licensed in most states most states training programs must adhere to national standards established by two accrediting organizations these include the committee on accreditation of educational programs for the emergency medical services profession professions and that is um also known as co co-amps and the commission of accreditation of allied health education programs or c-a-a-h-e-p frequent continuing education refresher courses and computer-based or mannequin based self-education exercises are measures intended to maintain and update emt skills and knowledge",
        "Prevention and Public Education": "prevention and public education and within this aspect is of ems is where the focus is on public health and public health examines the needs health needs of the entire population with the goal of preventing health problems ems works with public health agencies in two ways and so the primary prevention focuses on strategies that will prevent the event from ever happening so for example educating the community on pool safety and car seat insulation the second prevention occurs after the event has already happened the question then is how can we decrease the effects of this event so for example helmets and seat belts are examples of secondary prevention the table on this slide list examples of public health accomplishments so you can see vaccination programs fluoride helmet laws sewage systems formation of food and drug administration clean drinking water seat belt laws tobacco use laws restaurant inspections and prenatal screenings",
        "EMS Research": "next we're going to talk about the ems research and this helps determine the shape and impact of ems on the community evidence-based medicine it focuses on procedures that have proven useful in for improving patient outcomes many ema systems and states consult the national model ems clinical guidelines from the national association of ems officials these guidelines are based on a review of current research and expert consensus",
        "Roles and Responsibilities of the EMT": "roles and responsibilities of an emt are what we're going to talk about next and so an emts are healthcare professionals\nwhether paid or volunteer the roles and responsibilities of an emt include keeping the vehicles and equipment ready for an emergency ensure the safety of yourself your partner the patient and then bystanders be familiar with emergency vehicle operation be an on scene leader perform an evaluation of the scene call for additional resources we need to gain access to patients perform a patient assessment give emergency medical care to the patient while awaiting the arrival of additional medical resources also have to give administrative resp support we have to constantly continue our professional development cultivate and sustain community relations and give back to the profession",
        "Professional Attributes": "okay so professional attributes of an emt and these include integrity we have to act consistently maintain a firm adherence to the code of honest behavior we have to have empathy being aware of and thoughtful towards the needs of others self-motivation so discovering problems and solving them without someone directing you appearance and hygiene using your persona to project a sense of trust professionalism knowledge and compassion their self-confidence so this includes knowing what you know and knowing what you do not know and being able to ask for help\nyou have to have time management performing or delegating multiple tasks while insurance ensuring efficiency and safety communications including understanding others and making yourself understood teamwork and diplomacy include being able to work with others knowing your place in the team communicating while giving respect and also respect so holding others to a high regard or importance understanding that others are more important than you patient advocacy and constantly keep the needs of the patient at the center of the care careful delivery of care and this includes paying attention to details making sure that what is being done for the patient is done as safely as possible most patients will treat you with respect but some will not yet every patient is entitled to compassion respect and the best care you can provide as ems care professionals and emts are bound by patient confidentiality this includes patient privacy it must be protected findings or disclosures made by the patient should be discussed only with those treating the patient in limited situations as required by law with the police or other social agencies protection of patient patient privacy has drawn national attention with the passage of hipaa and this is the health insurance portability and accountability act so get used to that word okay so now we're to the review questions and at the end of the chapters there are review questions and we'll go ahead and go over these the first one is which of the following is an example of care that is provided using standard orders okay so which of the following is an example of care that is provided using standard orders i'll let you read through these is it medical care is contacted by the emt after the patient with chest pain refuses an emt defibrillates a patient in cardiac arrest a physician gives the emt an order via radio or following an overdose the emt contacts medical director for permission it is being so standing orders a form of offline it's indirect medical control this involves performing certain life safe life-saving interventions and so the answer was the emt defibrillates the patient in cardiac arrest begins cpr and then contacts medical control okay two quality control in the ems system is the ultimate responsibility of is it the paramedic the emt the medical director or the ems administrator and we said this directly in the slides it is the responsibility of the medical director and he for maintaining that quality control and it ensures that all staff members who are involved in caring for patients meet this standard on every single call okay number three upon arriving at the scene of a domestic dispute you hear yelling and the sound of breaking glass from inside the residence what should you do should you immediately gain access should you carefully enter the house should you retreat to a safe place until the police arrive or should you tell the patient to exit the residence and so you know that your safety is a paramount paramount and never enter a scene in which the signs of violence are present and so c was the answer then this included a retreat to a safe place until the police arrive which of the following is not a component of the continuous quality improvement so c q i and do you do review of run reports so we're looking for not the component discuss the needs for improvement negative feedback given to those who make mistakes or remedial training is deemed necessary now we know that we do not give negative feedback so the purpose of the cqi is to ensure the standard is provided this involves reviewing and discussing the needs but we do positive feedback should be provided during this process and so negative feedback given to those who make mistakes while on the call is not not what we do okay moving along so all of the following are the responsibilities of an ems director accept so are they responsible for evaluating patient insurance information serving as a liaison ensuring that the appropriate standard is met or ensuring appropriate empty education and so we know b c and d are correct and so the correct answer the medical director does not have anything to do with evaluating patient insurance information okay so which of the following situations would most likely qualify a person for in ems certifications so disqualified so a is a misdemeanor b is driving under the influence c is possessing a valid driver's license a or d is a mild hearing impairment and so in most states a person may be denied ems certification for being convicted of a felony such as driving under the influence or drugs and so we know that b was the answer number seven which of the following should the emts be the mt's highest priority and so we know that patients are very important however our own personal safety is the most important and so d always personal safety is the utmost concerned remember it's our safety our partner safety by standard safety and then patient safety okay okay a patient who requires cardiac monitoring in the field would require at a minimum level which level so which level 8 or is it emr emt paramedic or advanced emt and we know that of all the levels the paramedic is the one that's trained in the cardiac monitoring okay so the paramedic is the only one who is uh requires cardiac monitoring who could provide that number nine which of the following is a professional responsibility of an emt and so are emt's responsible for telling a family of the dying member that everything will be okay well we don't do that do we maintain only the skills that he or she feels comfortable with no absolutely not do we maintain a professional demeanor in even the most stressful situations absolutely and do we advise an emergency department nurse that the patient reports are only given to the physician absolutely not so we know that c is the responsibility and it's because the public relies on that emt to remain calm when others cannot okay okay and number 10 emergency patient cares uh occurs in progressive phases what occurs first is it the activation of ems is it the initial pre-hospital care is that the patient receives definitive care and so that means surgery or fixing of the problem and d instant recognition so d someone has to recognize there's an emergency before ems can even be activated so d is the correct answer okay and thank you for joining me for chapter one ems systems um i hope you have a good day"
    },
    {
        "Introduction": "hello and welcome to chapter 39 vehicle extrication and special rescue of the emergency care and transportation of the sick and injured 12th edition",
        "National EMS Education Standard Competencies": "after you complete this chapter and the related coursework you will be able to describe and apply in context ems rescue operations including vehicle extracration and its 10 phases additionally you will be able to describe various specialized components of ems operations including tactical ems trench rescue high angle rescue and the emt's roles in these operations the safety aspect of these operations are also discussed okay so let's dive right into it",
        "Introduction to Safety": "so you will usually not be responsible for rescue but you may assist with extrication rescue requires training beyond the emt level let's talk about safety okay so extrication requires mental and physical preparation priority is to provide patient care and personal safety and that of your team must be addressed before patient care is initiated the equipment that you use and the gear that you wear will depend on the hazards you expect to encounter as well as what you observe during the scene size up",
        "Vehicle Safety Systems": "so first things first let's talk about vehicle safety systems so vehicle safety systems can become hazards after a collision let first is the shock absorbing bumpers and they may be compressed or loaded following a front or rear-end collision approach the vehicles from the side they can release and injure your knees or legs also manufacturers are required to install supplemental restraints or airbags in all cars now so airbags fill with a non-harmful gas on impact and quickly deflate after the crash airbags are located in the steering wheel and the dash in front of the passenger you also could have side impact airbags and they may be located in the doors and seats when it comes to non-deployed airbags they may spontaneously inflate while you are providing patient care so you should maintain at least five inch clearance around side impact airbags that have not deployed and maintain at least 10-inch clearance around driver side airbags that have not deployed also maintain at least 20-inch clearance around passenger side airbags that have not deployed haze inside the vehicles in which the airbags have deployed is caused by corn starch or talk so appropriate protective gear including eye protection will reduce the risk of eye or lung irritation from that substance",
        "Fundamentals of Extrication": "so let's talk about the fundamentals of extrication and of course as with anything your primary concern is safety your primary roles are to provide emergency medical care prevent further injury to the patient you may provide care as extrication is going on around you so the definition of extrication is the removal from entrapment or from a dangerous situation or position then the definition of entrapment is a condition in which a person is caught within a closed area with no way out or has a limb or other body part entrapped let's talk about the roles and",
        "Roles and Responsibilities": "responsibilities ems providers are responsible for assessing and providing medical care and triaging and packaging patients providing additional assessment assistance and care as needed once patients are removed and providing transport to the emergency department the rescue team is responsible for securing and stabilizing the vehicle providing safe entrance and access to the patients and extricating any patients law enforcement officers on scene are responsible for controlling traffic maintaining order at the scene and establishing and maintaining a perimeter",
        "Firefighters' Responsibilities": "and then firefighters they're responsible for extinguishing the fire preventing additional ignition ensuring that the vehicle is safe and removing spilled fuel rules and responsibilities often are varied based on jurisdictions and available agencies good communication among team members and clear leadership is essential to safe efficient provision of proper emergency care so the table on this slide shows the 10 phases of extrication and that's what we're going to talk about next the first phase is going to be preparation",
        "Preparation": "prep preparation is preparing for an instant requiring extrication it involves pre-instant training with rescue personnel for the various types of rescue situations to which you might respond rescue personnel must routinely check the extrication tools and their responsible vehicles",
        "En Route to the Scene": "and then next is the enroute to the scene procedures and safety precautions similar to those in fate in the phase of an ambulance call are used when responding to a rescue incident",
        "Arrival and Scene Size-up": "next is the arrival and scene size up so we want to position the ambulance to block the scene from oncoming traffic we're going to use essential warning lights and choose a location that will allow safe access to the scene while leaving a way to drive the ambulance out we need to put on ppe and look for passing cars before exiting the vehicle we have to make sure the scene is properly marked and protected and the size up is an ongoing process of information gathering and scene evaluations to determine appropriate strategies and tactics to maintain or to manage that emergency the next thing we're going to do in that arrival and scene size up is evaluate the hazards and determine the number of patients by doing a 360 walk around of the scene and what we're going to be looking for is the mechanisms of injury that any downed electrical lines or perhaps leaking fuels or fluids smoke or fire broken glass any trapped or ejected patients or the number of patients in the vehicles involved and while we're looking at the vehicles involved in the motor vehicle collision we want to note the damage to the vehicles because a bent steering wheel may indicate a significant face or thoracic area trauma imprints on the dashboard may indicate lower extremity injuries such as fractures or possible hip dislocations and lift deployed airbags to see if there's some deformity to the steering wheel or dashboard and because that may indicate that the patient struck the structure after the airbag deflated we want to also see if we could find out unrestrained patients and they may have contact injuries as well as secondary injuries so we want to check the windshield for a spiderweb pattern of shattered glass and this is uh indicating possible head face or neck injuries and then include findings in our documentation we're going to use the information to maintain a high index of suspicion all right so we want to evaluate the need for additional resources during that scene size up right because we might need extrication or fire or law hazmat utility maybe advanced life care supports or some type of helicopter for transport we need to look for spilled fuel and other flammable substances right rain sleet or snow can present an added hazard for the scene crashes that occur on hills are harder to handle than those that occur on level ground in some crashes some crash scenes may present threats of violence so we have to be aware of that and we're going to coordinate our efforts with rescue teams and law enforcement we need to communicate with members of the rescue team throughout this extrication talking to the incident commander as soon as you arrive will help so you will enter the vehicle and provide patient care for the patients when only when approved by the incident commander",
        "Hazard Control": "then there's hazard control okay so hazard control um can deal with downed electrical lines and those are common hazards at vehicle crashes so we're never going to attempt to move a down electrical line if the power lines are close to the vehicle in a vehicle involved in the crash we're going to instruct the patient to remain in the vehicle until the power is shut off remain in the safe zone outside of the danger zone in the danger zone we call the hot zone okay so the illustration on this slide plays or displays the danger zone",
        "Family and Bystanders Hazards": "family members and bystanders can also create hazards the vehicle also can be the hazard too so an unstable automobile on its roof or side can be a danger to you rescue personnel",
        "Vehicle Stabilization": "can stabilize the car with a variety of jacks and cribbing so ensure that the car is in park with the parking brake set and the ignition turned off both battery cables should be disconnected to minimize the possibility of sparks or fire next we're going to talk about alternative fuel vehicles and the hazards that they might um have on scene so vehicles may be powered by electricity or some type of hybrid mix like electricity and gasoline mix or fuel such as propane natural gas gas methanol or hydrogen we're going to disconnect the battery to prevent further fire or explosion in more than 40 percent of today's alternative fuel vehicles the batteries are located in the trunk or under the seats not in the engine compartment there may be more than one battery present in hybrid vehicle systems hybrid batteries have a higher voltage than traditional automotive batteries and it may take up to 10 minutes for a high voltage system to de-energize after the main battery is turned off avoid high voltage cables those are typically orange okay so damaged high voltage batteries may give off toxic fumes do not approach the vehicle if unusual odor is detected and retreat if you experience burning in your eyes or throat",
        "Support Operations": "next we're going to talk about support operations okay so this is important support operations include lighting the scene establishing tool and equipment staging areas or marking helicopter landing zones fire and rescue personnel will work together on these functions gaining access so gaining access to the patient is a critical phase of extrication make sure that the vehicle is stable and hazards are eliminated or controlled the exact way to gain access to the patient depends on the situation you're having okay so the figure on this slide shows a motor vehicle collision the exact way to gain access just like we talked about depends on the factors including the terrain and the way in which the vehicle is situated and also don't forget the weather to determine the exact location and position of the patient consider the following questions so is the patient in the vehicle or some other structure is a vehicle or structure severely damaged what hazards exist that pose a risk to the patient and the rescuers and in what position is the vehicle is it on top of some type of surface or what type of surface is it on top and is the vehicle stable or is it apt to roll or tip so let's talk about rapid vehicle extrication and this is important because rapid vehicle extrication may be needed to quickly remove a patient if the environment is threatening or it's a patient needs cardiopulmonary resuscitation so cpr a team of experienced emts should be able to perform a rapid extrication in one minute or less during and during the assessment and extrication phases make sure that the patient remains safe okay so a heavy fire resistant blanket can be used to protect the patient from breaking glass flying particles or tools and other hazards okay so always describe what you're doing and what you're going to do before you do it and as you're doing it and even if you think the patient is unresponsive try to keep heat noise and force to the minimum okay so the figure on this slide shows the ems provider accessing the patient always explaining to the patient why you are there and what you are doing so we just had that rapid rapid access this is a simple access when you're doing an extrication so simple access is described as is trying to get the patient out as quickly and possibly as simply as possible without using any tools or breaking glass so automobiles are built for ease entry and exit okay it may be necessary to use forcible entry tools the rescue team should provide the entrance you need to gain access to the patient if the rescue team has not arrived yet use tools like hammers center punches pry bars and hacksaws they might be available on the ambulance so gain access by trying to use the door handles or by rolling down the windows before breaking any glass or using other methods of force entry and that's the simple access okay now when it comes to complex access complex asset access requires special tools such as mnemonic or hydraulic devices okay and these require special training it includes breaking windows and removing roofs these advanced skills are typically performed by specialized teams so on the figure on the slide shows an extrication process and this is a complex access and it's requiring the use of pneumatic or hydraulic devices okay you can see the spreaders right there in the photo",
        "Emergency Care": "all right so next we're going to talk about the emergency care the emergency care so providing emergency care to a patient who is trapped in the vehicle is essentially the same as for any other patient okay once entrance and access to the patient have been provided and the scene is safe perform the primary assessment and provide care before further extrication begins you want to address any hemorrhaging with direct pressure or a tourniquet if appropriate okay and then provide manual stabilization to protect the cervical spine as needed then of course we're going to do that abc we're going to open the airway give them high flow o2 if they need a assist with ventilations if needed and like we said earlier control any external bleeding and then treat all critical injuries",
        "Removal of the Patient": "then the removal of the patient so rescue personnel should coordinate with you to determine the best removal route the table on this slide list vehicle extrication techniques including complex access okay you should participate in the preparation for patient removal okay so determine how urgently the patient must be extricated determine where you should be positioned to best protect the patient after the patient has been extricated determine how you will move the patient to the backboard and then to the stretcher your input is essential so that the rescue team plans an extrication that protects the patient from further harm re-evaluate whether the patient needs rapid extrication often you will be placed in the vehicle alongside the patient so be sure to wear proper protective equipment",
        "Transfer of the Patient": "and then transfer the patient so perform a complete primary assessment once the patient has been freed make certain that the spine has been manually stabilized and move the patient to ac move the patient with a series of smooth slow controlled steps with designated stops to allow for repositioning and adjustments one person should be in charge of the move of course and choose a path that requires the least manipulation of the patient and equipment ensure that everyone understands the steps and is ready and move only on the team leaders command move the patient as a unit continue to protect the patient from any hazards and once the patient has been placed on the stretcher continue with any additional assessment and treatment that was deferred so move only on the team leaders command and move the patient as a unit okay so the figure on this slide shows the management of the patient during the extrication process once the patient has been assessed rapidly reassess the patient stabilize the spine manually and apply a cervical collar if not done previously",
        "Termination": "and then there's termination so termination involves returning those emergency units to service all equipment used on the scene must be checked before reloading them on the apparatus check and clean the ambulance thoroughly replacing used supplies and rescue and medical units are required to complete all necessary reports",
        "Specialized Rescue Situations": "all right so let's talk about specialized rescue situations so sometimes a patient can be reached only by teams trained in special technical rescues right so special skills of these teams include the following so you could have a cave rescue can find space rescue crossfield and trail rescue such as park rangers and then dive rescue person search and rescue mind rescue mountain rock and or ice climbing rescues ski slope and cross country or trail snow rescues like ski patrol or structural collapse rescues",
        "Special Weapons and Tactics": "special weapons and tactics and that's could that's the swat team um technical rope rescues so high and low or high angle rescue trench rescue water and small craft rescue and white water raft white water rescue",
        "Technical Rescue Situations": "technical rescue situation so let's talk about that a technical rescue situation requires special skills and equipment to safely enter and move around it is not safe to include personnel who have not been trained many members of technical rescue groups are also trained as emergency medical responders such as emrs or emts ensure the technical rescue team has been summoned and is in route okay so you want to check with the incident commander to see if they have done so okay and the incident commander is that overall command of the scene so it's one person they're clearly identified and um if there is no ic you want to follow your local guidelines",
        "Staging Area Setup": "when you arrive at a technical rescue scene you will be directed or led to a staging area what you want to do is you want to set up your equipment at that staging area a stable location where you will be able to treat the patient you're going to perform a primary assessment as soon as a rescue team brings the patient to you packaging and carrying the patient back to the ambulance requires a joint effort between emts and the technical rescue team",
        "Search and Rescue": "search and rescue so an ambulance is usually summoned to the incident command post when the person is lost outdoors and a search effort is initiated so your role is to stand by the command post until the missing person or persons have been found you may be asked to stay with a family member of a lost individual you want to gather any medical history and communicate the to those in charge only the incident commander should communicate any news or progress of the search to the family so you want to set your radio at a discrete volume and once the missing person is found you will be guided by the search personnel to the location where you're going to begin treatment time and effort can sometimes be decreased by relocating the ambulance or by using an altering vehicle so let's talk about trench rescue okay so many cave-ins and trench collapsing collapses have poor outcomes for victims collapses usually involve large areas of falling dirt that weigh approximately 100 pounds per cubic foot and victims with thousands of pounds of dirt on their chest cannot fully expand their lungs and may become hypoxic",
        "Trench Rescue": "the risk of a secondary collapse is also a concern so response vehicles should be parked at least 500 feet from that scene all vehicles should be turned off to avoid a secondary collapse by vibration so all road traffic should be diverted from the 500 foot safety area okay and construction vehicles and equipment at the collapse site may be unstable as well and could fall into that cave-in or trench site at no time no time at all should medical or rescue personnel ever enter the trench without proper shoring in place during the extrication of any survivors medical personnel trained in cave-in and trench collapses rescues will provide the most medical care you should be prepared to receive patients once they have been extricated from the site",
        "Tactical Emergency Medical Support": "okay then you let's talk about the tactical emergency medical support for um law enforcement officers okay so a steady increase in violence throughout the country has resulted in emts taking precautions to ensure personal safety when the potential for violence exists responding units should wait until the scene is secured by law enforcement officers sometimes the special weapons and tactics team and you'll hear it called the swat team is needed to secure an area many communities have incorporated specially trained emts paramedics nurses and even physicians into police swat units when called to the scene of a law enforcement tactical situation determine the location of the command post and report to the ic for instructions lights and sirens should be turned off and outside radio speakers should be should not be used when nearing the scene the command post is usually located in an area that cannot be seen by the suspect and is out of range of possible gunfire remain in this area okay so planning measures are key in these situations you need to have the incident commander identify a location the incident commander should determine when the scene is safe designate helicopter landing zones and identify quickest routes to the hospital burn center or perhaps the trauma center",
        "Structure Fires": "all right so next we're going to talk about structure fires all right in most areas an ambulance is dispatched with the fire department to any structure fires and what you want to do is ask the incident commander where you should park and stage and determine if there are any injured patients or whether you have been called just to stand by search and rescue in a burning building requires special training and equipment operations are performed by teams of firefighters wearing full turnout gear and self-contained breathing apparatus so sometimes a scene may be further complicated by the presence of hazardous materials okay so that concludes chapter 39 vehicle extrication and special rescue and next we're going to see what we've learned okay so let's see proper protective equipment will vary depending on hazards encountered so when which piece of equipment should be utilized during all patient contacts hmm helmet blood and non perf impermeable gloves all right i think they want us to say that uh the gloves we don't want to have uh so it's blood and fluid impermeable gloves it's my guess and we are right all right what is the first phase of extrication i think it's preparation right yeah because there's 10 phases and the first is to prepare so we want to get ready and we want we need to have all the training of the various rescue situations okay as you approach an unconscious patient who is still in the wrecked vehicle you note that there's a power line uh entangled in the wreckage of the vehicle so what should we do um we're not going to go in we're going to tell them to stay in the vehicle so i think a is the correct it's going to be retreat until the power line has been removed or the power is shut off all right so it's a we do not want to make ourselves a part of the problem okay a two-door passenger truck struck a tree while driving 50 miles an hour the doors are badly damaged and jammed and the driver appears to be unconscious inside the vehicle entering the vehicle by breaking the back window is an example of and i think that is a simple access we know it's either simple or a complex and i'm pretty sure this is a simple ah it says it's complex access because it requires the use of tools all right so examples of simple access would be just rolling the window down okay so we both learned all right so simple um it's just rolling the door the window down so this makes it a complex access a 30 year old semi-conscious man is pinned by the steering wheel of the badly wrecked vehicle once access has been gained to the patient the emt should okay we want to perform that primary assessment and provide any needed emergency care i'm almost possible i'm almost sure yeah so just like um just like we would anybody else once we get to the patient we're going to start with that primary okay and when the emt is in the vehicle assessing the patient the rescue team should be what should they be doing a while the patient is being accessed the rescue team should be assessing the degree of entrapment and determining the safest way to extricate all right proper removal of a critically injured patient from an automobile involves how should we do it all right so slow and controlled steps as a unit so it's going to be c moving the patient in slow smooth controlled steps a man has been stuck um sucked inside the bin of a grain silo in his trap which of the following rescue teams is most appropriate okay so i don't think we really talked about this but this is going to be a confined space rescue okay so confined space it's one of the technical rescue teams and grain silos are going to be confined spaces you respond to a wooded area to help search for a child who's been missing for 24 hours which of the following equipment should you leave in the ambulance hmm all right so backboard um it's not easy to carry and they they say it should be left in the ambulance all right and then finally you are dispatched to the scene of trans collapse upon arriving at the senior ambulance should be parked at least and we know this is 500 feet from that incident right so 500 feet okay all right so thank you very much for joining us for the vehicle extrication special special rescue chapter lecture um if you did like this lecture go ahead and push that subscribe button because we're going to be putting out all the lectures in the 12th edition book all right thank you have a great night"
    },
    {
        "Introduction": "hello and welcome to chapter 4 communications and documentation of the emergency care and transportation of the sick and injured 12th edition\ntransmission of information from one person to another whether it's verbal or through body language and that's considered non-verbal effective communication is essential component of pre-hospital care it is necessary to achieve a positive relationship with patients and co-workers so verbal communication skills are important this enables you to gather information from the patient and bystanders and makes it possible for you to coordinate all with all the responders who are often present at the scene and it's an integral part of transfer transferring the patient care to the nurses and physicians at the hospitals so let's talk about documentation the written or electronically recorded part of the patient's permanent medical record it demonstrates the appropriate care was delivered communicates the patient's story to others who may participate in the patient's future care adequate reporting and accurate records ensure continuity of patient care complete patient care records guarantee proper transfer of responsibility they guarantee that comply with requirements of health departments and law enforcement agencies and they fulfill your organization's administrative needs this drives funding for ems research so computer radio and telephone communications so the link the emt has to other members in ems fire department and law enforcement communities is through computer radio and telephone communications you must know what your system can do and cannot do and how to use the systems effectively and efficiently okay so next let's talk about therapeutic communication and what it means it uses various communication techniques and strategies both verbal and non-verbal and it encourages patients to express how they feel and achieves a positive relationship with each patient the shannon weaver communication model was developed to assist in the mathematical theory of communication for",
        "National EMS Education Standard Competencies": "after you complete this chapter and the related coursework you will have an understanding of the therapeutic communication means to communicate effectively with special populations such as children geriatric patients and hearing and visually impaired patients methods and procedures for effective communication components of effective written reports types of written reports and ways to correct errors found within written reports documentation of refusal of care special reporting situations use of medical terminology communication systems and equipment regulations and protocols governing radio communications and communication with medical control and hospitals as an introduction communication is the",
        "Therapeutic Communication": "bell telephone labs in the late 1940s this model remains a valuable tool in understanding communications and how it is how it goes is there's five different um areas and basically it starts with the sender takes a thought encodes it into a message then sends the message to the receiver the receiver decodes the message and then sends feedback to the sender and this figure on this slide illustrates the shannon weaver communication model and then this table on the screen lists the factors and strategies to consider during communication so you have age you want it eye contact body language facial expressions clothing sex culture posture education voice tempo environment and volume so let's start with age and culture and experience and this influences how a person communicates body language and eye contact are greatly affected by culture in some cultures people are encouraged to express emotion while in other other cultures they view it as a sign of weakness so in other cultures it is impolite to look away while speaking tone pace and volume of language offer clues about the mood of the person communicating it provides insight into the perceived importance of the message okay so let's talk about ethnocentrism and that's considering your own cultural values as more important than those of others and these people tend to translate messages they receive using their own world view and then you have cultural imposition and that's forcing your views on to others so healthcare providers may consciously or subconsciously force their cultural views onto the patients because their belief that their views are better",
        "Nonverbal Communication": "next is nonverbal communication and this is body language and it provides information more than words alone even without exchanging any words you should be able to tell the mood of your patient facial expressions body language and eye contact what we're going to talk about next and so eye contact and body language are powerful communication tools pay attention to body language both your own and that of your patients physical clues will help you and your patient truly understand the message being sent when you're treating a potentially hostile patient it's important that you understand and be aware of your own body language stay calm and try and diffuse the situation assess the safety of the scene do not assume an aggressive posture make good eye contact but do not stare speak calmly confidently and slowly and never threaten the patient either verbally or physically okay so next non-verbal communication we're going to talk about is physical factors and this could be the noise so anything that dampens or obscures true meaning of a message literal noise or sounds in the environment such as lightning in the distance or physical obstacles may affect your communication cultural norms often dictate the amount of space or proximity between people when communicating so as a person gets closer a greater sense of trust must be established your gestures body movements and attitude towards the patient are critically important in gaining the trust of both patient and family okay so we just talked about nonverbal communication now let's talk about verbal communication one of the most foundational functions of an emt is to ask the patient's questions so there's two types there's open-ended questions and these are questions that require some level of detail in the response use whenever possible you want to use open-ended questions so for an example what seems to be bothering you close-ended questions they could be answered with very short answers so the response is sometimes a single word like yes or no use if the patient could not provide long answers example are you having trouble breathing you may miss important issues to pertinent questions if if they are not asked you could use the closed ended questions for like difficulty breathing because they can't elaborate on on words right long words",
        "Communication Tools": "all right you can use many powerful communication tools when trying to obtain information for patients okay so facilitation this is encouraging patients to talk more and to provide more information you could use a pause and this gives the patient space and time to think and respond then there's reflection reflection is stating the patient's statements you made to them to confirm your understanding then there's empathy empathy is being sensitive to the patient's feelings and thought you could use clarification and this is asking the patient to explain what he or she meant by the answer confrontation is making the patient who is in denial or in a mental state of shock focus on the urgent and life critical issues then there's interpretation and that is restating the patient's complaint to confirm your understanding there's explanation and that's providing factual information to support a conversation then there's summary providing the patient with an overview of the conversation and the steps you will be taking when interviewing a patient consider the care consider the careful use of touch to show care and compassion so touch is a powerful tool use it consciously and sparingly okay if you are going to touch the patient approach slowly and touch the patient's shoulder arm respectfully or consider holding the patient's hand avoid touching the patient's torso chest or face simply by means of communication because these areas are often viewed as intimate",
        "Interviewing Techniques to Avoid": "interview techniques to avoid okay so providing false assurance or reassurance you should not do you should not give unsolicited advice you should not ask leading or biased questions you should not talk too much do not interpret interrupt use why questions you should not use authoritative language or speak in a professional jargon",
        "Presence of Family, Friends, and Bystanders": "okay so the presence of family friends and bystanders they may be a valuable tool during the patient interview process be sure to allow the patient to answer if he or she is able to do so even if well-meaning family members attempt to answer for the individual do not be afraid to ask others to step aside for the for a moment while you talk to the patient you may need to decide if having family and friends nearby will help or hinder your care",
        "Golden Rules": "and there are golden rules to help calm and reassure patients so make eye contact and keep it at all times provide your name and use the patient's proper name tell the patient the truth use language the patient can understand and be careful what you say about the patient to others be aware of your body and language speak slowly clearly and distinctly if the patient is hard of hearing face the patient so he or she can read your lips allow the patient time to answer and respond and act and speak in a calm confident manner",
        "Emotional Intelligence": "emotional intelligence okay that's what we're going to talk about next and this is people skills okay and the ability to understand and manage your own emotions and properly respond to others emotions it helps diffuse conflicts builds rapport communicate more effectively and manage difficult situations and so some attributes of emotional intelligence are self-awareness and this is the ability to recognize your emotions and how they affect your thoughts and behavior and then self-regulation that's the ability to control impulsive emotions and behaviors and to manage emotions in a positive way and then you have motivation the ability to motivate yourself and others in a positive direction empathy empathy is the ability to understand the concerns emotions and needs of others by picking up on communication and social cues and clues and then social skills that's the ability to develop and maintain positive rapport and relationships through effective communication\nunderstanding and improving your own emotional intelligence okay so you need to assess how you react to stressful situations and manage your frustration working on staying calm and in control when faced with minor irritations you need to practice mindfulness focus your attention on the present moment without blame and judgment of yourself and others take responsibility for your actions and consider how your actions will affect others next the last thing we're going to talk about emotional intelligence is behavioral change stairway model so this was developed by the federal bureau of investigation to manage hostage situations and adapted for most crisis situations okay so we want to employ active listening we want to display empathy build rapport and exert influence initiate behavior change all right so the next thing we're going to talk about is communication communicating with older patients and when you do this you want to identify yourself present yourself as competent confident and caring and do not assume that an older patient is senile or confused you may encounter hostility irritability or some confusion but do not assume this is a normal behavior so assess for signs of hypoxia a cva drug overdose infection hypoglycemia hyperglycemia or some type of insufficient perfusion okay approach an older patient slowly and calmly and allow plenty of time for the patient to respond to your questions watch for signs of confusion anxiety or impaired hearing or vision the patient should feel confident that you are in charge and that everything possible is being done for him or her be patient often older patients do not feel much pain they may not be fully aware of the important changes in the body systems and you must be especially vigilant for objective changes when possible give the patients time to pack a few personal items before leaving to the hospital locate any hearing aids glasses and dentures before you depart older patients are often worried about safety of their home valuable items and pets so share these concerns with the person assuming care of the patient at the hospital okay now we're going to talk about communicating with children so communicating with children fear is most obvious and severe in children and children may be frightened by your uniform the ambulance or a crowd of people gathering around them so let a child keep a favorite toy doll or security blanket and if possible have a family member friend nearby if practical let the parent or guardian hold the child during evaluation and treatment be honest children easily see through lies or deception and let the child ahead of time know if something's going to hurt and respect the child's modesty speak in a professional yet friendly way use an appropriate tone and vocabulary and maintain eye contact position yourself down at the child's level do not tower over the child okay and next we're going to talk about hearing impaired patients so communicating with patients who are hearing a hard of hearing most people who are hard of hearing have normal intelligence and are not embarrassed by their disability position yourself so that the patient can see your lips so hearing aids be careful that those are not lost during an accident or fall they may be forgotten if the patient is confused so ask the family about the use of hearing aids steps to take to effectively communicate with people who are hard of hearing have a paper and a pen available and if the patient can read lips face the patient speak slowly and distinctly and never shout listen carefully to shark questions and give short answers learn some simple phrases in sign language it can be useful to know the signs for sick hurt and help and on the slide figure 4-7 those are simple phrases in sign language signing requires movement and is best learned by attending a sign language class so a is sick b is hurt and c is help",
        "Communicating With Visually Impaired Patients": "communicating with visually impaired patients so ask the patient if he or she can see at all visually impaired patients are not necessarily completely blind many can perceive light and dark or can see shadows or movement and expect the patient to have normal intelligent explain everything that you're doing as you're doing it stay in physical contact with the patient as you begin at your care so if the patient can walk to the ambulance place his or her hand on your hand transport mobility aids such as a cane with the patient to the hospital so guide dogs these are easily identified by others special by their special harnesses so if possible transport the dog with the patient this alleviates stress for both the patient and the dog guide dogs are trained not to leave their masters otherwise arrange for care of the dog a conscious patient can tell you about the dog and give instructions for its care okay next we're going to talk about communicating with non-english speaking patients so you must obtain a medical history even though the patient does not speak english you cannot skip this step so find out if the patient knows a few english words or phrases use short simple questions point to the parts of your body and have a family member or friend interpret until a professional interpreter is available consider learning some common phrases in another language that is used in your area pocket cards that show the pronunciation of terms is available or use a smart app or website to help you translate remember to request a translator at the hospital",
        "Mission-Critical Communications": "all right so the next thing we're going to talk about is mission critical communications and what this is they are any communications where disruption may result in the failure of a task at hand it's shared mental model a mental model is the picture individuals have in their head of what's going on for any team to work effectively together all members must share a mental model to build a mental model the following questions must be answered and what is the focused prime priority of the patient what is the history of the prior care what is the patient's current state and what is the patient's immediate needs so answering the four questions quickly and effectively will help avoid errors and miscommunicate and misunderstandings patient care handover",
        "Patient Care Hand-Over": "so effective communication between ems providers and other healthcare providers in the receiving facility is essential to efficient effective and appropriate patient care patient care handover is the transfer of pertinent patient information and responsibility for patient care communication failures between reporting providers and receiving providers is a source of medical liability for the provider and organizations giving the handover report so things that you need to do when you give over the report you need to initiate eye contact so make eye contact with the person with whom the patient is being transferred manage the environment so whenever possible try to minimize noise interruptions and distractions and ensure the abcs if there is priority care that must be initiated and or continued it must be immediately conveyed and addressed to by the receiving clinician or team provide a structured report okay so the acronyms you we could use is sbar and this is the situation background assessment and the recap of treatment or sba2 a t this is situation background assessment and treatment okay and so provide documentation the verbal report should consist of the patient's priority condition prior care current state and immediate needs receiving the handover report so when you're receiving the care you need to do the exact same maintain eye contact manage the environment ensure understanding summarize and gather supplementary patient documentation",
        "Written Communications and Documentation": "all right so the next thing we're going to talk about is the written communications and documentations everybody's favorite and we're going to begin with the pcr pcr is the patient care report and it's known as the pre-hospital care report it is a legal documentation used to record all aspects of the care your patient received from initial dispatch to the hospital and there are two types of pcrs and it could be written or electronic the pcr serves six functions these six functions are continuity of care compliance and legal documentation administrative information reimbursement education and data collection for continuous quality improvement the following are examples of information collected on the pcr or patient care report so you start chief complaint mechanism of illness or injury level of consciousness using avpoos or mental status the vital signs initial and ongoing assessment management of demographics age gender and ethnic background transport information and how the patient was moved and reasons for the destination choice a lot of administrative information is used in billing research and quality improvement can be gathered in the pcr examples include the incident was reported the ems unit was notified the ems unit arrived on scene the ems unit left the scene the ems unit arrived at the receiving facility patient care was transferred and the unit was back in service okay so types",
        "Types of Forms": "of forms and on this slide you're going to see a very common epcr so that's an electronic format and that's what it's referred to and it's virtually they're designed to comply with nems's data collection requirement okay and epcrs allow patient information to be transmitted directly to the hospital computers and may be integrated with the patient's electronic medical record the narrative section of the pcr may be the most important standard narrative formats okay so there's two most common narrative formats used in healthcare are chart and soap all right so chart method chart method stands for chief complaint history and physical examination assessment treatment and transport it begins with a dispatcher information chief complaint or chief concerned and that states the condition most urgently requiring ems intervention then you have the history the history includes details relating to the current event and the patient's mental medical history prior to the event and then you have details that come from the patient or others on scene from dispatch or from the patient's record then a assessments this describes all assessments you performed on the patient including vital signs and a physical exam then the t or it stands for rx so treatment and that is the r in the chart method and that's detail all interventions that were performed then the t that's the transport so you're going to explain how the patient was moved to the ambulance how the patient was transported positioned and secured whether the emergency lights and sirens were used where the patient was taken including the room number and the name of the person to whom the report was given and the care was transferred next we're going to talk about the soap method and that's another very standard narrative format in the first part so it stands for subjective objective assessment and plan and that's soap subjective means you include information by the patient or others on the scene such as chief complaint events leading up the incident mechanism of injury and past medical history objective is the details you gather through your primary assessment the vital signs physical findings and other measurements such as blood pressure or oxygen saturation then assessment this summarizes the key findings so provide your impression of what the patient's problem might be possible fractured leg or stroke for example and then plan and document the treatment provided for the patient regardless of the method used the epcr's narrative section should include time of events assessment findings emergency medical care that you provided changes in the patient after treatment observations at the scene final patient disposition a refusal of care if obtained staff person who continued care in written documentation avoid radio codes and abbreviations all pcrs are confidential documents and once complete distribute copies to the appropriate locations",
        "Health Information Exchanges": "okay so next we're going to talk about health information exchanges and you'll see this abbreviated as h-i-e this improves the sharing of data between ems and other health care providers it allows ems providers to access relevant data avoid unnecessary duplication of effort in data entry and view patient outcomes related to hospital cares it allows emts to contribute to and assess electronic health information on both a regular basis and during times of the disasters most ehies follow the safer framework and so what safer stands for is search alert file and reconcile so search means ems providers can search for hospital and other records that help make treatment and transport decisions alert is hospitals are notified of incoming patients with automated systems that populate e.d emergency department dashboards with information entered by ems in the field and then file this is the data in the ems electronic patient care report are incorporated directly into the patient's health records and then reconcile and this is feedback on outcomes of the patients other hospital data is provided to ems agencies for billing and quality improvement",
        "Reporting Errors": "okay so reporting errors is what we're going to talk about next and if you leave something out of a record or record it inaccurately do not try and copy uh cover that up because this is falsification and it could result in poor patient care and may result in suspension or legal action and so on figure 4-13 if you make a mistake on a handwritten report the proper way to correct it is a single line you're going to draw it draw a single line horizontally through the era initial it and write the correct information next to it if an error is discovered after you submit a report follow the same process so add a note with the correct information if information was accidentally omitted draw begin a new section with the word addendum so you're going to write an addendum to add the new information in and then add and date your initials you're never supposed to use any type of correction fluid so do not erase or cover up the error",
        "Documenting Refusal of Care": "all right so documenting a refusal of care this is very important so refusal of care is very common source of lawsuits thorough documentation is crucial so document any assessment findings and emergency care given have the patient sign a refusal of care form have a family member police officer or bystander also sign the refusal of care form as a witness depending on local requirements the pcr might contain okay so here we go complete assessment evidence that the patient is able to make a rational informed decision decision with discussion with the patient as to what the care treatment of ems recommends discussion with the family and or patient as to what may happen if he or she does not allow care or transport discussion with family friends and bystanders to try to encourage the patient to allow care discussion with medical direction according to local protocol it should also include providing the patient and other alternatives for example going to see his or her family doctor or having a family member drive him or her to the hospital and the willingness of ems to return also signatures and then complete the pcr",
        "Special Reporting Situations": "special reporting situations and so these are uh depending on local requirements but examples of special reporting situations include gunshot wounds dog bites certain infectious diseases suspected physical and sexual abuse or mcis which is a multi-casualty incident",
        "Communications Systems and Equipment": "okay so communication systems and equipment next we're going to talk about ways to communicate so radio and telephone communications link your team with other members in ems fire and law enforcement community communities help the entire they help the entire team to work together more effectively and they provide an important layer of safety and protection",
        "Base Station Radios": "the first one we're going to talk about is a base station radio so the base station is a radio hardware containing the transmitter and receiver and it's usually located at a fixed place may also be equipped with one multi-channel and several single channel receivers a channel is assigned frequency or frequencies used to carry voice or other data communications a dedicated line also known as a hotline is used for specific point-to-point contact we talked about base station now we're going to talk about mobile and portable radios so a mobile radio is installed in the vehicle so mobile radios are used in the ambulance to communicate with the dispatcher or medical control and then an ambulance often has more than one mobile radio portable radios those are the handheld ones and portable radios are essential at a scene of a mass casualty incident when away from the ambulance a portable radio is helpful to communicate with a dispatch another unit or medical control",
        "Repeater-Based Systems": "repeater based systems okay so a repeater is a special base station radio this repeater based system receives messages and signals on one frequency then automatically transmits them to a second frequency and it allows two mobile or portable units that cannot reach each other directly to communicate using a greater power and antenna so the figure on the slide illustrates a rep repeater system and you can see a message is sent from the control center to a transmitter by a landline the radio carrier wave is picked up by a repeater for broadcast to the outline units return radio traffic is picked up by the repeater and broadcast to the control center",
        "Digital Equipment": "okay digital equipment and so digital equipment is used in the field the first one we're going to talk about is telemetry and this allows electronic signals to be converted into coded audible signals signals can be transmitted by radio or telephone to a receiver with a decoder at the hospital and so what we use these for is data from the cardiac monitors they can be transmitted via bluetooth enabled devices to monitoring centers digital signals are also used in some kinds of pacing and tone alerting systems",
        "Cellular/Satellite Telephones": "and of course there's cellular and satellite telephones so emts often communicate with receiving facilities via cellular telephone and then you have a sat phone or satellite phone and that's another option a scanner is a radio receiver that searches or scans across several frequencies and stops when it receives a radio broadcast on that frequency and continues once the message is complete conversations can be easily overheard",
        "Other Communications Equipment": "other communication equipment so ambulances usually have an external public address system ems systems may use a variety of two-way radio hardware and these two-way radio hardware could be broken down into simplex duplex or multiplex so simplex is a push-to-talk you release and then you listen duplex is a simultaneous talk to listen and then a multiplex utilizes two or more frequencies which enables more than one transmission to occur simultaneously then you have the med channels and those are reserved for ems use trunking or 800 millihertz systems assign many frequencies allowing the computer to constantly monitor for an open frequency so an inoperable communication system allows all of the agencies involved to share valuable information with one another in real time mobile data terminals inside the ambulance and so mobile data terminals are the computers in the ambulance and you could receive data directly from the dispatcher and allow for expanded communication capabilities so for example it'll have a map that pops up on the screen when you're dispatched to the the address",
        "Radio Communications": "okay now that we've talked about the different types of radios let's talk about the communications okay the federal communications commission fcc regulates all radio operations in the united states and the fcc has five principal ems related responsibilities so what they do is they allocate specific radio frequencies for use by ems providers they license base stations and assign appropriate radio call signs for stations they establishing license standards and operated specifications for radio equipment used by ems providers they establish limitations for transmitter power outputs and they monitor radio operations the fcc's rules and regulations section part 90 subpart b deals with ems communications issues okay so let's talk about responding to the scene the dispatcher will receive the call first from when the call is placed to 9-1-1 the responsibility of the dispatcher starts by properly screening and assigning a pro prime priority to each call so it's according to pre-determined protocols they select and alert the appropriate ems unit they dispatch the direct the ems unit to the correct location and they coordinate ems response units with other public safety services until the incident is over they provide emergency medical instructions to the cell phone caller the dispatcher signs the appropriate ems units based on several criteria so the nature and severity of the problem the anticipated response time to the scene the level of training and the need for additional support so the dispatcher should give the responding units information and this is the nature and severity of the injury or illness they should give us the exact location of the incident they should give us the number of patients they should give us the response of other public safety agencies and special directions or advisories so like is there road traffic problems or severe weather reports and then time the units are dispatched okay and then the emt should report any other problems that take place during the run to the dispatchers so the emt should inform the dispatcher upon arrival of the scene and what we should tell them is our arrival report and it should include any obvious details we observed during a scene size up radio communications must be brief and easily understood and we have to talk in plain english and not use code words then we need to report only in important information",
        "Communicating With Medical Control and": "then when we communicate with medical control or hospitals we need to to tell them the primary reason for radio communication is to facilitate communication between you and the medical control all right so medical control may be located at a receiving hospital in another facility and or sometimes even in another city or state when consulting with medical control it serves many purposes okay so it notifies a hospital of an incoming patient it provides an opportunity to request advice or receive orders from medical control and it advises the hospital in special situations also plans and organize your radio communication before you transmit all right so when you're ready you're going to give the patient report and the report is commonly includes 10 elements okay so 10 elements that is included and so it includes your unit identification level of services any special alert incident by the patient condition the receiving facility hospital and your estimated time your patient's age and gender the patient's chief complaint or other perception of the problem and its severity a brief history of the patient's condition a brief report of the physical findings a brief summary of the care given a brief description of the patient's response to the treatment provided and determine whether the receiving facility has any additional questions or concerns",
        "The Role of Medical Control": "so what's the role of medical control medical control is offline which is indirect or online which is direct and depending on how your protocols are written you may need to call medical control for direct orders which is the permission to conduct certain tasks so you may need to call if administering certain treatments determining the transport destination of the patients or stopping treatment or not transporting the patient you may need the call in most areas medical control is provided by physicians working at receiving hospitals many variations have developed across the country though in some areas medical direction may come from freestanding center or from an individual physician",
        "Calling Medical Control": "all right so when we call medical control there are a number of ways to control access on ambulance to hospital channels the dispatcher can monitor an assigned appropriate clear medical control channels or centralized medical emergency dispatch or response coordination centers your report must be precise and contain only important information never use codes when communicating with medical control unless you are directed to do so by your local protocol once you receive an order from medical control repeat the order back word for word and then receive confirmation do not blindly follow an order that does not make sense to you okay so let's talk about information regarding special situations you may initiate communication with hospitals to advise them of an extraordinary color situation so let's say a small royal hospital may be able to respond to multiple patients from a highway crash if notified when the ambulance is first responding or an entire hospital system must be notified of any disaster and so other special situations that you um they that you need to relay is hazardous material situations or rescues in progress or possible multiple cassidy casualty incidents or mcis when identifying the hospital of special situations keep several points in mind the earlier you notify them the better provide an estimated number of individuals who may need to be transported to the facility and identify any special needs the patients might have so let's say that there's burns or hazmat material exposure to assist the hospital in prepping and then follow your plan for your system maintenance of radio equipment so",
        "Maintenance of Radio Equipment": "like other ems equipment radio equipment must be serviced at the beginning of each shift check your radio equipment radio equipment may fail during a run so you must have a backup plan and it must be followed standing orders written are written documents signed by an ems systems medical director outlining specific directions and permissions when properly followed they have the same authority and legal status as orders given over the radio so this concludes the uh chapter four lecture next we're going to go into the questions see if we missed anything okay so when",
        "Review": "healthcare providers force their cultural values onto other patients because they believe their values are better this is displaying i think it's ethnocentrism nope forcing your own values on others because you believe it better is cultural imposition okay so cultural imposition when communicating with an older patient you should you should approach the patient slowly and calmly okay when caring for a five-year-old boy in respiratory distress you should allow a patient or caregiver to hold the patient if the situation allows right okay so d which of the following pieces of patient information is least pertinent when we're given that verbal report what is least pertinent so um patient's family medical history that's right which of the following stations statements about a patient care report is true okay which is true see yeah it can the continuity of patient care okay a device that receives low frequency signals and then transmits transmits it to a relatively higher frequency is and this is a repeater yeah c a repeater repeats the signal when treating a potentially hostile patient you should try to diffuse the situation by and this is going to be speaking calmly confidently and slowly okay all of the following are functions of the emergency medical dispatcher except d providing medical direction to the empty in the field right yeah so the emergency medical dispatcher is not giving us um coordinating medical direction after receiving an order from the medical director of the radio you should and it's repeat the order to the physician word for word okay and then finally you when requesting medical direction for a patient who was involved in the car accident the emt should and we're the mt should avoid using codes such as 1050 or signal 70. okay this includes the lecture for chapter 4 communications and documentation go ahead and if you like this go ahead and subscribe to the channel because we're going to have the rest of the chapters thank you"
    },
    {
        "Introduction to Team Approach in Healthcare": "hello and welcome to the emergency care and transportation of the sick and injured chapter 9 the team approach to healthcare after you complete this chapter and the",
        "National EMS Education Standard Competencies": "related coursework you will understand the significance and characteristics of a team approach to health care and the impact of this approach on positive patient outcomes you will also be able to list and describe the steps an emt should follow to assist with advanced life support skills including placement of advanced airways and vascular access alright so let's begin as an emt you are",
        "Role of EMT in Emergency Healthcare": "a critical member of the emergency health care team that includes not only first responders paramedics and other emts but also physicians nurses and other personnel who help your patient throughout the duration of his or her injury or illness a key goal of the ems agenda 2050 is ems systems that are designed to be inherently safe minimize exposure to injury infections illness and stress the culture of safety so there's data collection culture coordinated support and resources ems education initiatives ems safety standards reporting and investigating of errors and near misses and then there is just culture so that's an approach to leadership in organizations that balances fairness and accountability and encourages people to report errors and near misses and it focuses on risk management",
        "An Era of Team Health Care": "an error of team health care so previous models of emergency care often consisted of providers who work separately passing the patient from one individual or group to the next in time emergency health care providers recognize that working as a uniform team for first patient contact to patient discharge it was possible to improve individual and team performance patience and patient safety and patient outcome this concept is the continuum of care community paramedicine and mobile integrated health care mih teams may be the best example of this team concept of continuum of care health care is provided within the community rather than at the physician's office the structure and effectiveness of community healthcare teams differ from one system to system okay so let's talk about types of teams",
        "Types of Teams": "you have regular teams and temporary teams okay so regular teams consist of emts who constantly interact with the same partner team team members who frequently train and work together are more likely to move smoothly from one step in the procedure to the next and then you have temporary teams and these are emts who work with providers with whom they do not regularly interact or may not even know so providers must work within an environment that supports and promotes collaboration rather than competition it is crucial to have a clear understanding of the roles responsibilities and capabilities of each team member so special teams um these are type is another type of team and you have fire teams rescue teams hazmat tactical special event ems teams ems bike teams in hospital patient care techs and then mih technicians",
        "Groups Versus Teams": "okay and then you have group versus teams so groups versus teams the national incident management system which is nims defines a group as the organization level that divides the incident according to functional level of operation groups perform special functions often across gra geographic boundaries so a group consists of individual healthcare providers working independently to help the patient and this could be a group could consist of triage transport or treatment group a team consists of a group of healthcare providers who are assigned specific roles and who are working interdependently in a coordinated manner under a design leader the five essential elements of a group include a common goal an image of themselves as a group a sense of community of the group a set of shared values in different roles within the group",
        "Dependent, Independent, and Interdependent Groups": "dependent independent and intra-dependent groups okay so a dependent group independent group each individual is told what to do and often how to do it by his or her supervisor or group leader okay in independent groups each individual is responsible for his or her own area his or her own area and in interdependent groups everyone works together with shared responsibilities accountability and a common goal",
        "Effective Team Performance": "all right so effective team performance so to have effective team performance you have to have a shared goal and that means that every healthcare provider on the team must be committed to that goal you have to have clear rules and responsibilities and this means each provider must know what he or she needs to do and what is expected of him or her you have to have a diverse and competent skill set so practice with one another and become familiar with each other's tools techniques capabilities and preferences so that each team member is competent before the call comes in and then to be an effective team performance you have to have effective collaboration and communication so there are important elements of team communication and they include a clear message close-loop communication courtesy and constructive intervention and then to have an effective team performance you have to have supportative and coordinated leadership the team leader provides role assignments coordination oversight centralized decision making and a support and the support for the team to accomplish the goals and achieve desired results",
        "Team Leadership and Communication": "the team leaders foster communication and team dynamics using concepts such as crew resource management and team situational awareness good team members communicate effectively accepts feedback our good followers have confidence compassion and maturity maintain situational awareness and use appreciative or positive inquiry to approach organizational change crew resource management which is crm is a way for team members to work together with a team leader to develop and maintain a shared understanding of the emergency situation so crm recommends the use of pace mnemonic and a pace mnemonic stands for probe alert challenge emergency",
        "Transfer of Patient Care": "all right so transferring of patient care at several points along the continuum the patient care will be transferred or handed off from one unit of providers to another team these transfers introduce the possibility of critical patient care errors especially when they occur several times and in different changes along the continuum of care so effective teams minimize the number of transfers during patient care and adhere to strict and careful guidelines when such transfers are unavoidable whenever the not whenever the verbal transfer of care occurs all team members should do their best to ensure the following uninterrupted critical care minimal interference respectable interaction common priorities and common language systems so see chapter four communication and documentation for information on the patient care reports",
        "BLS and ALS Providers Working Together": "all right so basic life support and advanced life support providers working together so basic life support efforts must continue throughout the consumer of care you must carefully coordinate your efforts with the advanced tools and techniques used by advanced life support providers what may be a paramedic-only skill in your ems system may be common for an emt to perform in another it is your responsibility to understand what is allowed by the scope of practice standard of care and local protocols where you work the next thing we're going to talk about",
        "Assisting with ALS Skills": "is assisting with advanced life support skills so assisting follows a four-step process and this is the patient preparation equipment setup performing the procedure and then continuing care",
        "Critical Thinking and Decision Making in EMS": "effective decisions are based on sound up-to-date knowledge and information provided from the patient the patient's history and physical examination there are stages of a decision-making process okay and so when you talk about critical decision making and critical thinking there's a pre-arrival arrival during the call and after the call stages of the decision-making process okay so pre-arrival is when the decision-making process begins when the initial dispatch information is received mentally rehearse the steps in care that may be needed so designate a leader crew members discuss their roles in this pre-arrival decision-making process on arrival we provide the scene size up and request additional resources we assess and intervene for life threats immediately and during the call the team leader must gather information interpret the data develop a plan communicate the plan to the team and implement it and then evaluate the effect on that decision then there's after the call after the call you need to debrief and talk about what happened and listen the feedback with an open mind",
        "Decision Traps in EMS": "okay so when it comes to critical thinking and decision making there are decision traps okay so decision traps and these are traps that frequently lead to decision making errors in ems and they are bias anchoring and overconfidence okay so let's talk about those three things biases are fixed beliefs about something anchoring occurs when an emt settles on one possible cause for the patient's problem early and fails to consider other options and then overconfidence occurs when an emt overestimates his or her abilities",
        "Troubleshooting Team Conflicts": "all right so we need to talk about nexus troubleshooting team conflicts and when conflict occurs keep in mind the following five techniques the patient comes first do not engage keep your cool separate the person from the issue and choose your battles",
        "Review": "all right so that concludes chapter nine uh the team approach to healthcare and now we're going to go ahead and go through some of the review questions which of the following is a characteristic of a regular team okay and what is a regular team members of regular teams consistently interact with the same partner this allows for them to perform as a seamless unit okay so regular team is going to be members is b members consistently interacting with the same partner all right essential elements of a group that people must share include i think it's c working with the same set of shared goals that's right it's important for groups to set to have a set of shared goals fun twister all right members of an interdependent group what do they do interdependent group members of an interdependent group work together with shared responsibilities accountabilities and a common goal okay so that was d when a team member asked you should repeat the message back to him or her this is an example of and that's closed loop communication okay and so a clear message is delivered you speak calmly confidently and concisely so that the information delivered or action requested is clear to the listener and then you repeat it back to them okay a team leader i think it's all of the above yes a team leader is essential part of the success of a team when verbal transfer of care occurs all team members should do their best to ensure that all right when the verbal transfer of care occurs all team members should do their best to ensure that each team member is respectful of each other okay so everyone is respectful your partner is working a 48-hour shift and has had little sleep he disagrees with you over how to position the patient and how you should drive to the hospital you should pretty sure it's a you want to um to go ahead with it and then talk about it after right okay all right so this concludes chapter nine team approach to healthcare and thank you"
    },
    {
        "Introduction": "hello class and welcome to chapter 8 lifting and moving patients of the emergency care and transportation of the sick and injured 12th edition",
        "National EMS Education Standard Competencies": "after you complete this chapter in the related coursework you will understand the body mechanics of patient movement principles of safe reaching and pulling urgent and non-urgent moves how to move patients as a team types of patient packaging and moving equipment how to protect yourself from injury when moving patients and the use of medical restraints okay so let's get started in the course",
        "Introduction to Patient Movement": "of a call you will have to move patients several times to provide emergency medical care and transport so at a minimum you will have to lift and carry the patient to the stretcher move the stretcher to the ambulance and load the stretcher into the patient compartment to move patients without injury to the patient yourself or your team you need to learn how to lift and carry a patient properly knowledge of proper body mechanics and a power grip is important",
        "The Wheeled Ambulance Stretcher": "okay so let's talk about the wheeled ambulance stretcher it's also called the stretcher or gurney and the device most commonly used to move and transport patients generally not taken up or downstairs or to other locations where the patient must be carried for any significant",
        "Features of the Wheeled Ambulance Stretcher": "distance moving a patient by rolling using a stretcher or wheeled device is preferred when the situation allows and helps prevent injuries from carrying so some of the general features of the stretchers they have a specific head and and specific foot end and their strong rectangular their tubular metal main frame to which all other parts are attached the retractable guard rails are attached along the center portion of the main frame to prevent the patient from rolling off the stretcher the undercarriage frame allows the litter to be adjusted to any height and locked into place the stretcher remains locked at its present height when the controls are not activated so hinges at the center allow the head end to be elevated and the patient's back to be positioned at any desired angle the undercarriage is designed so that the litter can be adjusted to any height like i said and the mattress is fluid resistant so that it does not absorb potentially infectious materials and allows for easy cleaning and disinfecting and the patient is secured with straps and the straps protect the patient from further injury",
        "Backboards": "all right so once we move from backwards work or stretchers we're going to talk about backboards next and backboards are long flat boards made of rigid rectangular material they're used to carry and immobilize supine patients with suspected hip pelvic spinal and lower extremity injuries or other multi multiple trauma they can also be used to move patients out of awkward places parallel to the sides and ends of the board are long holes that serve as handles and that allows drops to be used to secure the patient to the board",
        "Moving and Positioning the Patient": "moving and positioning the patient so we're going to talk about that next and when you move the patient take care that injury does not occur to you your team or your patient so patient lifting and moving are technical skills that require repetitive training and practice so using proper body mechanics and maintaining physical fitness greatly reduce the chance of injuries moving a patient should be done in an orderly planned and unhurried manner you must master the skills necessary for the use of equipment and understand the advantages and limitations of each device before you use it in the field so let's talk about some body mechanics next and just a quick anatomy review so when you're standing upright the vertebrae are stacked on top of each other and aligned over the sacrum so the sacrum is both the mechanical weight-bearing base of the spinal column and the fused central posterior section of the pelvic girdle so when you talk about body mechanics that's the relationship between the body's autotomic structures and the physical forces associated with lifting moving and carrying so very little strain occurs when the spinal column remains in alignment okay so the lifting position you should have the shoulder girdle should be aligned over your pelvis your hands should be held close to the legs when this is happening force then goes essentially straight down your spinal cord and very little strain occurs this figure shows that the correct way to lift okay you may injure your back if you lift while leaning forward or if you lift while your back is straight but you're bent forward at the hips so lifting techniques so your legs should be spread about 15 inches apart or shoulder width you place um your feet so that they that your center of your gravity is properly balanced weight should be balanced on the balls of your feet not your toes with your back held upright bring your upper body down by bending at the legs grasp the patient or stretcher and make any necessary adjustments in the location of your feet we're gonna lift the patient by raising our upper body and arms and straightening our legs until we are in the standing position and then curling our arms up to waist height lifting by extending the properly placed flex legs is the safest and most powerful way to lift this is called the power lift do not lift a patient or heavy object with your arms outstretched avoid placing lateral force across the spine and sideways leverage against the low back keep your arms at a safe distance apart when when hanging your arms at the side of your body use the power grip to get maximum force from hands when you're lifting and so what the power grip is is the palms are up and the thumbs extend upward so hands are about 10 inches apart all fingers are at the same angle fingers and thumb are curled tightly over the top of the handle and fully support the handle with your curved palm not figure on the slide it shows a great photo of the power grip when directly lifting the patient tightly grip the patient in the place and manner that will ensure that you will not lose your grip on the patient",
        "Principles of Safe Reaching and Pulling": "all right so let's talk about some safe reaching and pulling principles so the same body mechanics and practices and principles apply to moving lifting and carrying a patient so let's talk about the body drag and when you do this you're going to keep your back locked in this slight curve created by tightening your abdominal muscles not curved or bent laterally kneel and extend your arms no more than 15 to 20 inches in front of you when you can pull no further because your hands have reached the front of your torso stop move back another 15 to 20 inches so alternate between pulling the patient by slowly flexing your arms and repositioning yourself this figure shows how to perform a body drag if you must drag a patient across the bed kneel on the bed to avoid reaching beyond the recommended distance drag the patient to within about 15 to 20 inches complete the drag while standing at the side of the bed use a sheet or blanket under the patient rather than dragging the patient by his or her clothing in the hospital when you're transferring the patients from the stretcher to the bed by a body drag the stretcher should be the same height or slightly higher than the bed you and your partner should kneel on the bed and drag in increments then there is the log roll so you can log rolling a patient onto his or her side to place the patient on the backboard you're going to kneel as close to the patient's side as possible and when you lean forward keep your back straight and lean solely from the hips roll the patient without stopping until the patient is resting on his or her side and braised against your thighs pulling towards you allows your legs to prevent the patient from rolling over completely and from rolling beyond the intended distance",
        "Principles of Safe Lifting and Carrying": "all right so let's talk a little bit more about safe lifting and carrying so whenever possible use a device that can be rolled to move the patient when a wheeled device is not available make sure that you can understand and follow the proper guidelines for carrying a patient to the stretcher so a patient's weight so you need to estimate the patient's weight before lifting adults often weigh between 120 to 220 pounds so two emts should be able to safely lift this weight use for providers to lift though when possible do not attempt to lift a patient who weighs more than 250 pounds with fewer than four providers know the weight limitations of the equipment and how to handle the patient who exceeds the weight limitations special bariatric techniques equipment and resources are generally required to move patients weighing more than 350 pounds lifting and carrying a patient on the backboard or stretcher so more of the patient's weight rests at the head of the stretcher than um half of the device than on the foot half the diamond carriers use uses one emt at the head and one emt at the foot of the backboard and one on each side of the torso and then the one-handed carry includes four or more rescuers each using one hand to support the backboard so that they are able to face forward as they're walking and these can be found in the skill drills in chapter eight right and then there's also a figure so the this figure shows the diamond carry for the stretcher when the stretcher must be carried it is best if four providers are available to carry it one provider should be positioned at each corner of the stretcher to provide an even lift and when you're rolling the wheeled ambulance stretcher make sure it is in the fully elevated position next we're going to talk about the stair chair so moving a patient with a stair chair use a stair chair to carry a patient up or down the flight of stairs or other significant incline if the patient is conscious and the patient's condition allows for him or her to be placed in a seated position so a stair chair is a lightweight folding chair with a molded seat adjustable safety straps and fold out handles at both the head and the feet most models have rubber wheels on the back with casters in the front so that they can roll along the floor and make turns you they're used to bring a conscious patient down to the stretcher and you could see this in the skill drill in chapter 8-4 okay moving a patient on stairs with a stretcher so a backboard should be used for a patient who is unresponsive or must be moved in a supine position so um also a patient who must be immobilized needs to be on the backboard so carry the patient on the backboard down the stairs to the prepared stretcher place the strongest emts at the head and foot ends of the board the taller person should be at the foot end of course and once you reach the stretcher place both of the backboard and the patient on the stretcher secure both the stretcher with additional straps to carry a patient on the stairs on a backboard follow the skill drills in 8-5 okay loading a wheeled stretcher into the ambulance so ensure the frame is held firmly between two hands so it does not tip newer models are self-loading so extra wheels at the end of the stretcher allow you to push the stretcher into the back of the ambulance models that are not self-loading need to be lowered and then lifted to the height of the floor of the ambulance clamps inside the ambulance will hold the stretcher in place during transport and then there's a skill drill it's 8-6",
        "Directions and Commands": "okay so directions and commands so team actions must be coordinated and we talk about having a team leader and this team leader indicates where each team member should be and rapidly describes the sequence of steps to perform before lifting they are preparatory commands and countdowns that they will use and so for example stop or all ready to stop you know countdowns are used okay and then carefully plan ahead so select the methods that you will involve the least amount of lifting and carrying consider whether there is an option that will cause some type of strain so emergency moves okay",
        "Emergency Moves": "so what are emergency moves emergency moves are used when there is a potential for danger before assessment can and care can be provided so use emergency moves when you cannot properly assess the patient or provide immediate care because of the patient's position so techniques to prevent an aggregation of the patient's spinal cord injury if there is one present we use a closed drag and this we could pull on the patient's clothing in the neck and shoulder area we could use a blanket drag and this is we place the patient on a blanket coat or other item that can be pulled we could use an arm drag rotate the patient's arm so that they are extended on the ground above his head and grasp the wrist and drag the patient or you could do the arm to arm drag and basically you're placing the arms under the patient's shoulders and through the armpits and what you're while you're grasping the opposite wrist and you're dragging the patient backwards and this these figures show the different types of drag so you have the close drag the blanket drag the arm drag and then the armpit drag removing an unconscious patient from a vehicle alone you need to move the patient's legs clear the petals rotate the patient so that his or her feet or back or towards an open door then place the arms under the patient's shoulders and through the patient's armpits and support the patient's head against your body if the legs and feet clear the car rapidly drag the patient from the seat to a safe location and this figure shows the steps to remove an unconscious patient from the vehicle",
        "Urgent Moves": "so urgent moves an urgent move may be necessary when we have a patient with an altered loss of altered level of consciousness or with inadequate ventilation in shock or in extreme weather conditions also a rapid extrication technique should be used when the patient is sitting in a vehicle and must be urgently moved whether a backboard is used for the skill will depend on your local protocols this technique should only be used if urgency exists so these special circumstances could be if the vehicle or scene is unsafe if explosives or other hazards are unseen maybe the car is on fire or is um there's a danger of that or the patient could not be properly assessed prior to the removal of the vehicle the patient needs immediate intervention that requires the supine position or if the patient has a life-threatening condition requiring immediate transport or the patient blocks your access to other serious injured patients so using the rapid extrication technique a patient can be moved from the sitting position in the vehicle to a supine on the backboard in one minute or less okay so because of its rapid nature this technique increases the risk of damage if the patient has a spinal cord injury so look at all available options before using this technique once a patient has been moved on to the backboard move the patient away from the hazard to begin life-saving treatment",
        "Nonurgent Moves": "all right so some non-urgent moves and we can use these when both the scene and the patient are stable and we're going to carefully plan how to move the patient so methods for lifting and carrying we could use the direct ground lift and this is used for patients with no suspected spinal cord who are found on the ground we use the direct ground lift when the patient will need to be carried a distance to the stretcher so emt stand side by side to lift the patient and carry the patient",
        "Nonurgent Moves Continued": "then there's the extremity lift and this is used for patients with no suspected or extremity or spinal cord injury they may be helpful when the patient is in a small space because it does not require emts to stand side by side one emt is positioned at the head and the other is positioned at the feet and you're going to coordinate the movements by using direct verbal commands okay then there's transfer moves transfer moves include direct carry draw sheet method or using a scoop stretcher or other carries okay so direct carry is with two or more rescuers we're going to move supine patient from the bed to the stretcher we're using a direct carry okay a draw sheet method we're using two or more rescuers we're moving the patient from the bed to the stretcher using a sheet or blanket using a scoop stretcher we're going to insert the halves of the scoop stretcher under the patient and we're going to fasten the sides other carries are the log roll or slide to move the patient to the backboard okay okay when it comes to geriatrics most patients transported by ems are",
        "Geriatrics": "geriatric patients and there are some skeletal changes okay so we need to be careful of those uh changes in older people may cause brittle bones rigidity or spinal curvatures and these patients cannot lie supine on the backboard or scoop stretcher without causing further injuries so consider using geriatric specific mobilization devices such as vacuum mattresses this figure is going to show the skeletal changes so this is kyphosis",
        "Bariatrics": "all right and then bariatrics so the management of or prevention of obesity or diseases and bariatrics okay bariatric patients are taking an increasing toll on the health of emts back injuries account for the largest number of missed days with emts so stretchers and equipment are being produced with over higher cap with ever higher capacity so increased capacity does not address the danger of users of that equipment so mechanical ambulance lifts are used in europe but are uncommon in the united states",
        "Additional Patient-Moving Equipment": "so some additional um devices so this is a on the figure you could see the bariatric stretcher it's a specialized wheel stretcher for overweight or obese patients um they have a higher or wider patient surface area and a wider wheelbase allowing for increased stability the most important feature is an increased weight lifting capacity and then the mnemonic or electric powered wheel stretchers so these are battery or air operated with electric controls to raise and lower the undercarriage devices limit the risk of injury to the providers and to the patients okay then there's portable or folding stretchers so these stretchers with long rectangular um tubular frame with rigid fabric stretched across it so they're used in areas where it's difficult to read they weigh much less than wheeled stretchers all right and then you have flexible stretchers and these can be rolled up",
        "Additional Patient-Moving Equipment Continued": "across the stretcher's width or length so that the stretcher becomes a smaller tubular package and it conforms around the patient's sides and does not extend beyond them when extended useful when removing patients from or through a confined space and then there's short boards short backboards and these are used to immobilize the head torso and neck of a seated patient with a suspected spinal cord injury until the patient can be moved to a long backboard short wooden backboards have mostly been replaced with this vest style type device that you see in the photo it's a ked and what that stands for is kendrick extrication device and you can see a photo of that on the slide then you have the vacuum mattresses this is an alternative to a backboard for mobilizing geriatric and pediatric patients the patient is placed on the mattress and the air is removed from the device allowing it to mold to the patient it provides a high degree of immobilization comfort and thermal insulation then you have basket stretchers so these are rigid and they're used to carry patients across an even terrain from a remote location that is inaccessible to an ambulance or another vehicle okay so if the patient has suspected spinal injury secure the patient to a backboard and secure the backboard inside the stretcher so when you return to the ambulance if the backboard lift the backboard out of the basket structure and place it on the ambulance stretcher so these are used for technical rope rescues and some types of water rescues okay these are designed to split into two or two or more pieces so this is the scoop stretcher and the pieces are fitted around the patient who's lying on the ground are on some other flat surface so the parts are then reconnected and the patient is lifted and put onto the backboard both sides of the patient must be accessible to use the scoop stretcher and you must fully immobilize and secure the patient onto the scoop stretcher so it's almost just like putting spatulas underneath them scooping them up and then there's a neonatal isolette and this is for the neonatal patient so birth to 30 days the first 30 days of that neonatal period it cannot be transported on the wheeled stretcher it keeps the neonatal patient warm with moistened air in a clean environment it protects from noise drafts infection and excessive handling this isolette can be placed directly on the wheeled stretcher and secured with seat belts and uh it's freestanding and secured onto the back of the ambulance in place or of where the stretcher could be",
        "Decontamination": "then there's decon so it's essential that you decontaminate the equipment after we use it and that's for our safety and the safety of the crew and then the safety of the patients of course and then preventing the spread of disease so know and follow your local standard operating procedures for disinfecting the equipment",
        "Patient Positioning": "let's talk about patient positioning okay so the patients must be properly positioned based on their chief complaint so when we talk about this if we have a patient who has no suspected injury reporting of chest pain or respiratory distress we should place the patient in the position of comfort and that's typically the fowler or semi-fowler position so patients who are in shock should be packaged in place in the supine position patients in late stages of pregnancy they should be positioned and transported on their left side if if they are uncomfortable or hypotensive supine exists okay so an unresponsive patient with no suspected injury hip or pelvic injury should be placed in the recovery position and a patient who is nauseated or vomited vomiting should be transported in the position of comfort",
        "Medical Restraints": "now let's talk about medical restraints so first evaluate as a patient for correctable causes of combativeness such as a head injury or hypoxia or hypoglycemia and follow your local protocols or obtain medical authorization if necessary you're going to require restraints require a minimum of five people so one for each extremity and one for the head one emt should be the established team leader the patient should be in the supine position and the patient in a prone position can develop some type of asphyxia so we want to keep them in the supine position each extremity should have a restraint applied to it the patient should be restrained to the backboard with one arm above his or her head and the other arm down by its side assess the abc's mental status and circulation um after endurance and um often okay and then document all that information",
        "Personnel Considerations": "personal consideration so ask yourself these questions before moving the patient am i physically strong enough is there adequate room for me to get the proper stance to lift the patient and do i need personal for lifting assistance do i need additional personnel so injured emts cannot help anymore",
        "Review": "all right so that concludes chapter eight lifting moving patients let's just go through the review questions see what how much we've learned so what is the first rule of lifting what do we know are we going to use our arms to do most of the lifting no we're going to always keep our back in the straight upright position it's the best use okay when lifting a stretcher using a power lift you should what should we do we should have our hands should be facing palms up this is a better power lift and it is not as stressful on the wrist okay so see place your hands palms up on the leader handle it is important to apply a vest type extrication device on a critically injured patient to remove him or her from a wreck because it oh it is impractical yes because it takes too long hey it takes too long proper guidelines for correct reaching include all of the following except all right which one does not include reaching no more than 30 inches in front of your body all right that's right we don't want to reach no more than 30 inches in front of our body okay an injured hand glider is trapped at the top of a large mountain and must be evacuated to the ground the terrain is very rough and even which of the following devices would be the safest and most appropriate i think it would probably be the stokes basket all right and what the stokes basket is it's a basket stretcher so i think that we went over it in it being called a basket stretcher when two emts are lifting a patient on a long backboard they should they should since there is more than half of the patient's weight is distributed to the head end of the backboard or stretcher you should always ensure that the strongest emt is in that position okay so position the strongest emt at the head of the board which of the following techniques is considered to be an emergency move the firefighter's drag is a one-person technique that's used when the patient must be removed from a life-threatening situation so that would be the firefighter's drug to extricate a patient from the basement of a building you must transport the patient up a flight of stairs in doing this you must ensure that we don't want the feet to go first we know that so we know that if we're going on up on an incline we want to ensure that the head the head goes first not the feet if an injured patient must be moved but is not in immediate danger from a fire or building collapse you should first of course the only time your attention should be directed away from the primary assessment is if there's a life immediate danger life threat so the first thing we should do is check the airway breathing and circulation the rapid extrication technique is to the rapid extrication technique is to remove a person rapidly from a vehicle to a supine position onto a backboard so that was d all right and thank you for joining us uh chapter eight uh lifting and moving patients"
    },
    {
        "Introduction to BLS": "hello and welcome to chapter 14 bls resuscitation of the emergency care and transportation of the sick and injured 12th edition",
        "National EMS Education Standard Competencies": "after you complete this chapter in the related coursework you will have reviewed the basic life support procedures for adults infant and children please note that bls knowledge is a prerequisite for the course and that this chapter should serve as a review",
        "History and Principles of BLS": "so as an introduction the principles of basic life support were introduced in 1960 and since then the specific techniques have been reviewed and revised regularly the most recent review in 2020 was conducted by the international liaison committee for resuscitation let's talk about some elements of bls",
        "Elements of BLS": "bls is non-invasive emergency life-saving care that is used to treat medical conditions they include airway obstructions respiratory rest and cardiac arrest it has a focus on abcs and what abcs are is airway which is the obstruction breathing example is respiratory rest or circulation cardiac rest or severe bleeding if a patient is in cardiac risk then a cab sequence we use that and that's the compressions airway breathing is used because chest compressions are essential and must be started as quickly as possible only seconds should pass the time you recognize that a bls patient needs to have treatment so permanent brain damage is possible if brain is without oxygen for more than four to six minutes the figure on this slide illustrates the concept that time is critical for patients who are not breathing if the brain is deprived of oxygen for more than four to six minutes brain damage is possible okay so let's talk about cpr cpr establishes this reestablishes circulation and artificial ventilation in a patient who is not breathing and has no pulse so cpr steps this is what you're going to do so restore circulation by performing high quality chest compressions to circulate the blood then you're going to open the airway restore breathing by providing rescue breathing you're gonna administer two breaths over one second while you visualizing for chest rise and fall okay so the figure on the slide demonstrates two ems providers performing cpr blf differs from als advanced life support which involves advanced procedures and these procedures could include cardiac monitoring administration of intravenous fluids and medications use of advanced airway adjuncts and while done correctly bls can maintain life for short time until als measures can be started the figure on this slide illustrates the six links of the chain of survival",
        "The System Components of CPR": "all right so let's talk about those six links and the components of cpr okay the chain of survival and the american heart association chain or survival includes so all of these links have to be have to be done okay so recognition and activation of the emergency response system then immediate high quality cpr we want rapid defibrillation and then basic and advanced emergency services advanced life support and post arrest care and then recovery if any one of those links in the chain is absent the patient is more likely to die okay all right so assessing the need for basic life support it always begins by surveying the scene you're going to complete the primary assessment as soon as possible in order to evaluate the patient's abcs first step is determining responsiveness a responsive patient does not need cpr an unresponsive patient may or may not need cpr this step should take no more than 10 seconds okay the basic principles of bls are the same for infants children and adults although cardiac arrest in adults usually occurs before respiratory rest the reverse is true in infants and children in infants and children it's usually respiratory that causes the cardiac arrest the figure on this slide demonstrates how to assess an unresponsive patient by first attempting to arouse him or her by tapping on the shoulder",
        "Automated External Defibrillation": "okay so an automatic external defibrillation or an aed is a vital link in that chain of survival the aed should be applied to a cardiac arrest patient as soon as possible if you witness cardiac arrest begin cpr and then apply the aed as soon as possible aed use in children so apply after the first five cycles so this is the difference we're going to do five cycles of cpr so 30 seconds of five cycles and use pediatric size pads and then a dose attenuating system if neither is available then use the aed with adult-sized pads with an anterior posterior placement okay so special situations such as pacemakers or implanted defibrillators we're going to pace or place the electrodes at least one inch away from this device on wet patients or if the patient's is in water we want to pull them out and dry the skin before we attach the aed pads okay and if the patient is in a small puddle of water or in snow the aed can be used but the patient's chest should be dried as much as possible and then transdermal medication patches remember to remove those patches and wipe the skin to remove any residue prior to attaching the aed pad",
        "Positioning the Patient": "positioning the patient for cpr to be effective the patient must be lying supine on a firm flat surface ensure enough space around the patient for two rescuers to perform cpr if possible log roll the patient onto a long backboard check for breathing in a pulse quickly check for breathing in a pulse these assessments can occur simultaneously and take no longer than 10 seconds total visualize the chest for signs of breathing and then palpate for a crowded pulse provide external chest compressions so we're going to apply rhythmic pressure and relaxation to the lower half of the sternum compression squeeze the heart it acts as a pump to circulate the blood so avoid learning or avoid leaning on the chest in between chest compressions because we want complete recoil proper hand and compression technique you want to see skill drill 11-1 because injuries can be minimized by proper technique and hand placement the figure on this slide illustrates the heart lie slightly to the left in the middle of the chest between the sternum and spine and the figure on this slide illustrates the concepts of compression and relaxation okay so compression and relaxation should be rhythmic and of equal duration a one to one ratio so press on the sternum uh it must be released so that the sternum can return to its normal position a resting position in between compressions all right so we started the cpr right away and we've gotten the aed on as soon as we can the next step to this bls um concept is to go ahead and open the airway so that's what we're going to talk about next so we're going to open the airway in adults with a head tilt chin lift we're going to remove any foreign materials if we found any in the mouth so we're going to use this for non-traumatic patients okay so that head tilt chin lift maneuver and then the jaw thrust maneuver if we suspect any any trauma at all okay so if the patient is breathing adequately on his or her own and no signs of injury to the head spine hip or pelvis place him or her in the recovery position the figure on the slide demonstrates that recovery position and the recovery position is used to maintain an open airway in an adequately breathing patient with a decreased level of consciousness who has no spinal injury all right so a lack of oxygen which is known as hypoxia combined with too much carbon dioxide in the blood which is hypercarbia is lethal so we need to provide deliberate ventilations that last for one second if the patient is not breathing ventilations can be given by one or two ems providers so we're going to use a barrier device such as a pocket mask one way valve or a bag valve mask these devices are used to supply supplemental oxygen when possible okay the figure on this slide demonstrates using a barrier device when providing ventilations for a patient with a stoma okay so place the bag bag mass device or pocket mass device directly over the stoma artificial ventilations may result in gastric distension so be ready to have a suction unit available in case the patient vomits because gastric distension can cause vomiting all right so the figure on this slide demonstrates how a barrier device attaches to a stoma the stoma connects the trachea directly to the skin so you use a back valve mass device or pocket mass device to ventilate the patient with a stoma",
        "Two-Rescuer Adult CPR": "all right so next let's talk about one rescuer adult cpr okay so if there's one rescuer adult cpr if we're providing cpr alone we must provide a continuous cycle of 30 compressions followed by two ventilations okay the ratio of compressions and ventilations like i just said was is 30 to 2 to rescuer adult cpr so if there's two people which is preferred we'd rather have two people it's uh preferred over one person the rescuer who is doing the compressions can be switched and this uh is less tiring and facility that facilitates effective chest compressions so by switching rescuers during cpr it's critical to maintain high quality compressions so it's recommended the switch positions every two minutes all right so now that we've talked about the one and two persons cpr we're going to talk about devices and techniques that can assist circulation active compression and decompression cpr so this involves compressing the chest and then actively pulling back up to its mechanical position or beyond and it may increase the amount of blood that returns to the heart then there's an impedance threshold device itd and those are divided to limit the amount of air entering lungs during the recoil phase in between chest compressions so the figure first figure on this slide is an active compression device and you can see that it's stuck on that sternum and then the second figure on the slide is an impedance threshold device okay then there's mechanical piston devices and that always that allows the rescuer to confirm the depth and rate of compressions okay and then there's load distributing band cpr and vest cpr then there's manual chest compressions manual chest compressions remain the standard of care however okay so this is a figure and it shows that load distributing band the autopulse",
        "Infant and Child CPR": "all right so we've talked about the adult cpr and now we're going to get into the infinite child cpr so like i said earlier in most cases cardiac arrest in infants and children follow respiratory risk which triggers hypoxia and ischemia to the heart so airway and breathing are the focus of pediatric basic life support so causes of respiratory problems leading to cardiopulmonary arrest in children and include there could be an injury an infection of the respiratory tract foreign body submersion such as drowning it could have been caused from electrocutions or poisonings or possibly sudden infant death syndrome which is sids all right so when it comes to children we're going to determine the responsiveness so we're going to gently tap on the shoulder and speak loudly if you find an unresponsive apnic so not breathing or pulseless child when you're alone and off duty perform cpr for five cycles so about two minutes and then call the ems system so that is when you are on when you are alone and you find an unresponsive child check for breathing in a pulse so we're going to palpate the brachial artery and infants the infant our child must be laying on a hard surface of course flat surface for effective chest compressions and we're going to use two fingers to compress an infant's chest and if two rescuers are performing cpr on an infant use the thumb two thumb and circling technique to deliver chest compressions in children especially older than eight years old you can use the heel of one or both hands to compress the chest follow this steps and skill drill 14-4 to perform the infant chest compressions and follow the steps in skill drill 14-5 to perform cpr in children between one year and the onset of puberty all right so in kids of course we talk a lot about airway and foreign body obstructions and because it's very common and as we mentioned earlier usually in children in infant cpr it's because of a respiratory issue so we're going to place the unresponsive breathing child in the recovery position and um the two common techniques for manually open the airway are modified for pediatric children okay so we're going to place a wedge of padding under the child's upper chest and shoulders to avoid partially obstructing their airway we're going to provide rescue breathing so if a child is not breathing but has a pulse then open the airway and deliver one breath every two to three seconds and that's going to be about 12 to 20 breaths a minute okay if the child is not breathing and does not have a pulse then we're going to do rescue breathing after every 30 compressions 15 chest compressions if two breast screws are present okay so if a child or small infant is breathing then provide prompt transport allow the child to stay in whatever position is most comfortable and in a child with a trach tube in the neck remove the mask from the bag and connect it directly to the trach tube to ventilate the child the face mask with a one-way valve or a barrier device over the tracheostomy site can be used okay so when are we going to interrupt",
        "Interrupting CPR": "cpr hopefully when the pulse has returned right so but cpr is critical right and it's crucial it's a life-saving procedure but it only provides minimal circulation and ventilation until the patient can receive defibrillation advanced life support treatment and definitive care in the emergency department so no matter how well it's performed cpr is rarely enough to save the patient's life if advanced life support is not available at the scene we must provide transport based on our local protocols continuing cpr on the way consider requesting a rendezvous and route to the hospital with the als unit okay try not to interrupt cpr for more than a few seconds especially when necessary except when necessary so chest compression fraction the total percentage of time during a resuscitation attempt in which the chest compressions are not being performed so try to maintain a chest compression fraction greater than 80 percent so to further explain that you're going to take the total time that you are on scene or with the patient and cardiac arrest and subtract the total time that you have been performing the chest compressions then the time left over is going to be the percentage of the resuscitation that is not performed and that's going to be the chest compression fraction okay all right so when not to start cpr",
        "When Not to Start CPR": "all right so three general rules regarding when not to start cpr so of course if the scene is unsafe second if the patient has obvious signs of death death okay so these include an absence of pulse and breathing of course along with any of one of the other following findings okay so no pulse not breathing and if they have any one of these you're not going to start cpr all right so rigor mortis rigor mortis is stiffening of the body after death dependent lividity you'll also hear it's called liver mortis putrification and that's when the body is decompensating or decomposition okay and then evidence of some non-survivable injury so on this slide is an example of dependent lividity and so what it does is um this patient has been rolled so you could see the libidity so it's that purple discoloration of the back and um basically what the patient was laying on the firm surface and the blood has pulled to the lowest um the lowest because of gravity center of gravity all right so and then the third is if the patient and physician have previously agreed on do not resuscitate orders okay so dnr orders",
        "When to Stop CPR": "all right and when to stop cpr so once you begin continue until one of the following occurs and we use this mnemonic called stop okay so the s stands for patient starts breathing and has a pulse that would be wonderful t the patient is transferred to another provider of equal or higher training okay so another provider of equal higher training all right and the o is you are out of strength then the p is the physician directs you to discontinue just remember that in the o the out of strength it does not mean you're tired but you are physically unable to continue okay all right let's talk about foreign body airway obstruction in the adults so we want to recognize foreign body airway obstructions but remember the most common is that relaxation of the throat muscles in an unresponsive patient so the tongue the tongue is very common so or you could have vomited or regurgitated stomach contents there could be blood or damaged tissue after an injury dentures or foreign bodies such as food or small objects so we want to recognize foreign body airway obstruction and in adults a foreign body obstruction usually occurs during a meal okay but in children that airway obstruction can occur during a meal or at play all right so with a mild airway obstruction we want the patient um so mild air obstruction the patient is going to be able to exchange a adequate amount of air but still has some signs of respiratory stress these mild airway obstructions we're going to leave them alone and we're going to observe for signs of severe obstruction just continue to reassess them so mild airway we're going to leave these patients alone responsive so a sudden severe obstruction is usually easy to recognize in response to patients the patient will suddenly be able to speak or cough they'll grasp his or her throat usually turn cyanotic and make exaggerated efforts to breathe also strider might be present so that's in responsive patients unresponsive patients suspect airway obstruction if maneuvers to open the airway and ventilate are ineffective removing a foreign airway obstruction in adult so we're going to use the abdominal chest maneuver and that's the heimlich maneuver and it's recommended in a patient in adults and children under and children older than one year so what this does is it creates an artificial cough if the patient with the severe airway obstruction is unresponsive then we're doing chest compressions okay so responsive and children older than one year we're doing the um chest thrusts which is the heimlich maneuver once they go unresponsive then we're going to do chest compressions all right so the figure on this slide displays how to perform an abdominal thrust maneuver in the responsive patient so that's the heimlich all right instead of abdominal thrust maneuver use chest threats for the following patients and so you're moving farther up on the body um and so that's women in advanced stages of pregnancy and also obese patients you're going to move farther up and those are the the abdominal thrust okay the figure on this slide displays how to perform chest threats on an on a responsive adult so see you're moving you're moving up so chest rests instead of abdominal thrust on those patients okay responsive patients who become unresponsive so the lower the patient you want to lower the patient to the ground and call for help or send someone for help and then we're going to do 30 chest compressions do not check for a pulse before beginning chest compressions because we're doing this to create that the power to to knock out that foreign body airway obstruction okay so open the airway and look in the mouth if you see an object that can be easily removed we're going to remove it with our finger and then attempt to ventilate but if you do not see the object we're going to just continue doing chest compressions repeat steps two and three until the observe of the obstruction is relieved or until the advanced life support providers take over so then in unresponsive patients of course when you come up you determine unresponsiveness you're checking for breathing in a pulse if the pulse is present but breathing is absent then we're opening the airway and attempting to ventilate if the first ventilation does not provide visible chest rise and fall then reposition the airway and attempt to ventilate both ventilation attempts do not produce visible chest fries then perform 30 compressions then open the airway look in the mouth attempt to carefully remove any visible object",
        "Foreign Body Airway Obstruction in Infants and Children": "okay so we've talked about adults and now let's talk about children and we did say that airway obstruction is very common in infants and children so in children who have signs and symptoms of an airway obstruction do not waste time trying to dislodge a foreign body administer supplemental oxygen if needed and immediately transport the child okay so that's signs and symptoms of an airway obstruction as long as the patient can breathe cough or talk do not interfere with his attempt to expel that foreign body administer supplemental oxygen if needed or tolerated and provide transport to the ed on a responsive standing or sitting child perform heimlich maneuver but with less force than what you would use on an adult okay so an unresponsive child older than one year who has an airway obstruction is managed in the same manner as an adult all right so this uh figure is going to show you those abdominal thrusts remember those are responsive so and then responsive infants so we're going to perform back slaps and chest thrusts which are also compressions and so this is going to it's going to demonstrate this figure on how to perform those back blows and chest flush so hold the infant face down with the body resting on the forearm we're going to support the jaw and face of your hand and keep the head lower than the rest of the body give the infant back blows between the shoulder blades so using the heel of your hand give the infant five back quick chest thrust so we're going to roll the patient over using two fingers placed on the lower half of the sternum all right so in unresponsive infants we're going to begin uh chest compressions do not check for a pulse before we start just like the adults we're going to open the airway and look in the mouth if we see an object that can be easily removed then we're going to remove it so if we do not see an object then we're going to resume chest compressions we're going to continue the sequence of chest compressions opening the airway and looking inside the mouth until the obstruction is relieved or advanced life support providers are taking over",
        "Special Resuscitation Circumstances": "all right so when it comes to basic life support there are some um special circumstances that we need to talk about okay so the when it comes to opiate overdoses emts may be allowed to administer narcan so we're going to narcan to reverse the arrest all right and in the cardiac arrest in a pregnancy so priorities are to provide high quality cpr to relieve pressure off the aorta and vena cava so if the pregnant patient is not in cardiac arrest then position her on her left side to relieve pressure on those great vessels all right so if she is in cardiac arrest and the top of the patient's uterus can be felt at or above the level of the umbilical umbilicus perform manual displacement of the uterus to the left patient's left to relieve atrial cavital compression while cpr is being performed",
        "Grief Support for Family Members and Loved Ones": "grief support for family members and loved ones family members may experience a psychological crisis that turns into a medical crisis okay so family members and loved ones will remember this event in detail for the rest of their lives so appropriate and supportive care at the onset of grief may positively affect the pain the family's grieving process so keep the family informed throughout the resuscitative process designate one provider to communicate the patient's status to the family member so you want to be concise and clear after the resuscitation has stopped these other measures can be helpful so take the family to a quiet private place introduce yourself and anyone with you use clear language and speak in a warm sensitive and caring manner try to exhibit calm reassuring authority use the patient's name and use eye contact and appropriate touch okay so except the family members will show emotion as they begin the grieving process while you are still on scene be supportive but do not hover and ask if a friend or family member can be called to come and support them when you need to leave turn the family member over to someone ensure the child or children are not ignored and see chapter 2 workforce safety and wellness for a discussion of the emotional aspects of emergency care and stress management",
        "Education and Training for the EMT": "all right so education and training for emts so cpr skills can deteriorate over time so we practice often using mannequin-based training cpr self-instruction through through a video or a computer-based module with hands-on practice may be reasonable alternative to an instructor-led course",
        "Education and Training for the Public": "education and training for the public so this is a major one and you are a patient advocate so not only are you responsible for providing the best care to the patient but you must do your part to facilitate the training of lay people in the critical skills of cpr and aed operation so if you are asked to train members of your community how to perform compressions only cpr then you should consider it your professional responsibility and be willing to assist all right so that concludes um the chapter of uh basic life support and we're gonna go through some of the reviews uh questions to see how well we did see if we can remember all right so brain damage is very likely in the brain that does not receive oxygen for how long what are you but what do you think four to six minutes oh my goodness okay permanent brain damage is very likely if the brain is without oxygen for longer than six minutes right it can begin in four to six minutes all right so four to six minutes is that brain damage is possible at this stage and then d six to ten is is brain damage is going to occur all right so which of the following sequence of events describes the advanced or american heart association chain of survival so i know that we want to early access we want to make sure that we see the p we get the call in early cpr early defibrillation early advanced care and integrated post rest and recovery so it looks like the c is our answer right all right so the american heart association uh determined the an ideal sequence of events okay all right let me set c number three so for cpr to be effective the patient must be on a floor surface lying in the blank position all right so hopefully you guys know this one and it will be c supine okay the pulse check should take how long do you guys think this will take so um we know it's 10 but we don't want it to take more than ten so five to ten okay all right so 10 seconds that's too long artificial ventilation may result in the stomach becoming filled with air and this is called it causes vomit but it is gastric dissension gastric distension is that air and then it causes vomiting the blank is a circumferential chest compression device composed of a constricting band and a backboard what do you guys think so this is that load distributing band there is a picture of it on the slide and it basically um it's a circumferential chest compression device and it constricts okay so which of the following scenarios would warrant an interruption in cpr so what about if we're tired no a hysterical family member no uh horn honking probably not what about if we have the walk down steps i think that that would probably be necessary but only for as quick as possible right okay so walking down the steps okay so once you begin cpr on the field you must continue until one of the following events occurs all right so we know that it's not a uh i think it's b so when we're transferred to another person who's trained or higher okay so b the t is the stop and it's a transfer acronym okay all right instead of abdominal thrust maneuver you can use blank for women in advanced stages of pregnancy we know it's the chest thrusts all right abdominal maneuver for adults and children however we're going to use the chest thrusts or for the pregnancy or the severely obese okay infants who have signs and symptoms of an airway obstruction you should not waste time trying to dislodge the foreign body you should intervene only if signs of blank develop severe airway obstruction okay so severe airway obstruction is the answer all right and this concludes the bls chapter 14. go ahead if you enjoyed this lecture subscribe to the channel and we will continue to post the emergency care and transportation of the sick and injured chapters 12th edition thank you have a great night"
    },
    {
        "Introduction to Transport Operations": "hello and welcome to chapter 38 transport operations lead this chapter and the related National EMS Education Standard Competencies (1014) coursework you will be able to describe and apply effective preparation for transport safe emergency vehicle operations appropriate transport decisions safe patient transfer techniques and a responsible approach to patient care during transport you will be able to identify the nine phases of a call and describe the emt's role in each phase you will be able to discuss the differences between ground and air transport and furthermore you'll be able to understand the steps necessary to properly clean disinfect the emergency vehicle and the equipment following the call",
        "Modern Ambulance Features": "so let's get started today's ambulances are stocked with standard medical supplies and many are equipped with state-of-the-art technology that can transmit data directly to the emergency department today's emphasis on rapid response places the emts in a greater danger while driving to calls",
        "Emergency Vehicle Design": "so let's talk about an ambulance is a vehicle that is used for treating and transporting patients who need emergency care to the hospital today's ambulances are designed and based on nfpa 1917 it's the standard for automo automotive ambulances and on suggestions from the ambulance industry and from ems personnel components of a modern ambulance include a driver's compartment also has a patient's compartment big enough for two amts and at least one supine patient and additional patients may be seated on the bench seat or swivel seat with appropriate safety restraints it has equipment and supplies to provide emergency medical care at the scene and during transport to safeguard personnel and patients from hazardous conditions and to carry out light extrication procedures it has it also has a two-way radio for communication and it's designed and constructed that to ensure a maximum safety efficiency and comfort okay and this table shows the basic ambulance designs and so there's three types you have type one type two and type three okay each state establishes its own stem standards for ambulance licensing and certification many states use federal specifications so the star of life enables and identifies vehicles as ambulances and is often affixed to the sides rear and roof of the ambulance the figure shown the different types of ambulance",
        "Phases of an Ambulance Call": "okay so let's talk about the phases of an ambulance call okay so you have the ambulance and it has nine different phases an ambulance call has the first phase is the preparation second is dispatch third is in route fourth is arrival at the scene five is the transfer of the patient um six is in route to the receiving facility or we also call this transport and um then you arrive at the receiving facility you deliver the patient then enroute to the station and post run",
        "Preparation Phase": "so let's talk about those different nine different phases of the ambulance call the first one we're going to talk about is the preparation phase and so this is when we make sure all the equipment and supplies are in their proper places and they're ready for use new equipment should be placed on the ambulance only after proper instruction on its use in consulting with the medical director equipment and supplies should be durable and standardized we are going to store the equipment and supplies in the ambulance according to how urgently and how often we use it so we're going to place items needed for life-threatening conditions within easy reach sometimes at the head of the stretcher and we're going to place items for cardiac arrest external bleeding and blood pressure monitoring at the sides of the stretcher so cabinets and drawers should be transparent they should have transparent fronts and be labeled um and should open easily and close securely okay and then medical equipment in the preparation preparation phase we're going to have basic supplies personal protective equipment and sharps containers airway and ventilation equipment basic wound supplies care supplies splinting child birth supplies aed patient transfer equipment medications communications and other appropriate supplies then we're going to have airway and ventilation and so we have to have the ops for adults children and infants nps for adults and children and cpap equipment we need to have equipment for advanced airway procedures we need to have a portable artificial vent and then um that needs to operate independently of an oxygen supply we want to have bag valves mask also non-rebreathers nebulizer masks portable and mounted suction units and at least two different types of oxygen supply units so portable and then one installed on board then for cpr equipment we need to have a cpr board mechanical device that could deliver chest compressions we could have that and then of course basic wound care supplies splinting and childbirth and an automatic aed patient transfer equipment and what would be a patient transfer equipment of course is that stretcher um maybe a stair chair a long backboard short backboards and immobilization devices then also medications we're also gonna have a jump kit and so what a jump kit is is it's a five minute kit it includes anything that we might need within the first five minutes with the patient so everything except for the aed of course okay and so including in the preparation phase is also the safety equipment we already talked about the the ppe and then maybe we want to have um equipment for work areas so maybe warning devices or flashers or some type of fire extinguisher maybe a dry chemical extinguisher hard hat or helmets with face shields portable flood lights and flashlights too and these could be in the um outside waterproof compartment then we want to have some type of gps so we need the navigational aids to help us get to the call mdt which are mobile data terminals and then we need to keep detailed street maps or areas in the driver's compartment just in case the electronic equipment goes goes down then extrication equipment so located in the another outside compartment usually outside of the patient compartment and it contains equipment that is needed for simple light extrication even if an extrication or rescue unit is readily available and then of course personnel we want to have our at least one emt in the compartment during transport the prep phase is going to have daily instructions or daily inspections and so these are items included in the ambulance inspection is usually fuel oil transmission levels engine cooling batteries brake fluid engine belts we want to make sure the wheels and the tires are inflated and all interior and exterior lights should work then windshield wiper fluid corn siren air conditioner ability of the doors to open and close communication systems must work it needs to be clean and positioned all the windows and mirrors and then we want to have inspect the cleanliness quality and function of all the medical equipment and then the safety equipment so this is the last uh last different area of the prep phase and we want to review standard traffic safety rules and rags make sure that the safety devices such as seat belts are working properly and then oxygen tanks must be secured while with a fixed clasp okay all equipment in the cab and rear and compartments must be secured appropriately",
        "Dispatch Phase": "so the next phase we're going to talk about dispatch so the second phase we have the prep phase then you have the dispatch phase and this is dispatch must be easily easy to access and in service 24 hours a day the dispatcher should gather the information so the nature of the call the caller's name present location and callback number the exact location and the number of patients and the severity of their conditions and other pertinent info",
        "En Route to the Scene": "and then we're going to have the end route the end route so in route to the scene in many ways the enroute to the scene phase is the most dangerous phase for the emt crashes cause many serious injuries so always fasten seat belts and shoulder harnesses before moving the ambulance review dispatcher information and prepare to assess and care for the patient assign specific duties and scene management tasks and decide which equipment should be taken",
        "Arrival at the Scene": "then the next the next phase is going to be the arrival at the scene if you are the first to arrive on scene you will perform a scene size up and give a brief report of your findings to dispatch use the following guidelines so we're going to look for safety hazards for ourselves the our partner by standards and patient we're going to evaluate the need for additional units or other assistance we're going to determine the mechanism of injury and the nature of illness and we're going to evaluate the need for spinal precautions and we're going to follow standard precautions for mass casualty incidents we need to estimate and communicate the number of patients to the incident commander",
        "Parking and Traffic Control at the Scene": "okay now we're at the scene so once we get to the scene we want to make sure that we're parking safely all right the very first thing is to park we're going to pick a position that will allow for efficient traffic flow and flow around the emergency scene we want to park 100 feet before or past the crash to create a barrier between the emt and traffic do not park alongside the scene you may block the movement of other emergency vehicles park uphill and upwind of the scene with smoke or hazardous materials we want to leave our learning warning lights on or devices and keep a safe distance between your vehicle and the operations at the scene so the figure on this slide shows a safe parking distance for the ambulance okay all right and so we're going to stay away from fires of course hazards down wires and unstable structures we definitely want to set the parking brake but we're going to park as close to the scene as possible to facilitate emergency medical care and rapid transport to the scene if it is necessary to block traffic to unload equipment or load the patient do so quickly and safely and then traffic control only when all the patients have been treated and the emergency situation is under control should you be concerned with restoring the flow of traffic traffic control is intended to ensure an orderly traffic flow warning the other drivers and prevent another crash crash so as soon as possible place warning devices such as reflectors on both sides of the crash",
        "Transfer Phase": "then we have the transfer phase so the patient must be packed for transport and this includes securing the patient to the backboard or scoop stretcher or the wheeled ambulance stretcher we want to properly lift the patient into the patient compartment secure the patient with at least strap three straps to the body and use deceleration or stopping straps over the patient's shoulders especially if the patient is lying flat or secured to a backboard okay so after the transfer phase we have",
        "Transport Phase": "the transport phase and we're going to provide dispatch with the inf with the following information when we're ready to leave with the patient and so we're gonna tell dispatch the number of patients we have in the ambulance the name of where we're going and the beginning mileage of the ambulance and that's some in some jurisdictions because they charge by the mileage we're going to monitor the patient in route we're going to recheck stable patients every 15 minutes and recheck unstable every five contact the receiving facility and let them know we're coming and do not abandon the patient emotionally be aware of the patient's need level of need and use common sense and defensive driving techniques at all times",
        "Delivery Phase": "then we have the delivery phase so we're going to inform dispatch as soon as we arrive at the hospital we're going to report our arrival to the triage nurse or any arriving personnel other arriving personnel at the hospital we're going to physically transfer the patient we're going to present a complete verbal report and we're going to complete a detailed patient report then we're going to restock items that we've used during the call",
        "En Route to the Station": "and route to the station we're going to talk to dispatch let them know that we're coming in service and where we're going as soon as we're back at the station we're going to clean and disaffect the ambulance and equipment if not done already at the hospital and then we're going to restock supplies if not already done at the hospital",
        "Postrun Phase": "and then the post run so the post run phase consists of completing and filing any additional reports and again informed dispatch of your status location and availability and this is the appropriate time to debrief following the call you could also perform routine ambulance inspections and refuel the vehicle and then so let's talk about some key terms and there's a difference between cleaning disinfecting high level disinfecting and sterilization okay so when you clean that's the process of just removing dust dirt blood or visible contaminants from the surface or equipment when you disinfect you're killing the pathogenic agents by directly applying a chemical made for the purpose for that purpose high level disinfection is killing the pathogenic agent by the use of potent means of disinfection and then sterilization this is a process such a uses heat that removes microbial contamination okay so after each call of that post run phase um you're going to strip in all the used linens from the stretcher and place them in plastic bags we're going to discard medical waste of course in appropriate receptacles and then we're going to wash contaminated areas with soap and water we're going to disinfect all non-disposable equipment used for the patient during the call we're going to clean the stretcher with an epa registered germicidal and vurocidal solution or bleach and water at a 1 to 100 dilution we're going to clean spillage or other contamination with the same solution or bleach water solution",
        "Defensive Ambulance Driving Techniques": "okay so let's talk about some defensive ambulance driving techniques so if their ambulance is invited involved in the crash that delays patient care at a minimum and at the worst it may take the lives of the emts or other motorists or pedestrians so you are strongly encouraged to participate in a certified defensive driving program before attempting to operate an emergency vehicle all right so you need to have certain driver characteristics to operate an emergency vehicle so you want physical fitness and alertness and that's very necessary to properly operate an emergency vehicle you should not be driving if you take medications that cause drowsiness or slow your reaction you shouldn't be driving if you're drinking alcohol you shouldn't be driving if you've been working long shifts or multiple consecutive shifts notify your employer if you have worked a shift previously and feel unable to safely operate an emergency vehicle emotional maturity and stability are necessary to operate under stress you cannot drive in a manner that pleases you simply because you have lights and sirens on you must operate the vehicle with due regard for safety and the safety of others and preservation of property so some safe driving practices so all drivers and passengers must wear their seatbelts and shoulder restraints at all times if you remove your seatbelt to provide care fasten it again as soon as possible unrestrained or improperly restrained patients and equipment may become airborne during a collision so become familiar with how your emergency vehicle accelerates corners sways and stops under various conditions in a multi-lane highway stay in the extreme left or fast lane allowing other motorists to move over to the right when they see you or hear you approach so the siren risk benefit analysis so the decision to activate the emergency lights and sirens will depend on several factors and this includes your local protocols patient conditions and the anticipated clinical outcome of the patient so consider the patient's condition before activating the lights because emergency lights and siren noise may increase the patient's anxiety level and then we're going to talk about driver anticipation we want to always assume that motorists around the vehicle have not heard the siren or public address system or or have seen you until proven otherwise by their actions so look at the direction of the other vehicle's front tires to get an early indication of which way they might turn always drive defensively we want to have a cushion of safety so what this means is we want to maintain a safe following distance from the vehicles in front of us and try to avoid being tailgated from behind we want to ensure that the blind spots in their vehicles mirrors do not prevent us from seeing other vehicles or pedestrians on either side of the ambulance to distance yourself from a tailgater slow down or contact police never get out of the ambulance or to confront the driver so there are three blind spots around the ambulance there's going to be a rear view mirror it creates a blind spot in front of the driver the rear of the vehicle cannot be seen fully through the mirror and then there's the sides of the vehicle okay so scan your mirrors frequently for any hazards and use a spotter and pre-determine hand signals when you're back in the ambulance excessive speed is unnecessary dangerous and does not increase the patient's chance of survival it makes it difficult for emts to provide care in the back it hinders the driver's reaction time and it increases the time and distance needed to stop the ambulance and then there's the siren syndrome so this causes the drivers maybe to drive faster in the pre in the presence of siren and that's due to increased anxiety so although a siren signifies a you know a request for the drivers to yield right away it does not mean the drivers are always going to do this all right so then there's vehicle size in in distance okay and so a vehicle's length and width are critical factors when maneuvering driving and parking preventable accidents often occurs when the vehicle is backing up so always use someone outside the ambulance as the ground guide when you're backing up to avoid any incidents vehicle size and weight greatly influence breaking and stopping distances so let's look at this road positioning and cornering road positioning means the position of the vehicle on the roadway on the inside and outside of the paved services okay so to keep the ambulance in the proper lane when turning the corner enter high in the lane to the outside and exit low to the inside weather and road conditions so ambulance have a longer breaking time and stopping distance the weight of the ambulance is unevenly distributed and it makes it for much more prone to roll over so be alert to changing weather and road conditions there's also hydroplaning so at speeds of greater than 30 miles per hour a tire may lift off the road as water piles up under it the vehicle may often feel like it's floating if hydroplaning occurs you should gradually slow down without jamming the brakes on and then there's water on the roadway so what brakes will not slow the vehicle as efficient as efficiently as drive breaks and the vehicle may pull to one side or the other so avoid driving through large puddles of standing water or through moving water then don't forget decrease visibility so in areas where there is a lot of fog or smoke or snow heavy rain just slow down to a soft safe operating speed you always use your headlights watch carefully for stopped or slow-moving vehicles and then icy or slippery surfaces so good all-weather tires and an appropriate speed will reduce traction problems significantly and consider using um snow tires or tire chains if they are permitted by law so that's good let's start talking about",
        "Laws and Regulations": "laws and regulations so although emergency vehicle drivers are exempt exempt from normal operating upper vehicle operations during a call certain laws and regulations must be filed followed so motor vehicle crashes account for a large number of lawsuits against eml per ems personnel and services if you're on an emergency call and you are using your warning lights and sirens you may be allowed to do the following you may be allowed to park or stand in an otherwise illegal location you may be able to proceed through a red light or a stop sign but never without stopping first you may be able to drive faster than the posted speed limit or drive against the flow of traffic on a one-way street or make a turn that isn't normally illegal and you may travel left of center to make an otherwise illegal pass an emergency vehicle is never allowed to pass a school bus though so if the if it is stopped or unloading children and it displays the flashing red lights you have to stop you need to use the use of warning lights and sirens is governed by three principles the unit must be a true on a true emergency call audible and visible warning devices must be used simultaneously unit must be operated with due regard for the safety of others right away privileges okay so state motor vehicle statutes or codes often grant an emergency vehicle the right to disregard the rules of the road when responding to an emergency so in doing so though the operator of the emergency vehicle must not endanger other people or property under any circumstances get to know your local right-of-way privileges and exercise them only when it's absolutely necessary for the patient's well-being you could also have the use of escorts and this uses police escorts to guide only when you're on unfamiliar territory so vehicles use warning lights or sirens should be in different tones or alerts um and if you are being guided follow at a safe distance then intersection hazards so intersection crashes are the most common and usually the most serious type of collision in which ambulances are involved always be alert and careful when approaching approaching intersections if you are on an urgent call and cannot wait for the light to change please come to a complete stop check all other motorists and pedestrians before proceeding and highways so shut down the emergency lights and sirens until you have reached the far left lane when you exit the highway follow the same procedure as when you've entered the highway and then on paid roads you have to take special care and operate the vehicle at a lower speed and maintain a firm grip on the handle on the steering wheel and then school zones so it's unlawful for an emergency vehicle to exceed the speed limit in school zones regardless of the condition of the patient",
        "Distractions": "and distractions so the ambulance is in motion focus the driving on driving and anticipating roadway hazards you want to mine minimize distractions from mobile dispatch terminals or mdt's minimize try and minimize the mounted radio or stereo cell phone or eating or drinking",
        "Driving Alone": "okay and so driving alone so when you're driving alone it's your responsibility to focus on figuring out the safest way of route while mentally preparing for the call such situations demand your complete attention and focus",
        "Fatigue": "understand that there's going to be fatigue you need to recognize when you are fatigued and alert your partner or your supervisor if you are feeling fatigued you should place out a service for the remainder of the shift or until the fatigue has passed and you are capable of operating the vehicle safely",
        "Air Medical Operations": "let's talk about air medical operations next so air ambulances are used to evacuate medical and trauma patients there are two different kinds so fixed wings units are used for inner facility patient transfers or distances greater than 200 to 250 miles an hour then you have rotary wing units these are helicopters and they are efficient for shorter distances specially trained crews accompany air ambulance flights the emt duties are limited to providing ground support so helicopter medical evaluation of evacuation operations so medical evacuation or medvac is performed exclusively by helicopters the capabilities protocols and procedures vary between ems systems when you're calling for a medvac why call for a medvac maybe the transport time to the hospital by ground is too long road traffic or environmental conditions may prohibit the use of a ground ambulance the patient requires advanced care beyond the emt's capabilities and there might be multiple patients who will overwhelm the resources at the hospital reachable by the ground unit so who receives a med vac patients with time dependent injuries or illnesses patient susceptible suspected of a stroke heart attack or spinal injury patients who are found in remote areas trauma patients or candidates for limb replantation a burn center or hyperbaric chamber or maybe a venomous bite center so whom do you call generally the dispatcher should be notified first in some regions ems may be able to communicate with the flight crew after initiating the request we want to establish a landing zone so the safest most effectively effective way to to land and take off is similar to that of fixed wing aircraft landing to at a slight angle allows for safer operations establish a landing zone is the responsibility of the ground ems crew an appropriate site for the landing zone should be a hard or grassy level surface 100 by 100 feet and no less than 60 by 60. you want to clear all loose debris you want it to be cleared of overhead or tall hazards you're going to mark the landing site using weighted cones or emergency vehicle position at the corner of the landing zone with the headlights facing inward to form an x never use caution tape or ask people to mark the spot do not use flares move non-essential persons and vehicles to a safe distance outside the landing zone and communicate the direction of strong wind to the flight crew landing zone safety and patient transfer so stay away from the helicopter and go only when the pilot or crew directs you keep a safe distance from the aircraft whenever it is on the ground or hot and hot means that the helicopter copter blades are spinning still so stay outside the landing zone perimeter unless directed to come by the aircraft or crew member and if you're asked to enter the landing zone stay away from the tail rotor the tips of the blades move so rapidly that they are invisible always approach the helicopter from the front even if it's not running an approach only after the pilot or flight crew member signals it's clear for you to do so enter only in the area between 10 o'clock and 2 o'clock and never duck under the body the tail or the rear section of the helicopter when you approach the aircraft walk in a crutch position so the figure shows the danger zones surrounding a helicopter keep the following guidelines in mind when operating at a landing zone be familiar with your jurisdictions helicopter hand signals do not approach the helicopter unless instructed or accompanied by a flight crew make certain that all patient care equipment and the patient are properly secured some helicopters may load patients from the side whereas others may have rear loading doors smoking open flames and flames are permitted within 50 feet of the aircraft at all times and you want to wear protection eye protection so this figure shows the hand signals used around helicopters",
        "Special Considerations for Helicopter Operations": "so special considerations when it comes to a helicopter so night landings do not shine spotlights flashlights or any lights up in the air to help the pilot they may be temporarily blinded so direct low visib low intensity headlights or lanterns towards the ground at the landing site and illuminate overhead hazards or obstructions if possible so landing on an even ground if the helicopter must land on uneven ground they need to use extra caution the main rotor blade will be closer to the ground on the uphill side okay so approach the aircraft from the downhill side only or directed by the flight crew and medvax at hazmat incident so immediately notify the flight crew of the presence of a hazardous material at the scene we want to consult the flight crew and instant commander about the best approach in the distance from the scene to for the med back the landing zone should be uphill upwind from the hazmat scene and properly decontaminate patients before you load them into the helicopter",
        "Medevac Issues": "then there's some med vac issues so factors that influence the decision to request mad back should include access the severity of the weather okay the most helicopter services are limited to fly below 10 000 feet above sea levels level so med vac helicopters fly between 130 to 150 miles per hour because of the cabin's confined space as us assess the number and size of the patient who can safely transport in that helicopter med evac flights are extremely expensive compared to an ambulance transport all right so this concludes chapter 38 of the transport operations chapter next we're going to go through some of the review questions to see what we learned",
        "Review Questions": "okay so which of the following are examples of standard patient transfer equipment all right so we have the stokes basket we know wheeled we have wheeled stair chair we have wheeled ambulance stretchers hmm long back boards i think it's a stokes basket so stokes baskets are called basket stretchers and that's usually a specialized piece of equipment okay the primary purpose of a jump kit is to and we know this is everything we need within the first five minutes so that's going to be d right so you are dispatched to a call for an unresponsive patient what is the most important information you should obtain from the dispatcher all right so initially we need to know the location of the patient right we need to know how where we're going so yep everything is important but first let's get us to the scene okay when in route took off for a motor vehicle crash the most important safety precaution that you and your partner should take are i think it's probably either seat belt or safety precautions seat belt most important safety precaution you could take which of the following is not a guideline for safe ambulance driving so we're going to use our sirens if you have the yep you want to exercise due regard you want to use one-way streets whenever possible i think that's probably the wrong one c okay at what speed will the ambulance begin the hydroplane if water's in the road we know that this is 30 miles an hour so 30 miles an hour greater we're gonna lose control of that the most common and often most serious ambulance crashes occur we know in the intersections in the intersections yep the recommended dimensions for the helicopter so we know it's a hundred hundred and minimal is sixty by sixty hundred by hundred which of the following statements about helicopters are true all right so the helicopter is considered hot when it's on the ground and the rotors are still going but it is possible that the main rotor blade will dip within four feet of the ground that is true okay upon arrival at the scene where hazmat is involved you should park oh well we know we want to park up wind and we want to be uphill so upwind a okay and that concludes chapter 38 transport operations lecture if you like this uh go ahead and check out some of the other lectures all right thank you"
    },
    {
        "Chapter Introduction": "Introduction and welcome to chapter 41 terrorism response and disaster management of emergency care and transportation of the sick and injured 12th edition after you complete this chapter and the related coursework you will be able to describe what constitutes terrorism and the emt's response to terrorism and you will be able to apply this knowledge additionally you'll be able to demonstrate an understanding of weapons of mass destruction agents and countermeasures as well as a fundamental knowledge of disaster management safety okay so let's get started",
        "Understanding Terrorism": "Introduction it is possible that you may be called on to respond to a terrorist event during your career the question is not will terrorists strike again but rather when and where they will strike you must be mentally and physically prepared for the possibility of a terrorist event it is difficult to plan and anticipate a response to many terrorist events yet there are several key principles that apply to every response so let's start off with what is terrorism terrorist forces have been at work since early civilizations the u.s department of justice defines both international terrorism and domestic terrorism with these points they involve violent acts or acts dangerous to human life that violate federal or state law and they appear to be intended to in intimidate or coerce a civilian population to influence the policy of a government by intimidating or coercion or to affect the conduct of a government by mass destruction assassination or kidnapping one difference between the two is location okay so international terrorism occurs primarily outside the the jurisdiction of the united states and domestic terrorism occurs primarily within the jurisdiction of the united states modern-day terrorism is common in the middle east where terrorist groups frequently attack civilian populations in the united states domestic terrorists have carried out multiple attacks only a small prevent percentage of groups actually turn towards terrorism as a means to achieve their goals so religious excrement extremist groups or doomsday cults are example of terrorism and extremist political groups they include violent supremacy groups and those who seek political religious economic and social freedoms also cyber terrorists and single-issue groups next we're going to talk about active",
        "Active Shooter Events": "Active Shooter Events (1 of 4) shooter events and an alarming new trend in domestic terrorism involves the concept of a lone wolf terrorist attack this has become a frequent threat in the united states the national security critical issue task force defines lone wolf terrorism as the deliberate creation and exploitation of fear through violence or threat of violence by a single actor who pursues political change linked to a formulative ideology whether his own or that of a large organization and who does not receive orders direction or material support from outside sources the motives of a lone wolf terrorists are not always clear attacks may be targeted at schools music festivals or shopping centers and are difficult to predict many lone wolf terrorist attacks involve firearms and not explosives this type of event is classified as an active shooter event these attacks are have prompted discussion of gun laws mental health and education of the public and first responders on how to treat the casualties of active shooter events the hartford consensus recommends that a response plan for active shooter response should include the acronym threat threat stands for the t is threat suppression hemorrhage control is the hr rapid extrication to safety a is assessment by medical providers and finally transport to definitive care ems crews may be equipped with ballistic vests and helmets so that they can potentially be prepared with law enforcement to assist with threat and evacuation of injured people from the active scene a key component to safely uh incorporating ems crews with law enforcement teams who are moving forward into an active shooter scene is interagency training next we're going to talk about weapons of mass destruction so a weapon of mass destruction or a wmd or a weapon of mass casualty a wmc is any agent designed to bring about mass death casualties or massive damage to property and infrastructure such as a bridge of bridges or tunnels airports ores and or seaports we use the acronym be nice or c-b-r-n-e and these are mnemonics to remember the kinds of weapons of mass destruction okay so be nice is biologic nuclear incinerary chemical and explosive and then the c b r and e is chemical biologic radiologic nuclear and explosive to date the preferred weapons of mass destruction for terrorists have been explosives weapons of mass destruction are relatively easy to obtain or create and are specifically geared towards killing large numbers of people chemical terrorism warfare so chemical agents are manufactured substances that can have devastating effects on living organisms they can be produced in liquid powder or vapor form depending on the desired route and of exposure and dissemination technique so these agents consist of the following type so we have first vesicans these are blister agents next are respiratory agents and those are choking agents nerve agents and then metabolic agents so cyanides so let's talk about biologic terrorism and warfare a little bit more so biologic agents are organisms that can cause disease they're generally found in nature for terrorist use however they can be cultivated synthesized and mutated in a laboratory so weaponization of a biologic agent is performed to artificially maximize the target population's exposure to the germ so the primary types are viruses they can be bacteria or toxins next we're going to talk about nuclear or rheologic terrorism so there have",
        "Nuclear and Radiologic Threats": "Weapons of Mass Destruction (56) been only two publicly known incidents involving the use of a nuclear device hiroshima and nagasaki it is possible for a terrorist to secure radioactive material or waste to um use one of these as a an act of terror so these materials are far easier for a determined terrorist to acquire and require less expertise to use they're called dirty bombs and they can be they can cause widespread panic and civil disturbances",
        "EMT Response to Terrorism": "EMT Response to Terrorism (1 of 3) all right so we've talked a little bit about the different types of terrorisms and so now we're going to talk about emt response to this so the basic foundation of patient care remain the same the treatment can and will vary slightly so always remember situational awareness and recognize a terrorist event or indicators so the planning of most acts of terror is covert which means that the public safety community generally has no prior knowledge of the time location or nature of the attack so you must be constantly aware of your surroundings and understand the possible risks for terrorism you must know the current threat level issued by the government through the department of homeland security or dhs on april 2011 the color-coded homeland security advisory system was placed by was replaced by the national terrorism advisory system or ntas this alerts from the ntas contain a summary of the threat and actions that first responders government agencies and the public can take to maintain safety make sure you are aware of the information sent out by that advisory system at the start of your work day so on every call make the following observations and this is what we mean by the situational awareness so what type of call are you responding to where's the location what are the number of patients do you what about the victim statements or any pre-incident indicators all right so when we respond we have to remember scene safety and remember to stage your vehicle a safe distance from this incident we need to wait for law enforcement personnel to advise us if the scene has been secured so if you have any doubt that it may not be safe do not enter the best location for staging is upwind and uphill from the incident remember the following rules so we're going to failure to park your vehicle at a safe location can place you and your partner in danger if your vehicle is blocked by another emergency vehicle or damaged by a secondary device you will be unable to provide victims with transportation or escape yourself all right so let's talk about a secondary device and this is an additional explosive that are set to explode after the initial bomb it's intended primarily to injure those responders and to secure media coverage may include various types of electronic equipment such as cell phones or pagers and so the figure on this slide shows an example of the safely staging an ambulance all right so responder safety or personal protective equipment when we're responding so the best form of protection from a weapons of mass destruction is preventing yourself from even coming in contact with that agent the greatest threats are contamination and cross-contamination so what we want to do is as soon as we realize there's the terrorist attack we need to make those notification procedures we have to notify the dispatcher when we suspect that terrorist attack or weapons of mass destruction and what we're going to tell dispatch is the nature of the event any additional resources that we need and the estimated number of patients the upwind route of approach or an additional or optimal approach it is important to establish a staging area and this is where other units are going to converge train responders and the proper protective equipment are the only people to handle the weapons of mass destruction event okay so keep in mind that there may be more than one event or one device next we need to establish command so as the first provider on scene the emt may need to establish command until additional personnel arrive you and other emts may function as a medical branch triage supervisor treatment supervisor transport supervisor logistics officers or command and general staff and if the incident command system is already in place immediately seek out the medical staging officer to receive your assignment okay so then we need to reassess scene safety we're constantly assessing and reassessing scene safety important component of situational awareness",
        "Chemical Agents": "Chemical Agents (1 of 2) all right so if there's chemical agents such as liquid or gases that are dispersed to kill or injure the characteristics of of an agent can be described as liquid gas or solid material and it could be persistent or non-volatile asian and it can remain on the surface for long periods of time usually longer than 24 hours a non-persistent or volatile agents evaporate quickly when left on the surface in an optimal temperature range okay so persistent stays for longer than 24 hours sometimes and non-persistent agents can evaporate almost immediately so routes of exposure is how is how the agent most effectively enters the body okay so agents with a vapor hazard those are going to enter the body through the respiratory tract in agents with a contact hazard of course you get they give off very little vapor or no vapors and they enter the body through the skin okay next we're going to talk about vesicans so vesicans are blister agents the primary route of exposure of blister agents or vesicans is skin so that's a skin contact however if vesicans are left on the skin or clothing too long they produce vapors that can enter in through the respiratory tract this can cause burn-like blisters to form on the victim's skin and in the respiratory tract and the agents can consist of so we could have sulfur sulfur mustard leucite or phosgene gases the vesican usually can cause the most damage to damp or moist areas of the body such as armpits groin or respiratory tract signs of vesican's exposure on the skin include the following so you're going to have skin irritation burning and reddening immediate intense skin pain formation of large burst blisters or a gray discoloration of the skin swollen and closed or irritated eyes permanent eye injury including blindness and signs and symptoms of vapors if they're inhaled they could cause hoarseness and strider or severe cough or hematosis or severe dipsnia all right so let's go through these vesicans sulfur mustard is a brown yellow oily substance that is generally considered very persistent okay so it stays around a long time as the agent is absorbed into the skin it begins an irreversible process of damage to our cells so this mustard is considered a mutant gin and which means that it mutates it changes and causes the struc changes the structure of cells the patient will experience a progressive redlining of that area which will generally develop large blisters so mustard also attacks vulnerable cells within the bone marrow and depletes the body's ability to reproduce white cells so sulfur mustard vapors can be inhaled creating upper and lower airway compromise okay leucisite and phase gene gas produce blister wounds very similar to those caused by mustard they produce immediate intense pain and discomfort when contact is made the patient may have a gray discoloration at the contaminated site so vesicant treatment so how are we going to treat these um there are no antibodies for mustard or cx exposure so british anti-leucite um is an antidote for agent l ensure that the patient has been decon before you initiate any treatment if agency has been inhaled the patient may require prompt airway support so soon as decon is complete generally burn centers are the best equipped to handle wounds and in subsequent infections from these vesicans all right so pulmonary agents and these are choking agents and gases that can immediately calm or harm a person if when they're exposed to them so this includes chlorine and phosgene and they produce respiratory related symptoms such as dipsnia and tachypnea the role of exposure is through the respiratory tract which makes them an inhalant and a vapor hazard so place inside the lungs they damage the lung tissue and fluid leaks into the lungs pulmonary edema develops and this results in difficulty breathing because of the severely impaired gas exchange right so let's talk about chlorine chlorine was the first chemical agent ever used in warfare it has a distinct odor of bleach and creates a green haze so initially it produces upper airway irritation and a choking sensation the signs and symptoms are shortness of breath tightness in the chest hoarseness and strider and gasps gasping and coughing with serious exposure patients may experience pulmonary edema and complete airway obstruction or even death next we're going to talk about fosgene so phosgene has been produced in chemical warfare and is a product of the combustion such as might be produced in a fire okay so it's a very potent agent that has developed a delayed onset of symptoms usually hours the odor produced by the chemical is similar to that of freshly mown grass or hay all right so fosgene is smell it smells like freshly mown grass or hay okay the chlorine chlorine smells like what did we say chlorine smelt like chlorine smelt like um bleach and it's green haze okay so back to phosgene um the result is that much more of a the gas may enter the body unnoticed okay so initially a mild exposure may include the signs and symptoms of nausea chest tightness severe coughs dipnia on exertion and pulmonary edema may be severe that the patient continues to cough up white or pink tinged fluid okay and so a severe exposure produces large amounts of fluid in the lungs that may that's going to cause the patient to be eventually become hypovolemic and then of course hypotension tensive all right so pulmonary agent treatment that's what we're just been discussing is the pulmonary agent so we're going to remove the patient from that atmosphere and we need to do aggressive management of the abcs okay so do not allow the patient to be active we want them to rest and there are no antidotes to counteract pulmonary agents so primary goals are to perform abc's allow the patient to rest in a position of comfort with the head elevated and initiate proper transport if the patient's condition does not improve with basic airway support we need to consider requesting our advanced life support intercept and continuous positive airway pressure or cpap may benefit some patients others will require advanced airway management",
        "Nerve Agents": "Nerve Agents (1 of 4) all right so now let's talk about nerve agents so nerve agents are among the most deadly chemicals developed and they're classified as weapons of mass destruction they're not readily available to the general public public they're extremely toxic and rapidly fatal with any route of exposure so weapons of mass destruction can cause cardiac arrest within seconds to minutes after exposure a class of chemical agents are organophosphates these are the nerve agents which are found in household bug sprays agricultural pesticides and some industrial chemicals at much higher or lower strengths than a weaponized form so organophosphates what they do is they block an essential enzyme in that nervous system and it causes the body's organs to become over stimulated and burn out and so that what they do so we're going to talk about some of the organophosphates okay so first we have or the g agents and they came from the early nerve agents the g series okay so we have sarin sarin is a gb and is highly volatile it's colorless and odorless okay and basically um the standard measurement that represents the amount that would kill 50 of the population exposed to this level it's about one drop okay so especially dangerous and enclosed environments when it comes into contact with the skin it's quickly absorbed and then evaporates so when it's on the clothing it has the effect of off-gassing right so that was sarin now we have salmon so s-o-m-a-n that's a g agent it's a g-d agent okay and it's twice as persistent as sarin and five times more lethal so som a n someone it has a fruity odor and generally has no color this agent is in contact and an inhalation hazard okay so the next agent we're going to talk about is tubbin so it's a ga agent t-a-b-u-m toubon and it's approximately half as lethal as sarin and 36 times more persistent okay so it stays around a very long time this is another one that has a fruity smell and an appearance similar to sarin it is a contact inhalation hazard next we have a v agent v x is what you'll see how you'll see it written and it's clear oily agent has no color and looks like baby oil it is more than 100 times more lethal than sarin and extremely persistent it is usually absorbed into the skin and the oily residue remains in extremely difficult to decontaminate so this is going to show you guys um the this table shows the slide of um which compares nerve agents and so you could see the names of those agents on the left side and then the comparison of the the different types of special features the onset volatility and the exposures okay",
        "Nerve Agent Symptoms and Treatment": "Nerve Agents (4 of 4) all right so nerve agents are produce similar symptoms but have varying routes of entry so symptoms are described using the military mnemonic sludge m okay or you could use the medical mnemonic dumbbells and that's what we use okay all right and so um basically how you treat these is you're going to use a duo dot auto injector okay and so let's talk a little bit more about what the what these nerve agents do so they cause meiosis and it's most common symptom of a nerve agent exposure and can remain for days and weeks and so what happens is um scenes quickly in vapor exposure and may occur after an isolated skin exposure and so the patient may have some form of exposure to both sometimes so seizures can continue until the patient dies or until treatment is given with an antidote kit and that's that duodo auto injector okay so nerve agent treatments so you can greatly increase the number of chances of survivability by providing o2 and ventilative support so i want to talk about the duode auto injector and what that is it contains 2.1 milligrams of atropine and 600 milligrams of poloxidine chloride and that it's called two pam so 600 milligrams of 2 pam",
        "Metabolic Agents": "Metabolic Agents (1 of 4) all right so now we're going to talk about metabolic agents and these are cyanides cyanides are metabolic agents okay hydrogen cyanide and cyanide chlorine affect the body's ability to use oxygen and so cyanide is a colorless gas with an odor similar to almonds okay so when you see almonds think of cyanide all right so effects of cyanide begin on the cellular level and are very rapidly seen in the organ and system levels they're commonly found in many industrial settings such as gold and silver mining photography and plastic processing and often present in fires associated with textile and plastic factories so in low doses these chemicals are associated with dizziness lightheadedness headache and vomiting okay all right so high doses will produce",
        "High Dose Metabolic Agent Symptoms and Treatment": "Metabolic Agents (4 of 4) symptoms which include shortness of breath respiratory distress to kidney flesh skin and tachycardia alter mental status seizures coma apnea and cardiac arrest so cyanide how do we treat cyanide exposures okay so all the patient's clothes must be removed and this presents off-gassing in the ambulance so we want to decontaminate any patients who may have been exposed to liquid contamination prior to initiating treatment of course we have to support the abcs",
        "Biologic Agents": "Biologic Agents (1 of 2) okay so now we're going to talk about biologic agents okay so biologic agents pose many difficult issues when used as a weapons of mass destruction biologic agents can be almost completely undetectable and most disease causing by these agents will be similar to that of a minor illness so biologic agents are grouped as viruses bacteria and neurotoxins and may be spread in various ways so dissemination is the means by which the terrorists will spread the agent okay so a disease vector is an animal that once infected spreads that disease to another animal how easily the disease can spread from one human to another human it's called communicability communicability in instance when communicability is high such as smallpox the person is considered contagious so incubation is the period of time between the person becoming exposed to the agent and the appearance of the first symptoms all right so the first one we're going to talk about is virus viruses it seems we're living this right now so germs that require a living host to multiply and survive and once in the body the virus invades healthy cells replicates itself and spreads throughout the host so it moves from host to host by direct methods such as respiratory droplets and through vectors and some viral agents do have vaccines however there are not often treatment for viral infections all right and so we're going to talk about smallpox so smallpox is highly contagious all forms of standard precaution must be used to prevent cross-contamination we're going to wear exam gloves hepa filters and eye protection and before the rash and blisters show the illness will start with high fever body aches and headaches and it's easily easy quick way to differentiate between small pox rash and other skin disorders is to observe the size shape and location of these lesions okay so in smallpox all the lesions are going to be identical in their den in their development okay they're small blisters and they begin on the face and extremities and eventually grow towards the chest abdomen that's smallpox the disease is in its most contagious phase when the blisters begin to form here's a table and on this table it shows a list of characteristics of smallpox okay then we have vhf so viral hemorrhagic fevers and this group of diseases causes it's caused by viruses and it includes ebola risk valley murberg and yellow fever viruses among others so it causes the blood in the body to seep out of the tissues and blood vessels eventually the patients will have flu-like symptoms progress to more serious symptoms such as internal and external hemorrhaging all standard precautions must be taken when treating this illness okay so on this table it shows a slide of characteristics of viral hemorrhagic fevers vhf",
        "Bacterial Agents": "Bacteria (4 of 6) and then next we're going to have the bacteria so bacteria they do not require hosts to multiply and live they bacteria are complex and larger and can grow up to 100 times larger than a virus so bacteria infections can be fought with antibiotics but most bacterial infections will generally become flu-like symptoms okay so inhalation or cutaneous anthrax okay so this is caused by deadly bacteria that lays dormant in a spur spore and when exposed to at the optimal temperature and moisture the germ will be released from the spore so the routes of our inhalation cutaneous and gi and the inhalation form or pulmonary anthrax is the deadliest and often persist as a severe cold and then pulmonary and flax is associated with about 90 death rate if it's not treated antibiotics can be used to treat anthrax successfully and a vaccine is available in this table on the slide is going to show you some characteristics of the anthrax right now we have the plague and you have a bubonic plague or mnemonic plague okay so the plagues natural vectors are infected uh usually rodents and fleas and the bubonic plague infects the lymphatic system okay so the patient's lymph nodes become infected and they grow and the glands of the nodes become large and round forming um big huge um large round lymph nodes and if you're untreated the infection may spread through the body leading to sepsis and then death so pneumonic plague though it's a lung infection and so it's also um plague also known as plague pneumonia that results from inhalation of that plague bacteria this form of disease is contagious and has much higher death rate than the bubonic form all right and so this figure slide shows the plague swollen lymph nodes and so that bubo at the lymph under the underarm and then a plague bugo at the lymph node in the neck the table on this slide shows characteristics of the plague okay so botulinum toxin this is the most potent neurotoxin and it's a botulum in which it's produced by bacteria so when introduced into the body this neurotoxin affects the nervous system's ability to function and so the voluntary muscle diminishes as the toxin spreads eventually the toxin causes muscle paralysis leading to respiratory rest okay so this table on the slide lists the characteristics of the botulinum toxin next we have of the neurotoxins is ricin so this is derived from mash that is left from the castor bean okay so it causes pulmonary edema respiratory and circulatory failure which leads to death it's quite stable and extremely toxic by many routes of exposure including inhalation signs and symptoms of rice and ingestion is fever chills headache muscle aches nausea vomiting diarrhea severe abdominal cramping dehydration gastrointestinal bleeding necrosis of the liver spleen kidneys and gi tract so signs and symptoms of rice and inhalation are fever chills nausea local irritation of the eyes nose and throat sweating headache muscle aches productive cough chest pain dips near pulmonary edema severe lung infections cyanosis seizures and respiratory failure okay yikes and this table on the slide lists the characteristics of ricin",
        "Other EMT Roles": "Other EMT Roles (2 of 2) okay so other emt roles so you could be doing syndromic surveillance and so what this is is you might be called to monitor the patients presenting in an emergency department and alternate care facilities you may need to record ems call volume so it may also be for monitoring the use of over-the-counter medicines okay so patients with signs and symptoms that resemble influenza are particularly important quality measurement and dispatch operations need to be aware of the an unusual number of calls from patient and unexplainable symptom clusters coming from the particular region or community so points of disruption disruption this is this strategic national stockpile and they have it's a pod of distribution sorry so an existing facilities that are established in a time of need for mass disrupt distribution of antibiotics antidotes vaccines and other medical and supplies so medications and supplies so these medications can be released in deliveries called pushbacks by the center for disease control and prevention strategic natural stockpile so these push packages have a delivery time of about 12 hours wherever or anywhere in the country so emts amts and paramedics may be called upon to assist in delivery of medications to the public your role may include triage treatment and transport",
        "Radiologic/Nuclear Devices": "Radiologic/Nuclear Devices (1 of 10) all right so what is radiation does anybody know and it's a ionizing radiation is imminent from rays or particles it's in in the form of rays okay so this energy can be found in radioactive material such as rocks or and or metals so radioactive material is any material that emits radiation this material is unstable and it attempts to stabilize itself by changing its structure in a natural process called decay so the energy that is emitted from a strong radiologic source is alpha beta gamma or neutron radiation alpha is the least harmful penetrating type and cannot move through most objects beta radiation is slightly more penetrating than alpha and requires a layer of clothing to stop it then you have gamma rays and they're far faster and stronger than alpha and beta rays these rays can easily penetrate through the human body and require lead or several inches of concrete to prevent penetration and then you have those neutron particles and those are among the most powerful forms of radiation so neutrons easily penetrate through lead and require several feet of concrete to stop them this figure on the slide shows what can deflect the four types of radiation alpha beta gamma neutron okay so sources of this radiological material include and they're generally used for purposes that benefit humankind such as medicine or killing germs or construction and once rheologic material has been used for that purpose the material remaining in the radiologic is waste and so these materials can be found in hospitals healthcare facilities colleges and or universities north power plants or nuclear power plants and chemical and industrial sites all right so rdds these are radiologic dispersal devices and so any container that is designed to disperse radioactive material all right so a dirty bomb carries the potential to injure victims with not only the radioactive material but also the explosion material used to deliver it okay the explosive material and so the destruction capability of a dirty bomb is limited to the explosives that are attached to it so the jury bomb is an ineffective wmd okay all right then you have nuclear energy so artificially made by altering or splitting radioactive atoms they the result is an immense amount of energy that usually takes a form of heat and so nuclear material is used when uh in medicines weapons naval vessels and power plants and nuclear material gives off all forms of radiation including neutrons all right so nuclear weapons keep only the they're kept only in secure facilities around the world the likelihood of a nuclear attack is extremely remote and since the cause of the formal the collapse of the formal soviet union the whereabouts of many small nuclear devices are still unknown though okay so these small suitcase size nuclear weapons are called special atomic demolition mutant muntunes or s-a-d-m sands these are believed to be missing all right so symptomology so patients exposed to known or suspected source of excessive radiation are considered victims of acute radiation toxicity the effect of radiation exposure will vary depending on the amount of radiation and to that person and the rod of entry so radiation can be introduced to the body by all routes of entry as well as through the through the body so irradiation right and so this table on the slide lists the common signs of acute radiation toxicity so how are we going to manage it so being exposed to a radiation source does not make a patient contaminated or radioactive however when the patients have a radioactive radioactive source on their body they are contaminated and must be initially cared for by hazmat responder so once a person is deconned you may be able to treat them and you're going to start with the abcs and treat the patient for any burns or trauma we have to wear appropriate pre-pe and we're going to secure plastic bags with body fluids obtained from the patient place all body fluids and containers and properly dispose of them with other potentially radioactive waste okay protective measures we're gonna um there are no good suits or protective gear designed to completely shield from radiation but the best way to protect yourself from the effects of the radiation is time distance and shielding all right so explosive devices we're going to talk about next and these are incendiary devices and they are weapons used to start fires terrorists use the flamethrowers chemicals multi cocktails and other explosive devices so it's important for you to be able to identify the objects you've become or you and any object you believe is a potential device notify the proper authorities and safely evacuate the area so remember that their possibility of secondary devices when you are responding to the scene all right so mechanisms of injury the type of injury of wounds primarily depend on the patient's distance from the epicenter of the explosion so blast explosions are usually current a number of ways so we have a primary blast and a secondary blast so the primary blast is due solely to the direct effects of the pressure on the body the injury is seen almost exclusive in the hollow organs and then the secondary you have in that persists of non-patented traded injury and it results from being struck by flying debris so objects are propelled by force and blood the blast and strike the victim causing injury and then you have tertiary so we talked about primary secondary blasts now tertiary blast okay and this results from the whole body displacement and the impact with the environment and so other indirect effects include crush injury or because of the collapse of a structure and then we have the quad quadranery blast so the number four blast injury and uh any other injury caused by the blast including toxic inhalation of that gas burns medical emergency sustained while fleeing the scene of an explosion so even metal a mental health disorder that develops immediately after or days to weeks after that definition of the explosive device",
        "Incendiary and Explosive Devices": "Incendiary and Explosive Devices (5 of 6) so what happens with the physics of that explosion all right so when the substance is detonated a solid or liquid uh chemical is converted into large volumes of gas under pressure which results in explosive energy release this generates a pressure wave in the shape of a basically a spherical blast wave and it extends in all directions from the point of explosion so flying debris and high winds commonly cause conventional blunt and penetrating traumas so tissues are at risk when we have these explosive devices and so the hollow organs such as the middle ear or lungs or gi tract are susceptible to pressure changes the junction between these tissues of very different densities and exposed tissues such as head and neck are prone to injury as well so the ear is an organ that is sensory sensitive to blast injuries and the patient may report tingling or pain in the ears or some type of hearing loss primary blast injuries occur as contusions and hemorrhages and solid organs are relatively protected from the shock wave but may be injured by a secondary missile okay and hollow organs may be injured by similarity mechanisms as lung tissue the tqi to large hematomas are the most visible sign and according to the cdc blast lung is the most common cause of death okay so neurologic injuries and head trauma are also common causes of fatal fatality from the blast injury all right so extremity injuries include traumatic amputations are also common and patients may die of massive hemorrhage without the rapid application of a tourniquet",
        "Review and Conclusion": "Review okay so uh that concludes the lecture portion now we're going to do a little bit of review questions okay so let's see how much we've learned what type of terrorist group would most likely bomb an abortion clinic all right so what did we learn we know that this is a domestic terrorist attack and we're going to say it's a single incident terrorist attack okay the term weaponization is defined as right so is it a method is it a period of time is it a cultivation or synthesization of mutant mutation of an agent let's see or the definition of an explosive item what do we think so we're going to say weaponization is a creation of a weapon from a biologic event or agent generally found in the nature that causes disease all right so that was c and that's the correct answer okay the department of homeland security posts a daily advisory system to help the public aware of the current terrorist level so what does orange indicate we didn't really talk much about the colors but let's see what does orange indicate what do you guys think i bet it is it's b so b the orange color indicates a high risk of terrace the red is the highest okay all right so we're dispatch a balm along with 15 other ambulances on arrival where should we stage the ambulance and we know we want to be upwind and uphill right so we always want to be up when oh no downwind we want the hazmat we want to make sure that we're upwind from the and uphill yep up went up hill all right so that is the answer b up went uphill all right a terrorist would most likely use a secondary explosive device why did they use this why would they use this i bet it's to injure the rescuers and to gain that maximum public attention and we were right yep secondary is to get the rescue workers and to get caught on camera all right so when assessing a patient who was exposed to a vesican agent uh oh we should expect to encounter i bet some blistering blistering yep primary exposure route of vesicans also called blister agents is the skin okay all right number seven what does sulfur mustard do to those cells does it make it retain water does it cause it to release does it cause it to mutate or does it cause all the fluids and it causes severe high dehydration what do you guys think and it's c so it also it causes cells to mutate pinpoint pupils vomiting bradycardia and excessive salivation are signs of what do you guys think they're signs of i betcha it is uh the gd nerve agent so this is going to cause death within seconds and it's you could use the pneumonic dumbbells all right you respond to plastic factory where numerous people present with shortness of breath flesh skin and altered mental status one of the patient tells you he smelled almonds uh oh what do we know about almonds right away cyanide right so cyanide is that almond smell very good okay factors that have the greatest impact on the severity of radiation exposure include what do you think i think it's time distance and shielding you think yep the best way to protect yourself is time distance and shielding so we want to reduce the time increase the distance and the shielding okay all right so this concludes chapter 41 lecture if you enjoyed this lecture go ahead and subscribe to the channel and like it and we're going to uh and stand by for multiple more lectures i will be producing the 41 chapters of this book okay all right and thank you"
    },
    {
        "Introduction to Workforce Safety and Wellness": "hello and welcome to chapter 2 workforce safety and wellness of the emergency care and transportation of the sick and injured 12th edition after you complete this chapter and the related coursework you will understand the importance of recognizing important hazards coping with physical and mental stress assisting patients and families with the emotional aspects of injuries illness and or death taking appropriate preventative actions to ensure personal safety dealing with patients and co-workers with sensitivity taking proper precautions when dealing with infectious diseases and preventing on-the-job injuries",
        "Self-Care and Stress Recognition": "okay so to take care of others we must take care of ourselves recognition of hazards to your health safety and well-being is very important this includes personal neglect environmental and human-made threats and mental and physical stress the emotional well-being of an empty and the patient are intertwined especially in high stress rescues health is a complex interaction between physical mental and emotional connections chronic physical mental or emotional stress can worsen or increase the chance for developing health conditions not all reactions though to stress are negative so your stress that creates a positive response this is increased focused increased energy in the short term and increased job satisfaction and self-image in the long term however distress causes a negative stress response wellness is the active pursuit of a good",
        "General Health, Wellness, and Resilience": "state of health resilience is the capacity of an individual to cope with and recover from distress the following practices can help increase resilience you could eat healthy and maintain a well-balanced diet ensure a minimum of seven to nine hours of sleep strengthen positive relationships with close family and friends build relationships with peers and colleagues incorporate daily stretching movement and exercise and build habits of mindfulness and positivity you could strategies to manage stress you could minimize or eliminate stressors as much as possible you could change partners to avoid a negative or hostile personality change work hours or change the work environment and cut back on overtime possibly you could change your attitude about the stressor and talk about your feelings with people you trust you could seek professional counseling if needed do not obsess over frustrating situations that are unable to change such as relapsing alcoholics and nursing home transfers focus on delivering high quality care brian adopt a philosophical outlook you could expand your social support system beyond your co-workers develop friends and interests outside of emergency services and you could limit the intake of caffeine alcohol and tobacco use",
        "Nutrition": "okay so a little bit about nutrition you could eat regular well-balanced meals and limit your consumption of sugar fat sodium and alcohol complex carbohydrates are comparable to simple sugars in their ability to produce energy so complex carbohydrates such as pasta rice and vegetables are among the most reliable sources for long-term energy production fats are easily converted to energy but eating too much fat can lead to obesity cardiac disease and other long-term health problems maintain adequate fluid intake water is generally the best fuel available",
        "Exercise and Relaxation": "exercise and relaxation so regular exercise will enhance the benefits of maintaining good nutrition and adequate hydration when you are in good physical condition you can handle stress more easily engage in at least 30 minutes of moderate or vigorous activity at least five days per week include cardiovascular endurance muscle strength building and muscle flexibility the national sleep foundation and the american academy of sleep medicine recommends that adults sleep a minimum of nine or seven to nine hours half of the ems personnel gets less than six hours of sleep per 24 hours and reports severe mental and physical fatigue short-term effects of sleep deprivation can lead to medical errors vehicle crashes and other harm to patients bystanders and other ems providers long-term effects of hypertension sleep apnea respiratory issues diabetes depression and other medical conditions increased stress can contribute to sleep deprivation and fatigue issues evidence-based guidelines for fatigue management have been developed under the u.s department of transportation and through the national association of state ems officials fatigue sleeplessness should measure and monitor fatigue among ems personnel ems personnel should work shifts shorter than 24 hours ems personnel should have access to caffeine to save or to shave off fatigue ems personnel should have the opportunity to nap while on duty to mitigate fatigue ems personnel should receive education and training to mitigate fatigue and fatigue related risks recommendations to combat fatigue include getting an adequate duration of quality sleep and where allowed take 20 to 30 minute naps or rest breaks during shift work increase physical activity be careful about caffeine consumption engage in mental exercise such as having a conversation or playing a game so we just talked about recommendations for combating fatigue now we're going to discuss recommendations to improve sleep quality so you want to avoid caffeine nicotine and other chemicals that interfere with sleep for at least four hours prior to bedtime ensure your sleep environment is dark quiet and cool exercise early but with enough time to relax before you try and fall asleep you want to nap early and avoid heavy pre-sleep meals and balance fluid intake establish a calming pre-sleep routine sleep when truly tired don't watch the clock and keep your sleep schedule as consistent as possible when possible expose yourself to natural light during your waking hours to maintain healthy sleep wake cycles we're going to talk about disease prevention and health promotion next and so disease prevention focuses on medical care and prevention to avoid or reduce the effect of disease on the individual health promotion is focused on personal practices and social habits to improve one's health smoking vaping or chewing nicotine so tobacco products can lead to cardiovascular and respiratory disease smokeless tobacco is associated with cancers of the throat mouth and pancreas vaping has been shown to cause cardiovascular and respiratory illness and disease strategies for quitting products containing nicotine include to create a plan that addresses the challenges that may trigger the use of these products set a quit date tell a friend family or co-worker your plan to quit remove tobacco and vaping products from your home car at work and talk to your doctor about the other resources that may have maybe able to help you quit alcohol abuse and so acceptable amount of alcohol is described to be one drink per day for women and two for men according to the centers for disease control and prevention the cdc excessive alcohol use causes about 88 000 deaths per year in the united states with an economic cost of more than 200 billion per year approximately 75 percent of total cost of alcohol abuse is contributed to binge drinking so excessive alcohol use may adversely affect the cardiovascular hepatic immune and central nervous systems and may increase the risk of developing cancer of the mouth throat breast esophagus and liver and then there's drug use so both prescription medications and illegal or illicit drugs may be abused or misused according to the cdc drug abuse costs the united states more than 190 billion dollars annually in lost work productivity health care and crime many ems agencies drug test their their employees for illegal and prescription drugs",
        "Balancing Work, Family, and Health": "balancing work family and health when possible rotate your schedule to give yourself time off you need to take vaccinations and if at any point you feel stress of work is more than you can handle seek help",
        "Infectious and Communicable Diseases": "next we're going to talk about infectious and communicable diseases so an infectious disease is caused by organisms within the body and a communicable disease can be spread so a communicable disease can be spread from person to person or from one species to another infection is a risk infection risk can be minimized by immunizations protective techniques and hand washing so next we're going to talk about some terminology that's related to the infectious and communicable diseases okay so a pathogen is the first thing we're going to talk about and a pathogen is a microorganism that is capable of causing disease in the host and then next is contamination so the presence of an infectious organism or foreign body on or within objects such as dressings water food or needles wounds or a patient's body exposure so that's a situation in which a person has had contact with blood body fluids tissues or airborne particles in a manner that may allow disease transmission to occur protective personal protective equipment or ppe protects it's basically a protective equipment that an individual wears to prevent exposure to a pathogen or a hazardous material",
        "Routes of Transmission": "so routes of transmission the different routes of transmission in which an infectious disease can spread are direct contact indirect contact such as a needle stick airborne transmission like for example sneezing food borne transmission and that's contaminated food and vector-borne transmission an example of that would be flea or a mosquito",
        "Risk Reduction and Prevention for Infectious and Communicable Diseases": "so risk reduction and prevention for infectious and communicable diseases the occupational self and health administration so osha develops publishes and enforces guidelines concerning reducing hazards in the workplace all emts are trained in handling blood-borne pathogens the cdc has developed standard precautions for healthcare workers to use in preventing and or in treating patients standard precautions are preventative measures designed to prevent healthcare workers from coming in contact with objects blood body fluids and other potential risks that can lead to exposure of germs the cdc recommends from 2 2016 is to assume that every person is potentially infected or can spread an organism that can be transmitted in a healthcare setting and so apply infection control procedures to reduce the infection osha refers to the same concept as universal precautions so you'll see that used interchangeably notify your designated officer if you were exposed",
        "Donning and Doffing PPE": "donning and doffing full ppe so putting on is dawning and taking off is doffing the full complement of ppe in a consistent sequence is essential to reduce the risk of contamination the most common component of ppe are a mask eyewear or full face shield gloves and a gown proper hand washing that's the simplest yet most effective way to control disease transmission wash hands before and after patient contact even if you wear gloves okay so gloves",
        "Gloves": "very important subject you're going to wear gloves if there's any possibility for exposure to blood or body fluids so vinyl nitrile and latex gloves are effective protection wear heavy duty gloves so when cleaning the ambulance change gloves between patients removing gloves requires a technique to avoid contaminating yourself with the materials on the outside of the gloves",
        "Eye Protection and Face Shields": "all right so next we're going to talk about eye protection and face shields so eye protection prevents or and protects from blood splatters and prescription glasses are not adequate so goggles or a face shield are the best",
        "Gowns": "and then there's gowns so provide protection for extensive blood splatter and they may be worn in situations such as aerosolized generating procedures field delivery of a baby or some type of major trauma",
        "Masks, Respirators, and Barrier Devices": "okay next mask and we're all very familiar with this so mask respiratory respirators and barrier devices so wear a standard surgical mast for fluids batter place a surgical mask on a patient and a particulate air respirator such as an n95 on yourself if you suspect the patient has an airborne or droplets for a disease such as tuberculosis influenza or cova-19 protection protective eyewear using safety glasses with side shields goggles where a full face shield is also needed if the patient needs oxygen place a non-re-breathing mask instead of a surgical mask on the patient and such set the air oxygen flow rate to 10 to 15 liters use of a particulate air respirator must comply with osha guidelines and must be fit tested to ensure their efficiency okay so mouth to mouth or mouth to mass resuscitation is recommended in a situation where there is active community spread of an airborne virus bag valve ventilation is an aerosol generating procedure that should be avoided in epidemic scenarios such as covet 19.",
        "Proper Disposal of Sharps": "so sharp stick sharps disposals and so proper use of and proper disposal helps to avoid exposure uh to hiv and hepatitis do not recap break or bed needles dispose of used sharps items in an approved closed and rigid container",
        "Employer Responsibilities": "so employer responsibilities the risk of being exposed to a communicable disease is a hazard of the job you should follow osha guidelines and other national guidelines and standards to reduce the risk of exposures to airborne pathogens and airborne diseases know your department's infection control plan and follow it cleaning and decontaminating the",
        "Establishing an Infection Control Routine": "ambulance and equipment is important you must clean the ambulance after each one and on a daily basis whenever possible cleaning should be done at the hospital there is more information about cleaning the ambulance in chapter 38 transport operations we're going to remove any medical waste and it should be placed in a red biohazard bag and disposed of at the hospital contaminated equipment left at the hospital should be cleaned by hospital staff or placed in a red bag for transport and cleaning to the station use bleach water solution at a dilution rate of 1 to 10 to clean the unit remove contaminated linen and place it in the appropriate bag for handling reusable equipment should be properly cleaned and sterilized per your department standard operating procedure",
        "Immunity": "and immunity so even if germs reach you you are not necessarily at risk for infection immunity is a major factor in determining which hosts become ill from which germs you can be immune or resistant to particular germs so the definition of immunity is having been immunized immunized or vaccinated and able to recover from an infection or from that germ",
        "Immunizations": "a history of all your childhood infectious diseases should be recorded and kept on file this includes chickenpox mumps measles rubella and whooping cough the cdc recommends the following immunizations for healthcare workers hepatitis b that is required by osha influenza that would be yearly measles mumps and rubella or mmr the varsarella vaccine or having had chickenpox tetanus diphtheria pertussis which is the tdap shot every 10 years and skin tests for tuberculosis prior to higher and annually is recommended",
        "General Postexposure Management": "general post exposure management so if you're exposed to a patient's blood or bodily fluids you need to turn over patient care to another ems provider clean the exposed area with soap and water and if it's in your eyes if they were exposed rinse your eyes for 20 minutes activate your department's infection control plan you will have to complete an exposure report and be screened to determine whether there is a significant exposure to bloodborne pathogen if you were exposed to a highly communicable disease such as covet 19 without proper pve you may be required to quarantine for a predetermined period of time post-exposure prophylactics and treatment for significant exposure okay so now we're going to talk about",
        "Scene Safety": "scene safety the personal safety of all those involved in an emergency situation is very important and it begins with protecting yourself as soon as you get dispatched so you need to wear your seatbelt and don the appropriate ppe continue to protect yourself once on scene and make sure the scene is well marked place warning devices to alert other motorists on scene park at a safe distance from the scene and make sure there are plenty of light if it's dark also wear reflective clothing if it is dark scene hazards so if you're looking at this slide this is the 2020 emergency response guide book and upon arrival you need to look and treat or try and read the labels placards an identification numbers from the distance perhaps with binoculars a specially trained and equipped hazardous material team will be called to the scene to handle disposal of materials or removal of patients do not begin caring for the patients until they have been moved away from the scene and are deconned or the scene is safe for you to enter do not enter the scene unless it's safe to do so the u.s department of transportation erg emergency response guidebook lists common hazard materials and proper procedures for the scent control and emergency care of patients smartphone and tablet apps are also available so there's general guidelines do not enter the scene if there is evidence of a hazmat you need to remain up wind and uphill from that scene keep your distance and quickly contact dispatch and request additional responses so do not enter the scene until instructed by trained hazardous material responders",
        "Scene Hazards: Electricity": "okay so next scene hazard we're going to talk about is electricity dealing with downed power lines is beyond the scope of emt training you need to mark off a danger zone around the down lines until the poles have been secured in this safe safety zone is one span of the power poles distance do not approach a downed wire or touch anything which downed with down wires are in contact with so lightning is a threat in two ways um it you could be it could be a threat because of a direct hit or a ground current a repeat lightning strike in the same area can occur so avoid high ground to minimize risk of a direct lightning strike to avoid being injured by the ground current stay away from drainage stitches moist areas small depressions and wet ropes when lightning is nearby make sure the smallest target possible that you become and drop all equipment okay the next hazard scene hazard we're going to talk about is fire",
        "Scene Hazards: Fire and Vehicle Crashes": "and common hazards include smoke oxygen deficiency high temperatures toxic gases there could be a building collapse because of the fire equipment or explosions next is vehicle crashes so at vehicle crashes they are common events and vehicle collisions hazards include traffic unstable vehicles down power lines risk of violence airbags and fluid and sharp objects so use sufficient proper protective gear to reduce the risk and then there's violence on scenes and this includes assaults hostile situations riots or other disturbances and a scene assessment should begin while you are in route and once on scene continue your assessment using personal observation and information from other responders while maintaining personal safety and the safety of your team okay and then another scene type of violence could be mass violence and with mass violence several agencies may be involved so you need to know who is in command you also have to remain vigilant for potential for violence at all times allow law enforcement to secure the scene before your approach at scenes in ja involving projectiles find protection so two types of protection there's one it's called cover and that's the tactile use of some type of impenetratable barriers for protection then there's concealment and concealment is hiding behind objects to limit the person's ability to see you if you believe the event is a crime scene attempt to maintain the chain of evidence and do not disturb the scene unless it is absolutely necessary for patient treatment violence against responders so the rate of violence related injuries with work loss for emergency responders is 22 times higher than the overall rate for other employees in the united states recommendations for prevention of violence so training and practice in identifying scenes of potential violence you need to get training and practice in de-escalation strategies and techniques practice in ongoing scene assessments and dispatch identification and alerting of past or potential threats of violence recommendations for protection against violence include training and practice in self-defense and escape techniques training and practice in physical and chemical restraint techniques fitting and use of body armor and training and practice in operations with law enforcement",
        "Protective Clothing: Preventing Injury": "protective clothing wearing protective clothing and other appropriate gear is critical to personal safety become familiar with the protective equipment available to you inspect your clothing and wear your gear regularly ideally before you reach the scene types of protective and clothing include cold weather gear and that usually consists of three layers so the first one is a thin inner layer and that pulls moisture away from the skin then there's a thermal middle layer that serves as ice insulation and then finally an outer layer that resists wind rain sleet or snow then the another type of protective clothing is turnout gear and this protects the firefighters from heat fire sparks and flashover it's also called bunker gear okay and then you have gloves they protect from heat cold and cuts they also may reduce dexterity in a rescue situation and then helmets it should be worn anytime you're working in a fall zone helmet should provide top and side protection as well as secure chin strap construction types helmets are not well suited for rescue situations a helmet with a chin strap and face shield should always be worn in situations involving electrical hazards and then there's boots these should be water resistant fit well and be flexible steel-toed boots are preferred and traction is important for rescue situations eye protection includes eye glasses with side shields during routine patient care and when tools are in use use a face shield and goggles then there's ear protection and this could be soft foam industrial type ear plugs skin protection is important so this protects against sunburn during outside work also use of sunscreen with a minimum of 15 spf and then there's body armor and this includes bulletproof vests and it ranges from light weight and flexible to heavy and bulky vests may be practical they may not be practical for everyday use they are costly and do not protect against rifle ammunition or stabbing attacks so long loose hair rings and jewelry many ems services have restricted policies regarding hair rings and jewelry you should tie hair up neatly limit the number of rings worn and wear only a watch on your wrist okay so the next section we're going to start talking about is caring for critically ill and injured patients and so a patient needs to know who you are and what you're doing so let the patient know that you're attending to his or her immediate needs avoid making unprofessional combat comments during resuscitation and treat all patients with dignity and respect techniques for communicating with critical patients include avoid sad and grim comments and these remarks about a patient's condition may increase the patient's anxiety orient the patient so use brief statements orient the patient to his or her surroundings you need to be honest so decide how much information your patient can understand and accept allow the patient to be part of the care being given also allow for hope if there's a slightest chance of hope relating transmit that message to the patient and locate and notify family members so assure the patient that you are that you will take care of notifying the appropriate people critically uh injured children so children should be cared for as any adult would be it's important that you that a relative or responsible adult accompany the child to relieve anxiety and assist in care as appropriate so coping with the death of a child the death of a child is a tragic and dreaded event help the family through the initial period of death and you're going to be helping family members so acknowledge death in a private place shock denial and disbelief are common emotions if circumstances allow let the parents hold the child use your best judgment to determine if this is appropriate let the family's actions be your guide the family may want to see the child and you should allow them to do so so prepare the parents for what they will see do not overload the grieving parents with information",
        "Death and Dying": "okay so death and dying so death is likely to be either quite sudden or after a prolonged terminal illness the emt will sometimes face death the grieving process has stages in the first stages it could be denial anger hostility bargaining depression or acceptance so what can the emt do you can ask the patient and family if there is anything you could do to help reinforce the reality of the situation you need to be honest with the death and dying do not say you know how the patient or family feels let the patient or family members grieve in their own way so this table shows us slides suggesting words of comfort when responding to grief all right so next we're going to talk about some stress management and of course you probably have suspected that ems is a high stress job it's important to know the causes of stress and ways to deal with them so stressors they include emotional physical and environmental situations there are general adapt adaption syndromes and so alarm responds to stress then the reaction and resistance to stress and then there's recovery or exhaustion from that stress physiological manifestations of stress so it creates an increased respirations and heart rate increased blood vessels dilated vessels near the skin surface dilated pupils tense muscles increase blood glucose levels and perspiration it also decreases blood flow to the gastrointestinal tract situations that are stressful for ems providers include the following so you could be in a dangerous situation physical or psychological demands critically ill or injured patients dead or dying patients are overpowering sight smells and sounds multiple patient situations angry or upset patients families are bystanders and unpredictability and demands of ems cause stressful situations",
        "Stress Reactions": "there are stress reactions so there is an acute reaction and that can occur during that event there's a delayed reaction and that manifests after the stressful event and then there's a cumulative stress and that's a prolonged or excessive stress so there's physical symptoms of stress and that can include fatigue changes in appetite gi problems headaches insomnia irritability inability to concentrate or hyperactivity or under activity there's physiological symptoms and that could be fear a dull or non-responsive behavior depression guilt or oversensitivity anger ill irritability and frustration critical incident stress is brought about by acute severe stressors these could include mass casualty incidents serious injury or or traumatic death of a child crashes with injuries caused by an emergency provider while traveling to or from a call and death or serious injury of a co-worker in the line of duty they may develop after a person has experienced a physiological distressing event and so this is post-traumatic stress disorder and it's characterized by re-experiencing the event and over responding to stimuli that you recall from that event critical instant stress management or also called cism is used to help providers relieve stress and this can occur formally or at an ongoing scene trained cism professionals facilitate they facilitate diffusing sessions and they're held during or immediately after the event also debriefing and those sessions are held 24 to 72 hours after the event an important rule is not to turn the debriefing session into an operational critique if cism or critical instant stress management is not an option private counseling by a mental health professional may be preferred",
        "Burnout": "then there's burnout so burnout describes a combination of exhaustion cynicism and related performance resulting from long-term job stress the effects of well-being of an emt along with that of his or her colleagues and patients can result in an increased major medical errors increase rates of health care associated infection and increase patient mortality also contributes to decreases in work morale overall work effort effective teamwork patient satisfaction and an increase in job turnover",
        "Compassion Fatigue": "then there's a thing called compassion fatigue and what happens it's common among healthcare providers it's also known as a secondary stress disorder it's characterized by gradual lessening of compassion over time the symptoms are high absenteeism difficult relationships with colleagues and co-workers inability to work in teams aggressive behavior towards patients strong negative attitudes towards work lack of empathy for patients judgmental attitude towards patients preoccupation with non-work issues while on duty and other symptoms of increased stress",
        "Responder Risk for Suicide": "responder risk for suicide so the re the suicide rate among emergency responders is higher than that of the rest of the population job stress is widely considered to be the largest contributing factor to suicide several organizations and mental health services are available to provide emotional support",
        "Emotional Aspects of Emergency Care": "emotional aspects of emergency care so at times even the most experienced health care provider has difficulty overcoming personal reactions and proceeding without hesitation the struggle to remain calm in the face of horrible circumstances contributes to the emotional stress of the job stressful situations you must exercise extreme professional care in both your words and your actions on scene factors that influence how a patient reacts to stress of an ems incident include a social economic background fear of medical personnel alcohol or substance abuse disorders history of chronic stress mental disorders reaction to medication age nutritional status feelings of guilt past experiences with illness or injury so quickly and calmly assess the actions of the patient family members and bystanders use a professional tone and show courtesy along with sincere concern and efficient action patients must be given the opportunity to express their fears and concerns religious customs or needs of the patient must be respected so some people might have religious convictions that strongly oppose the use of medications blood and blood products report this information to the next level of care in the event of death handle the body with respect and dignity",
        "Workplace Issues: Cultural Diversity and Harassment": "next we're going to talk about workplace issues so cultural diversity on the job you're expected to work alongside co-workers with varying backgrounds attitudes beliefs and values and to accept their differences culture is not restricted to different nationalities you should also consider age sex sexual orientation marital status work experience and education communicate in a way that is sensitive to everyone's need your ultimate goal should be to cultural humility remain curious about others and consistently reflect on their viewpoints with an open mind there's two types of sexual harassment we're going to talk about next and there is the quid pro quo that's when the harasser requests sexual favors in exchange for something else such as a promotion then the next type of harassment is going to be hostile working environment this could be just jokes touching requesting a date or talking about body parts the intent of the harasser does not matter but rather the perception of the act and the impact of the behavior on someone else because emts and other public safety professionals depend on one another for their safety it is especially important for you to develop non-adversarial relationships with co-workers report harassment to your supervisor immediately",
        "Workplace Issues: Substance Abuse and Injury Prevention": "next we're going to talk about a workplace issue which is substance abuse and this increases risk of accidents and tension it causes poor treatment decisions many ems systems now require personnel to undergo periodic random tests for illegal drugs and have for cause testing when it is believed that the individuals are under the influence of alcohol or drugs addicts and alcoholics develop great skills at covering their behavior seek help or find a way to confer confront an addicted coworker allowing substance abuse to go on presents a tremendous hazard to the public employee assistance of programs which is eaps are often available next workplace issue is injury and illness prevention so ems providers visit emergency departments for work related injuries and exposures over 20 000 times each year each program should include interrelated and inter-dependent elements and this is management leadership worker prevention hazard identification and assessment hazard prevention and control education and training and program evaluation and improvement okay so now we are at the review questions for the chapter and i'm just going to go through them with you so the first one number one is a disease that can spread from person to person is known as okay so communicable disease this can spread from one person or a species to another the most effective way of preventing the spread of disease is very simply we're living through it right now and it should be hand washing so according to the cdc the most effective way of preventing the spread is through hand washing two while caring for a trauma patient the emt has blood splash into their eyes this is an example of it's an example of an exposure so an exposure occurs when a person comes in contact director in direct contact with blood or other body fluids protective measures that prevent healthcare workers from coming into contact with germs are referred to as you should know this it's going to be standard precautions so this prevents healthcare workers from coming into contact with germs when is the second stage of response in the stress response known as the general adaption syndrome or what is sorry what is the second stage of response and that is the body typically reacts to stress in three stages there's the alarm response then there's the reaction and then there's the resistance then the recovery okay so a condition characterized by re-experiencing an event and over responding to that stimuli that they recall is called and we should you should know that that is a post-traumatic stress disorder so ptsd it may develop after a person has experienced that distressing event okay blank is the fuel to make the body run and that is the nutritious food i would have said sleep but the physical exertion and stress they require high energy output so c so food food which then which stage of grieving commonly results in blame and that is going to be b so the person may lash out at the emt or blame the emt for the unfortunate event so it's going to be anger and hostility okay now number nine placards are used on and this is the one about the transport so the placards are used on buildings and transport vehicles and it shows you right there so buildings transport vehicles okay the five most common hazards associated with a structural fire include all right so oxygen deficiency we know smoke there are a lot of temperatures gases and building collapse i think it's a all right so that's the five so it's structural fire is smoke oxygen deficiency high temperatures toxic gas and building collapse risk okay and thank you very much for joining us for chapter two um i hope you have a good night"
    },
    {
        "Introduction to Incident Management": "hello and welcome to chapter 40 incident management of the emergency care and transportation of the sick and injured 12th edition after you complete this chapter and the related coursework you will be able to describe and apply in context the national incident management system or nims including describing command and general staff roles additionally you will be able to describe various specialized components of establishing incident command and its inherent responsibilities this chapter also describes the importance of using the instant command system in hazmat incidents and setting up ems branch operations control zones personal protective equipment and triage methods are also discussed okay the most challenging situations you can be called to are disasters and mass casualty incidents or otherwise known as",
        "Mass Casualty Incidents": "mci's the mass casualty incident refers to any call that involves three or more patients or any situation that places such a great demand on available equipment or personnel that the system would require a multi-multi-aid dis response the agreement what a multi-aid response is is an agreement between neighboring ems systems to respond when local resources are insufficient to handle the response these events can be overwhelming because you will find a large number of patients and not enough resources use of the instant command system or ics makes it possible to do the greatest good for the greatest number of people as an emt you will typically be assigned to work within the ems medical branch under ics the national incident management system or nims was developed to promote efficient coordination of emergency incidents at a regional state and national levels so what is the national",
        "National Incident Management System": "incident management system the secretary of homeland security implemented nims in 2004. it provides a framework to enable federal state and local governments as well as the private sector and non-governmental organizations to work together effectively the organizational structure must be flexible enough to be rapidly adapted for use in any situation the nims provide standardization in terminology resource classification personnel training and certification another important feature is the concept of interoperability which refers to the ability of agents agencies in different types or from different jurisdictions to communicate together the ics or instant command system is one component of nims the major nems components are as follows so you have a communication and information management resource management and command management the standard incident command structure are based on three key components okay so you have ics or instant command system multi-agency coordination systems and public information systems",
        "Incident Command System": "okay so the instant command system let's talk about that the incident command system is sometimes referred to as the incident management system the purpose of ics is to ensure responder and public safety to achieve instant management goals to ensure efficient use of resources and communication is the building block of good patient care and so they use common terminology and the use of clear text communications and it helps responders from multiple agencies work effectively together the goal of ics is to make the best use of your resources to manage the environment around the incident and to treat patients during an emergency the ics is designed to control duplication of effort and freelancing one of the organization's principles of ics is limiting the span of control of any one individual okay so organizational levels may include sections branches divisions and groups the figure on this slide illustrates the ics organizational structure okay so the ics rules and responsibilities the general staff includes command finance logistics operation and planning command staff includes a public information officer or pio a safety officer and a liaison officer so let's talk about command the incident commander or ic is in charge of the overall incident large incidents require a multi-agency or multi-jurisdiction response and need to use what's called a unified command a single command system is one in which one person is in charge even if multi agents multiple agencies respond so it is important that emts know who the ic is the instant commander is and how to communicate with the ic and where the command post is located if the incident is very large emts will report to a supervisor who is working under the ic an incident commander or ic may turn over command to someone with more experience in a critical area when an in incident draws to a close there should be termination of command an agency should be demobilized and they should have demobilization procedures to implement as soon as the situation de-escalates or continues or comes to the end finance so let's talk about finance they are responsible for documenting all expenditures at an incident for reimbursement various functions within the finance section are time unit procurement unit compensation or claims unit they could have a cost unit and then the next part is going to be logistics so the logistics section or section chief has responsibility for communications facilities food and water fuel light lighting medical equipment and supplies for patients and emergency responders then there's the operations section at a very larger complex incident the operations section is responsible for managing the tactical operations usually handled by the ic the operations section chief will supervise the people working at the scene of the incident who will be assigned to branches divisions and groups then you have planning so this section solves problems as they arise it obtains data about the problem and it analyzes the previous instant plan it works with who or what is needed to make the new plan work works closely with the operations finance and logistics sections another function is to develop an instant action plan which is the central tool for planning during a response to a disaster emergency it provides clear concise information about the incident activities including objectives tactics and assignments and then finally the command staff the safety officer monitors the scene for conditions and operations that will be present that will present a hazard to responders and patients he or she has the authority to stop an emergency operation whenever a rescuer is in danger a safety officer should remove hazards to ems personnel and patients before the hazards cause an injury the public information officer or pio provides public and media with clear and understandable information the pio must keep the media safe and for becoming part of the incident they may cooperate with pios from other agencies in a joint information center the liaison officer relies information and concerns among the command and general staff and with other agencies okay so communications and informations management communications has historically been the weak point of most major incidents it is recommended that communications be integrated all agencies should be able to communicate quickly and efficiently effortlessly via radios communications allow for accountability throughout the incident as well as instant communication between recipients okay so mobilization and deployment so when the incident has been declared and the need for additional resources has been identified a request is made for additional resources check in at the incident so on arrival at the incident you should check in with the incident commander checking in accomplishes different functions so it allows you to be assigned to a supervisor for job tasking it allows for personnel tracking throughout the incident and it ensures the cost pay and reimbursement can be calculated accurately initial incident briefing so when you report to your supervisor for an initial briefing it will allow you to get the information regarding the incident as well as a specific job function and responsibilities okay so record keeping of the incident if a large piece of equipment becomes inoperable it may be possible for the replacement costs to come from the incident record keeping allows for tracking of time spent on an actual incident for reimbursement purposes so accountability accountability means keeping your supervisor advised of your locations actions and completed tasks this includes advising your supervisor of the tasks that you have been unable to complete and what tools you need to complete them and then instant demobilization so once the incident has been stabilized and all of the hazards mitigated the incident commander will determine which resources are needed or which are not needed and when to begin demobilization this process allows for a prompt return of resources to their parent organizations to be placed back in service",
        "EMS Response Within the Incident Command System": "so let's talk about the ems response within this incident command system first you have to be prepared so preparedness involves the decisions made and basic planning done before the incident occurs sharedness in a given area involves decisions and planning about the most likely natural disasters for the area among other disasters your ems agency should have a written disaster plan that you're required to train and do regularly train to carry out a copy of the disaster plan should be kept in each ems physics vehicle your local ems organization should develop an assistance program for families of ems responders okay so the scene size up sizing up a scene starts with dispatch and when you arrive on scene you will make some initial assessments and some preliminary decisions the size up will be driven by three basic questions and those three are what do i have what do i need and what do i need to do the figure on the slide shows a mobile emergency room all right so establishing command a command should be established by the most senior official notification to other responders should go out and the necessary resources should be requested a command system ensures that resources are effectively and efficiently coordinated command must be established early preferably by the first arriving most experienced public safety official now communications so if possible use face-to-face communications to limit radio traffic if you communicate via radio do not use 10 codes or signals most communication problems should be worked out before the disaster happens by designated channels strictly for command during a disaster communications equipment must be reliable durable and field tested be sure there are backups in place",
        "The Medical Branch of Incident Command": "the medical branch of instant command so let's talk about this and it is commonly known as medical branch of ics okay so the medical branch director will supervise the primary roles of the medical branch triage treatment and transport of injured people the medical branch director will help ensure that the ms units responding to the scene are working with the ics each medical division or group receives a clear assignment before beginning work at the scene responsible or personnel remain at their vehicle in the staging area until they are assigned their duties okay so on the figure on this slide illustrates the component components of the medical branch the triage supervisor ultimately in charge of counting and prioritizing patients ensures that every patient receives an initial assessment of his or her condition one of the most difficult parts of being the triage supervisor is that you must not begin treatment until all patients are triaged and you will or you will compromise your triage efforts then you have the treatment supervisor and this will locate and set up the treatment area with a tier for each priority patient it ensures the secondary triage of patients are performed and the adequate patient care is given and as resources allow and the treatment supervisor assists with moving patients to the transportation area and then we have the transportation supervisor so this person coordinates transportation and distribution of patients to appropriate receiving hospitals and helps to ensure the hospitals do not become overwhelmed by a patient surge documents and tracks the number of transport vehicles patients transported and the facility destination of each patient then you have the staging officer so a staging supervisor is assigned when a mass casualty incident or disaster requires a multi-vehicle or multi-agency response emergency vehicles must have permission from the staging officer or staging supervisor to enter the mass casualty scene and should only drive in the directed area the staging area should be established away from the scene so that the park vehicles are not in the way all right then as part of the medical branch of the instant command you could have physicians on scene and so it makes they make difficult triage decisions they provide secondary triage decisions in the treatment area deciding which priority patients are to be transported first and provide unseen medical direction for emts and they can provide care in the treatment sector as appropriate then you have a rehabilitation supervisor so this person establishes an area that provides protection for responders from the elements of the situation so the rehabilitation area should be located away from the exhaust fumes and crowd and out of view of the scene itself rehabilitation is where a responder's needs for rest food fluids and protection from the elements are met and it monitors responders for signs of stress all right so extrication and special rescue this determines the type of equipment and resources which are needed for the situation the morgue supervisor so they work with area medical examiners coroners disaster mortuary assistance teams and law enforcement agencies to coordinate removal of bodies and body parts the morgue supervisor should attempt to leave dead victims in the location found if possible until their a removal and storage plan can be determined the morgue area should be out of the view of living patients and other responders and it should be secured from the public and mass casualty incidents an emergency situation that involves three or more patients places great demand on the ems system and or has the potential to produce multiple casualties all systems have different protocols for when to declare a mass casualty incident and initiate the ics so as an emt ask yourself the following questions when considering whether the call is a mass casualty incident so how many serious injured or ill can you care for effectively and transport in your ambulance what happens when you have three patients to deal with how long will it take for additional help to arrive and what happens in the number of patients exceeds the number of available ambulances so you and your team cannot treat and transport all of the injured patients at the same time you so at an mci you will often experience an increased demand for equipment and personnel you should never leave the scene with patients if there are still other patients present who are sick or wounded if there are multiple patients and not enough resources to handle them without abandoning victims you should declare an mci request additional resources and initiate ics and triage procedures so let's talk about triage this simply means to short patients based on the severity of their injuries the goal of doing the greatest good for the number greatest number means that triage assessment is brief and that the patient condition categories are basic so you have a primary triage and that's the initial triage done in the field then you have a secondary triage and this is done as patients are brought into this treatment area during primary triage patients are briefly assessed and then identified in the same way such as by attaching a triage tag or triage tape after the primary triage the triage supervisor should communicate with the following information to the medical branch director so he should tell them the number of patients the number of patients in each triage category recommendations for extrication and movement of the patient and resources needed to complete triage and begin movement of patients when the initial triage has been completed secondary triage or some people call it a re-triage allowing for the mt to reassess all remaining patients and to upgrade the triage category if necessary okay so let's talk about the triage categories there are four common triage categories first you have the immediate and that is red then you have delayed that is yellow then you have minor or minimal which is green expectant is black and that means that they're likely to die and then possible additional of an orange tag so that's an immediate category between the red and yellow and a patient could be more appropriately prioritized if treatment or transport of his condition requires a specific destination that was not a trauma center okay so the table on the slide defines the four categories of triage okay so triage tags tagging patients early assist in tracking them and can keep the accurate record of their condition so triage tags should be waterproof and easily read the patient tags or tape should be color coded and should clearly show the category for the patient the tags will become part of the medical patient's record and however labeling system is used or whatever labeling system it is imperative for the transport officer to be able to identify which patient was transported by which unit and to which destination and the priority of the patient's condition so let's start with let's start talking about start triage and this is one of the easiest methods of triage it stands for simple triage and rapid treatment it uses a limited assessment of the patient's ability to walk respiratory status hemodynamic status or pulse and neurologic status the first step is performed on arrival at the scene by calling out to all the patients at the disaster study and and then directing them to an easily identified landmark the injured persons in this group are the walking wounded and those are considered green or third priority patients the second step is directed towards non-walking patients we want to move the first non-ambulatory patient and assess the respiratory status if the patient is not breathing then open the airway by using a simple maneuver okay a patient who is still does not begin to breathe is triage as expectant and this is black if the patient begins to breathe tag him or her as an immediate place the patient in the recovery position and move to the next patient if the patient is breathing make a quick estimation of the respiratory rate okay a patient breathing faster than 30 minutes breaths a minute or less than 10 is triaged as immediate okay if the patient is breathing from between 10 and 29 breaths a minute move to the next step all right so we're just moving right along the next step is to assess the hemodynamic status of the patient by checking for bilateral radial pulses an absent pulse implies the patient is likely hypotensive so tag him or her as an immediate priority the final assessment is to assess the patient's neurologic status by assessing the patient's ability to follow simple commands a patient who is unconscious or cannot follow simple commands is an immediate priority okay so we're going to talk about jump start patients next and so we use start triage for the adults and we're going to use jumpstart triage for the pediatric patients and this is intended for use in children younger than one year or who appear to weigh less than 100 pounds okay so it begins by identifying the walking wounded just as the adults infants and children not developed enough to walk though or follow commands including children with special needs should be taken as soon as possible to the treatment sector for immediate secondary triage there are several differences within the respiratory status assessment compared to start okay so if you find a pediatric patient who's not breathing we're going to immediately check for a pulse of course if there's no pulse label the patient as expected or black if the patient is not breathing but has a pulse open the airway with the manual maneuver if the patient does not begin to breathe we're giving them five rescue breaths and check respirations again a child who does not begin to breathe should be labeled as expected the most common cause of a cardiac arrest in children is respiratory rest so the next step is to assess the appropriate rate of respirations the next assessment is the hemodynamic status of the patient so we're going to assess the pulse and to what you're going to do is feel the most competent and comfortable checking okay so if there's absence of the distal pulse label the child as immediate priority and move to the next patient the final assessment for neurologic stats so it's a modified avpoo and a child who's unresponsive or responds to pain by posturing or with incomprehensible sounds or is unable to localize pain is tagged as immediate so triage special considerations patients who are hysterical and disruptive to rescue efforts may need to be handled as immediate priority and transport off the site even if they are not seriously injured a responder who becomes sick or injured during the rescue effort should be handled as an immediate priority and be transported offsite as soon as possible hazardous materials or hazmat and weapons of mass destruction incident forced the hazmat team to identify patients as contaminated or decontaminated before the triage process begins all right so destination days decisions so let's talk about this all patients triaged as immediate or delayed so red or yellow should preferably be transported by ground ambulance or air ambulance if available in extremely large situations a bus may transport the walking wounded immediate priority patients should be transported two at a time until all are transported from the site then patients in the delayed category couldn't be transported two or three at a time until all are transported finally the walk and wounded are transported expecting patients who are still alive would receive treatment and transport at this time dead victims are handled and transported according to the standard operating procedure for the area early notification and re of receiving facilities will allow the hospitals to increase staffing and move patients within their facility as required okay so let's talk about disaster management a disaster is a widespread event that disrupts functions and resources of the community and threatens lives of property many disasters may not involve personal injuries on the other hand many disasters such as floods fires and hurricanes will result in widespread injuries unlike an mci which generally lasts no longer than a few hours emergency responders will generally be on scene of an astro natural disaster for days to weeks and sometimes months so only elected official can declare a disaster your role in a disaster is to respond when requested and to report to the incident command for assigned tasks in a disaster with an overwhelming majority of casualties area hospitals may decide they cannot treat all the patients in their facility they may mobilize medical and nursing teams with equipment so using the facility such as a warehouse near the disaster scene will they will set up a casualty collection area so they'll perform triage provide medical care transportations to the hospital on a priority basis if a casualty collection area is established it will be coordinated through the instant command in the time same way as all other branches and areas of the operation so let's talk about some hazmat so a little bit of an introduction when you arrive at a possible hazardous or hazmat incident you must first step back and assess the situation rushing into an unsafe scene can have catastrophic results so if overcome you will be able uh if overcome you will be unable to assist patients because of the unique aspects of responding to and working at hazmat incident osha has published a set of guidelines known as hazardous waste operational operations and emergency response it's called hazwoper standard okay first responders at an awareness level should have sufficient training and expert experience to demonstrate the following competencies an understanding of what hazardous substances are and the risk associated with them and an understanding of the potential outcomes of an incident the ability to recognize the presence of a hazmat or hazardous substance the ability to identify the hazardous substance if possible the understanding of the role of the first responder awareness individual in the emergency response plan and the ability to determine the need for additional resources and to notify the communication center",
        "Recognizing a Hazardous Material": "okay so recognizing the hazardous material a hazardous material is any material that poses an unreasonable risk of danger or injury to persons property or the environment if it is not properly controlled during handling storage manufacture processing packaging use and disposal and transportation train yourself to take the time to look at the whole scene so that you can identify the critical visual indicators and fit into what is known as about the problem hazardous materials may be involved in any of the following situations so you could have like a truck or train crash in which the substance is leaking from the truck or the train or the railroad tank car leak or fire or any emergency that added industrial plant refinery or a complex where chemicals or explosives are produced used or stored and leak or rupture of an underground natural gas pipe you could also have a degradation of underground fuel tanks and seepage of the oil or gasoline into the surrounding ground buildup of methane or other by-products of waste decomposition in sewers or sewage processing plants or a motor vehicle crash resulting in ruptured gas tanks it is important to approach the scene from a safe location and direction the traditional rules of staying uphill and upwind are a good place to start so use binoculars and view the scene from a safe distance if possible be sure to question anyone involved in the incident the figure on this slide shows two examples examples of a hazardous materials incident so occupancy and location okay so let's talk about this a wide variety of chemicals are stored in a wide range of occupancies and locations the location and type of the building are two good indicators of the possible presence of a hazardous material senses the senses can be safe can be safely used are the sight in sound okay so using any of the other senses that brought you in proximity to a chemical should be done with caution or avoided clues that are seen and heard from a distance may enable you to take precautionary steps",
        "Containers and Storage": "so containers a container is a vessel or receptacle that holds the material often the container type size and material of construction provide important clues about the nature of the substance do not though rely solely on the type of container when making a determination of a hazmat incident hazmat incident so one way to distinguish containers is to divide them into two categories based on their capacity so you could have bulk or non-bulk storage containers container volume so a bulk storage container could be a fixed tank a highway cargo tank railroad tank cars totes intermodular tanks in general bulk storage containers are found in buildings that rely on and need to store large quantities of a particular chemical often these bulk storage containers are surrounded by a secondary containment system to help you control if an accidental release happens secondary containments is an engineered method to control a spill or release products if the main containment vessel fails so a large volume horizontal tanks are also common totes have the capacities ranging from about 119 gallons to 703 gallons they can contain any type of chemical including flammable liquids corrosives food grade liquids or oxidizers shipping and storing totes can be hazardous because they have no secondary containment system and on the figure on this slide shows totes all right so then intermodular tanks are both shipping and storage vessels and they could hold between 5 000 to 6 000 gallons of a product and can be pressurized or non-pressurized so the figure on this slide shows one of those interim module or tanks okay and then you have non-bulk storage vessels so all types of containers other than bulk are considered non-bulk they hold commonly used commercial and industrial chemicals such as solvents industrial cleaners and compounds drums are easily recognizable and they're barrel shaped containers bags are commonly used to store solids and powders an example of this would be like pesticides bags and it when those when you have a pesticide bag it must be labeled with specific information okay then you have carboys and those are used to transport and store corrosives and other types of chemicals the figure on this slide shows a carboy okay an uninsulated compressed gas cylinders are used to store substances such as nitrogen argon heligen helium and oxygen",
        "Department of Transportation Marking System": "the department of transportation or dot marking system so let's talk about this you have labels placards and other markings and they're used on buildings packages boxes and containers marking systems such as the presence of a hazardous material from a safe distance and provide clues about the substance the figure on this slide shows examples of labels plaque cards and markings placards are diamond shape indicators that are placed on all four sides of the highway transport vehicle railroad tank cars and other forms of transportation carrying hazardous materials labels are smaller versions of placards and they're placed on all four sides of the individual boxes and smaller packages being transported so the figure on the slide shows examples of placards",
        "Other Considerations": "now let's talk about some other considerations the dot system does not require that all chemical shipments be marked with placards or labels in most cases cases the package or cargo tank must contain a certain amount of hazardous material before a placard is required the kersham commercial package delivery services often carry small amounts of hazardous materials that fall below that weight limit the vehicle's exterior will not display placards to warn of dangers so some chemicals are so hazardous that shipping any amount of them requires the use of labels placards as such and they are explosives poisonous gases water reactive solids high level radioactive substances okay okay so let's talk about the erg and this is a reference it's called the emergency response guidebook what it does is it offers a certain amount of guidance for responders operating as a hazmat site it's updated every three or four years it provides information on approximately 4 000 chemicals then there's the material safety data sheets or msds it's a common source of information about a particular chemical it provides basic information about the chemical makeup of the substance the potential hazards if present the appropriate first aid in the event of an exposure other pertinent data for safe handling of the material all facilities that use or store chemicals are required by law to have an msds on file for each chemical stored at the facility and then there's shipping papers okay so they are required whenever materials are transported from one place to another includes the names and addresses of the shipper and the receiver identify the material being shipped and specify the quantity and weight of each part of the shipment shipping papers from road and highway transportations are called bills of lady or frequent bills freight bills and are located in the cab of the vessel or vehicle then you have chemtrack let's talk about chemtrac so chemtract is operated by the american chemistry council it provides invaluable technical information for first responders of first responders of all disciplines who are called upon to respond to a chemical incident when you call chemtruck be sure to have the following basic information ready the name of the chemical the name of the caller and callback telephone number the location of the actual incident problem the shipper manufacturer of the chemical container type rail car or vehicle markings or numbers the shipping carrier's name the recipient of the material and the local conditions an exact description of the situation identification so let's talk about",
        "Identification": "identification so despite the availability of resources identification can still be difficult little consistency is used on labels and",
        "Identification Challenges": "placards and dishonest transporters sometimes will not label containers or vessels appropriately okay so always maintain a high index of suspicion when approaching a scene of a truck or train tanker accident in the event of a spoiler leak a hazardous incident is often indicated by the president's presence of the following so if you can see a visible cloud or strange looking smoke from escaping substance a leaker spill from the tank container truck or railroad car with or without hazmat placards or labels or an unusual strong harsh odor in the area could be an indicator a large number of hazardous gases or fluids are essentially odorless even when the they leak or spill has occurred so if you approach the scene where more than one person has collapsed or is unconscious in respiratory distress you should assume that there has been a hazmat leak or spill and that the uh the scene is unsafe okay the safety of you and your team and the other responders and the public must be your first priority and concern if you approach any sign suggests that the hazmat incident has occurred you should stop at a safe distance and park upwind and uphill from the incident after rapidly sizing up the scene call for hazmat if you do not recognize that danger until you are too close immediately leave the danger zone try to rapidly assess the situation and provide as much information as possible when calling the hazmat team do not re-enter the scene and do not leave the area until you have been cleared by the hazmat team do not allow citizens to enter the scene if possible and avoid all contact with material hazmat scene operations so focus your",
        "Hazmat Scene Operations": "efforts on activities that will ensure the safety and survival of the greatest number of people use ambulances public address systems to alert individuals near the scene and direct them to move to a safer area you want to establish a control zone so control zones are established at a hazmat incident based on the following so if you have a chemical or physical properties of the release material environmental factors at the time of the release and general layer layout of the scene so securing access to the incident helps ensure that no one will accidentally enter the contaminated area if the incident takes place inside a structure the best place to control access is at the normal points of in egress and ingress doors if the incident occurs outside control intersections on and off ramps perhaps service roads and other access routes to that scene all right so control zones may expand or contract as needed the hot zone is the area immediately surrounding the release which is also the most contaminated area all personnel and equipment must be decontaminated when they leave this hot zone the warm zone is where personnel and equipment transition into and out of the hot zone the decontamination area is set up in the warm zone the cold zone is the safe area where personnel do not need to wear any special protective clothing for safe operation personnel staging the command post ems providers and the other area for medical monitoring support and treatment after decon are all located in the cold zone so your role of an as an emt your job is to report to a designated area outside with hot and warm zones and you're going to provide triage treatment transport and rehabilitation classification of hazmat materials so nfpa or the national fire protection association 704 hazardous materials classification standard classifies hazmat materials according to and there's four ways so health hazard or toxicity level fire hazard chemical reactive hazard and special hazards toxicity levels measure the health that the substance health risk that the substance poses to someone who's come into contact with it the higher the number the greater the toxicity okay so you have zero and that would cause little if any health problem you have one and that would cause some irritation but contact uh but only mild two includes material that would cause temporary damage three involves materials that are extremely hazardous and four involves materials that are so hazardous that minimal contact will cause death all health hazard levels with the exception of a zero require special training in respiratory and chemical protective gear that is not standard on most ambulances the table on this slide lists the toxicology toxicity levels of a hazmat incident personal protective level so let's talk a little bit about that and the",
        "Personal Protective Equipment Levels": "equipment levels indicate the amount and type of protective gear that you will need to prevent injury from a particular substance level a that's the most hazardous that requires fully encapsulated chemical resistant protective clothing that provides full body protection as well as an scba and special sealed equipment level b it requires non-capsulated protective clothing or clothing that is designated to protect against a particular hazard also eye protection and breathing devices that contain your air or supply such as an scba that's a level b then level c like level b it requires the use of non-permeable clothing and",
        "Personal Protective Equipment Levels Continued": "eye protection in addition face masks with the filter uh in that filter inhaled air must be used then level d that's your work uniform such as coveralls it provides provides minimal protection all levels of protection require the use of gloves and two pairs of rubber gloves are needed for protection in case one pair must be removed before the heavy contamination or because of heavy contamination the figure on this slide shows all four levels so you have a b c and then d",
        "Caring for Patients at Hazmat Incidents": "so caring for patients at hazmat incident all right so it is practical only to provide the simplest assessment in essential care in a hazardous zone right before they are deconned because there's dangers time restraints and then bulky protective gear that team members wear to avoid entrapment and spread of contaminants no bandages or splints are applied okay except for the pressure dressings that are needed to control bleeding so the emt providing care in the treatment area should assess and treat the patient in the same way that they would any other patient who has been previously assessed and treated your care of the patients at a hazmat incident must address the following two issues so first any trauma that has resulted from another related mechanism such as a vehicle collision fire or explosion and the injury and harm that has resulted from that exposure to the toxic hazardous substance most serious injuries and deaths from hazardous materials result from airway breathing problems if the patient appears to be in distress give them oxygen at 12 to 15 liters via non-rebreather and then assist ventilations if needed with a back valve mask and high flow oxygen treat the patient's injuries in the same way that you would treat any injury your treatment for the patients exposure to the toxic substance should focus mainly on supportive care and initiating transport to the hospital it may be necessary to simply cut away all the patient's clothing and do a rapid rinse to remove the majority of the contaminating matter before before transport you will need to increase the amount of protective clothing you wear and you want to wear an scba two pairs of gloves goggles or face shield a protective coat respiratory depression and disposable fluid impervious apron or some type of similar outfit to make decontaminating the ambulance easier tape the cap cabinet door shut any equipment kits monitors and other items that will be used in round should be removed from the patient compartment in place in the front of the ambulance or on the side compartments before loading the patient turn the power vent ceiling fan on and patient compartment air conditioning unit fan okay so when you leave the scene inform the hospital that you're transporting a critically injured patient who has not been fully deconned you need to let them know",
        "Review and Conclusion": "okay so that concludes chapter 40 of the incident management lecture so let's see what we have learned okay so what is the purpose of an instant command system so we want to make the safety we want to achieve goals and we want to ensure effect efficient use of resources so d all of the above okay so upon arriving at a scene in which the instant command system is being activated you should um expect to let's see we know we want to talk to ic or report to ic but we should expect to be passed from sector to sector as needed in between assignments okay when ems responds to a disaster as part of their response with the ics ems would start with the scene size of what is the next step for the first responding units okay so we need to probably establish command i think that's probably the next yep so we arrive we look around we establish command okay which of the following best describes a mass casualty incident okay so right away looking at all four of these i think the best answer is when the patient count exhausts the resources available yeah that's exactly what it is which of the following patients would have the highest priority treatment okay so right away i'm going to look at that we have an unconscious snoring respiration severe burns we have a pulses okay full cardiac arrest those are those are expectant expectant and then 32 open head exposed brain matter no carotid pulse so b c and d those are all expectants right so the one that we're going to go to is a how does a disaster differ from an ass match casualty incident okay so disasters may not involve personal injuries as a disaster you must may be on yet and only elected officials can declare yep so we know it's d all of the above a large tanker truck has overturned on the highway when we arrive we see clear liquid leaking from the rear the driver appears to be unconscious is still in the vehicle and is bleeding heavily what should we do so we want to fully assess the situation and request the appropriate assistance yeah we do not want to make ourselves part of the problem which of the following situations most likely involves a hazardous material milk a tractor-trailer rig that is emitting a cloud moving van that collided with head-on with a small car or a pickup truck from a gas company that struck a tree i think that they want you to do b because that's that spill or leak right a visible cloud so visible cloud is the answer when dealing with the hazardous materials incident you should set up your decontamination area so decon is going to be in that warm zone right okay so the decon should be set up in the hazardous zone in the treatment area this way patients cannot bring any hazardous materials into the treatment area and decon so see see between the hazardous zone and the treatment area it's usually the warm zone right okay which toxicity level would you assign a hazardous material spill that could cause a person temporary damage or residual injury unless prompt medical treatment is given which one do we think that is okay be level two so level two is the correct answer and thank you once again for joining me for chapter 40 instant management lecture if you like this lecture go ahead and subscribe to the channel because we're going to complete the whole books of lectures okay so all 41. thank you for joining us and have a great night"
    },
    {
        "Introduction to Medical, Legal, and Ethical Issues": "hello and welcome to chapter three medical legal and ethical issues of the emergency care and transportation of the sick and injured 12th edition after you complete this chapter in the",
        "National EMS Education Standard Competencies": "related coursework you will understand the ethical responsibilities and medical legal directives and guidelines pertinent to an emt the mt approach to patient care relating to confidentiality consent to treat refusal of care and advance directives are going to be explained organ donor systems and policies evidence preservation and end of life issues are also discussed",
        "Principle of Emergency Care": "all right so let's get started the basic principle of emergency care is to do no further harm so a health care provider usually avoids legal exposure if he or she acts in good faith and according to an appropriate standard of care so even when emergency medical care is properly rendered though sometimes you may be sued by a patient seeking monetary compensation so let's talk about consent first consent is permission to render care and if a person a person must give you consent for treatment if the patient is conscious and rational and capable of making informed decisions he or she has the legal right to refuse care the foundation of consent is decision making capacity so what this means is the patient can understand and process the information provided and the patient can make an informed choice regarding medical care so patient autonomy is the patient's right to make decisions about his or her own health so in determining a patient's decision-making capacity consider these factors so is the patient intellectual capacity impaired by mental limitation or dementia and is the patient of legal age so usually it's 18 years in most states is the patient impaired by alcohol drugs serious injury or illness and does the patient appear to be experiencing significant pain does the patient have a significant injury that could distract him or her from a more serious injury and are there any apparent hearing or visual vision problems is there a language barrier or does the patient appear to understand what you're saying does the patient ask rational decisions that demonstrate an understanding of the information you are trying to share",
        "Expressed Consent": "next we're going to talk about express consent and so with express consent the patient acknowledges he or she wants you to provide care and transport to be valid the consent that the patient provides must be informed consent which means that you explain the nature of the treatment being offered along with the potential rests benefits and alternatives to treatment as well as the potential consequences of refusing care",
        "Implied Consent": "next we're going to talk about implied consent so implied consent applies to patients who are unconscious or otherwise incapable of making a rational informed decision about care and so on this slide you'll see figure 3-1 when a serious threat to life exists and the patient is unconscious or otherwise unable to give consent the law assumes that the patient would give consent to care and transport to the hospital this is implied consent okay implied consent like i said only when a serious medical condition exists and should never be used unless there is a threat of life or limb so the principle of applied consent is known as the emergency doctrine it is a good idea to try and get some consent from a spouse or spouse or relative before treating a patient based on implied consent",
        "Involuntary Consent": "all right and then there's involuntary consent so involuntary consent applies to patients who are mentally ill in a behavioral crisis or developmentally delayed and so obtain consent from the garden guardian or conservator it is not always possible to obtain consent so understand your local provisions for example many states have protective custody statutes that allow such a person to be taken under law enforcement authority to medical facility",
        "Minors and Consent": "and then when we talk about consent there's minors okay so we need to discuss that so the parent or legal guardian usually gives consent all right in some states though a minor can give consent um with these following cases so it could be an emancipated minor and this means a person who is under the legal age in a given state but otherwise uh because of other circumstances is legally considered an adult many states consider minors to be emancipated if they are married or if they are a member of the armed surface services or if they are parents themselves also school teachers and school officials officials may act in place of the parents and provide consent for treatment to injuries that occur in a school or camp setting if a true emergency exists and no consent is available the consent to treat the minor is implied just as it is with an adult",
        "Forcible Restraint": "and then you have forcible restraint so this is necessary for patients who are in need of medical treatment and transportation but are combative and present a risk of danger to themselves or others so forcible restraint is legally permissible and if the consult medical control for authorization and utilize law enforcement on the scene restrained without legal authority exposes you to potential civil and criminal penalties once applied do not remove restraints and route unless they pose a risk to the patient also consider calling als advanced life support backup to provide chemical pharmacologic restraint okay so we've talked about the different types of consents and now we're going to talk about the right to refuse treatment so adults who are conscious alert and appear to have decision making capacity have the right to refuse treatment even if the result is death or serious injury they can withdraw that from treatment at any time even if the result is death or serious understand though that calls involving refusal treatment are commonly litigated in the ems and require you to proceed very cautiously involve online medical control and document this consultation a patient parent or caregiver decision to accept or refuse treatment should be based on information that you provide your assessment of what might be wrong a description of the treatment you feel is necessary any possible risks of treatment the ability of alternative treatments and the possibility of consequences of refusing treatment so when treatment is refused you must assess the patient's ability to make an informed decision ask and repeat questions assess the patient's answers observe the patient's behavior if the patient appears to be confused or delusional you cannot assume that the decision to refuse is an informed refusal",
        "The Right to Refuse Treatment": "when in doubt providing treatment is much more defensible position than failing to treat the patient do not endanger yourself to provide care though use the assistance of law enforcement to ensure your own safety before leaving the scene where a patient parent or caregiver has refused care you should gain you should again encourage the patient parent or caregiver to permit treatment and to call for an ambulance if he or she has changed their mind or if the condition worsens worsen so advise patients parents and caregivers that they can call 9-1-1 back if they change their mind advise the patient parent or caregiver to contact his or her own physician as soon as possible ask the patient parent or caregiver to sign a refusal of treatment form and a witness should be present thoroughly document all refusals all right so we've talked about refusals",
        "Confidentiality": "and now we're moving into confidentiality so communication between you and the patient is considered confidential confidential information includes a patient's history assessment findings and the treatments provided if you inappropriately release this information you may be liable for breach of confidentiality which is disclosure of information without proper authorization so in most states records may be released only if the patient signs a release if a legal subpoena is present or if they need are needed by billing personnel okay so let's talk about hipaa and hipaa is the health insurance portability and accountability act of 1996. hipaa contains a section on patient privacy that strengthened privacy laws and so hipaa provides guidance on which types of information are protected the responsibility of health care providers regarding that protection and penalties for breaching that protection so hipaa considers all patient information you obtain in the course of providing medical treatment to the patient to be protected information so this is phi protected health information phi includes medical information and any information that can be used to identify that patient a failure to abide by the provisions of hipaa's laws can result in civil or criminal action against you in your agency the general public is often permitted by law to record identifying and protected patient information and images all right so of course next let's talk about social media and unless you are operating as an official spokesperson from your agency avoid logos uniforms vehicles and other markings that associate you with your agency while off duty conduct yourself with the same professionalism that you would while on duty respect your patients their friends and families bystanders colleagues and other organizations for which you work for in person and online recognize that free speech does not mean everyone has a right to say anything under any circumstances and without repercussions",
        "Advance Directives": "all right so now let's talk about some different directives and we'll talk about advanced directives next so you may respond to a call where a patient is dying from an illness and a do not resuscitate order dnr gives permission to withhold resuscitation do not resuscitate does not mean do not treat though even in the presence of a duet dnr you are obligated to provide supportive measures and so some of the supportive measures might include oxygen or pain relief and comfort to the patient who is not in cardiac arrest whenever possible each ambulance service should have a protocol to follow in these circumstances right so next is advance directives so a written document specifying medical treatment for a competent patient should he or she become unable to make decisions so most commonly used when the patient becomes comatose so often referred to as a living well or healthcare directive in general a valid dnr order must meet the following requirements okay so a dnr must have a clear statement of the decision of the patient's medical problem a dnr must have a signature of the patient or legal guardian it must have a signature of one or more physicians or other lice licensed health care provider and the dnr order with an expiration date must be dated within the proceeding 12 months to be valid okay so on this figure in this slide you're going to see it an example of a wallet size dnr order you may encounter physicians orders for sustaining treatment so in medical orders versus life-sustaining treatment m-o-l-s-t forms when caring for patients with terminal illnesses these orders these medical orders explicitly describe acceptable interventions for the patient they must be signed by an authorized medical provider to be valid and if you encounter these documents contact medical control for guidance and some patients may have name surrogates to make decisions for them when they can no longer make it on their own so these are called durable powers of attorney for healthcare or also known as healthcare proxies physical signs of death so next we're going to talk about determining the cause of death and that's a medical responsibility of a physician okay so presumptive signs of death though um include unresponsive to painful stimuli lack of crotted pulse or heartbeat an absence of chest rise and fall no deep tendon or corneal reflexes absence of pupillary activity",
        "Physical Signs of Death": "no systolic blood pressure profound cyanosis and lowered or decreased body temperature now definitive signs of death okay so definitive signs of death are um obvious mortal damage so some type of decon decapitation dependent lividity so dependent lividity is blood settling to the lowest point of the body causing discoloration of the skin and so in the figure on this slide you could see that that the patient was um laying a supine in and to show the dependent lividity has been ruled onto its side okay also rigor mortis and that is stiffening of the body muscles caused by chemical changes within the muscle tissue this occurs between 2 and 12 hours of death so that is the second sign of death physical death and then you have algomoritas that's the cooling of the body until it matches the ambient temperature okay and then putrification or decon decomposition of body tissues which depending on the temperature conditions it usually occurs between 40 to 96 hours after death",
        "Medical Examiner Cases": "all right so medical examiner causes so involvement of the medical examiner depends on the nature and scene of death in most states the medical examiner or coroner in some states must be notified in the following cases okay so a person who is dead on arrival sometimes called dead on scene death without previous medical care or when the physician is unable to to state the cause of death so in any suicide any violent death or any poisoning known or s which is known or sus suspected and so that's when you're going to get the medical examiner involved okay also a death from an accident suspicion of a criminal act or any infant in child deaths the medical examiner are going to be involved so you should make every attempt to limit your disturbance of a scene involving a death if emergency care has to be initiated keep thorough notes of what is done or found",
        "Special Situations": "okay all right so special situations and organ donors have expressed a wish to donate their organs okay because so consent is um uh information on the donor core card or driver's license treat potential organ donors the same as you would any other patient and your priority is to save the patient's life so remember that organs need oxygen okay and so this is a figure the figure on this slide shows a sample of an organ donor card all right so at medical identification insignia and these can come in the form of bracelets or necklaces maybe a keychain or a card indicating a dnr order an allergy or any other serious medical conditions that might be helpful in assessing and treating the patient so some patients wear medical bracelets and it could have a usb flash drive and this uh often stored as a pdf file that can be read on most computers the figure on the side displays an example of a medical identification bracelet",
        "Scope of Practice": "all right so next we're going to talk about scope of practice and this outlines the care that you are able to provide usually is defined by a state law the medical director further defines the scope of practice by developing protocols or standing orders authorization of treatment to provide care is given by the medical director okay and so um you are going to have that authorization by the medical director it could either be online and this includes when you call into the hospital on the radio or a telephone or also offline and these are standing orders okay so standing orders and carrying out procedures outside the scope of practice may be considered negligence okay so just to reiterate medical director can give you online orders via the radio or telephone and offline via standing orders or protocol",
        "Standards of Care": "all right so standards of care what are these and this is the manner in which you must act or behave and that's called the standard of care it is defined as how a person with similar training would act under a similar circumstance so standards of care are established in many ways and the first one is it's a standard imposed by a local custom so how a responsibly prudent person with similar training and experience would act in a similar circumstance with a similar equipment and in the similar same place or similar place okay so that's imposed by a local custom then you have standards imposed by law and these standards of medical care can be imposed by state statutes ordinance is administration regulation or case law so be familiar with the particular legal standards in your state and then you have a standard of care that's established by professional or institutional standards and so these are recommendations published by organizations and societies that are involved in emergency care for example the american heart association standard for bls or cpr then you have specific rules and procedures of your ems agencies then you have standards imposed by textbooks okay and then you have them standards imposed by states and these could be medical practices acts so in some states the emt is except from licensure requirements of a medical practices act then you have certification and licensure so credentialing is established process to determine the qualifications necessary to allow allow people to practice in a particular profession or a function of an organization so emts may be licensed or certified",
        "Duty to Act": "all right so the next thing we're going to talk about is the duty to act okay so duty to act is an individual's responsibility to provide patient care so once your ambulance responds to a call or treatment has begun you have the legal duty to act in most cases if you're off duty and come upon a crash you are not legally obligated to stop and assist patients you must know local laws and policies pertaining to your duty to act",
        "Negligence": "now we're going to talk about negligence so negligence is a failure to provide the same care that a person with similar training would provide in the same or similar situation all four of the on duty factors must be present present for legal doctrine of negligence to apply and for a patient to prevail in a lawsuit against an ems service provider okay so you have to have all four of these you have to have a duty so the obligation to provide care then you have to have breach of duty so emt did not act within the accepted or responsible standard of care next you have to have damages so a patient must physically or physiologically harmed in some noticeable way then you have causation okay so um causation is a cause and effect relationship between a breach of duty and the damages suffered by the patient so all four of those have to be present for negligence to apply all right next we're going to talk about rey's spa locutor and that's an emt can be held liable under the theory if it can be shown that an injury has occurred so that the cause of the injury was in the control of the emt and that the injuries generally do not occur unless there is negligence okay so then we have negligence per se and that's a theory that can be used when the conduct of the person being sued is alleged to have occurred in clear violation of statute so for an example an emt performs an advanced life support skill that resulted in injury to the patient okay then you have torts and so that's a civil wrongs not within the jurisdiction of u.s criminal courts and examples include defamation of character and invasion of privacy",
        "Abandonment": "all right next we're going to talk about abandonment and so abandonment is a unilateral termination of care by an emt without the patient's consent and without making any provisions for care to be continued by a medical profession who is competent to provide care for the patient so once care started you have assumed a duty that must not stop until an equally competent medical provider assumes responsibility abandonment may take place at the scene or in emergency department where you are dropping off the patient so obtain a signature on your patient record from the person accepting transfer of care at the hospital",
        "Assault and Battery, and Kidnapping": "all right next we're going to talk about assault and battery and kidnapping okay so assault is unlawfully placing a person in fear of immediate bodily harm this includes treating or threatening to restrain a patient who does not want to be transported battery is unlawfully touching a person and that that includes providing medical care without consent kidnapping is seizing confining abducting or carrying away by force that includes a situation where a patient is transported against his or her will false imprisonment is unauthorized confinement of a person and serious legal problems may arrive in situations in which a patient has not given or resends consent for treatment and transport",
        "Defamation": "all right so understand that defamation is the communication of false information that damages a person's reputation the two types of defamation written is libel so written is liable and then spoken as slander so understand the two s maybe an s you can unders uh remember that so slander spoken all statements on your run report should be accurate relevant and factual",
        "Good Samaritan Laws and Immunity": "okay so good samaritan laws and immunity good samaritan laws are based on a common law principle that when you reasonably help another person you should be you should not be held liable for errors or omissions that are made in giving care so to be protected though by provisions of the good samaritan law several conditions must generally be met okay so you must have acted in good faith and rendering care you rendered care without exception expectation of compensation okay and you acted within the scope of your training and you did not act in a grossly negligent manner so gross negligence um is you conduct conduct that constitutes a willingful or reckless disregard for a duty or standard of care okay so immunity statutes apply to ems systems that are not considered governmental agencies and sovereign immunity provides limitations on liabilities and is not complete",
        "Records and Reports": "all right so next we're going to talk about some records and reports so you should compile a complete and accurate record of all incidents involving sick or injured patients and such records is an important safeguard against legal complications so the court's perception of records and reports include if an action or procedure was not recorded on a written report it was not performed okay so remember that incomplete or untidy reports are evidence of incomplete and inexpert emergency medical care provided nymphsis is the national ems information system okay so this provides the ability to collect store and share standardized ems data throughout the united states",
        "Special Mandatory Reporting Requirements": "so special mandatory reporting requirements so some states have a reporting obligation for health care providers and emergency responders including emts the following are all mandatory reporting requirements that may vary from state to state though so child abuse abuse of an elder can person or abuse of at risk adults are mandatory reporting also injury during commission of a felony or drug related injuries and childbirth or all mandatory reporting requirements attempted suicides dog bites certain communicable diseases assaults and domestic violence are also special mandatory reporting required sexual assault or rape exposures to infectious diseases transports of patients in restraints seen of a crime or the deceased are all mandatory reporting requirements",
        "Ethical Responsibilities": "all right so next we're going to talk about ethical responsibilities so in addition to legal duties emts have certain ethical responsibilities as health care providers ethics is a philosophy of right and wrong moral duties and ideal professional behavior so morality is a code of conduct affecting character conduct and consequence bioethics specifically addresses ethical issues that arise in the practice of health care emts will encounter ethical dilemmas that will require you to evaluate and apply ethical standards so these include your own and the those of the profession so applied ethics is the manner in which principles of ethics are incorporated into professional conduct allow rules laws and policies to guide your decision making",
        "The EMT in Court": "all right next we're going to talk about the emt in court and of course you don't ever want to end up in court but you can end up in court as either a witness or a defendant so the case could be either civil or criminal whenever your subpoena detestified in any court proceeding you should immediately notify your service director and legal counselor if you're our witness remain neutral during your testimony and review the run report before the court appearance as the defendant an attorney is required so the attorney is generally supplied by your service in a civil suit defenses may include statutes of limitations so the time within which a case is must be commenced governmental immunity generally applied to municipalities or governmental entities if your service is covered by immunity it may mean that you cannot be sued at all or that it would limit the amount of monetary judgment rentered and then contributory negligence so a legal defense that may be erased when the defendant feels that the conduct of the plaintiff somehow contributed to injuries or damages sustained by the plaintiff and then there's discovery so an opportunity for both sides to obtain more information to reach a better understanding of the case so discovery includes depositions and that's an oral request or for questions and then also includes interrogatories so that's a written request or question and then there's the trials so most cases are settled following the discovery phase during a settlement phase and do not go to trial um for those those that do go to trial several types of damages could be awarded so you could have consent cons compensatory damages and those are intended to compensate the plaintiff for the injuries here she is sustained and then punitive damages are intended to deter the defendant from repeating the behavior and are reserved for cases where the defendant has acted um reckless disregard or intentionally for the safety of the public so these damages are not commonly awarded in negligent cases okay all right in most cases if a judgment is rendered against you your service or its insurance carrier will pay the judgment any emt charge with a criminal offense should secure the services of a highly experienced criminal attorney immediately okay and that concludes chapter three next we're going to go over the um review questions okay see if we missed",
        "Review": "anything so you arrive at a scene of an older woman complaining of chest pain in assessing her she holds her arm out for you to take her blood pressure this is an example of what do you think express consent so also called actual consent is when the patient authorizes you to provide treatment and transport either verbally or non-verbally her holding her arm out is that non-verbal consent okay which is the following example of abandonment okay so that's when we're going to leave the patient with somebody less trained than us okay so an emt leaves the scene after a refusal emt transfers care in the department nope to a nurse amt transfers to paramedic or an amt so an advanced emt transfers to an um in emr and that's going to be it d okay so a lesser training was uh was transferred all right the unauthorized confinement of a person is called false imprisonment and so that's confinement the person without the legal authority or their consent okay so failure of an emt provide the same care as another emt with the same training is called and we know this is that's negligence right okay so c is negligence liable is the written remember and slander is the statement verbal okay an eight-year-old boy was struck by a car he's unresponsive and bleeding from his mouth the police officer tells you that he isn't able to contact the parents you should and we're going to continue to treat the child and transport as soon as possible because that's what we would think that they would want us to do right right it's implied consent an advanced directive is and what is an advanced directive well we know it's written document right and uh so let's see it is a written document i'm almost positive of um of what the provide the patient would um would want to be care provided okay so that was c which of the following patients is competent and can legally refuse ems care okay so no confusion a man who's staggering nope a conscious and alert patient who is in severe pain hmm um let's see what they say oh they say a conscious and alert even though they're in a lot of pain they can refuse okay you are treating a patient with an apparent emotional crisis after the patient refuses care you tell him that you will call the police and have him restrained if he does not give you consent your actions in this case are an example of what do we think oh my goodness um it is unlawfully placing a person in fear of immediate body bodily harm right so it is assault okay so an emt has a legal duty to act if he or she is what do you think it's paid for services um but is not on duty a volunteer is on duty and dispatched well i said all right there you go um paid or volunteer and last one which of the following statements about records uh and reports are false okay let's see so d your patient care report does not become a part of the patient's hospital report that's false because it does become a part of the patient's hospital report that this concludes chapter three medical legal and ethical issues and if you like this lecture go ahead and subscribe and like thanks"
    },
    {
        "Introduction": "hello and welcome to chapter 51 disaster response lecture",
        "National EMS Education Standard Competencies": "a main function of ems is responding to disasters a disaster is any event that causes or has a the potential to cause injury or death destruction and distress a disaster can be man-made or natural and disasters overwhelm ems and community resources because critical infrastructure has been damaged or destroyed",
        "Introduction Continued": "so let's get started as an introduction responding to disasters is a main function in ems so the definition of disaster we said it on the last slide and that is a sudden event such as an accident or catastrophe that causes great damage loss or destruction it can be man made or natural and it overwhelms the ems and community resources critical infrastructure has been damaged or destroyed including electrical power grid or communication systems fuel for vehicles and drinking water and sewage removal also sometimes transportation systems in hospitals and food so anything that overwhelms ems and community resources in smaller rural services is considered an is a disaster disaster management requires planners to look at preparedness planning training response and after action reviews",
        "Disaster Response Planning": "disaster response planning so ems plans to manage disasters plans should be suited to the geography and population and the potential risks of that specific area the best way to plan for a disaster is to think what could happen here and what plans do we have in place for the possibility an all hazards approach is the act of conducting comprehensive planning for all types of disasters general considerations must be addressed before specifics are planned so the number of personnel needed equipment required and which hospitals to transport",
        "Phases of a Disaster Response Plan": "so phases of disaster response plans so there's keys to planning the disaster and those are thinking meeting and brainstorming there are three phases of any response plan and that's before the event so that's the planning phase during the event and after the event",
        "Before the Event": "before the event planning is a process for preparing for potential events no disaster is predictable but some events are more likely to happen in certain areas such as a snowstorm in the northwest or a tornado in the midwest an all hazards approach will put your agency in the best position to handle any disaster the main items to consider when planning for a disaster include the geography of the response area is the area prone to a particular type of disaster and are there obstacles and terrain features that can affect response and hinder access to equipment and maybe the entry to a facility okay so the population is also a consideration and is the population spread out or densely packed or maybe mixed is there a daytime population in the area as well as the nighttime population are there language differences or cultural aspects to consider and are there different facilities that may present hazards or evacuation issues such as retirement communities or prisons or handicapped facilities ems resources so items needed to respond effectively and efficiency to any incident may include additional staff or personnel specialized staff for medical supplies and equipment to handle tasks so agencies might have mutual aid agreements and this is also known as an automatic aid agreement and agencies may have disaster stashes and these are supplies on hand for just emergencies and the inventory is kept up to date so agencies may have access to special transportation equipment and in the event of the gps loss or if it loses satellite connection paper maps and lap maps may be needed or and they may be needed to be used partnership with private businesses so what supplies and expertise are available from the private sector in your response area non-governmental organizations and disaster relief agencies so an example could include salvation army and red cross and your agency will determine the best way to contact these organizations law enforcement resources so your disaster response plans must also take into account state regional or county and local law enforcement resources and their goals and objectives fire and rescue response so the disaster response plan will outline fire and rescue response it's important to have drills on a unified command system within the instant community command system and understand how your agency will work within a unified command structure training standards so training is usually done in phases following a set process agencies frequently update and train on procedures to follow during a disaster personal protective equipment and safety procedures also infrastructure you so familiarize yourself with your agency's communication backup plan telephone landlines may go down and then cell phone towers may be overwhelmed so include backup procedures such as vehicle fueling in the event of a power outage internal communication so there should be a plan to maintain communication with all members for your agency hospitals and health care systems so familiarize yourself with the level of care available in your area you may participate in drills with local hospitals and there may be agreements in place to provide personnel at your agency or theirs and then media organizations so there should be training um with the public information officer within your agency and have a backup public information officer incident escalation so know when and how to contact the next higher level of authority there should be a list within your agency and dispatch system with contacts at the state and federal levels and redundancy is built into the plan the system should be tested at least semi-annually and know what steps to take to ensure higher levels of authority know who you are and where you are and what you're doing okay so immunizations and personnel keep immunizations up to date the designated control officer or services medical director should know the health status of all employees and be familiar with your agency's plan of inoculations persistent to a specific emergency sheltering and protection so plans will include information on sheltering community members and personnel and the plan will include information on supplying food water waste disposal and bathroom facilities also animal control so if an agency is assisting in evacuations address animals such as pets that must be left behind rural areas must have precautions to manage the carcasses there should be plans with concerns pertaining to zoo areas of zoo wildlife refugees and veterinarian facilities",
        "During the Event": "and then during the event okay so that's what we're going to talk about next that was before the event now this is going to be during it's best to stick to a plan but changing conditions and oversight and plea planning may require modification you may have advance warning of the upcoming event such as a tornado or an ice storm considerations during the disaster include inventory during the alert or preparation period take an immediate inventory of supplies on hand and anticipate what you will need determine how much space is available and a mobilization of personnel so gather the crew and activate the notification system personnel must be briefed and notified of changes of the plan agencies will assign jobs as needed and the agency will start an is 211 form that tracks the personnel if this includes who reported and when and where they were assigned have consistent and continual inventory of where people are and what they're doing and every paramedic must have the necessary credentials on his or her person command and setup so command must be visible in unified command so fire police ems and other agencies should you should be represented in the command structure a lead agency directs the efforts and cooperation is essential personnel protective equipment and safety equipment so ppe must be replaced immediately as needed and personnel must not take shortcuts to neglect to wear the gear that they are assigned equipment resupply so equipment can wear out break or expend during crisis so new incoming personnel may not use the same equipment and may need to be trained triage classification so patient classification may be disaster dependent and these are constant and ongoing depending on patients need and the availability safety and sustainability of ems providers also there needs to be patient tracking so you must make a record for every patient you see or assist during the event and you must complete a patient care report for patients you transported the transport supervisor must maintain a log of the patients and the hospitals they're transported to so information you must collect and give to the incident commander includes the patient's names injury categories which units transported and where the patients were transported and then the assignment of personnel so assess new resource personnel must be done before they begin and choose appropriate personnel for patient care demands on several factors so choose them on the level of training the duration and the amount of stress related to the event personal physical needs so patients and personnel need to eat drink and use the restroom so in long lasting instance personnel will require areas to sleep assess their medications and ways to communicate to their loved ones personal mental health needs so use the buddy system an approach to monitor stress exhaustion aggravation and burnout provide downtime in areas where ems workers can unwind ems providers are encouraged to talk about their experiences but be on the alert for mental health issues and incident fatigue hospital updates it's important to maintain communication with those facilities and so hospitals may be able to resupply your equipment and supplies you need you may need help and get some of the personnel and they may need help from you so keep hospitals updated on field conditions providing and accepting relief so your agency must ensure there is enough coverage in its home area if it is providing relief make sure the equipment is capable before you go and the rules apply in reverse if your agency is accepting relief also with surveillance in a terrorism event suspicious people and packages should be reported so report on evolving trends of diarrhea vomiting and rashes during flooding environment can assist with disease monitoring and then during the event there's the weather condition weather is the cause of many disaster events and it can significantly affect the ability of ems to provide care during and after the event so monitoring is critical for proper deployment operation and protection of the ems responders key items to consider include time for the event areas that's been affected population affected and special hazards that may be triggered in the media so members of your agency may be trained to respond to questions from the press and measures to control rumors a press area may be necessary and use the press to your advantage and legal issues so proper documentation during a crisis is essential most legal issues will resolve long after the event and all patients who are transported should have a patient care report written unit leadership reinforcement so a commander or supervisor should perform occasional field checks a strong concern until commander can do a lot to bolster the morale many issues can be resolved with early intervention",
        "After the Event": "after the event there are specific measures to take after an event considerations include accountability so agencies must account for every worker and patient involved duty rosters must be completed for each ems provider and a patient care report or triage tag is required for every patient seen transported or assisted you want to resupply and repair so all equipment used in the event and check that all equipment that was used was not weathered or contaminated and then repair the equipment if needed and service vehicles that were used in inventory so complete an inventory of all physical assets after the resupply and repair stress reaction review so with it long term events or high mortality rate events consider using critical stress management teams concerns should be reported immediately in line with your agency's employee assistant program or critical incident stress debriefing plan open communication should be encouraged physical exam of personnel so a physician should examine all injured personnel the ems providers should be notified of test results as soon as they're possible and counseling services should be made if available if requested or required and then brainstorm so the agency should solicit input from the staff when evaluating the response to the disaster it makes ems providers stakeholders in the event and after the action report so the official internal report of an entire event it should contain a chronological and accurate description of the facts of the incident can be used to provide retraining in a specific area when it comes to finance and reimbursement government organizations or insurance may cover money spent on equipment personnel and loss in large incidents a declaration of a disaster may open the door for state and federal disaster relief funds and low interest loans so acknowledgement a good performance should be praised so ems providers feel good about their service award dinners and plaques help increase morale and retention of personnel",
        "Natural Disasters": "okay so let's talk about natural disasters so there are two types of disasters natural and man-made some disasters are a combination of both for example riots and looting may occur after a hurricane when it comes to natural disasters drivers of emergency vehicles should understand breaking differences and traction problems when driving in inclement conditions ems should be represented both in the emergency operations center so the eoc and in unified command ems may be initially deployed to assist in evacuation efforts and emergency reports should be coordinated with local and state departments of transportation or public work agencies landmarks may be gone use light to direct displace people towards emergency services radio communication and cell phones will likely be unreliable and dignitaries may visit the site of the event for various reasons ems duties may be expanded for standard practice to deliver or administer medications or perform other related health public health services",
        "Forest and Brush Fires": "when it comes to forest and brush fires ems considerations for forest brush and lightning strike fires are remember that you are not there to fight fire lightning can be dangerous and try to predict what injuries you'll be treating so for firefighters it might be smoke inhalation or exhaustion and for civilians it might be exposure or burns or exhaustion or smoke inhalation ppe should include proper gear in addition to infection control gear so maybe um air purifying respirator or heavy duty gloves or extinguishers to um and protective blankets follow directions of the fire command and stay in touch at all times with the command post expect cardiac events in firefighters even those who appear young and healthy",
        "Snow and Ice Storms": "snow and ice storm so make sure agency vehicles are snow ready carry snow shovels in the ambulance in case you need to dig a path and to provide traction carry the following on the ambulance clay kitty litter or calcium chloride crystals or rock salts points to remember when working in snow and ice storms our clothing should be weather ready your agency may have equipment like snowmobiles or snow blowers or plows so you also need to take your time because stretchers don't roll well in snow and you may not be able to park close to the seam basket stretchers such as stroke stokes litters will be helpful and make sure your crew has enough people look at the roof for snow and ice slides before entering structures and if your company is on standby prepare portable warm-up shelters",
        "Tornadoes": "when it comes to tornadoes maintain supplies in tornado proof shelters during the event keep crews in tornado proof shelters as well and after the event be ready to stage in directed area to wait for instructions important points to remember when working in tornadoes include helicopter and air assets will probably not be available after the tornado landmarks will be gone and you may need to help set up field hospitals and first aid stations at casualty collection points",
        "Hurricanes": "okay so when it comes to hurricanes usually not but not always there is some type of warning so there are five categories for hurricanes in uh including category one and cat um all the way through category five so category five winds are greater than 155 miles an hour severe damage is expected always plan for at least one level higher than the worst category predicted safety is always a first so you cannot help if you're injured if you are told to hunker down do it you may be able to use the time before the storm hits to fill sandbags and restock equipment in addition to ppe make sure you have a weather gear and personal floatation devices most patients care will come after the storm so stay updated on post-storm failures the levees that are overcome or bridges and roads that are flooded if you don't know the depth of the water do not drive through it",
        "Tsunamis": "when it comes to tsunamis so tsunamis are tidal waves and they're large waves that travel thousands of miles and hit the shore at speeds of 500 to 600 mile per hour or more there can be very little time if any for advance preparation your personal safety is it is essential and it is safe to assume that nothing the water hits will survive so bring all of your vehicles uphill and inland and make as many supplies as or take as many supplies as you can with you tsunamis can come in a series so even if additional tsunamis are less severe your first line defense will probably be overwhelmed the following are important points relating to ems response and tsunamis so pay strict attention to the warning systems in place and comply with instructions those who have drowned will likely be dead at the time by ems arrival your agency should plan to set up temporary morgue sites and you cannot respond until the tsunami has done its damage",
        "Earthquakes": "earthquakes so there's not going to be there'll be little or no warning depending on the size duration and strength they can cause thousands of deaths and billions of dollars worth damage within minutes after shocks occur regularly and can be substantial and may last for days the biggest immediate danger comes from the structural collapse severed gas lines electrical power lines and fuel tanks can also contribute to fires important points relating to ems response to earthquakes include if you have advanced warning your building and the vehicle contents should be secured during and after the earthquake roads will likely be damaged and or cut off and dust suffocation can occur during the quake it's caused by particles of dust and debris loosened and released into the air if you're responding to patients at scene of a building collapse leave the rescue to train rescue personnel rescuers will need ongoing rehab so if possible have extra food and water available and call your local hospitals to find out if they are able to receive patients when you're out in the field take notes of all the hazards and if your local hospital schools and buses government offices or fire departments participate in regular earthquake drills try to be part of them",
        "Landslides, Avalanches, and Mudslides": "when it comes to landslides avalanches and mudslides there are many reasons for landslides avalanches and mudslides severe winter storms heavy rainfall or wildfires perhaps flash flooding or hurricanes and so important points related the ems response to these events include cliffs high hills and anything in the gravity path of the landslide avalanche or mudslide will obviously be in the danger area when a landslide occurs it is it can cause such a buildup of soil and vegetation that it can block a stream or river so you you may need to consider putting water rescue procedures in place underground piping conduit for electrical lines and telephone lines can be damaged so mudslides or mud flows are similar to a river of concrete the the intense heat of brush fires seals the oil the soil surface making mudslides and avalanches and landslides move even faster over terrain equipment that may be planned for in advance should include backhoes and earth movers",
        "Cave-Ins": "okay so when it comes to cave-ins the bedrock that is not as important as consideration as it is the actual soy soil composition so cavins can be caused by rapid freezing and thawing or heavy rain or excess vibration such as the that associated with earthquakes and tremors there are considerations for ems personnel at um during a cave-in so check with your local utility company to make sure power lines are not separate or unstable and watch for loose rock in the collapse areas so there are almost always be an accumulation of water so be prepared to treat patients for hypothermia there are three ways to secure the area for evacuation so they're sloping benching and choring the atmosphere in the caven is generally toxic so if the patient care area is located in the collapse area continuously monitor for carbon dioxide or hydrogen sulfide gas or oxygen levels and cavins can release sewer and chemical gases so after atmosphere security consider positive pressure ventilation",
        "Volcanic Eruptions": "okay so next we're going to talk about volcanic eruptions the primary emergency from the explosion so the explosion that occurs in the um bubbling magma so lava flow is rarely a problem as its course is slow and predictable since volcanic eruptions occur at the height rescue workers may be affected by secondary problems such as melting ice or snow or landslides identify buildings that are in the volcano proof during pre-planning and this should include your squad building are there warning slot warning systems in place so considerations when responding to a volcanic eruption include the population and where it's located and warning if it's a non-existent panic may spread so expected injuries include burns respiratory problems or crest trauma injuries and ash fall is the residue left behind from the eruption asphalt can cause inhalation injuries so mass should be issued to everyone the weight of the ash can cause roof to collapse and drive carefully because ash can make roads slippery try to make the public aware of the importance of wearing respiratory protection even after the initial danger has resolved",
        "Flooding": "okay so the next disaster we're going to talk about is flooding and most preparations for flooding occur during pre-planning issues to watch out for include um slow degradation of the levees and debris flow in a sudden catastrophic degradation of levees additional water or additional considerations include to wear proper wet gear driving through water can be challenging so walking in water that is over six inches deep will likely result in a fall and you may be swept away so when the water starts to recede contaminants and residue can cause serious health problems",
        "Sandstorms and Dust Storms": "when it comes to sand storms and dust storms so most problems associated with sandstorms are related to the abrasive and visual effects ems considerations for responding to a sandstorm or dust storm include sensor area and eye protection and do not rub your eyes nose or skin during the sandstorm respiratory protection should be used and lip balm as well as some kind of cloth barrier over your whole head is a good idea so driving is a challenge and blowing sand may hit objects",
        "Drought": "okay so the next disaster we're going to talk about is the drought it's caused by a lack of water available to public primarily based on the lack of participation over length of time causes a myriad of problems for medical community and security of the agency's working water supply so civil unrest could spread if talbs people think ems crews have water prolonged cold weather",
        "Prolonged Cold Weather": "cold stress can develop and cold stress is a condition that occurs when someone is exposed to cold weather for long periods of time even though sheltered cold stress is similar to seasonal affective disorder if maintenance or repair issues can wait until warmer weather let them and try to limit physical demands if possible additional considerations for working in prolonged cold weather include to dress loosely and in layers and if you have to do standbys try to switch crews frequently keep an eye on the older ems providers they do not handle the cold as well as the younger ones",
        "Heat Wave": "so when it comes to heatwave ems personnel are very cognitive of three main types of heat injury and patients of heat cramps heat exhaustion and heat strokes but ems personnel are less familiar with working in these conditions every day so there are some problems and potential solutions to issues that occur during the heat wave so villa vigilance is the key do not wait until you feel thirsty to consume water small frequent meals are better than large ones and set up water trains so as you empty your water bottles have them refilled use air conditioning in buildings and vehicles place wet towels on your head or body to reduce body temperature and try to break up work schedules during the hottest part of the day",
        "Meteors and Space Debris": "meteors and space debris so space debris or space junk burns up when entering the atmosphere and space junk is considered it can be any man-made material or meteors are generally stones with a high content of iron most space debris and large meters coming from space can be detected so keep an open mind when a patient has a history of sudden sharp pain with local bruising",
        "Pandemics": "when it comes to pandemics an epidemic is the situation that occurs when an illness affects a disproportionately large number of people in a specific gender geographic area at the same time a pandemic is an epidemic that occurs over an extensive area so personal protective from the disease is the most important consideration such as n95s or respiratory protection hand washing and sanitation and the best method of detecting disease and workers is direct observation so if someone appears sick that person should be pulled from duty a person can transmit a sneeze or cough from a distance of six feet in a pandemic situation the full workforce may not be present the public should be instructed on how to care for sick people your agency should set up guidelines for which emergencies you will respond to and which calls you will wait your agency may have to set up field hospitals or care stations and your agency may be called on to become a point of distribution for medicine or vaccinations",
        "Structural Fires": "okay so some man-made disasters include structure fires so structure fires have a much higher death and injury rate than wildfires they occur in populated areas and involve products of combustion that can be explosive toxic or fast spreading so let the firefighters fight the fire your agency must ensure that it has someone in a unified command who will have face-to-face contact with command as the events materialize additional key points for ems response include watching for falling or collapsed items collapsing so prepare to treat burns and respiratory problems stay upwind be prepared to evacuate quickly and be ready for cardiac events",
        "Construction Failures and Building Collapse": "so construction failures and building collapse ems crews and agencies must be ready to handle engineering failures as part of planning check out new construction areas and take note of conditions and placement of equipment such as trains and update plans frequently consider what special ppe might be needed such as helmets steel-toed boots eye protection knee pads and heavy duty work gloves other considerations when responding to include if there is a lack or lockout tag out information sheet on site review it so during response crews may be called on to do perimeter search for patients when victims are brought to you collect as much information as possible and document this info on a patient care report or triage tag include rescuer names you may need to supply backboard straps in stoke's basket to the rescuer so careful thought is required to find the safest area for triaging and treatment it should be in the cold zone",
        "Power Failures or Disruptions": "power failures and disruptions so if your squad building has electric locks on the doors or equipment rooms the agency should consider getting a manual override device have alternative sources for heating and cooling if fluids and medications are stored in agencies refrigerators or heaters and backup generators must be checked on a regular basis make the make sure battery powered devices are fully charged have the ample supply of all types of batteries available and make a list of patients who use electric powered life-saving devices you will not be able to download electronic patient care reports and cell phones and gps may be out of service as well",
        "Riots, Civil Disturbances, and Stampedes": "okay so another man-made disaster is riot civil destroy disturbances and stampedes so dangers are multiplied when people are in the state of panic before and during the response get as much information as possible about the scene and stay updated and maintain communication events change quickly ems considerations during riots civil disturbances and stampedes include scene safety or police presence prior to reporting to or setting up a staging area determining what is happening right now and what could potentially happen also vehicle safety do not drive over broken glass and if the crowd is there consider using a ground guide to walk in front of the slow moving vehicle and then maintain situational awareness such as use the buddy system and make sure you always have 360 degree view of the scene police escort and wear body armor or helmet documentation of anything you see at the scene that could later be used in a criminal or civil court",
        "Strikes and Labor Disputes": "also strikes in labor disputes so strikes can involve large or small groups of people and may last a long time some strikes or labor disputes involve disagreements and are generally peaceful ems considerations for strikes and labor disputes include should ems providers cross a picket line and if the patient is ambulatory he or she might be brought safely to you television coverage of the event can act as a deterrent to physical or verbal attacks on ems providers so document and record all your findings sniper shooter or hostage situations so ems should be staged out of gun range in all shooter and sniper scenarios if gunshot victims are still exposed do not go to them make sure that you do not say anything to the press about the accident and during the long standoff do not lose your sense of urgency regarding communication security",
        "Explosions": "when it comes to explosions explosions can be intentional or unintentional so ems considerations for explosions include secondary or tertiary explosions that may have been placed and carefully record anything a seriously injured patient has to say ear injuries are common and air particles are probably contaminated so your agency may consider setting up field hospitals if local hospitals are overwhelmed",
        "IT (Cyber) Disruptions": "information technology disruption so internet technology has helped ems in many ways but the downside is that hackers can penetrate ems security and steel information so every agency should have an information technology professional available to update the te and test the system regularly use of the computer system should be limited to your agency and protect systems with passwords and change them frequently and if you recognize a cyber threat immediately report it to your supervisor and stop using the threatened browser or program okay so that concludes chapter 51 disaster response lecture thank you for joining us this evening"
    },
    {
        "National EMS Education Standard Competencies": "hello and welcome to chapter 48 vehicle extrication and special rescue upon completion of this chapter and the related course assignments you will be able to explain the three levels of training in technical rescue as well as discuss guidelines for special rescue teams there are special steps of special rescue as well as specific hazards that may be encountered and paramedics must ensure safety at every scene for example certain vehicle components may be hazardous to responders and patients after a crash the situational safety at scene of a vehicle extrication should be insured and ems providers must understand simple methods to gain access to a patient whether or not technical extrication is required okay so let's get started ems",
        "Introduction": "departments must be prepared to respond to a variety of special rescue situations types of special rescue incidents include vehicle extrication confined space trench water hazmat agricultural and wilderness rescue paramedics are often first on the scene and rescue means to deliver from danger or imprisonment as a paramedic you may not be responsible for special rescue and extrication you should be prepared for it and be aware of the associated hazards",
        "Rescue Training": "so rescue training all ems providers must have some formal education or training and rescue techniques education and training focus on awareness and enabling paramedics to identify hazard and secure the scene the function of a paramedic on a scene at a rescue incident depends on the company safety is a primary concern providers must wear personal protective equipment a technical rescue incident or tri is a complex rescue incident a tri involves vehicle extrication water ice or confined space rescues trench structural collapse high angle hazmat wilderness search and rescue tris require specially trained personnel and special equipment there are three levels of tr i training and it's defined in nfpa 1006 and 1670 and they include awareness and awareness is the introductory level training focused on identifying hazards and securing scenes there's operations and that's geared towards working in the area directly surrounding the hazard that's the warm zone it teaches the paramedic to directly assist those conducting the operation and then there's the technician and that's direct involvement in the rescue operation including use of equipment patient care and incident management guidelines for rescue operations follow these guidelines when assisting rescue team members you want to be equipped prepared and ready to meet the expectations of your role maintain situational awareness work as a team and follow the golden rule of public service it's easy to concentrate only on the technical aspects of the rescue forgetting about the patient stay with the patient whenever possible providing updates about the rescue actions",
        "Steps in Special Rescue": "okay steps to special rescue there are eight steps to ensure safety effectiveness and efficiency the first is preparation then response arrival and scene size up stabilization of the scene access detanglement removal and transport",
        "Preparation": "so let's talk about these the first one remember is preparation so training with fire departments and special rescue teams allows you to be prepared to respond to mutual aid calls and assess the following issues before responding to tris so does the department have a personnel and equipment needed to handle this and which equipment and personnel will be first on scene and are department personnel familiar with the hazard areas in their response area",
        "Response": "response is the next step and if your department has its own technical rescue team it will respond with a rescue squad an ambulance a fire company and a chief officer some ems units the rescue squad will come from an outside agency in others the ems department itself provides the primary technical rescue services",
        "Arrival and Scene Size-Up": "when you arrive and the scene size up now that's the next step information received during the initial dispatch call is critical to the success of the rescue operation you need to know the location in nature the condition and position of the patient the number of patients the specific injuries and the hazards at the scene the scene size up includes the initial evaluation of the scope and magnitude of the incident the nature the potential number and severity of patients hazards access to an egress from the scene environmental factors operating and immediately available resources and additional resources needed you want to focus your awareness and simplify how you communicate important size up information using a you can format as a guide you want to do unit conditions actions and needs the unit is considered not just your unit identification but also your role at the incident your conditions is to focus on crucial points related to your role actions is to clarify your immediate your next immediate actions so that you can focus on operating effectively and your needs it's to identify additional resources with which you will need to coordinate immediately and then hazards at a tri you may be tempted to immediately approach the patient or the accident area your own safety is paramount you must also protect your partner and the public consider the hazards such as utilities and environmental conditions that may be immediately dangerous to life and health do not rush the incident scene until you have completely assessed the situation  okay and consider the traffic incident management it's the method of controlling the flow of motor vehicle traffic ongoing traffic is perhaps the most common and dangerous hazard encountered on rescue scenes all emergency responders should know the crucial components of traffic instant management to identify when it is needed and whether it is being managed correctly ident individuals are at risk of being injured or killed due to crashes that may occur as traffic flows through or around rescue scenes",
        "Scene Stabilization": "and then there's scene stabilization stabilization of an incident once additional resources are on the way observe the geographic area identify routes of access and exit note weather and wind conditions and consider evacuation problems and transport distances assumption of command so the first arriving responder begins using the incident command management system at any tri follow the instant commander's orders the ultimate goal is to protect the team and patients it is crucial to follow the ics orders there are three guidelines which should be followed at every rescue scene you want to approach the scene cautiously position the apparatus properly and assist specialized team members as needed so emergency vehicles when determining where to locate your vehicle take into account the safety of emergency workers patients and other motorists large emergency vehicles can be positioned to provide a barrier device against unobservant motorists place apparatus at an angle to the crash to ensure that it is pushed to a side of the scene if it is struck from behind use only essential warning lights because too many lights tend to distract or confuse drivers and law enforcement can coordinate traffic control outer and inner circle surveys so as you approach the rescue area begin with the outer circle survey this involves evaluating the area surrounding the tri important step is to identify any life-threatening hazards and taking measures to avoid or mitigate them determine whether the situation is a rescue search or recovery perform an inner circle survey on the heart of the tri once the outer circle survey is complete if possible conduct a 360 evolution around the center of the incident controlled zones the ic should coordinate with law enforcement and other fire department to secure a perimeter surrounding the scene you want to establish three control zones the hot zone and that's the zone for entry and rescue teams only the hot zone immediately surrounds the scene and the size is proportional to the hazards the warm zone is next and that's for trained personnel and equipment personnel equip personnel only decontamination and hot zone support and then there's the cold zone for staging vehicles and equipment and it contains the command post so specific hazards the emergency response guidebook that's used to identify idlh environments and determine primarily primary actions it provides information on approximately 4 000 different chemicals that may be encountered when we talk about motor vehicle stabilization any motor vehicle involved in the grass must be stabilized before you can gain access to the patient simple ways of stabilizing a motor vehicle after a crash include engaging the parking brake placing the vehicle in park and shutting off the engine when it comes to utility hazards maintain distance from the utility hazard such as a down line which require the assistance of specially trained personnel do not touch any electrical source until they have been de-energized the ic should ensure the utilities are shut off in the rescue area protective equipment specialized teams should use devices approved for the rescue environment considerations include visibility of ppe flamer flash protective a ppe for certain rescue situations footwear protective headgear protective or puncture or cut resistant gloves approved safety glasses and goggles other useful items include binoculars chalk or spray paint a compass first aid kit a whistle or a handheld gps system also light sticks accountability at the scene is very important the accountability system tracks personnel on the scene identifies assignment and location the system restricts scene access to rescuers with specific assignments and then patient contact tris can last for hours and patients may be alone attempt communication via radio cell phone or yelling if possible stay in communication with the patient throughout the scene the patient is likely injured or scared or sick so remain calm as your demeanor will in turn calm the patient and then access once the scene is stabilized focused on how to access the patient simple access requires just hand tools such as a sledge hammer a glass saw or a center punch complex access requires specialized tools such as a reciprocating saw hydraulic ram a spreader or cutter communication with patients during the rescue is essential to ensure that they are not injured further by the rescue operation gaining access to the patient depends on the type of incident and nature and severity of the patient's injuries",
        "Disentanglement": "disentanglement so in emergency medical care you should should begin as soon as the patient is assessed a team member should stay with the patient while he or she is being disentangled in order to direct the rescuers unless there is immediate threat of danger perform a primary assessment before date disentanglement begins disentangle bit involves freeing a patient from whatever is trapping him or her for example cutting the vehicle away from the patient in vehicle extrication",
        "Removal": "and then there's removal preparing a patient for removal involves maintaining control of life-threatening problems dressing wounds and stabilizing suspected fractures and spinal injuries expedite removal if the patient is deteriorating rapidly or hazards are present packaging involves preparing the patient for movement as a unit it often accomplished with a backboard or similar device a basket stretcher you could hear these called stokes litters or stokes baskets helps move patients to safety this method is used in a variety of situations baskets can be lifted by a rope carried by vehicles or by hand and carrying by hand is effect efficient and comfortable for the patient it requires a team of six or eight rescuers though and carrying hand carrying can be physically demanding for rescuers the caterpillar or lap pass is a good option when footing is unstable what the caterpillar lap passes is team members sit down in two rows facing each other rescuers pass the stretcher down the line as a stretcher moves down the line team members move in the direction of travel",
        "Transport": "okay and then next is transport so transport varies depending on the severity of the patient's injuries and the distance to the medical facility",
        "Vehicle Anatomy and Structural Parts": "all right so let's talk about vehicle anatomy and structural parts so use standardized terminology when referencing specific vehicle parts refer to left and right as they relate to the vehicle not you the left side is the driver's side the right side is the passenger side roof posts are known as pillars they add vertical support to the roof typically labeled alphabetically the a post is located at the front of the vehicle and it forms the sides of the windshield the b is located between the front and the rear door c is located behind the rear door and d found on larger vehicles with windows behind the rear doors there is an engine compartment and a passenger compartment the hood covers the engine compartment the bulkhead divides the engine and capac passenger compartments and the firewall protects passengers from the engine structural integrity affects passenger safety most modern vehicles have a unibody construction this combines the vehicle body and frame into one component this is safer than older frame types when impact occurs crumple zones redirect energy away from the passenger compartment lack of frame means that the vehicle could split into two in a severe crash though",
        "Alternative Powered Vehicles": "okay so alternate powered vehicles and they may be powered by electricity or petroleum gas ethanol or biodiesel fuels other less common sources sources of elect alternative power include electric vehicles and trained rescue personnel can secure the electrical system by disconnecting the batteries the high voltage system in hybrid and electric vehicles shut down when the vehicle is powered down the systems can be completely disabled by disconnecting the standard 12 volt car battery the discussion or decision to do so and the disconnected procedure itself typically is the responsibility of the ic or rescue crew hazard of leakage or of chemicals from damaged battery packs can occur and this releases toxic gels liquid or gases and should be handled in the same way as other hazardous materials then you have liquefied petroleum gas and vehicles use compressed petroleum gas or a mixture of petroleum and butane this presents a hazard after crash if large amounts of highly flammable or reactive gas leak from breech containers in or around the vehicle and then you could have ethanol and flex fuel and that's almost identical to traditional gasoline-powered vehicles in appearance and operation there's also biodiesel and it's almost identical as well to traditional diesel counterparts and appearance and operation",
        "Safety": "when it comes to safety alternative powered vehicles present a range of safety concerns and special challenges most basic safety procedures are the same at the scene of a motor vehicle crash regardless though of the vehicle follow these tips for managing alternative powered vehicles look for markings specific to alternative powered vehicles do not use flares to mark the incidency stabilize the vehicle by engaging the brakes a quiet hybrid or electric vehicle is not necessarily turned off or powered down so be aware of the possibility of toxic vapors gases and fumes and avoid contact with any fluids leaking from the vehicle call for a hazmat team as soon as possible and set up a safety zone around the perimeter",
        "Hazardous Materials": "okay next we're going to talk about hazardous materials so any extrication of vehicle extrication incident may require specialized teams to manage the hazardous materials a car wreck may have additional hazards from the vehicles so a possibility of ignition sources include fires or electric electrical hazards fuel surfaces or fuel runoff and follow a proper size up and evaluation process responders trained at the awareness level may assist operations and technician trained responders by gathering information from the placards sealing off the site and consulting the erg to identify pertinent data okay so next let's talk about hand tools",
        "Hand Tools": "and the hand tool is a tool or equipment that operates from human power in categories include with their striking tools and an example would be a hammer there's a leverage prying or spreading tool and that could be an example of a pry saw and then cutting tools such as trauma shears or lifting pushing or pulling tools such as hooks and this figure shows examples of some of those hand tools",
        "Vehicle Stabilization": "vehicle stabilization so objects in vehicles that are unstable pose a threat because they may shift slide or fall injuring victims rescuers or bystanders so cribbing is the most basic tool used for vehicle stabilization it usually is made of wood plastic or composite material or steel and several are designed designs are used including step chocks wedges or shims and shims are similar to a wedge but smaller in size a vehicle may still move after cribbing is in place and types of movement include horizontal movement vertical roll bounce or yaw movement movement during extrication may cause further injuries so after the vehicle is completely stabilized set the parking brake put the vehicle in park or turn the vehicle off these figures show the five directional movements",
        "Gaining Access to the Patient": "okay so gaining access to the patient you could open the door of course try all doors first even if they appear damaged break tempered glass if a patient's medical condition is serious and you cannot enter the vehicle through the door consider breaking the window side and rear windows are made from tempered glass and they break more easily and do not try to break or enter through the windshield because it is probably made of laminated glass try to break the window that is not in close proximity to the patient and place a blanket over the patient prior to breaking the glass if possible wear proper ppe when breaking glass including gloves or a mask and safety glasses or goggles lower the windows as far as possible before breaking them and always aim for the low corner give the other ems personnel a verbal warning such as breaking glass and after the window is broken use a hand tool to clean out the remaining glass to properly break tempered glass use a spring-loaded center punch refer to refer to your skill drill 48-1 once the glass is removed try to unlock the door again the rear window may provide a large enough opening to reach a patient if no other means is possible if you cannot gain access heavier tools and trained personnel are required provide initial medical care and so this includes assessment and management of the abc's care should be occur simultaneous simultaneous with extrication",
        "Disentangling the Patient": "the goal of disentangling patient is to remove this sheet metal and plastic from around the patient do not cut the patient of the vehicle assessment of the situation so perform only procedures necessary to disentangle the patient the order of procedures will be determined by the specifics of the incident the patient should be protected with a blanket or backboard before disentangling all right let's talk about airbag safety next so identify undeployed airbags through the airbag labeling system no modern airbag system is mechanically deployed the computer will retain power for about 10 to 30 minutes at the vehicle's power is cut and remember the following an airbag that has deployed during a crash presents no safety hazard for the rescuer if the airbag did not deploy disconnect the battery and allow the airbag capacitor to discharge do not place a hard object between the patient and the undeployed airbag do not cut a steering wheel if the airbag has not deployed avoid working in a deployment area of airbags and restraint systems so displacing the seat this can relieve pressure on the driver and give rescuers more um room to work begin the simple steps of displacement ace displacing a seat backwards so move the seat backward on its track if these methods are unsuccessful you may need to perform a seat displacement so removing the roof this allows equipment to be passed into the rescuer it increases space for medical equipment and disentanglement it helps reduce the feeling of panic by confined space and it provides a large exit route protection and of protection of the patient and rescuer inside the vehicle and then there's displacing the dashboard so the dash roll technique is often used to lift the dashboard and move it forward if it is entrapping the patient but first the roof must be removed and it requires hydraulic cutter and a hydraulic ram and cribbing maintains the opening created by the tools",
        "Confined Spaces": "okay so next we're going to talk about confined spaces the location surrounding surrounded by a structure that is not designed for continuous occupancy confined spaces have limited openings for entrance and exit confined spaces can occur in a farm commercial and industrial settings an example is grain silo or a well casting or septic tank so limited ventilation presents special hazards the potential for stored electricity must also be considered and scene safety must be considered before entering a confined space when it comes to confined spaces oxygen deficiency and poisonous gases need to be considered such as hydrogen sulfide and that's a colorless toxic flammable gas there's also carbon monoxide and that's also a colorless odorless tasteless gas that cannot be detected by normal senses then you have carbon dioxide and that's a colorless gas associated with asphyxiation risks then there's methane it's not toxic but it will burn if it's ignited ammonia is toxic and corrosive chemical with a pungent odor and then there's nitrogen dioxide and that's a reddish brown gas with sharp biting odor it's um toxic by inhalation you want to do a safe approach and gather information from bystanders and assume an idlh atmosphere at any confined space call do not make entry prior to atmospheric monitoring you want to assist other rescuers and prevent an accident from becoming worse by recognizing and securing the scene and share the rescue with the rescue team information from the size up and description of any rescue attempts exposures hazards or extinguishment of fires you may be asked to assist by bringing rescue equipment to the scene or maintaining a charged hose line or handling a crowd control",
        "Trenches": "after confined spaces there is trenches and those are unstable and prone to further collapse patients should be carefully dug out by after shoring and stabilization and the evacuation at the evacuation site you have to approach this safely you have to stay away from the edges shut off heavy equipment stop and divert nearby traffic and when attempting to make verbal contact with a trap person prioritize your personal safety",
        "Water": "and then there's water rescues so water rescues vary and ranging from small streams to the ocean to a swimming pool self-rescue techniques include immersion in fast water and a depth a self-rescue position so you want to roll into a face up arch position keep your lower back higher than your feet and keep your feet together in the direction of travel and arms to your side and so water temperature of less than 98.6 or our body temp will cause hypothermia to maintain body temperature keep your head and face above the water assuming the heat escape lessening position or help so um in water colder than 70 patients may benefit from the cold protective response and so heat is conducted from the body to the water hypothermia can protect vital organs and whenever a person dives or jumps into cold water the diving reflex may cause immediate bradycardia so a loss of consciousness may occur and the patient may survive for long periods of time underwater because of the lowering of the metabolic rate and a decrease in oxygen man and consumption other water rescue situations include the most common is a swift water rescue scenario involving people driving a vehicle through flood waters the vehicle may be swept away and the danger special danger is presented by difficulty in determining the water depth special hazards of surface rescues include strainers or dams or hydraulics created by moving water there's a psych approach so wear proper ppe do not exceed your level of training and use the reach throw row and then go approach specialized equipment exists for ice rescuers and recover situations so occur when the victim is not visible in the water upon arrival at the site this requires trained personnel with equipment including snorkels and masks and dive gear and a grappling hook it could be used as a last resort so there's spinal injuries and submersion incidents so submersion incidents may be complicated by spinal fractures or other spinal cord injuries so when a spinal cord injury is suspected the neck must be protected while the patient is still in the water",
        "Rope Rescue": "okay so the next specialty rescue we're going to talk about is a rope rescue and that there are types of rope rescue so we have low angle and then high angle operations okay so low angle the ground provides primary support and the rope provides secondary support ropes can be used to help raise or lower basket stretchers and the rope can be controlled through belay system when the angle is severe climbers may descend by repelling high ankle operations include situations where the slope of the ground is more than 45 degree angle rescuers and patients are dependent on the rope for their support not a fixed surface so you use this technique only when other means of raising and lowering are unavailable these rescues are demanding and dangerous and there's safe approach so take the time to set up the equipment properly protect yourself by putting distance between you and any loose materials and move bystanders out of the way",
        "Wilderness Search and Rescue": "next type of rescue we're going to talk about is wilderness and there's two parts of a search and rescue mission first there's search you're looking for a lost person and then there's rescue and that's removal of the patient from that hostile environment many situations such as small children wandering off or older adults with dementia or people hiking or engaging in other outdoor activities the safe approach is to be aware that terrain and environmental factors will vary terrain hazards include cliffs or steep slopes caves or wells maybe mines or streams or rivers you need to bring drinking water and food use a handheld strobe light for additional visibility and be aware of your physical limitations",
        "Lost Person Search and Rescue": "and then a last person search and rescue so standard protocol a search base with an ambulance and prepare equipment so that no time is wasted monitor progress via radio tuned to that search frequency and the safe approach is to once the patient is found distribute equipment evenly among responding personnel and keep to a pace that allows personnel to stick together cooperation between ems and special team for safe delivery of the patient back to the base",
        "Structure Fires": "and then there's structure fires so ambulances may be dispatched along with the fire department to structure fires a structure fire is any fire occurring in a building and examples are houses or apartment buildings schools or offices the instant command will determine an appropriate parking spot for the ambulance you want to have it far enough from the fire to be safe and it should not block arriving equipment the next step is to determine if there is or are injured patients at the scene or if you are on standby the safe approach is to stay in the ambulance remain present even after the fire is out because a firefighter may become injured during salvage and overhaul do not leave the scene unless you are transporting a patient or have been released by the incident commander",
        "Agricultural and Industrial Rescue": "there are agricultural and industrial rescues that can occur and tractors or other powerful machines used in agricultural and industrial settings create extraordinary hazards rescue personnel should visit their local farms and industrial plants and learn about this equipment over time protective shields and guards have may become damaged or removed and this could cause a pinch points or wrap points shear or crush and the majority of u.s farms are not subject to inspection by osha a safe approach to industrial accidents or agricultural rescues as uh cribbing and it's critical to crib in order to stabilize that equipment so keep in mind that farm machines made of strong steel and cast metal may be taken apart more readily than cut and then isolate the injury site determine alternative methods of disentangling the patient and assess the patient while rescue personnel planned this disentanglement be aware of the differences between industrial and farm settings so industrial co-workers may be able to halt the machinery and begin that extrication in farms farmers typically work alone there's no one to call ems so lag time between the time of injury and medical equipment or medical treatment may occur",
        "Tactical Emergency Medical Support": "next we're going to talk about tactical emergency medical support so if an incident develops in a tactical situation such as a hostage situation law enforcement may call in special weapons and tactics and that's a swat team and many special weapons and tactic teams may include specially trained ems providers working in partnership with law enforcement tactical paramedics receive additional training and they must be able to provide medical care intense situations they dawn in special ppe as law enforcement officers including body armor and ballistic helmets and eye protection tactical ems personnel carry a special medical kit that is compact enough not to impede movement the main duty of tactical paramedic is to provide immediate medical care to persons who become injured during the incident if you are not part of specially trained tactical team follow these steps when responding you need to turn off your lights and sirens as you approach the scene request direction from the ic a law enforcement officer will guide you to a shielded area and as you exit the vehicle stay low and remain near the side of the vehicle unless you're directed to another place of safety do not turn on the vehicle's outside speakers do not look around the sides or over the top of the building or structure and stand by at the staging area to treat the package the injured patients after special weapons and tactics team or other law enforcement officers have evacuated them when you're ready to transport ask a law enforcement officer to notify ic as you exit the scene follow the specific route indicated by icr law enforcement they have assigned to guide you",
        "Patient Care": "okay so let's go through patient care assessment of medical and trauma conditions during the rescue process so we're going to talk about crush syndrome and this occurs when the chest abdomen or lower limb or other extremity is compressed for four to six hours crush syndrome elevates pressure and reduces blood flow the resulting oxygen deprivation in the area necessitates anaerobic metabolism within its tissue and so pressure can also break down cell walls allowing the leakage of metabolic waste and intracellular fluid and electrolytes when pressure remains bleeding is typically controlled and when pressure is released blood pressure plummets bleeding can resume and toxic materials are then released into the bloodstream potassium which is no longer regulated can affect heart rhythm and may produce pronounced peak t waves on the electrocardiogram you want to treat positive pressure ventilation and administration of sodium bicarb calcium chloride and fluid boluses",
        "Pain Management": "so pain management paramedics may use both pharmacologic and non-pharmacologic methods to manage pain in injured patients such as non-pharmacologic could be splinting or gentle handling or talking to the patients to treat a distraction or to make a distraction during the assessment pharmacologic treatment of pain in the pre-hospital setting is an important function of the paramedic and pain control should be considered according to the medications indications the relative and absolute contraindications also possible side effects",
        "Medical Supplies": "basic medical supplies should be carried in an off-road medical pack you could see this some medical supplies on that table 48-1",
        "Patient Packaging": "package patient packaging so basket stretchers such as the stokes basket so it's a rigid frame structure that the patient is set into and then secured to so there's two types a wire basket and then a plastic fiber basket a wire basket is more suitable for water rescue and helicopter hoist situations and a plastic or fiberglass basket is more suitable for most other evacuation types similarly between the two types so there could be a wheeled device to facilitate movement over trails or low level debris minimum or no belts or straps packaging systems are used instead and the goal is to secure the patient's pelvis to the basket so there are packaging obstacles so patients with fractured pelvises will be caused great pain by basket packaging packaging spinal immobilization package on the backboard in a basket stretcher so place the package or the patient in the kendrick extrication device instead of the backboard reverse reversal of the process once the patient has been safely extricated or evaluated consider consideration of all patient needs when packaging so set up and secure a portable oxygen tank tubing for the mask or nasal cannula must be secured and monitor the amount of oxygen in the cylinder avoid maintain the iv lines of course and keep the patient warm and provide head and eye protection consider using a ked or ked sched combination in narrow spaces",
        "Conclusion": "okay all right so this concludes the chapter lecture for chapter 48 vehicle extrication and special rescue thanks for joining us this evening and consider liking and subscribing to our channel thank you"
    },
    {
        "Introduction": "hello and welcome to emergency care in the streets chapter 52 crime scene awareness lecture",
        "National EMS Education Standard Competencies": "as an educated and effective health care provider you need to know how to avoid violence when possible and how to protect yourself when violence erupts sounds survival skills training will help you identify and avoid potentially dangerous situations once you recognize a violent situation your goal is to treat retreat to the safe location and await the assistance of law enforcement personnel",
        "Introduction to EMS Dangers": "within the past few years emergency medical services has become increasingly more dangerous for providers you may encounter different types of calls such as the following mass shootings or a patient under the influence of substances paramedics have been severely injured or killed while attempting to reach and treat sick and injured people according to injuries and fatalities among emergency medical technicians and paramedics in the united states more than 4 540 pre-hospital providers were injured during a four-year long period that data has been collected many assaults that do not result in serious injury or loss of time are not reported you need to know how to avoid violence when possible and how to protect yourself when violence erupts actively seek out protection courses geared towards ems providers once you recognize a violet situation your goal is to retreat to a safe location and await the assistance of law enforcement",
        "Awareness": "so let's start with talking about awareness you need a well-tuned sense of situational awareness throughout your career you will respond to an unknown number of different situations all with dynamic qualities violence is not isolated to one socioeconomic class it does not live in only one neighborhood so proper awareness begins when you are dispatched to the call look for information in the call notes that might raise a red flag such as reports of a loud party or address is a known crack house or addresses previously underage drinking violations so trust your gut if you feel the scene is not safe request law enforcement personnel to secure it so many paramedics are mistaken for law enforcement personnel the general public may have difficulty distinguishing among law enforcement personnel and ems in the fire department in some cases the uniforms may be similar this can lead to unintentional violence towards you and your partner evaluate your service uniforms and advocate for easily identifiable character characteristics like unique colors for ems it clearly marked",
        "Body Armor": "and body armor so various types of body armor may be resilient to different things know what type of body armor your service provides what caliber handguns is your vest safe and effective against and what type of weapon is it not effective against there are weapons available today that will penetrate some of the most resilient vests so take the time to understand exactly what your body armor is designed to do local law enforcement agencies may be best resourced to answer your questions take the time to ensure your body armor fits you properly body armor serves no purpose if it is not worn or worn improperly even with body armor on you should not be entering areas that you will not normally enter without law enforcement personnel",
        "Indicators of Violence": "so let's talk about some indicators of violence if you are dispatched to the scene of a shooting stabbing or attempted suicide potential violence can be obvious obvious always maintain a heightened sense of awareness when you arrive at the scene of an injured person the patient may be upset confused or combative a family member can become emotionally extreme when you when they see a loved one that is severely injured or killed so expect the unexpected identify any potential indicators of violence such as abnormal behavior or body positioning harsh language and do not attack do not develop tunnel vision so becoming so completely involved in the patient care that you fail to see the possibility of harm there are times when there are almost no obvious signs of danger as responders approach the scene so be vigilant and always maintain the highest level of safety",
        "Standard Operating Procedures": "so some standard operating procedures or you'll hear these written as sogs some agencies or regions have developed standard operating procedures for dealing with potentially violent incidents specific procedures for response to potentially violent incidents provide paramedics with specific steps to take at such scenes all always use sops and policies as the basis for your approach to the scene or to the patient sops or policies will not be able to cover every single possible scenario so be prepared to modify them if they interfere with the preservation of life and or your partner's life",
        "Highway and Rural Road Incidents": "highway enroll incidents so in a study published in 2013 86 of all fatalities involving ems were transportation related be aware of violent patients moving vehicles and drivers gawking at the scene of an incident a major motor vehicle crash could be a common communation combination of a number of events so it could be an armed robbery or drug use or stolen vehicles also perpetrators fleeing the scene of a violent crime",
        "Approach and Vehicle Positioning": "an incident with a single vehicle where dangerous high and you're the first responder stop a minimum of 21 feet behind the stop vehicle stop at a 10 degree angle to the driver's side facing the shoulder your front wheel should be turned all the way to the left wheels and the motor block will provide limited protection in the event of a gunfire if you are not the first vehicle at the scene ask the incident commander or the ic where you should park your vehicle and try and park downstream of the incident your agency may have specific policies regarding the use of light after dark you may be your vehicles you may use your vehicle's high beams and spotlights to illuminate the patient's vehicles bright light will also conceal you as you approach the vehicle do not walk between the spotlight and the vehicle i'll alert any responsive occupants to your position do not approach a vehicle if you have an uneasy feeling about it before leaving your vehicle consider notifying the dispatcher of your situation your location and the license number and state of the motor vehicle the motor vehicle that you're approaching if something appears or something happens to you and your partner a record of the motor vehicle will then exist this information will allow the agency to react quickly",
        "Approaching the Motor Vehicle": "okay and when you approach the vehicle use a systematic approach to this vehicle and it's usually not required by ems personnel though but if you arrive at the scene of a rollover crush you find a vehicle on its side you can approach with a standard method if you are responding to an unknown problem and you may consider a more strategic approach okay so let's follow these procedures when there are two or more paramedics in the unit the person riding in the right front seat makes the approach all other members of the response team remain in the ambulance or medical unit proceed to the rear passenger trunk area look out for people hiding in the trunk of the vehicle check the trunk lid to ensure that it is properly closed if the trunk lid is open retreat to your vehicle proceed to the sea post on the passenger side of the vehicle so stop at the sea post and look in the rear and side windows notice the number of people in the vehicle pay particular attention to the location of their hands look for weapons if you see a deadly weapon retreat to a safety safe location and call for law enforcement never attempt to unload a weapon your awareness that an object such as a bat or a pipe is within the reach of people in the vehicle gives you time to react if you if the object becomes a weapon if the back seat is occupied do not pass the sea post move forward to the b post if there is no passengers in the back seat examine the front seat area are there occup where are the occupants hands and what are the occupants doing were are any visible weapons when letting the driver know what you are that you are there and why you are there do so without moving past the b post into the driver's area law enforcement refer to this zone as the kill zone tap lightly on the window at the vehicle of the vehicle and announce yourself paramedic do you need help after the ic declares that this incident is safe follow your sops for your department keep your flashlight off until you need it and hold the light at arm's length away from your body before you turn it on illuminate the scene for any for only a few seconds during each use take special precautions when approaching vans vans can carry many types of cargo cargo and a large number of people that you cannot see take the following steps for a safe approach to a van so move 10 to 15 feet away from the passenger side of the van remain clear of the side door with throughout the approach walk parallel to the van until you are approximately 45 degree forward of the a post this will give the greatest visibility inside of the van from this distance and it keeps you at a safe distance as well",
        "Retreating From Danger": "okay if you have to retreat from danger the safest means of retreat is to back away and call for law enforcement assistance if your partner is injured while approaching the motor vehicle back away and call for assistance the dispatcher with the following info so you want to identify your ambulance your location and the location of the injured the number of aggressors involved the number and type of injuries the number and type of weapons the make model and color and license plate number of the vehicle involved and the direction of travel if the vehicle leaves the scene before leo arrives make sure you document in detail why you had to leave the scene",
        "Residential Incidents": "okay so when it comes to residential incidents there could be warning signs so the calls that require an obvious level of caution include assaults domestic disputes shootings or stabbings routine calls also have the potential for violent outcomes so for any call involving violence allow law enforcement personnel to arrive and secure the scene before you enter ensure that the scene is safe before going in to provide patient care and continually re-evaluate the situation while providing patient care",
        "Approaching a Residence": "when you and your partner arrive at the scene of the residence listen for loud threatening voices glance through the available windows for signs of a struggle and look for visible weapons one of you should approach the house while the other one stays a short distance away anytime you perceive danger back away to your vehicle call for law enforcement assistance and wait for officers to arrive",
        "Entering a Residence": "when you enter the residence use an alternative path while approaching rather than using the path to the front door once at the front door stand on the stand on the doorknob side of the door when you are preparing um to knock if you stand on the hinge side any person in the room can observe you by opening the door only slightly knock on the door and announce paramedics or fire department or rescue squad and this will ensure that you are not mistaken for law enforcement ask whoever opens the door to lead you to the patient the person who leads you acts as a shield for you this gives you an extra few minutes to react if the situation deteriorates when entering any type of structure pick a primary exit usually the door that has used that is used to enter the building or pick a secondary entrance or exit this might be a rear door or a rear window and try and keep at least one means of escape accessible at all times as you arrive at the person's location scan the room for weapons back your way out of the residence if there is a gun or knife and call for law enforcement many people keep loaded firearms in the house for personal protection such as in nightstands dresser drawers or a table next to a comfortable chair be aware of objects that can be used as weapons such as ashtrays scissors bottles or fireplace pokers knitting needles or and move any potential weapons out of the patient's",
        "Domestic Violence": "reach when it comes to domestic violence if a violent or physical dispute is in progress when you arrive at the residence wait for law enforcement personnel these types of scenes typically involve heightened emotions that are already reaching a boiling point prior to arrival use good communication skills in conjunction with eye contact and appropriate body language to defuse the situation know that words to to use or not to use and be aware of tone pitch and rhythm of the your voice and talk to people with the same respect as you would expect from them you may also use a technique known as contact and cover one paramedic makes contact while the other one will provide care so the second paramedic obtains patient information and guides the level of tension warns his or her partner at the sign of trouble so conduct yourself as a professional no matter how unpleasant or difficult the situation crisis intervention is not part of your job and should not be left and should be left to professionals you may be required by law enforcement to report certain conditions to local authorities such as domestic violence or child abuse",
        "Clandestine Drug Laboratories": "okay so let's talk about violence on the streets and the first one we're going to talk about is clandestine drug labs okay the the popular most popular substance manufactured in clandestine labs is methamphetamines and this is also known as meth or speed or crank um so clandestine lab drug labs are incredibly dangerous to medics because the chemical chemicals are highly flammable and toxic so you want to evacuate immediately and request appropriate personnel to respond some methamphetamine cooking operations may look like a chemistry laboratory but others are harder to recognize with only a few signs there are large quantities of over-the-counter cold remedies they contain epi epiphedrine and pseudoephedrine in gallon containers of camping fuel you may see or sulfuric acid in the form of lye some cookers use booby traps to safeguard their operations so fragmentation or incendiary devices animal traps or impaling stakes so once a clandestine laboratory is identified remain clear of the area until the scene is secured by trained law enforcement personnel and hazardous materials specialists take any patients with you if you do if you can do so without exposing yourself and your team to additional danger",
        "Gangs": "okay so the next violence in the streets we're going to talk about is gangs and in 2012 the national gang center estimated there are pro approximately 32 000 gangs with almost 1 million members gang activity has migrated to suburban and rural places in order to evade law enforcement and other gangs also to extend their influence to recruit new members promote drug trafficking into virgin areas and gangs predominantly survive through the drug trade but also earn money through robbery extortion human trafficking gun running prostitution rings identity theft there are three different types of gangs so you have street gangs you have prison gangs and then you have motorcycle gangs gangs operate differently with rules on sex age race religion and national origin but all have similar codes with regards to committing violence most gang communication is far more sophisticated than the um familiar gang signs so multiple prepaid cell phones that are easily discarded they use text messaging email and satellite communications as well also internet social networks so contact your local law enforcement to ask about gang known gang territories and when entering these areas be mindful of the threat of gun violence and the types of activities these local games might be involved in encourage your service or agency to work with law enforcement to share this information new gangs that may be entering or turf wars that are ongoing or may start illegal activities that are on the rise last thing a rival gang wants to see his paramedics coming to rescue their person that they just shot or stabbed situational awareness is the best and often the only defense in potentially violent situations so you should know your surroundings the people and groups in your environment and the climate of violence and or strife",
        "Mass Shootings, Active Shooters, and Snipers": "okay the next um violence in the streets we're going to talk about is mass shootings active shootings and snipers and so the paramedic is an integral part of emergency operations at mass shootings paramedics must prepare plan and train for these complex and difficult violent incidents you may find yourself on the site on the scene of an active shooter an active shooter is a gunman who has begun to fire at people persons who appear to be released hostages could in fact be perpetrators so paramedics must make direction from take direction from law enforcement personnel whom to treat whom when to treat and never how to treat okay so this situation is largely based on the safety of the location you may have ethical or moral questions about whom to treat you may be directed to leave someone who may be medically salvageable but in is not in a secure area the time to dispute the ethics of what is being asked of you is not while there is an active shooter at large refer any serious matters to your on-scene dispatcher only if time permits if it is a crime scene you must follow the directions of law enforcement personnel until the scene is secured with a rescue task force ems can move forward with law enforcement minimizes the time before injured personnel can receive initial treatment and it also also the patients with penetrating trauma may benefit from early hemorrhage control or simple airway maneuvers paramedics should remain in the staging area until the scene is secured they may need to be one half to one mile away from the active scene line of sight or line of fire from windows must be avoided paramedics who respond to a mass shooting or active mass shooting seen need to know how to use cover and concealment cover objects are obstacles that are difficult or impossible for bullets to penetrate such as trees utility poles male collection boxes dumpsters curbs vehicles depressions in the ground use concealment when coverage is not readily available so concealment could be tall grass or shrubs or dark shadows paramedics should consider having a training session with local police to learn how to assist the police officer who has been shot and address specific topics on removal of the body armor and on officer duty belt and establish the protocol for who removes the officer's weapons and how tactical paramedics are used when there is actual violence or violent potential for violence so tactical paramedics are specially trained medics who provide medical care for swot or mobile response teams barricaded patients or patients being held hostage or other special circumstances they these are excellent training opportunities where multiple agencies can practice their response plans to identify their strengths and weaknesses there is an ongoing discussion about the role of a paramedic in an active shooter response become active with your local law enforcement agencies to plan the best approach",
        "Hostage Situations": "okay we mentioned this on the last slide but we're going to talk now about hostage situations and so hostage situations are under the jurisdiction of law enforcement until the scene is secure hostage situations or hostages are usually held as collateral to ensure compliance with a promise if you are taken hostage you can increase your chances of survival if you can anticipate the feelings and actions of the hostage taker and negotiations psychological results of being held hostage are a greater concern than physical problems a person can develop post-traumatic stress disorder it is wise to seek counseling after your release even if you think you don't need it if you are taken hostage manage yourself in your personal environment do not do anything that will attract unwanted attention do not stare at them if you're hostage can takers believe you are in any way or you irritate them then they might kill you okay so your chance of survival is to maintain your role as a bargaining chip your hostage may look to you for guidance and strength because of your uniform your captors may consider this as a threat to their authority so remove the badges collar pins and patches from your uniform or turn your shirt inside out ask to treat the wounded if possible even for minor injuries this will serve to help you gauge their intentions okay so it may make you seem less threatening as well and your mind will stay sharp by performing tasks that are you're used to doing and this will hopefully offer your captors some comfort okay so you may also consider offering treatment to any of the captors as well",
        "Contact and Cover": "so once again let's talk about coverage and concealment so there's no guarantee for your safety for paramedics if you see law enforcement personnel seeking cover you must not remain in the immediate vicinity remember the objects that provide cover and those that offer concealment only you should make your body conform to the shape of the object as much as possible people shooting from a higher position can usually see the upper part of your torso or head over the cover use the engine block or wheel area of a motor vehicle accident select a fire hydrant as a cover only if you cannot immediately find larger objects your central body mass vital organs will be protected items inside a structure can provide coverage or concealment such as you can use furniture or appliances a solid oak base or refrigerator can stop a bullet and a sofa or stuffed chair can be used for concealment so this figure on the slide shows areas of the car",
        "Using Walls as Cover": "okay so using walls as a cover you cannot assume that the wall will provide safe cover many only provide concealment you must determine if the line or the type of the wall that you've chosen gives you coverage or concealment so a brick or concrete are much safer than cinder blocks cinder blocks will not absorb the bullet's energy most interior walls are constructed of wood or aluminum studs and cover covered with drywall or siding they are not or they are not impenetrable so they can be penetrated if you're only protected protection is from behind a frame wall stand near the door or wood or windowed frames the frames of the usually construction with extra framing materials and contain more wood or in the frames",
        "Evasive Tactics": "okay so we're going to talk about evasive tactics next and so change locations only if the new location is better cover or further from the hostile atmosphere or accessible without revealing yourself to the attacker before changing locations look out for your cover several times look for a different height and angle each time and always return to cover as quickly as possible if you decide that you would be safer in another location run in a zigzag pattern you have less chance of being hit if your movement takes you across the assailant's field of view",
        "Concealment Techniques": "so concealment techniques um we talked about this a tiny bit we mentioned tall grass shrubbery and large shadows are considered areas of concealment so when coverage is not readily available use concealment to provide some protection while you assess your position and seek cover areas of concealment are more common after dark than daylight hours so if you are involved in a violent situation at night move into the darkness or shadows and stand still in rural areas tall grass or a cornfield can conceal you whether it is day or night so remain motionless so the foliage does not move all right so recognize the potential for violence when you arrive on the scene and we're going to talk about self defense next so this gives you time to request support and protection from law enforcement personnel if you um stage but you must also consider what you what to do if the violence is ongoing or breaks out while you're providing care you need to consider taking a self-defense course identify yourself if someone prevents you from reaching your patient instruct the person to move away and inform the person you will not be able to help the patient if you are not allowed access you should still contact your dispatcher and request law enforcement personnel to assist if the person moves out of your way still contact them if the person doesn't move take a side step and repeat the request keep in mind that a verbage change or threats to some in law enforcement may only further anger the opposition so if you can control an unexpected attack always make sure your exit path is not blocked and you can easily retreat the way you came in hold household household objects to obstruct the assailant's path towards you as you retreat stretchers and equipment are also excellent obstructions",
        "Self-Defense in Armed Encounters": "self defense in armed encounters so distraction techniques are useful in breaking the chain of events in a shooting incident and in preventing attacks with shop objects decrease your inc increases your chances of survival by giving you time to escape it does not have to be elaborate when something is coming towards you your initial instinct is to blink or flinch this is the type of reaction you want to provoke throwing a lightweight object may elicit the desired response so this does not have to be accurate or in order to erupt the chain of events as long as you it as long as it causes enough time to prevent you to get out of the line of fire and run to safety if the patient takes aggressive action during your initial interview one technique is to throw a light object directly at the aggressor's nose use a soft or lightweight object that will not cause undue harm and once the object leaves your hand turn towards your vehicle get out of the potential line of fire and run to safety put as much distance between you and the aggressor as possible and use physical force as a defensive technique not as an aggressive motion the amount of defensive force needed to protect you varies with each incident if you believe your life is an imminent harm any action that gets you out of the situation is reasonable level of force",
        "Crime Scenes": "okay so crime scenes maintaining the integrity of a crime scene increases the probability that the suspect will be captured and convicted",
        "Preserving Evidence": "when you when you talk about preserving evidence there are generally two types of evidence there's testimonial evidence and then there's real or physical evidence so testimonial evidence is oral documentation by a witness of a criminal act and real or physical physical evidence it ties a suspect to or ties a suspect or victim to the crime and includes body materials objects and depressions do not disturb damage or alter physical evidence at the scene small blood stains can yield critical for forensic information an unnecessarily cutting or removal of clothes can destroy or dislodge fibers hair or other evidence when using trauma shears to remove clothing necessary to assist and treat the patient of ensure to avoid any bullet holes or knives marked in the clothing cut along the seams of the clothing clothing so the larger surfaces remain attacked and do not shake clothes once they have been removed you do your best not to leave any of your own evidence on the scene if you must remove a piece of evidence in order to treat the patient place each piece of evidence into the brown paper bag if the item is saturated place the paper bag into the plastic bag for biohazard control there are situations in which you must recognize that life-saving efforts are feudal and the initial initiation of resuscitation is not medically indicated your response may involve high levels of emotions and adrenaline do not get caught up in the emotions of the call and attempt a full resuscitation on a patient who is not salvageable there are many there will be many times law enforcement officers ask for you to enter into a crime scene to determine if the patient is dead based on your predetermined criteria always follow local protocols follow law enforcement direction when you are asked to park in a specific area or to avoid a certain location the number of ems personnel entering the scene should be limited to only those that are necessary every time they enter a crime scene they deposit evidence so evidence can collect on their clothes and damage it or make it unuseful so every interaction with a space or surface entails the disposition of your dna into that area you want to limit your time and interaction of what you touch with the crime scene okay so always wear your gloves as well when entering first responders are typically the first to enter a crime scene regardless of how careful you are the scene is automatically altered paramedics are often asked to speak with investigators and prosecutors who will want to know um actually what they saw what they touch what they smelled what they heard what did they what did they do while they were there do not clean up the scene do not alter items do not move bodies unless doing so is essential to establish the need for resuscitation be mindful of bullet casings weapons blood splatter and puddles whenever possible walk around such evidence do not pick up expended cartridge casings to determine the caliber do not use cell phones flush toilets or turn on water in the sink it's imperative that the instant be properly documented a lot of time can elapse between the call and when you're asked to provide information or testimony so your documents may be read by dozens of people and potentially the jury the better you document the more likely it is that you will recall what the witnessed what you witnessed years later and finally elements of proper documentation include what you saw what you heard what you were told what you spell smelled if there are any odors and what you moved altered or disturbed pain of custody of items that were presented to you and what you found on the patient a description of the scene um so how many patients or was the patient supine or prone and where was the weapon were any characteristics of the scene noteworthy and do not draw conclusions or uns overstated facts so when i document any statements made by the patient during transfer to the medical facility and they should be documented as well okay so thank you for joining us today for chapter 52 we hope that you've enjoyed it thank you"
    },
    {
        "Introduction": "hello and welcome to chapter 46 transport operations of the paramedic nancy caroline's emergency care in the streets",
        "National EMS Education Standard Competencies": "upon completion of this chapter and the related course assignments you will be able to summarize the types of medical safety and operations equipment carried on the emergency vehicles completing regular vehicle inspections is very important there are dangers to consider while operating an emergency vehicle in emergency mode and safety guidelines that should be followed while driving the emergency vehicle the risk of operating the emergency vehicle in emergency mode should be analyzed and additional risks during travel and transport need to be considered issues of safety also need to be considered for air medical transport particularly when preparing a landing zone and approaching the aircraft this chapter will help you understand the operational rules and responsibilities to ensure the safety of yourself your patients and the public so let's get started",
        "Emergency Vehicle Technology": "today's emergency vehicles are equipped with state-of-the-art technology defibrillators and monitors that can transmit information to the emergency department blood ox testing equipments automatic ventilators automatic cpr machines global positioning systems and mobile data terminals are just a few of the equipment so driving an emergency vehicle or service vehicle requires good techniques and judgment you need to be aware of the safety of your crew and passengers you're responsible for the safe passage of other vehicles on the road and activating the lights and sirens does not ensure that you will be heard or understood by other drivers",
        "Emergency Vehicle Design": "so let's talk about emergency vehicle design first current specifications for emergency medical transport vehicles were originally developed by the u.s general services administration in the 70s design and manufacturing guidelines are outlined in dot kkk 1822 were renewed and updated every five years many states adopted the guidelines for emergency vehicles in their area because the guidelines allow for more government grant funding there are two specifications being considered as replacements for this 1822 guidelines so the first one is the national fire prevention agency and that's the nfpa and it published the first specifications for emergency transport vehicles in the nfpa 1917 guidelines in 2013. then the second is the commission on accreditation of ambulance services and that was developed they developed a set of guidelines for emergency vehicle specifications and it's uh in gvs dash 2015. okay so there's three major emergency medical vehicle designs there's type one through three but there's also a heavy duty um style design so the type one is conventional it's a truck cab chassis type two is a standard van and type three is a specialty van but then you also have the heavy duty and it's an extra heavy duty vehicle improvements made to emergency vehicles over the years include enlargement of the patient compartment safety nets on the squad bench padded cabinet counters and corners and recommendations from the society of automotive engineers have been made",
        "Emergency Vehicle Equipment": "okay so emergency vehicle equipment every inch of space on an emergency vehicle is dedicated to storing and securing equipment many organizations have influenced the list of supplies and equipment that should be carried on today's units osha so the occupational safety and health administration makes recommendations regarding infection control practices and the american college of surgeons developed the first standardization list of equipment in 1970",
        "Checking the Emergency Vehicle": "checking the emergency vehicles what we're going to talk about next and so prior to a call crew members are responsible for ensuring the unit is capable of responding and that the proper equipment and supplies are available each time supplies and equipment are used they should be properly cleaned and replaced medication expiration dates must be checked regularly and diagnostic equipment must be tested and calibrated regularly the emergency vehicle inspection should include fuel levels oil levels transmission fluid levels engine cooling system and fluid levels batteries brake fluid engine belts and tires and wheels you want to check the inflation pressure and look for signs of unusual or uneven wear wear all interior and exterior lights horn including the siren and air conditions ventilation system and doors communication systems and which include the vehicle and portable you want to check the mirrors and then check for cleanliness any threat to one of the four s's should prompt the operator to put the vehicle out of service immediately and so this is uh the four s's include start steer stop and stay running warning signs of impending problems should include belt noise so if you hear squeaking or brake fade so that is the sensation of your losing power in the brakes it could be overheating of the brakes or loss of vacuum or maybe loss of brake fluid and then you have brake pool so that feels like something's trying to pull the steering wheel from left to right when you depress the brake also drift that's when the vehicle wanders to left or right when you let go of the steering wheel also the steering wheel so persistent tug on the steering wheel as it drifts from one side to the other that could be from any uneven tire pressure or misaligned wheels or maybe a mechanical problem pulsating brake pressure so up and down motion of the brake pressure when decelerating and steering play so that's a looseness in the steering tire squeal that singing sound when you turn the vehicle at parking speeds or wheel bounce that's a vibration felt in the steering wheel or driver's seat or wheel wobble that's a common finding at low speeds when a belt wheel is bent sorry at low speeds when i when you have a bent wheel okay so emergency vehicle staffing and development so emergency vehicle staffing has been a major source of controversy over the past decade due to escalating costs of medical care fuel and emergency vehicle ops an effort to maximize productivity and minimize response times high performance ems systems analyze response teams productivity unit costs and taxpayer subs disease an emergency vehicle and ems system so in the united states most first response emergency vehicle services are delivered by the fire department whose personnel are cross-trained in ems in other areas emergency vehicle service is provided by private or for-profit agencies every vehicle service may also be delivered by public agency that's not part of the fire department so staffing of emergency vehicles varies between and within ems systems okay so",
        "System Status Management": "you're going to hear the term system status management throughout your career and uh it's uh ssm and it was developed by jack stout in 18 or 1983 the goal was to minimize response times and maximize efficiency so its data is compiled and used to determine emergency vehicle service demands taking into consideration peak loads and the peak load is an increased demand during certain hours and strategic deployment is used to maximize response times when demand is higher so deployment is a positioning location and it can take advantage of satellite vehicle location and gps so ssm helps organize peak demand staffing and you shift schedules to provide a significant number of sufficient number of emergency vehicles during peak load hours ssm can take a toll on personnel who have less downtime in between calls",
        "Emergency Vehicle Stationing": "in emergency vehicle stationing so the goals are to maximize efficiency and minimize response times okay so factors include distance versus call volume so special facilities that create increased emergency medical demands for example long-term care facilities need for maintenance of vehicles storage you want classrooms for training and meetings and also sleeping quarters for personnel who spend the night",
        "En Route to Scene": "mitigating hazards throughout the call okay so let's talk about enroute to the scene the end route phase is potentially very dangerous due to collisions as you prepare to respond to the scene fasten your seat belts inform dispatch and confirm the nature and location of the call ask for available information while you're in route prepare to assess and care for the patient review dispatch information assign specific duties and scene management tax decide which equipment to take and if appropriate decide which stretcher to take",
        "Securing Equipment": "and then when you're securing equipment make sure all equipment is secured before placing a vehicle in motion driving rapidly will cause objects to shift in the rear compartment items placed on the squad bench can end up scattered all over or broken on the floor and a piece of diagnostic equipment or portable oxygen cylinder can become a lethal projectile if it's not secured",
        "Arrival at the Scene": "all right and so after we are in route to the scene we arrive at the scene we want to perform that scene size up and report to dispatch and we're not going to enter the scene if there are any hazards if there are hazards the patient should be moved before care is begun and we're going to use the following guidelines so we want to look for safety hazards evaluate the need for additional units and determine that mechanism in trauma patients or the nature in the illness patients we need to evaluate the need for any specialized equipment take standard precautions as well and if we're the first ems provider at the scene with multiple patients we need to estimate the number and inform dispatch if we need more units ems personnel might be assigned such rules as triage treating and loading patients",
        "Traffic Control": "and then there's traffic control so the purpose is to ensure orderly traffic flow and prevent another crash traffic control is difficult under ordinary circumstances emergency workers are required to wear reflective vests in both daytime and nighttime mops on federal aid highways you as soon as you can place reflectors and other warning devices on both sides of the crash",
        "Safe Patient Transfer": "so safe patient transfer so excessive speed is unnecessary and dangerous in most cases the goal is safe transport of the patient to the appropriate medical facility in the shortest practical time secure the patient with at least three straps across the body a deceleration straps or stopping straps are over the shoulders and that prevents forward movement if the emergency vehicle suddenly slows or stops okay so after the call is over you have the post run activities that includes restocking cleaning and disinfection so clean and disaffect emergency vehicles and equipment use restock supplies perform routine inspections and decontaminate the emergency vehicle so the definition of cleaning we're going to talk about four different definitions right now you have the definition of cleaning and that's removing just dirt dust and blood then you have disinfection and that is killing pathogenic agents by applying chemicals then you have high level disinfection that's killing pathogenic agents by use of a potent disinfectant and then you have sterilization that's removing all microbial contamination with the use of heat or other appropriate processes after each trip you must do the following you need to strip the linens place in a plastic bag or designated receptacle appropriately discard disposable equipment and wash and contain wash all contaminated areas with soap and water scrubbing blood vomit and other substance disinfect all non-disposable equipment and clean the stretcher with the eap registered germicidal solution or bleach and water with a 1 to 100 dilution clean up all spillage with the same germicidal or bleach solution replace or repair broken or damaged equipment and replace any equipment or needed supplies refuel the vehicle check the oil restock any supplies you do not get from the hospital and create written procedure for cleaning each piece of equipment okay so defensive emergency vehicle driving techniques is what we're going to talk about next more than 6 000 emergency vehicle crashes occur each year learning how to properly operate your vehicle is just as important as knowing how to care for your patient an emergency vehicle involved in a crash delays patient care and could take the lives of ems providers other motorists and pedestrians participation in a certified defensive driving course is strongly recommended every emergency vehicle service must ensure the personnel are safe drivers before they begin deployment or employment and continue their training after they are hired",
        "Driver Characteristics": "so some driving characteristics not everyone who drives an automobile is qualified to drive on in some states you must pass an emergency vehicle operations course so important characteristics to possess include diligence positive attitude and tolerance requirements also include physical fitness so do not drive if you're taking medications that could cause drowsiness or drinking alcohol or if you're too fatigued and then emotional fitness so emotional maturity and stability are directly related to your ability to operate under stress proper attitude and good judgment and knowledge",
        "Safe Driving Practices": "safe driving practices you need to route planning and navigation so even if you use gps make sure you have easy access to detailed street and area maps and become familiar with roads and traffic patterns in your area so that you can plan alternate routes avoid heavy traffic areas and no ways around open bridges or congested areas maybe school zones or construction zones and be familiar with special facilities and locations in your area such as medical facilities or airports okay so recognize when you're fatigued and do not be ashamed to admit when you're fatigued and place yourself out of service until the fatigue is passed distractions also so personnel riding in the passenger seat are responsible for taking on the radio and operating audible devices do not rely totally on gps as well and while driving never attempt to type on the computer or text or listen to music or eat or drink use of safety restraints so all passengers including ems personnel should wear seat belts parents should not be allowed to hold their children and children should not be transported on the stretcher unless they are restrained also speed do not allow the type of the call to affect how you're responding while driving and lights and sirens should never be used to transport a non-emergency patient paramedic riding in the rear of the vehicle should uh with the patient should make that decision so decisions should not be guided by the surrounding traffic and driver anticipation so the driver should recognize that all other drivers are unpredictable do not expect them to pull to the right to allow your vehicle to pass some drivers may not even realize you're behind them and then some may stop suddenly out of panic so always maintain a safe distance traveling between vehicles and do not respond aggressively and do not accelerate through intersections make eye contact with fellow drivers use turn signals and never force a vehicle into oncoming traffic when we talk about a cushion of safety this is maintaining the safety following distance from vehicles so you want to drive four to five seconds behind the vehicle driving at an average speed you need to avoid being tailgated and make sure you're aware of blind spots so blind spots could include mirror obstructions or rear of the vehicles or side of the vehicles the vehicle size and distance judgment so the vehicle length and width are critical when maneuvering driving and parking and to brake and pass effectively you must know the width and length of your vehicle you should avoid um whenever possible backing and if back if backing up a vehicle is necessary you should follow the rules use a spotter to guide you and agree with the spotter before you begin moving the vehicle and keep your spotter in view at all times stop if you lose sight of them so keep your window crack or roll down in the motion so you can hear them do not walk around be or do a walk around before getting behind your wheel and use audible warning devices when the vehicle is in motion and do not rely totally on that backup camera if there is one available so when you park at emergency scene allow for efficient traffic flow to be controlled and do not block the movement of other emergency vehicles so they want you to park about 100 feet past the seam on the same side of the road park uphill and upwind that's important in case smoke and hazards exist and keep warning lights on if you park on the back side of a hill or a curve or if parking at night and stay away from fires explosions down down wires and structures that might collapse and always use your parking brake leave emergency warning lights on we just talked about that try to park as close to the scene as possible and park where your departure will not be hampered and be aware of the terrain turn your headlights on um but don't blind oncoming traffic at night just be aware of that and always wear visible protective clothing such as a reflective vest",
        "Emergency Vehicle Control": "so emergency vehicle control when we talk about this there are two ways to control a vehicle you can change directions or change speed and so both require continuous rolling contact between surface and tires and the surface of road so you want to grip on the road and it may vary depending on the condition of the surface or age of the road tires or weather and drivers must constantly evaluate the road surface especially when cornering so road positioning and cornering so a road position so position of the vehicle on a road relative to the inside or outside edge of the paved surface so take the corners at a speed that will put you in the proper road position an apex of turned through a curve so point at which vehicle is closest to the inside edge of the curve so if you reach it early the vehicle will be forced outside the roadway but if you reach it late the vehicle will stay inside of the roadway you could see that in the picture on the slide then when we talk about braking you get getting a feel for the brake pressure comes with experience and practice so type one and three vehicles have heavier feeling breaks than type two get to know each vehicle you drive",
        "Controlled Braking": "so there's a thing called control braking and a controlled braking u is used to control the vehicle's movement and direction braking while traveling in a straight line is most effective efficient of course in weather and road conditions so weight distribution of the vehicle should be taken into consideration during inclement weather you will need more room to come to a complete stop and the line of sight is limited we're going to talk about hydroplaning and that's the tire that's when the tire is lifted off the road as water piles up under it it occurs at speeds of greater than 30 miles per hour on wet roads you want to gradually slow down without slamming on your brakes when it does come to water on the roadway when possible try to avoid it driving through standing water because what breaks increases the stopping time and pool it could pull to one side if you cannot avoid it lightly tap the brakes several times after driving over the water just to try and drive dry them because if anti-lock breaks apply steady light pressure to dry the brakes if you have those then there's decreased visibility so during fog snow smog heavy storm or heavy rain slow down and use your low headlights always use headlights during the day to increase your visibility then when it comes to ice and slippery conditions all weather tires and appropriate speeds will reduce traction problems so consider using snow tires and be especially careful on bridges and overpasses when temperatures are close to freezing",
        "Laws and Regulations": "okay so we talked about driving so we're going to talk about laws and regulations of driving and they vary from state to state and city to city emergency vehicle drivers have certain limited privileges so there are privileges but they don't lessen the liability in any crash the use of warning lights and sirens allows ems drivers to do the following so to park or stand in an otherwise illegal location to proceed through a red light or stop sign only after stopping first though complete stop to drive faster than the posted speed limit to drive against the flow of traffic on a one-way street or make an illegal turn to travel left of center to make an illegal pass so right-of-way privileges so they vary from state to state just as i said and should be used only when absolutely necessary some states allow you to proceed through a red light or stop sign but you have to stop first and some states will allow you to proceed through a controlled intersection with due regard that's the key thing there do regard using flashing lights and sirens and know your right away privileges the use of morning lights and sirens so unit must be on a true emergency call to the best of their knowledge both audible and visible warning devices must be used simultaneously when taking except when taking exceptions to traffic laws so units must be operated with due regard for safety of all others and sirens must not siren is most overused piece of equipment on the ambulance okay so when it comes to use of escorts uh following another emergency vehicle that uh through traffic that would be using an escort is generally not a good idea many drivers only see that first set and then they assume it's clear so if doing so leave enough space between the vehicles so you have enough time to react if somebody pulls out in front of you instruct family members that they cannot drive close to you if someone has not heeded the warning consider turning off your lights and sirens and slowing down to a normal speed so there's intersection hazards and these crashes are the most common and most serious type of crash look for motorists and pedestrians before proceeding and a motorist who time the traffic lights are serious uh hazards and so unpaved roadways and rural settings operate the vehicle at a lower speed and maintain a firm grip on the steering wheel do not drive onto unpaved or grassy areas when the ground has been saturated and often uh other agencies such as forestry service will help in remote locations so be cautious of animals also entering the roadway when it comes to school buses so you can never pass a school bus that has stopped to unload or load children stop before reaching a bus when it's flashing you have to wait for the driver to ensure the children's safety close the door and turn off those lights before you could proceed and also when it comes to school zones lights and sirens could attract children onto the roadway this creates a dangerous situation in many states it's illegal for an emergency vehicle to exceed the speed limit in a safe school zone and then also with funeral processions most states offer no exception when approaching a funeral procession out of respect most drivers turn off those audible devices",
        "Air Medical Transports": "okay so we talked about the rules and regulations now we're going to start into talking about the air medical transports so air medical transports can speed the transfer of patients from a trauma scene to definitive care only appropriate in certain circumstances though and you need to consider some factors and those are does the patient's condition warrant the risk of using air transport also will the use of air transport truly save time so we're going to talk about some different types of the aircraft so you have the rotor wing versus a fixed wing and so rotor wing is a helicopter and they're the standard of care for transport of critically injured and there's a fixed-wing aircraft and they are used mainly for long distance transport and so we're going to talk about some advantages of using them they may help the patient receive definitive care within the golden hour and sometimes you'll hear it called the golden period it could reduce transport time if distance is extreme so the decision should be made as early as possible also weigh all the time factors so you have to remember that the the helicopter has to be started and personnel and gear must be loaded sometimes there's great distances that may need to be covered aircraft must land on the scene and then you have to transfer the care to the crew and then the patient must be packaged so but it provides less injury to patients and spinal injury over if you're on rough terrain so paramedic on scene is the best judge of all of those needs and you're going to have to be that person",
        "Disadvantages of Using Aircraft Transport": "there's disadvantages though of using that aircraft cardiac arrest patients need to be transported by ground because of the limitations you can't do cpr the chest compressions and then there's weather and terrain they can prevent prevent use so uneven ground and loose objects should be taken into account before landing and then altitude limitations air speed limitations and then there's the cost patient's condition and then the potential for the crash and restraints on number of caregivers as well",
        "Helicopter Medical Evacuation Operations": "so helicopter medic medical evacuation operations so med evac is a medical or trauma air evacuation become familiar with med evac on the capabilities protocols and procedures i'm calling for one of a medivac so why would you call and uh of course that's ground transportation will take too long or road traffic and environmental conditions is limits and prohibits the use of ground transport also patient requires advanced care and or multiple patients will overwhelm the hospital if reached by ground and who would should receive the medvac um patients with time dependent injuries or illness or patients with serious conditions or trauma patients and candidates for limb re-plantation or burn center or also hyperbaric chamber or maybe a venomous bite center and who to call so notified dispatch if requesting it um and uh after air medevac or medevac has been initiated ground crew may assess flight crew access flight crew on the radio frequency so present patient's condition clearly and concisely there are some issues though so factors of course is the weather um and if it if there's they can't operate in severe thunderstorms or blizzards so um then the environment of course the helicopter must be able to safety land and then in some conditions there's altitude problems and then air speeds so they typically fly between 120 to 150 miles an hour also cabin space and cabin size and of course because that limits the number of patients that can be transported and the size of the patient and then we talked about the cost and a military helicopter might be able to transport critically ill or injured patients and that's depending on the availability and circumstances",
        "Establishing a Landing Zone": "so when you establish a landing zone for these helicopters um it's the responsibility of the ground crew and so it's going to be your responsibility and the area um should be a hard or cropped grassy level in my area usually it's the law enforcement that does it but ultimately it's the ems crew and so it should not be less than 60 by 60 feet it's recommended to be a hundred by hundred feet for that um landing zone and should be cleared of all those breeze including branches and trash bins no accident tape or medical supplies or equipment so the immediate area should be cleared of overhead or tall hazards such as telephone poles antennas and trees you want to mark the landing zone using weighted cones or position emergency vehicles at the corner of the zone with the taillights facing inward to form an x never use tape or people or flares non-essential persons and vehicles should be moved to a safe place and radio the flight crew the direction of the wind if it's strong okay so you want to be prepared to improvise a wind direction device and um if asked by the flight crew so a bed sheet would work well never use tape and this will allow them to see the direction of the wind as they're approaching right and so many aircraft are now equipped with night vision goggles and large landing zone lights so but they might require turning off and flashing emergency lights at the landing zone once a pilot is aware of the exact location so landing zone safety so be familiar",
        "Landing Zone Safety and Patient Transfer": "with the capacities protocols and methods for assessing helicopters in your area be sure to do nothing near the helicopter and go only where the pilot and crew directs you so keep the pilot in sight and view at all times and keep a safe distance from the aircraft whenever it is on the ground and hot so when it means that the aircraft's hot that's when the tail rotor is spinning if asked to enter the landing zone stay away from that tail rotor tips of the blades move so rapidly that they are often invisible and so this figure shows how to approach that helicopter never approach the helicopter from the rear or duck under the body tail boom or rear um walk in a crouch position when approaching the aircraft and never carry anything above your head when you are operating at the landing zone pay attention to the flight crew become familiar with hand signals used in your jurisdiction and do not approach helicopter unless instructed by the flight crew this figure shows examples of helicopter hand signals make sure all equipment and patients are properly secured and always approach the vehicle from the front unless otherwise instructed by the flight crew smoking open lights or flames or flares are prohibited within 50 feet of the aircraft",
        "Special Considerations": "so some special considerations are night landings so don't shine spotlights flashlights or any lights in the air to help the pilot and direct light towards the ground and smoking open lights or flames and flares are prohibited within 50 feet of that aircraft also when landing on uneven ground approach the aircraft from downhill side only because the motor blade will be closer to the ground on the uphill side and do not move the patient to the helicopter until signaled now medevacs at hazards materials incidents so flight crew should be notified immediately of hazardous materials because the aircraft generates tremendous wind and hazardous vapors will spread landing zones should be established uphill and upwind from the scene and patients exposed to hazardous materials must be decon before they can be loaded into the aircraft okay so this concludes chapter 46 transport operations lecture thank you so much for joining us today and we'll hope that you'll um listen to one of the other lectures have a great day"
    },
    {
        "Introduction to Medical, Legal, and Ethical Issues": "hello and welcome to chapter 4 medical legal and ethical issues lecture and upon completion of this chapter and the related coursework you will understand laws and ethics applicable to pre-hospital emergency care you will be able to differentiate among personal professional and medical ethics including the role of each in providing pre-hospital care you will be familiar with the united states legal system in terms specific to criminal civil and employment law relevant to the paramedic and ems system you will also be able to describe legal accountability of a paramedic as a professional health care provider and be able to explain expectations of the paramedic in patient encounters as it relates to consent and treatment of the patient including how to protect against negligence claims okay so let's get started with the chapter medical professionals provide care under a set of laws affecting how patients must be treated ethics are principles personal and social that determine what is right and wrong and laws have sanctions for violations that are enforceable define the obligations of paramedics and protect our rights and the rights of others they may be set forth by either or both of the federal or state government impacting a paramedic responding to an emergency so there are motor vehicle laws ems legislation medical licensing statutes and regulations civil and criminal statutes and confidentiality laws such as the hipaa which is health insurance portability and accountability act basic understanding of laws and ethics applicable to pre-hospital care failing to perform your job within the law can result in civil and criminal liability and practicing outside of the law can result in regulatory action or action by your agency and medical director an ems provider can be prosecuted in any or all of the jurisdictions for the same case",
        "Ethics": "so ethics it's the branch of philosophy that deals with the study of distinction between right and wrong and the way these concepts are applied applied ethics refers to the use of ethical values okay so there's text as a framework to help you develop legal understanding laws and legal obligations differ among states and contact an attorney who specializes in representing medical professionals if you need legal advice okay so next we're going to talk about",
        "Medical Ethics": "medical ethics and these are personal ethics are the product of your upbringing family community and religion professional ethics arise out of standards and practices of your profession the code of professional contact conduct and state and federal laws in cases where your personal ethics conflict with your professional ethical standards you must temporarily set aside your personal ethics put them aside the interests of your patient must take precedence over your personal beliefs sometimes called bioethics medical ethics are related to the practice and delivery of health care your understanding of medical ethics must be consistent with general codes of the health care professional many ethical codes for health care professionals have existed throughout history",
        "Declaration of Geneva": "the declaration of geneva it was drafted by the world medical association in 1948 it's taken by medical students upon completion of their studies when they are about to enter the medical profession refer to page 97 of the text to review a copy of this oath also the code of ethics for ems practitioners it's issued by the national association of emergency medical technicians in 1978 it's still in use today and under this code the emergency medical technician pledges to conserve life alleviate suffering and promote health provide services based on human need with respect for dignity unrestricted by considerations of nationality race creed and status not use personal knowledge and skill in a way detrimental to public good respect and hold in confidence all information obtained in the course of professional work unless required by law understand and uphold the laws of citizenship particularly when working with other citizens and health care professionals in promoting efforts to meet the health needs of the public maintain personal competence and demonstrate concerns for the competence of other members of the medical profession assume responsibility have the responsibility to participate in study of an action on matters of legislation affecting the profession and emergency services to the public adhere to standards of personal ethics and reflect credit upon the profession contribute to reason in relation to a commercial product or service but not lend a to professional status to advertising promotional sales advertise professional services within the con conformity and dignity of the profession not delegate a service to a person less qualified and refuse to participate in unethical procedures and assume responsibility to expose incompetent or unethical conduct in others to appropriate authorities varying codes of ethics policies and rules for ems professionals by state service or company",
        "The Icare Program": "the icare program this was developed by a group of ems students and educators it incorporates many of the finest qualities of ems professionals icare stands for integrity compassion accountability respect and empathy incorporate eye care into the care you provide to your patients ultimately these codes stem from a concern for patient welfare if you prioritize patient welfare you will rarely if any commit an unethical act regardless of the ethical circumstances you may encounter apply three basic ethical concepts when making a decision the first one is to do no harm the second one is to act in good faith the third one is to act in the patient's best interest so let's talk about the first one",
        "Do no Harm": "to do no harm first do no harm this means take all do care to ensure your patient receives the best possible care and your actions do not harm the patient in assessment treatment and transport to a vi to avoid exacerbating the illness or injury the second one is to act in good faith the third one is to act in the patient's best interest so acting in good faith and in the patient's best interests go hand in hand reinforce your commitment to place interests of the patient above all else and make decisions motivated by a clear desire to benefit your patient so paramedics must be accountable for their actions at all times your behavior on the job and the way you handle situations will shape your career choose a mentor whose style and professionalism you wish to emulate",
        "Professional Ethics": "professional ethics are extremely important ethics are especially important as ems continues to seek funding and recognition similar to other medical professionals immature unprofessional behavior is unacceptable criminal acts are unethical and illegal negative publicity lessens the public's confidence in the service you provide and you should never falsify training records or falsely represent your level of certification always be respectful of patience never do anything to violate their trust in you as a professional and avoid misconduct that could question your ethics or integrity the ethics of your pers profession require a total commitment to acting in the best interests of your patient do not overlook other providers who engage in misbehavior report it to the appropriate chain in the command and report medical errors you make or witness to your medical director as soon as possible the most successful and fulfilled paramedics choose to become patient advocates participate in and actively seek out the best training and professional development and put the good of the team above their own personal aspirations you are responsible for the future of",
        "Ems Ethics Applies to Ems Research": "ems ethics applies to ems research as well so ems practitioners have largely evolved from grassroot efforts properly randomized controlled studies are not common but they are emerging so remember the first principle of medical practice is to do no harm seek continue to seek further education about the effectiveness of the ems practice ems care relies on anecdotal experience that is unsupported by research so some procedures prove not be helpful to patients you should act on those recommendations as well conducting studies on critically ill or injured patients without their informed consent is a true ethical dilemma make yourself aware of how researchers are handling ethical debates concerning patients in research okay so the legal system in the united",
        "Legal System": "states passage administration and interpretation of federal and state laws affecting paramedics so the legislative branch is composed of elected officials congress and state legislators that make laws the judicial branch is composed of the court system it enforces and interprets laws it resolves disputes based on the interpretation of laws",
        "Common Law": "common law is defined as a decision that has been made by a judge through a court base on his or her interpretation of the statutes and constitutions a number of court levels so examples there are trial and appellate and precedence of the law of the state in which the paramedics practice in most cases court decisions establish standard of negligence",
        "Executive Branch": "and then there's the executive branch or the administrative branch this reports directly to the president or the governor it's composed of cabinets and agencies or bureaucrats that carry out and administer laws often use regulations to establish how things should be done for example the us department of transportation at the federal level your responsibility to know and understand your state's laws and administration regulations that affect your practice so let's talk about the types of laws next",
        "Civil and Criminal Law Govern Paramedics in Court": "civil and criminal law govern paramedics in court under civil law a patient can sue you for a perceived injury criminal law allows the state to prosecute a paramedic for breaking a legal statute and malpractice suits are tried under civil law they may be based on statutes but also claims usually arise from principles of negligence in cases of medication misuse are usually tried under criminal law most civil law is concerned with establishing liability or otherwise known as responsibility the judicial process determines who is responsible when a person is injured and seeks redress so citizens have a constitutional right to take legal action against a medical provider they believe provided inadequate care however they must prove that the medical provider was negligent actionable cause could lead to a civil lawsuit so legal action instituted by a private person or entity the defendant is the person or entity against whom a legal action is brought and tort is the wrongful act that gives rise to a civil suit there are two classifications of tort there's unintentional which is negligence and intentional where there is intent to cause harm the purpose of a civil suit is usually compensation or otherwise known as damages for injury the plaintiffs sustained in most medical liability cases the plaintiff seeks compensation for physical suffering mental anguish medical bills and lost earnings the court may also award punitive damage if the misconduct it was intentional or constituted a disregard for public safety to succeed in a civil suit the plaintiff needs to show a majority of evidence favors his or her position the plaintiff must convince the jury of his or her position most ems lawsuits result from emergency vehicle crashes so safe driving is key to preventing lawsuits crashes cause expensive damage and serious harm to providers patients and bystanders other kinds of lawsuits against ems providers are on the rise though many involve dispatch and transport issues so example of this would be a delayed transport response patient deterioration after not being transported others involved the quality of medical care provided by the ems providers especially paramedics and sometimes the same act that sparks a civil suit may elicit criminal prosecution so criminal prosecution is an action taken by the government against a person the prosecutors feel has violated criminal laws the government must prove guilt beyond all reasonable doubt to the jury if found guilty the defendant can be fined imprisoned or both okay so next let's talk about criminal",
        "Criminal Laws": "laws which are most likely to apply to pre-hospital care and some examples of these include assault battery and false imprisonment or kidnapping now assault is when a person let's say the ems provider instills the fear of immediate body bodily harm or breach of body security to another person and that would be the patient regardless of whether the threat of harm is uh actually carried out so an example would be threatening to restrain a patient that is assault now battery is when the defendant so let's say the ems provider touches the person the patient without his or her consent so example of this would be to distinguish the difference saying i'm going to kick your teeth in that's assault or actually kicking in a teeth is battery",
        "False Imprisonment": "so false imprisonment is when a person is unintentionally and unjustifiably detained against his or her will some examples would be if a paramedic transports a patient without his or her consent or uses restraints in a wrongful manner any act of medical treatment performed without consent may be considered assault or battery or both in criminal cases the prosecution needs to prove there was intent to do harm in civil cases the plaintiff needs to establish that the conduct took place without his or her consent criminal",
        "Criminal Charges of False Imprisonment or Kidnapping": "charges of false imprisonment or kidnapping are rarely filed in civil suits alleging false imprisonment or kidnapping are more common usually they arise from patients claims of transport or restraint against his or her will and paramedics may be sued for defamation as well so defamation is intentionally making a false statement through written or verbal communication that inquire injuries a person's good name or reputation liable means making a false statement in written form that injures a person's good name when written the patient in the patient report avoid using terms that may be considered insulting or offensive for example the patient appears to be drunk think of how that report would read in court thoughtless comments may be used as evidence against you slander means verbally making a false statement that injures a person's good name so avoid using terms that could be considered offensive when transferring patient care so next we're going to talk about the",
        "The Legal Process": "legal process a civil lawsuit begins when a dissatisfied patient contacts an attorney who then files a document for a lawsuit with a local court the complaint contains general allegations against the paramedic in the ems system but may not contain specific information about what the patient thinks went wrong the patient's attorney must deliver a copy of the complaint and the summons to the person involved in the lawsuit from start to finish the lawsuit may take several years normally an attorney will be assigned to you by the insurance company that handles the claims for your employer the complaint will be filed and your attorney will answer then the discovery period begins this can last a few months or more than two years attorneys on both sides seek as much information about the case as possible the following may take place the exchange of written questions which must be answered under oath the exchange of documents and then dispositions which are statements taken under oath stay in touch with your attorney during this time and your attorney will prepare you for depositions by telling you where to go and what to wear and how to respond to certain types of questions attorneys may also file motions and argue them before the judge most civil cases are resolved during a settlement process taking a case through trial is expensive and time consuming and settlement involves both parties and their attorneys in mediation and arbitration if the case cannot be resolved during the settlement it will proceed to trial",
        "Paramedic and the Medical Director": "the paramedic and the medical director so the relationship between the paramedic and the medical director is complex ultimately the paramedic has three lines of authority to answer to within the ems system so the medical director the licensing agency and the employer there may be some overlap but these distinctions are important usually state ems legislation requires the paramedic to perform advanced life support procedures and skills only under physician supervision so legislation may also require a medical director the acts of the paramedic are not the actions of the physician however the medical director can be accountable for failing to supervise closely or take action when the paramedic is not meeting the standards a medical director may do any of the following if he or she does not believe the paramedic is performing the standards so they may restrict the paramedics practice withdrawal supervision entirely requirement remedial training so medical directors are not responsible for an employer's disciplinary actions many paramedics activities require an order from a physician so orders may be given on radio or by cell phone and that you know that that's online medical control and orders may be defined by protocols or standing orders and that's offline medical control paramedics cannot disregard or reverse a physician's order unless carrying out the order will harm the patient paramedics may be at the scene of the emergency with an inexperienced physician so paramedics may feel the orders of the physician are inappropriate disregarding orders from a physician takes physician places the paramedic on questionable legal ground ask the service medical director to develop protocols in advance the physician is not required to ride to the hospital with the ems unless procedures have been performed above the ems provider's level of training or the physician has assumed responsibility for patient care ensure the physician is licensed in your state and continue document the physician's name and contact information prior to patient care conflicts should be resolved by online medical control",
        "Ems Enabling Legislation": "so let's talk about ems enabling legislation this defines how ems is structured it designates responsibilities to government agencies and provides framework for the paramedics practice what is permitted in the field so for example it defines the need for the medical director it defines the scope of practice for the different levels of ems personnel and it leads to regulations that paramedics should be familiar with",
        "Administrative Regulations": "and then there's administrative regulations so these are set forth by bureaucracies at the state and federal levels they affect and define the specific rules under which paramedics practice so for example regulations may set out precise skills and medications to be used by each level of ems provider usually developed by state gov department of health or county agency responsible for regulating ems practice may further define the paramedics role in patient care and they may define the requirement for licensing and renewal and continuing education the action against the paramedics license for providing less inadequate care for failing to meet the requirements for recertification and serious consequences for failure to abide by these regulations",
        "Licensing and Certification": "and then there's licensing and certification so these terms are often confused paramedics are considered licensed in some states but in others they are considered certified certification is the level of credentials based on hours of training and competency which may be granted by the governmental agency or by a private organization certification does not mean someone has the authority to practice the skills in that certification licensure permits a carefully defined level of practice usually granted by an agency or local authority a license is a privilege granted by the governmental authority on certain conditions the paramedic must comply with the government re requirements of or risk losing their license so they must have a professional behavior continuing education and licensure renewal rights and privileges conferred by licensing in one state may not be conferred on other states that certify rather than licensed paramedics credentialing may be encountered by the paramedic as well",
        "Discipline and Due Process": "so discipline and due process paramedics who commit an infraction to licensure rules may have their license restricted suspended or revoked by a granting agency administrative agencies can propose a license action licensing action called due process and so a due process is it's a right to a fair procedure for the action the agency proposes to take and there are two components you have to be have the notice and the opportunity to be heard the paramedic is notified by receipt of a certified letter of the notice of action the letter informs him or her of the action to be taken and the regulations the agency is alleging were violated",
        "The Medical Practice Act": "so let's talk about the medical practice act next and this enables physicians and other health care practitioners to function the medical practice act defines the minimal qualifications of those who perform various health services and the skills that each type of practitioner is legally permitted to use it may contain requirements for re-licensure or re-certification based on continuing education and it may require a physician to assume responsibility for competency of the paramedics so the training the skills the in review run and it varies from state to state and then there's the scope of practice so the scope of practice may be spelled out in your state's ems legislation or regulations",
        "Scope of Practice": "the scope of practice is care that a paramedic is permitted to perform occurring to the state under his or her license or certification the medical director might not permit a paramedic to perform all the skills or give all the medications for which the paramedic is licensed or certified a paramedic carrying out procedures outside his or her scope of practice may be considered for negligence or criminal offense so scoop of practice should not be confused with standard of care standard of care is what a reasonable paramedic would do in a similar situation and then there's the health insurance portability and accountability act and you want to be very familiar with this this is otherwise known as hipaa this provides stringent privacy requirements for patient information it was enacted in 1996 and it provides for criminal sanctions as well as civil penalties for releasing a patient's private medical information to an in an unauthorized manner",
        "Hipaa Privacy Rules": "hipaa privacy rules are the most relevant part of hipaa for health care providers they're enforced by the u.s department of health and human services they establish what is considered to be the person's protected health information and the medical information can also be disclosed by if necessary for a patient's treatment to receive payment for billing and if release has been authorized in writing by the patient or lawful patient representative requires each agency to have a privacy officer and awareness of the location of the patient information casual discussion about patient where the conversation may be overheard so use caution when giving records or discussing patient information in public areas liability of sharing the patient stories and caution during ride-along situations patients entitled to a copy of their service for privacy policies so they may may be difficult in an emergency setting but they're obligated to do your best to follow com compliance with the law most services make up leaflets state laws pertaining to patient confidentiality and there's a code of ethics for emergency medical texts and confidentiality so it's issued by the national association of emergency medical technicians it's a release of medical information without the patient's authorization it's legally mandated reporting there are dog bites gunshot wounds or child abuse authorized data collection research for public health agencies authorized requests by law enforcement information required to be disclosed persistent to a valid subpoena or exchange of health information for a medical need so it's allowed and is necessary",
        "Hipaa Implications for Electronic Communication": "hipaa implications for electronic communication so some agencies prohibit ems providers from carrying camera enabled mobile phones while on duty ensures everyone on the call understands the patient information should never be posted on any social media network and it ensures no patient identifiers are present if an emergency scene is captured in any photographs or videos the safeguard principle of hipaa requires that reasonable administration technical and physical safeguards be put into place to aid the protection of patient information knowledge of hipaa rules and regulations by all agencies involve your agency's privacy provider can help you better understand all the rules and regulations associated with hipaa and your role in ems okay so then there's the emergency",
        "Emergency Medical Treatment and Active Labor Act": "medical treatment and active labor act and this was established in 1986 it combats the practice of patient dumping so when a hospital emergency department denies medical screening or stabilizing treatment or inappropriately transfers a person who is not stable historically it's occurred when the hospital discovered that the patient did not have health insurance and was unable to pay",
        "Economic Triage": "so economic triage is a practice of making health care decisions based on the ability of the patient or the insurance carrier to provide payment for services so paramedics have been accused of providing a lower standard of care for indigent persons or those on public assistance so understand local protocols require or regarding hospital to transfer patients rural hospitals may have limited choices and other places may have several options so some systems require patients to be transported to the nearest hospital the paramedic may be required to consult with medical control and issues severe fines for hospitals and doctors who violate the provisions and issues are regulated by the centers for medicare and medicaid services okay the next thing we're going to talk",
        "Emergency Vehicle Laws": "about is emergency vehicle laws and most states have specific statutes that define an emergency vehicle and what traffic should do when the emergency vehicle approaches but the laws vary from state to state and emergency vehicles they must be operated in a safe manner laws do not authorize speeding running red lights or driving the vehicle in an unsafe manner if any of those activities put the public at unreasonable risk state laws establish higher standards for the operator in a crash often the ems provider will be found at fault in a civil case against the driver the driver may be charged criminally know the laws of state about emergency vehicle operation the blue star of life and the flashing red lights do not exempt you from defensive driving and common courtesy emergency vehicle operators are professionally trained to operate vehicles safely at all times and to anticipate reactions of other drivers in stressful situations a collision could result in injuries and or delayed patient treatment and then transportation so patients should be transported to the hospital of their choice most ems systems have protocols to transport certain types of patients to particular hospitals so for example a trauma stroke or cardiac event may be homeless patients mentally ill patients or obese patients the capacity of each hospital should guide the ems system in delivering or developing the transport protocols paramedics who have decided not to transport patients have been the subject of litigation studies have demonstrated that paramedics should not decide which patients need to be transported to the hospital for any health problems the whole ems system does not have access to sophisticated diagnostic tools or radiography in a pre-hospital setting in crime scenes and emergency seem responsibility so when handling a situation involving death or a potential crime scene it may take law enforcement officials time to figure out whether the scene involved a suicide homicide or some other form of criminal activity so use extreme caution and do not disturb evidence or destroy any potential evidence so if the scene is a vehicle crash do not move anything unless you have to including broken glass or pieces of metal if the scene is indoors try not to touch anything that you do not have to for the risk of eliminating fingerprints such as telephones or doorknobs document statements made by witnesses and get their contact info limit the number of ems personnel to enter the scene notify law enforcement personnel if furniture or other objects need to be moved and do not alter evidence on the clothing in cases of sexual assault the patient may carry vital pieces of evidence so for example fibers or hair or blood in the event of death at the scene stay with the body until the police arrive protect the scene from contamination by by standards and family members in most jurisdictions the paramedic is not legally authorized to pronounce a patient dead when in doubt about the possibility of saving the patient initiate resuscitation and mandatory reporting in each state has its own requirements for reporting to authorities every state has laws requiring ems to report child and elder abuse so become familiar with the reporting requirements of the state in which you're employed the obligation to report is frequently applied to neglect or abuse of children neglect or abuse of older people domestic violence injury from a felony drug related injuries rape animal bites or certain communicable diseases and then the coroner and medical examiner cases so ems agencies have a list of procedures that involve the coroner or medical examiner generally the police should be notified in all cases so obvious homicides or suicides violent or sudden unexpected death or death of a prison inmate",
        "Paramedic and Patient Relationships": "okay so paramedic and patient relationships most important role in medical care is do what is best for the patients paramedics are trained in emergency medical care not law every decision should be based on the standards of good medical care not on the possibility of legal consequence so doing what is best for the patient will avoid problems with the law",
        "Consent and Refusal": "consent and refusal so obtain consent of the patient prior to providing emergency medical care consent refers to the patient who are of legal ages and possess decision-making capacity making medical care decisions for themselves there are two types of consent there is",
        "Informed Consent and Implied Consent": "informed consent and implied consent and we're going to talk about those next so informed consent must be obtained from every adult patient who has decision making capacity a number of things may impede you giving patients what they need to make decisions though there may be a language barrier or an emotional state or the mental ability ensure the patient understands that you are what you are trying to do and grant you permission to treat informed consent",
        "Informed Consent": "may lack formality in the hospital so document the patient's consent to provide yourself against potential legal action informed consent is routinely obtained verbally it may also be communicated through the patient conduct so rolling up sleeve to allow for a blood pressure check",
        "Express Consent": "and then there's express consent so when the patient demonstrates he or she is giving you permission to provide care all right so then there's implied consent",
        "Implied Consent": "and implied consent is a form of consent assumed to be given by an unconscious patient or those who are too ill or injured to consent verbally to emergency life-saving treatment assume the patient would want care due to the severity of the condition so if the patient exhibits signs that he or she does not have the decision-making capacity treat the patient under implied consent so these might be like mental illness or shock or stress confusion or head injury some ems personnel incorrectly use the term involuntary consent so this term is incorrectly used in situations where law enforcement officer or legal guardian grants permission to treat someone who is under arrest incapacitated or a minor or for those for some other reason so it is actually an oxymoron consent can neither never be involuntary persons under arrest or person uh in prison they do not necessarily lose the right to be involved in the medical decisions it is not uncommon for law enforcement or direct ems personnel to treat a person under arrest so medical control should be involved if the prisoner refuses treatment and do not assume that law enforcement officer or anyone else has a right to refuse treatment for a patient okay so",
        "Decision Making Capacity": "next we're going to talk about decision making capacity refusals must be informed the same prerequisites as consent apply so decision making capacity is the ability of the patient to understand the information that is being provided to them and make a choice regarding appropriate medical care the best tool to evaluate a patient decision making capacity is the ability to talk to the patient to see if he or she understands what is happening to him or her if a pulse ox or blood glucose measurement are outside of normal ranges these can provide information about the patient's ability to understand and communicate include detailed documentation of decision making capacity in the patient care report if the patient with decision-making capacity refuses medical care the person may not be treated without a court order so consult with medical control for instructions inform the patient in a calm and sympathetic manner of the potential consequences of refusing treatment remember many people who refuse medical care do so out of fear and emotional distress it is not uncommon for patients to refuse treatment and transport to the hospital due to cost the cost of the ambulance and the hot cost of hospital treatment so addressing these concerns can be challenging in situations like this may require all of your people skills a patient may be alert and oriented but still incapable of making an informed decision even after you have communicated with him or her to the best of your ability then many factors may prevent the patient from making an informed refusal such as a head injury or altered mental status or unstable vital signs contact medical control for guidance and consider calling for assistance or law enforcement psychiatric emergencies",
        "Psychiatric Emergencies": "present problems of consent a police officer is generally the only person given authority to restrain and transport a patient against his or her will ems should not do so unless at the express request of police ems service must establish protocol based on local laws dealing with mentally disturbed patients who refuse transport and police may be required the role of each agency involved should be clearly defined beforehand if you believe that a patient is not competent to make the reasonable decision regarding his or her care and the treatment is necessary it is better to treat the patient some patients refuse treatment as a way to deny they have a problem so for example a middle-aged man with chest pain refuses treatment in order to deny he's having a heart attack patients speaking with medical control by radio or telephone may be helpful so maintain a courteous and sympathetic attitude let the patient know your chief concern and is his or her well-being and tell the patient it's okay if you change your mind urge the patient to seek further medical evaluation from a physician of their choice and help the patient make concrete plans for follow-up some patients will consent to treatment but not transport and the opposite some people will some people patients will consent to transport but not treatment so document the patient refusals is critical litigation may arise and the patient may claim you committed abandonment so document all findings of your assessment and the patient's mental status carefully okay the report should be signed and pre-hospital refusal forms must be backed up with action so legally you must have undertaken the process of attempting to obtain informed consent to treat the patient the patient's signature on the refusal form does not mean the patient has given informed consent you must inform the patient of what you propose to do including the potential risk of refusing care and providing the information in the manner the patient can understand a patient refusing care can be difficult for the paramedic but the patient's rights must be respected regardless of your beliefs or what you think you should be doing courts have upheld patient refusals when paramedics documented a patient's decision-making capacity okay then there's miners so minors",
        "Miners": "present special issues for a medic as well minors have no legal status and they cannot refuse or consent to medical care consent must be obtained from the parent or medical or legal guardian of the children or adults who have legal guardians so be aware of the legal principle in loco parentis so in local apprentice means in place of parent and it may apply to school or daycare or summer camp decisions by the school administrators or daycare directors on behalf of the minor difficult circumstances may arise if the parent or legal guardian refuses to grant consent to the minor who clearly requires life-saving or limb-saving treatment adults have the right to refuse treatment state laws generally do not permit a parent or guardian to deny treatment for minor child but the failure to allow treatment may constitute neglect the paramedics should notify law enforcement or medical control and state law may permit the state to assume custody of the child emancipated minors are under the legal age in a given state but can be treated as a legal adult due to qualifying circumstances so individual state laws determines the circumstances but in most states they recognize any minor who has been emancipated by a court order in some states um there's criteria so if the marriage or pregnancy or active military service emancipated minors may be treated as adults when obtaining consent or refusal okay so violent patience and restraints so the use of force by paramedics can be the case of many lawsuits force can only be used in response to a patient's use of force against you so if you're attacked you may be able to defend yourself and the use of temporary disabling sprays knives or firearms are usually prohibited by the ems agency the amount of force allowed by law is either equal or slightly greater than the force offered by the patient violence against ems providers is on a rise but do not enter a scene that is unsafe let law enforcement secure that scene restraint can be used for medical reasons only when the patient is a danger to himself or others so violence can be a result of a medical reason such as hypoxia or hypoglycemia mental illness or brain injury",
        "Negligence and Protection against Negligence Claims": "okay so negligence and protection against negligence claims no protection from liability or gross negligence other than immunity so negligence occurs when the paramedic or ems system had the legal duty to the patient so for example a paramedic is hired to serve the community has the legal duty to the citizens of that community",
        "Breach of Duty": "there is a breach of duty when the person accused of negligence failed to act as another person with similar training would have acted under the same or similar circumstances the failure to act appropriately was the approximate cause of the plaintiff's injury and harm resulted a paramedic in the ems systems are protected from liability as long as they perform according to the standards for paramedics and ems systems the best protection is to behave in circumstances according to established procedures and standards set by national agencies these standards are not law but can be introduced as evidence in litigation they may affect the outcome of the lawsuit ensure your vehicles maintain an optimal condition and equip the vehicle according to prevailing standards paramedics may obtain their own insurance coverage in addition to their employers to provide for additional protection having additional insurance provides protection if your employer's insurance carrier is required to pay out a claim based on wrongdoing for which you're responsible or if you're sued as a result of having provided off-duty emergency assistance one aspect of negligence is",
        "Negligence": "foreseeability so this implies that the injury or harm could have been predicted avoid if proper precautions were taken so for example giving an incorrect dosage of a drug will foreseeably result in harm of the patient negligence is divided into three categories so there's malfeasance misfeasins and non-feasons so malfeasance when the paramedic performs an act that he or she was never authorized to do so for example a medical intervention outside the scope of practice misfeasance when the paramedic performs an act that he or she is legally permitted to do but improperly carries it out and then non-feasens that's when the paramedic fails to perform an act that he or she is required or expected to perform so failure to perform cpr when the patient's in cardiac arrest is an example and then there's elements of neglect so you have a duty it's prescribed by the law what you must do and how you must do it first duty is to do no further harm we've talked about that it's a successful lawsuit is a breach of duty proof of the duty so a duty is an obligation to which law will give recognition and con effect and confirm to a particular standard of conduct together so um confusion around the concept of legal duty in ems so there's an ex here's an example many paramedics think that there is that they are legally obligated to stop at roadside crashes because they are paramedics in most uh in all but few states this is not the case obligation to respond to calls when working on shift or volunteering for a squad so most services have a policy addressing the passing by of another accident while enroute to a call or to a hospital with a patient make sure the appropriate personnel are dispatched",
        "Common Misconceptions": "common misconceptions are a requirement to stop at all emergencies due to the paramedic sticker on your personal vehicle there's a legal duty to perform within the standard of care if this decision is made to stop but further legal duty not to abandon a patient once the treatment has began but legal obligations went off duty usually not there are state laws and education of peers regarding off-duty obligations but um",
        "Legal Duty of Ems": "legal duty of ems agencies though agencies have a duty to respond to calls for aid the use of mutual resources um appropriately if call volume is heavy and the concept in the law that tells you what your standards of practice are so often defined in the context of a case tried in a court of law okay so another element of negligence is the breach of duty and a lawsuit will be successful if the paramedic failed to perform within the standard of care a jury will listen to testimony of an expert witness on both sides and the jury will decide whether the paramedic's care was reasonable or not the expert witness will provide sources including their own training the paramedic textbook protocols national standards sops and the patient care report good documentation will help provide your standard of care or prove your standard of care some states differ",
        "Ordinary Negligence and Gross Negligence": "between ordinary negligence and gross negligence okay so some states follow a gross negligence standard in lawsuits against paramedics will not be successful unless the paramedic was seriously departed from acceptable standards an approximate cause so a proximate cause applies in cases where the paramedic has a legal duty to the patient and breaches that standard of care and so the plaintiff must link the act that fell between the standard of care directly to his or her injury by showing that the act or failure to act approximately caused the harm so an example is a paramedic treating a patient with a spinal cord injury the paramedic drops the stretcher or the patient may try to show that his or her injury resulted from the drop stretcher and careful documentation of the patient's status at their first encounter will be essential to the defense and then harm the final element plaintiffs must prove in the negligence",
        "Negligence Lawsuit": "lawsuit in addition to physical injury patients can claim damages for emotional distress loss of income loss of enjoyment of life loss of household services and loss of future earning capacity plaintiff will need to show the paramedics actions were proximate causes of each of these losses",
        "Abandonment": "and then there's abandonment so abandonment is a form of neglect that involves the termination of care without the patient's consent abandonment implies the patient had continuing need for medical treatment and the abrupt termination of the treatment caused injury or death you may not leave the patient in need of medical treatment until another competent health care professional with equal or higher level of training has taken responsibility and you must notify an appropriate healthcare professional of the patient's presence in the emergency department notify the person that is that you're transferring responsibility to care to him or her you have to complete a written report and often submitted it electronically frequently submitted after the call and received by the ed physician or nurse the report will be permanent in their records so some situations may not require transport but are not considered abandonment so frequent calls for patients who do not really need treatment or transport many have fallen and just need help up patients may need help taking meds or patients with hypoglycemia may feel fine after the treatment so some ambulance services have a mix of providers of various training in service may not have a full staff at all times the paramedic may not need to be part of the transport crew if the patient does not need advanced care and some systems have tiered responses so they might have basic life support providers reach them quickly and then advanced life support providers follow",
        "Patients Autonomy": "okay let's talk about patients autonomy next so the patient's right to direct their own care make end of life decisions so the patient's autonomy and medical ethics does not apply when the patient is a minor or lacks decision making capacity and the patient's decision so decisions may not be accepted by other members of public or the patient's family it's important to remember that in courts including the us supreme court they have recognized the right of people to make their own decisions about their medical care so people make their own decisions even if it means death ethics has become the subject of many paramedic discussions the paramedic find themselves being accountable to more systems than the average healthcare provider and trying to respect the wishes of the patient okay so competing interest can create an ethical conflict physician's orders so you may feel that they are detrimental to the patient's best interests immediately discuss your feelings with the physician you are in a better situation to understand your job is to communicate fully with that physician never perform a procedure or administer a med that you feel or believe will harm the patient for example if the physician asks you to perform a procedure in which you are not trained obtain clarification from the physician and communicate your objections discuss your current standing orders and offer a feasible alternative within your scope of practice act in the patient's best interests as his or her advocate all right now we're going to start talking about advanced directives and these are usually a written document and it can be an oral statement though some examples are living wills or dnr's or organ donations and they differ from state to state and a dnr order may restrict advanced life support care state law covers whether ems personnel are bound by advance directives and those that cover dnr orders are usually very strict though learn and follow the laws in your state and state law provides a framework for your decisions okay so now we're going to go through some of the advanced directives and the first one",
        "Living Will and the Healthcare Power of Attorney": "we're going to talk about is the living will and the healthcare power of attorney",
        "Living Will and Healthcare Power of Attorney": "so living will and healthcare power of attorney these are types of advanced directives a patient can express wishes regarding end of life medical care and these are sometimes called health care durable power of attorneys these documents can sometimes be confusing and there are various types of powers of attorneys older patients commonly execute powers of attorney and it enables others conduct to conduct financial affairs on their behalf they have no effect on health care whatsoever these documents may have been executed outside the state in which the patient now resides so effect in your state may be questionable ask to see it and carefully review it and determine whether it authorizes the agent to make health care decisions but when in doubt contact medical control living wills need to be preconditioned to activate so for an example terminal illness or irreversible coma it spells out exactly what kind of treatment the patient wishes the health care power of attorney is often called a surrogate and they are just surrogates and decision making so surrogate is a legally obligated to make decisions as a patient would want and they have discussed these decisions with the patient and it has no authority until the patient has become incapacitated of making decisions so if the healthcare surrogate decision maker is attempting to make decisions that conflict a competent patient's decision the patient's decisions are always followed and then you have dnr's so these orders are also known as",
        "Do Not Attempt Resuscitation": "do not attempt resuscitation so an advance directive that describes which life-saving procedure should be performed if the patient's condition suddenly deteriorates dnr's have been recognized in pre-hospital settings in the last 20 years ems recognizes both patients outside and inside the hospital have the same rights many states have dnr forms specific to ems patients have the right to direct the process and states have their own procedures for recognizing valid dnr's some states rely on written physician orders and others require the patient wear a bracelet or a necklace dnr orders expire in some states and must be renewed to remain valid so some dnr orders do not expire though in some cases the dnr order must be executed within your state by physician license to practice medicine within that state so be familiar with the dnr documents in your state okay so withholding or withdrawing resuscitation you need to rely on the use of common sense and reasonable judgment in deciding when to stop cpr and resuscitation efforts or to decline to initiate them the national association of ems physicians has pushed data and guidelines for termination of resuscitation of non-traumatic cardio-pulmonary rest that demonstrates the benefits of on-scene resuscitation along with when to terminate resuscitation medical studies show that resuscitation of medical and trauma patients is sometimes feudal or may become futile consider the time it will take for the patient to receive care and the likelihood of survival each state has different laws defining",
        "Role of a Paramedic and Resuscitation Issues": "the role of a paramedic and resuscitation issues in some jurisdictions a paramedic can pronounce death other states only a medical investigator or physician may do so so state laws govern your practice even if the patient is critical deceased some laws include guidelines for basic life support the decision the halt resuscitation is difficult and emotional this is especially true when dealing with a pediatric patient paramedics and medical professionals tend to be action oriented sometimes you can do more for the grieving family than for the child who has died so guidance and concerns about difficult resuscitation efforts come from various sources training and literature reviews open discussion and continuing education acquire a thorough understanding of basic consequences of ems interventions okay so let's talk about end of life",
        "End of Life Decisions": "decisions next treat the patient and his or her family with the utmost respect and empathy never question their reasoning understand that family of a dying patient may not know how to check a pulse and a loved one despite knowing that death is near may call for an ambulance many people have never been with someone at the moment of their death and your job is to provide information and respect your moral code in conflict with the patients so the patient's value system may be different than your own you will encounter patients with varied cultural beliefs so be prepared to respect a patient's lifestyle even if greatly differs from your own confusing scenarios when dnr paperwork is not available so begin resuscitation efforts and then discontinue when the paperwork is confirmed in most cases dnr paperwork may be valid but the patient's family may disagree with the dnr order so avoid hostile encounters but carry out the patient's wishes to the best of your ability and contact medical control in confusing situations or questions the medical control physician can be a valuable resource medical control orders for life-sustaining treatment so the end-of-life document so more expansive than a dnr it's intended to be followed by all healthcare providers and applies to patients who are in cardiac arrest may apply to patients with impending pulmonary failure who are not in cardiac arrest yet though so typically contain provisions addressing cpr or feeding tubes or the use of antibiotics it applies only when the patient has lost decision making capacity and not used in all states so find out in your state",
        "Organ Donation": "and then there's organ donation so organ donation is a major issue in medical ethics and organs are badly needed many patients wait years so major organs are not appropriate for organ donation after a prolonged hypotension or cpr the other tissues may be valuable though in some states they have programs allowing patients to agree to organ donation so additional resources include workshops and ems leaders as continuing education for paramedics so be aware of the vital role you play in securing transplants all right so now we're going to get into",
        "Defenses to Litigation": "defenses to litigation so public awareness due to media and public education lawsuits based on citizens perception of delayed response and incompetence explain to your patients why you were delayed and explained why a procedure is difficult not doing so leaves you open to consequences a patient may seek legal action and your first defense to litigation is an open informative and trust-based relationship with the patient when a lawsuit is filed the paramedic and his or her employer may implement one of two defenses statute of limitations so every state has laws that limit the time with which a lawsuit could be filed and usually that time varies by state but it's between one to six years and contributory negligence so this applies when the plaintiff has done something that contributes to his or her injuries for an example a paramedic encounters a patient with chest pain that appears to be a cardiac prior to administering nitrogen the paramedic inquires about current medications the patient does not tell the truth and the paramedic administers medicines the patient almost dies as a result of the interaction between the medications and files a lawsuit in this lawsuit the paramedic is able to assert the defense of contributory negligence the patient failed to state he used medications and the dosage contributed to adverse reaction to the treatment okay so let's talk about good samaritan",
        "Good Samaritan Legislation": "legislation now and every state has some form of good samaritan legislation but not every state extends protection to all the citizens and off-duty ems personnel so this legislation provides immunity from liability to any family member of the community who stops and helps at the scene of an emergency the legislation was initially passed to encourage the public to help on an emergency scene the law provides some protection for ems personnel who are off duty and assist in an emergency the law of most states limit legal protection provided so the emergency care must be provided free of charge an emt or paramedic providing emergency care while on duty is not protected and the law may help cover paramedics rendering assistant in another state though the requirements the requirements",
        "Good Samaritan Laws": "of good samaritan laws are that the person responding to an emergency must do all they can and they must not expect to function as a physician so the paramedic is expected to deploy those skills that any other paramedic with similar training would do under the same or similar circumstances okay now the next thing we're going to talk",
        "Governmental Immunity": "about is governmental immunity in english law you cannot sue the queen or the king so such sovereign immunity has some application though in the united states legislation that identifies only limited types of lawsuits that can be filed against governmental agency and they may set limited time frames in which lawsuits can be filed and they may limit the amount of money a plaintiff can recover and then qualified immunity so governmental immunity does not cover civil rights violations lawsuits have been filed against public sector paramedics an example would be an ems personnel improperly restraining a patient or using excessive force another example would be conduct that deviates from the standard of care where civil rights violation is said to occur and paramedics working or volunteering for public agencies may have qualified immunity so this does not apply though to tort cases",
        "Employment Law": "employment law and the paramedics so important laws affecting their relationship with their employer becoming involved in a legal issue regarding your employment is more likely than being sued by the patient so re relationships with employer and employee involves a complex complexity of state and federal laws and regulations so have a basic understanding of these laws and now let's talk about the ada which is the american with disabilities act it's a federal law it's adopted to protect qualified persons with disabilities from being discriminated against in employment and it applies to all employers with a minimum of 15 employees possible state law protection for employees working for smaller employers and applause to all aspects of employment so hiring promotions training salary benefits and termination the misconception though that employers must hire disabled employees not qualified for the job qualifications for protection so they have a physical or mental disability that impairs one or more major life activities such as hearing seeing walking or speaking and they possess the basic qualifications of of the job and be able to perform the essential functions of the job adequately without or with reasonable accommodations",
        "Inquiries and Accommodations": "inquiries and accommodations so an employer may not inquire about an applicant's disability or require a medical exam until a job offer has been made if a disabled person could perform a job using reasonable accommodations the employer may be required to provide and pay for the cost of these accommodations no requirement for giving reference to a person with a disability and this requires a employer make employment decisions based on reasons that are unrelated to the disability decisions based on the applicant or employee being capable of performing the essential functions of the job",
        "Title 7 of the Civil Rights Act": "next we're going to talk about title 7 of the civil rights act and this prohibits discrimination in employment based on race color religion gender national organ origin or sexual discrimination it provides protection against sexual harassment in the workplace and applies to all aspects of employment including recruiting hiring promotions benefits and termination it applies only to businesses with more than 15 employees and it's unusual for an employer to blatantly refuse to hire promote someone based on their race gender religion color or national origin successful claims involve the identification of a discriminatory hiring pattern it develops over time violations of title vii even when hiring practices appear normal so an employer places a classification ad that states the qualification for the job is a minimum height requirement the ad may seem neutral in respect to gender this is a negative impact on the ability of women to apply so the employer would have to prove the necessity of the hype requirement",
        "Sexual Harassment": "and then sexual harassment so most common claim filed under title vii ems has seen its share of sexual harassment so there are two types of sexual harassment there's the quick pro quo and that's when a person authority attempts to exchange work related benefit for sexual favors and then there's the hostile environment and this is when the agent or employer creates or allows to continue an offensive practice related to sex that makes it uncomfortable or impossible for an employee to continue working sexual harassment can occur between any combination of sexes most claims fall into the category of hostile environment and there is no presence definition precise definition in the law for sexual harassment court decisions have identified a number of circumstances that can be considered harassment so sexual jokes or sexually offensive photographs unwanted sexual advances or inappropriate and unwelcome touching or kissing all employers have an obligation to prevent sexual harassment and investigate any and all claims appropriately and promptly an employer should provide training to all new employees and employees on an annual basis additional federal law is dealing with discrimination so there are several federal laws that prohibit various types of discrimination in the workplace",
        "Pregnancy Discrimination Act": "there's the pregnancy discrimination act and this is an illegal to discriminate against pregnancy childbirth or any medical condition relating to pregnancy and it was adopted in 1978 as an amendment to title vii",
        "Equal Pay Act": "and then there's the equal pay act of 1963 and it's illegal to pay different rates of pay to men and women",
        "Age Discrimination Act": "and there's the age discrimination act of 1967 so it prohibits persons who are 40 years of age or older from discrimination based on age that applies to businesses with 15 more employees and then there's state laws so they deal with discrimination in the workplace state laws address the same issues covered under federal laws and they may apply whether or whether or not there are 15 or more employees so become familiar with laws of your state",
        "The Family Medical Leave Act": "all right and then there's the family medical leave act so it was established in 1993 it grants employees to take up to 12 weeks of unpaid leave per year under certain certain circumstances it applies to employers with at least 50 employees and it covers those who have worked for the employee for at least 12 months so this allows leave to deal with the medical condition for employee or family for birth or adoption of a child in states own versions of fmla so they have their own versions and it may provide the employee with more rights than the federal law and may apply to employers with fewer than 50 employees okay and next there's osha we're wrapping",
        "Osha": "this up um osha so this is uh occupational safety and health administration it's a federal agency that regulates safety in the workplace states may enforce regulations tighter than those set by osha and states may not make regulations more lenient though so osha was enacted in 1970 and all employers have several basic responsibilities and they have to comply with osha standards and provide all employees with a safe workplace free of hazards and then to warn employees if there are potential hazards to ensure that employees are provided with appropriate safety equipment healthcare employers have additional responsibilities so to develop an exposure plan develop training programs uh an annual refresher training make the hepatitis b vaccine available and osha regulations and standards are challenging though so be familiar as possible with these changes thousands of ems agencies employees sustain injuries and illness each year and you share an obligation to do all you can to avoid these injuries okay and so uh the second the last thing we're going to talk about is the ryan",
        "The Ryan White Act": "white act and this is a federal law that provides certain safeguards and protections for health care workers who are potentially exposed to certain designate designated diseases so they have been established by the centers for disease control and prevention and they include hiv aids tuberculasis hepatitis b meningitis diphtheria hemorrhagic fevers plague and rabies it contains several provisions so states that hospitals and emergency response employees are required to establish a notification system to be used when exposure occurs employers must appoint a designated infection control officer to handle exposures and to assist all employees who have been exposed notification of infection control officer of possible exposure to the infectious disease and the infectious control officer will be aware of any state specific laws relating to infectious disease exposure okay and finally in conclusion there's the national labor relations act and many paramedics are employed by ems services that are not unionized employees have elected to have a union represent them as a collective bargaining agent for purposes of negotiating issues such as compensation benefits and work conditions this law is also known as the",
        "The Wagner Act": "wagner act and this is a primary law establishing the rights of union and union workers this law regulates unfair labor practices by employees and employees have a wide range of rights that which they should be familiar each state has its own set of laws and in some states the right to work laws do not allow employer or union to require you to join a union as a condition of being hired or retained on the job other states may require you to join the union within a certain time period after you are hired okay so this concludes the lecture for medical legal and ethical issues chapter four and we hope that you've enjoyed it if you have subscribed to the channel because we'll be releasing the rest of the chapters shortly thank you"
    },
    {
        "National EMS Education Standard Competencies": "hello and welcome to emergency care in the streets chapter 5 communications lecture upon completion of this chapter and the related course assignments you should be able to identify the role and significance of effective communication by the paramedic you should be able to describe the phases of communication during an ems event including those performed by the emergency communications dispatcher and you should be familiar with the intricate role of the emergency dispatcher as part of the ems team you should also be familiar with standard interview techniques and common errors to avoid as well as non-verbal skills that may be employed during a patient interview and you will understand the methods and strategies employed to assess a patient's mental status development patient report and interview patients of various ages cultures disabilities mental statuses and levels of cooperation",
        "Introduction": "so let's get started clear communication is the core emergency ems skill you must be able to communicate with the dispatcher other members of the ems system also patients family members and bystanders factors are going to influence how effectively you are able to communicate and these include the communication style knowledge level ability to listen and comprehend and your ability to accurately convey information also life experience is going to influence communication communication can be affected by your tone of voice body language and ability to use technology so let's talk about communication theory communication is both an interactive and circular process the sender formulates and encodes a message and is sent and coding involves determining the words and ideas to be sent and formatting the information for transmission the message is transmitted to a receiver and the receiver receives and decodes the message to get the information being relayed the most common methods of transmitting information include verbal non-verbal written visual and electronic the final step in effective communication is feedback and feedback is the confirmation by the receiver that the message was accurately received this illustration shows the communication loop so there are barriers to effective communication and some potential barriers to communication include language barriers vision or hearing and impairment impaired cognitive or confusion psychiatric conditions substance abuse or pre-existing medical conditions lack of ability to comprehend stress also preconceptions so adjust how you communicate to minimize these barriers your attitude and demeanor can also affect communication",
        "Response to the Call for EMS": "so let's talk about response to the call for emergency medical services so there are phases of ems dispatch all ems calls originate when someone recognizes that a potential medical emergency exists and reports it to a local emergency response system the call is automatically routed to the public safety answering point calls to 911 for emergency medical assistance are answered in most ems systems by a program called emergency medical dispatch and this is known as emd in some states the emd process also includes emergency medical care instructions to the 911 caller information is gathered so when a 911 call comes in the dispatcher will try to elicit the following information so we need to know the exact location the telephone number of the caller why ems is being called the any information about the patient's condition also details about the location and information about the situation such as types of vehicles or number of people injured or the extent of the injuries and then dispatch happens as soon as the dispatcher has obtained the address of the emergency the telephone number of the caller and the nature of the emergency he or she will determine what resources need to be dispatched and then notify those resources after the ambulance is dispatched the dispatcher will return to the caller to obtain the rest of the information and relay this information while the responding unit is enrolled most ems systems utilize computer aided dispatch systems and this is known as a cad they make use of link dispatch center computer consoles and mounted mobile data terminals they enable the dispatcher to view all information about the call and visual prompts that list the key questions to ask the caller they may display maps in the fastest route to the location also maybe prior calls at that same location and known hazards and they may make recommendations about which ems units to dispatch and the location and response times so after they dispatch the appropriate resource and alert responders to any special circumstances the dispatcher will return to the telephone and inform the caller what's happening it is important for the dispatcher to remain aware of what is occurring in the field and to stay in contact with the ambulance and other responders so the ems communication system so there's a variety of communications equipment and communication systems and devices use regular radio signals to send and receive information so basically they use basic two-way radio they also can use a computerized radio system or cell technology and then there's always a backup communication system those are essential okay so let's talk a little bit more",
        "Basic Radio Communications Theory": "about the basic radio communications theory so a radio transmit signals by electromagnetic magnetic waves and the radio frequency is the number of cycles per second it's measured in hertz common abbreviations are hertz which are the cycles per second kilohertz or a thousand cycles per second megahertz is a million cycles per second and then gigahertz that's one billion cycles per second frequencies are grouped into bands by the federal communications commission for specific purposes two most commonly used bands for medical communication are the very high frequency or vhf band and the ultra high frequency which is a uhf band the vhf band extends from 30 to 300 megahertz and the uhf band extends from 300 megahertz to three gigahertz effective january 1st 2013 frequencies in public safety radio spectrum between 150 to 175 and 421 to 470 were assigned with a spacing of 12.5 referred to as a narrow band technology radios using older 25 technology may no longer be in use radio communication requires two types of devices so a transmitter it takes date or sound converts it into radio signal and transmit it on to the designated frequency a receiver collects the radio signal and transmits it back to data and sound so transceivers are two ray radios they contain both a transmitter and a receiver range is a limiting factor affecting all radio signals background noise is present on all radio frequencies",
        "Communications System Components": "so let's talk about the communication systems components so there are a base station and then it's a transmitter output power of up to 275. they have a fixed location they serve as dispatch in coordination areas they have large antennas and then there's mobile transceivers that's a two-way radio mounted on a vehicle or an aircraft the antenna is externally mounted on the vehicle and then you have portable transceivers those are the small battery-powered units known as handhelds or walkie-talkies then there are radio systems so you could have simplex duplex multiplex or digital so simplex is all transmissions on the same frequency a duplex is radio signals are transmitted on one frequency and received on a second then multiplex is a they utilize radio signals to carry multiple streams of radio and or data at the same time and so used to transmit voice and ecg readings such as bio telemetry then you have digital they allow the transmission of digital signals like computers or analog voice they can be they can communicate with other digital and analog radios and then you have repeaters so this is a specialized base station transceiver with a powerful transmitter and a large antenna typically located on a high spot such as a tower mountain top or tall building and they pick up weak signals and transmit them to higher power on another frequency it extends the range of low power portables so sharing of frequencies and repeaters via encoded radio signals allows multiple users to share frequencies and repeaters those who have uh ctcs which is a continuous tone coded squelch system will be able to receive the transmission receivers without it will not okay then there are digital trunked radio systems so this is a sophisticated digital communication network the transceiver what is set to a channel or mode rather than a frequency then there are radio dead spots so dead spots are areas where mobile or portable radios are unable to communicate with the repeater or each other dead spots may be caused by distance or obstructions you must learn the locations of those radio dead spots in your area and you may need to use alternative communication systems or establish a temporary relay station",
        "Interoperability": "so inoperability is what we're going to talk about next the local agencies enter into mutual aid agreements with neighboring or regional jurisdictions to offer assistance to one another in the event of a large-scale incident each agency's communication system must be compatible with the other agency this principle is referred to as interoperability the u.s department of homeland security developed the safecon communications program to address the issue of incompatible radio systems between agencies these national interoperability standards released in 2006 are intended to develop a system of interoperable public safety communication across local tribal state and federal first responder communications systems each state is has established its own internal standards for interoperability between local jurisdictions which are to be used for mcis mass casualty incidents or other local mutual aid responsive the project 25 or p25 standards are digital radio hardware standards established by the association of public safety communications they ensure the pieces of digital radio equipment supplied by different manufacturers to public safety communications communities are capable with one another",
        "Cellular Technology": "next we're going to talk about cellular technology so cell phones are commonly used in ems communication systems they include low power portable radios or linked computer systems or connected to the telephone network paramedics need to know commonly used phone numbers for example like medical control or local hospitals maybe dispatch centers or poison control numbers smartphones have brought previously unheard of capabilities to ems providers they must be aware of the privacy implications of taking photographs or videos using smartphones they all they allow users to communicate wisely take and send photographs use gps receivers and mapping software and access a huge range of medical applications and then you have a cn so this is automa automatic crash notification technology and it is another evolving use of cell technology so it utilizes specialized onboard computers in motor vehicles to send data to a monitoring station in the event of a crash and it could send the location vehicle type severity or whether seat belts were used or whether airbags were deployed and it may allow direct two-way voice communication with the occupants of the vehicle",
        "Satellite Communications": "also there's satellite communication so sat phones can be valuable in royal and remote areas with unreliable or absent radio and cell phone coverage but the technology is expensive the global positioning system or gps is a satellite network that utilizes handheld or vehicle mounted receivers to locate the user's position and provide directions to other locations geographic information system so gis technology utilizes computerized gpf mapping systems to track and predict ambulance response times determine the distance to the closest trauma centers track the frequency of motor vehicle crashes determine the location of hospitals and provide the information useful in ems systems operating and planning satellite distress beacons and messengers can be worthwhile safety technology for ambulances and emergency medical personnel who operate in royal and remote locations",
        "Backup Communications Systems": "and then you have backup communication systems all ems and public safety communication systems need to have some type of backup most states include hand or landline and cell phone network as a backup to the radio communication in disaster situations having redundant or backup systems is essential backup plan may include the use of amateur radios or radio amateur civil emergency services",
        "Biotelemetry": "okay so next we're going to talk about biotelemetry and biotelemetry is a measurement and transmission of vital signs and other data to a remote terminal it is mostly used to send ecg data to medical control physician or ed ecg telemetry has been used less frequency frequently over the past decade decade because paramedics are more skilled in dysrhythmia recognition two developments occurred to bring a reassessment of pre-hospital ecg telemetry all right and so the national standard of care for patients with an acute st segment elevation myocardial infarct or stemi is percutaneous coronary intervention or pci or cardiac ath so cell phone broadband networks and digital radio systems made it possible to transmit a 12-lead ecg from a moving ambulance to the hospital and it can diagnose a stemi before the patient even reaches the hospital and make appropriate destination and treatment decisions telemedicine technology uses specialized computer terminals and networks that permit secure two-way transmission of diagnostic data advancements and technology are occurring rapidly and ems systems must keep up with the technology that will improve communication of patient information",
        "Communicating by Radio": "so communicating by the radio and the effectiveness of ems communication network depends on the technical software and the people who use it",
        "FCC Regulations": "the fcc is an agency that regulates u.s radio and television communication the fcc issues radio license and allocates frequencies develops technical standards and establishes and enforces rules and regulations for operating radio equipment the fcc monitors transmissions on various frequencies and conducts spot checks of base stations to ensure that they are licensed fines can be imposed for failing to follow fcc rules and recommendations the fcc requires that frequencies allocated for emergency medical use are confined to that use the communic to communicate a personal message notify recipient by radio to contact base the base by phone to communicate a personal request to the dispatcher use a telephone basically",
        "Clarity of Transmission": "all right and then the clarity of transmission is what we're going to talk about next so the following guidelines can improve the clarity of your transmission you want to know what you want to say before you begin your transmission so you could take notes or anticipate what questions are going to be asked before you begin to transmit make sure the radio is on check the volume and then listen to make sure the channel is clear keep your mouth close to the microphone but not too close about two to three inches is usually ideal and once the channel is quiet press the transmit key for at least one second before you start speaking start your transmission with identifying information so perhaps uh the name of the of your unit or um you could i your identification so for example williamsburg hospital this is medic three wait for response to ensure that the station is listening and speak slowly and clearly pronouncing each word carefully don't shout and keep calm and keep your voice free of emotion use a plain language and only use radio codes that are specifically approved by your system that everyone will understand if you have a lot of information to convey break your transmission into about short into short 30-second chunks and when speaking a word or name that might be misunderstood spell it out using the international radio telephony mnemonic alphabet or similar system confirm recipient of or receipt of all replies and indicate when your transmission is complete okay so content of transmissions are",
        "Content of Transmissions": "what we're going to talk about next and radio transmissions should be accurate and concise guidelines for what you should and should not include in ems radio communications include remember anyone could be listening protect the privacy of the patient at all times be impersonal so by this we mean use we and not i to refer to yourself use proper and correct medical terminology avoid using words that are difficult to hear act professionally and when you receive instructions by radio from the dispatcher from medical control echo the order back to make sure that you understood them correctly question orders you did not hear clearly or did not understand and if you have a lot of information to convey once again break your transmission into short 30 second chunks and when you're finished transmitting just like we said on the last slide notify the receiver it could be as simple as over or ended transmission",
        "Codes": "so codes the 10 code system and other radio codes have been phased out of the ems system a medical priority dispatch system is used by many ems systems the national incident management system or nims discourages the use of all radio codes clear text communications that's the preferred communications format in all systems simplify means using regular language and accepted terms to communicate communication formats used during the different phases of response okay so different formats for each agencies or regions radio and other communications so familiarize yourself with the format used in your area dispatch communications so when you respond to the dispatcher that you have received a message confirm the location and call reference",
        "Response to the Scene": "when you're responding as you travel towards the scene notified dispatch your transmission should be also you should let them know about the rival on scene and it allows you to update dispatch and establish your arrival time and it can be used to record your observations and findings regarding the scene it could also give pre-arrival instructions to other responding agencies if applicable",
        "On-Scene Communications": "when you're on scene you need to stay in contact with other responders at the scene this is typically accomplished using a portable radio large-scale instance may need a more involved communication plan and then patient transport communications after you've treated your patient and are ready to provide transport you have to tell dispatch it'll establish a time stamp for departing the scene",
        "Relaying Information to Medical Control": "and relaying information to medical control so legal basis for paramedic practice so offline medical control allows a paramedic to perform certain procedures or treatments based on protocols or standing orders but online medical control is when the physician gives patient specific orders and instructions directly to the paramedic by radio or telephone radio communications between paramedic and physicians should be concise and accurate and using a standard format for communicating with medical control ensures information is relayed consistently and completely",
        "Reporting Medical Information": "a format for reporting medical information so the key to good radio report are is to be organized to know what you want to say before you say it and to include all required information the following medical information should be included in your report so destination facility and estimated time of arrival you want to say your patient sex and age the chief complaint a brief history of the present illness or injury medications and important allergies anything else from the patient's history that might be relative to the current situation and the patient's level of consciousness and the degree of distress also the patient's mental status vital signs and physical findings ecg findings treatments given so far and response to that treatment okay so transmit information quickly completely and in a well organized fashion so let's give you an example okay so memorial hospital this is paramedic garcia on medicaid we are in route chair facility with an eta of 11 minutes on board we have a 53 year old male patient reporting shortness of breath which awakened him from sleep and worse when he was laying down he has a history of hypertension and hydrochlorothiazide is what he takes he is alert denies chest pain and is insignificant respiratory distress cardiac monitor sinus attack at 130 with a corresponding pulse respirations of 36 and labored blood pressure of 190 over 120 a pulse ox uh that went up from 88 to 96. he has crackles and wheezes in both lung fields there's no jvd he has a two pass pitting echo edema we have him on low concentration oxygen and have established a saline lock do you have any questions or orders so reduced physicians need to ask questions to get get them the essential information and gather information thoroughly at the scene and organize it clearly before reporting continue to monitor and assess the patient and report any changes",
        "Communication With Health Care Professionals": "okay so then when you get to the hospital you're going to do an in-person report and transfer of care you could also do this on scene if you're transferring to another medical provider the final phase of your patient care communication is at bedside usually to the receiving facility or nursing staff and rely relay all pertinent information use the same format as your radio report and share any information that wasn't clearly provided keep in mind the patient and family may be listening and answer all questions from the medical and nursing staff patient handoff also involves written documentation okay so let's talk about medical terminology it's one of my favorites you need to learn establish medical terms and abbreviations your ems system may have approved lists and terms so be familiar with those",
        "Therapeutic Communication": "and then people are at their worst and most vulnerable vulnerable so we want to use therapeutic communication at least half of calls involve entering people's homes at a very private moment treat each invitation into the home as a personal honor in a time and place where others would not be welcome you will often work in noisy chaotic bizarre and sometimes dangerous environments try to reduce the noise and promote a calm atmosphere try not to shout if noisy situations are like a bar ask the bartender to turn down the music and if you need to run a compressor or engine shut it off as soon as you can talk close to your patient's ears and in a calm voice therapeutic communication involves the use of specific strategies to encourage the patient to express ideas and feelings it allows you to convey your respect acceptance and genuine concern for someone you have never met before it could convince people you want to hear what they have to say and give them your undivided attention pay attention to the patient's answers the first time employee active listening so repeat the key parts of the patient's response to the questions and developing rapport good rapport with your patient is essential for obtaining good medical information if patients are reluctant to share information explain why you need them if patients have trouble focusing move them safely to the ambulance this might create a calmer atmosphere and make talking and listening easier if patients feel threatened cautiously approach using open postures and smile and be calm reassure the patient and take things slower if possible introductions are the first step in promoting open communication introduce yourself as soon as possible and make and maintain eye contact get on the same level to the patient and position yourself so the patient can easily see you and be aware of body language use the patient's name in all interactions and speak slowly and calmly respect and protects the patient's modesty this is especially important for the elderly adolescents and sometimes the very young even if the patient is not personally sensitive to modesty family members are",
        "Conducting an Interview": "so next let's talk about conducting the interview and there are two types of interview questions and you need to know these there's open-ended questions and close-ended questions so open-ended allows patients to give feedback on the info so an open-ended question for example could be how are you feeling at this moment a close-ended question it's also known as a direct question an example of a closed-ended question is what year were you born always start with open-ended questions ask one question at a time and let the patient answer at his or her own pace develop a standard set of questions for collecting medical history and avoid talking down the patients but use terms people without medical training will",
        "Strategies to Elicit Useful Responses": "understand there are some strategies to elicit useful responses to questions so there's reflection and empathy and the confrontation there's also a couple others but we'll talk about these first so let's talk about reflection and that's repeating a word or phrase to a patient that has used to encourage more detail so let's say for example the patient says i can't catch my breath and you say you said you can't catch your breath and the patient may then respond more fully explaining the condition and the circumstances in more detail then there's empathy and that's putting yourself in the patient's position so for example the patient expresses sadness about the situation such as a recent death you may say something like i am terribly sorry i don't know how i would feel about the situation but i am sure i would feel similarly and then there's confrontation and this involves making your patients aware that you understand something is inconsistent about their story so if the patient is in a motor vehicle accident and denies drinking and they say anything you tell me is confidential and i did but i detect the smell of alcohol on your breath there were also some empty bottles in your vehicle it's important you tell me the truth so that i can make and make sure that we and the hospital staff take proper care of you then there's interpretation so vocalize what you think the patient is saying and invite the patient to correct you so for example if a teenager acts on distress and says she is afraid she might hurt her parents if she tells you what is wrong you might ask a question like this may be totally wrong but i must ask you a question so i can inform the doctor of your well-being do you think you are pregnant and then there's facilitation so you use phrases to encourage patients to provide more information so please say more or please feel welcome to tell me about and then there's silence so if a patient seems to be trying you i'm trying to put something in the words the patient be patient do not say anything for the next few seconds there's also clarification you ask the patient to explain what they mean um if you don't understand there's also redirection and if a patient mentions something in passing or avoid a certain question politely redirect your attention their attention back until you get the answer and then there's simplification and summarization so if a patient's response is confusing or disoriented or organized try summarizing his or her comments in simpler terms see if the patient agrees okay so let's talk about some common interviewing errors so providing false assurance or making unlikely claims or offering a diagnosis or medical advice that is beyond your scope of practice also asking leading questions or interrupting the patient or talking too much",
        "Nonverbal Skills": "and then there's non-verbal skills so first impressions are super important you want to be patient avoid gestures or facial expressions and close postures that send negative signals some people do not like to be touched while others think it's reassuring",
        "Special Interview Situations": "some special communications techniques you may need these techniques with patients who are uncommunicative hostile very young or very old or have special needs but avoid stereotyping any patient group",
        "People Who Are Hostile or Violent": "people who are hostile or violent so there's a heightened emotion of emergency situations can cause patients to become hostile so acknowledge the hostile person's concerns you may need to get a help from law enforcement to defuse that hostile person and expect to receive insults from people in crisis possibly almost daily hostile patients may present a threat to your others and so you want to always approach with caution and try not to interview any patient by yourself identify escape routes approach the patient from the front with hands visible and open and if safe get on the patient's level",
        "Sexually Aggressive Patients": "then sexually sexually aggressive patients if you encounter this follow your agent's agency's policies make sure a second person is always present communicate professionally and politely and make sure your words are not sexually ambiguous document your encounter and get witnesses",
        "Special Considerations of Age": "also special considerations so older people don't assume that they're harder to communicate older people tend to have more complex illnesses but older people may be taking more meds as well then there's children so children tend to protest pain they may be afraid of strangers and they may panic when separated from their parents so tips for communicating with small children you want to use eye contact and smile minimize movements and lower your voice and keep at their level and involve the parents of course and if absence of parents toys such as teddy bears may be helpful and improvised toys such as inflating an exam glove and marking it to look like a chicken adolescence so children aged 13 and above may not want parents around during exams do not refuse the parents to be present with the adolescent but communicate to the physician if the parents insist over the adolescent's wishes so also avoid disrobing the patients unless necessary",
        "People With Special Challenges": "and then there's patients with special challenges so when you encounter a patient who has trouble communicating remember that family members or caregivers can facilitate your efforts caregivers may take classes in sign language or lip reading to aid in communication and help patients access their glasses hearing aids and other devices that might help communicate or reduce fears persuasive developmental disorders such as autism cause delays in childhood development and may have lifelong effects children with autism may have difficulty with language skills they may also have difficulty with communicating non-verbally people with pdds range widely in skill development from being able to speak to having problems with meaning and rhythm of words or sentences so communicate with patients with pdd through their caregiver if possible",
        "Cross-Cultural Communication": "and cultural competence so ethnocentrism is the belief that one's own culture or ethnic group is inherently superior to others or that one's own cultural viewpoint is always right while others viewpoints are wrong cultural competence may interfere with your ability to provide appropriate emergency medical care because you have misinterpreted information so be aware that cultures and religions may have certain beliefs that conflict with standard medical procedures such as the use of oxygen culture can be defined as the system of beliefs attitudes or behaviors that are learned by shared members of a group human beings are not born with a sense of culture it's learned every person you encounter has a mixture of cultural influences that will impact how they behave and how they will react when stressful situations arise",
        "Cultural Awareness": "cultural awareness so body language may also be interpreted differently by different cultures a smile is used almost universally as a sign of goodwill the following is a list of some cultural practices paramedics should be aware of eye contact so avoiding direct eye contact shows respect in some asian african latin american and caribbean countries eye contact shows interests and honesty in arab somalia and brazilian cultures touching with the left hand islamic and hindu cultures avoid touching with the left hand it's rude and offensive touching the head many asians do not touch the head as it is considered the most sacred part of the body feet showing the bottom of the feet is offensive in muslim nations and much of thailand hands on the hips this can convey hostility in mexico and argentina nodding indian and arab cultures may signal agreement by moving the head side to side they may indicate no by tipping the head back and clicking the tongue also hand gestures these may have very different meanings in different cultures some gestures may um be something different in one culture group but insulting in another so just be aware of that",
        "Traditional Folk Medicine and Understanding of Illness": "in traditional folk medicine and understanding so many immigrants to the us follow the traditional folk medicine practices of their own culture traditional models of illness typically involve a belief that health is the result of balance of forces and some medicine practices have regained popularity among followers of so-called new age movements so immigrants and children of immigrants may practice a blend of western and traditional health practices and this table shows a few traditional beliefs about health and illnesses of and folk treatments cupping and coining are two fold practices that you must be aware of because they may be easily misinterpreted for signs of abuse the use of herbal medicines is another area of traditional folk medicine the patient may not share the beliefs of his or her family or cultural background though so always remain sensitive to the patient's individual religious cultures and social logic beliefs",
        "Language Interpretation": "and then there's language interpretation so the biggest communication challenge with members of other cultures is a situation in which no common language exists it may be impossible to perform a good history and assessment so use a qualified interpreter if possible and when dealing with a patient who speaks another language you should always assume you are missing something important in their history and assessment and act accordingly okay so this concludes chapter 5 communications lecture and thank you for joining us today"
    },
    {
        "Introduction": "hello and welcome to the emergency care in the streets chapter 39 responding to the field code",
        "National EMS Education Standard Competencies": "upon completion of this chapter and the associated learning materials you will be able to integrate comprehensive knowledge of causes and pathophysiology into the management of cardiac arrest and pre-arrest states you will be able to explain the importance of the american heart association five links of survival to successful code and describe the management of the smart acronym and of its objectives",
        "Historical Context and CPR Training": "so let's get started in the early 1970s few people survived a pre-hospital sudden cardiac arrest cpr training programs in the mid-1970s began to improve outcomes and today's ems crews expect the return of spontaneous circulation of rosk during the resuscitation of a patient in cardiac arrest the ems systems have trained in public have trained the public in cpr and aeds in public places leading to tremendous success in rosk the ross crate in some communities is as high as 40 percent careful implementation of emergency cardiovascular care or ecc guidelines improves outcomes the american heart association and the internal liaison committee on resuscitation revise the guidelines for ecc and cpr every five years",
        "Chain of Survival": "so improving the arrest response to cardiac rest there is a chain of survival and to assist and manage cardiac arrest in the field the five links in the chain of survival are needed you must have recognition and activation of the emergency response system immediate high quality cpr needs to be performed rapid defibrillation and basic and advanced ems care and then advanced life support and post-arrest care a team of skilled providers is required including cpr trained community members first responders with an aed and emts and paramedics who have been trained in high quality cpr the pre-hospital team should practice working together directed by a co-team leader",
        "Developing Prehospital Program Objectives": "so community-based programs to improve the survival of pre-hospital cardiac arrest patients can benefit from smart objectives smart objectives are specific measurable obtainable and achievable realistic and relevant and then timely the following questions can help improve response so is there a universal access number and does the public know how and when to use it do all citizens have an address number clearly posted on the residence are the dispatchers and communicators trained in to provide hands-on cpr telephone instruction does their medical director review 100 of the cardiac arrest for response time and compliance with protocols also does the dispatcher center use a web-based system or mobile app that alerts nearby cpr trained bystanders in the communication or in the community of the location of the cardiac arrest patients is a community cpr training program available at little to no cost and and if so does the public know and if so have 25 to 50 percent of the population been trained is learning cpr in high school a graduation requirement if not how can we change this and are 100 of the emergency responders trained in cpr and use of the aed",
        "Simulation Training": "so next we're going to talk about simulation training in simulation training modules can help train for low frequency high risk situations such as lethal dysrhythmias and cardiac arrests these simulations and actions and results are tracked for critique and review high fidelity mannequins combined with computer simulated simulators to play a pre-programmed scenario involving alterations in vital signs ecg spo2 end-tidal carbon dioxide and other parameters",
        "Ongoing Development of CPR": "okay so let's talk about some ongoing development of cpr guidelines so strong emphasis on high quality cpr during the 1990s cpr quality seemed to slip as providers focus on innovation drugs defibrillation and other aspects of field management the depth of the compressions was inadequate the rate of the compressions was too slow and almost half the time no compressions were even being provided ventilations were too fast and the chest was rarely allowed to fully fully recoil so cpr is important both before and immediately after defend immediate cpr can double or triple the survival rate with the v-fib or sudden cardiac arrest cpr guidelines emphasize the importance of high quality cpr beginning with compressions the base of the resuscitation pyramid is high quality compressions success does not rely on iv or endotracheal tube or circulation adjuncts or drugs continuous uninterrupted high quality cpr compressions are the best chance of success okay so airway management so there is a reduced emphasis today on securing the airway with endotracheal tube innovation research shows that high quality compressions can double or triple the chance of survival if administered promptly focus on interventions that make a measurable difference such as defibrillation endotracheal tube insertion is not priority if the airway can be opened and ventilation is successful using basic adjuncts so the control of ventilation volume and rate is important with ventilating or in airway management ventilation should be one second in duration the volume should be just enough to see the chest rise and fall you should never over ventilate this can cause gastric distension or regurgitation some medical directors have encouraged paramedics to use an itd or an independence threshold device the device is placed in a ventilation circuit between the mask and the back valve mask or automated transport ventilation ventilator it sometimes compresses um by creating it enhances compressions by creating a vacuum in the chest that allows more blood flow to return to the heart and brain a prompt helps keep track of the ventilation rate so as to not exceed the recommended rate okay of two ventilations for every chest compression 30 compressions if the chain of survival is in place there's about a 40 percent chance of rask if the patient wakes up it's best not to have an endotracheal tube in place if the patient does not make wake up uh and is a candidate for post-arrest hypothermia therapy you may need to innovate and provide medication to prevent for shivering so theories about blood flow during cpr there's a heart pump theory and this is that the heart is directly squeezed by compressions between the sternum and spinal cord and basically there's a thoracic pump theory and this theory says that the compression of the sternum raises pressure in the chest cavity there is also a theory that the harder and faster compressions will increase pressure to a greater degree so interruptions in compressions cause blood movement to cease and the current emphasis is on continuous chest compressions with minimal interruptions and there are current theories which consider the importance of negative inner thoracic pressure so patients in cardiac arrest are not being are not breathing on their own so they do not produce negative inspiratory pressure to assist in blood flow during cpr some negative pressure develops and as the sternum and ribs rebound to their normal position during decompression the 2005 guideline emphasizes full chest recoil greater negative pressure in the chest push hard and fast allow full chest recoil causes a greater amount of blood to be returned to the heart then on the next compression more blood is forced to the heart's coronary arteries and vital organs a device such as an itd in combination with an active compression decompression cpr device could enhance this negative pressure gradient",
        "Adult CPR": "okay so let's talk a little bit about adult cpr adult bls healthcare algorithm is the first thing we're going to talk about and the key to successful outcome is how quickly compressions are initiated so determine on responsiveness and lack of normal breathing and spend no longer than 10 seconds determining pulselessness the table on this slide shows the adult bls procedures and if there is a no pulse begin cpr immediately and continue for two minutes or five cycles of 30 compressions and two ventilations always bring your aed or defibrillator monitor on your potent potential cardiac arrest call when necessary begin cpr and attach the aed as soon as available the public is generally not taught to make a pulse or or to take it pulse or perform rescue breathing or two-person cpr to help make cpr easier to learn remember and perform the general public or lay rescuers are taught to provide hands-only cpr bystanders are often reluctant to begin cpr for the following reasons cpr steps may have been too complicated or hard to remember the new guidelines emphasize simpler hands-only cpr with a focus on compressions only training methods may have been inadequate and skill retention typically declines rapidly after a course so a video based watch and do method has been incorporated into most courses now also some people are afraid of transmitted diseases and are reluctant to perform mouth-to-mouth resuscitation barrier devices in hands only compression only cpr is encouraged in such cases many bystanders who are trained but not help with cardiac arrest stated that they were afraid of doing the wrong thing",
        "Two-Rescuer CPR": "so next we're going to talk about two-person cpr and it's less tiring and facilitates effective chest compressions a team approach to cpr and aed use is far more superior to the one-person approach once one rescuer cpr is in progress additional rescuers can easily be added prior to assessing with cpr a second rescuer should apply the aed set up airway adjuncts including a bag valve mask or section insert an oral airway and if cpr is in progress the second rescuer should enter the procedure after the cycle of 30 compressions and two ventilations rotate the compressors every two minutes with two-person cpr a third rescuer should kneel on the side of the patient's chest from the rescuer performing compressions the on-deck compressor can take over after five cycles or two minute intervals studies show that the compressor tires after two to five minutes quality will suffer if the compressor is not replaced to perform properly perform to rescue cpr refer to skill drill 39-1",
        "CPR for Infants and Children": "so the guideline use the following definitions of age groups for the purposes of resuscitation newborn is an infant within the first few hours of birth a neonate is an infant within the first month after birth an infant is one month to one year a child is aged one year to adolescent or signs of puberty and an adult is adolescent and older in most cases cardiac rest in infants and children follows respiratory rest which triggers hypoxia and ischemia of the heart children consume oxygen two to three times as rapidly as adult and you must open the airway provide artificial ventilation often this will allow the children or the child to resume spontaneous breathing and prevent cardiac arrest airway and breathing are a focus of pediatric bls this table shows a review of pediatric bls procedures respiratory problems in children have can have a number of different causes including injury both trauma or blunt and penetrating infections of the respiratory tract or other organ systems foreign body in the airway submersion electrocution poisoning or drug overdose and sudden infant death syndrome pediatric bls can be divided into four steps and the four steps are determine responsiveness circulation airway and breathing",
        "Technique for Children and Infants": "cpr technique for children has a few slight variations and um so to properly perform cpr and a child we want you to refer to skill drill 39-2 so cpr technique for infant very slightly as well and to perform to properly perform cpr on an infant refer to skill drill 39-3 if two rescuers are available then compressions can also be performed using the two thumb encircling hands technique if the chest does not rise and fall only a little then use a head tilt chin lift to open the airway so next we're going to start talking about defibrillation and so this we know is one of the first pieces of equipment to obtain from the ambulance and that's the aed defibrillation delivers a surge of electricity and electric energy to the heart a paramedic is likely to administer electricity in one of three ways and so we could defibrillate cardiovert and transcutaneous pacing defibrillation is appropriate when the patients in cardiac arrest v-fib or pulseless v-tac and if you are the first responder you are more likely to use an aed than a manual defibrillator but many communities have placed aeds in public places okay so we're going to add here to the following guidelines adults use a standard adult aed unit a child age one year to the onset of puberty remember is uh we're going to use aed with a pediatric dose dose attenuating if available and if n available we're going to use the standard aed okay so this figure on this slide shows that pediatric dose attenuator system so infants ages one month to one year a manual defibrillator should be used if available otherwise use a pediatric dose attenuator and if neither is available use a standard adult aed with pads in the a anterior and posterior position that's what amp stands for and so newborns burp to one to age one month focus on cpr with an emphasis on ventilation all right so carry out defibrillation as soon as possible in the two rhythms that we've talked about so v-fib and pulseless v-tac if you witness the arrest begin cpr and chest compressions and attach the aed as soon as it is possible if the arrest was not witness perform five cycles of cpr before applying the aed the heart is more likely to respond to defibrillation within the first few minutes after ventricular fib if the arrest interval is prolonged metabolic waste products accumulate in the heart energy stores are rapidly depleted and the chance of successful defibrillation is reduced a two minute period of cpr before aet use is prolonged arrest greater than four to five minutes that's what we define as prolonged arrest and it can restore oxygen to the heart so the cpr prior to the aed remove metabolic waste products and increase the chance of a successful defibrillation so if the cardiac arrest is not witness and cpr is not in progress immediately start cpr and prepare the aed to assess for a shockable rhythm if the rhythm is it converts to v-fib or pulseless v-tac and the defibrillator is already attached perform cpr only long enough to change the defibrillator and then to do or charge the defibrillator and then to defibrillate the fibrillation is not useful in a systole or pulseless electrical activity there is no evidence that the myocardial cells are spontaneously depolarizing so defibrillation of a systole is harmful due to the unnecessary interruption of compressions if you are unsure about a systole after checking more than one lead resume cpr and follow the assistely pathway in the pulseless arrest algorithm to shorten the post defibrillation interval ems may practice defibrillation with one compressor hovering over but not touching the patient's chest",
        "Manual Defibrillation": "okay so let's talk about manual defibrillation and some defibrillators can perform manual or automated defibrillation in manual defibrillation you interpret the cardiac rhythm and determine if defibrillation is needed manual units require you to select the appropriate dose a default setting of 200 joules is usually used however settings may range from 120 joules to 200 joules depending on the manufacturer's recommendation the figure shows the use of manual defibrillator on an adult patient in cardiac arrest after you deliver the shock immediately begin chest compressions for two minutes then reassess for the pulse return and rhythm change if your unit has a manual a manual and an aed mode it's faster to use the manual mode so you can interpret the rhythm more quickly than the aed can all right so let's talk about the six steps for manual defibrillation of an adult patient and they are the follow-up the following so take standard precautions prepare the skin for placement of adhesive defibrillator pads if needed you're going to attach the pads to the chase to the patient's chest as instructed on the package turn on the main power switch and then set the energy level to 200 joules or follow the defibrillator manufacturer's recommendations regarding the appropriate energy level charge the defibrillator remember to not defibrillate the patient who is laying in the pooled water also ensure that the patient is not touching metal clear the area ensure the compressor is hovering but not touching the patient's chest announce all clear and press the button on the machine to deliver the shock resume cpr immediately continue cpr for two minutes or five cycles and then pause to check for a pulse and re-evaluate the rhythm if at any point you see an organized rhythm on the monitor check for pulse but make it a maximum of 10 seconds today's pre-hospital agencies use defibrillator pads not paddles petals require use of a conductive jelly and firm pressure on each paddle to make good skin contact the steps for manual defibrillation of an infant or child are similar to those of the adult with the following additional points so you want to place one adhesive adhesive defibrillated pad on the anterior chest wall to the right of the sternum inferior to the clavicle then place the other pad on the left mid clavicular line at the level of the zifluh process for children who are younger than one year or way less than 22 pounds or 10 kilograms you may use an interior posterior placement and the figure shows this anterior and posterior pad placement and also the paddles most ems systems use pre-gel defibrillator pads instead of paddles so place pads in the same location you would when you use an aed ensure that there's no air pockets on the skin and they may result in skin burns or decrease effectiveness if there's air pockets the initial energy setting for defibrillation of a pediatric patient is two joules if this level is not successful you're going to repeat at four joules per kilogram further defibrillation should be should occur at four joules per kilogram after cycles of cpr as needed with ongoing cpr search for and treat underlying reversible causes and we call this the h's and t's give epi only after the second shocks consult your medical director medical control physician or other local protocols for transport decisions early rosk less than five minutes in and v-fib or v-tac as a presenting rhythm are associated with improved neurological outcome for survivals of pediatric cardiac cardiopulmonary arrest",
        "Shockable ECG Rhythms": "so let's talk about shockable rhythms the two shockable rhythms as we've mentioned earlier are v-fib and pulseless v-tac shockable rhythm means that the heart is quivering but blood is not pumping defibrillation stuns the heart muscle monetarily and allows the normal conduction system to resume control if the patient is not defibrillated the v-fib will deteriorate to a systole or flat line in the first moments of a cardiac arrest the heart is oxygenated and ready to receive a shock begin cpr and attach the aed as quickly as possible if a shock is recommended administer immediately the chances of successful defibrillation drop seven to ten percent for every minute that passes when a patient is in cardiac arrest for four to five minutes or longer even if the initial ecg showed a shockable rhythm the successful success rate is poor perfusion and oxygenation are needed first begin cpr provide with uh proceed with five cycles or approximately two minutes of 30 compressions to two ventilations and then analyze the rhythm if the patient is still in v-fib or v-tac he or she is ready for a dose of electricity",
        "Effective Shocks and Special Circumstances": "so when shock is effective occasionally the patient wakes up the majority of effective defibrillations take a minute or so to bring back circulation defibrillation stuns the heart allowing the pacemaker to begin to beat this may not be enough of a heartbeat to generate a pulse yet though after defibrillation immediately begin compressing compressions the patient may begin to move after a minute or so after two minutes of cpr take 10 seconds to check for a pulse and review the rhythm if there is rosk cease compressions and check for pulse respirations and blood pressure when using a manual defibrillator the patient's ecg is monitored and displayed throughout the arrest thus you can observe a rhythm change to a shockable rhythm when compressions are being done and then begin to charge the unit after the aed is fully charged the operator should clear the rescuers and deliver the shocks remove detach and the ventilation device from the advanced airway to prevent oxygen from flowing across the patient's chest while a shock is being delivered special circumstances for defibrillation include the following the patient is an infant use the appropriate pediatric pads and an attenuator if available the patient has hairy chest and the electrodes will not stick shave the patient just as you would to obtain a 12 lead if the patient is submerged in water or soaking wet you need to move the patient to your ambulance or dry them off prior to applying electrodes if the patient has an implantable cardio a defibrillator or pacemaker avoid these devices by a few inches when placing the electrodes the patient if the patient has a transdermal medication patch remove the patch and gently wipe the chest dry wear disposable gloves too to avoid absorbing the nitrile onto your skin so this table shows the key elements of a cpr for adults and infants and children and then this table shows the key elements of cpr and it's continued",
        "Advanced Cardiac Life Support Algorithm": "okay so we're going to talk about an acls algorithm and we're going to build it builds on the healthcare provider algorithm after providing supplementary or oxygen use the monitor or defibrillator to determine whether the patient is still in a shock above them and we talked about this there are basic two pathways though so we know um the shockable rhythms are v fib and pulses vtac and um then we have the non-shockable rhythm so that's the other pathway that we're going to talk about and that is asystole and pulseless electrical activity so medications are drawn up and ready to administer prior to the rhythm checks medications are administered during cpr without needing to stop for compressions as long as the patient has an effective bls airway and is adequately ventilated placement of an advanced airway should never take priority over delivering high quality compressions or a shock when needed practice innovation techniques so that you can insert the advanced airway device with no more than 10 second interruption in chest compressions so this figure shows the advanced cardiac life support algorithm for cardiac arrest",
        "Managing Patients in VF or VT": "patients with v-fib or pulses v-tac are the most likely to be resuscitated continue to perform high-quality cpr and do rhythm checks at each two-minute point if the patient is in a shockable rhythm administer a single shock and immediately begin chest compressions with three persons and an advanced airway compressions and ventilations could be asynchronous so prepare and administer medications while performing cpr and a time keeper can remind the team lead about upcoming actions okay so drug therapy for v-fib and v-tac include a vasopressor and we usually use epinephrine the one to ten thousand and it's given as a one milligram iv push we repeat the dose every three to five minutes as long as the there's a pulse is absent and the new acls algorithm says every four minutes okay also vasopressin is given as 40 units iv push one time only and a single dose may be substituted for the first or second epidose but not both after the third shot you may decide to administer an anti-dysphoric so amiodarone is given in a 300 milligram bolus during cpr it may be repeated once at 150 milligrams in the three to five minutes after the initial dose if amiodarone isn't available we can use lidocaine and that's a 1 to 1.5 milligram per kilogram push and followed by a 0.5 or 0.5 to 0.75 milligram per kilogram it's a max dose of three milligrams per kilogram and do not combine these two anti-disrhythmics with amio if the patient is intersod's we consider using mag the loading dose is one to two grams iv or io we always allow the drugs to circulate then reanalyze at the two minute point if the patient remains in a shockable rhythm we're going to consider another shock and we also consider treating those causes the h's and t's so the table shows possible reversible causes of cardiac arrest and these will list the h's and t's",
        "Managing Patients in PEA or Asystole": "all right so let now let's talk about pea or systole so pea is pulseless electrical activity and it's an organized cardiac rhythm so that's the key it's organized cardiac rhythm other than ventricular attack so on the monitor with no detectable pulse we're going to continue providing high quality cpr we're going to conduct a rhythm check at each two minute point and if the patient is in either a systole or pa at that point we need to consider the possible causes and manage them appropriately some issues can be managed in the field while others will require interventions in the emergency department with three rescuers in an advanced airway compressions and ventilations can be asynchronous prepare and administer medicines while performing cpr as we said earlier and the timekeeper can remind the team lead about upcoming actions so drug therapy for pea and assistely includes only a vasopl vasopressor so epi one to ten thousand is given as one milligram iv push and repeat this dose every three to five minutes as long as the patient's pulse is absent if the patient changes to v fib or beef tack we're going to move back to those shockable sides of the algorithm we're going to allow drugs to circulate re-analyze at the next two-minute point okay and paramedics are trained to follow the current algorithms and use good medical judgment high fidelity simulators provide excellent learning opportunities for low frequency high risk or high impact calls all right so there's some key points when managing cardiac arrest and they include performing high quality cpr with compressions and minimizing interruptions from the start to completion of the code you want to organize the code around 2 minute cycles of 30 to 2 so that's 30 compressions to two ventilations then switch compressors and analyze the rhythm if the advanced airway is inserted switch to asynchronous compressions of at least 100 chest compressions a minute and ventilate every 6 to 8 seconds that's a rate of 8 to 10 per minute if a shockable rhythm is identified continue compressions until the defibrillator is charged to the appropriate dose stop clear and deliver the shock and immediately begin compressions unless the patient is awake without interrupting cpr obtain iv io access and administer epi every three to five minutes for the duration of the code after the cycle of cpr and shock if necessary administer the anti-disrhythmic for a for v-fib and v-tac for systole and p-d-p-e-a do not deliver the shocks for all cardiac arrests consider and treat reversible causes if you decide to insert an advanced airway confirm and monitor the waveform capnography and switch to asynchronous compressions and ventilations never over ventilate this causes a deadly restriction on coronary perfusion and if the patient experiences rosk capno is going to show a sustained increase in end title so that's a good thing to look at you'll see a huge spike we say in the capnography",
        "Mechanical Adjuncts to Circulation": "okay so american heart association standard guidelines manual chest compressions for treatment of cardiac arrest so mechanical adjuncts can be used in certain settings where delivery of high quality chest compressions can be difficult or dangerous",
        "Load-Distributing Band CPR or Vest CPR Device": "now this is a load distributing band this is called the autopulse it delivers consistent uninterrupted adult chest compressions and thus improves hemodynamics during cardiac arrest it's automated and portable it's easy to use and it has this load distributing band which squeezes the entire chest thereby improving blood flow to the heart and brain during cardiac arrest it also frees up a rescuer and that's a good thing all right so this load distributing band cpr device can be integrated into the code as following so you want to ensure first that you you know you're giving the high quality cpr then align the patient on the device platform you're going to close the chest band over the chest perform push the start button and the device is going to perform the chest compressions and you're going to provide bag valve mem ventilation at the rate of two ventilations for 30 compressions",
        "Mechanical Chest Compression Device": "all right so this is a mechanical chest compression device and it's an adjunct to the adult cpr that provides continuous chest compressions and it can be used with a pocket mask or a advanced airway okay and you need to carry additional portable oxygen tanks because these use high pressure and it could really diminish the oxygen on your truck",
        "Mechanical Piston Device": "okay so then this is the mechanical piston and this is what we use this is a lucas device we use in the field the mechanical piston is a mechanical chest compression device that depresses the adult sternum via a compressed gas powered plunger mounted to a backboard and it does not offer ventilation because it many services use atv for this purpose it's portable and easy and it's powered by a small battery at the top of the piston and it eliminates the need for air hoses",
        "Impedance Threshold Device": "okay so the next thing we're going to talk about is an impedance threshold device now this is marketed as a rescue pod in the united states it enhances chest compressions by creating a vacuum in the chest that allows more blood flow to the heart and brain when the chest wall expands a vacuum pulls air into the lungs and back into the heart an itd prevents unnecessary air from rushing into the chest maximizing the vacuum during recoil phase of the compression aha guidelines does not recommend an itd as an adjunct during on during conventional cpr use of an iad or itd has been shown to enhance the effects of active compression decompression cpr device it should be removed from the ventilation system as the patient's pulse returns and use in conjunction with compressions",
        "Postresuscitative Care": "all right so let's talk about some post arrest care so posters care is important component of caring for cardiac arrest patients if an effective cardiac rhythm is restored in the field provide immediate transport if the patient is comatosed afros begin hypothermia treatment immediately so here's a summary of the post arrest care you want to stabilize that cardiac rhythm and you could administer an antidote rhythmic drug for post fifib or post feed tag you want to administer atropine if you need to or use transcutaneous pacing for symptomatic bradycardia you also want to normalize the blood pressure and you can administer dopamine or epi to give to raise the systolic to at least 100 you can elevate the head 30 degrees if blood pressure allows or obtain a 12 lead monitor glucose level assess oxygen need and prevent seizure activity we want to provide targeted temperature management or ttm for patient with roscoe's in a coma",
        "When to Start and When to Stop CPR": "all right so there's two exceptions to a paramedic's responsibility to start cpr in all patients who are in cardiac arrest and of course we're not going to start cpr if the patient has obvious signs of death and um if they have obvious signs of death and and one of the following that i'm about to talk about we're not going to start cpr okay so if they have rigor mortis and that stiffening of the body after death if they have dependent lividity or we call that liver mortis that's the skin discoloration caused by pulling of blood if they have putrification and that's of course decomposition of the body that body decomposing or evidence of a non-survivable injury and so we consider non-survivable injuries decapitation dismemberment or burned beyond recognition we're also not going to start cpr for the patient or and his or her physician have previously signed a do not resuscitate order cpr in terminal stage of an incurable disease only prolongs the patient's death we want to document the patient's wishes and they may not be readily producible though by the family or caregiver so if they cannot produce them you need to start of course the cpr process so in such cases begin cpr under the rule of implied consent and medical control if a valid dnr medical order for sustaining treatment or a living well is produced we're gonna we're gonna be withhold the resuscitated efforts okay so learn some state laws local protocols and system standards for treating terminally ill patients in other cases begin cpr for anyone who's in cardiac arrest and do not stop until one of the following events occur so if the patient begins to breathe and has a pulse and that's of course rosk if the patient is transferred to another healthcare provider of equal or more advanced training if you are physically no longer able to perform cpr or if a physician assumes responsibility for the patient always continue cpr until care is transferred to a physician or a higher medical authority your medical director or a designated medical control physician may order you to stop cpr every ems system should have clear standing orders or protocols",
        "Terminating Resuscitative Efforts": "okay so in 2015 aha guidelines say the following about lengthy resuscitation efforts in transport few instances require transporting a non-traumatic cardiac arrest patient who has failed to survive a properly executed pre-hospital acls resuscitation effort to the emergency department to continue the resuscitation attempt so rare exceptions may include severe pre-hospital hypothermia and drug overdose transporting a diseased patient who is in re who is refractory to proper bls and als is usually not appropriate",
        "Termination Rules": "cpr quality is compromised during transport and the survival is linked to optimizing seen care for a patient who is receiving only bls consider terminating bls support before transport if all of the following criteria are met so you're going to start or you're going to stop if the arrest was not witnessed if no risk occurred after three full rounds of cpr and if no aed shocks were delivered if als personnel are present consider terminating resuscitated efforts before transport if all of the following criteria are met if the arrest was not witnessed by anyone if bystander cpr was not provided no rosk occurred after complete and als in the field no aed shocks were delivered and the transportation decision should involve pre-planning by regional and service medical directors",
        "Scene Choreography and Teamwork": "okay so scene choreography and teamwork division of task multiplication of chances for successful resuscitation so each person has a role in a regular practice leads to better outcomes all team members must be totally committed to the success of the team rather than the personal achievements field code team members who are rested fit and well nourished have a positive outcome practice their skills know the plays and work together as a team are ready to resuscitate patients to be successful take the following steps know the plays expertly and automatically through practice have a practice ethic success equals practice a positive mental attitude well-designed plays and excellent coaching utilize cpr feedback devices and the team's effectiveness is about succeeding as a group",
        "Code Team Member and Code Team Leader Roles": "you should know your role and the roles of your teammates you must be prepared have practice regularly and have mastered the algorithms and be committed to success code team members roles generally include you could have a ventilator role and they manage the airway you have an active compressor which is actually providing the compressions then you have the on on-deck compressor and that person's going to relieve the compressor at two minutes and then you have other support devices or support people and they could analyze the ecg deliver shocks they could gain ivio access or provide documentation for the patient care report also support family members the code team leader has many rules and responsibilities they must know and be able to perform all skills expertly and they will occasionally serve as a backup for a team member and often responsible for making sure everything gets done correctly and at the right time okay so they're also going to obtain the patient's history and perform the physical exam they're going to interpret the ekg they're going to keep track of time and they're going to make a medication decision following the algorithm change they could delegate tasks to the code team members they could talk to medical control and they can control the resuscitation scene and foster the concepts of crew resource management they could also help train future leaders they could seek to improve the effectiveness of the entire team through continuous quality improvement and they could also practice after the resuscitation to help prepare for the next code",
        "Plan for a Code": "now the following sample plan focus on out of hospital ems agency response to a cardiac arrest in a private home assuming a five-person team that could arrive on different units at the different times in the first few minutes okay so we have compressor one and they are immediately performing high quality chest compressions they stay in position and compress for two minutes and then they're going to rest for two minutes okay because you have a compressor too so that person is going to perform high quality chest compressions for um 100 to 120 per minute they're going to press hard and fast allowing full recoil and they're going to stay in position and compress for two minutes then they're going to rest for two minutes okay they could also assist with the application of the thumper or the other some other adjunct to circulation and then we're going to have the ventilator so this is person number three they're going to provide ventilations at a ratio of 30 to 2 they're going to ensure visible chest rise and fall with each ventilation they may need to suction briefly as necessary then switch over to that aetv as appropriate they could assist with the transition from bls airway to advanced life support although it's not a high priority and once an advanced airway is in place of course we're going to ventilate eight to times a minute and then we have the fourth we have the fourth person and that's a code team leader they're going to be responsible for the initial ecg analysis and defib they're going to be responsible for the overall timing of the code and the reassessment after two minutes of cpr they're gonna after the initial shock they're gonna establish ivio and they're gonna begin administering uh vasopressor every three to five minutes one milligram of epi of course and one to ten thousand so they're going to help to transition the airway from bls to advanced airway and continue with single shocks every two minutes if the patient is still in ventricular fib or pulses vtac and then you have the number five that's the field supervisor and they're going to bring in the auto pulse or other adjunct and work it um to transition to that mechanical cpr compressions and they're going to assist the medic and iv with ivio or advanced airway placement and so managing a field code is complex but not impossible so have confidence and expect the patients to survive if you come on a scene and somebody is already performing cpr okay so this concludes chapter 39 the field code and thank you for joining us this evening and then there is a harder and faster"
    },
    {
        "Introduction": "hello and welcome to chapter 3 public health lecture of the nancy caroline's emergency care in the streets 8th edition",
        "National EMS Education Standard Competencies": "public health is a field that encompasses health promotion and disease prevention for groups of people public health related issues can include disasters such as hurricanes and wildfires or illness outbreaks such as the h1n1 flu federal state and international rules regulations guidelines and laws govern public health ems providers hold an important place in public health arena through prevention and education efforts",
        "Introduction to EMS Role": "so let's get started ems providers have an important role to play in injury and illness prevention injury and illness prevention are an important part of public health",
        "Role of Public Health": "so let's talk about the role of public health the american public health association our apha defines public health as the practice of preventing disease and promoting good health within groups of people public health professionals examine an overall needs of the population at a large at large to determine the best use of health resources to enhance the quality of life for public in the general so some examples of this are efforts to promote and control communicable diseases immunizations nutritional programs environmental health monitoring and regulation and community planning when you talk about public health threats one of the the highest ones is injuries so you have intentional injuries and you have unintentional injuries those are the two categories an an intentional injury is an injury or death that is self-inflicted or perpetrated by another person usually in the context of violence so some examples of intentional injuries or assaults self-harm behavior intentional overdosing and suicide and then with unintentional injuries they occur without the intent to cause harm so accidents and they account for the vast majority of the injuries and you can see on the slide it's 93 percent there are risks and a risk is a potentially hazardous situation in which the well-being of the person can be harmed then you have risk factors and those are characteristics that increase the likelihood that the person will suffer in a particular disease or injury injury is the lead the third leading cause of death for all age groups when it comes to unintentional injuries in children in the united states injury is the leading cause of death in children under children ages 19 and under compared to adults children have thinner skin smaller airways a larger head in proportion to their bodies and lesser ability to protect themselves from harm so the risk factors for children the injury patterns vary widely depending upon the children's age gender socio-economic status developmental status family environment and a whole host of other factors so most injuries received at school occur during sporting activities industrial art classes and playground activities each year about 200 000 children 14 years of age or younger receive injuries while playing on playgrounds more than 2.6 million children and teenagers are evaluated in the ed each year for sports related injuries okay so the next one we're gonna talk about after injuries is chronic illness as a health a threat public health threat annually seven out of ten americans die from chronic diseases with cancer heart disease and stroke causing more than 50 percent of the death in 2012 about half of all adults 117 million americans had at least one chronic illness in 2011 asthma was a primary diagnosis in one million seven hundred and eighty one thousand visits to the emergency room the third public health threat is acute illness and the united states declared a public health emergency in 2009 when h1n1 influenza was detected the world health organization or who declared a global pandemic in 2019 and in 20 2009 the food and drug administration the fda approved four vaccines to prevent the disease and the who declared an end to the emergency in august 2010 and of course the updated books are going to talk all about covid i'm sure so another public health threat is water supply or food contamination radiation leaks lack of sanitary conditions following a natural disaster and increased incidence of cancer after major incidences okay so there's a cost of public health",
        "Injuries as Public Health Threats": "threats and the cost of injury and illness are far-reaching so years of potential life lost and that's why pll you'll see written so assume a productive work life is until 65 deduct the year of death from that age for example a 22 year old who dies in a bicycle crash loses 43 years of potential productive work life medical conditions such as heart disease and cancer typically result in a lower years of potential life lost even if the patient did not die but remained in a comatose state for the rest of his life he lost years in which he would be earning income paying taxes and making other contributions to society and we all pay the price for this loss the figure shows years of potential life loss before the age of 65 categorized by cause of death all races both sexes and death",
        "The Teachable Moment": "so there are teachable moments and to articulate and reinforce safety messages when opportunities arise near misses cause people to realize how vulnerable they are the lesson is more likely to stick so this is a teachable moment use good judgment and be sensitive in the situation factors of a teachable moment include injury or illness are such that the patient or family will be receptive ethnic and religious differences must temper the message so the scene is conducted to delivering the message in the non-threatening non-judgmental way you are not introducing inappropriately or causing embarrassment so this is a definitive preventive measure that could be helped vague advice is not helpful or useful so sometimes a teachable moment can be preemptive example you are providing a wellness check to a home of an older patient who you notice a potential tripping hazard in the living room taking the time to inform the patient of the danger and giving advice as to how this threat can be averted may very well save the patient from a fall and injury in the future okay so then there are prevention so interventions are specific actions intended to improve health and safety outcomes",
        "The 4 Es of Prevention": "the four ease of prevention so you have education enforcement economic incentives and engineering or environment so let's talk about these four e's now okay education so citizens do not always know the certain behaviors that put them at right at risk so examples you're putting a baby seat in the front passenger seat you can inform people about the potential dangers and persuade them to change their behaviors to be effective messages should be tailored to specific groups reinforced with meaningful rewards and effective techniques include contract or participant commitment incentives behavioral feedback modeling and then so then the second you we're going to talk about is enforcement so even if the members of the community do not change their behavior your educational efforts may lead to legislation legislative or environmental or technical changes so sometimes behavior change can be facilitated by changes in the law so legislation regulation formulates rules that require people manufacturers and governments to comply with safety practices and then you have economic incentives so economic so self-interest provides monetary incentives to reinforce safe behavior so some examples of this are insurance rate reduction for careful drivers organizations may also offer free or subsiste subsidized safety products to encourage use and then finally the fourth is going to be engine engineering and environmental so passive in inventions changing the design of products or spaces to offer the automatic protection so often without conscious behavior change some example is the child resistant medicine bottles this approaches by social legal political and cultural and modifications usually happen once awareness is raised",
        "The Value of Automatic Protections": "the value of passive intervention so passive interventions are often the most successful also called automatic protection some examples are sprinkler systems and commercial buildings or airbags and cars they provide cons constant protection without conscious action from the user a combination of approaches is still the most effective strategy and education is always an important component",
        "Why EMS Should Be Involved": "so why do we need to be involved as a paramedic the consensus statement on the ems role in primary injury prevention was published in 1996 primary injury prevention should be an essential activity primary prevention is the action that stops injuries and illness before they begin secondary prevention is a measures taken after a patient has an injury or illness to prevent the problem from becoming worse so it's a traditional focus of ems ems culture has changed in recent years and providers are now more involved in the primary prevention efforts so ems providers have more opportunities for prevention education than other health care professionals they're widely distributed in the population they may be the most medically sophisticated persons in the rural community they may be the most um and are considered advocates of the health care consumer and work in concert with their patients and their patients families they're welcome in schools and other environments and they're considered authorities on injury and prevention",
        "How EMS Can Get Involved": "how ems can get involved so ems providers have emerged as strong advocates and practitioners of injury and illness prevention strategies that promote in interventions might include fundraisers to purchase and distribute free bicycle helmets to children car seat checks and insulations appearing at health fairs giving speeches to community groups and children blood pressure checks fall prevention services for older adults case so one of the most visible ways ems professionals interact with public health agencies is through the provision of immunizations ems professionals are ideally suited to reach at risk populations because their inherent mobility allows them to reach widely dispersed populations there is typically positive perception of ems and small communities and many ems providers have the clinical training in medication security aseptic techniques and medication administration post-injection care documentation of informed consent for treatment and how to discuss risk benefits and possible side effects with the patient ems must work closely with the local population or public health agency to develop a plan a dr it must address all logistical matters and clearly defines each person's role and responsibilities identifies and resolves any issues pertaining to the need for additional training and clearly explains the procedures for procuring the vaccine and talks about the potential liability issues the concept of community paramedicine gives providers many new and expanded avenues for preventing illness and injuries as part of their regular daily duties conducting home and health visits and well-being checks providing wound care and other in-home therapies and ensuring medication compliance by offering these expanded services ems agencies could have a more proactive approach in decreasing the mobility and subsequent mortality of their patients they can also play a significant role in unnecessary hospitalization readmission opportunities for reimbursement could exist through creative contracting with hospitals managed care agencies and other third party payers",
        "Injury and Illness Surveillance": "when it comes to illness and injury and illness surveillance so in prevention surveillance refers to ongoing systemic collection analysis and interpretation of data planning implementation and evaluation of public health practices data are in analysis and interpreted by epidemiologists information can be used to develop interventions intended to prevent further injury and illness strong surveillance systems are fundamental and to effective prevention programs so who is being injured where and by what mechanism and why",
        "The Haddon Matrix": "so there is a thing called the hand in matrix and william handen he's md created a matrix that identified several principles of injury prevention added factor of time to previous models to address causes of injury so the host agent and environment interact over time to cause injury and correspond to three phases of the event so there's a pre-event there's an event and then there's a post event and so the matrix uses nine components to analyze the injury it encourages creative thinking to to in understanding causes and the potential interactions for injury most ems providers are trained to respond in the post-event phase after an injury or illness has taken place this is reactive not preventive may be optional optimal time to reflect on the event and allow for first-hand knowledge so why did this happen how might this be prevented in the future paramedics are uniquely qualified to speak to the problem and compel others to examine the problem more closely and ultimately to pursue and implement strategies solutions in the pre-event phase so this table shows childhood motor vehicle vehicle occupant injuries using this hand matrix",
        "Getting Started in Your Community": "all right so getting started in your community the most effective prevention programs focus on problems that impair the health and the well-being of the greatest number of people so you want to recognize injury and illness patterns in your community to be affected effective you need to understand injury and illness patterns characteristics of population and environment and the types of risk that are present your regional or state ems department or public health office should be an excellent place to start they will likely have the data statistics and other resources with relevant information many state organizations even make this information available on the internet ems providers play an important role in prevention by carefully reporting data and noting risk factors while on scene paramedic training provides or prepares you to recognize and report signs and risk factors associated with vi intentional violence this empowers you to be proactive in the fight against suicide domestic violence and child abuse and remember you are an example to your colleagues",
        "Prevention Programs for Children": "prevention programs for children's what we're going to talk about next and so there are various government and private grants commercial sponsors and non-profit groups that support car seat installations helmet donations fundraising events there's a safe kids worldwide this is a non-profit organization made up of more than 400 coalitions in the united states with partners in over 30 countries the goal is to reduce the prevalence and preventable of preventable injuries in children so the website is filled with helpful information so you want to focus on children's issues and that can have unintended benefits so the pass-long effect other benefits of children's family benefit from the message originally intended solely for the welfare of the child so for example a third grader is educated on the importance of wearing seat belts but later insists that daddy needs to buckle up too so experts in public health suggest focusing preventive efforts on injuries associated with a high rate of mortality hospital frequencies accompanied by long-term disability or those known to have a high effective counter measures",
        "Five Steps of a Prevention Program": "there are five steps in developing a prevention program you need to conduct a community assessment and when you do this it you need to bring people and groups together to assist with this what is already being accomplished and resources potentially already available invite people who represent the community at large and this includes survivors and their families and potential partners including ems groups law enforcement school groups media public health officials and health care providers members of the business community religious organizations civic groups service clubs sports related organizations non-profit groups celebrities community leaders elected officials and research groups so the five steps of prevention program number two is to define the problem and so on a basis of community assessment the data can be collected defined the program is specific in quantifiable terms so examples what are the most frequent causes of fatal and non-fatal childhood injuries and what are the most frequent causes of disease and chronic illnesses in our community you the third step is to set goals and objectives so you want to make this a broad general statement about a long-term changes and then objectives is to make specific time limited and quantifiable so there's two types of objectives you could have a process objective and an outcome objective and that's the impact you're going to make is the outcome objective number four or the fourth step in this five prevention program you want to plan and test interventions and so interventions is defined as the actions you take to accomplish your goals and objectives using the four ease of prevention and brainstorm options consider your available resources already and review what others have already done be aware of timing and cultural considerations and get a sample group together to test before rolling out the entire program implement and evaluate your interventions the results must be measurable for formal evaluation it will tell you whether or not you met your goals or objectives objectives you want to spend your time and resources on efforts that you can show make a difference and be aware that many interventions demand ongoing attention to remain effective",
        "Community Organizing": "to develop a successful prevention program do the following as you build your team and create and implement your plan you want to have it is designated leader build a broad build as broad a support base as possible create a res realistic timeline choose smart um goals and objectives and so what smart stands for is simple measurable accurate reportable and trackable so that's what the acronym smart stands for build um consensus in your community on the need for action and understand the religious ethic cultural and language challenges you may face do not reinvent the wheel seek others with experience and anticipate opposition and some losses when lobbying legislators be brief set up your program to measure results that make changes as needed establish a self-sustaining funding source and keep a sense of humor and persistence and challenge change takes time",
        "Funding a Prevention Program": "so when it comes to funding a prevention program you want to consider innovations um innovative ways to fund programs so partnering with local media to create prevention messages seeking grants from regional state and national organizations you could also seek scholarships from local nonprofit service organizations or commercial farms and networking with other organizations often provides greater leverage when seeking grants or sponsorships okay so",
        "Summary": "as we wrap up chapter three the public health lecture in summary the field of medicine continues to dedicate more and more attention and resources to the missions of public health promoting health and wellness preventing illness and injury prevention is not a goal reserve solely for health care specialists and how can we make a difference in the community is the question we must constantly ask us ourselves as paramedics so thank you for joining us today for chapter three the public health lecture we hope that you've enjoyed it"
    },
    {
        "Introduction to Documentation": "hello and welcome to chapter 6 documentation lecture of the emergency care in the streets",
        "National EMS Education Standard Competencies": "upon completion of this chapter and the related course assignments you will be able to discuss the purpose of thorough documentation of all aspects of the patient care report including those applicable to the documentation of the refusal of care so let's get started the",
        "Importance of EMS Documentation": "ems documentation is an important part of the patient care process the pcr which is the patient care report may be called the pre-hospital care report it's the only written record of the events that occurred during the call for service it's a legal record for the call and becomes part of the patient's medical record and the emergency department chart it allows other health care providers to obtain information about what has occurred from start to finish of the call and helps guide future patient care and quality assurance an ems professional needs to know what constitutes a pcr what information must be included who might read the report and when the report must be completed also what terminology may be used information can be objective or subjective objective information is measurable signs that are observed and recorded such as blood pressure subjective information is information given but that cannot be seen such as symptoms patients described like an example is the degree of pain so try to utilize the patient's own words as much as possible for every call the pcr should include objective information and subjective information also details of patient care the pcr must be complete accurate and legible it can be the basis of defense in legal proceedings and it facilitates quality and continuity of care and it's also used to bill insurance companies",
        "Legal Implications of a PCR": "so let's talk about the legal implications of a pcr reports may include subjective statements from the patient but cannot include any personal biases or opinions a paramedic may have regarding the patient for example the patient was drunk and out of control versus the patient had an altered mental status and stated he had eight beers today pcrs that are poorly written or improperly documented could be adverse or could have adverse implications for patient care and for a paramedic's career omissions or errors could lead to further errors in patient care improper and inadequate reports could result in litigation job loss or demotion or poor reputation of ems providers paramedics have been found guilty of neglect based on failure to perform patient exams and submit completed paperwork reports must be complete well-written legible professional and the sole source of information about the call they may be used in legal proceedings years after the call and may be your only defense against a complaint about a call to use proper spelling grammar and accurate terminology sloppy documentation imply sloppy care hipaa has ramifications related to patient care reporting",
        "Purposes of Documentation": "so the purpose of the documentation and it is it serves as a continuity of care the pcr serves as a record of the patient's condition upon arrival at the scene the care that was provided and any changes that the patient's condition happened in route also the condition on arrival at the hospital so the patient pcr should be accurate and clear to ensure better patient care at the hospital it paints a picture of the environment the patient was taken out of and the mechanisms of injury or nature of illness minimum requirements and billing so the pcr writing must be accurate and complete for billing and administration purposes for complete and accurate revenue recovery you must ensure procedures performed are documented insurance codes are obtained and medical necessity signatures are obtained where required the reason the patient needed to be transported by ambulance is documented and be as specific as you can in the narrative portion of the pcr inaccurate or incomplete documentation delays billing processing your agency may require additional billing paperwork",
        "EMS Research": "so ems research research use of the information collected by ems providers to justify innovate innovative life-saving techniques many states now require ems agencies to submit data to their state office to verify call volumes and skills used including the number of calls an agency responds to the types of calls the care provided the patient outcomes patient care data collection can improve the ems system as a whole the national emergency medical services information system or nemsis stores standardized ems data from each individual state this central repository provides research nationwide to assist in future curriculum development the goal of nemsis is to define ems care by collecting data to improve patient care indicating equipment needs defining a standard of care across the nation so instant review and quality assurance occasionally ems reports may be requested for medical audits and other educational activities run review are sessions where peers or other medical professionals review care reports to be sure local protocols quality assurance and quality monitoring are adhered to this allows the reviewers to learn from the patient care techniques used by others and should be placed regularly reports may be used to calculate the number of times you perform a specific skill such as an oral tracheal innovation and always accurately document skills attempted and performed with patient care",
        "Types of PCRs": "so let's talk about types of pcrs most ems reporting agencies pcrs are done electronically electronic documentation has many benefits it can be easily shared between facilities and personnel involved in patient care it improves continuity and efficiency of care and it can be shared among state and national databases which improves national data collection and further advances evidence-based practices the figure on this slide shows different software programs used for creating electronic pcrs there are many different types of ems report designs ranging from half page notes to complete and thorough reports it didn't happen unless it was written down is a good motto to follow some services have developed check boxes and drop down menus instead of narrative sections the narrative section is the part of the pcr that allows for free form writing the proper information must be obtained and documented regardless of the form of pcr used agencies are shifting away from paper reporting paper reporting is duplication of work information on paper must be entered into an electronic system anyway so paper also requires storage and reporting on paper may result in errors penmanship and spelling errors can lead to medical mistakes you will most likely use a handwritten refusal form when it is necessary though to obtain a signature from the patient many different companies have also created electronic patient care reports for the refusals epcrs range from scanning paper forms to computer-based programs and applications for desktops laptops tablets and smartphones modern data systems incorporate data from various sources such as multiple facilities to improve patient care the result is one comprehensive record of the patient care computer based pcrs should be nemsis compliant so data can be stored on the national level to assess and improve ems throughout the country",
        "Documentation for Every EMS Call": "okay so documentation for every ems call every ems call requires documentation the minimum data set is mandatory clinical assessment standard information that must be documented on every call and this is set by medicare and medicaid it's per the national highway traffic safety administration and for the purpose of the national data system the minimum data set is divided into run data and patient data so run data consists of incident times locations responding units and crew members working at the incident patient data includes basic patient information collected on the pcr such as chief complaint level of consciousness or mental status vital signs assessment and patient demographics also should they obtain objective observations of the scene treatments provided effects of the treatments changes in the patient's condition during the emergency call and depending on the type of transport the service treatments that need to be differentiated between scheduled and unexpected an example of a schedule treatment is a transfer transport uninspected treatments re result from changes in the patient's condition",
        "Transfer of Care": "and then the transfer of care it is important to document in those in whose care the patient was left to avoid allegations of abandonment some agencies may require nurse or physician signatures to verify that the patient was transferred properly you may need to document transfer of care when you hand over the patient to another agency such as an air medical team",
        "Care Prior to Arrival": "and then the care prior to your arrival so more emergency dispatch centers are going to a system called emergency medical dispatch or emd emd allows the dispatcher to provide directions to the caller for medical care and medication administration over the phone when you encounter an emd it is important to obtain information from the patient or caller as to what care has been provided prior to your arrival and you need to document the findings an example of what an emd center might do is prescribe aspirin to a caller experiencing chest pain you want to document that correctly to ensure that the patient does not receive the same medication again also off-duty health care providers and lay personnel may provide emergency care prior to your ems arrival include the following information in your report by standards procedures with specific notations that care was provided prior to your arrival",
        "Refusal of Care Reporting": "situations requiring additional documentation so there are special situations that require additional or different reporting procedures and these include the refusal of care the growth of malpractice lawsuits makes documentation of refusal of care very important a competent adult patient has the right to refuse care or consent to treatment know and understand the patient's rights learn applicable state laws about patient care and who has a right to refuse care a decision to refuse care must be based on the patient's knowledge of his or her situation your most important job is to ensure the patient is fully informed about his or her current situation the right to receive and refuse care and the consequences of refusal of care the patient must be told in great detail and understand the potential consequences of refusing care and necessary medical care including the possibility of death the information given to the patient must be conveyed in a language the person understands documented on the pcr witnessed by an observer and initiated by or initialed by the patient and signed by the patient the refusal documentation should clearly show the process you went through how the process is documented and who witnessed the process unresponsive patients may be treated under implied consent and paramedics should be familiar with the individual state laws also the age of consent the care of minors emancipated minors and people with mental and cognitive impairments including mental illness and drug and alcohol use confirm that every reasonable effort has been made to ensure your patient's welfare and best interests if the patient has an obvious injury or medical condition that requires immediate medical attention and is refusing care involve online medical control for further guidance and assistance if you disagree with the refusal a protocol or policy should be in place of what the next step should be additional steps could include contacting a supervisor involving law enforcement or involving medical control document all contacted parties on the pcr as well as the events that transpire it is vital to have a witness present during the process ensure that your patient has significant knowledge of the situation to make an informed decision and witness the patient's refusal of care record all of the following information on the pcr observations of the witness name and contact of the information of the witness attempt to obtain a complete patient history and assess meant whenever possible and practical including a full set of baseline vital signs if a patient refuses assessment document this on the pcr evaluate the patient's mental status mental status may be considered impaired if the patient is not oriented to person place or time impairment may be a result of injury a medical condition such as an electrolyte imbalance or hypoglycemia mental illness drugs or alcohol politely explained to the patient's rights to change his or her mind and ems call ems later again have a witness observe the exchange of information and provide the following a signature and identify information such as phone numbers document the care you intended to provide if the patient had not refused care so document in whose care you left the patient propose all potential methods of care including alternative options that may not be your first choice for example a patient is going to be driven to the hospital by a family member rather than being transported via ambulance always encourage transport by ambulance because patient condition could change at any time patients may agree to transport but refuse a particular procedure and when this occurs refusal of the specific procedure should be handled as if it is a refusal of care and should be include the following an explanation of the associated risk and complications of that refusal a signature by the patient acknowledging refusal of the portion of care a witness and complete and accurate documentation so workplace injuries and illness osha guidelines require that workplace injuries must be logged institutions may have their own forms and requirements for documenting workplace injuries minor injuries requiring basic first aid do not require an osha record but documentation may be required by the company document what precautions were taken and what protective equipment was being worn by the person involved fines may occur if incidents are not reported correctly reporting regulations vary from state to state so be familiar with your state's requirement paramedics may also perform medical monitoring for hazardous material teams respond to public employee workplace injuries and experience on the job illness or injuries every situation needs to be appropriately documented and reported to supervisors for workers compensation follow-up",
        "Special Circumstances": "so there are special circumstances situations that may require specialized forms per the state or local agency include mass casualty incidents occupation occupational exposure reports abuse and neglect and physician arrival on scene of the call in an mci documentation often occurs initially on triage tags so become familiar with triage tags and where they are stored information needed on the tags and situations that may warrant their use in an agency or department it is important for each emergency responder completing the tags to supply as much information as possible on them even if the information is limited a pcr for each patient should be completed to best of their ability occupational exposure reports should be completed if a barrier device fails or fails to offer enough protection from bodily fluids each agency or state creates their own forms for these exposures become familiar with state requirements if a co-worker is treated or transported for an occupational exposure complete a full pcr in addition to the occupational exposure form additional specialized specialization documentation may be needed for alleged neglect or abuse so supply as much detail as possible about the circumstances do not be fearful of slander when documenting findings a physician of any specialty may have the authority under local protocol to interject with patient care and give directions when he or she arrives on scene so most protocols require the physician to accompany the patient to the hospital once the physician begins care that is beyond the paramedic scope document all orders and actions given by the physician once he or she arrives on scene document the use of all mutual aid services such as helicopters specialized rescue teams and other agencies called to assist also document all unusual unusual occurrences including securing the patient with restraining devices for safe transport or having to summon additional crew or specialty vehicle to lift a heavy patient or extending extended scene time for prolonged extrication maybe severe weather conditions delaying transport response or drawing a blood sample as evidence for law enforcement personnel who have a driver suspected of being under the influence follow the policy of your medical director in special circumstances paramedics involved in community paramedicine programs may be required to complete additional documentation and also paramedics are held responsible for the security and accountability of controlled substances so double signatures are often required when a controlled substance is checked or used discarded or replaced documentation of controlled substances in the pcr includes the amount used versus wasted the patient to whom was given date and time it was administered and by whom it was given include any specialized accountability forms your agency uses as documentations",
        "PCR Narrative": "all right so now let's talk about the pcr ems documentation is a required and necessary element of patient care just as much pride should be taken in the documentation skills as the patient care skills the pcr narrative contains check boxes as well as a narrative portion usually the narrative portion of the pcr should be a detailed segment indicating the element of the call written in a form accepted by your agency it needs to be accurate and complete and specific for example the patient was innovated with a 7.5 et tube and ventilator assistance provided with supplemental oxygen at 15 liters a minute et2 placement was confirmed by breast sounds chest rise and a tube check before securing the et tube at the mark of the 26 at the teeth the end tidal co2 detector and pulse ox were placed immediately and the recordings were spa sp02 94 and co2 entitled 35 millimeters of mercury some agencies attach a copy of the readings of their documentation each of the following should be documented in the narrative section the consultations orders requested or received from medical control refusal situations in which medical control was consulted just do not just write ref see refusal on back any methods for narrative documentation exist ems agencies or medical directors may prefer prefer a specific method so be familiar with the approved methods and all the required elements for your agency's report writing examples of narrative writing styles for reports include first is chronological order and that's telling the narrative in a story format from initial dispatch until the call was completed the call can be explained from start to finish then you also have what's called the soap method that the soap subjective is s objective information is o assessment is a and p is plan for treatment it's simple and logical and allows you to document various aspects of the patient care encounter and then you have the chart method and its chart stands for chief complaint history assessment treatment transport and exceptions it's similar to the soap method but it breaks narrative into logical sections similar to your assessment okay so body systems or parts approach is another form of a narrative writing and its assessment of each body system is documented from head to toe and it may be difficult to apply to ems it may be too time consuming also for paramedics but regardless of the style of narrative report use the same report reporting method consistently you want to switching from one format to another may cause certain elements of the call to be forgotten and essential details to be omitted proper grammar and spelling are essential when writing reports it may be helpful to carry a pocket guide or reference terminology book or medical term book pertinent negatives should be documented when writing the ems call as well a record of negative findings that warrant no care for the intervention but indicate that a thorough and complete exam and history were performed for example the patient denies shortness of breath with chest pain the use of pertinent spoken accounts made by the patient and others on scene may be essential to continuum of patient care indicate who made the statement quotation marks around the exact statement or spoken accounts may include statements about the patient's behavior or the mechanism of injury safety related information such as the use of weapons the following may also be useful to list in the narrative section so information that may be useful to criminal investigations disposal disposition of valuables admissions of suicidal intentions by the patient or any first aid interventions provided by bystanders prior to your arrival",
        "Elements of a Properly Written Report": "all right so let's talk about the elements of properly written report so documentation accuracy depends on all information provided comprehensively and concisely including incident times narrative information and checkboxes all sections of the pcr should show that you completed them even if the section was not applicable to the call so for example if a pcr has a section of checkboxes specific information on cardiac arrest but that the call was not a cardiac arrest call note on the report in the manner approving approved by your agency leaving the boxes blank may arise questions about the completeness of your part handwritten reports should be legible written in ink and the color of the ink may be determined by your ems agency black and blue are the most common be neat and easy to read and report should not be contaminated with any liquids found in the field place all completed pcrs in a secure location that protects the patient's privacy agreed upon by you and your partner so a pcr needs to be timely even in ems systems where call volume is high if multiple calls are responded to without accurately completing a pcr before proceeding to the next call then the following may result you may forget details or important information may be left out so ems agencies should allow time for the following before you return the service completing reports and replenishing supplies and cleaning and disaffecting vehicles many paramedics use assessment cards during calls to take notes so you use the ecg monitor to note times and vital signs time should be set aside at the hospital to neatly complete all documentation some type of written record must always be left with the patient a drop report or transfer report is a single page abbreviated form used as a memory aid during the ems call leave a copy of a drop report or transfer report with the nurse or physician at the hospital if a pcr cannot be completed all pcrs should be free from jargon slang and personal opinions be certain that your documentation is not liable liable is written or false statements that could be harmful to a patient's current or future reputation only true and accurate statements should be documented and if quotes by bystanders or statements are made by the patient be sure to indicate who made them and place the exact words in quotation marks on the report carefully review all reports before submitting them to the receiving medical facility and ems agency review for completeness accuracy grammar and spelling proper use of all medical term and abbreviations written reports reflect on the paramedic and a call is considered incomplete until the documentation has been processed",
        "The Consequences of Poor Documentation": "okay so let's talk about the consequence consequences of poor documentation inappropriate inaccurate and poor documentation can adversely affect the quality of care received by patients after arrival at the hospital documenting what the patient or family members tell you and your findings from examining the patient enhances the quality of care remember to document the specific time and a suspected stroke patient was seen normal by family members there are legal implications of documentation poorly written inaccurate or illegible reports may lead to judge and jury to decide in favor of the plaintiff poor documentation skills can affect a paramedic's reputation poorly written inappropriate or inaccurate reports might make others question the care provided well written reports indicate the following organizational skills knowledge of patient conditions and needs and respect for organizational policies and procedures part of being a good paramedic is completing the paperwork and reports as required if writing reports is difficult seek additional classes or study report writing skills to enhance your abilities also ask your agency if they have an educational program to assist you",
        "Errors and Falsification": "at times it is necessary to revise or correct a pcr if a revision or correction must be made to a pcr note the date and time of the revised report and include the purpose for writing the revision or making the correction never discard or destroy the original pcr only the person who wrote the original report can revise it additions or notations added to other added by others after completing the report may raise questions about the authenticity of the report the confidentiality practices of your agency routine administrative report handling and review are necessary for entering information into computer databases billing services and quality assurance monitoring administration strait of activity should never involve altering or rewriting the report or portions of it if a correction needs to be made while writing a report place a single line through the error initial and date the line preferably in a different color ink and write the corrected information next to the line do not erase information do not scribble through errors do not use corrective fluid or tape remember the pcr is a legal document most electronic reporting systems will allow for amendments but will prevent erasure in a completed document refer to the system's directions as to how to make an amendment to your original document and addendums may be needed to add forgotten information to the report or write statements of the events for matters related to quality assurance or risk management addendum should include a note that the addendum was added to the original report the reason for the late entry the date the time and the signature of the author supplemental narratives may be needed for additional information if information becomes available after the original report has been written and that should you should document the following so the time the date the reason for the added info and the signature of the author some ems agencies use a supplemental report to write lengthy information once based on the original report is limited billing information may be needed for the ems agency as well so this information is confidential and know the laws and regulations pertaining to billing and documentation security under hipaa ems agencies should not add additional information to the to the information provided after the report has been submitted always be honest and thorough in the documentation report and loss reports pose huge legal implications all paramedics are responsible for ensuring the reports are completed and turned in as required by the policy and procedures do not keep copies of reports and trying to recreate pcrs is irresponsible and possibly illegal record-keeping may be a legal requirement in your state and there may be specific time requirements for submission of reports",
        "Documenting Incident Times": "documentation of incident time so accurate time keeping is essential to all ems operations the role of timekeeper falls to dispatchers paramedics must also keep track of time during documentation of an incident so compare times with the dispatchers to ensure that accuracy and proper time keeping occurs and that yours and your dispatcher's clocks are synchronized the following incident times are important to keep track of time of the call time of dispatch time of arrival on scene time with the patient time of medication administration time of medical procedures and time of the departure from scene time of the arrival at the medical facility time of transfer of patient care and the time back in service times are kept in military units to avoid confusion so midnight through 11 a.m are written as 000 through 1100 noon through eleven pm are written twelve hundred through twenty three hundred okay so this concludes chapter six documentation um lecture and we appreciate you joining us today and join us for the additional lectures"
    },
    {
        "Introduction": "hello and welcome to chapter 2 work for safety and wellness lecture",
        "National EMS Education Standard Competencies": "after you complete this chapter and the related coursework you will understand the importance of recognizing hazards coping with physical and mental stress assisting patients and families with emotional aspects of injuries illness and or death taking appropriate preventative actions to ensure personal safety dealing with patients and co-workers with sensitivity taking proper precautions when dealing with infectious diseases and preventing on-the-job injuries a paramedic is dedicated to providing",
        "Introduction to Pre-Hospital Emergency Care": "pre-hospital emergency care and transport for the sick and injured making the job very gratifying and very demanding do not lose sight of the most important factor and that's your personal wellness and safety both on scene and off scene safety issues include scene hazards environmental conditions handmade threats and infectious diseases do not compromise your safety your sleep or your eating habits with the increasing demands placed on paramedics your preparation is of the utmost importance you may be assigned with a veteran paramedic who will serve as a mentor the mentor may have been trained before wellness and safety training were given high importance maintaining your health from the beginning will hopefully ensure a long healthy and satisfying career several recent studies have assessed injury illness and death among emergency medical service workers 2013 study of the injuries and fatalities among emergency medical technicians and paramedics in the united states says the ems is one of the lowest overall fatality rates compared to other emergency services such as law enforcement and fire service fatalities tended to be linked to transport crashes with ambulance crashes resulting in the highest number of deaths in non-fatal injuries ems also beat out all other emergency professional professions in non-fatal injuries with strains and sprains being among the most common injuries and the most common injury being the back the authors concluded that these injuries are costly tax the system with loss of available providers and that fatigue and sleep deprivation were the major contributing factor data from the national highway traffic safety administration shows an annual estimate of 1500 ambulance crashes in the united states per year 59 percent occurred during emergent response and 34 occurred while non-emergent from 2007 to 2011 there were over 3 000 crashes involving ambulances causing 1400 injuries of the number 29 crashes were fatal with 33 total fatalities these findings emphasize that new paramedics should be aware of their own health and well-being while being aware of their limitations don't push yourself beyond your normal limits and seek assistance whenever possible always be aware of hazards and other traffic",
        "Components of Well-Being": "so there are components of well-being and a wellness was first defined in 1654 as the quality or state of being in good health especially as an actively sought goal a focus on wellness is important in the ems training because it enables providers to have a long rewarding career in patient care there are three components of wellness there's physical wellness mental wellness and emotional wellness some believe that spiritual wellness is also essential next component of well-being that we're",
        "Physical Well-Being": "going to talk about is physical well-being and people in top physical condition before injuries heal more quickly when injured than those in poor physical condition your quality of life is affected by all of the following muscle strength flexibility cardiac endurance emotional equilibrium posture both sitting and standing states of hydration the foods that you eat and the amount of sleep that you get these factors may directly impact your chances of avoiding injury and illness on the job the american heart association simple seven are seven factors that have been found to improve heart health get active control cholesterol eat better manage blood pressure lose weight reduce blood sugar and stop smoking",
        "Nutrition": "these steps can improve mental well-being too nutrition so nutritional information changes regularly but current nutritional guidelines are readily available consequences of poor nutrition include heart disease type 2 diabetes obesity and a variety of other medical conditions many ems service requires providers to work 24-hour shift oftentimes without meal or rest breaks these are challenging conditions to ems providers who try to live a healthy lifestyle the u.s department of agriculture dietary guidelines for americans from 2015 to 2020 suggests eating foods from six categories so it's fruit vegetables protein grains dairy products and oils each person's requirements are different so nutritional requirements should be designed for individual needs for example a moderately active woman ages 19 to 30 years old requires around 2 000 calories a day okay so on the choose my plate website it's produced by the usda the my plate icon provides a quick look at recommended portion sizes for five of the five food groups okay so the first food group is of course fruits and they say that any fruit or a hundred percent fruit juice counts as part of this group fruits may be fresh canned frozen or dried and whole cut up or pureed and then there's vegetables so any vegetable or 100 vegetable juice counts as part of the group vary the vegetables you eat and eat more dark green vegetables orange vegetables beans and peas then there's grains that's the third one so any food made from wheat rice oats cornmeal barley or any other cereal grain is a grain product bread pasta oatmeal breakfast cereals tortillas or grits are examples of grain products then you have protein foods so any foods made from meat poultry seafood beans peas eggs processed soy products nuts and seeds are considered part of the protein group go lean on protein vary your choices with more fish beans peas nuts and seeds then you have dairy so all fluid milk products and many foods made with milk are considered part of this group so choose low-fat or fat-free items then you have oils so oils are fats that are liquid at room temperature like the vegetable oil used in cooking oils come from many different plants and from fish oils are not a food group but they provide essential nutrients so read the nutrition label of prepared or processed foods and review the sodium levels they can reach as high as 50 of your daily allowance so the amount and type of fat also read about the composition of carbohydrates such as starches sugars and fibers look for high fiber content foods and be aware of fat-free products plan for your shift as if you would get minimal time to rest or eat a meal so bring bottles of water and various healthy snacks and fruit avoid candy bars caffeine and energy drinks they will ultimately leave you feeling exhausted",
        "Weight Control": "okay so next we're going to talk about weight control staying fit is an important component for all people who work in areas of public service many of the habits you practice as an adult were formed during your youth it may be challenging but you can change habits developed in childhood the usda's dietary guidelines include the following key principles follow a healthy eating pattern across your lifespan focus on a variety of nutrient density and the amount of food limit calories from added sugars and saturated fats and shift to a healthier food and beverage choice support healthy eating patterns for all the guidelines define a healthy eating pattern and de-emphasize dieting because diets are generally not as effective as making healthy food choices gradual weight reduction is key and it requires you to plan rather than taking coffee breaks take a walk or perform other forms of activity if you must eat out consider smaller meals eating oatmeal or cold cereal for breakfast eating a salad with minimal or no dressing or eating a sensible dinner that consists of baked or boiled foods",
        "Exercise": "also exercise so regular exercise has shown links to overall body weight nutritional status and hydration regular exercise has been shown to improve sleep mental capacity ability to cope with stress improve sex life long-term health the exercise program for you depends on personal preference and fitness goals it should be something you enjoy it should be targeted at maintaining or improving your cardiovascular endurance flexibility or overall physical health it is recommended that you consult your primary care physician before beginning an exercise program although you may be eager to achieve weight loss and get in shape you must take it slowly to avoid injury it is recommended that adults engage in at least 30 minutes of moderate to vigorous physical activity every day to help build optimal cardiovascular endurance activity on an ems call is not sufficient to meet the suggested activity required for wellness to stay in good physical condition you need to find a healthy balance between full out physical activity and no activity at all many ems services provide their employees with workout equipment to use on each shift depending on your level of health you should attempt to reach your target heart rate every time you exercise the american heart association should suggest that your target heart rate be between 50 to 69 of your maximum heart rate so to find your target heart rate calculate it as the following take 220 and subtract your age in years this is your estimated maximum heart rate so for example if you're 40 years old then your maximum heart rate would be 180 beats per minute",
        "Smoking and Tobacco": "all right so smoking in tobacco the negative effects of smoking in relation to health continues to grow some studies suggest that the presence of smokers in the family increases your likelihood to smoke with numerous regulations that have been placed on smoking and advertising the number of smokers are dropping this habit has seen a resurgence though especially among the millennial generation with the creation of vape type smoking devices everyone responds differently to smoke some of your patients may be highly sensitive so if you smoke right before a call the smell on your uniform may be enough to cause serious effects in an already sick patient if you do smoke and are trying to quit remember that smoking is truly an addiction and quitting may not be easy so seek help in recent years electronic cigarettes have become a popular alternative to tobacco also called electronic nicotine delivery systems or personal vaporizers these devices stimulate smoking by producing an aerosolized or aerosol made by vaping a flavored liquid solution those studies indicate that e-cigarettes are less dangerous than other tobacco products the extent of the danger has not yet been determined so these devices should be avoided",
        "Alcohol Use": "and then there's alcohol use so alcohol is a drug that can modify how the brain perceives stress alcohol cannot alleviate stress the uncomfortable nature of stress persists beyond the duration of the effects of alcohol so be aware that using alcohol to cope with stress can lead to dependence and result in a magnification of the impact of stress situation on your life",
        "Circadian Rhythms and Shift Work": "circadian rhythms and shift work so your job as a paramedic will often conflict with your body's circadian rhythms circadian rhythms are the body's natural timing system they govern as a person's internal clock and ignoring your circadian rhythms can cause you to experience consistent difficulties with sleep higher thought functions physical coordination and social functions try to determine what your natural rhythms are and design your schedule that best fits for you to help deal with shift work avoid caffeine eat healthy meals and try to eat at the same time every day keep a regular sleep schedule the most important thing for paramedics is to not overlook the need for rest whatever your rhythms it is dangerous to operate an emergency vehicle or administer medicines without adequate sleep so hereditary factors may also affect your overall health research your family's healthy history alzheimer's disease chemical addiction cancers cardiac illness high blood pressure migraines mental illness and stroke all feature prominent hereditary factors the most common of all hereditary health risk factors are heart disease and cancer work with your personal physician to set up a schedule for health assessments building them into your routine physical checkups",
        "Body Mechanics": "next we're going to talk about body mechanics so a paramedic is required to lift and move a variety of patients prepare yourself to lift most weight ranges using the following actions you want to minimize the number of total body lifts you have to perform when a patient needs to be lifted be prepared and lift plan to lift in many cases patients do not need to be lifted to the cot or any other location so evaluate every situation to identify the easiest and safest way to lift or move the patient coordinate every lift prior to performing the lift advise your patients regarding what you what they may experience during the lift use clear communication to execute the lift for example on the count of three lift minimize the total amount of weight you have to lift so if you have an extra people available as ask for assistance in some cases your patient might be able to offer some assistance without moving remove any unneeded equipment from the stretcher so never lift with your back a back injury can be career ending but you can prevent it if you do not lift with your back always keep your back in a straight upright position and lift without twisting when lifting spread your legs about 15 inches apart and place your feet so that they that you have your center of gravity is properly balanced keep your head upright and facing forward hold your back upright as you bring your upper body down by bending your knees lift by raising your upper body and arms and by straightening your legs until you're standing always lift with your legs not with your back breathe while you lift do not hold your breath and if you're working with a partner when lifting then be sure to plan your counting style and exactly how the lift will be performed do not carry what you can put on wheels meaning position the ambulance and the cot as close to the patient as you can most dare chairs have tracks and make going downstairs safer and easier and then always ask for help anytime you need to move a patient who cannot or should not walk consider asking extra person to help you",
        "Mental Well-Being": "okay next we're going to talk about mental well-being when you are subjected to stress your fight or flight response is activated this is a same system that is activated when you exercise or do something fun to promote the feeling of well-being this is known as positive stress preparation on how to react when this response activates is crucial if you are unconditioned or unprepared for stress then you will not adapt as well when the fight-or-flight response is activated the fight-or-flight response creates psychological responses to a stressor including increased sympathetic tone which results in the following you get dilation of pupils increased heart rate dilation of the bronchi mobilization of glucose and shunting of blood away from the gi tract and cerebrum you get increased blood flow to the skeletal muscles these responsive responses help you deal with the situation immediately as a paramedic you will need to be in control of your emotions at all times regardless of the situation a professional is someone who can remain calm and think clearly when everything else is in disarray so plan for your behavior to help control it",
        "Emotional Well-Being": "emotional well-being so the key to remaining healthy throughout your ems career is to make a deliberate effort to create a healthy balance between your work and home life you must separate yourself from your career from time to time and focus on your personal life and family family members may not understand your ems life and may feel neglected or may otherwise be impacted by the effects of the stress ems professionals must be able to deal with the stress they are exposed to on the job a common stressor is how you deal with patient disability and death another common stressor is a frequent flyer and the competitive or belligerent patient remember many of these patients have medical conditions or traumatic injuries that cause their behaviors but nonetheless such conditions will be stressful to you good paramedics are strong positive people these traits are intertwined with normal emotional reactions to stressors on the job you must develop strategies for coping with stress if a co-worker or leader has noticed a negative change in your behavior take his or her concerns seriously these could be warning signs that you need to seek assistance if you note changes in your partner or your co-worker do not ignore them pick the appropriate time in a calm manner and express to them what they are what you're noticing put aside any discomfort you may have about expressing your observations or fear of the reactions okay and then there's spiritual",
        "Spiritual Well-Being": "well-being so human spirituality is an unseen dimension of human experience some people address spirituality with formal religion medical care supports the dignity and value of life and the sacredness of all people your respect for the beliefs of patients and families will help in providing effective patient care",
        "Disease Transmission": "so next area we're going to talk about in this chapter is going to be disease transmission so paramedics are called on to treat and transport patients with a variety of communicable or infectious diseases at times they may have to transport a chronically ill patient without knowing that he or she has an infectious or contagious disease until well after the call so an infectious disease is a medical condition caused by the growth and spread of small harmful organisms within the body communicable disease is a disease that can spread from one person or species to another do not confuse the terms infectious and contagious all contagious diseases are infectious only some infectious diseases are contagious so for example pneumonia caused by bacteria is an infectious process but not contagious it will not be transmitted from one person to the other another example is hepatitis b virus it's contagious because it has been transmitted from one person to the other the following dramatically minimize the risk of infection so immunizations personal protective equipment hand washing and properly cleaning and disaffecting the ambulance and equipment after each call will help to prevent transfer of diseases to other patients inform other health care providers and co-workers who may come in contact with a patient of the potential risk but use discretion and do not give out sensitive patient information over the radio or to anyone who is not directly involved with the patient care different germs use different means of attack known as the mechanisms of transmission so transmission is the way the infected infectious agent spreads and infectious diseases can be transmitted by indirect or direct contact airborne foodborne or vector borne and that's transmitted through insects or parasites contact transmission is a movement of an organism from one person to another through physical touch direct or indirect are two types of contact transmission direct contact occurs when the organism is moved from one person to the other through touching without any intermittent dairy so bloodborne pathogens are microorganisms that present in human blood and can cause disease if the pathogen enters the bloodstream so in indirect contact involves the spread of infection between a patient with an infection to another person through contaminated uh inanimate object the object can be like needle sticks and then there's airborne transmission this involves spreading an infectious agent through the mechanism such as droplets or dust a common cold is spread by coughing and sneezing so unsanitary to use your hands to cover a cough or sneeze a tissue better controls the spread of organisms",
        "Protecting Yourself": "so to protect yourself much has changed in ems since its inception the use of ppe was not common in early years being covered in blood and dirt used to be a status symbol in the 1800s surgeons took particular pride in messy operating aprons day though ems is changing continuously and new protection suggests suggestions are frequent the centers for disease control and prevention developed a set of universal precautions for health care providers to use in treating patients so we're going to talk about immunizations next and using basic protective measures can minimize a paramedic's risk for acquiring an infectious or communicable disease so maintain your personal health the cdc and occupational safety and health administration otherwise known as osha have developed requirements for protection from blood-borne pathogens such as hepatitis b an immunization program should be in place in your ems system and immunization should be kept up to date and the record should be in your file a skin test for tuberculosis is recommended before working as a paramedic to identify if you have been exposed to it in the past and it should be repeated every year if you have been ex to see if you've been exposed to the disease if you know you are transporting a patient with a communicable disease and you know you have already had the disease or been vaccinated then your risk is significantly reduced or eliminated this information is not always available though so always follow your standard precautions",
        "Personal Protective Equipment and Practices": "so let's talk about personal protective equipment and practices each ambulance should be equipped with certain ppe and at a minimum you should have access to the following gloves facial protection gowns n95 or n100 respirators wear gloves so gloves are absolutely essential on any emergency call so more than one pair may be necessary depending on the procedure the patient's history and environment anytime you could be exposed to a patient's body fluids get a pair of gloves on before loading the patient and getting in the ambulance wash your hands before and after using the bathroom before ingesting anything by mouth before getting into your personal car or after your call or on shift before after any physical contact between you and a patient or an instrument after you remove your gloves wash your hands use hand lotion frequent hand washing will cause your hands to crack because of the natural oils are going to be removed so use hand lotion several times a day also use eye protection so many seasoned paramedics make it a standard practice to wear anti-splash eyewear throughout any patient contact and consider wearing a mask protect yourself with a surgical mask at a minimum if you either you or your patient have an airborne disease protect your body so mask and gowns are appropriate whenever you care for patient who is extremely messy or bloody also incontinence barriers should be laid out on the surface when the patient is leaking any type of fluid or has skin lesions so n95 respirators so tuberculosis is one of the most common diseases contracted in 2014 the cdc and world health public associations estimated that 9.6 million people are affected with tb worldwide it causes 1.5 million deaths a year clean your ambulance and equipment so sanitize your patient compartment surfaces frequently but especially the following the ems stretcher bench seat grab rails the deck the deck hardware interior and exterior areas around the door handles clean daily and after every call remove the cot mounts at least once a week clean more often if you have any messy calls and sanitize the your phones and the microphones routinely focus on patient compartment and sanitize or replace your pen often sanitize your stethoscope with alcohol or disinfectant wipes after every call discharge discard any single use piece of equipment in the hazmat bag use a commercial disinfecting agent for decontamination of equipment that has had direct contact with the patient or his or her body fluids bleach and water in a 1 to 10 ratio can be used dis disinfection kills any of the microorganisms on the surface of your equipment",
        "Management of an Exposure": "if you have been exposed to a patient's blood or body fluids follow your local ems guidelines generally you're going to do the following you're going to turn over care to another emsa provider wash your hands with soap and water if your eyes were exposed you need to rinse them with water for at least 20 minutes follow your department's infectious control plan comply with all reporting requirements get a medical eval obtain proper immunization boosters and document the incident",
        "Hostile Situations": "so hostile situations as a paramedic you may be involved with or asked to assist during hostile situations hostile situations can often be identified using dispatch information such as a report that the patient is uncooperative or the patient is making verbal threats a december 2003 position statement by the national association of ems physicians outlined an official endorsement of rights and safety of patients and ems providers if you must respond to a hostile situation then it is best to stage at a distance safe enough away and wait for law enforcement to secure the scene be aware of the following call descriptions so a fight or stabbing shooting domestic disturbance or person down or even an unknown medical could be a hostile situation so suspicious calls warrant an initial response by police ask for police response to any call that your gut instincts suggest could be violent it's imperative that you seek a necessary training to understand how to safely handle hostile situations never enter the scene first if the element of hostility is known or can be anticipated in advance carefully review your surroundings before you come in contact with a hostile patient identify the fastest way to exit the area and look for potential weapons in the general area or within the reach of the patient once you're in contact with the hostile patient do the following listen more and talk less do not argue concentrate on de-escalating the patient's emotions be aware that hostile patients in their home are much more dangerous than anywhere else and show empathy and understanding on scene knowledge of diverse cultures plays a major role in effective communication treat all patients with respect and dignity",
        "Traffic Incidents": "motor vehicles may move at high speeds they may carry hazardous substances and they may collide with one on another in locations that are dangerous for you and all involved it's important to stay aware of your surroundings even the familiar ones distracted driving is becoming a problematic as driving under the influence of drugs and alcohol with widespread use of smartphones and gps at many scenes bystanders and other motorists will focus on the incident and not pay attention to you your approach at traffic instances should include visual assessment of surroundings look for hazards before entering the scene and b come familiar with your response area to determine your best and safest route alert those who are available to help you some states have programs in place that help with traffic incident management so traffic may be only one of the hazards at the scene of the mva for example a parking a hot running ambulance over dry grass may initiate a grass fire so primary concern is safety for yourself and those around you you need to identify the hazards begin making physical observations watch traffic pay attention the wind direction look for smoke and begin planning for lighting and weather related issues okay the next we're going to talk about is stress so ems is a high stress job understanding the causes of stress and knowing how to deal with stress is crucial to your job performance health and interpersonal relationships to prevent stress from negatively affecting your life you need to understand what stress is its physiologic effects what you can do to minimize these effects how to deal with stress on an emotional level is any event that causes physical emotional or mental reaction stress effects may be unpleasant pleasant mild or intense so stress is a reaction of the body to any agent or stimul stimulation so a stressor that requires the person to adapt adaptation is necessary for meeting the demands of everyday life by itself stress is neither good thing or a bad thing stress could not be avoided and it should not be so it's classified into two categories eustress is a positive stress the kind that motivates a person to achieve and distress is a negative stress the stress that a person finds overwhelming and debilitating",
        "What Triggers Stress?": "so let's talk about what triggers stress a stress response often begins with the events that are perceived as threatening or demanding the specific event that triggers the reaction vary enormously from person to person the following factors are the most common stressors triggers in most people so loss of a loved one or valued possession personal injury or illness major life events such as divorce or pregnancy or marriage job related stress such as conflicts with others or the possibility of losing your job or changing one during the past three decades there have been a number of studies on physiological stress levels and paramedics the levels usually examine the life change units and this is lcu's lcu's were originally described in a life change theory further explored by thomas holmes and richard ray the social readjusting rating scale ranks 46 stress producing events in a person's life and provides a weighted score for each event the score above 150 could cause or be associated with the development of disease and illness okay so to deal effectively with stress as a medic you need to be aware of the stress triggers in your life and make a plan to minimize their effects",
        "The Physiology of Acute Stress": "so let's talk about the physiology of acute stress one of the fundamental models for stress evolve from studies of how humans respond to threats it is observed that when a person perceives an event as threatening a standard series of physiological reactions are triggered these physiologic reactions provide us with the fight-or-flight response by activating a sympathetic nervous system in the modern world the fight-or-flight response to stress circumstances is not as useful as it once was most negative stress responses are the result of an accumulation of smaller stress events thereby placing the body in a continuous un relieved state of alert you should evaluate and handle every stress event immediately especially if it is negative in nature reactions to stress can be categorized as acute delayed or cumulative acute stress reactions occur during a stressful situation and as a paramedic you may feel nervous and excited your ability to focus may increase and you may experience negative emotional and physical reactions to stress if the situation becomes too great delayed stress reactions manifest after the stressful event so during a crisis you will be able to focus and function you may be left with nervous excited energy that continues to build after the crisis cumulative stress reactions can occur when occur when you are exposed to prolonged or excessive stress after the stressful event is over you may be unable to shake the effects another stressful situation will inevitably occur and then another and each time you may find it harder to recover and you become more and more exhausted and overwhelmed cumulative stress can have the following physical symptoms fatigue changes in appetite gastrointestinal problems and headaches stresses may cause insomnia irritability hyperactivity or underactivity and stress may be manifest itself in physiological reactions such as fear depression oversensitivity anger frustration isolation or inability to concentrate loss of interest in work or sexual activity your fast-paced lifestyle as a paramedic compounds these effects by not allowing you to rest or recover after periods of stress prolonged or excessive stress has been proven to be a strong contribute contributor to heart disease hypertension cancer alcoholism depression and job burnout",
        "Responses of Patients to Illness and Injury": "how people react to stress situations so patients family members bystanders and healthcare professionals who confront critical illness or injury respond in the same way to stress of each emergency responses of patients to illness and injury so patients responses to emergencies are determined by their physical methods of adapting to stress recognizing certain common patterns of coping is helpful to a paramedic a common response by many patients to stressors is anxiety several common reactions include fear depression anxiety anger and confusion some people may also show one or more of the following physiological defense mechanisms denial regression projection and displacement most of the physiological stress responses are not under the patient's conscious control reactions to illness or injury are often rooted in the patient's cultures many americans place great emphasis on making eye contact having a firm handshake and respecting personal space learn the cultural differences of the population you serve",
        "Responses of Family, Friends, and Bystanders": "responses of family friends and bystanders so bystanders and family members may exhibit responses similar to those exhibited by patients including anxious behavior panicky behavior or anger as a paramedic you must recognize that the patient's family and friends have concerns too and their behavior arises from distress so do not take it personally remain calm and reassure family members that you're doing everything you can for them situations involving mcis may cause both parties and bystanders to react by becoming dazed disorganized or overwhelmed so reactions to stress are defined differently depending on the organization or resource below are five of the most common reactions so anxiety panic depression overreaction or hysteria",
        "Responses of the Paramedic": "you are not immuned as a paramedic to the stresses of emergency situations and should expect to experience a multitude of feelings not all of them pleasant that's perfectly natural you must be controlled during the emergency or dealing or when dealing with patients and their loved ones so a common reaction among healthcare professionals is a feeling of irritation at a patient who does not appear to be particularly ill or injured all right",
        "Coping With Your Own Stress": "coping with your own stress so early warning signs include heart palpations rapid breathing chest tightness sweating you may find that you no longer enjoy your career or that you lack the energy or desires you once had it is important that you identify your body's reaction to that fight or flight response you may this may include rapid breathing unnecessary shouting the use of an appropriate language often noticed by others who then alert you so take appropriate and immediate action remember that once you enter that fight or flight mode you are primarily functioning on instinct so consider the following stress management techniques control deep breathing progressive relaxation and professional assistance focus on the immediate situation when on duty avoid excessive amounts of stimulants such as caffeine and attempt to get enough natural rest and exercise vigorously and regularly and identify people and activities that make you laugh or feel good befriend a co-worker who can relate to you and offer support when needed",
        "Burnout": "burn out so burnout needs to be considered at the earliest stage of ems career because it is the time to start developing attitudes and habits that will start prevent burnout burnout is defined as exhaustion of physical or emotional strength so a paramedic's job is full of potential stress and ems professionals are not the only people susceptible to burnout it could happen to anyone in the field and the timeline for burnout will vary among people a situation that burns out one paramedic in one year may take 10 for the next and a medic who never takes a vacation may experience burnout more quickly than other colleagues do a person's ease is stress may be another's de-stress so de-stress is a learning reaction based on the way a person perceives or interprets the world around them some beliefs common in among ems personnel include i have to be perfect at all time my safety depends on being able to anticipate every possible danger i am totally responsible for what happens to patients if they die it's my fault so a good medic never makes mistakes these are all false beliefs and can lead to burnout burnout is a type of illness and has its signs and symptoms symptoms of burnout include chronic fatigue and irritability cynicalness negative attitudes or a type of desire to a lack of desire to work also emotional instability changes in sleep patterns loss of inner interest in hobbies or decreased ability to concentrate also declining health the paramedics who do not experience burnout are those who have learned to respect and value themselves they have also identified and dealt with the causes of burnout and take actions to prevent it as a new paramedic you should learn from them",
        "Coping With Death and Dying": "okay so we're going to talk about coping with death and dying and as a paramedic you will deal with death sometimes in your career so death is a western hemisphere in the western hemisphere is generally regarded as a traumatic experience as a medic you will be there when people are born and you will also be there when they die so in some cultures births and deaths are a holy time as a medic you will have an opportunity to help a great many people but few will be successful resuscitations yours may be the last face a dying person sees so make it count",
        "Stages of the Grieving Process": "there are stages of grieving process and um elizabeth ross this md defined five stages through which grieving people often proceeds and so each of these stages helps the dying um or the family member adapt to the reality of it so um so they go through the following stages first is denial then anger bargaining depression and acceptance",
        "Dealing with the Dying Patient": "so people who are dying generally know their situation is serious and some health care professionals are reluctant to discuss death with the patients so the most important thing you can as a healthcare professional is to let the dying patient know that you understand and you will talk about death if they wish do not give them a false sense of hope of the situation do not say that they will recover when he or she may not",
        "Dealing with a Grieving Family": "the fact that there is nothing you can do for the victim does not mean that the call is over your local protocol might state that you have to verify death by cardiac monitor strip things you can do for grieving family may help them begin the process of dealing with the loss so do not use euphemisms for death such as expired or passed away do not be in a hurry to clear away from their your resuscitation equipment give the family some time with their loved ones especially when the deceased patient is a child try to arrange for further support such as a family member or a neighbor or maybe the family's clergy except the family's right to experience a variety of feelings such as guilt or shock denial or anger",
        "Dealing with a Grieving Child": "and then dealing with a grieving child so you may need to be particularly sensitive to the emotional needs of children and how they differ depending on their age group children up to three years of age will be aware that something has happened and people are sad children from three to six of age believe that death is temporary and may continually ask when the person will return from six to nine they may mask their feelings in an effort to not look baby like and then from 9 to 12 they want to know the details surrounding the incident",
        "After the Call Is Over": "and after the call is over so many calls can be shocking and everyone involved in the call is likely to experience some intense feelings if feelings stay bottled up there may be all types of problems later so most calls should not disrupt your normal life functions critical incident is one of the o that overwhelms the ability of the ems worker or the ems system to cope with experience at the scene or later most paramedics never experience ptsd let your supervisors know though if you or co-workers experience one of the following signs of ptsd trouble getting an incident out of your thoughts you keep having flashbacks your appetite's not the same you laugh or cry for no good reason you find yourself withdrawing from co-workers or family members after the incident and you relay on alcohol or cigarettes or make unhealthy choices to calm you down critical incident stress management or cism is a resource available for emergency personnel who have been involved in particularly traumatic calls or incidents it process it's a process developed to address acute stress situations and potentially decreases the likelihood that ptsd will develop public safety organizations have used cism for more than 30 years suggested events where some sort of debriefing or management may be considered include a series of injury or death of a fellow worker suicide of a fellow worker multi-casualty incidents serious injury or death of a child or intense media attention to an incident it is impossible to predict how any given person will react so cism teams are often available after traumatic call but some are available during the incident and they may be brief about 30 minutes diffusing sessions right after the call some services may offer an employee assistance program so eap this resource is normally provided by trained professional counselor who works outside of the service and is off duty so successful eaps should not focus on the related work issue because some personal events may lead to poor work choices and unacceptable behaviors the eap is successful only if those who attend do so by their own choice and are willing to share every issue that may bother them and then there's peer support and suicide prevention so ems providers are not immune to thoughts of suicide or suicide attempts because prolonged stress is a risk factor for suicide prevention starts with recognizing that you or your colleagues are becoming overwhelmed so do not disregard what you recognize or what others tell you be aware of the signs of stress and burnout in yourself and others and any suicidal thoughts or attempts must be taken seriously okay so this concludes the lecture for chapter two workforce safety and wellness we hope that you have enjoyed and we hope that you come back and listen to some more of the lectures thank you"
    },
    {
        "Introduction to Incident Management and Mass-Casualty Incidents": "hello and welcome to chapter 47 instant management and mass casualty incidents the paramedic has operational roles and responsibilities in establishing command under the incident command system in order to ensure patient public and personal safety upon completion of this chapter and the related course assignments you will be able to explain the purpose of the medical incident management in the ics and describe the major components of the national incident management systems otherwise known as nims you will also be able to describe how start and jump start triage methods are performed and discuss triage principles resource management and the need for re-triaging you will also be able to discuss the specific conditions that define a situation as a mass casualty incident including the role and purpose of critical instant stress management in an mci but let's start the chapter talking about incident types disasters and mass casualty incidents are the first two that we're going to talk about and a disaster is declared by local county state or federal government for purposes of providing additional resources and funds to those in need an mci is declared when the number of patients and the severity of the injuries suggest that available community resources will be overwhelmed mutual aid response is required in a multi-casualty incident that's any situation with more than one patient but that will not overwhelm available resources there is a set numerical cutoff at which a multi-casualty incident becomes a mass casualty incident so nims you're going to hear a lot about the national incident management system and this system designed to improve efficiency in the management of incidents regardless of the size and complexity nims courses may offer certifications that can be prerequisites co-requisites or any part of entry-level courses the instant command system so ics prepares responders to provide a coordinated effort during an incident as a paramedic you will typically be assigned to work within the ems or medical group under ics but you may also be asked to function in other areas let's talk a little bit about the",
        "The National Incident Management System": "national incident management system or nims and it was implemented in 2004 to provide a consistent nationwide template to promote effective and efficient emergency response it's used to prepare for prevent respond to and recover from domestic incidents regardless of its size and complexity flexibility and standardization and interoperability are the key principles of nims the organizational structure must be flexible and quick to adapt to use for any incident nims provides standardization and terminology resource classification personal training and certification",
        "Interoperability": "interoperability allows agencies of different types or from different jurisdictions to communicate with each other through interoperability a common incident communication plan is developed and facilitates interoperable communications all resources must be able to work using a for similar framework so the major component of nims is command and management so incident management is standardized for all hazards across all levels of government so the command structure is based on an ics multi-agency coordination systems and public information systems preparedness this institutes procedures for all responders to include in their systems in preparation to respond to any incident at any time and",
        "Resource Management": "resource management sets up systems that describe inventory track and dispatch resources before during and after the incident it creates standard procedures to recover equipment that has been used communications and information management this enables the necessary functions needed to provide interoperability in ongoing management and maintenance a nims integration center will be created to provide strategic direction and oversight of the nims so the incident management command system using common language and clear text ensures better communication among various agencies the ics creates a modular organizational structure and the goal is made is to make the best use of resources to manage the environment and treat the patients follow local standard operating procedures to establish the ics the ics is designed to control duplication of effort and freelancing freelancing is defined as individual units or agencies making independent decisions about the next steps the ics limits span of control it keeps the supervisor to work your ratios at one supervisor for three to seven workers a supervisor who is overseeing more than seven people must delegate tasks and supervision and so organizational divisions include sections branches divisions and groups and resources some areas have emergency operation centers operated by state city or federal government usually only activated in large emergencies with hundreds of patients and that will or could continue for days so responders in a mass casualty incident or disaster should use the instant command system and what you want to do is find out from your service if ics exists and who is in charge how's it activated and what is your role in the ics system",
        "Instant Command System Rules and Responsibilities": "so instant command system rules and responsibilities the general rules within the icms include command finance logistics operation and planning the command function includes public information officer and that's the pio safety officer and a liaison officer and then there's command so the incident commander evaluates the incident and creates a plan of action based on true strategic objectives and priorities the number of duties that the ics is responsible for depends on the size of the instance a small incident often mean that the ic will do it all instant of a medium or complexity uh often mean that the ics will delegate some functions but re retain others and then in a complex incident the ic may appoint team members to all command roles",
        "A Unified Command System": "a unified command system is used when an incident requires multiple organizations or jurisdictions so plans are made in advance by the organization that takes on responsibility in the decision making the plan assigns the lead and support agencies for example hazmat team takes the lead during a chemical leak where the medical team would take the lead in a multi-vehicle car crash now a single command system is one in which one person's in charge so generally used with incidents in which one agency has the majority of responsibility for the incident ideally used for short term durations or limited incidents for small scale incidents that are not anticipated to increase in complexity ic may be located somewhere on the fringes of the scene that is clearly identified so know who the ic is where the command post is located and how to communicate with the ic for large scale instance or instance with several injured responders it may be responsible for the ic to be located a short distance from the scene it decreases distractions improves flow of vital information and helps ensure safety of those in command from secondary attacks okay transfer of",
        "Transfer of Commands": "commands so the ic command to one more experienced person in a critical area that could be transferred this transfers to be done in an orderly manner and ideally face to face your agency should have standard operating procedures or sops that direct the transfer of command at the conclusion of an incident there should be a termination of command and this includes demobilization procedures and it should be implemented as a situation de-escalates and operations so they manage the tactical operations job at a large scale incident and at a complex incident the operations chief oversees the responders working on the scene often have managerial experience within the fire department and then the finance of responsibility uh responsible for documenting all expenses at the incident that should be reimbursed so not always necessary for a small incident and tracks and reports personnel hours and cost materials and supplies at meetings the finance chief will help your organization receive reimbursements if you're eligible and the roles of the finance sections are time unit procedure unit and compensation unit and claims",
        "Logistics": "and then there's logistics so they're responsible for the calm equipment or communications equipment facilities food water fuel lighting medical equipment and supplies in large incidents many people may coordinate logistics but only one reports to the incident commander",
        "Planning": "and then there's planning planning solves problems as they arise during the mci typically for units associated with the planning section so that's resources situation demobilization and documentation they use data from the current incident to analyze the previous plan and predict the next steps for the new plan they work closely with ops finance and logistics and they call upon technical experts to help with the planning process they set up a plan for demobilization and they develop the incident action plan",
        "Command Staff": "and then you have command staff so command staff include the safety officer the public information officer and the liaison officer we'll talk a little bit about each of those so the safety officer they continually monitor the area for hazards to responders and patients possibly will interact with environmental health and hazmat teams and they have the authority to stop an emergency operation when a rescuer is endangered then you have the pio they present information with the public and media take posts away from incident to keep media safe from the emergency and keep distractions to a minimum they may work in conjunction with other organizations in a joint information center or jic and then there's the liaison officer and they relay information between command general staff and other agencies so let's talk about communications and",
        "Communications and Information Management": "information management next so communication should be integrated so that all agencies can communicate easily and quickly by radio this allows for accountability throughout the incident and instant communication you need to maintain professionalism on the radio communications communicate clearly concisely and using clear text and mobilization and deployment so once an incident is declared and additional resources and personnel are requested they are immobilized and deployed to a staging area the steps of a mobilization",
        "Steps of a Mobilization and Deployment": "and deployment are they want to check with the ic upon arrival at a small scale incident or on with the resource on unit on a large scale incident they want to check in with the supervisor for the initial briefing about the incident and their job responsibilities this keeps they keep records as a way to document items that may need to be reimbursed and they keep their supervisor up to date on their location actions and completed and uncompleted tasks so that's accountability once the incident is controlled the ic will decide on demobilization of resources okay so the ems responds within the incident command system so the first thing that ems response will will do within the instant command system is preparedness preparedness is the decisions and basic plans that are made before the incident even occurs each ema ems agency generally has a",
        "Written Disaster Plan": "written disaster plan and it's usually located at each ems station as well as on each ems vehicle you may have a checklist of supplies that need to be at your station which may include water batteries cots or other items for the personnel who will be staffing that station you should have your own disaster plan in place for your family in the event that you need to respond to a disaster make sure that you have all necessary immunizations and training is one of the most critical components of preparedness mock scenarios with multiple agencies working together should be practiced monthly after the preparedness you have the scene size up and dispatch will inform you if the mci scene is safe or unsafe do not hesitate to request more resources early on if the dispatch information suggests you need that when you arrive on scene ask yourself two basic questions what do i have and what will i need so check for hazards to warn other responders safety concerns such as hazmat fuel spills or electrical hazards and determine the resources you're going to need and then establish commands so establish command early on preferably by the first uni um arriving unit or the most experienced public safety official evaluate the scene then return to your post if working as the ic retain the mindset that you are there to service command do not become distracted with patient treatment and other tasks",
        "Communications": "and then communications this is often the key problem at an mci or disaster to limit radio traffic use face-to-face communication when possible and if you are communicating by radio do not use codes or signals there are typically radio channels specified as emergency command channels the communication equipment you are using should be reliable durable field tested and have backups and you should also have a plan b for communication",
        "Medical Instant Command": "medical instant command is what we're going to talk about next and so medical",
        "Medical Incident Command": "incident command is also known as the medical branch of ics the medical branch director is appointed during incidents that call for large amounts of medical attention they oversee primary roles of the medical team triage treatment and transport they make sure the ems units are working with the ics they assign each medical unit with tasks prior to working at the scene and depending on the size of the incident ems may be its own command and work under the logistics section and then you have the triage unit leader they count and prioritize patients at the incident they ensure that the patient receives all initial assessment and treatment on patients must begin must not begin until every patient is triage",
        "Treatment Unit Leader": "the treatment unit leader so after the triage unit leader you have the treatment unit leader and they locate and set up the treatment area with a tier for each priority patient they see that each patient has secondary triage and that each gets enough care they assist with moving patients to the transport area and they communicate their request for sufficient quantities of supplies including bandages burn supplies respiratory supplies and patient packaging equipment after the triage treatment you have the transportation unit leader and they coordinate the transportation and distribution of the patients to appropriate hospitals and they track and record the number of vehicles transporting patients the patients transported and the destinations of both",
        "Staging Area Officer": "and then you have the staging area officer so they are assigned when a situation calls for multiple emergency vehicles or agencies they designate an efficient location for the staging area away from the incident they plan for assess and exit from the site they prevent traffic congested congestion among responding vehicles and they release vehicles and supplies when needed and then often in large instance you'll have physicians on scene they provide secondary triage decisions and on-site medical direction one treatment is required then you have the rehabilitation group group leader they treat uh create a rehab area for responders when they need to rest eat drink and get protection from the elements during the an incident that will last for a while so they monitor ems personnel for stress fatigue altered thinking and collapse then you have extrication and special",
        "Extrication and Special Resources and Special Rescue": "resources and special rescue so an extrication task force leader or rescue task force leader may need to be appointed if there is a need for search and rescue or extrication of patients the supervisor coordinates the equipment and resources needed the supervisors will usually function as a specialty group under the operations group of the ics because extrication and rescue are medically complex",
        "Morgue Unit Leader": "then you have the morgue unit leader and in this instant where their victims have died a morgue supervisor is appointed the deceased should be left untouched until removal and storage plans are made and if the morgue area is created it should be out of sight so that there is no further psychological trauma to living patients and responders we talked about this earlier but i want to reiterate it an mci may overwhelm available resources and a",
        "Mutual Aid Response": "mutual aid response is when neighboring ems systems respond to mass casualty incidents in each other's regions when there aren't enough local resources so let's give some examples of these they include bus or train crashes maybe an earthquake or a big residential building fire or loss of power to a hospital or nursing home and response to an mci will vary depending on location and how spread out the patients are and so this figure shows a diagram of an mci",
        "Identify an Mci as an Open Incident": "to identify an mci as an open incident or a closed incident so an open incident is an unknown amount of casualties when you are first answer a call a patient may need to be searched for or treatment of multiple locations so possibly an incident that's ongoing for example like a tornado or school shooting a close incident is the number of patients is not expected to change so patients are triaged and treated as they are removed and may turn into an open incident however when deciding what qualifies for an mci regions will use varying standards and protocols previous experience will help determine the status of an incident regular use of ics and participating in disaster planning drills tabletop mci exercises and other training will help prepare you for an instant having a solid understanding of the rules of mci and regular use of the m of ics and nims will help to keep the incident responders organized and efficient the following questions will help you",
        "Determine whether an Incident Is a Mass Casualty Incident": "determine whether an incident is a mass casualty incident how many injured or ill patients are on scene what resources are available how long will it take for additional help to arrive and where should these patients be transported never initiate transport of patients if there are unattended unintended patients present or who are sick or injured so consider relocating the patients to a smaller area to initiate treatment of the critical patients while continuing to observe those who are less injured if needed use your resources and delegate tasks to your partner or responders and other agencies such as police officers and always follow local protocol next we're going to talk about triage",
        "Triage": "so triage is sorting patients by severity of their conditions and prioritizing them for care accordingly the goal is to do the greatest amount of good for the greatest number triage should be brief and it categorizes the patients are placed in should be basic triage primary triage is used to rapidly categorize patients patients will be identified with a triage tag in primary triage and after primary triage the triage leader will report to the medical branch director secondary triage is re-triage in the treatment group so the category of the patient could change suddenly and can be upgraded or downgraded due to patient condition avoid spending too much time assessing a single patient so we're going to talk about four common",
        "Common Triage Categories": "triage categories and they could be remembered using the mnemonic idme okay so idme is immediate which is red d is delayed m is minimal and e is expected immediate patients are force priority they need immediate care and transport these patients may have problems with abc's head trauma or shock delayed patients are second priority they will need care and transport but they can be delayed and minimal patients are third priority need little to no on-scene treatment and patients are known as walking wounded then you have the e and that's expectant patients and they are last priority they are either already dead or have little chance to survive these include cardiac arrest open head trauma or respiratory risk patients a new fifth triage category the orange tag category may be added and this represents an immediate category between critical red tagged and non-critical which is non-ambulatory yellow and there may be ambulatory patients who require prompt evaluation and treatment for medical comorbidities that are not acute trauma injuries associated with this event so let's talk about the tags it is important to label track and record patient's condition no matter what system you use",
        "Triage Tags": "so the triage tags should be weatherproof easy to read and color coded and clearly show triage categories this tag will be added to the patient's medical records and may be a tear off receipt it tracks the patient's location and identifies the patients if they are unresponsive digital photos are sometimes used in identification of victims so another method of tracking patients is a bar code scanner and triage tag that have barcodes whatever label system is used it's imperative for the transportation supervisor to be able to identify it okay so let's talk about the common most commonly used triage system in the united states and it is called",
        "Start Triage": "start triage okay so it stands for simple triage and rapid transport and the staff at hagg memorial hospital in newport beach california created a simple form of triage named start triage that's what this is so it's used uh uses a limited evaluation of the patient so it uses the um i usually say rpm but they have written here the ability to walk respiratory status hemodynamic status and neurologic status so um let's talk a little bit more about this so the first step of the start triage",
        "Start Triage System": "system when you first get there you call out and you say hey can you hear me if you could hear me and if you could walk come stand up and walk so these injured patients are considered the walking wounded and they're categorized as minimal priority or third row priority patients okay the second step of start triage is to",
        "Evaluate the Non-Ambulatory Patients": "evaluate the non-ambulatory patients you want to check for respiratory status so that's the r if the patient is breathing or not open the airway using a simple manual maneuver okay if the patient begins to breathe they're crap they're categorized as a red but if they don't they're categorized as a black okay so if the patient i should say if the patient starts breathing quickly estimate their respiratory rate if it's faster than 30 breaths a minute they are categorized as a red if it's fewer than 30 breaths a minute you could continue down and check the radial pulse and what that's going to do is evaluate the hemodynamic status so this is the p in the rpm that i said so p check for the radial pulse if it's absent this suggests that the patient is hypotensive and you should categorize them as an immediate okay so that's a red if the radial pulse is present continue to move on then you're going to check",
        "Neurologic Status": "the neurologic status and this is the m so rpm you could ask the patient to follow three commands show me three fingers if they don't understand the command and are unresponsive they're an immediate a patient who understands command is categorized as delay okay so start triages is how we categorize adults and jump start triage is how we",
        "Jump Start Triage": "categorize not only pediatric patients but people who appear to weigh less than 100 pounds or 45 kilograms so this system is used to assess children younger than eight or who appear to weigh less than 100 pounds first say same thing as star triages we're gonna identify the walking wounded and with jumpstart triage differs slightly only slightly so if a pediatric patient isn't breathing we're checking for a pulse if there's no pulse of course we're going to label them as expectant but if there is a pulse open the airway with a manual maneuver and give five rescue breaths so that's the big difference we're gonna give five rescue breaths if the patient still isn't breathing then we're gonna label them as expected okay major difference we're giving rescue breaths then we're gonna check with the rate of respirations so children fewer than 15 breasts or more than 45 breasts we're going to give as immediate okay um and then uh we're going to continue on the same as the start triage there's also a thing called salt triage and salt stands for short sort assess life-saving interventions and treatment and transport this triage system begins by prioritizing order in which the patients are assessed so patients will lay still and have obvious life-threatening injury or patients who are unable to walk but demonstrate purposeful movement or patients who are ambulatory and can follow commands to walk to a designated area and so salt method allows for immediate rapid interventions including bleeding control opening the airway needle decompression and auto injector antidotes so as you progress through your assessment you'll assess the airway mental status perfusion respiratory status and bleeding control the salt method is unique in that there are five patient categories so black tags are assigned gray tags are assigned and then there are three other that are similar to triage immediate delayed and minimal so when you talk about special triage",
        "Special Triage Considerations": "considerations patients who are hysterical and disruptive to rescue efforts may need to be an immediate priority and transported out of the disaster site even if they are not seriously injured this type of behavior could create panic for other patients and rescuers do not hesitate to have the walking wounded assist you with simple tasks an injured or sick responder should be categorized as immediate and transported away from the scene so other responders do not lose their morale if hazardous materials or weapons of mass destruction are present the hazmat team must categorize patients as contaminated or uncontaminated before regular triage can begin some incidents will require multiple teams or areas of triage if patients are spread out",
        "Destination Decisions": "so let's talk about destination decisions using the 2001 american college of surgeons committee on trauma field triage decision scheme refers patients to trauma centers using category including the physiologic criteria the anatomic criteria mechanism of injury the special considerations which is age and underlying health and this guideline helps pre-hospital responders identify individuals who will benefit from transportation to a trauma-specific center what you want to do is consider the hospital that has appropriate means to help the patient so some hospitals may become overwhelmed by a large number of patients some patients may require specialized care such as burn centers or pediatric centers and given hundreds of patients not all critical trauma patients will go straight to the trauma center patients may need to be transported to a hospital that is not ordinarily capable of accepting a trauma patient some patients may require specialty centers transport patients that are categorized as immediate or ambulance or air ambulance so you can start walking wounded by bus if needed in large situations and these patients should be taken to a hospital further away from the scene so as they don't overwhelm the closest hospitals at least one emt or paramedic must ride on the bus and an ambulance should follow transport immediate patients two at a time transport delayed two or three at a time and transport slightly injured last expected patients are treated once all the other patients have been transported dead victims are handled and transported according to the sop for the area",
        "Critical Incident Stress Management": "so critical incident stress management an mci response is incredibly stressful there are a few things more emotionally wretching than discussing triage and management of an mci suicide rates have increased among ems workers and firefighters and police debriefing with others who respond to the event it may be beneficial once out reach out to colleagues struggling with emotional toll of the incident within your department it's a disaster plan there should be a resource for debriefing and diffusing the responders before during and after the mci depends on service director and medical directors views critical incident stress management or cism should be available to all responders participation is encouraged but not required all responders should have access to coping mechanisms and these services should always be available the physiological impact on responsible responders should be included in the post-incident evaluation",
        "After Action Review": "and then there's an after action review so all agencies should participate in review after an incident ends for future future events include what worked and what didn't work and all observations should be written down for future review and never accuse someone of doing something wrong during the incident so all mcis are different and all reactions will be different okay so thank you for joining me for chapter 47 lecture on instant management and mass casualty incidents um if you enjoyed this lecture go ahead and subscribe to my channel i will be releasing all the other chapters thank you"
    },
    {
        "Introduction": "hello and welcome to emergency care in the streets chapter 1 ems systems lecture",
        "Lecture Overview": "after you complete this chapter in the related coursework you will understand the origins and present-day structure of emergency medical care delivery systems the paramedic's role in responsibilities and his or her relationships to the emergency medical services system are explained as well as the paramedic's role in quality improvement process other ems provider levels are described the foundations necessary for being a competent effective caring and ethical paramedic are presented the inner relationships of the highway traffic safety administrations components of the ems systems are outlined also described is the paramedic's impact on research data collection and evidence-based decision-making as well as the paramedics responsibilities as a student and a practitioner",
        "EMS System Introduction": "okay so let's get started the emergency medical services or ems system is always involving originally its primary role was transportation as awareness of ems complexities grew the need for improved systems in various and primarily rural locations became evident this awareness along with research and guidelines from national organizations has led to the advancement of ems as a paramedic you will encounter many different situations so remember your call is a true emergency in the eyes of the callers or patients do not judge them if you feel it is not in reality the majority of your calls will not entail true life threats but they are to your patients the public's perception of you is based on what they have seen on television or read in articles the patient's previous experiences your treatment of their beloved ones continued education is a must what you learn today may not be applicable tomorrow so treat all people with respect and dignity this applies whenever you are in uniform or representing your profession whether you are on duty or off okay so let's talk about the ems system development in the visionary advances much of the pre-hospital emergency care you will deliver as a paramedic can be attributed to the visionary advances of pioneers in the field including dr peter stafford and nancy caroline you may be surprised to learn how long organized systems have been in place",
        "History of EMS": "so let's talk about the history of the ems in 1487 the first use of an ambulance occurred during the siege of malagna no documented medical care was provided simply transport in the 1800s their chief physician in napoleon's army is credited with establishing the first pre-hospital system for triaging and transporting patients in 1865 the first civilian ambulance was used in cincinnati ohio in 1869 the first ambulance service started at the bellevue hospital in new york city in the first year alone ambulance responded to more than 1800 calls for help throughout the throughout the city in 1899 the first operated automobile type ambulance was used at the michael reese hospital in chicago illinois a major shift occurred between world war one and world war ii because many hospital-based ambulance services did not survive in 1926 the phoenix fire department started service similar to the present-day ems in 1928 julian stanley wise launched the first rescue squad in roanoke virginia soon after numerous other rescue and squad organizations were developed along the east coast primarily in new jersey in 1940s ems was turned over to fire and police departments due to the lack of personnel there was no minimum standard of training and care was not always welcomed 20th century in modern technology during world war one and world war ii systems for field treatment and transport known as battlefield corps continuously evolved ems made major strides following world war ii military medical researches searchers recognize bringing hospital-type services closer to the field giving the patients a better chance of survival helicopters were first used in 1951 during the korean war they brought patients to mobile army surgical hospitals or mass units these helped thousands survive in 1956 mouth-to-mouth resuscitation was developed by dr elian and schaffer the portable defibrillator was developed by frank patridge in 1959 late 1950s early 1960s there was a focus moved back to bringing the hospital to the patient mobile intensive care units or micus were developed they were staffed by specially trained physicians there was a shortage of physicians that led to training of non-physicians in 1965 the national academy of sciences and the national research council released the white paper this is also called the accidental death and disability the neglected disease of modern society the findings of the white paper included a lack of uniform laws and standards ambulance and equipment of poor quality or non-existence lack of communication between ems and hospitals lack of personal training hospital staff only where part-time and higher number of people died in motor vehicle accidents then in the vietnam war the findings outlined 10 critical points to establish a functioning system this led to the national highway safety act it was enacted in 1966 it created a u.s department of transportation or usdot the usdot provided authority and finances for the development of life support programs in 1968 task force of the committee of ems created basic training standards and principles of a 9-1-1 system to provide universal access to emergency services so refer to table 1-1 for the critical points required components and system elements of the ems developed as a result of the white paper in 1969 dr eugene nagle of miami florida created the first true paramedic program it trained firefighters with advanced emergency skills developed a telemetry system okay so this telemetry system allowed firefighters to transmit patients electrocardiograms or ecgs to physicians firefighters receive medical instructions from those physicians he's often called the father of paramedicine standards of ambulance design and equipment were published this year and in the 1970s more helicopters became available and the national registry of emergency medical technicians or nremt began in the 70s so in 71 the emergency care and transportation of the sick and injured was published it was the first emergency medical technician textbook it was published by the american academy of orthopedic surgeons and aaos began training emts through a national workshop emergency the first television program focused on ems began an eight-year run the lead characters in this series became household names in 1973 the emergency medical services systems act was passed it defined 15 required components of an emergency medical system referred to table 1-1 emphasis on regional develop and trauma care it provided a structure in uniformity to the ems systems that came out of pioneering programs in miami seattle and pittsburgh and illinois trauma system in 1974 federal report disclosed fewer than half of the ambulance personnel completed training guidelines published for development and implementation of ems systems and then in 1975 the american medical association recognized emergency medicine as its own branch within medicine many cities set up an individual advanced ems training and in 1977 the first national standard curriculum for paramedics was developed by the united states dot the first paramedic curriculum was based on nancy caroline's work then when we move into the 1980s and 90s the number of trained personnel grew significantly the national highway traffic safety administration developed 10 system elements to help sustain an ems system federal funding and staff for ems was reduced responsibility for ems was transferred to the states funding continues to be a major roadblock for states and local governments major legislation initiatives such as ems for children emsc program implemented in 1985. amendment to public safety officers benevolent or benefit act in 1986 and families of firefighters memory members of rescue squad and members of ambulance crews are now compensated if a provider is killed in the line of duty trauma systems started making headway in the 1990s and some of these secondary programs receive federal funding some advances for are held back due to the lack of funding however",
        "EMS Campus Measurements": "as we roll into the 21st century numerous initiatives are appearing one example is a ems campus measurements it measures performances in ems and helps identify best care practices and establish performance benchmarks throughout the country ems training is being used in many other areas of health care instead of strictly in the ambulance and it's being used in hospital emergency departments health care clinics physician's offices and community pair medicine in the healthcare model in which experienced paramedics receive advanced training to provide additional resources is making continuous strides these additional capabilities are not being developed to replace current healthcare modalities but rather to utilize the capabilities of paramedics in areas not served previously okay so let's get into some licensure certification and registration discussions so registration means that records of a paramedics education state or local licensure or recertification will be held by a recognized board of registration depending on your state or location you may be licensed or registered once you complete your initial paramedic education depending on your state you will be eligible to take your state certification examination some states require you to test and establish licensure through a registry system such as a the nremt",
        "Certification": "so a certification examination is used to ensure that all health care providers have the same best basic level of knowledge and skill once you have passed the required examinations your state and or nremt will give you a certificate or license",
        "Licensing": "licensure is how states control who is allowed to practice as a health care provider depending on the state it may be known as a licensure certification or credentialing this text uses the term licensure performing functions as a paramedic before licensure is unlawful most you must be directly supervised by a paramedic program internship preceptor as a part of your training program so holding your lice holding a license shows you have completed initial education it shows you have met requirements to advance the license and it does not mean you can perform as a paramedic without the supervision of your services physicians medical director okay and this is because state local and national agencies require that paramedics receive medical direction now direction can either be online or offline if your state requires you to pass the nremt cognitive and psychomotor examinations to be become licensed you will have to pass a written exam and numerous practical skills to be eligible you must successfully complete initial paramedic education through an accredited program your school is required to verify your course completion before you can sit for the exam the national registry exam test to the paramedic psychomotor competency portfolio a comprehensive collection of skills and scenarios",
        "Accreditation": "the committee on accreditation of education programs for ems professionals this is known as co-amps is the only accrediting body for paramedic programs to date their mission is to continuously improve the quality of ems education through accreditation and recognition of services the number of paramedic training facilities will grow significantly over the next few years because of changes to the national scope of practice the need to expand the professional image of ems and the desire to establish consistent guidelines for repair medicine retroprossity addresses training that occurred in a place other than where a paramedic wants to practice so each state has different licensing and score certification requirements and procedures retroprosidy is when certification is granted to a provider from another state or agency investigate the licensure process beforehand if you're planning to relocate to another country okay and so many countries will not accept the training provided in the united states and retroprocessity will not be automatically accepted many states recognize the national registry certification as part of their retroprosity process the for retroprocessing most states require that you hold a current state license are in good standing have national registry certification individual states may require you to undergo the state's written or practical eval provide your education transcript and continuing education hours and provide information for a criminal background check and pay a fee to process your retroprosidy application and provide a license",
        "Traditional EMS Employment": "all right so next let's get into traditional ems employment once you become licensed you will have a variety of different career options available to you some career possibilities include the following so you could be fire based ems and which has been integrated into the fire department and most are paid and operated by municipal governments some locations operate fully with non-paid volunteers while other used providers who are paid per call they do not receive compensation until a call comes in ems could have a separate management system and operate independently from the fireside though so managers often report to the main chief or director fire and ems personnel may respond together to major incidents when additional manpower is required and you may have a dual rule working with both fire and ems providers fire departments can better justify keeping a staffed in-house department if they have add ems you could also work for a third service ems provider and depending on the financial capability some municipalities establish and operate their own ambulance service independent of other public safety entities independent ambulance agencies may also offer their services under contract to municipalities who can't afford their own services some states allow municipal municipalities to share services with each being an equal owner this reduces cost to all allowing them to cover the cost of providing paramedic service usually citizens need to request response they may not be set automatically the fire service would also have to request ems response unless a prearranged process exists then there's also private ems agencies this could be profit or non-profit they operate similar to third service ems agencies they contract services with municipalities the contract can include anything from managing an existing service to providing full service to the communities the operations vary greatly some follow the standard 24-hour shift practices while others follow a status systems management structure and then there's hospital-based ems these services can vary vary greatly in most cases hospital based services tend to offer inter-facility type transports as well as aero medical services which are offered in larger and remote organizations some also offer 9-1-1 response and paramedic intercept systems or service paramedics are required to assist with patient care and other areas of hospital on their downtime typically paramedics will function in an emergency department but they may be part of an integral emergency response team one benefit is access to information paramedics have from various medical providers and you could also have a hybrid of any of the three many large companies such as oil drilling platforms and factories with hundreds or thousands of employees have their own medical response and care facilities in some areas paramedics work in conjunction with primary care providers physicians assistants and nurse practitioners there are numerous companies whose businesses is to hire personnel to fill medical positions at specific locations such as national parks amusement parks and other venues",
        "The EMS System": "let's talk about the ems system so the ems system is a complex network of coordinated services that provides various levels of care to the community these services work in unison to meet the needs of the community the ems system begins with citizen involvement you may first need to dispel miscommunication about ems and educate them on the truth the public needs to be taught how to recognize what an emergency is and what is not activate the emergency uh the ems system and provide basic care for before ems arrives the public usually does not have any medical training or knowledge so a simple cut may be an emergency to the caller do not become angry if the patient calls for a non-emergency be compassionate and caring with your or with your patient this will build the patient's trust of both you and the ems system factors that play a role in determining the outcome or likelihood of a patient's survival include bystander care dispatch including pre-arrival directions response both mode and distance pre-hospital assessment and care provided transportation including ground ambulances critical care units and air transport emergency department care on duty trained emergency physicians and staff definitive care and that includes includes trauma pediatric and neurologic specialists and then rehab",
        "Dispatch": "the public's first contact is usually a dispatcher requirements for dispatcher training vary greatly from state to state they often have to cover police and fire communications and all general department phone calls so dispatchers must intercept the caller's needs and determine if it is an emergency also need to decide what resources need to be sent the scene may be different from what was relayed to the dispatcher dispatch is only able to provide information that the caller provides to them so never under or overestimate that information never get angry with dispatch if their information is completely different from the scene",
        "Care Plan": "as a paramedic you must develop a care plan ask yourself does the receiving facility have the resources needed for this patient if not then ask is there an appropriate facility within a reasonable distance consider the patient's request for a certain care facility if it is different from the facility you feel would be most appropriate do not argue but educate your patient federal to local levels of ems functioning is what we're going to talk about next at a federal level the nht created the national ems scope of practice model this provides overarching guidelines as to what skills each level of ems provider should be able to accomplish the state level licensure is usually a state function laws and regulations are enacted to specify how ems providers will operate licensure is controlled by state-level ems administrative offices the services local and regional medical director develops a set of patient care patient care guidelines that outline the approved skills and treatments for each level keep in mind that every state varies on the role of the medical director so ensure you understand and follow your state's process okay and then at the local level medical direction decides day-to-day limits of ems such as what medications will be carried on the ambulance and where patients are transported consistency has resulted because of the national guidelines the medical director can limit the scope of practice expanding the scope of practice however requires state approval and in 2009 the national standard for all levels revised to the national ems education standards this is nhtsa which is a federal administration source it covers four levels of ems providers and it can be downloaded from the internet",
        "Dispatcher": "okay so let's talk about the dispatcher they play a critical role he or she must receive and enter all information on the call and interpret the information they relay it to all the appropriate resources so they may be trained as an emergency medical dispatcher and they have an added task of giving simple pre-arrival instructions and this could include cpr or bleeding control and they offer at the after asking a series of call related questions to the caller the goal is to benefit the patient until ems personnel arrive on scene and then you have emergency medical responders and these are known as emr until recently the emr was known as the first responder not all states have the certification and or licensing level the considerable variation between requirements and allowed skills depends on the state the emr is usually trained in cpr or first aid in some states emr can function only as part of an organized group or that group must be affiliated with a transport service you should familiarize yourself with the level of training of the emr in your system emr should be able to recognize the seriousness of the patient's condition administer appropriate basic care and relay information to the paramedic emrs are an essential level of provider in the ems system especially in rural areas then you have the emts an emt was formally called an emt basic or an mtb the emt is the backbone and primary care provider level in most ems systems the providers must be emt certified before entering the paramedic program and much life-saving care is provided by emts skills and treatments vary from state to state in some states emts may be trained in advanced airway intervention or limited medication administration also intravenous iv therapy even if you have an expanded scope of practice emts are not recognized with a different certification level per the national ems education standards more providers are trained and certified at this level than at any other level in the ems system",
        "Advanced EMT": "and then you have an advanced emt or aemt they are formerly called emtis and initially developed in the 1985 a major revision took place in 1999. recent changes to the national scope of practice replace emti with aemt level in most states and these they are trained in more advanced pathophysiology some advanced procedures such as establishing inv access or administering iv fluids performing blood glucose monitoring administering several medications and performing some advanced airway management okay and then you have the paramedic and the paramedic is the highest ems skill level to be certified or licensed at the national level major revisions to the curriculum in 1998 increased level of training and skills greatly to test through nremt a paramedic student must have attended and successfully completed training at an accredited institution states that do not employ nremts may not require institutions to be re accredited even if one holds a license or certified independently states still require paramedics to function directly under the guidance of a licensed physician and be affiliated with a paramedic level service some states allow paramedics to complete further education and earn the title of critical care paramedic and this varies from state to state and research your state's laws to see if this is allowed",
        "Paramedic Education": "okay so paramedic education so your initial education most states base paramedic education on the national ems education standards as part of the 2009 revisions to the standards inclusion of a college level anatomy and physiology course was recommended as part of the training program some training institutions offer this as part of the paramedic training program others require it as a prereq okay so the standard outline the minimum of what a paramedic must know to practice states require varying hours of education so national averages fall between a thousand to 1500 hours of combined classroom clinical and field education some leaders want to structure paramedic education so it is advanced through an accredited associates or bachelor's degree program when you talk about continuing education most states require paramedics to complete a certain number of continuing education hours to refresh this keeps you up to date on new research findings new techniques and skills it helps prevent degradation of skills use less frequency and it showcases current issues in your state that affect you and your system's ability to provide quality emergency care attend conferences and seminars whenever possible ideally some should be outside of your region or state consider attending conferences targeted to nurses or physicians okay and keep up with reading ems journals and research publications make sure internet-based commun continuing education programs meet your states in national requirements consider continuing education organizations that are accredited through the commission on education accreditation for pre-hospital continuing education formerly called the continuing education coordinating board for ems it develops continuing education standards and is involved in setting accreditation standards for pre-hospital providers get everyone in your service involved in post-run critiques this may help identify problem areas in your practice and it can be considered a form of continuing education in some states responsibility for continuing education ultimately rests with the individual paramedic you know which areas of your knowledge have diminished continuing education helps ensure problems do not occur in the field if someone something goes wrong after the call it is not the time to realize that you should have done something different or attended extra training continuing medical education is a way to help ensure you are following the latest best practices and will build confidence in your skills so additional types of transports so transport to specialty centers many ems systems include specialty centers focusing on specific types of care or specific types of patients some examples of these could be trauma burns poisonings cardiac or psychiatric conditions or pediatric patients specialty centers normally have in-house staff of surgeons and other specialists other faculties or facilities must page surgeons specialists or from the outside of the hospital so typically only a few specialty hospitals are in a region transport time to especially care center may be slightly longer than the time to the emergency department but patients will receive definitive care more quickly so know the location of the centers in your area and the protocol for transporting the patient directly to one sometimes air transport will be necessary local regional and state protocols may guide your decision so when it when we start talking about working with other professionals we're talking about working with hospital staff um that's what we'll stop start talking about and you want to become familiar with the receiving hospitals you will transport to by observing the functions of the staff members and their normal operating procedures in the areas of the hospital especially the emergency department this experience will help you understand how your care influences the patient's recovery the importance and benefits of proper pre-hospital care and the consequences of delay inadequate care or poor judgment okay so internet or interact professionally with all hospital personnel who will be part of your patient care never ridicule or undermine any member of the hospital staff remember that the care a patient receives in the hospital may differ from what you do in the field you may consult with appropriate medical staff by using the radio through established online medical procedures through these experiences you will become more comfortable with using medical terms interpreting patients signs and symptoms and developing patient management skills the best patient care occurs when all emergency care providers have a close rapport working with the public safety agencies okay so some public safety personnel have ems training and others are better prepared than you to perform certain functions for example employees of a utility company can better control downed power lines and law enforcement personnel are better able to handle violent scenes and traffic control the best most effective patient care is achieved through cooperation between agencies continuity of care is what we're going to talk about next and the community has expectations of ems providers you must project confidence to the community you serve if you are a public sector in the public sector encourage people in the community to become more involved focus on prevention take a look at your community and the most frequent types of calls develop prevention strategies or activities to reduce these calls example would be accidental falls so a fall prevention program available to identify causes of falls you can visit homes to offer suggestions for prevention so you will work side by side with other professionals and groups other medical professionals law enforcement emergency management and disaster services you'll also work with home health groups such as hospice and other emergency responders it is vital that you understand your role and the roles of those with whom you interact be prepared for different situations and establish expectations for each role national ems group involvement overview okay so many national and state organizations exist and invite paramedic memberships have an impact on the future direction of ems they provide access to valuable resources for developing yourself your service area your problem solving skills and promote uniformity of ems standards and practices some listed on table 1-2 on your slide a profession is a field of endeavor that requires a specialized set of knowledge skills and expertise it's often gained after a lengthy education a healthcare professional conforms to the same standards of other health care professionals so they also provide quality care and they instill pride in the profession they strive continuously for high standards they earn respect from others in the profession and they meet high societal expectations of the profession whether they're on duty or off duty okay so as a paramedic you will be measured by standards competencies and continuing education requirements also performance parameters and code of ethics it's imperative that you are that you remember you are a highly visible uh role in your community professional image and behavior must always be the top priority you represent the agency city county district or state you work in it is said people make the initial judgment within 10 seconds of meeting you a positive impression will usually instill complete trust from your patients and their family however a negative impression will not only reflect on you but also on your service to provide the best possible care you must install still confidence establish and maintain credibility and continually show concern for the well-being of your patients and their families your appearance is of the utmost importance and has more impact than you think do not arrive at the call in dirty clothes with dirty hands or smelling offensively look and act like a professional at all times professionalism holds no boundaries saying you are only a volunteer or part-time work is not an excuse you must represent a professional image and treat others in the profession with respect you would want to be treated with it is inappropriate to argue with any other health care provider or hospital staff okay so the differences of opinion should be addressed by contacting a supervisor the these conversations may identify differences different practices by branches of other ems due to different expectations or requirements so let's talk a little bit about attributes of professionalism and what they include integrity that's the single most important attribute openness honesty and truthfulness with your patients and co-workers and then there's empathy empathy shows your patients their families and other health care professionals that you identify and understand their feelings it's okay to show emotions to some extent then there's self-motivation have an internal drive for excellence continuously educate yourself accept negative or constructive feedback perform with minimal supervision then confidence you need to show you are confident with your skills and abilities strive to be the best paramedic you can build confidence by attending educational sessions and performing self-critiques and then with your communications express and exchange ideas thoughts and findings with colleagues listen well speak directly and do not use confusing medical terms clear professional written documentation is important record keeping and reporting are your responsibilities okay then teamwork and respect everyone must work together to provide the best possible pre-hospital care and ensure the overall well-being of the patient the paramedic is considered the team leader never under undermine your team but help guide and support the members remain flexible and open to change communicate at the appropriate place and time with your team members to resolve problems and always be as respectful to others as you would expect them to be to you okay patient advocacy is next we're going to talk about advocacy includes advocating for patients you treat and for changes in the ems system that will provide care or save lives always act in the best interest of the patient respect the patient's wishes and beliefs regardless of your own never allow your personal feelings to impact the care you provide maintain a high level of confidentiality be on the lookout for spousal abuse child abuse or neglect and elderly abuse or neglect communicate your findings to the appropriate authorities or as outlined in your state's law and then there's injury prevention if you spot a potential hazard in your patient's surroundings diplomatically talk about it to your patient or family member get involved with training programs such as those on the topics of fall prevention or child passenger safety encourage the use of bike helmets safety belts and child car seats whenever you can next we're going to talk about careful delivery of service so deliver the highest quality patient care pay careful attention the details continuously evaluate and re-evaluate your performance use other medical professionals as resources follow policies protocols procedures and other orders of your superiors time management is the next attribute of professionalism you want to prioritize your patient's needs keep your ambulance always ready to go document each emergency call as should as you should as it as soon as it is concluded and research and retrain yourself on rarely used skills or topic areas next attribute is going to be administration so part of your role will be administrative you may be asked to take on special project or station duties you may play a role in working with other agencies and forging partnerships with other public safety resources and you may be appointed to a leadership position within your organization this is your opportunity to help others achieve their goals within your service more health care locations are now using paramedic services within their organizations health hospital emergency departments and clinics physicians offices local public health departments and health some home health organizations and services include administering vaccines or performing special transports some of the paramedics primary responsibilities are shown here on figure 1-11 these include preparation and that is being prepared physically mentally and emotionally keep up your knowledge and skills abilities have the appropriate equipment for your call you need to make sure it is in good working order and your chance to prepare has ended when the call has come in the next one is response and you have to respond to the event in a timely safe manner never run hot without regard for the safety of yourself your partner your patient and other personnel or persons on the highway in most cases running hot offers no measurable benefit to the patient outcome then there's scene management you need to ensure your own safety and the scene safety is your first priority you must also ensure the patient safety and the safety of the bystanders prior to reaching the scene consider all the possibilities from the dispatch information and never never set your mind on a single possibility based on the disastrous information and scene safety includes but is not limited to your use of personal protective equipment including gloves masks and goggles the paramedic often sets the example for the safety of the ems system and then there is the patient assessment and care so perform an organized assessment of the patients recognize a prior and prioritize the patient's need based on the injury sustained an illness most in need of urgent care then there's the management disposition so sometimes you will discover that protocols or guidelines might not cover the situation you are in and if this happens make online contact with medical control physician and use critical thinking skills if you are unable to make contact with your medical director weigh your decisions closely before an intervention communicate with your medical director as soon as possible afterwards be aware of other transport and destination decisions beyond transport to an emergency department carbon monoxide poisoning requires a hospital with a hyperbaric chamber and know the capabilities of all receiving facilities with which you may interact before the call and then there's the patient transfer transfer and report so once you arrive at the receiving facility continue to act as a patient advocate give the appropriate facility staff a brief concise hand-off report if the receiving facility is extremely busy do not become frustrated or angry give them as much pertinent information as possible and ensure that the facility is aware and ready to take over patient care use discretion to protect your patient's privacy then seven is going to be documentation so after you transfer the patient it is extremely important that you um that a patient care report may be filled out at a sap so as soon as possible if the report is not possible or required inform the facility how to reach you in case someone at the facility has a question the report serves as a legal record of what you did in the field then finally the last is going to be a return to service and every person in the ems team is responsible for restocking and preparing the unit as quickly as possible preparing for your next call should be the first item you complete when you return from the call serious legal consequences can result if another call comes in and the team is not ready to respond never miss an opportunity to teach the community about prevention of injury and illness explain to people how to appropriately use your service in areas where trained ems staff is limited promote programs that get public involved in cpr and aed training cpr and aed is one of the major deterrence determinants of whether or not a person in cardiac arrest will survive in some regions paramedics may be responsible for working in clinics free-standing emergency facilities and hospitals home visits of paramedics under medical control are in the early stages of development for influenza and possible pandemic issues paramedics along with home health nurses are now being used to evaluate people at home and provide some immunization and medication administration set out a well-thought campaign for ems so research your community look for strengths and weaknesses in the system develop initiatives to improve the system involve yourself in the community and educate the media and public and advocate for ems continue your education and be a mentor for the new ems professionals",
        "Medical Direction": "next we're going to talk about medical direction so paramedics carry out advanced cardiogenic pharmacologic and trauma care skills they cannot act independently they must take direction from a medical director medical directors are physicians who are educated about the levels and extent of the education of ems personnel so ems medical directors may educate and train personnel they may recommend or select new personal equipment and they may develop clinical protocols or guidelines with other ems experts okay and they may develop an assist in the quality improvement program and they may provide input into patient care they interface between ems systems and other health care agencies and they serve as ems advocate to the community they serve as a medical consciousness of the ems system and they provide online and offline medical control so when it comes to online direction or medical control this is given in real time by radio or other electronic communication so typically provided by an emergency room physician which works in the hospital emergency department that serves as a base station for ems units in the area and not directly by a medical director when it comes to offline or indirect medical control this is given through a set of protocols or policies and or standards which are developed by or with the approval of the medical director okay so um when offline medical control allows for the development of protocols or guidelines standing orders or procedures and training one way to improve quality is through continuous quality improvement and this is known as cqi it's a tool used to continually evaluate your care so through quality control another it's that's another process that evaluates problems and find solution c q i is a process of assessing current practices and looking for ways to improve this will reduce the chance that problems will arise it's a dynamic process and your ems system should develop a structure before a qci or cqi assessment program is launched check with your state or region to identify any requirements that may have for the cqi a good continuous quality improvement process should include a way to identify any department or system-wide issue identify specific items that need to be measured conduct an in-depth review of those issues evaluate the issues and develop a list of remedies develop an action plan for correction of the issues enforce a plan of action and include time frames re-examine the issue identify and promote excellence found in patient care during the evaluation identify modifications that may be needed to protocols and standing orders and identify situations that are currently not addressed by protocols or standing orders okay so whenever possible all ambulance runs should be reviewed okay so ultimately the focus of the cqi should be improving patient care use your cqi process as a constructive tool for continuous improvement not a punitive tool okay so cqi can be in the form of a peer review and cqi can be a good learning experience if proper and consistent guidelines exist and those reviewing keep an open mind everyone makes mistakes and misses things from time to time so pure recommendations for improvement should be educational tools in an ideal system members of the peer review team rotate and they're always professional okay so a cqi program can help to prevent problems by evaluating day-to-day operations and identifying possible stress points including medical direction issues education communications pre-hospital treatment transportation issues and financial issues and receiving facility review and dispatch also public information and education and disaster planning and mutual aid right so what we're doing is you through that process you look for ways to evaluate a human error and you want to eliminate it okay so you want to ensure adequate lighting when handling medications limit interpretations um keep medications in a safe location and in their original packaging handling patients off uh is a high risk activity also so you must deal with physical transfer in communication with the next caregiver provide a written and verbal report of a patient's care and any changes that occurred and other safety issues include advanced airway management medication administration and safe transport of the patients with potential traumatic injuries okay so it's important that you understand the circumstances that cause errors to help you identify those that can be prevented and there are three main sources of errors so rules-based errors or failures an example of this is a legal right to administer medication then there's knowledge-based failures for example that's knowing all pertinent information about the medication and then there's skills-based failures and that is a proper use of equipment okay so some states use guidelines instead of protocols agencies need clear protocols which are detailed plans that describe how certain patients issues such as chest pain or shortness breath are to be managed all right so services that have active medical directors offer guidelines to describe allowable treatment plans and you can use these guidelines to determine what you need to do and when without contacting medical control first okay so protocols they outline a care plan in a specific order they do not allow you to flex outside of the medical director's treatment plan without contacting him or her first so be prepared to make modifications and use the best resources you have available online which is direct medical control and the environment can be a reason for errors as we mentioned earlier so limit distractions and ensure you can find what you need in a timely manner make sure all drugs and equipment are labeled and organized and when performing a skill ask yourself why am i doing this this allows you to reflect and make informed decisions it should be clear in your mind why you are using a skill or administering a medication if you cannot come up with a solution to the patient's problem ask for them ask for help from your partner medical control or your ema supervisor and use cheat sheets carry a copy of your protocol book in actuality you cannot memorize all aspects of your protocol viewing and confirming that your decision is correct shows true professionalism and certain concern for your patient use reference books or reliable resources and be understand your protocols and do not allow interruptions when providing care use decision making aids such as algorithms and reflect on what has been done as an informal critique talk with your supervisor or patient after a troublesome call so ems and evidence-based practice protocol should be based on specific findings the department of transportation national ems research agenda has described the process and processes and sets goals to optimize pre-hospital care a publication of ems.gov website titled progress on evidence-based guidelines for pre-hospital emergency care outlines some of the progress in relation to research findings historically ems operations has been standardized and not evidence-based example studies show that a hands-on cpr technique by bystanders along with early use of aed greatly improves the chance that victim of cardiac arrest will survive to release from the hospital previously the treatment protocol dictated for airway and breathing first and then care for circulation after so the abcs research has shown that to provide the best outcome for the patients in cardiac arrest circulation should be addressed first changing it uh changing the abcde acronym in the cardiac arrest context to c-a-b-d-e similar studies are in progress to either change or reaffirm the standards of care in pre-hospital medicine okay so we're going to talk about the research process and this identifies specific problem procedure or question to be i investigated so generally a research topic arises when a practice is questioned you may identify items during your paramedic calls that could initiate valid research projects so topics can be revised even if they have been investigated before so a new study may identify flaws or in enhanced findings carefully reviewing the research in its entirety is very important some research topics are driven by a product manufacturer or an entity that is strictly out to prove something right or wrong regardless of its importance to ems okay so once the question is determined develop a research agenda by specifying questions to be answered specific aims to be addressed methods by which the study is going to be carried out and methods to gather data additional questions may result from the study but the researchers must stick to the research agenda and answer the specific question at hand other questions may become topics in a separate study all right so when it comes to determining the research domain a research consortium is a group of agencies working together to study a topic okay a research domain is the area of research so domains include clinical and this could be like an example of stroke research involving clinical trials that would lead to improved patient care or how about basic science an example of this is a study of the effectiveness of a new drug in limiting carbon monoxide poisoning in an animal model so a resource consortium just like i said is a group of agencies working together to study that topic and paramedics may be involved in this collaborative research by gathering data so for example you may be part of a study to determine the outcome of a stemi patient so stemi of course is st segment elevation myocardial infarct so if transported to a facility that does not offer cardiac specialty services such as a cardiac cath lab or whether time is saved in helicopter transport truly improves outcomes so in some cases you may be asked to identify certain populations for research or gather volunteers for calls that you are on if you're asked to identify the patients have some information with you regarding research okay so funding researchers should use an institutional review board when a project begins so approval of this institutional review board is required to ensure that the rights of study subjects are protected throughout the study so an irb is a group of institutional institution that reviews the research major research requires specific funding large clinical trials or systems research can be expensive funding comes from local or federal governments non-profit foundations or grants or industry or corporate funding okay so um studies must go through an evaluation process to ensure that they will answer a question in the domain covered by the grant any type of support given to a research project is considered funding okay to prevent bias or conflicts of interest researchers should disclose all resources of funding and maintain total transparency regarding research methods okay so there's types of research and it depends on the topic and what the researcher wants to learn so when it comes to qualitative research that focuses on questions surrounding events and concurrent processes so it attempts to build a more complete holistic procedure or holistic picture and it takes into account real world factors and that may be influenced by the study so often used when answers cannot be identified in quantitative research okay so there's no set guidelines each study must have parameters specific to the question and sometimes medical research and then you have quantitative research and this is based on a numeric data there are three examples you have experimental research non-experimental research and then survey research all right and then you have retrospective research and this type of research uses available data such as medical records or patient care reports one example of this type of research could be examine available data to determine the types of calls that occur at night versus day or the number of calls where substance abuse was the cause of the patient's complaint so retrospective research may be used for developing educational sessions for ems personnel or public planned public education and public prevention strategies okay so researchers may need to collaborate with hospital group um or a group of hospitals in the gathering data in large studies data is often collection from widespread patient databases and techniques used by large studies to gather and analyze data can be used at the local level as well and then you have some other types of receipt of research so you have prospective research this gathers information as events occur in real time cohort research this examines patients of change and consequences of events or trends over time within a certain population you have case study and this is investigation and documentation of a single case over a period of time then cross segmental design that's a snapshot of all the data at one point in time and then longitudinal design this uh this design collects information at various set time intervals and then literary review and that analyzes existing literature to draw a conclusion the first step in research is to identify the group necessary for the research so once eligible subjects are identified researchers randomly choose who will be involved in that research and there are many ways to select subjects to be part of the research you could have cis systematic sampling and uh then you could also have alternative time sampling and then um convenience sampling so even the best cases sampling or errors occur uh it's it is recommended that select that you select a much higher number than you need so you allow for those who will not complete the study or will fall fail out of the research parameters so parameters should be identified and studies can be blinded or unblinded okay so blinded investigators are unaware of the study arm into which the subject being interviewed has been enrolled so studies may be single double or triple blinded unblinded participants are advised of all aspects of the project so gathered research statistics can be in a descriptive or inferential format and a standard deviation outlines how much the values is a set of data differ from the mean the organization's irb monitors whether the study is conducted ethically so this ensures the protection of study participants and ensures appropriate conduct any risk to the study subjects must be out must not outweigh the potential of benefits and potential conflicts of interest must be identified all subjects must give consent and subjects must participate voluntarily they must be informed of all potential risks and be free to withdraw at any time when evaluating an article look for certain criteria to determine the research quality once you've identified the quali the type of study its methods and its strengths look at the body of um of the study itself to start determine what the hypothesis of the study is and whether the population base matches your region next look at the patient and selection criteria okay determine how the data was analyzed identified the authors of the study determine whether the outcome and results are significant both statistically and clinically consider the type of journal to which the research is public published when determining quality and validity and one method for insurance ensuring quality is through peer review internet sites can be valid tools for assessing research including google scholar medscape and public med research studies must follow a structured process and there will always be limitations to what can be measured and how accurate the measurements can be as a new paramedic it is extremely important that you review research carefully so evidence-based practice this principle is becoming an integral part of functioning as a paramedic patient care should be focused on procedures that have proven useful in improving patient outcomes so ems providers should stay up to date on the latest advances in healthcare for example roughly every five years or more frequently as needed the american heart association releases revised guidelines based on review of new evidence okay so when reading new research make sure you understand what they mean to ensure quality evidence researchers often rate the quality of their study research determines the effectiveness as the treatment okay and when following a new studies recommendation your service should measure the results of your cqi program combined research efforts eventually will lead to a higher professional image to the community of the service that you provide okay so thank you very much that concludes chapter one ems systems lecture i hope you've enjoyed it"
    },
    {
        "National EMS Education Standard Competencies": "hello and welcome to chapter 12 critical thinking and clinical decision making upon completion of this chapter and related course assignments you will understand the importance of the development of critical thinking skills for the paramedic by incorporating the stages of critical thinking for those patients with critical life threats you'll be able to recognize the significant role critical thinking has in the clinical decision making you will be able to discuss how to identify problems incorporate data gathered through assessment and evaluation of the patient and synthesize this information to develop a treatment plan that supports a positive patient outcome you will also be able to compare and contrast patient protocols or standing orders with patient care algorithms while understanding that neither of these is intended to replace critical thinking in the pre-hospital environment",
        "Introduction": "on a daily basis paramedics must be able to identify problems set patient care priorities develop a care plan and execute the plan you could be a cookbook medic and so what the definition of that is is a medic who blindly follows steps without fitting them into specific circumstances involved it not only it's not an effective way to practice paramedicine because many patients typically present atypical the pre-hospital environment is dynamic the scene may be unstable and emergency settings may be chaotic or unsafe paramedics are expected to provide quality patient care",
        "Gathering, Evaluating, and Synthesizing Information": "so let's talk about cornerstones of effective paramedic practice gathering evaluating and synthesizing information the first first cornerstone of your paramedic practice involves gathering evaluating and synthesizing synthesizing is also known as processing information you must be able to communicate and obtain information from many different patients different age groups different educational backgrounds different abilities to communicate and patients who have consumed drugs or alcohol have language barriers or maybe perhaps hearing impairments assess and evaluate gathered information to develop a treatment plan by checking the viability of the information using your judgment and communication skills for example a patient with a sprained ankle may request morphine the patient may be an illicit drug user or may not be able to may not be knowledgeable about medication and have a low tolerance for pain you may need to explain to the patient why morphine cannot be administered in this situation be as objective as possible in decision making process evaluate the information you've obtained from the scene the patient and by standards determine which information is valid and which is invalid so process or synthesize this information okay so for example a 64 year old man is reporting chest pains type 1 diabetic since childhood started smoking in high school and has had copd since his 50s so synthesis requires that you consider how each element interacts with the others and ultimately how they affect your patient's current condition a comorbidity is when the patient has two or more chronic diseases or conditions a comorbidity like diabetes is directly related to circulatory complications diabetes often leads to the development of vascular disease with shock a high blood glucose level can make progressively thickening blood stickier low blood glucose can kill someone or result in brain damage quickly chronic high blood glucose takes a toll on every organ or body system such as vision impairment or amputated fingers and toes the patient's other comorbidity copd is a disease of poor gas exchange that frequently results in hypoxia and hypercarbia you must consider the patient's comorbidities while you assess his new symptom the onset of chest pain it is likely that coronary artery disease has caused one or more of the vessels of the heart muscle to become blocked resulting in death of that part of the heart synthesis in this case i have a patient with disease of both circulatory and gas exchange there is a possibility that part of the heart patient's heart is dying because blood vessels are unable to deliver oxygenated blood to a portion of the heart muscle you must treat the combined effect of your patient's disease process to prevent the unperfused section of the patient's heart from dying this is synthesis taking the individual conditions and mentally gluing them together together to determine their potential for having a life-threatening impact in this scenario assume the patient is having an acute coronary syndrome",
        "Developing and Implementing a Patient Care Plan": "developing and implementing a treatment plan the second cornerstone of your paramedic practice is your ability to develop and implement a treatment plan after you have determined the patient's primary problem by identifying the chief complaint and establishing your working diagnosis your treatment plan is guided by patient care protocols or standing orders from the ems system where you work a differential diagnosis is a list of possible diagnosis based on the patient's assessment findings and a working diagnosis is the one diagnosis from the differential list on which you are basing your treatment plan protocols or standing orders define the essential clinical standard of care for patient with certain disease illnesses injuries or behavioral conditions they will specify the performance parameters and that's what therapies or interventions you can and cannot do without contacting medical control when you need to contact medical control before providing additional care protocols promote both a standard approach and the standard quality of care as defined by regional state or national standards protocols also provide parameters for medical control so that they do not do not order treatment with medications beyond your level of training and what is usually carried on your unit protocols standing orders and patient care algorithms do not generally address vague patient complaints that do not fit into a neat clinical depres description or multiple disease etiologies patients with atypical presentation will require multiple treatment modalities",
        "Using Judgment and Independent Decision Making": "so let's talk about using judgment and independent decision making the third cornerstone of your paramedic practice is to use his use of judgment and independent decision making for example you are called to a factory where a machinist was injured on the job and has a serious gash to the upper part of his leg a substantial amount of blood is gushing from the femoral artery in this situation it is best to delay contact with medical control until the bleeding is controlled and you are in route even under the best circumstances the patient may have died before you completed a call with medical control to save the patient you must immediately recognize a life threat and treat it in this case with continuous direct pressure and ideally a tourniquet or a hemostatic dressing circumstances must determine the paramedics treatment plan necessary treatment changes will only happen if you are using your critical thinking and decision making skills to the best of your abilities",
        "Thinking and Working Under Pressure": "thinking and working under pressure so the final cornerstone of your paramedic practice is the ability to think and work under pressure for example you ring the doorbell of an address to which you have been dispatched and a hysterical mother opens the door she hands you a cyanotic ethnic 14 month old who has been submerged in a bathtub only a combination of knowledge coupled with excellent clinical skills will allow you to avert a patient care disaster you must be able to work under extreme pressure analyze a situation and perform quickly and effectively you must be able to determine if a patient is sick or not sick for patients who are sick you must be able to quantify how sick they are this allows you to make the best choices as to the care you must provide both at the scene and in the ambulance and route this process becomes more complicated when you have multiple sick or injured patients be clear thinking in an emergency starts with a triage process a process of sorting out your patients into four categories based on the severity of their injuries",
        "The Range of Patient Conditions": "patients in critical condition need immediate care and transport to survive those are the red tags patients in unstable condition are a second priority their care and transport can be temporarily delayed for a few minutes to possibly the next half hour otherwise they can become critical patients and those are the yellow tags two groups remain those non-survivable injuries or obviously dead those are the black tags also called priority zero and walking wounded or minimally injured those are the green tags patients with life threats include those with major multi-system trauma devastating single system trauma end stage disease presentations or acute presentations of chronic conditions patients in unstable condition include those with multi-system trauma acute presentations of first-time medical events or multiple disease etiologies patients with minimum life-threatening injuries include those with simple abrasions partial thickness burns of the extremity of less than five percent total body surface area or small lacerations with only capillary bleeding",
        "Concept Formation": "okay so critical thinking and clinical decision making concept formation the first stage of the thought process in pre-hospital care is gathering information from things you see hear smell and feel that which you gather from your diagnostic tools it starts as you arrive on scene become situationally aware evaluate the scene to ensure the safety of yourself your crew and your patient determine the mechanism of injury for trauma and for medical the nature of the present illness does how the patient present or how does the patient present does the patient present as uncomfortable frightened or deathly ill what is the patient's level of consciousness or loc and to determine if the patient can provide you with reliable information to determine baseline to refer to later as the patient's condition changes the process continues with the performance of a primary survey to identify and correct any immediate life threats to your patient's life relative to the abcdes and that's airway breathing circulation disability and exposure you continue on as you perform the secondary assessment and the physical exam and identify the patient's chief complaint a sample and that signs and symptoms allergies medications pertinent past medical history last oral intake and events leading up to the illness or injury and history follows to determine a pertinent medical history any medications the patient is taking whether they are prescription over-the-counter illicit or herbal the patient's effect and that's the emotional state reflected by physical behavior and vital signs and relative relevant clinical test results are obtained",
        "Data Interpretation": "and then we talk about data interpretation and that's the second stage of critical thinking process you evaluate all gathered information and form the conclusion a paramedic should understand how the body works and how it responds when complications arise and should also have a solid background in anatomy physiology and pathophysiology another key event or element is your level of education and experiencing before becoming or coming to the paramedic program emergency medical technicians have an excellent platform to build on applying yourself in your studies will also help you meet the challenges a good attitude is paramount in good health care and involves showing compassion and interest for your patient and providing the best care for your patient",
        "Application of Principle": "and then the third stage of critical thinking is application of the principle field impression becomes a working diagnosis and so a working diagnosis is what you tentatively believe to be the problem and focus of your treatment working diagnosis could be a number of conditions from your differential different diagnosis and the conditions for which you are treating the patient the treatment plan is determined by patient care protocols or standing orders all right and then the fourth stage and",
        "Reflection on Action": "that's the reflection and action of the critical thinking process is actively treating the patient while monitoring the intervention effects periodically check your interventions in order to revise your impression the situation does not improve then additional interventions may be appropriate avoid tunnel vision focus and tunnel vision is defined as focusing on or considering only one aspect of the situation keep your mind open to all the possibility possible causes of your patient's current condition patients may have a condition that presents in one way that differs from typical signs and symptoms and then the last stage is reflection on action and this is a critical thinking process that occurs after the call is over reviews runs critiques and debriefings so reflect on how you gathered and process information and reach the decisions that you did a review of the run is an opportunity to accept that something went wrong or to better treat treatment choices could have been made an open attitude of learning from each call will help paramedic improve his or her personal or professional skills provides an opportunity to improve your thinking decision making and patient care growth will only happen if you can admit mistakes and are willing to continue to learn a fundamental element that contributes to critical thinking and clinical decision making processes include adequate knowledge of anatomy physiology and pathophysiology the your ability to gather and organize data and form concepts the ability to focus on specific and multiple elements in data the ability to identify and deal with medical ambiguity skill in differentiating between relevant and irrelevant data capability to analyze and compare similar situations capability to analyze and compare con contrary situations and the ability to articulate your reasoning and construct arguments",
        "From Theory to Practical Application": "okay so each call has unique circumstances that will require appropriate care changes and call variables will determine a paramedic's ability to manage the call so each call must be handled in a professional manner with the possible best possible care provided and paramedics must learn to deal with their own reactions when dealing with extreme medical emergency scenes by improving their mental conditioning improving their skill performance muscle memory the following checklist may facilitate better thinking under pressure scan the scene stop and think move forward make decisions and act on behalf of the patient stay calm and control and maintain situational awareness and continually re-evaluate the patient",
        "The Six Rs": "okay so taking it to the streets remembering that the six hours of clinical decision making can help a paramedic out on a call and the six hours are read the scene read the patient react re-evaluate revise the treatment plan and review performance so we're going to go through those and the first one is read the scene an emergency scene is filled with information readily available to only only you okay so it becomes unavailable the moment you initiate transport to the hospital to effectively read the scene you must evaluate an overall safety environmental conditions immediate surroundings any access or egress the mechanism of injury or nature of illness other issues to consider when you size up the scene include assessing the environment so was it hot wet or cold when are there witnesses available to provide additional information okay and then you want to read the patient offer the patient your hand to shake when introducing yourself or an appropriate gesture based on his or her culture or customs if the patient takes your hand and answers appropriately you can determine that the patient has a glass cal score of 15. observe the patient the level of consciousness level of comfort or discomfort skin color position work of breathing deformatory or asymmetry talk to the patient determine the chief complaint obtain a medical history in the events leading up to the illness or injury touch the patient assess skin for color temperature and condition assess pulse rate regularity and strength auscultate breast sounds confirm adequacy or inadequacy of breathing and assess the patency of the airway identify and correct any life threats relative to the abcdes and obtain complete and accurate vital signs to determine a baseline for patients with serious conditions do two sets of serial vital signs for compare comparative data for patients in critical condition do three or more sets of vital signs to assess trends and to reassess whether the patient's condition is stabilizing stabilizing and then we have react the first priority is to treat any life threats then consider possible causes of symptoms to develop a differential diagnosis and ultimately a working diagnosis if you are unable to narrow down the differential diagnosis to a working diagnosis provide care based on presenting signs and symptoms okay and then you have reevaluate so follow up on any interventions you make and make sure that they're improving the patient's condition so avoid fa falling into the treatment mode while reassessing the patient at information from the secondary assessment to the primary survey and then the fifth uh r is going to be revise your treatment plan so keep your mind open to revising the treatment plan as other information becomes available and then finally review your performance so once a call is over a review will create an opportunity to re-examine the work learn how to avoid repeating the mistake and how to do better next time reviews can be a formal continuous quality improvement meeting or a simple debriefing after a field code or an informal conversation with partners okay so thank you very much for joining us this is chapter 12 critical thinking and clinical decision making we've hoped that you've enjoyed this lecture thank you"
    },
    {
        "Introduction to Career Development": "hello and welcome to chapter 53 career development this chapter discusses the importance of career development including the four components of career development self-assessment career exploration career identification and creating an action plan it discusses the growth of ems and opportunities within the ems and the larger health care system and provides tips for making ems a lifelong career",
        "Paramedic Career Opportunities": "paramedics have unlimited possibilities in the field of health care and public safety the u.s bureau of labor statistics in 2016 244 4960 emergency medical technicians and paramedic positions the number is projected to grow 24 from 2014 to 2024 faster than any other occupation the top five industries with the highest levels of employments include other ambulatory health care systems local government general medical and surgical hospitals other support services and outpatient care centers as of may 2016 states with the highest employment level of emergency medical services providers include texas california new york illinois and pennsylvania so there are factors in that are influencing the continued need for paramedics and they include the growth in the middle age and older population and age-related health emergencies in these groups so the increased lifespan for patients with special health care needs including patients with chronic or debilitating conditions who are living at home and who are dependent on technology increase success of advanced life support providers and administrating life-saving interventions in the pre-hospital environment previously pre-hospital providers were less able to intervene in meaningful ways to provide health and save lives increase in these roles responsibilities and education levels of pre-hospital providers and increase in the number of conditions in which they have effectively intervened creates an increased need for providers with a higher level of education preparation and training increasing numbers of specialized medical facilities and the need for transport and transfer patients with specific conditions to these facilities for ongoing care creation of non-traditional rules for paramedics within the larger healthcare system such as in emergency departments and urgent care clinics and in locations such as cruise ships hollywood movie sets oil rigs and schools there's also an increase in the number of suicides availability of lethal drugs on the streets and a rise in violent crimes and terrorist activities okay so a career plan that includes your",
        "Career Development Plan": "short and long term goals and the steps you need to take to achieve those goals is important as a newly certified paramedic determine if there is other goals in your plan now do you want to specialize in training or become a flight paramedic or do you want to pursue an advanced degree to lead your ems organization only you can determine your personal goals and create a plan to achieve them the four components of career development include self-assessment career exploration career identification and creating an action plan self-assessment and creating an action plan are key so let's talk about the self-assessment you want to assess your current skills honestly enlist options and advice from friends and mentors determine your strengths interests and values your initial ideas will help you structure your goals then you need to have an action plan this is the achieving goals it requires action make a list of achievable short and long term goals and the steps you want to take determine the organizations that can provide you with this help and periodically re-evaluate these goals and change them to keep them personal and relevant",
        "Mobile Integrated Health Care Provider/Community Paramedic": "okay so mobile integrated health care providers community pair medicine this differs from the traditional role of paramedic because focus is on working with the patient in the home and the goal is to prevent conditions from escalating into threats requiring emergency care now the mobile integrated health care providers and community paramedicine program across the united states have grown exponentially over the last few few years due to issues such as reducing preventable ed visits reducing preventable hospital readmissions and safe navigation of patients to destinations more suitable for medical care than emergency departments the primary goal of this group is to get the right patient to the right resource and the right treatment with the right tools at the right time paramedicine is essential for providing patient-centered care and must develop a plethora of knowledge as well as a high skill base to treat the patient directly and navigate the patient to the appropriate resource now there are requirements and they are still evolving additional training either through a college-based training program or other specially designed educational curricula by local agencies it focuses primarily on pathophysiology public health social assessment needs and preventative medicine now the mobile integrated health care provider and community paramedicine can identify address treat or navigate all aspects of a patient's needs such as nutritional social clinical and psychologic there are general responsibilities and those are to function as a field paramedic perform direct advanced life support care activities be team oriented and able to communicate and work effectively and efficiently efficiently with other members of the healthcare team to coordinate care for enrolled patients also monitor and manage chronic diseases in the home setting and provide wellness checks obtain patient medication inventory communicate with multiple agencies to facilitate continued continuing care participate in data collection identify clinical barriers that the patient may have in navigating health care needs identify social barriers identify nutritional needs and identify psychological support needs the primary role is to assist patients to manage their health care needs more frequently additional roles are helping patients asset access and use primary care educating patients on the need for medication and diet adherence assisting patients and managing chronic illness providing point of care blood testing modifying patient care plan best based on results all right so they may implement treatment modalities such as in-home diuresis for patients in heart failure or antibiotic antibiotic administration may be breathing treatments for patients with chronic obstructive pulmonary disease or dextrose administration for patients with diabetes in some parts of the countries you may arrange for patient transport to physician or clinic visits and help staff at fixed sites clinics and also may serve as an adjunct member of any emergency disaster response team",
        "Critical Care Paramedic": "and then you have critical care paramedics and that's ccp sometimes referred to as critical care transport profession recommended educational qualifications for the critical care paramedic vary but they must be able to provide at the same level and in most cases at a higher level than the non-critical care or emergent transport counterparts cctps must also be educated and proficient in advanced practice providers such as advanced airway management with a mechanical ventilators administration of a vasoactive iv medication hemodynamic monitoring monitoring chest tubes and intracranial pressure monitors interpretation of lab data management of patient on intra aortic balloon pumps or bypass machines and management of neonatal patients also utilization of sonography and medical diagnosis tools training programs typically consists of formal course of study also clinical internships certification exam administered by either a national agency or a local agency body and some agencies are using cctps for in addition to 9-1-1 team responses for highly critical incidents and to assist with mobile strike units",
        "Flight Paramedic": "and then there's the flight paramedic they work as a part of an air rescue team that provides either on-scene care in remote field settings or inter-facility transports from one clinical setting to another a career as a flight medic may require the following skills aircraft fundamental safety and survival flight pathophysiology trauma management advanced airway management neurologic emergency management critical care pediatric neonatal management toxic exposure management flight paramedics and cctps undergo many of the same training and clinical continuing education hours the difference in their training is the understanding of the flight philosophy and survival so flight medics must be able to provide high levels of critical care in  odd environments",
        "Bicycle Emergency Response Paramedic": "then you have bicycle emergency response paramedics they provide ems standby assistance in events with large crowds or where standard ambulances or critical capacity is not possible bicycle emergency response teams have the following skills so basic nutrition and physical fitness bicycle maintenance and repairs bicycle fundamentals on all terrains public safety cycling response bicycle emergency response is crucial to the success of the first response in areas where vehicles cannot be used bicycle paramedics undergo a significant amount of training they work with other bicycle professionals such as bicycle police unit they must be in good physical condition and able to maintain long-term physical fitness training and certification is provided by the international police mountain bike association",
        "Tactical Paramedic": "and then you have tactical paramedics in the training additional training to learn how to practice medicine while in a hot zone they work as a member of a specialty trained team that includes law enforcement officers they provide rapid basic and advanced life support to officers or patients when the situation is considered unsafe for traditional paramedics tactical paramedics have gained skills and credentialing pertaining to combat casualty assessments stabilization and execution of patients in hospital hostile environments tactical principles triage and operational medicine weapons training and management rescue techniques body armor and tactical specialty tactical paramedics were may work with in the military combat or civilian settings as such of special response teams and in special response law enforcement teams or as training instructors for law enforcement agencies",
        "Wilderness Paramedic": "the next thing we're going to talk about is wilderness paramedic and they provide trauma care and other emergency services in remote and frontier areas this rule can be clinically demanding due to the extended length of time between injury and illness and definitive care and physically demanding most you must apply the principles and concepts of urban and traditional emergency medicine in an environment for an extended period of time with limited resources responsibility may include tropical and travel medicine high altitude and mountaineering expedition medicine safety rescue and evacuation or preventative medicine field sanitation and hygiene and general environmental medicine improvised medicine survival skills disaster and humanitarian assistance the training takes place in a in the most observed environments such as high elevation or deserts or under all weather conditions and you must be able to manufacture a splint and transport device stabilize a patient secure the patient transport the patient and deliver the patient and some wilderness guys obtain certification to enhance their marketability",
        "Clinical Roles in the Emergency Department": "so growth and opportunities in a large health care system clinically the changing dynamics of health care system have created additional career opportunities for paramedics in the past emts and paramedics have been generally limited to a technician role the need for cl clinical care in an area of managing scar scarce resources has led hospitals and health care systems to move paramedics into clinical roles paramedics are in the emergency department and they can start ivs administer meds provide advanced airway procedures some examples of new clinical roles include a code leader or an orthopedic technician some paramedics expand their health care careers by becoming nurses nurse practitioners physicians assistants or even physicians some paramedics become physicians while still maintaining their paramedic license returning to the ems profession as medical directors",
        "Health Care Administration": "so hospital ems coordinators it's a vital link between the hospital and the ems community it serves as a bridge in communication and relationships by offering patient outcome feedback learning what ems may desire from the hospital system resolving any conflict between ems and the hospital providing continuing education to the ems providers in the area programs in some areas are able to provide clinical rotations for continuing education some examples are catheterization lab and in interventional radiology labs so emergency management coordinator is a position dedicated to emergency management within the hospital it assists hospitals with disaster planning drills and training on the concepts of the hospital incident command system it works in hospitals and local governments and utilizes federal emergency management agency standards and then there's a transportation coordinator that's navigation includes being able to transport patients effectively from one facility to the other within the system in the safest least expensive way possible and many hospital systems have a transport coordination center that provides patient transfers requests and then there's the ems educator and",
        "EMS Educator": "paramedics with a passion for teaching that would be your ems educator and opportunities include working at colleges or local ems agencies entry-level courses or specialty certification courses also working at higher education institutes by providing assistance with education of future physician assistants and physicians on authorizing textbook and presenting at conferences",
        "EMS Agency Leader": "and then you have the ems agency leader that's a career advancement within your ems system and paramedics and the ems based fire departments often move up the ranks too so lieutenant captain ems chief or fire chief and to prepare for advancement set personal goals and understand the steps needed to achieve those goals seek higher education degrees such as a bachelor's or master's seek educational opportunities within your agency and seek a mentor to learn how he or she achieves success in the field many ems agency leaders also serve on various community boards and task forces",
        "EMS Researcher": "and then there's an ems researcher okay so there is little peer-reviewed research to provide the efficiency of ems on patient outcomes learn to be an ems researcher by attending conferences to learn how to conduct ems research these professionals are given the opportunity to publish research participate on institutional review boards and evaluate the effectiveness of ems in clinical care",
        "EMS and Health Care Sales Representative": "so ems and healthcare sales reps are also another career goal training and experience in the ems field as a paramedic exposes one to products and devices and medications so some paramedics are sales reps for manufacturers of let's say aed's or ambulances or ambulance stretchers and they work with ems agencies and providers",
        "Making EMS a Lifelong Career": "so making ems a lifelong career there are many important roles you can pursue with an ems and the broader health care system other areas into which a paramedics career can develop include the rules of a patient advocate or prevention specialist or a driving instructor maybe a writer or an editor so visualize and strategize your career dreams and you must make plans to achieve those goals motivate yourself daily to make your plans a reality and seek out peers who inspire you to take on all new challenges you will gain invaluable career skills as a medic including understanding of how to remain calm in chaotic environments emergency management and preparedness and effective communication and self-care there is no limit to the number of skills and the amount of experience you can gain as a paramedic lifelong success on the job satisfaction is in ems relies on you okay so that concludes chapter 33 career development lecture thank you for joining me today i hope you've enjoyed it"
    },
    {
        "Introduction to Hazardous Materials": "hello and welcome to chapter 49 hazardous materials lecture the material provided in this chapter is intended to help you understand a hazardous materials incident as well as help you understand the consequences to a person or persons who may become exposed to the substances and where you fit into a hazardous materials incident okay so let's get started",
        "Definition and Challenges of Hazardous Materials": "hazardous material is defined as any substance or material that is capable of posing an unreasonable risk to human health safety or the environment when transported in commerce used incorrectly or not properly contained or stored our civilization requires manufacturing transporting storing using and disposing of tens of thousands of potentially harmful substances each year operating at a hazardous material scene presents challenges that you don't normally encounter during a normal ems call the potential for you to be exposed to a toxic substance and turn into a victim is there and handling exposures properly and with confidence is needed so let's talk about some rules and",
        "Regulations and Standards": "standards okay so regulations for responding to hazardous materials incidents are created by the u.s occupational safety and health administration so osha and the u.s environmental protection agency or the epa has whopper stands for hazardous waste operations and emergency response and is the osha document that outlines the",
        "Hazardous Materials Response Competencies": "hazardous materials response competencies",
        "Training Levels": "training levels found in the osha regulation are the first one is awareness then it moves up to operations then technician then specialist then the incident commander okay so first responders at the awareness level should have sufficient training and experience to understand what hazardous substance they are and the risk associated with them also to understand the potential outcomes of an incidence and to be able to recognize the presence of a hazardous substance be able to identify the hazardous substance if possible understand the role of the first responder's awareness individually in the emergency response plan and determine the need for additional resources consensus-based standards can also help guide responders so nfpa",
        "NFPA Standards": "472 is the standard for competence of responders to a hazardous materials weapons of mass destruction incident and nfpa 473 is the standard for competencies for ems personnel responding to hazardous materials weapons of mass destruction incidents all ems personnel should receive",
        "Hazmat Training": "appropriate hazmat training the appropriate training is based on the needs and requirements of the authority having jurisdiction and the local ems agency the level of training will dictate when and where you will use your ems skills training in hazardous materials is conducted in three levels and we mentioned these on the a couple slides ago but the first one of course is awareness second is operations and then the third is technician federal state and local regulations and standards govern the use storage and transportation of hazardous materials okay so let's talk about paramedics and hazmat incidents when on scene of a hazardous materials incident you must rely on training and references as sources to help you respond know how and when to access specific information you want to be able to access reference sources the poison control center medical control and the hazmat team understand how a hazardous material scene is organized from a command and control perspective and where you fit in familiarize yourself with the different types of personal protective equipment how patients will be decontaminated and how to access and treat exposures you may be called on to support teams through on-scene medical monitoring",
        "Types of Hazardous Materials Incidents": "a hazardous materials incident may include but it's not limited to say a highway or rail incident in which a substance is leaking from a cargo tank a rail car a leak fire or another emergency at an industrial plant a leak or rupture of an underground natural gas pipe or incidents in an agricultural setting buildup of methane or other by-products of waste decon in sewers or sewage processing plants or even an incident with criminal intent in which the suspected hazardous materials agent is intentionally released so let's start talking about the scene ensuring your own safety in the presence of a hazmat material so it may not be possible to identify what hazards are present you may be able to recognize the threat from warning signs so signs and symptoms from patients on scene or placards or labels found on the buildings or trucks or rail cars or drums or other storage vessels sometimes containers and vessels aren't labeled properly though or the labels can be misleading so maintain a high index of suspicion during scene size up you may be well into the call before you have a firm grasp of what is happening you may be able to identify leaks or spills by a visible cloud or a leak or spill from a tank container truck or rail car with or without hazmat placards in place or an unusual strong odor in the area some chemicals are odorized to indicate the presence of normally odorless gases such as propane and methane some chemicals can only be detected by air monitoring incidents in or instruments and that's carbon monoxide never rely on your sense of smell to identify the presence of a hazmat",
        "Recognizing Hazardous Materials": "you should suspect the presence of hazardous materials if you approach a scene where more than one person has collapsed is unconscious or is in respiratory distress there will be times when your ambulance crew is the first to respond so if you notice any signs that suggest a hazardous material incident has occurred stop at the safe distance upwind and uphill from the scene once you rapidly size up the scene isolate the hazardous area the best you can so deny entry to the affected area and call for additional resources such as law enforcement and fire department a hazmat team once your safety is insured you may begin the process of identifying victims and beginning patient care if you do not recognize the danger until you are too close leave the danger zone immediately once you have reached a safe place and reassess the situation provide as much information as possible when calling for additional resources you want to tell them your exact location the atmospheric conditions if appropriate the size and the shape of the container or cargo tankers the exact name of the substance the chemical id number or symbols if visible the number of victims the type and number of additional resources requested the location of a safe staging area and the location of the instant command post don't re-enter or leave the hazardous area until a hazardous materials team clears you so let's talk about identification",
        "Identification of Hazardous Materials": "information at a hazardous materials incident may come in the form of observations reports by bystanders signs and symptoms of victims labor labels and placards shipping papers or safety data sheets the most recent edition of the dot's",
        "Emergency Response Guidebook": "emergency response guidebook or erg should be carried on every emergency response vehicle the erg is a guidebook for first responders during the initial phase of a dangerous goods hazardous materials transport incident it provides information on specific properties of hazards and substances what is shown on placards and recommended isolation distances there are nine dot chemical families recognized in the erg and let's talk about those um different chemical families so the first one the class is explosives the second is gases third is flammable combustible liquids fourth is flammable solids the fifth is oxidizing substances and organic peroxides six is toxic substances seven is radioactive materials class eight is corrosive substances and class 9 is miscellaneous hazardous materials and products substances or organisms",
        "Marking Systems": "so the marking system the usdot system is characterized by labels placards and markings they are used when materials are being transported within the united states and the same marking system is used in canada",
        "Placards and Labels": "placards are diamond shape indicators they're placed on all four sides of the vehicles carrying the hazmat and they identify a broad hazardous class the material inside belongs to so it can be flammable or poisonous or corrosive united nations or north american coating system so the most common are placards and they show a four digit number for identification of hazardous materials labels are smaller versions of placards they're placed on individual boxes and smaller packages and only refer to the potential hazard in that particular box the dot system does not require that all chemical shipments be marked most often there must be a certain amount of hazardous material before a placard is required you may also identify hazardous",
        "Identifying Hazardous Materials in Transport": "materials in transport from the bill of lading or freight bill or the waybill or consist which is carried by a conductor of a train dispatchers can assist by collecting more information from organizations like chemtreck chemtrax stands for chemical transportation emergency center chemtrac has an extensive database of chemical information to assist emergency responders when calling chemtrac they want the following information so they're going to want the name of the chemical involved the name of the caller and a callback number location of an actual incident shipper of the manufacturer container type rail car or vehicle the shipping carrier's name receipt of the materials and location or local conditions and the exact description of the situation the canadian equivalent of chemtrac is c-a-n-u-t-e-c and that's the canadian transport emergency center and then the mexican equivalent is c h e m t e-m-t-r-e-c and that is s-e-t iq",
        "Fixed Facility Marking Systems": "so fixed facility marking systems nfpa 704 is the standard system for identification of hazardous materials for emergency response it outlines a marking system used for fixed facilities the system is characterized by a placard which a set of diamonds are found on the outside of the buildings or doorways or fixed storage tanks the diamond shape symbol is broken into four smaller diamonds that represent a particular property or characteristic the placards are colored and indicate specific hazards and information so the red is a fire hazard the blue is a health hazard white is specific information yellow is reactivity hazard and each small diamond is rated on a scale of 0 which is no hazard to 4 which is a severe risk at permanent manufacturing or storage facilities you should obtain a safety data sheet",
        "Safety Data Sheets": "that provides basic information to help save lives later so it's going to have the chemical makeup of the substance the potential hazards appropriate first aid and other data for safe handling this figure shows an example of a safety data sheet for liquid nitrogen okay",
        "Containers and Storage": "let's talk about containers next and that's any vessel or receptacle that holds a material often there's no correlation between the color of the drum and the possible contents examples of how hazardous materials are packed or stored or shipped are you could it could be in a bag or a drum high pressure gas cylinder or a railroad tank car maybe plastic bucket or cargo tank or pipeline so it's divided into two categories based on the capacity so you have either",
        "Bulk Storage Vessels": "a bulk storage vessel or a non-bulk storage vessel when it comes to bulk storage vessels these types are fixed tanks highway cargo trucks or rail tank cars also totes or intermodal tanks they're found in buildings that rely on and need to store a large amount of a particular chemical and there's secondary contain containment an engineered method that controls spilled or released product if the main containment vessel fails then there are large volume horizontal tanks so they're common they're referred to as above ground storage tanks and also underground storage tanks they can hold a few hundred gallons to several million gallons of product and they're usually made of aluminum steel or plastic when it comes to totes they're also common they're referred to as intermediate bulk containers they can hold between 119 gallons to 703 gallons they're portable plastic tanks surrounded by a stainless steel web they can contain any type of chemical hazardous shipping and storage and no there usually is no secondary containment system and it's difficult to patch the leaks due to the steel webbing around the tote okay so the next bulk storage vessel we're going to talk about is the",
        "Intermodal Tanks": "intermodal tanks for both shipping and storage they hold 5 000 to 6 000 gallons of product can be pressurized or non-pressurized and usually shipped stored and returned to the shipper for refilling then there's non-bulk storage vessels and so all there's all types of containers that aren't bulk containers they can hold a few ounces to 119 gallons of product they include drums bags compressed gas cylinders solvents industrial cleaners and compounds and then you have drums they're barrel-like containers they store a wide variety of substances and they're made out of low carbon steel cardboard stainless steel nickel or other products the construction of the drum is based on the nature of the chemical then you could have bags they're used to store solids and powders constructed out of plastics or paper or plastic lined and specific information on pesticides bags so you have to have the name of the product the active ingredient a hazard statement total amount of the product in the container the manufacturer eap registration number eap established number and signal words to indicate the relative toxicity of the material so they want to have either the danger or warning or caution words on them and also they have to have the practical first aid treatment and directions for use agricultural use and precautionary statements on them and it has to say keep out of reach of children okay car boys these are transport and store corrosives and other chemicals they're containers made out of glass plastic or steel and they can hold between 5 to fifteen gallons of product then you have cylinders they hold liquids and gases a number of various substances in i unisolated compressed gas cylinders and the sizes vary",
        "Roadway Transportation of Hazmat": "so roadway transportation of hazmat or hazardous materials the most common transportation of hazardous materials is over land a cargo tank is a bulk package that may or may not be permanently attached to a motor vehicle okay so this dot-406 flammable liquid tanker is the most common and reliable transportation vehicle it transports liquid food grade products gasoline or flammable and combustible liquids its oval-shaped tank pulled by a diesel tractor it can carry 6000 to ten thousand gallons of product it's non-pressurized made of aluminum or steel and has several safety features including full rollover protection and remote emergency shut shutoff valves and then you have the dot-407 chemical",
        "DOT-407 Chemical Hauler": "hauler and it's similar to the 406 it's a round or horseshoe shaped it holds six thousand to seven thousand gallons of liquid it's tractor drawn and transports flammable liquids mild corrosives and poisons it may be insulated or uninsulated and may have higher internal working pressures so up to 35 psi and then you have the dot 4012 corrosive",
        "Corrosive Tanker": "tanker and it's commonly used to transport corrosives so it's smaller dynamic diameter then the dot-406 or dft-407 can be identified by the presence of several heavy-duty reinforcing rings around the tank it operates at approximately 15 to 25 psi and it can hold approximately six thousand gallons and then you have the",
        "MC331 Pressure Cargo Tanker": "mc331 pressure cargo tanker it carries hazardous materials like ammonia propane freon and butane the tank's capacity varies from 1000 gallons to 1100 or 11 000 gallons it has rounded ends it's constructed of steel or stainless steel has a single tank compartment it operates at about 300 psi and there is an explosive hazard if the tank is impinged on by a fire",
        "Cryogenic Tanker": "and then you have the cryogenic tanker it's a low pressure tanker that relies on tank insulation to maintain the low temperature required for the cryogens so the control valves are usually in the box-like structure on the rear of the tanker small puffs of white vapors are vented from the control valves tube trailers carry compressed gases like hydrogen oxygen helium and methane they are high volume transportation vehicles they are made of several individual cylinders banded together and fixed to a trailer they operate at working pressures of 3 000 to 5000 psi so high psi one trailer can carry several different gases in individual tubes the valve control box is usually found on the rear of the trailer and each individual cylinder has its own relief valve then you have bulk cargo these are dry tanks and they carry bulk goods such as powders pellets fertilizer and grain they're not pressurized and they usually have a v shape with rounded sides okay so let's talk about establishing",
        "Establishing Safety Zones": "safety zones know the safety perimeters for hazardous materials that are toxic and those that pose a fire or explosion danger take the following steps if you are dispatched to a hazardous materials incident of course protect yourself first isolate the incident as much as possible to avoid further harm notify your dispatcher of any other ems fire law enforcement responders and inform incoming responders of what you observe about the wind direction terrain and a safe response route as the incident progresses hazardous materials specialists will establish hot warm and cold zones remember that the hot zone is the contamination zone the warm zone surrounds the hot zone and the cold zone is the buffer from the hazards in the hot and warm zones now paramedics usually perform triage and patient transport in the cold zone observe the initial isolation and protection distances and the hazardous materials team will use air monitoring equipment to determine the explosive limits oxygen levels and the concentration of hydrogen sci-fi sulfide and the concentration of carbon monoxide hazardous materials team can determine the ph of spills in computer aided emergency management of emergency operations is one of the many programs that help predict downwind concentrations of hazardous materials it uses input of environmental factors into a computer model and it helps predict the size and direction of gas or vapor clouds be familiar with the personal protective equipment used at hazardous materials scenes so usually the hazardous materials team or trained responders will determine the appropriate ppe needed for the specific incident you should recognize certain levels or combinations of ppe and understand what hazards the people inside those garments are facing considering heat related or cold related issues or potential house health risks on how to treat an exposure",
        "Protective Clothing": "protective clothing is classified as level a through level d so let's talk about these this is a level a and this assemble requires the greatest respiratory and skin protection it covers the full body and has a self-contained breathing apparatus or other supplemental air system you may need to monitor this technician for heat stress and you should know how to get in and out of these garments in case you need to provide patient care",
        "Level B Protective Clothing": "this is a level b and it's used when a high level of respiratory protection is needed and there is no threat of skin absorption it's not fully encapsulating it's worn with a self-contained breathing apparatus and usually worn by responders who are performing decon then there's level c and this is designed to protect against a known substance it provides minimal splash protection it's worn with an air purifying respirator and it's worn by exposed patients in an emergency department and law enforcement protecting the perimeter and then there's the level d it's usually worn by personnel working in the cold zone worn when there is little to no threat by the release substance and there's no respiratory protection other than a dust mask the nfpa does not certify any garments certification is common misperception in the hazardous materials and weapons of mass destruction response industry the intent of the nfpa clothing standard is to provide guidance on manufacturing quality and performance standards the osha has whopper regulation 29 cfr 1910 120 appendix b of the osha haswhopper regulation offers guidance on which level of chemical protection to use and the conditions under which the various levels of protection should be chosen okay so let's get into the contamination",
        "Contamination and Toxicology": "and toxicology hazardous materials getting into the body and interfering with the body's processes so the harm caused by hazardous material is affected by the route of exposure the dose and concentration how long the toxin wasn't contact with the body and whether it exhibits acute or delayed toxicity if the patient has a chronic pre-existing condition as well okay so let's talk about the primary contamination is a direct exposure of the patient and secondary contamination is transfer of hazardous materials to a person from another person",
        "Routes of Exposure": "when we talk about routes of exposure the physical properties of the hazardous material and the physical surroundings can expose a patient in different ways there are four primary methods of entry",
        "Methods of Entry": "and their ingestion inhalation injection and absorption other factors that can affect treatment are the air temperature the concentration of the hazard and the amount of time a patient was exposed a local effect is reddening of the skin a systemic effect is damage that occurs inside the body you need to identify the exposure scenario and substances involved and provide support care during transport so some hazardous materials can have significant adverse reactions or effects on the neurologic renal or hepatic systems effects may be seen immediately or not for hours or years later so your records should indicate the elements required by the authority having jurisdiction or medical director description of the scene anything you were told about the substance how your patient looked initially treatment rendered and the positive or negative changes sends the initial contact the dose effect principle applies no matter what the route or type of exposure is and so the greater the length of time or the greater the concentration of the material the greater the effect probability will be on the body",
        "Cycle of Poison Action": "the cycle of poison action includes absorption delivery to target organs binding to those organs and the biotransformation and elimination of the toxin through the gi tract kidney or respiratory systems so let's talk about some chemical terms vapor pressure is the amount of pressure in the air space between the top of the liquid and the container it is held inside the vapors released must be contained in order to exert pressure vapor pressures directly correlates to the speed at which the material will evaporate once it is released from the container so evaporation increases when air or pavement temperature is elevated and evaporation rates are also influenced by wind speed shade humidity and surface area of the spill so we just talked about vapor pressure",
        "Vapor Density": "now this is vapor density it's a comparison of the hazardous material gas to air air has a vapor density of one so if the gas is heavier than the air it will sink into little valleys and ditches and propane and butane and carbon dioxide are heavier than air if the gas is lighter than air it rises and dissipates such as methane or hydrogen those are lighter than air this is why you should approach a scene from uphill and upwind okay so now the next chemical term we're",
        "Flash Point": "going to talk about is flash point the temperature at which liquid fuel gives off sufficient vapors that when an ignition source is present it will result in a flash fire flash fires will go out once the vapor fuel is consumed so responders should be mindful of the ignition sources at flammable and combustion liquid incidents low flash point liquids typically have high vapor pressures and they can't be expected to produce a sufficient amount of flammable vapors so now let's talk about an ignition",
        "Ignition Temperature": "temperature and that's the temperature at which liquid fuel will ignite without an external ignition source also flammable range that's the fuel air mixture that reflects an amount of flammable vapor mixed with a given volume of air and so if a given fuel air mixture falls between the upper and lower flammable limits and it reaches an ignition source there will be a flash fire hazardous materials team in many cases can cool down the heat or dissipate the concentration of vapors with cool water before the water is applied the team will decide if the material may be water reactive or water soluble so the next term we're going to talk about is a",
        "Threshold Limit Value": "threshold limit value and it's the maximum concentration of a toxin that someone can be exposed to for a 40 hour work week over a typical 30-year career it's established by the american conference of governmental industrial hygienists and it's a permission permissible exposure limit a corresponding value established by osha threshold limit value or short term exposure limit is the concentration a person can be exposed to for a limited number of brief time periods the threshold limit value ceiling is a concentration that a person should never be exposed to and the threshold limit value skin is significant exposure from absorption due to direct or airborne contact with the material",
        "Lethal Dose and Concentration": "lethal dose or ld is a single dose that causes the death of a specific number of the group of test animals exposed and lethal concentration or lc it's the concentration of the material in the air that is expected to kill a specific number of the group of the test animals when administered over time okay so the next two slides",
        "Definitions of Toxic and Highly Toxic": "have the definitions of toxic and it talks about the chemical the milligrams per kilogram and who's it's administered too so um it talks about rats and then rabbits and then of course this slide talks about the milligrams per liter when administered by inhalation so it just defines the toxic the term highly toxic is the next definition and it says the specifics of the milligrams and the weight of the test animals and then immediately dangerous to life and health atmospheric concentration of any toxic corrosive or asphyxiant substance that will pose an immediate threat to life irreversible or delayed adverse effects or serious interference for a team member's attempt to escape when it comes to decontamination and treatment understanding the situation before beginning to treat a patient at a hazmat scene is important so you must keep yourself safe which can take discipline and emotional coolness",
        "Decontamination": "decontamination is the highest priority when a substance provides an unacceptable risk to responders patients must be decontaminated before they are given treatment let's talk about some of the",
        "Decontamination Methods": "decontamination methods and they're going to depend on the type of the hazardous material involved the stability of the scene and the number condition and location of the patients consider the protection of the environment while decontaminating as well and make sure that you have plans to contain the runoff and this is a secondary when lives are at stake however there are four common types of",
        "Common Types of Decontamination Methods": "decontamination methods that are used in the field so there's the dilution",
        "Dilution": "and this is most common method and easiest to perform it just relies on copious amounts of water to flush the contaminant from the skin or eyes",
        "Absorption": "next is absorption this is accomplished with large pads that soak up the liquid and remove it from the patient such as towels",
        "Neutralization": "and then there's neutralization so neutralization involves a chemical to change the hazardous material into a less harmful substance and then there's disposal this is more",
        "Disposal": "of a result of the decontamination process to remove as much of the patient's clothing as possible in order to reduce the amount of contamination that contacts the body simply removing the clothing can reduce the level of contamination by as much as eighty percent to ninety percent in some cases you may need to make an immediate decision to treat patients despite the contamination so you must always ensure that you have the appropriate protection",
        "Emergency Decontamination": "emergency decontamination is the process of removing the bulk of contaminates from a person as quickly and completely as possible okay so you could brush off powder or give the person bags to put their personal belongings in and water from available resources is most often the universal decontamination solution when it comes to mass decontamination",
        "Mass Decontamination": "firefighters can set up hose streams to perform mass decon a decontamination corridor and that's like a controlled area can be set up um in warm zones by parking to fire engines parallel to each other and approximately 10 to 30 feet apart 20 feet apart nozzles can be attached to each discharge port and set up to create a fine particle fog stream decon shower technical decon is the thorough cleaning process used by responders to clean ppe tools and equipment using cleaning solutions scrub brushings brushes and decontamination corridors the following steps are an indication of a technical decon process so the responders exit the hot zone they approach the decon corridor contaminated tools and equipment should be left in the hot zone hazardous materials personnel are showered and washed paramedics stay alert for signs of ongoing primary or potential secondary contamination problems team members move into an area of the decon corridor where another member of the decon team helps them out of their ppe respirators and self-contained breathing apparatus mass are and under gloves are removed and placed in plastic bags ideally responders proceed to local location where they can take a personal shower and entry team's personnel undergo medical evaluations",
        "Treatment of Patients Exposed to Hazmat": "so when we talk about treatment of patients exposed to hazmat or hazardous materials invasive procedures should be minimized if possible such as endotracheal tube inhibition it may expose the patients to airway contamination or placement of iv or io may allow contaminants to bypass the skin barrier so weigh the risk against the benefits familiarize yourself with references and how to assess technical expertise when demanding or deciding how to treat patients assists assistance may be obtained through the erg or chemtreck you could also consult agencies such as poison control centers or local medical control corrosives acids and bases so corrosives are chemicals that include both acids and bases such as toilet bowl cleaner or lye or hydrochloric acid acids have a low ph and bases have a high ph substances with either high or low ph can cause severe burns to the skin eyes and mucous membranes okay so once the patient is decontaminated treatment is support such as enter the airway and oxygenate treatment for pain if needed always consult medical control to determine the proper course of action when treating patients with chemical exposures",
        "Solvents": "next we're going to talk about solvents so they could be liquid solids or gases common solvents are paint thinners or nail polish removers solvents are capable of dissolving other substances and many give off vapors that can be inhaled or absorbed respiratory exposure in particular can cause immediate pulmonary symptoms such as pulmonary edema and exposures may require extensive decontamination to the point where it is considered a form of treatment some of they can be metabolized into other toxic substances once absorbed into the body so pay special attention to the potential for vomiting if a substance is or solvent is ingested okay so the next we're going to talk",
        "Pesticides": "about is pesticides and it can cause runaway nervous system stimulation the stimulation in turn produces a collection of signs known as the the pneumonic dumbbells and so it stands for diarrhea urination meiosis or muscle weakness bradycardia or bronchospasms emesis lacrimation seizures salivation or sweating exposures can produce tachycardia or bradycardia twitching muscles or excessive pulmonary secretions",
        "Treatment of Pesticides Poisoning": "treatment of pesticides poisoning includes aggressive decon protection of the airway high flow o2 and the use of atropine to block the over stimulization of the receptors of the parasympathetic nervous system chemical asphyxians interfere with the use of oxygen at the cellular level an asphyxian is any gas that displaces oxygen from the atmosphere and cyanide is a common example treatment for cyanide exposure is so this is for a non-smoke inhalation patient it's uh patients should inhale anal nitrate ampoules for 15 seconds every minute follow with an iv administration of 300 milligrams of sodium nitrate followed by 12.5 of sodium thiosphate follow the instructions found in the cyanide antidote kit for definitive treatment carbon monoxide is another common cause of chemical asphyxiation it ties up the hemoglobin to the extent that oxygen in the blood becomes inaccessible to the cells treatment includes removal of the patient from the source and consider transport to emergency department with hyperbaric oxygen capabilities",
        "Toxic Products of Combustion": "toxic products of combustion are hazardous chemical compounds released when a material decomposes under heat so toxic gases are liberated during a residential structure fire remember the phrase garbage in garbage out whatever objects are involved in a fire will break down in heat and a host of chemical byproducts are created and found in smoke so burning wood gives off more than 70 harmful chemical compounds other toxic substances found in most fire spoke include soot monoxide dioxide water vapor cyanide compounds and many oxides of nitrogen carbon monoxide affects the ability of the body to transport oxygen like we said earlier cyanide compounds affect oxygen uptake and oxides of nitrogen are deep lung irritants and can cause pulmonary edema or fluid buildup in the lungs so when you talk about transporting these patients it is ideal to have paramedics who are not involved in the decontamination or cold zone patient treatment standing by to transport patients to emergency department do not assume that the patients received after the field decon are completely decontaminated wear appropriate ppe if indicated and be trained to wear the level required you should be given a complete report from the hazardous materials team and you should never transport a patient if there hasn't been significant decon done before transporting the patients you can prepare in several ways so reduce the amount of supplies and equipment that the patient will contact plan to wrap the patient in a plastic barrier to reduce the potential of secondary contamination and give the emergency department plenty of notice prior to transport so that it can properly train personnel together and prepare equipment",
        "Medical Monitoring and Rehab": "medical monitoring and rehab so you may be asked to assist with medical monitoring of hazmat team members ppe often causes heat stress and toxins the team is working with can cause serious health effects so factors that influence the hazardous materials team members health include the level of physical fitness the activity the level of ppe in the environment factors like let's say temperature",
        "Medical Monitoring": "medical monitoring includes documenting the incident factors which includes the hazardous material involved the toxic effects the ppe warn the ppe's resistance to permeability with hazardous materials and the type of decon used have a planned treatment transport and the potential availability of antidotes you may assess the hazardous materials team before they enter and after they leave the hot zone so you should assess them for the complete set of vitals and ecg possibly and temperature and body weight team members should pre-hydrate with water or sports drinks before they re-enter the hot zone they need to be evaluated again for their hydration status and vital signs and any symptoms for the potential exposure to the toxic agent team members should remove their protective clothing and be given time to rest reassess vital signs and perform a neurologic assessment okay so that concludes chapter 49 hazardous materials lecture thank you for joining us today we hope you've enjoyed it"
    },
    {
        "Introduction to Vehicle Extrication and Rescue Operations": "chapter 40 vehicle extrication special rescue and hazardous materials rescue operations Encompass a variety of processes and environments each with its own complexities and challenges these situations often demand skills and training beyond the scope of an aemt as an aemt your initial actions at the scene Factor heavily in the efficiency and success of the rescue as early interventions and decisions can significantly influence the course and outcome of the operation extrication demands both mental and physical preparation as it involves a process of safely removing a patient from entrapment or any hazardous situation or position during patient contact it's imperative to wear gloves that are impermeable to blood and other bodily fluids in order to prevent exposure additionally if you are participating in the extrication itself it's recommended that you wear a pair of leather gloves over the Disposable gloves to provide added protection and durability during the operation in the fundamentals of extrication safety Remains the top priority for all involved the primary roles of the aemt during extrication include providing emergency medical care to the patient and preventing any further Injury Care should be administered while the extrication process continues provided it is not POS additional risk to you or the patient in some instances you may also be responsible for performing simple extrication techniques when mechanical tools are not necessary it's important to recognize in trapment situations which are defined as a person being confined within a space with no means of exit or having a limb or body part trapped necessitating careful and coordinated extrication efforts",
        "Preparation and Scene Size-Up": "the extrication process is divided into 10 distinct phases each designed to systematically approach the rescue of a patient preparation is a foundational phase that includes pre-incident training with rescue Personnel to address a variety of potential rescue scenarios this phase also involves routinely checking and maintaining extrication tools and response vehicles to ensure Readiness while in route to the the scene it is necessary to follow established procedures and safety precautions similar to those in place for all rescue calls ensuring that you arrive prepare to initiate the extrication process safely and efficiently upon arrival at the scene a thorough scene size up is necessary to ensure safety and efficiency this process requires situational awareness which involves identifying and understanding ing any potential threats while preparing to respond appropriately if you were the first responder to arrive position your unit in a location that ensures safety for both you and the patient if other emergency units have already arrived select a position that provides secure access to the scene while maintaining a clear exit path in the case of a motor vehicle collision use only the necessary warning lights to minimize visual distraction and confusion if law enforcement is not present it's important to designate someone to manage Traffic Control in order to maintain the safety of the scene if you were the first responder on scene it may be necessary to request additional support based on the needs of the situation this could include specialized extrication equipment fire service personnel and apparat Rus law enforcement Assistance or specialized Crews for Unique hazards performing a comprehensive 360\u00b0 walk around the scene helps to identify hazards assess potential injuries and determine the number of patients involved during this assessment look for down power lines leaking fuels or hazardous substances visible smoke or fire broken glass mechanisms of injury and any trapped or ejected patients additionally evaluate the number of patients and vehicles involved pay close attention to physical changes to the structure of any Vehicles such as damage to the steering wheel which may indicate face or thoracic trauma or dashboard deformation which could suggest lower extremity injuries it's also vital to determine whether the patient was restrained at the time of the incident as this can provide insight into the types of injuries sustained during the scene evaluation consider the need for additional resources which may include extrication equipment fire suppression units law enforcement Hazmat teams utility companies for infrastructure concerns ALS units or aeromedical transport for Rapid evacuation be vigilant for leaked fuel or other flammable substances as these can pose immediate threats to safety moreover environmental conditions such as extreme weather can introduce additional hazards to the rescue some scenes may even present risks of violence especially if they are intoxicated individuals or agitated bystanders remain alert to the potential presence of weapons and be prepared to manage scene accordingly to maintain the safety of both patients and responders",
        "Coordination and Command Structure": "upon arriving at the scene immediately report to The Incident Commander or I to receive instructions and integrate into the command structure under the incident command system or IC rescue operations function as a distinct group and providers should coordinate closely with both the rescue team and law enforcement in order to Main maintain an organized and effective response the rescue team ensures the safety and stability of the scene their responsibilities include securing and stabilizing the environment whether it be a vehicle or another structure and providing safe access to patients this team is tasked with the careful extrication of patients ensuring that proper precautions are taken to protect them from further harm additionally they Ensure sure there is adequate space to facilitate the safe removal of patients allowing for appropriate Medical Care and transport as an aemt your primary responsibilities at a rescue scene typically include assessing the patient condition and delivering immediate Medical Care based on their needs you will also need to triage patients to determine the order of treatment based on the severity of their injuries properly packaging patients for safe transport is another key Duty ensuring they are immobilized and stabilized as necessary Additionally you are responsible for providing further assessments and interventions as needed while the extrication and rescue process continues once the patient is stabilized and ready you will facilitate their transport to an appropriate medical facility for definitive care",
        "Hazard Control and Scene Safety": "Hazard control is a collaborative effort between various emergency response teams with each having distinct responsibilities to maintain scen safety law enforcement officers are tasked with managing traffic control and flow to secure safe access for emergency Personnel they also maintain public order conduct investigations into crashing or crime scenes and establish parameters to ensure that bystanders are kept at a safe distance from hazards firefighters manage fire related risks they're responsible for extinguishing any active fires preventing potential sources of ignition from causing further damage and ensuring overall seen safety additionally they address hazards related to spilled fuels or other fluids to mitigate the risk of secondary incidence or environmental contamination this coordinated effort between law enforcement and fire Services ensures that the scene remains safe for both responders and patients throughout the extrication process down power lines frequently pose significant hazards at the scenes of vehicle crashes as a responder never attempt to move down power lines yourself if power lines are touching or in close proximity to a vehicle involved in a crash instruct any patients inside to remain in their vehicles until the power can be safely shut off by the utility company if you were not the first on the scene identify the designated safe Zone that has been marked to provide protection from electrical hazards conversely the danger zone is an area where exposures to risks such as live power lines or hazardous debris is possible and should be avoided scenes may also be Complicated by the presence of hazardous materials which can pose further risks to patients and responders additionally bystanders and family members can create hazards themselves whether by interfering with rescue operations or entering unsafe areas the danger zone should remain off limits to bystanders and if you arrive before the rescue team coordinate with law enforcement officials to establish and maintain crowd control for the safety of everyone on scene",
        "Vehicle Safety and Alternative Fuel Hazards": "Vehicles involved in crashes can present significant hazards so taking steps to ensure safety is essential ensure that the vehicle is placed in park the parking brake is engaged and the ignition is turned off to prevent any unintended movement disconnect the battery to reduce the risk of Sparks or fire which could result from damaged electrical systems be aware of other potential hazards such as the spontaneous deployment of airbags in some Vehicles as well as the risk of vehicle fire or leaking fuel if a vehicle is on fire or leaking fuel do not approach it without wearing the proper turnout gear designed for fire or hazardous material protection always prioritize your safety and adhere to protocols to prevent unnecessary exposure to these dangers Vehicle Safety Systems while designed to protect occupants can become hazards to responders shock absorbing bumpers are intended to absorb impact in low-speed collisions but they may unexpectedly release energy posing a risk of injury particularly to the knees and legs for this reason always approach vehicles from the side to avoid potential harm from bumper deployment airbags also present a hazard in damag vehicles if they have not yet deployed when working around these vehicles use caution as the airbags can deploy unexpectedly and with significant Force additionally be aware of seat belt pre-tensioners which are designed to tighten seat belts during a crash these systems are triggered by sensors that can activate suddenly posing a risk to those working in or around the vehicle alternative fuel vehicles which are increasingly common on the road come with their own set of Hazards they can be identified by specific markings on the vehicle which indicate the type of fuel systems present when responding to an incident involving such Vehicles do not approach without the appropriate personal protective equipment to safeguard against potential risks if you detect an unusual odor this could indicate a hazardous leak and you should not approach further Retreat immediately If you experience any irritation or burning in your eyes or throat as these symptoms May indicate exposure to toxic substances handling the vehicle's high voltage battery pack requires specialized training as these batteries compose significant risks if improperly managed there may be more than one battery in the vehicle so it's important to work with trained responders to disable the system safely and ensure the safety of both The Rescuers and patients",
        "Support Operations and Access to Patients": "support operations at a rescue scene are key elements that facilitate a safe and efficient extrication process these operations include Illuminating the scene to ensure visibility for all Personnel setting up designated areas for staging tools and equipment and marking helicopter landing zones for potential Air transport fire and rescue teams collaborate closely to coordinate these tasks ensuring a seamless flow of operations when it comes to gaining access to patients the approach varies based on the specific situation and conditions at the scene the priority is to identify the safest and most efficient method for reaching the patient in incidents involving multiple vehicles or multiple patients quickly locate and triage each patient to prioritize care and coordinate appropriate medical interventions effectively when determining the exact location and position of a patient during an extrication several factors must be considered first establish whether the patient is located within a vehicle or another type of structure as this will dictate your access and extrication strategy assess the extent of damage to the vehicle or structure to understand the complexity of the extrication process and any potential risks involved identify hazards that may pose risks to both the patient and Rescuers such as fuel leaks electrical systems or unstable debris additionally evaluate the position of the vehicle considering whether it's on a stable surface or in danger of rolling over and assess the type of surface such as gravel p or incline in order to plan for stabilization before approaching the patient when planning an extrication carefully evaluate the patients injuries and their severity to determine the urgency and approach to their removal in certain situations such as when CPR is immediately needed rapid vehicle extrication may be required however this should only be used as a last resort due to the potential for further injury to the patient throughout the process of gaining access and conducting the extrication the patient's safety must remain the priority always communicate clearly with the patient explaining each action before performing it to reduce anxiety and ensure cooperation if there is any concern for potential spinal injury maintain cervical spine immobilization throughout the extrication ensure that both you and the patient are wearing appropriate protective gear cover yourselves with a thick fire resistant Canvas OR blanket to Shield against debris and potential fire hazards minimize exposure to heat noise and force using only the tools and actions necessary for safe extrication",
        "Extrication Techniques and Emergency Care": "extricating a patient from a vehicle is often an intensive multi-step process that requires careful coordination it typically involves stabilizing the vehicle to prevent movement providing Immediate Care is needed disentangling the patient from wreckage or other entrapments and maintaining constant communication among the rescue team and the patient to ensure smooth and safe operations accessing a patient can be categorized as either simple or complex depending on the situation and the condition of the vehicle or structure simple access is always the preferred approach aiming to reach the the patient as quickly and straightforwardly as possible without the use of tools or Force before resorting to more aggressive measures attempt to open all doors or other points of Entry to gain access if these initial efforts are unsuccessful a complex access may be required which involves specialized training and the use of advanced tools or equipment complex extrication skills include various techniques to create access and free the patient such as brake and gas pedal displacement dashboard rollup to create space door removal for side entry roof opening or removal for vertical access seat displacement for freeing the patient's lower body and steering column or steering wheel displacement and cutting to clear the area around the patient's upper body emergency care for a patient during an extrication is fundamentally the same as for any other patient with the focus on stabilizing and addressing life-threatening conditions start by performing a primary assessment and administering any necessary interventions before beginning further extrication efforts this includes providing manual stabilization of the cervical spine if indicated ensuring the airway is open delivering high flow oxygen and assisting or providing adequate ventilation if needed additionally control any significant external bleeding promptly and address any other obvious injuries the immediate priority is to control any life-threatening external Hemorrhage as rapid blood loss come quickly become fatal by addressing these threats to profusion before the extrication progresses you help ensure that the patient's condition is as stable as possible during the more technical phases of rescue good communication and clear leadership are vital throughout the extrication and Emergency Care process it's important that one member of the team is clearly designated as the leader to guide the rescue efforts effectively the absence of a clear leader can lead to confusion hinder rescue operations and ultimately compromise patient care when it comes to removing the patient coordination with rescue Personnel is key together you should determine the best route for safely extricating the patient considering both the patient's condition and any environmental hazards this collaboration ensures that the patient is removed in the safest and most efficient manner possible participate actively in the preparation phase of the patient's removal Begin by assessing the urgency of the extrication which will guide the pace and method used determine in the optimal position for yourself during the extrication to ensure the patient's protection while maintaining your own safety plan how you will move the patient onto a backboard and then onto the stretcher in a manner that minimizes movement and potential injury as part of the preparation carefully examine exposed areas of the patient's body to assess the extent of injuries and identify any signs of internal bleeding throughout the process prioritize both your safety and the patient safety in order to avoid any further harm during the extrication and transport during the transfer of the patient once they have been freed from entrapment promptly assess any additional patients who were previously inaccessible conducting a complete primary assessment for each ensure manual stabilization of the spine is maintained and apply cervical collar to prevent further spinal injury coordinate with sufficient Personnel to safely move the patient and then designate one person as lead and to direct the move in order to ensure a smooth and controlled transport thus minimizing the risk of injury when transferring the patient select a path that minimizes movement or manipulation of both the patient and equipment in order to reduce the risk of further injury after the patient is securely placed on the stretcher continue ongoing assessment and administer any additional treatment as needed to stabilize and support the patient during transport",
        "Termination Phase and Specialized Rescue Teams": "the termination phase involves returning emergency units to service ensuring Readiness for future calls all equipment used during the extrication and patient care must be thoroughly checked for proper functioning and cleaned or replaced as necessary additionally the unit should be decontaminated to maintain hygiene and safety standards finally complete all required documentation and reports in order to record the incident details and ensure that all operational and legal requirements are met before returning to service in certain situations access to a patient is only possible through specialized teams trained in technical rescue operations these specialized teams are equipped and trained for Unique environments and situations including but not limited to special weapons and tactics or SWAT teams for highrisk scenarios missing person search and rescue units technical rope rescue for low and high angle situations and mountain rock and Ice climbing rescue teams other teams May focus on Cross Field and Trail rescues often managed by Park Rangers as well as water-based scenarios such as small craft white water and dive rescues additionally there are rescue teams trained for cave rescues convin space operations ski slope or cross country snow rescues managed by ski patrol and lost person search operations lastly teams also exist for structural collapse situations trench rescues and mine rescues each of these teams possess specific skills and Equipment that's necessary for the challenging and varied environments they encounter technical rescue situations often present hidden dangers that require responders to possess specialized technical skills for safe entry and navigation within the environment a technical rescue group is comprised of personnel who are specifically trained in various types of technical rescues ensuring that they are equipped to handle the unique challenges of their assignments once the patient has been successfully moved to a staging area it's imperative to perform a primary assessment immediately in order to evaluate their condition follow the initial assessment and provision of necessary treatment the patient should be then appropriately packaged for transport to ensure their safety and stability during transfer to a medical facility",
        "Tactical Emergency Medical Support": "scenarios involving armed conflict such as hostage situations robberies or active shooter incidents requires technical emergency medical support these types of incidents significantly Elevate risks for EMS providers necessitating the involvement of specialized law enforcement units such as the SWAT team EMS personnel must adequately prepare plan and train for these situations emphasizing safety protocols as responders approach the scene it's important to turn off lights and sirens and refrain from using outside radio speakers to avoid drawing attention additionally understanding the distinction between objects that provide cover and those that offer mere concealment is essential for safety during tactical incidents EMS providers must adhere to the directions of law enforcement Personnel who may spe specify whom to treat and when to initiate care it's important to carefully document any requests or demands that diverge from established protocols to ensure accountability and Clarity in the response efforts upon arriving at the scene of a tactical emergency it's important to determine the location of the command post which is typically situated in a safe Zone report to The Incident Commander for specific instructions and situational updates additionally it's imperative to identify the closest Hospital Burn Center and Trauma Center in order to facilitate efficient transport of patients if necessary coordinate with tactical EMS providers upon your arrival to ensure a unified approach to Patient Care and safety tacnical medicine refers to the specialized emergency medical care delivered by trained providers including EMTs aemts paramedics nurses and physicians in tactical situations many communities have integrated tactical medicine into their SWAT programs allowing for immediate medical support during high-risk operations in most jurisdictions tactical EMS providers are responsible for the care of law enforcement personnel as they make tacnical entries into volatile environments while also attending to any injured patients training for tactical EMS extends Beyond standard Emergency Care practices for instance spinal immobilization restriction techniques may not be employed in certain situations due to the risk of exacerbating injuries or exposing responders and patients to further danger the standards of care utilized in tactical medicine often mirror those established by military EMS providers focusing on rapid and effective interventions that are tailored to the unique challenges of tactical environments",
        "Search and Rescue Operations": "in search and rescue operations each team is required to include a member trained at the EMR EMT or a EMT level this team member should carry essential equipment to provide Immediate Care to patients in need the role of the aemt typically involves standing by at the command post or staging area until the missing person or people have been located as soon as you receive a briefing on the situation it's important to isolate and prepare the necessary equipment you may need to carry to the patient's location this ensures that you're ready to deliver care promptly once the patient is found during search and rescue operations you may be tasked with staying with the relatives of the missing person person to provide support and reassurance during what can be a highly stressful time once the missing individual has been located you will receive instructions regarding where and when to meet with the search team to provide the necessary medical treatment",
        "Trench Rescue Operations": "trench rescue operations are primarily concerned with incidents involving cave-ins and collapses which pose significant risks to both the trapped individual and the responders one of the major concerns during such operations is the potential for a secondary collapse which can further jeopardize the safety of those involved to mitigate these risks response Vehicles should park at least 500 ft away from the scene of the trench Rescue all vehicles in the vicinity should be turned off to reduce the risk of ignition and to maintain a safe environment additionally it's important to divert all road traffic from this 500t safety area to ensure that responders can work effectively without distractions or additional hazards identifying Witnesses at the scene of a trench rescue is an important step as they may provide valuable information about the circumstances leading to the incident additionally medical or rescue personnel must adhere to strict safety protocols particularly regarding trench depth they should not enter a trench that is deeper than 4T without proper Shoring in place to prevent further collapses during the extrication of any live victims it's essential that medical personnel trained specifically in Cavin and trench collapse rescue provide the majority of Medical Care their specialized training equips them to handle the unique challenges posed by these situations ensuring that victims receive appropriate And Timely medical attention while minimizing additional risks to both The Rescuers and the individuals being extricated",
        "Structure Fire Response": "in response to structure fires an ambulance is typically dispatched alongside the fire department apparatus to ensure immediate medical support is available upon arrival it's important to consult with The Incident Commander to determine the appropriate location for parking the ambulance ensuring it is positioned for safe access access and eress additionally ascertain whether there are any injured patients at the scene or if your role is to stand by as a precautionary measure engaging in search and rescue operations within a burning building require specialized training and Equipment due to the inherent dangers involved as a responder you should remain with the ambulance unless otherwise directed by The Incident Commander it's essential to leave the ambulance only when transporting a patient or when The Incident Commander has officially released you from your duties this protocol helps ensure that medical resources are available and ready to respond to any emergent needs during the incident",
        "Handling Hazardous Materials": "hazardous materials are defined as any substances that pose an unreasonable risk of damage or injury to people property or the environment when encountering ing a situation involving hazardous materials it's imperative to assess the circumstances thoroughly before taking any action this initial evaluation helps to identify potential risks and determine the appropriate response the occupational safety and health administration or OSHA has established regulations under the Hazardous Waste operations in emergency response standard also known as ha Whopper this provides guidelines for safe practices when dealing with hazardous materials First Responders at the awareness level must possess adequate training or experience to demonstrate competency in several key areas when dealing with hazardous materials they should understand what substances are and the associated risks they pose to health and safety additionally responders must be able to anticipate the potential outcomes of an incident involving hazardous materials recognizing how different substances May react in various scenarios providers must be able to recognize the presence of hazardous substances in the environment along with the capability to identify specific materials when encountered First Responders should also have a clear understanding of their role in managing hazardous materials incidents including their responsib possibilities and limitations finally they must be able to assess the situation and determine whether additional resources such as specialized response teams or equipment are necessary to ensure safety and effective response to the incident recognizing a hazardous material requires a methodical approach akin to detective Work First Responders should approach the scene from a safe location as as well as a safe Direction in order to minimize exposure to potential hazards this cautious strategy helps ensure personal safety while gathering information about the incident using binoculars Can Be an Effective tool for assessing the scene from a safe distance this allows responders to observe and evaluate the situation without placing themselves at risk by maintaining a safe Vantage Point responders can identify potential hazards and gather the necessary information for making informed decisions about the appropriate response in the process of recognizing hazardous materials it's essential to question anyone involved in the incident including Witnesses victims or Personnel on the scene gathering information from these individuals can provide valuable insights into the nature of the materials involved and the circumstance es surrounding the incident once sufficient information has been collected responders should formulate a plan for addressing the incident taking into consideration the identified hazards and the safety of all individuals present understanding occupancy and location helps in assessing for the potential presence of hazardous materials many chemicals are stored in various facilities or businesses within your response area making it important to be aware of these locations the type of building and its designated use can serve as good indicators of the likelihood of hazardous materials being present familiarity with local facilities that handle or store chemicals can enhance situational awareness and inform the response strategy during incidents involving these materials when assessing a hazardous material situation use your senses with caution approaching chemicals using sight smell or touch can pose significant risks and such interactions should be avoided whenever possible the presence of Vapor Clouds Hazmat placards or labels at the scene serve as a clear indication to move to a place of safety immediately these visual cues signal that hazardous substances may be present warranting a safe distance from the area Additionally the alarm from a toxic gas sensor can provide an important warning about the potential presence of harmful gases reinforcing the need for prompt evacuation and ensuring the safety of responders and bystanders containers assist in identifying hazardous materials as their type size and material of construction can provide important clues about the nature of the substance they contain understanding these characteristics can help responders assess potential risks and formulate appropriate response strategies containers are generally divided into two categories bulk and non-bulk bulk containers are designed to hold large quantities of materials typically measured in gallons or tons and may include tank trucks rail cars or large storage tanks nonb containers on the other hand include smaller packages such as drums boxes or cylinders which contain smaller amounts of hazardous substances by evaluating the container's attributes responders can gain valuable insight into the potential hazards which are associated with the materials inside and tailor their response accordingly container volume is a key factor in assessing hazardous materials as it can indicate the potential risks associated with a particular chemical bulk storage containers are typically located in facilities that depend on and require large quantities of specific chemicals for their operations these containers are designed to handle significant volumes and must meet stringent safety regulations secondary containment systems are engineered Solutions designed to control any spills or releases from primary containers providing an additional layer of protection against environmental contamination large volume horizontal tanks are categorized based on their location above ground storage tanks are situated above ground while underground storage tanks are buried beneath the surface totes which are intermediate bul containers made of plastic and surrounded by a stainless steel web also hold substantial volumes of hazardous materials while providing added durability Intermodal tanks serve a dual purpose functioning as both shipping and storage vessels these containers are designed for efficient transport and Secure Storage of hazardous materials making them essential in the supply chain of chemical handling non-bulk storage vessels are essential for the safe storage and transport of various materials the most recognizable types include drums which are barrel-like containers typically made of metal or plastic designed to hold liquids powders or granular substances their sturdy construction helps prevent leaks and Spills another common type are bags used primarily for storing solids and powders made from materials like plastic paper or woven fabrics bags are versatile and come in various sizes providing easily handling and protection against moisture and contamination car boys are specialized containers used for transporting and storing certain corrosive chemicals and other types substances a Carboy typically holds between 5 to 15 gallons of liquid and can be made from glass plastic or steel providing various levels of protection depending on the material used cylinders are another common type of container designed to hold both liquids and gases on insulating Compressed Gas cylinders come in various sizes allowing for flexibility in the storage and transport of different gaseous substances both car boys and cylinders play important roles in the safe handling of hazardous materials and understanding their characteristics is essential for risk assessment transportation and facility markings assist in identifying hazardous materials and ensuring Safe Handling during Transit the Department of Transportation employs a marking system characterized by labels placards and other markings designed to convey information about the hazards present placards are diamond-shaped indicators that are fixed to all four sides of Highway transport Vehicles providing visible warnings of the materials being transported these placards along with accompanying labels and markings serve to give responders and the general public an understanding of the hazards associated with the contents of the particular container this system is essential for facilitating appropriate responses to emergencies involving hazardous materials and ensuring safety during transportation and handling in addition to the dot marking system there are several other considerations regarding the transportation of hazardous materials the dot system does not mandate that all chemical shipments be marked with placards or labels rather the requirement for such markings typically depends on the quantity and the type of hazardous material being transported in most cases a package or cargo tank must contain a certain minimum amount of hazardous material before the use of a placard becomes necessary however some chemicals are classified as so hazardous that any amount shipped requires the use of appropriate labels or placards to ensure safety and awareness furthermore certain placards are required to display a four-digit United Nations number which provides specific information about the type of hazardous material being transported the NFPA 704 marking system is a standardized system used to identify the hazards of materials for emergency response purposes classifying hazards materials stored in fixed facilities the NFPA marking system utilizes a diamond shaped symbol divided into four smaller colorcoded diamonds each Diamond represents a different type of Hazard Health flammability reactivity and specific hazards the levels of risk associated with each category are indicated by numbers ranging from zero being minimal to four being severe understanding the type and degree of Health fire and reactive hazards is a essential for responders to operate safely at a scene it's important to note that all health hazard levels with the exception of level zero require the use of respiratory and chemical protective gear to ensure the safety of personnel working in proximity to hazardous materials a key resource tool for providers who are dealing with hazardous materials incidence is the Emergency Response Guide book or ERG which provides comp ensive guidance for responders operating in Hazmat incidents this guide book is updated every 3 to 4 years to reflect the latest information and best practices the book details approximately 4,000 chemicals offering valuable insights into the properties potential hazards and recommended response actions for each substance safety data sheets are a common in poal source of information regarding specific chemicals unlike the previous material safety data sheets sdss possess a structured format and include information that was not mandated in earlier versions they are designed to provide comprehensive details about the chemical makeup of a substance ensuring that users have access to vital safety information an SDS is organized into a 16-part format that may include the sections on the screen all facilities that use or store chemicals are legally required to maintain an SDS on file for each chemical present this requirement ensures that employees and emergency responders have access to information that can help mitigate risks associated with hazards enhancing safety in the workplace and during emergencies shipping papers are essential documents required whenever hazardous materials are transported from one location to another they provide vital information regarding the shipment and include the names and addresses of both the shipper and the receiver for Road and Highway Transportation these papers are often referred to as bills of lading or Freight bills these documents not only facilitate the safe and efficient movement of goods but also serve as a reference for emergency responders in the event of an incident the chemical transportation Emergency Center or chemtrek serves as a resource for technical chemical information essentially functioning as a clearing house for data related to hazardous materials cemre is equipped to provide immediate assistance and detailed technical information via various communication methods including telephone phone fa and other Electronic media this resource is invaluable for emergency responders as it allows them to access specific information about chemicals involved in incidents aiding in decision-making and response strategies when contacting kemre for assistance during a hazardous materials incident have specific information readily available in order to facilitate a Swift and effective response providers should be prepared to provide the following details the name of the material involved in the incident the name of the caller and a call back telephone number a description of the incident and any actions that has already been taken the name of the shipper or manufacturer of the chemical the type of container and the number of containers involved any rail car or vehicle markings or numbers associated with the shipment the name of the shipping carrier the recipient of the material and the information about the location time and current weather conditions at the scene identification of hazardous materials requires a Vigilant approach as responders should always maintain a high index of Suspicion when assessing a scene shipping papers can serve as an initial clue indicating the possibility of a Hazmat incident providing a essential information about the materials involved several indicators can suggest the occurrence of a hazardous material's incident including the presence of a visible cloud or strange looking smoke resulting from the escaping substance which may signal a release of hazardous chemicals a leak or spill from a tank container truck or railroad car which may occur with or without accompanying Hazmat placards or labels and an unusual strong noxious or harsh odor in the area which can indicate the presence of harmful substances and may require immediate action to protect those nearby continuing with the identification of hazardous materials if you approach a scene where multiple individuals have collapsed are unresponsive or are experiencing respiratory distress you should assume that there's been a Hazmat leak or spill in still proven otherwise providers must understand the potential dangers associated with hazardous materials in order to operate safely at a Hazmat incident if you don't recognize the danger until you were too close to the scene it's imperative that you leave immediately to protect yourself from exposure no one should enter the affected area without the proper protective equipment respiratory protection and the necessary training to handle hazardous materials safely it's vital to avoid all contact with the material as even brief exposure can lead to serious health risks upon recognizing an incident involving hazardous materials immediately call for the HazMat team to ensure a professional response your focus should be on activities that prioritize the safety and survival of the greatest number of individuals affected by the incident utilize the ambulance's PA system to alert nearby individuals of the situation informing them to evacuate the area or take necessary precautions this proactive communication can help minimize exposure and enhance Public Safety additionally establish a perimeter around the scene to prevent traffic and pedestrians from entering the area this perimeter should serve as a protective barrier helping to contain the situation and uring that untrained individuals do not inadvertently expose themselves to the hazards present establishing control zones is an integral component of managing a hazardous materials incident these zones are defined based on the chemical and physical properties of the release material allowing responders to effectively manage safety and exposure risks control zones are typically labeled as hot warm or cold The Hot Zone is the area immediately surrounding the release and is considered the most contaminated Zone access to this area is restricted to train Personnel wearing appropriate protective equipment to prevent exposure to hazardous materials the warm Zone serves as a transition area where personnel and Equipment move in and out of The Hot Zone this is where decontamination procedures may be conducted and where Personnel can prepare to enter The Hot Zone Zone while still maintaining a safe distance the cold zone is important to note as it's the area where no contamination is expected and it's safe for unprotected Personnel this zone is typically used for command operations and staging of resources the level of PPE required at a hazardous materials incident indicates the amount and type of protective gear needed to prevent injury from specific substances PPE levels are categorized based on the hazards present with each level designed to offer varying degrees of protection depending on the chemicals properties and the potential exposure risks PPE is rated for its Effectiveness which is determined by its ability to protect against specific hazards such as chemical exposure biological agents or physical dangers this rating system helps responders select appropriate gear based on the identified risks associated with the incident ensuring the Personnel are adequately protected while performing their duties the Environmental Protection Agency or EPA defines specific levels of protection for PPE based on the type and degree of Hazards present in the Hazardous Materials incident these levels are categorized as follows level a protection requires a fully encapsulated chemical resistant garment providing the highest degree of protection against hazardous materials this would be used in situations where the greatest risk of exposure to Vapors gases or liquids exists level B protection necessitates chemical resistant clothing boots gloves and a self-contained breathing apparatus or SCBA this is appropriate when the chemical hazards are known and there is a potential for exposure to Vapors or gases but the exact nature of the substance is not fully determined level C protection requires standard work clothing in combination with chemical protective clothing and gloves this is suitable when the concentration and type of Airborne substances are known but there's no immediate threat of exposure Level D represents the low lowest level of protection requiring coveralls work shoes a hard hat gloves and standard work clothing this is appropriate for situations where there's minimal risk of exposure to hazardous materials caring for patients in the Hazardous Materials incident involves specific protocols to ensure safety and effective Medical Response responders should provide a simple assessment and essential care within the hazard Zone and decontam ation area recognizing that this care must be delivered while considering the potential risks associated with hazardous materials it's important to refrain from applying bandages or splints in the hazard Zone as these actions can complicate decontamination processes and expose responders to additional risks care of patients must specifically address any trauma that may have resulted from related mechanisms and injuries and harm resulting from exposure to hazardous substances which may include chemical burns respiratory distress or other health effects a significant concern in such situations is that most serious injuries and fatalities are often a result from Airway and breathing problems therefore maintaining Airway patency and ensuring adequate ventilation is critical the focus of patient care should be primarily on providing supportive care and initiating transport to a medical facility this approach prioritizes stabilizing the patient condition and facilitating their timely transfer to receive further medical attention Special Care Protocols are essential when managing patients exposed to hazardous materials ensuring both patient safety and the safety of medical responders Begin by cutting away all of the patients clothing and performing a rapid rinse to remove any contaminants from their skin this step minimizes further exposure to hazardous substances if you're treating and transporting a patient who has not been fully and properly decontaminated it's important to increase the amount of protective clothing you wear the decision to transport any patient with critical injuries ultimately rests with the IC this decision must consider the patient's condition potential hazards and available resources to facilitate itate the decontamination of ambulances after transporting the contaminated patient tape the cabinet door shut this precaution helps prevent contaminants from spreading within the ambulance making the cleanup process easier and ensuring a safer environment for future patients before loading the patient into the ambulance turn on the vent ceiling fan and the patient compartment air conditioning unit fan as this helps to ventilate the compartment reduce ining the concentration of any potential contaminants and improving air quality for both the patient and the responders as you leave the scene inform the Receiving Hospital that you were transporting a critically ill injured patient who has not been fully decontaminated this information allows the hospital staff to prepare adequately for the patient's arrival and ensure the necessary precautions are taken if sufficient ambulances are available at the Hazmat one ambulance may be isolated and designated solely for the transport of contaminated patients this isolation minimizes the risk of cross-contamination with other vehicles used for non-contaminated patients the ambulance must be decontaminated thoroughly before transporting another patient as this ensures any hazardous materials or contaminants are removed which safeguards the health of future patients",
        "Extrication and Hazardous Materials Summary": "extrication is a complex process that requires both mental and physical preparation with safety always taking precedence the primary roles of responders during this process include providing emergency medical care and preventing further injury to patients it's essential to deliver care while extrication is underway unless conditions are deemed too dangerous for either the responders or the patients involved in some cases responders may be tasked with performing simple extrication techniques when tools are not required especially for individuals trapped within the confined space the extrication process can be broken down into 10 distinct phases and if you were the first to arrive on the scene it may be necessary to call for additional resources such as extrication equipment fire service Personnel law enforcement and specialized rescue crews upon arriving at the scene report to the Incident Commander and coordinate efforts with the rescue team in law enforcement the rescue team is responsible for properly securing and stabilizing the scene or vehicle ensuring safe access to patients and executing the extrication process while providing adequate protection for the patients involved as a responder you carry significant responsibilities that include assessing and providing immediate Medical Care triaging patients packaging them for transport and then continuing further assessments as needed understanding Vehicle Safety Systems and being aware of the unique hazards posed by alternative fuel vehicles are vital responders must always wear proper personal protective equipment and then Retreat from the scene if there are any indications of danger such as unusual odors or physical symptoms recognizing hazardous materials is a critical skill for all First Responders who should remain at a high index of suspicion at all times times familiarity with the National Fire Protection Association 704 marking system can Aid in the identification of hazardous substances and their Associated risks First Responders at the awareness level must demonstrate competency in understanding what hazardous substances are recognizing their presence and identifying them accurately they should also be trained to determine the potential outcomes of these incidents involving these materials and understand their roles in the response effort the level of personal protective equipment required is determined by the type of hazardous materials present highlighting the importance of choosing the appropriate gear to prevent injury effectively by preparing for these scenarios comprehensively responders can ensure both their safety and that of the patients they serve"
    },
    {
        "Introduction to Patients with Special Challenges": "chapter 38 patients with special challenges many individuals with chronic diseases and long-term inuries reside at home or in environments outside of Hospital settings requiring ongoing management and Care among these patients with special Health Care needs are children born prematurely who may have respiratory complications and infants or small children with congenital heart disease requiring specialized cardiovascular care patients with neurologic conditions such as cerebral paly or traumatic brain injury they also require unique interventions While others live with congenital or acquired disorders that demand continuous medical attention those with sensory deficits such as visual or hearing impairments and geriatric patients managing chronic diseases like diabetes or heart failure also fall into this category as healthc care providers you may encounter both pediatric and adult patients who are reliant on devices such as mechanical ventilators for resp resp atory support IV pumps for medication administration or hydration and other LIF standing equipment in their daily management.",
        "Developmental and Intellectual Disabilities": "developmental disability refers to the insufficient development of the brain leading to varying degrees of dysfunction or impairment in cognitive motor or social abilities intellectual disability a subset of Developmental disability is characterized by limitations in cognitive functioning and adaptive Behavior resulting in difficulties with learning and social adaptation at a rate below the expected developmental milestones for age Developmental and intellectual disabilities may arise from a range of etiologies including genetic factors congenital infections birth complications malnutrition and environmental influences prenatal exposure to drugs or alcohol is is also a significant factor for the development of intellectual disabilities additionally other causes may present postnatally such as traumatic brain injury and poisoning clinically these patients May exhibit a range of characteristics including a slowed ability to understand limited vocabulary or immature behavior for their age they may also struggle with basic self-care communication understanding and response responsiveness to their environment furthermore they often have difficulty adapting to changes or disruptions in their routine which can further impact their ability to function and interact socially.",
        "Autism Spectrum Disorder": "autism spectrum disorder or ASD is a complex neurodevelopmental condition with a wide variation in signs and symptoms among affected individuals a primary feature of ASD is impaired social interaction often accompanied by significant behavioral challenges repetitive motor behaviors and impairments in both verbal and non-verbal communication individuals with autism frequently have difficulty making eye contact and may resist encouragement to do so often displaying discomfort in such situations they generally struggle with complex multi-step tasks and respond best to simple one-step instructions open-ended questions can be challenging for these patients to answer and they may confuse pronouns during conversation a subset of individuals with autism may be nonverbal sensory sensitivities are also common with many exhibiting heightened sensitivity to noise or physical stimuli Theology of autism remains unclear with no single explanation for its development although it is observed to occur five times more frequently in boys than girls despite their unique communication and behavioral challenges individuals with autism typically have medical needs similar to those of their neurotypical peers.",
        "Down Syndrome": "Down syndrome is a genetic condition caused by a chromosomal defect specifically when the two 21st chromosomes fail to separate properly during fetal development leading to an extra copy of chrom 21 a condition also known as trism 21 risk factors for Down syndrome include Advanced maternal age and a family history of the disorder individuals with Down Syndrome often present with a range of physical abnormalities although not all individuals will exhibit every characteristic these features may include a round head with a flattened oxop put an enlarged and protruding tongue slanted and WID set eyes and folded skin on either side of the nose other common traits are short wide hands a small face with proportionally small features and congenital anomalies such as heart defects and thyroid dysfunction hearing and vision problems are also prevalent in this population because many of these signs are visibly Apparent at Birth a diagnosis of down syndrome can often be be made promptly clinically individuals with Down Syndrome are at an increased risk for various medical complications a notable consideration is the potential instability of the cervical spine which can complicate area management and spinal precautions this instability particularly atlantoaxial instability or AI can Elevate the risk of neurological complications in the setting of trauma additionally managing the airway can be challenging due to anatomical differences making bag Mass ventilation difficult in cases of Airway obstruction a jaw thrust maneuver may be needed to ensure patency another common comorbidity is epilepsy with many individuals experiencing tonic clonic seizures.",
        "Interacting with Patients with Developmental Disabilities": "when interacting with patients who have developmental disabilities or Special healthc Care needs it's important to approach them as you would any other patient with respect and dignity however keep in mind that the patient may not immediately recognize that you were there to assist them particularly if they have communication difficulties or heightened anxiety to improve the interaction it is beneficial for team members to hold off on approaching until you have established Rapport by introducing yourself in a calm Manner and allow the patient to see and if appropriate touch the equip equipment before it's used this approach can help alleviate fear or uncertainty about your interventions throughout the assessment and treatment process work to soothe the patient's anxiety or discomfort by maintaining clear communication providing reassurance and being patient with any unique needs or concerns they may Express.",
        "Patients with Brain Injury": "patients with a brain injury can present unique challenges in assessment and treatment as our cognitive function communication abilities and behavior may be altered it's important to gather a thorough medical history from the patient family members or friends to gain insight into the patient Baseline function and any challenges that may have occurred when speaking with the patient maintain a calm soothing tone and be observant for any signs of anxiety or aggression as these can be triggered by the stress of the situation avoid expecting the patient to move independently to the ambulance or stretcher as this may be beyond their capabilities and could cause distress throughout the encounter ensure that the patient is treated with dignity and respect being mindful of their specific needs and comfort.",
        "Visual Impairment": "visual impairment can arise from a variety of causes including congenital defects diseases such as glaucoma or diabetes traumatic injuries infections or degenerative conditions affecting the eyeball octave nerve or Associated neural Pathways the extent of impairment can vary significantly ranging from partial loss of vision to complete blindness this may manifest as a loss of either peripheral or central vision and some patients May retain the ability to distinguish between light and dark or perceive General shapes and outlines recognizing visual impairment in a patient can sometimes be challenging it's important to be observant for any signs that suggest the patient may have difficulty seeing as this will affect how you communicate and provide care when interacting with a visually impaired patient immediately introduce yourself upon entering the room and have all team members do the same if the patient uses any visual aids such as glasses ensure these are retrieved and handed to them promptly always provide verbal updates to keep the patient aware of what is happening throughout your assessment and treatment as they rely heavily on auditory cues for context for ambulation the patient may use assistive devices such as a cane or Walker be sure to take these along if they are being transported in non-emergent situations any service animal should remain with the patient as these animals are an important part of their mobility and Independence if the patient is ambulatory and does not have a service animal they can be guided with a light touch on the arm or elbow or by resting a hand on your shoulder it's important to ask which guiding method the patient prefers guide them gently avoiding pulling or pushing and be sure to communicate any upcoming obstacles or changes in terrain to ensure safe navigation.",
        "Hearing Impairment": "hearing impairment can range from slight hearing loss to complete deafness affecting the ability to perceive pitch volume and Clarity of speech some individuals may learn to speak without ever having heard sounds and certain disease processes can influence U speech patterns leading to slurred words slow speech or a monotone delivery the most common forms of hearing loss include sensor neural deafness and conductive hearing loss sensor neural deafness resulting from nerve damage is the most prevalent type and may be caused by lesions or damage to the inner ear it's common among older adults who often experience varying degrees of this type of hearing impairment conductive hearing loss occurs when there is a problem with the transmission of sound waves through the ear canal causes can include an accumulation of ear wax fluid in the middle ear due to infection or allergies benign tumors or a perforated eard drum identifying clues that a patient might have a hearing impairment is important for effective communication and care these Clues include the presence of hearing aids poor pronunciation of words and a failure to respond appropriately to your presence or verbal questions when communicating with a patient who has a hearing impairment it's important to face them directly while speaking maintain a natural speaking manner without exaggerating lip movements and avoid looking away while talking ideally position yourself about 18 in directly in front of the patient as most hearing impaired individuals rely on body language and facial cues for better understanding avoid shouting as this does not enhance comprehension and may distort the sound further for patients who use American Sign Language or ASL consider if an interpreter is available or use alternative means of communication as needed a few practical tips to enhance communication include adjusting indoor lighting to ensure your face is visible speaking slowly and distinctly and maintaining clear one-on-one interaction providing paper and pencil can facilitate written communication if necessary and it's helpful to ensure only one person asks interview questions at a time to prevent confusion the reverse stethoscope technique where the patient listens through the earpieces while you speak into the diaphragm can also assist in amplifying sound for those who have some residual hearing ability.",
        "American Sign Language for Healthcare": "this figure illustrates common American Sign Language terms used to communicate about illness and injury which can be particularly helpful when interacting with hearing impaired patients the signs depicted include sick the sign for sick involves placing the middle finger of one hand on the forehead while placing the middle finger of the opposite hand on the stomach conveying a sense of feeling unwell hurt the sign for hurt is represented by holding both index fingers pointing towards each other and then twisting them as if indicating pain or discomfort in a specific location help the sign for help is made by placing a closed Fist and an open palm and then raising both hands slightly symbolizing the act of offering assistance these basic ASL terms can greatly enhance communication with patients who are hearing impaired ensuring clear understanding of their needs and symptoms.",
        "Hearing Aids": "hearing aids are devices designed to improve hearing and listening ability but do not restore hearing to normal there are several types of hearing aids each designed to meet different needs and preferences including behind the ear models conventional body types in the canal and completely in the canal versions in the ear devices and implantable options for those with less found hearing loss when working with the patient who uses a hearing aid allow the patient to insert the device themselves if they were able ensuring it follows the natural shape of the ear and fits snugly without Force if a whistling sound occurs after the hearing aid is turned on it may indicate that the device is not inserted far enough or that the volume is too high if you were unable to insert the hearing aid correctly after two attempts place it in its box and take it with you to the hospital it's important never to attempt cleaning hearing aids as they are delicate devices if the hearing aid is properly inserted but still not functioning several troubleshooting steps can be taken ensure the device is switched on replace the battery check the tubing for twists or bends and confirm the switch is set to M for microphone for conventional hearing aids try using a spare cord if available and inspect the ear mold to ensure it is not obstructed with ear wax.",
        "Cerebral Palsy": "cerebral paly is a physical disability characterized by impaired control of body movements often resulting in muscle stiffness uncoordinated movements and involuntary muscle contractions the condition can arise from a variety of causes including developmental brain defects occurring in utero traumatic brain injury or perinatal oxygen deprivation which can affect brain development additionally infections during the neonatal period or infancy as well as genetic factors May contribute to the development of cerebral pausy these etiologies can result in a wide range of motor and functional impairments which vary greatly among individuals with the condition individuals with cerebral pausy often present with a variety of symptoms in Associated conditions such as movements of the limbs and difficulty maintaining proper posture Visual and hearing impairments are common as well as communication challenges often due to uncontrolled movements and facial grimacing that make speech difficult to produce and understand epilepsy and intellectual disabilities are also frequently seen in this population Mobility varies significantly with some patients having limited movement and others utilizing motorized wheelchairs or other Mobility AIDS many individuals rely on technology to assist with daily activities such as computerized household controls speaking AIDS and devices for speech simulation to help communicate and perform tasks like temperature regulation and lighting control when providing care to a patient with cerebral pausy it's vital to assess the ABCs with particular attention paid to the airway patients may have increased production of secretions and dysphasia which can put them at risk for air Airway compromise in such cases aggressive suctioning may be required to clear the airway effectively and ensure adequate ventilation when treating patients with cerebral pausy do not make assumptions about their cognitive abilities not all individuals with cop paly have intellectual disabilities due to the underdevelopment of the limbs these patients are at an increased risk for fractures and other injuries additionally those who can ambulate May exhibit an unsteady gate making them more susceptible to Falls if the patient uses specialized equipment such as a custom pillow or chair they may prefer to use these during transport to maintain comfort and proper positioning providers should pad the patient appropriately to ensure comfort and avoid forcing the extremities into an unnatural position as this can cause pain or injury Walkers wheelchairs or other assisted devices should be transported along with the patient to maintain their mobility and Independence it's also important to recognize that approximately 25 to 35% of children with cerebral pausy have coexisting epilepsy which may require specific considerations during care and transport to manage potential seizures.",
        "Cystic Fibrosis": "cystic fibrosis is a genetic disorder characterized by excessive mucus production in the lungs and digestive system this leads to respiratory and gastrointestinal complications it's typically diagnosed in infants and young children and results from a defective recessive gene inherited from both parents parents with cystic fibrosis are also at a higher risk of developing Venus thrombosis pulmonary manifestations are common and include recurrent pneumonia spontaneous pneumothorax persistent cough respiratory distress and potentially respiratory failure patients with cystic fibrosis often experience malnutrition and poor growth due to difficulties in nutrient absorption caused by thickened mucus in the digestive tract this condition can lead to early mortality often due to Chronic pneumonia and Progressive lung damage these patients typically receive frequent or continuous antibiotic therapy to manage respiratory infections as well as other treatments aimed at improving lung function and aiding the removal of mucus such as chest physiotherapy nebulizers and Mechanical Devices it emerges Mercy Care maintaining a Payton Airway is Paramount providing supplemental oxygen and suctioning as needed to clear mucus secretions can be crucial to stabilizing the patient the use of humidified oxygen is particularly beneficial as it helps to thin mucous secretions and improve respiratory effort facilitating better gas exchange and easing the work of breathing.",
        "Multiple Sclerosis": "multiple sclerosis is a severe incurable degenerative disorder of the central nervous system characterized by demolin of neurons which disrupts neural communication while the exact cause is not fully understood there is evidence suggesting an interplay between genetic predisposition environmental influences and potential factors like nutrition or exposure to certain viruses Ms predominantly affects women with onset typically occurring in their 20s and 40s and it's more prevalent in women than men clinically patients with MS present with a range of symptoms primarily related to neuromuscular function including impaired muscle coordination altered muscle tone sensory disturbances and changes in Gate the disease is often characterized by episodes of exacerbation and remission with periods of improvement followed by relapses and disease progression given the extensive neurologic involvement patients May exhibit a wide array of signs and symptoms including visual disturbances fatigue and weakness due to the changes with mobility and positioning these patients are also at risk for skin breakdown and pressure ulcers while life expectancy for individuals with Ms may be normal the disease often leads to significant disability and impairment in Daily function due to its Progressive nature management of Ms includes a multifaceted approach involving medications such as immunomodulators corticosteroids and muscle relaxants physical therapy to maintain mobility and function and counseling to support mental health and coping strategies during patient assessment additional time may be necessary due to potential cognitive or communication barriers supportive measures play a key role and acute management which can include intravenous hydration for dehydration or medication administration analgesics for pain control muscle relaxing for spasticity careful positioning to prevent pressure sores and discomfort and when necessary assisted ventilation to support respiratory function.",
        "Muscular Dystrophy": "muscular distrophy encompasses a group of incurable genetic disorders characterized by the gradual prog aggressive degeneration of muscle fibers leading to increasing weakness and loss of function certain types of muscular distrophy may present with severe manifestations such as cardiomyopathy cognitive impairment and respiratory compromise specifically affecting patients overall health and quality of life to Shane muscular distrophy or DMD is the most common form and primarily affects males Pres in early childhood and progressing rapidly treatment is focused on supportive care as there is no cure this includes careful positioning to prevent contractures and pressure sores maintaining respiratory function through assisted ventilation when necessary and providing supportive treatment to manage symptoms and enhance the patient's quality of life.",
        "Spina Bifida": "spinal bifida is a congenital defect characterized by incomplete closure of the spinal column leaving a portion of the spinal cord exposed although surgical intervention can close the defect patients are frequently left with varying degrees of spinal and neurological damage this may result in partial or complete paralysis of the lower extremities as well as loss of bowel and bladder control a significant number of patients with spinal bifida also have a latex allergy making it important to use latex-free products during care and transport keeping latex free supplies on the ambulance is necessary to prevent allergic reactions and ensure the safety of these patients during medical interventions.",
        "Paralysis": "paralysis is a condition in which there is a loss of motor function in one or more parts of the body resulting from various causes including stroke trauma or congenital birth defects there are different types of paralysis each associated with specific patterns of motor impairment hopia involves paralysis of one side of the body which can result from a stroke or head injury affecting the arm and leg on the same side parapa is paralysis of the lower body typically caused by thoracic or lumbar spinal trauma or congenital conditions such as spinal bifida this results in impaired motor and sensory function below the level of injury quadriplegia also known as tetelia refers to paralysis affecting all four extremities in the trunk commonly resulting from cervical spine injury this condition significantly impairs both motor and sensory function and often affects respiratory muscles necessitating careful Airway and breathing management patients with paralysis often face several complications that require careful management dysphasia or the difficulty swallowing is common and places the patient at risk of choking or aspiration of food in liquids which can lead to respiratory issues or aspiration pneumonia paralysis affecting the respiratory muscles results in complete dependence on mechanical ventilation or other supportive devices for breathing due to prolonged immobility these patients are also at risk for developing decubitus ulcers or pressure sores which can be challenging to treat and prevent another significant risk is automatic disr flexia a life-threatening condition where a bodily stressor such as bladder distension or skin irritation triggers an exaggerated response from the autonomic nervous system causing a surge in catacol amines this can lead to dangerous spikes in blood pressure and other systemic effects requiring immediate intervention for patients with spinal cord injuries external devices such as Halo vests are often employed to immobilize the spine and prevent further injury ensuring stability while the body heals or to maintain alignment post surgery patients with paralysis often have impaired Thermo regulation making them particularly susceptible to environmental extremes such as heat and cold it's important to note that paralysis does not always involve a complete loss of sensation patients may still experience pain pressure or other Sensations in affected areas requiring careful assessment and gentle handling in cases of parismj juries maintain patient privacy while continuing to provide supportive care for patients with neurogenic bladder issues scheduled urinary catherization is often necessary to manage bladder function effectively and prevent complications when carrying for patients with quadriplegia total lifting assistance is required a gentle touch is imperative when lifting or moving these patients to avoid discomfort or injury additionally when establishing intravenous access or administering medications aim to use the non-affected side of the body whenever possible tox maximize comfort and Effectiveness for treatment.",
        "Obesity": "obesity is defined as having an excessive amount of body fat in the field of buiatrics focuses on understanding its causes prevention and treatment while the precise causes of obesity are not fully understood it's often associated with the low metabolic rate genetic predisposition and other factors such as diet and lifestyle clinically a person is categorized as obese when their body mass index is 30 or higher in the context of Emergency Care obesity poses several challenges Airway management is often more complicated due to anatomical differences such as a larger tongue larger head size and restricted neck Mobility making standard Airway procedures and bag mask ventilation difficult establishing peripheral intravenous access can also be problematic due to adapost tissue which may obscure veins additionally intramuscular injections require longer needles to reach the muscle tissue effectively as standard needles may not penetrate deeply enough oscilation of heart lung or bowel sounds is more challenging because excess body fat can obscure these sounds complicating diagnosis and assessment in a similar fashion assessing the extent of injury in bariatric patients can be difficult as body habitus May Mass signs of trauma or injury that are otherwise more apparent in non-obese patients when interacting with patients who have obesity it's important to approach them with sensitivity and respect these individuals may feel embarrassed or feel ridiculed often due to past negative experiences in healthc care settings to Foster trust and cooperation work to put the patient at ease by maintaining a non-judgmental and supportive attitude recognize that many patients with obesity have complex and extensive medical histories requiring thorough assessment and attention to detail if transport is necessary plan early and arrange for additional support to ensure safe and efficient movement a member of your team should be assigned to identify the safest and most except ible exit route to facilitate the transport process taking into account any physical barriers or equipment that's going to be needed to support the patients needs when interacting with patients with morbid obesity treat them with dignity and respect throughout the assessment and transport process before attempting to move the patient ask them how they prefer to be moved or positioned as they may have specific insights into what is most comfortable or safe avoid lifting by a single limb as this can cause discomfort and injury instead use a coordinated team approach to ensure safety and even distribution of weight communicate all planned movements clearly before starting any lift and if at any point the move becomes uncontrollable stop immediately reposition and then continue safely pay attention to any potential pinch or pressure points caused by by equipment straps gurns or other devices as these can cause pain or injury to the patient note that very large patients often have difficulty breathing while lying in a suine position so consider positioning alternatives to maintain respiratory Comfort many manufacturers offer specialized equipment such as bariatric stretchers and wheelchairs which can facilitate safe transport for both the patient and the lifting team plan egress routes carefully to accommodate the patient size the necessary equipment and the lifting crew lastly notify the receiving facility early to ensure that they are prepared for the patients arrival and any special needs that may arise during transfer.",
        "Tracheostomy Tubes": "tracheostomy tubes are plastic tubes inserted into a sto a surgically created opening in the neck to facilitate breathing brething these tubes can be either temporary or permanent depending on the patient's medical condition at tracheostomy is commonly placed in patients who require long-term Airway support such as those who depend on home ventilators or have chronic pulmonary diseases in cases where the linic have been surgically removed a procedure known as a laryngectomy the patient will no longer be able to produce normal speech and must learn Al alternative communication methods these may include swallowing and regurgitating air from the stomach to produce sound or using assistive devices specifically designed for speech it's important to avoid introducing any liquids into the stom as this can lead to aspiration and respiratory complications care should be taken to keep the tracheoscopy tube clear and ensure it remains functional particularly for patients reliant on mechanical ventilation are those with chronic respiratory conditions obstruction of a trick ostomy tube is a life-threatening emergency that requires immediate assessment and intervention a helpful memonic to remember during such situations is dope which stands for displacement or dislodgment of the tube obstruction of the tube which could be caused by mucus plugs or other blockages Numa thorax indicating a potential collapse of the lung and Equipment failure meaning any malfunction or problem with the ventilator or oxygen source when faced with the tracheostomy emergency promptly assess Airway patency by ensuring the tube is properly positioned in clear of obstructions evaluate the flow of oxygen ensuring it is sufficient to meet the patient's needs if any issues are identified take steps to resolve them quickly as maintaining a clear and function Airway is Paramount for the patient survival.",
        "Home Oxygen Therapy": "home oxygen therapy is often used by patients with chronic lung diseases such as COPD to manage their respiratory needs there are two main types of home oxygen Delivery Systems Compressed Gas cylinders and oxygen concentrators Compressed Gas cylinders are similar to those found on ambulances but typically come in smaller more portable versions they are advantageous in that they do not require electricity or complicated Machinery to operate however they have limitations such as restricted portability a finite oxygen supply and their heavy cumbersome nature which can make transport challenging oxygen concentrators work by removing nitrogen from the air to provide a concentrated supply of oxygen the compression capability varies by machine but most concentrators generally deliver up to 10 L per minute of oxygen these devices can supply an unlimited amount of oxygen provided there is a continuous power source smaller portable versions of concentrators are available typically delivering 1 to 3 lers per minute making them more manageable for patients who need to maintain Mobility these devices enable patients to receive constant oxygen therapy while performing daily activities.",
        "Mechanical Ventilators": "mechanical ventilators are used for patients who require respiratory support and may lack an adequate or functional respiratory drive when assessing a patient on a mechanical ventilator it's important to observe their chest for synchronized movement with the ventilator Cycles proper synchronization indicates that the ventilator is functioning correctly and the patient is receiving adequate ventilation any asynchrony such as paradoxical movement or visible signs of distress may suggest ventilator malfunction or patient ventilator D synchrony requiring prompt evaluation and intervention to ensure effective respiratory support remember worst case scenario if the ventilator is malfunctioning you can unhook the patient from the ventilator and utilize a bag valve mask to effectively ventilate the patient manually a tracheostomy collar is an oxygen delivery device designed specifically for patients with tracheostomies allowing them to receive supplmental oxygen through their stom for patients using home mechanical ventilators it's important to provide assisted ventilation consistently throughout transport to ensure their respiratory needs are met when caring for these patients avoid making any adjustments to the ventilator settings unless you are specifically trained and credentialed to work with that particular model as improper adjustments can compromise patient safety and ventilation.",
        "Apnea Monitors and Pacemakers": "apnea monitors are often used for infants born prematurely typically for a duration of 2 weeks to two months after birth these devices are designed to alert caregivers by sounding an alarm if the infant experiences episodes of bradicardia or apnea the monitor is attached to the infant using electrodes or a belt wrapped around the chest or stomach to detect respiratory and heart rate changes in case of an event parents may be able to provide a computerized print out from the monitor which can be helpful for medical evaluation and determining the infant's condition internal cardiac pacemakers are devices implanted Under the Skin to regulate heart rate typically placed on the non-dominant side of the chest to minimize interference with daily activities some of these pacemakers may also incorporate an automated implanted cardioverter defibrillator or aicd to detect and correct lifethreatening arrhythmias when using external defibrillators or pacing patches it's critical never to place the paddles or patches directly over the pacemaker or aicd as this can damage the device and affect its function.",
        "Left Ventricular Assist Devices": "left ventricular assist devices or Lads are mechanical pumps designed to take over the function of one or both heart ventricles providing circulatory support for patients awaiting heart transplantation as a bridge to transplant or as a permanent solution for those who not qualify for a transplant when assessing a patient with an elad osculate the chest for a hum which indicates that the device is working properly if no hum is heard but the patient shows signs of circulation begin troubleshooting the device by looking for an alarm code checking all cables and connections verifying the power supply and contacting the manufacturer support line for assistance if needed it's also important to transport the patient's go bag which contains essential equipment and supplies for the elad be aware that patients with El vads are at an increased risk for complications such as excessive bleeding infection thromboembolism and acute heart failure it's also notable that these patients may not have a palpable pulse despite adequate circulation due to The Continuous Flow nature of the device in all situations involving elv ads promptly contact medical control or follow your local protocols to ensure proper placement.",
        "External Defibrillator Vests": "an external defibrillator vest is a wearable device that contains built-in monitoring electrodes and defibrillation pads to detect and treat life-threatening arrhythmias it's connected to a monitor that provides alerts and voice prompts to the patient and caregivers regarding its status and upcoming shocks if the device warns that it's about to deliver a shock avoid any contact with the patient to prevent accidental injury in the event of cardiac arrest the vest should remain in place during CPR as it may still be able to monitor the patient Rhythm and deliver necessary shocks while resuscitative efforts are ongoing.",
        "Intra-Aortic Balloon Pumps": "intraaortic Bloom pumps or iabps are used for patients experiencing cardiogenic shock structural heart abnormalities myocardial infarction are those recovering from cardiac surgery these devices function by decreasing myocardial oxygen demand reducing cardiac workload and improving systemic circulation as a health care provider in an emergency setting you will never be solely responsible for the care of a patient with an iabp as they require specialized management and monitoring however it's important to note that the device is bulky and can be challenging to move and properly secure within an ambulance during transport requiring careful planning and assistance to ensure a safe transfer.",
        "Central Venous Catheters": "Central Venus catheters are typically placed in the chest upper arm or subclavicular area to provide long-term access for medication administration fluid therapy or other treatments patients with these catheters have an increased risk of cardiovascular complications such as infection clot formation or bleeding before moving a patient with the central Venus catheter it's important to thoroughly inspect and secure all external components of the device to prevent dislodgment or damage during transport.",
        "Gastrostomy Tubes": "gastrostomy tubes also known as gastric tubes or G tubes are surgically placed through the abdominal wall to provide direct access to the stomach for nutrition fluids or medication patients with G tubes remain at an increased risk for aspiration so during transport they should be positioned either sitting or lying on their right side with the head elevated about 30\u00b0 to reduce this risk supplemental oxygen should be provided as needed based on the patient's respiratory status if the the G tube is functioning properly and has not been dislodged or even partially dislodged tube feedings can continue as normal and the feeding pump should be transported with the patient to ensure uninterrupted care.",
        "Shunts for Hydrocephalus": "shunts are medical devices implanted for patients with chronic neurologic conditions such as hydris this prevents the buildup of excess cerebral spinal fluid in the brain for hydris patients shunts extend from the brain to either the abdomen or the heart where the excess CSF is drained a ventricular peritoneum shunt diverts fluid from the brain's ventricles into the peritoneal cavity while a ventricular Atrium shunt directs fluid into the right atrium of the heart these shunts are designed to regulate intracranial pressure and prevent fluid accumulation in the brain during a physical assessment you may palpate a fluid reservoir which is a component of the shunt located beneath the skin on the side of the head often behind the ear complications from a shunt can arise if it becomes blocked or infected patients May exhibit changes in mental status and respiratory arrest is possible if the issue is not addressed promptly infections commonly occur within the first two months following shunt insertion and can lead lead to an increase in intracranial pressure which presents as a headache along with vomiting lethargy or other neurologic symptoms patients with shunt complications May exhibit various signs of distress indicating increased intracranial pressure or infection these signs include bulging font nails and infants headache projectile vomiting altered mental status irritability a high-pitch cry in children fever nausea difficulty with coordination blur Vision seizures and redness along the shunt track additionally cardiovascular signs such as bardia and heart dysrhythmias may occur in such situations Prompt Care is essential treatment priorities include Airway management and providing artificial ventilation if necessary while ensuring rapid transport to a facility equipped to evaluate and manage shunt complications.",
        "Vagus Nerve Stimulators": "Vegas nerve stimulators are devices used to control seizures in patients who do not respond to anti-epileptic medications or are not suitable candidates for brain surgery these stimulators are used in conjunction with medication to reduce the frequency and severity of seizures but are not intended as a replacement for medication typically they're not used in Children Under 12 the stimulator is surgically implanted under the patient's skin usually in the chest area and connected directly to the vagus nerve once in place the device can function for up to six years or until the battery is depleted providing consistent neurom modulation to help control seizure activity.",
        "Colostomies, Ileostomies, and Urostomies": "colostomies ostomies in urostomies are surgical procedures that create openings to the body surface to divert bodily waste a colonostomy involves creating an opening between the colon and the surface of the body to allow stool to exit directly into a collection bag an ostomy is similar but involves the ilium the last part of the small intestine providing a different route for waste removal for patients who have undergone these procedures it's important to assess for signs of dehydration especially if they report diarrhea or vomiting as this can lead to fluid and electrolyte imbalances maintaining strict daily hygiene is critical for patients with these stoas to prevent infections and ensure the proper function of their ostomy equipment a urostomy is another type of procedure connecting the urinary system directly to the surface of the skin allowing urine to be excreted into a collection device each type of stom requires diligent care to maintain patient health and comfort.",
        "Home Care and Hospice Care": "when assessing a patient it's important to start by obtaining Baseline Vital Signs and gathering information on allergies medications and any other relevant medical history determine the patient's normal Baseline status to better understand their condition and how it may differ from their current state utilize short and simple questions avoiding complex language to ensure clear communication additionally pointing out specific body parts while asking questions can help facilitate understanding especially for patients with communication difficulties or cognitive impairments Home Care encompasses a wide range of services for patients with various Health Care needs including infants older adults individuals with chronic illnesses and those with developmental disabilities the services provided can vary greatly and may include meal delivery house cleaning laundry yard maintenance physical therapy and personal care in many cases it's the Home Health provider who discovers the patient's injury or notices a change in their health status these Personnel can be a valuable resource for gathering information about the patient Baseline Health as well as any recent changes in relevant medical history when responding to such situations it's important to obtain any necessary Health Care documentation such as medical records or care plans as well as current medications to ensure a comprehensive understanding of the patient's condition and needs Hospice Care is designed to provide Comfort or Pala of care for terminally ill patients during their final days which may occur in a hospice facility or at home the focus of this care is not Curative but aims to enhance quality of life and alleviate discomfort for patients with conditions such as cancer Heart and Lung failure in stage Alzheimer's disease and acquired immuno deficiency syndrome or aids for terminally ill patients the primary goal is supportive care these patients May rely on a range of pain medications and management devices tailored to address their specific symptoms and maintain comfort when providing emergency care for hospice patients it's often necessary to consult medical direction to ensure that interventions align with the patient's end of life care plan and do not inadvertently cause distress or contradict their wishes when called to a facility providing hospice care it's important to adhere to local protocols respect the patient's wishes and review any legal documents such as a DNR living will or a durable power of attorney while DNR orders often require withholding life sustaining treatment in the event of cardiac or respiratory arrest they do not prude all forms of Care Hospice patients should still receive appropriate pain management supplemental oxygen nutrition and hydration is needed to maintain comfort and dignity even with a DNR in place family members May struggle to understand what to do or may not be emotionally prepared for the death of their loved one in such cases take a thorough history and discuss the patient's wishes with the family compassionately always review the DNR order carefully and contact medical control to ensure that you are acting within the patient's care plan and legal requirements if called to a scene where death is imminent show compassion understanding and sensitivity recognizing that the situation may be chaotic or emotionally charged clarify the family's wishes regarding transport if a family member wishes to accompany the patient accommodate this request if it's within your policy to do so if the family prefers for the patient to remain at home honor this preference as long as it aligns with local or state protocols in all situations involving hospice or terminally ill patients follow local protocols and policies for managing the patient's care and handling endof life circumstances appropriately.",
        "Impact of Poverty and Homelessness on Health": "poverty has a profound impact on health and well-being as individuals and families struggling to meet the basic needs often face barriers to essential resources like stable housing nutritious food health care and medications the inability to afford adequate Child Care can hinder parents' ability to work or pursue education perpetuating the cycle of poverty Additionally the lack of health insurance makes accessing Medical Care challenging forcing many to delay or forego preventative Services and treatments for ACC in chronic conditions this can exacerbate Health disparities increase the risk of complications and ultimately result in more severe Health outcomes when poverty leads to homelessness the challenges become more complex homeless individuals often experience environmental and social conditions that further compromise their health including exposure to extreme weather limited sanitation C crowded shelters and a higher risk of trauma and violence these factors make it difficult to manage existing health conditions or recover from illnesses homelessness also limits Access to Health Care Services due to lack of Transportation identification or Insurance creating obstacles to receiving Primary Care Mental Health support and Social Services as a healthcare provider provider is essential to advocate for patients rights and ensure they receive appropriate care this includes providing emergency medical treatment and transporting patients to an appropriate facility for further assessment and Care under the emergency medical treatment and active Labor Act or mtala all healthc care facilities are required to offer a medical assessment in any necessary treatment regardless of the patient's ability to pay or their insurance status in addition to Emergency Response the role of EMS May extend to providing a broader range of services such as telephone advice for 911 callers preventative care chronic disease management and follow-up care post discharge.",
        "Conclusion and Overview of Special Challenges": "this lecture focuses on patients with special challenges covering various conditions and their impact on Healthcare delivery it begins with developmental disabilities such as intellectual disabilities and autism spectrum disorder describing their causes symptoms and considerations for care we then discuss Down syndrome detailing its physical characteristics and potential complications followed by the principles for interacting with patients who have these disabilities particularly emphasizing a respectful and patient- centered approach further we discuss sensory disability including Visual and hearing impairments outlining communication strategies and patient care techniques this presentation also addressed complex conditions like cerebral palsy cystic fibrosis multiple sclerosis muscular distrophy spinal bifida and paralysis discussing their causes symptoms and specific care considerations additionally this lecture delves into obesity exploring the challenges in clinical management and transport followed by an overview of patients using Medical Technology assistance this includes tracheostomy tubes mechanical ventilators apnea monitors pacemakers Lads and more key assessment guidelines and considerations for patients receiving home and hospice care as well as those affected by poverty and homelessness were presented to ensure a comprehensive understanding of diverse patient needs and Care approaches"
    },
    {
        "Introduction to Communication in EMS": "chapter 4 Communications and documentation communication is the transmission of information to another person effective communication is required in prehospital care ensuring accurate relay of patient information and interventions a robust EMS Communication System connects team members with EMS fire and law enforcement facilitating coordinated emergency responses additionally excellent communication is essential for transferring patient care information to hospital staff ensuring continuity and quality of care and ultimately improving patient outcomes verbal communication skills are vital for advanced emergency medical technicians as they enable effective information gathering from patients and bystanders during emergencies essential for assessing conditions and determining interventions proficient communication facilitates seamless coordination with EMS Personnel firefighters and law enforcement ensuring clear instruction and cohesive response strong listening skills are also a key component allowing providers to fully understand the emergency scene and patient issues thus verbal communication including speaking and listening is integral to aemts for efficient information exchange and optimal patient care",
        "Documentation in Patient Care": "documentation in patient care involves the written or electronically recorded portion of patient interactions which become part of the patient permanent medical record this includes detailed reports such as the patient care report or PCR or prehospital care report which are required for communicating the patients's medical history and treatment to other healthc care profession Prof involved in their future care such documentation should be completed only after the patient's condition has been stabilized to ensure accuracy and thoroughness adequate reporting and precise recordkeeping ensures the continuity of patient care allowing for seamless Transitions and informed decision-making by all subsequent Health Care Providers complete patient care records ensures the proper transfer of responsibility from one provider to another guaranteeing the patient care is continuous and that all relevant information is communicated effectively these records must also comply with the requirements of Health departments and law enforcement agencies meeting legal and Regulatory standards for accuracy completeness and timeliness additionally maintaining comprehensive patient records fulfills the administrative needs of healthcare organizations supporting billing resource management and quality assurance processes",
        "Radio and Telephone Communications": "radio and telephone Communications link you and your team to other members of the EMS fire and law enforcement communities facilitating coordinated responses to emergencies providers must understand the capabilities and limitations of their Communications system including its range Clarity and potential interference issues additionally knowing how to use the system efficiently and effectively is vital as this ensures timely and accurate information exchange Mastery of these communication tools enhances inter agency collaboration and the overall effectiveness of Emergency Response operations",
        "Therapeutic Communication": "therapeutic communication involves the art and skill of engaging with individuals during some of the most challenging moments of their lives it employs a range of communication techniques and strategies both verbal and non-verbal to encourage patients to articulate their feelings and Foster a positive relationship between the patient and the healthc care provider effective therapeutic communication recognizes that people communicate through various means including eye contact body language and facial expressions it requires sensitivity to cultural and age related differences ensuring that communication is tailored to each patient's unique context for patients with special needs alternative communication methods may be necessary to elicit genuine expressions of concerns or problems from patients healthc care providers must demonstrate a sincere interest in listening this involves giving patients undivided attention and actively listening rather than simply talking to ensure they feel heard and understood this builds trust and facilitates an open dialogue",
        "Cultural and Personal Influences on Communication": "age culture and personal experience play significant roles in shaping an individual's thoughts and communication style social and personal influences impact how people perceive and express their emotions with some cultures encouraging open expression of feelings related to illness and injury while Others May view such Expressions as signs of weakness culture and personal experience also affect communication patterns including the tone pace and volume of speech which can indicate the communicator's mood and the importance of the message body language and eye contact are culturally influenced as well for example in some cultures direct eye contact is considered imp polite whereas in others avoiding eye contact while speaking is frowned upon nonverbal communication differences include gestures such as placing the hands on the hips which is seen as hostile in Mexico and Argentina in cultural practices like avoiding the use of the left hand in Islamic Hindu Traditions additionally many Asian African Latin American and Caribbean cultures avoid direct eye contact to show respect while prolonged eye contact is seen as a sign of honesty in Somalian and Brazilian cultures slouching is regarded as rude in Japan and in northern Europe ethnocentrism which is the belief belief in the superiority of One's Own cultural values often leads to misinterpretations as people filter messages through their own cultural lens cultural imposition which is an extreme form of ethnocentrism occurs when healthc care providers consciously or subconsciously impose their cultural values on patients believing their own values to be superior this practice can hinder effective Comm communication as well as Health Care by failing to respect and accommodate the cultural values and practices of patients",
        "Nonverbal Communication": "nonverbal communication encompassing facial expressions body language and eye contact plays an important role in patient interactions body language often conveys more information than verbal communication alone providing insights into a patient's emotional and physical state even without verbal exchange healthc care providers should be able to discern the mood and condition of their patients through non-verbal cues attention to body language both that of the provider and the patient allows for effective communication recognizing and interpreting physical cues accurately enhances Mutual understanding which fa facilitates better patient care and ensures that the messages being conveyed are fully comprehended by both parties",
        "Physical Factors in Communication": "physical factors significantly influence communication Effectiveness in the healthc care setting noise including literal noise and other environmental factors such as poor lighting distance and obstacles can obscure the true meaning of a message making it difficult for patients and providers to understand each other proxemic which is the study of space and distance and communication highlights that appropriate distance varies based on the level of trust and intimacy between individuals as one moves closer to another person especially into their intimate space a greater sense of trust must be established for someone who is sicker injured and may be scared and confused nonverbal cues such as gestures body movements and overall demeanor become crucial in gaining and maintaining the trust of both the patient and their family",
        "Verbal Communication Techniques": "skilled verbal communication with patients their families bystanders and the healthc care team assists in providing in highquality patient care it requires the ability to organize thoughts swiftly and accurately to deliver clear instructions to all involved parties a fundamental responsibility of the aemt is to ask patients questions to gather information open-ended questions which encourage detailed responses should be used whenever possible such as asking what seems to be bothering you conversely close-ended questions which are suitable for obtaining brief or single word answers can be useful when patients are unable to provide longer responses as in asking are you having trouble breathing these questioning techniques facilitate effective communication ensuring comprehensive patient assessment and care coordination here we see some examples of open and close ended questions other types of questions that can reveal underlying issues include specific targeted inquiries devised by aemts in the field these questions are designed to uncover hidden concerns in emotional states that may impact patient care examples include asking have you ever felt like this before to understand if the current condition is recurrent and have you been upset about anything lately to identify recent stressors inquiring are you afraid of someone should be reserved for private settings like the ambulance to ensure both your safety and the patients as well as their confidentiality questions such as have you been thinking about hurting yourself help assess for potential self harm risks while what happened last time you felt this way helps in understanding past experiences and their outcomes these questions provide deeper insights into the patient's mental and emotional health",
        "Communication Tools and Techniques": "there are many powerful communication tools you can use when trying to obtain information from patients facilitation is encouraging the patient to talk more or provide more information silence gives the patient space and time to think and respond by not speaking reflection restates the patient statement to confirm your understanding empathy is being sensitive to the patient's feelings and thoughts clarification is asking the patient to explain what they meant by an answer confrontation is making the patient who is in denial or in a mental State of Shock focus on urgent and life critical issues interpretation sums up the patient's complaint to confirm your understanding explanation provides factual information to support a conversation and the summary provides the patient with an overview of the conversation and the steps you will be taking when interviewing a patient consider the careful use of touch to show caring and compassion touch is a powerful tool and it can provide Comfort reassurance and a sense of connection however it should be used consciously and sparingly to avoid discomfort or misinterpretation appropriate use of touch such as a gentle hand on the shoulder or a light touch on the arm can convey empathy and support enhancing the therapeutic relationship and fostering trust being mindful of cultural differences and individual preferences ensure that the use of touch is received positively and contributes to the patient's overall sense of well-being",
        "Avoiding Communication Pitfalls": "when conducting patient interviews it is important to avoid certain techniques that can hinder effective communication and Trust providing false Assurance or reassurance can undermine credibility and lead to unrealistic expectations giving unsolicited advice may appear presumptuous and disre regard the patient's autonomy asking leading or biased questions can influence responses and compromise the accuracy of the information gathered talking too much can overshadow the patient's opportunity to share important details while interrupting the patient can disrupt their thought process and convey a lack of respect using why questions can seem confrontational and provoke defensiveness employing authoritative language can create a power imbalance and discourage open dialogue lastly speaking in a professional jargon can confuse patients and obscure the intended message by avoiding these techniques Healthcare Providers can foster a more effective and empathetic communication environment",
        "Role of Family and Bystanders": "the presence of family friends and bystanders can be valuable during the patient interview process as they may provide additional context and support however the provider should allow the patient to answer questions independently if they are capable and willing even if well-meaning family members attempt to respond on their behalf in situations where the presence of Others May impede open communication or cause discomfort healthc care providers should not hesitate to ask them to step aside temporarily additionally it's important to assess whether the presence of family and friends will alleviate or exacerbate the patient's anxiety adjusting the environment accordingly to ensure the most effective and comfortable communication balancing these considerations helps to maintain patient autonomy and optimizes the accuracy and quality of the information obtained",
        "Golden Rules for Patient Interaction": "to help calm and reassure a patient adhere to several golden rules maintain eye contact to show attentiveness and build trust establish a rapport by watching your inflection responding appropriately to the patient anticipating and addressing their fears respecting their experience of pain and protecting their modesty in introduce yourself and address the patient by their proper name to personalize the interaction always tell the truth to maintain credibility and Trust use language that the patient can easily understand to ensure communication be mindful of what you say about the patient to others as careless remarks can cause dist stress pay attention to your body language as it can convey reassurance or anxiety speak slowly clearly and distinctly to avoid misunderstandings if the patient has difficulty hearing face them directly so they can read your lips allow the patient ample time to answer or respond to your questions demonstrating patience and understanding finally act and speak in a calm confident manner to provide a sense of stability and competence during their care",
        "Emotional Intelligence in Healthcare": "emotional intelligence is the capacity to recognize understand and manage one's own emotions as well as to accurately perceive and appropriately respond to the emotions of others often referred to as people skills emotional intelligence and enables providers to diffuse conflicts by remaining calm and empathetic build a strong rapport with patients and their families and enhance overall communication Effectiveness by understanding and managing emotional Dynamics aemts can navigate and control stressful and challenging situations more effectively ensuring a more supportive and therapeutic interaction with their patients emotional intelligence is commonly understood to Encompass five key attributes self-awareness is the capacity to recognize one's own emotions and understand how they influence thoughts and behaviors self-regulation involves controlling impulsive emotions and behaviors and managing emotions constructively motivation refers to the ability to inspire oneself and others towards positive actions often prioritizing long-term success over immediate gratification empathy is the ability to understand and share the feelings of others by interpreting communication and social cues social skills are essential for developing and maintaining positive relationships through effective communication to enhance your emotional intelligence consider the following tips assess how you react to stressful situations and practice mindfulness take responsibility for your actions and think about the impact of your actions on others before you proceed the five-step behavioral change stairway model can further improve communication",
        "Managing Difficult Patients": "communicating with difficult patients require specific strategies to manage potential hostility or defensiveness towards healthc care providers patients in distress may act aggressively and providers must diffuse escalating situations by maintaining a calm demeanor open and honest communication helps build trust and reduce tension utilizing open-ended questions encourages patients to express their concerns more fully while positive feedback can help reassure them the safety of the scene must always be a priority and calling for law enforcement backup may be necessary in volatile situations it is important to never threaten the patient as this can exacerbate hostility and never to respond in kind threats or insults from the patient as maintaining professionalism is crucial for deescalation and effective care",
        "Communicating with Older Adults": "when communicating with older adult patients it's important not to assume that it will be more difficult than communicating with younger individuals do not presume that an older adult is scile or confused without evidence providers should exercise patience and compassion approaching the patient slowly and calmly to avoid causing unnecessary stress allow ample time for the patient to respond to questions as they may need more time to process information and articulate their thoughts older adult patients must have different physiological responses compared to younger individuals they may not feel pain as a cutely and might be unaware of significant changes in their body systems therefore Healthcare Providers must be vigilant in observing objective changes in the patient's condition as these May provide much needed information that the patient cannot convey understanding these nuances ensures that older adult patients receive the respectful and attentive care that they need",
        "Communicating with Children": "communicating with children in a medical setting presents unique challenges children can be difficult patients due to several factors they pose communication challenges as they may have limited vocabulary or understanding they are very likely to be frightened by the unfamiliar environment and situation they tend to protest pain vigorously they may be afraid of strangers including Healthcare Providers and they can panic when separated from their parents additionally their bodies may not be as familiar to Health Care Providers as those of adults making assessment and treatment more challenging in initial interactions with children the use of medical equipment is less important than establishing trust through friendly eye contact smiles and calm subdued explanations providers should discipline themselves to minimize their movements lower their voice and touch the child as gently as possible to avoid causing additional fear or discomfort placing oneself at or below the child's eye level can also help in making the child feel more at ease and fostering better communication",
        "Involving Parents in Pediatric Care": "involving a parent in the Hands-On care of an alert small child can significantly enhance the child's comfort and cooperation during medical assessments or treatments this approach leverages the parent presence to provide reassurance and emotional support helping the child feel more secure when caring for noncritical Pediatric patients demonstrating the assessment procedure such as taking blood pressure on a sibling or a parent can also help put the child at ease this allows a child to become familiar with the procedure through observation of a trusted individual and can help reduce fear and anxiety Additionally the use of toys can be highly effective for Bridging the emotional gap between the aemt and the young patient toys can distract and engage the child providing a sense of normaly and comfort and creating a more positive interaction environment these techniques collectively contribute to a more effective and compassionate approach to Pediatric Care",
        "Honesty and Clarity with Children": "when communicating with children in a medical setting honesty is Paramount as children can easily detect lies or deception which can erode trust and increase anxiety it is important to tell the child ahead of time of a treatment or procedure that will cause pain as this prepares them mentally and fosters trust respecting the child's modesty ensures that they feel secure and dignified during examinations or treatments additionally clearly explaining what you were doing and why you were doing it helps demystify the medical process and reduces fear by by providing simple age appropriate explanations healthc care providers can help the child understand the necessity of the procedures and feel more in control which can significantly alleviate their apprehension and improve cooperation",
        "Communicating with Hard of Hearing Patients": "heart of hearing patients are typically not ashamed or embarrassed by their disability and possess normal intelligence allowing them to understand what is happening around them many of these patients can read lips to some extent so it's important to position yourself so the patient can see your lips maintaining social distancing is important especially when not wearing a mask and using a mask with a clear window can facilitate lip reading additionally hearing aids are essential for many heart of hearing patients the provider should ensure that they are not lost during an accident or fall and are not forgotten always look around for hearing aids or ask the patient or their family about them to ensure the patient's ability to hear is maximized this careful attention to communication needs can significantly enhance the care and comfort of Heart of hearing patients to effective communicate with patients who are hard of hearing several steps should be followed firstly always have paper and Pen available for written communication if necessary if the patient can read lips ensure you face the patient directly and speak slowly and distinctly to enhance their ability to understand you it's important to never shout as raising your voice can distort speech and make it more difficult for the patient to comprehend hand additionally practice active listening by paying close attention to the patient responses asking short and clear questions and providing concise answers learning some simple phrases in Sign Language can significantly enhance communication with patients who are hard of hearing familiarizing yourself with basic signs such as sick hurt and help can facilitate more effective interactions and ensure that important information is conveyed accurately these key phrases can assist in assessing the patient's condition quickly and responding appropriately to their needs incorporating sign language into your communication repertoire not only improves patient care but also demonstrates respect and inclusivity towards patients with hearing impairments",
        "Communicating with Visually Impaired Patients": "when communicating with visually impaired patients it is important to first ask if they have any Vision as many visually impaired individuals are not completely blind and may retain some degree of sight visually impaired patients typically have normal intelligence so their cognitive abilities should not be underestimated throughout the interaction provide detailed explanations of everything you were doing as you do it this continuous verbal communication helps the patient understand what is happening and reduces anxiety helping them remain informed and comfortable during the medical procedure by addressing their specific needs in providing clear descriptive communication providers can offer more effective and Compassionate Care to visually impaired patients when when beginning care for a visually impaired patient it is important to maintain physical contact to provide reassurance and orientation this tactile connection can help the patient feel secure and aware of your presence which helps in reducing anxiety and facilitating cooperation additionally when transporting the patient to the hospital ensure that their Mobility AIDS such as a cane accompany them these AIDS are essential for their independence and navigation and having them readily available at the hospital ensures the continuity of care and their Mobility once they arrive this approach not only addresses their immediate medical needs but also respects their autonomy and comfort",
        "Guide Dogs and Service Animals": "guide dogs or service animals easily identified by their special harnesses the these dogs are specifically trained to remain with their owners and not respond to strangers ensuring their primary focus is on assisting their Handler if the patient is alert they can provide valuable information about the dog's needs and care instructions whenever possible the guide dog should be transported with the patient to maintain their support system and reduce stress for both the dog and the patient if transporting the dog is not feasible alternative Arrangements should be made to ensure the dog is cared for appropriately maintaining the welfare of both the patient and their service animal",
        "Communicating with Non-English Speaking Patients": "when caring for non-english-speaking patients a provider should still obtain a medical history despite the language barrier utilize short simple questions and straightforward words to facilitate understanding pointing to parts of the body can also help in communication learning some common words or phrases in the prevalent languages of your area can be beneficial pocket cards that display the pronunciation of medical terms can Aid in effective communication if the patient does not speak any English use a smartphone app or website it for translation or find an interpreter in emergencies a family member or friend may need to assist with translation additionally request a translator at the hospital while providing the radio report allowing for the continuity of care and accurate communication of the patient condition and needs",
        "Communicating with Special Needs Patients": "when caring for special needs patients do not Overlook the needs of those with speech or communication disorders engaging family members and primary caregivers who are familiar with the patient can significantly AG your efforts as they can provide valuable insights and assistance utilizing touch and eye contact can serve as effective bridging mechanisms to facilitate communication patients with autism May struggle with developing language skills in non-verbal communication if you encounter difficulties in communicating with a patient with autism it is advisable to direct your questions to their caregiver who can offer guidance and help ensure accurate information exchange this approach respects the unique needs of special needs patients and promotes effective and Compassionate Care",
        "Transfer of Patient Care": "transfer of patient care is a process that begins when you arrive at the hospital with your reporting responsibilities commencing immediately effective communication with other Health Care Professionals at the receiving facility is fundamental to ensuring efficient effective and appropriate patient care this process involves a coordinated effort among various providers including bystanders First Responders paramedics primary care physicians Ed nurses and other Health Care staff adhering to General guidelines for the transfer includes maintaining uninterrupted care to ensure the patient's stability minimizing interference to avoid unnecessary disruptions and engaging in respectful interactions to foster a collaborative environment it is also important to establish common priorities among the team to ensure aligned goals and to use a Common Language or system to facilitate clear and precise communication for optimal coordination during the transfer of patient care it is advisable that a single person typically the team leader manage the process and convey the patient information this allows for consistency and Clarity in communication when receiving a patient handle report the receiving care provider should initiate eye contact to establish a connection and demonstrate attentiveness the provider should confirm the ABCs to prioritize the patient's immediate physiological needs a structured report should be provided using the esbat format or situation background assessment and treatment to ensure comprehensive and organized information transfer",
        "Patient Care Report (PCR) Overview": "the patient care report is legal document used to record all aspects of the Care a patient receives from initial dispatch to arrival at the hospital there are two types of pcrs written and electronic information collected during a call is documented in the PCR and ultimately entered into a data pool for further F analysis and recordkeeping the National Emergency Medical Services information system or nysus has been collecting patient care information for research purposes since the early 1970s nysus has identified specific data points which serve as uniform components to facilitate communication and comparison of EMS runs between various agencies regions and states this standardized data improves patient care helps conduct research and enhances the overall effectiveness of EMS using 24-hour or military time in EMS documentation is the standard to avoid confusion and ensure Precision developing the skill to write effectively and accurately ensures clear communication and proper documentation of patient care information documented in reports can be categorized as objective or subjective objective information includes measurable signs that are observed and recorded such as blood pressure readings subjective information encompasses details shared by the patient that cannot be directly observed such as their description of symptoms every report must be complete accurate and legible to maintain high standards of care and legal compliance",
        "Types of Patient Care Reports": "various types of patient care reports are used across the United States ranging from brief half-page notes to comprehensive and thorough reports some Services have developed pcrs that minimize the narrative section using checkboxes are drop-down menus instead paper reporting is becoming obsolete as the shift towards Electronic Reporting aims to reduce documentation errors numerous companies have created diverse epcrs offering solutions from scanning paper forms to fully computer-based programs for desktops tablets laptops and smartphones modern Data Systems can integrate information from multiple sources such as different Health Care Facilities enhancing the completeness and accuracy of patient records to facilitate Nationwide data sharing electronic documentation systems should comply with the standards set by the National Emergency Medical Service information system this compliance ensures uniformity and compatibility of data across various EMS agencies and region promoting efficient communication and Analysis",
        "Objective and Subjective Information in PCR": "when documenting a patient care report the provider should avoid including any bias or personal opinions for instance instead of writing the patient was drunk and out of control a more appropriate and objective statement would be the patient presented with an altered mental status and stated he had eight beers today ensuring that your report is complete well- written legible and professional is Paramount proper spelling grammar and accurate medical terminology should be used throughout the report furthermore avoid using medical terms and abbreviations if you do not fully understand their meanings as this can lead to inaccuracies and miscommunication adhering to these guidelines not only maintains The Professional ISM of the report but also ensures that it meets legal standards and provides clear factual information for ongoing patient care",
        "Functions of a Patient Care Report": "a patient care report serves six essential functions firstly it ensures continuity of Care by providing detailed and accurate information about the patient's condition and the treatments administered facilitating seamless transitions between healthc care providers secondly it acts as legal documentation recording the care provided and the patient responses thirdly it serves as an educational purpose offering valuable insights and case studies for training and improving the skills of healthc Care Professionals Additionally the PCR provides administrative information supporting operational needs such as billing and resource allocation it also functions as an essential research record contributing data for studies and Analysis aimed at enhancing medical knowledge and practices lastly the PCR plays a role in the evaluation and continuous quality improvement providing a basis for reviewing and improving patient care protocols and outcomes documenting any changes in the patient's condition in route to and upon arrival at the hospital ensures continuity of care and accurate medical records examples of patient information collected on a PCR include the chief complaint level of Consciousness assessed during the avpo scale Vital Signs assessment findings impatient demographics such as age sex an ethnic background these reports also provide valuable administrative information such as details for patient billing administrative information gathered from a PCR includes the times the incident was reported the EMS unit was notified the EMS unit arrived at the scene the EMS unit left the scene the EMS unit arrived at the receiving facility and when the patient care was transferred this data can be analyzed to understand the causes severity and types of illnesses or injuries requiring emergency medical care required components of a PCR Encompass the patients's name sex date of birth address Chief complaint signs and symptoms found during the patient assessment response to treatment and the name of the person receiving the patient care report",
        "Narrative Section of a PCR": "The Narrative section of a patient care report includes all facts related to the EMS call this section should comprehensively detail negative findings and important observations about the scene avoid recording personal conclusions or opinions about the incident instead use clear and objective descriptions that do not apply any judgments about the patient's condition carefully and thoughtfully choose your words to ensure accuracy and professionalism The Narrative should be fact-based reflecting findings rather than opinions when documenting sensitive information note the source to maintain accuracy and credibility always record the time with all assessment findings to provide a precise timeline of events examples of components in the narrative portion of a PCR include why the EMS unit was called scene size up pertinent bystander or family information the patient's mental status demographic information and any loss of consciousness these details provide a comprehensive and accurate account of the patient's condition and the scene",
        "Medical Terminology in Documentation": "medical terminology is primarily derived from Latin providing a universal language that ensures all Health Care Professionals regardless of their location in the chain of care can understand the patient's complaint this system employs a combination of prefixes word roots and suffixes to accurately describe medical conditions and diseases for example if a patient experiences a headache it is termed calgia in medical language this term is formed by combining the Latin roots seph meaning head and Alia meaning pain this structured approach to medical terminology allows for precise and consistent communication across various healthc care settings",
        "Correcting Errors in Documentation": "when reporting error in medical documentation do not attempt to cover up any omissions or inaccuracies falsification of Records can lead to poor patient care and may result in the suspension or revocation of your certification or license if an error is discovered while writing your report draw a single horizontal line through the error initial it and write the correct information next to it erasing or altering the error is not permitted as it can be seen as an attempt to conceal the mistake after submitting a written report follow the same error correction procedure using a different color ink if possible and initial and dat the correction for electronic Reports most systems allow for amendments but prevent the Eraser of completed documents if information was accidentally omitted start a new section labeled addendum include the new information and add the date time and your initials only the person who wrote the original report is authorized to revise it as additions or notations by others after the report's completion May compromise its authenticity",
        "Minimum Requirements and Billing in EMS Documentation": "minimum requirements and billing in EMS documentation mandate that all procedures performed are thoroughly documented Insurance codes are accurately obtained and the appropriate medical necessity signatures are secured the patient care report should clearly indicate the reasons why the patient required Emergency Care Medicare establishes the criteria for medical necessity which must be adhered to for compliance reimbursement significant findings that justify ambulance transport include the patient being unresponsive or in shock needing restraints experiencing severe Hemorrhage or requiring emergency treatment while being transported medical necessity extends to the level of care provided to the patient during transport obtaining signatures ensures the EMS agency is properly reimbursed for services rendered and every effort should be made to secure the appropriate signatures from the patient or Guardian to validate the care provided and facilitate billing processes",
        "Health Information Exchanges": "health information exchanges or hies significantly enhance the sharing of data among EMS and other healthc care providers these systems enable EMS providers to access Health Data such as past medical history medications allergies and endof life preferences facilitating informed decision making during emergencies hies help avoid unnecessary duplication of effort in data entry by providing a uniform platform for data access and input they also allow EMS providers to view patient outcomes related to hospital care improving the continuity of care aemts can contribute to an assess electronic health information ensuring that patient Health Data is updated and available in real time most hies operate using the sapper Network which stands for search alert file and reconcile this is done to streamline the data management process and enhance the efficiency of healthc care delivery",
        "Documenting Refusal of Care": "documenting the refusal of care is critical as it is a common source of lawsuits in the medical field thorough documentation protects both the patient and the health care provider if a patient refuses treatment despite efforts to persuade them it is important to document all assessment findings any emergency medical care provided the attempts made to obtain consent and the patient's response the patient should be asked to sign a refusal form and ideally a family member law enforcement officer or bystander should also sign as a witness depending on local protocols informing online medical control may be required when a patient refuses care even if care is refused the PCR must still be completed noting that a full assessment could not be performed due to the patient's refusal key components of a thorough patient refusal document include a complete assessment evidence that the patient can make a rational and informed decision documentation of the full assessment and discuss discusss with the patient about the recommended care or transportation and potential consequences of refusing care efforts to involve family friends or bystanders to encourage the patient to accept care should be documented as well as any discussions with medical Direction per local protocols providing the patient with alternative options such as visiting their family doctor or having a family member drive them to the hospital should be noted along with Em's willingness to return if needed refusal of care documentation is necessary not only for patients who decline transport to the hospital but also for those who refuse specific aspects of care such as full immobilization after a motor vehicle crash any refusal of standard treatment must be documented in the epcr with the patient signing for the care they are declining",
        "Special Reporting Situations": "in special reporting situations is imperative to file detailed reports with the appropriate authorities these situations include cases involving gunshot wounds dog bites certain infectious diseases suspected physical or sexual abuse and any exposure or injury to the advanced ENT when treating or trans reporting a cooworker For Occupational exposure it's necessary to complete a full patient care report along with the occupational exposer form to ensure thorough documentation and compliance with safety regulations Additionally the use of mutual aid services such as helicopters specialized rescue teams and other agencies should be meticulously documented to maintain a clear record of all resources utilized during the incident another significant reporting situation is a mass casualty incident where the local MCI plan should include protocols for temporarily recording medical information to manage the large volume of patients effectively this ensures that all relevant data is captured and can be accessed for subsequent analysis and Reporting",
        "Submitting the PCR": "submitting the PCR involves several steps to ensure confidentiality and compliance with medical protocols the PCR form along with all the information it contains is considered a confidential document and must be handled accordingly typically a copy of the PCR remains at the hospital becoming a part of the patient's permanent medical record due to time constraints you may not always be able to complete the full PCR while at the hospital in such cases most systems provide for the creation of a drop report or transfer report to ensure that patient information is promptly documented and available to the receiving medical team this in report can be completed quickly allowing for a more detailed and comprehensive PCR to be finalized later",
        "Conclusion: Importance of Communication and Documentation": "effective communication and meticulous documentation are fundamental aspects of prehospital care provided by the aemt verbal communication skills enable aemts to gather critical information from patients and bystanders coordinate with other responders and provide clear instructions which are vital for Effective emergency response nonverbal communication including body body language and facial expressions also plays a significant role in understanding and conveying messages special attention is required when communicating with diverse patient groups including older adults children and those with special needs or disabilities ensuring that communication methods are adapted to meet each patient's unique requirements emotional intelligence further enhances the aem's ability to to manage their emotions and respond appropriately to others improving the patient interactions and outcomes documentation is equally important as it provides a permanent medical record of the care provided from dispatch to the arrival at the hospital the PCR serves multiple functions including continuity of care legal documentation and administrative purposes accurate documentation involves recording objective and subjective information ensuring completeness and correcting errors appropriately special reporting situations such as occupational exposures or mass casualty incidents require additional documentation protocols the transition from paper to electronic pcrs has streamlined this process reducing errors and facilitating data sharing through the health information Exchange properly handling and submitting to PCR including in reports when time is constrained ensures that all relevant patient information is accessible to Health Care Providers maintaining the Integrity of the patient's medical record and supporting ongoing patient care overall am EMTs must excel in both communication and documentation to ensure highquality patient care by effectively Gathering and conveying this information adapting communication strategies to diverse patient needs and maintaining detailed and accurate records aemts play a crucial role in the Health Care System their ability to manage complex situations with empathy Clarity and precision ensures that patients receive the best possible care during emergencies"
    },
    {
        "Introduction to EMS Systems": "chapter 1 EMS systems emergency medical Services constitute a multidisiplinary system designed to provide prehospital and outof hosp acute Medical Care and transportation to definitive care this chapter will discuss the various components that comprise the EMS system it delves into the different types of VMS providers ranging from basic emergency medical responders to advance paramedics highlighting the distinct levels of care they deliver furthermore it discusses the intricate facets of EMS Administration including the oversight by medical directors the implementation of quality control measures and the regulatory Frameworks that ensure the standardization and efficiency of EMS operations Additionally the chapter explores the specific roles and responsibilities of advanced emergency medical technicians or aemts emphasizing their critical function as healthc Care Professionals within the EMS system this encompasses their duties in patient assessment emergency medical intervention and the coordination of care during medical emergencies.",
        "Structure and Governance of EMS": "EMS is a cohesive system of professionals and agencies collaborating to deliver prehospital and Hospital Emergency Care to individual ual who are sick or injured this system operates within local or Regional Frameworks integrating various prehospital and Hospital components that are essential for the provision of comprehensive emergency medical care the governance of EMS is established by state specific legislation with regulatory oversight typically managed by state EMS offices this ensures that the operations standards and Protocols of EMS are uniformly maintained and that the care provided aligns with both medical and legal requirements individuals who provide emergency medical care aside from licensed Physicians must be certified EMS Personnel or hold state lenser certification exams ensure that all healthc care providers possess a standardized level level of basic knowledge and skills necessary for their roles upon passing the certification exam individuals become eligible to apply for State lure a process that verifies their competency through formal examination settings this lure process allows states to regulate who is authorized to function as a healthcare provider credentialing further involves the verification of a health care providers qualifications which may be conducted locally or even regionally.",
        "Levels of EMS Training and Certification": "Providers are generally categorized into four levels of training and lure emergency medical responders are the first medically trained professionals to arrive at an emergency scene providing initial care until more advanced responders take over emergency medical technicians are trained in basic life support including the use of aeds and Airway adjuncts and they assist in administering specific medications Advanced EMTs undergo Advanced Training in particular aspects of advanced life support such as IV therapy and are capable of administering certain emergency medications and managing Advanced Airway techniques paramedics possess extensive training in ALS including skills and IND traal intubation emergency pharmacology cardiac monitoring and other Advanced assessment and emergency treatment procedures in Most states healthc care providers are classified into four distinct training and licensure levels the first is the EMR or emergency medical responder who is typically the initial medically trained professional to arrive at the scene of an emergency they provide preliminary care and stabilization before the arrival of an ambulance playing a crucial role in assisting more advanced responders the second level is the EMT who is trained in BLS techniques this includes the use of aeds in various Airway adjuncts EMTs also assist with the administration of certain medications providing essential care that supports the stabilization and transport of patients to a higher level of care increasingly we are seeing EMS systems that utilize BLS only transport ambulances to Greater efficiency in overburdened systems the third level is the advanced EMT who undergos advanced training in specific aspects of advanced life support this includes IV Therapy which allows the aemt to administer fluids and medications directly into the patient's bloodstream additionally aemts are qualified to administer certain emergency medications and perform Advanced Airway management techniques which are important for patients with compromised respiratory function the fourth level is the paramedic who receives comprehensive training in various ALS skills paramedics are proficient with endotracheal intubation a critical procedure for securing the patient's Airway they are also trained in emergency pharmacology which involves the administration of a wide range of medications used in emergency situations paramedics possess Advanced skills in cardiac monitoring enabling them to assess and manage patients with complex cardiovascular conditions they training includes other Advanced assessment and emergency medical treatment skills allowing them to provide a higher level of care in prehospital settings.",
        "EMS Education Standards and Competency": "Training and lcer requirements for EMS Personnel vary by state but nearly all states adhere to or surpass the guidelines that are set forth in the current national highway traffic safety administration em EMS education standards this ensures a consistent level of Competency and skill among EMS providers Nationwide the standards outlined in this textbook align with the 2021 National EMS education standards and the 2019 National EMS scope of practice model providing a comprehensive framework for the practice and skills expected of EMS personnel the nhtsa serves as the federal administrative Authority for education standards and related documentation ensuring that the educational requirements for EMS providers are up toate and uniformly applied across the country.",
        "Roles and Responsibilities of Advanced EMTs": "Advanced EMTs are trained to provide emergency care to individuals who are sick or injured addressing a range of medical needs they are equipped to manage patients with life-threatening conditions requiring immediate and Advanced Medical interventions to stabilize their condition and prevent further deterioration this includes performing Advanced Airway management administering IV fluids and medications and using other sophisticated medical equipment conversely aemts also encounter patients who need only supportive care these patients may require basic medical assistance monitoring and reassurance rather than aggressive intervention the Dual focus of aemt training ensures that practitioners are prepared to deliver appropriate care across a broad spectrum of medical emergencies enhancing patient outcomes and continuity of care among the subjects discussed in aemt training are several critical areas essential for Effective Emergency Medical Services one key topic is seen size up which involves gaining a comprehensive understanding of the emergency call assessing whether it is safe to proceed determining the necessity of additional resources and then formulating an initial approach to manage the emergency scene effectively this is crucial as EMS Personnel operate in diverse and potentially hazardous environments and maintaining personal safety is Paramount another fundamental subject is patient assessment which forms the Cornerstone of any EMS call the primary goal of patient assessment is to identify the patient's condition and then ascertain which complaints are life-threatening this enables EMS providers to priori Ize interventions appropriately treatment protocols covered include ensuring the patient is adequately oxygenated administering necessary medications and IV Therapy controlling Hemorrhage assisting patients during childbirth and managing individuals experiencing emotional crisis these treatment measures are vital for stabilizing patients and addressing immediate medical needs packaging refers to the preparation of a patient for transport ensuring they are securely immobilized using devices like backboards or other stabilization tools to prevent further injury during movement to medical facilities.",
        "EMS as a Career and Historical Context": "Finally EMS as a career encompasses topics on self-car strategies for effectively managing the stresses associated with the job this includes understanding the import an of physical and mental well-being to maintain the capacity to provide highquality Care on a consistent basis the history of Emergency Medical Services is deeply rooted in Military and civilian Innovations over the centuries the origins of EMS can be traced back to the Civil War where field treatments and transport methods were developed to provide immediate care to Injured soldiers this period saw the Advent of organized systems for medical evacuation and treatment on the battlefield laying the groundwork for modern EMS practices during World War I the concept of volunteer ambulances emerged further advancing the field of Emergency Medical Care these volunteer driven ambulances played an important role in transporting wounded soldiers from the front lines to medical facilities ensuring they receive timely and necessary care World War II saw the introduction of specially trained cormen who are responsible for providing field care and transporting casualties to Aid stations these core men were equipped with Advanced Medical Training allowing them to administer critical care and combat zones and significantly improving survival rates the Korean in Vietnam conflicts brought about significant advances in traumacare driven by the need to address the high number of casualties Innovations in medical evacuation techniques such as the use of helicopters for Rapid transport and improvements in field medical practices were developed and later adapted to civilian EMS systems in more recent history conflicts in the Middle East and the global response to ter terrorism have continued to shape EMS practices these experiences have led to the development of new protocols and Technologies designed to enhance the efficiency and effectiveness of emergency medical responses in both military and civilian contexts.",
        "Development of Modern EMS Systems": "The modern EMS system as we know it today began to take shape in 1966 with the publication of the seminal report accidental death and disability the neglected disease of modern society commonly referred to as the white paper this report was a collaborative effort prepared by the Committees on trauma and shock of the National Academy of Sciences and the national research Council the white paper brought to light the significant deficiencies in prehospital emergency care and transportation in emphasizing the urgent need for systemic improvements in response to the findings of the white paper Congress took decisive action by mandating two federal agencies to address the identified issues the national highway safety traffic administration of the Department of Transportation and the Department of Health and Human Services were tasked with creating funding sources and developing programs aimed at enhancing EMS capabilities additionally states were required to prioritize the training of EMS personnel and to establish legislation and regulations to standardize EMS Personnel levels one of the critical outcomes of these efforts was the development and publication of the First National Standard Curriculum by the do in the early 1970s this curriculum provided essential guid guidelines for the Education and Training of emergency medical technicians this in turn ensured a more consistent and effective level of prehospital care Nationwide this initiative marked a significant step towards the professionalization and standardization of EMS laying the foundation for the comprehensive EMS systems that we rely on today.",
        "Advancements in EMS Training and Practice": "In 1971 the American Academy of orthopedic surgeons made a significant contribution to the field of Emergency Medical Services by preparing and Publishing the first comprehensive EMT textbook emergency care and transportation of the sick and injured this seminal work provided foundational knowledge and guidelines for EMTs standardizing the training and practices in prehospital care throughout the 70s States across the US developed legislation and established comprehensive EMS systems during this period emergency medicine emerged as a recognized medical speciality leading to the establishment of fully staffed emergency departments as a standard care in hospitals this recognition underscored the importance of having dedicated emergency medical professionals and Facilities equipped to hand Le acute medical situations in the late 1970s the do took further steps to standardized training by developing a recommended National Standard curriculum specifically for paramedics this included Provisions for the training of advanced EMTs ensuring a clear educational pathway for those providing Advanced levels of prehospital care during the 80s many regions continued to enhance the EMS National Standard Curriculum by incorporating higher levels of training for providers this advancement enabled professionals to deliver key components of advanced life support further improving the quality and scope of Emergency Medical Services available to the public these enhancements reflected the ongoing commitment to elevating the standards of prehospital care and ensuring that EMS Personnel were well equipped to meet the involving needs of emergency medicine.",
        "Expansion of EMS Roles and Responsibilities": "In recent years the availability of paramedics and advanced life support level Care on emergency calls has increased significantly this expansion has allowed EMTs and advanced EMTs to perform several Advanced skills in the field that were previously reserved specifically for paramedics these skills include Advanced Airway management administration of IV fluids and medications and other critical interventions to enhance the level of care as a scope of practice for EMS providers expanded the roles and responsibilities of these professionals begin to vary from state to state each state developed its own regulations and standards for EMS practice leading to differences in how EMS services are delivered across the country in the '90s the National Highway traffic safety administration recognized the need for a more standardized approach to EMS education and provider levels to address this the nhtsa developed the EMS agenda for the future a comprehensive document aimed at creating a unified plan for EMS systems Nationwide this agenda sought to standardize the levels of EMS education ensuring that all providers met consistent highquality training standards in 2019 the nhtsa revised the EMS agenda for the future and published the EMS agenda 2050 this updated agenda placed a greater emphasis on patient- centered care reflecting the evolving priorities in healthcare the new agenda aims to ensure the EMS systems not only provide high quality critical care but also focus on the needs and experiences of patients promoting a more holistic approach to EMS.",
        "State and Federal Guidelines for EMS Practice": "The Lure of advanced EMTs is managed at the state level resulting in variations in practice training and lure requirements across different states each state establishes its own standards and protocols at the federal level the national EMS scopa practice model provides overarching guidelines lines that Define the minimum skills each level of EMS providers should be able to perform this model ensures a baseline of Competency and uniformity in the training and abilities of EMS Personnel Nationwide state laws regulate the operations of EMS providers determining the scope of their practice and the specific protocols they have to follow these regulations are designed to ensure the EMS service services are delivered safely and effectively within each State's jurisdiction at the local level the medical director plays a crucial role in determining the day-to-day operational limits of EMS Personnel this includes decisions about the types of medications that can be carried on ambulances and the destinations to which patients are transported while the medical director can impose rest restrictions on the scope of practice these limitations must remain within the boundaries set by state law and cannot expand beyond what is legally permitted.",
        "Public Training and Community Health": "Public basic life support and immediate aid training are critical components of Community Health millions of lay people are trained in BLS and CPR enabling them to respond effectively in emergency situations additionally many individuals have completed basic first aid courses that teach essential skills such as bleeding control and other fundamental interventions these courses are structured to equip lay people with the ability to provide Critical Care before aemts or other professional responders arrive on the scene this training is inclusive often involving teachers coaches babysitters and others who are in positions to respond to emergencies thereby enhancing Community Readiness and resilience.",
        "EMS Agenda 2050 and Future Directions": "We'll now talk a little bit more about the EMS agenda of 2050 as stated earlier this represents a comprehensive multidisiplinary National Review of all aspects of EMS delivery this initiative aims to create a more cohesive and consistent EMS system across the US by evaluating and improving various components of EMS such as training protocols and Technology integration the agenda seeks to ensure uniform standards and practices this endeavor is intended to enhance the efficiency Effectiveness and quality of Emergency Medical Care ultimately leading to better patient outcomes and a more reliable EMS system Nationwide the EMS agenda 2050 document highlights five key aspects of a people centered EMS system first it emphasizes the importance of providing comprehensive highquality and Convenient Care ensuring that patients receive thorough and accessible Medical iCal Services second it advocates for evidence-based clinical care promoting the use of research and data to inform medical practices and improve patient outcomes third the document underscores the need for efficient and well-rounded care aiming to streamline EMS operations and enhance the overall patient experience fourth it recognizes the value of preventative care focusing on strategies to prevent emergencies before they occur lastly it stresses the importance of comprehensive and easily accessible patient records facilitating better continuity of care and more effective medical decision-making these aspects conveniently aim to create a more responsive and patient focused system.",
        "Vision of EMS Agenda": "The vision of em agenda 2050 centers on creating a people focused EMS system where individuals receive comprehensive and highquality Care in the most comfortable and convenient settings this Vision includes several key components first patient transport will prioritize safety and efficiency without necessarily relying on high speeds or the use of lights and Sirens creating a calm and secure journey to care facilities second EMS care will extend beyond life-saving interventions to also address and mitigate physical emotional and psychological suffering providing holistic support to patients additionally EMS systems will be seamlessly integrated into the broader healthc care framework with an emphasis on preventing injuries and illnesses rather than solely responding to emergencies this proactive approach aims to improve overall Community Health outcomes finally EMS clinicians will have access to and contribute to comprehensive patient medical records this will facilitate the continuity of care this integration will lead to enhance treatment for individual patients and allow for ongoing updates in prevention diagnosis and treatment strategies ensuring that care remains current and effective.",
        "Guiding Principles for an Advanced EMS System": "The agenda outlines guiding principles for an advanced EMS system characterized by several key attributes firstly the system is inherently safe and effective meticulously designed to minimize exposure to injury infections illness or stress throughout the entire care process secondly it is integrated in seamless ensuring full integration with all other healthc care components engagement from other emergency services and active participation within the communities that serves furthermore the system is reliable and prepared consistently delivering Compassionate Care Guided by sound research this principle is upheld by all EMS providers at every level and across all agencies the EMS system is also socially Equitable ensuring the access to and quality of care are not influenced by a patients age socioeconomic status gender ethnicity or location Additionally the system is sustainable and efficient emphasizing fiscal responsibility and Community value by minimizing waste and maximizing accountability lastly it is adaptive and Innovative continuously evolving to meet the changing needs of the population it serves this evolution is driven by the ongoing evaluation of new tools techniques education programs and system designs ensuring the EMS system remains at the Forefront of Medical Care advancements.",
        "Emergency Communication Systems": "Easy access to emergency assistance is crucial for Effective Public Safety in the United States most emergency communication centers that coordinate fire police police Rescue and EMS units can be reached by dialing 911 these centers are staffed by train dispatchers who gather critical information from callers and promptly dispatch the appropriate ambulance screw equipment and other responders typically the Communication Center serves as the primary Public Safety access point ensuring that all emergency services are efficiently coordinated and dispatched to address the situation as quickly as possible enhance 911 systems display the caller's address on the screen ensuring that dispatchers have location information even if the caller is unable to speak or hangs up as the address remains visible until released by the dispatcher many emergency centers are equipped with special tools to assist individuals with speech or hearing difficulties facilitating their access to Emergency Services in some regions a different emergency number other than 911 may be used to summon EMS units public education on how to summon an EMS unit is important and social media may play a growing role in this effort by enabling lay people trained in CPR to be alerted to nearby cardiac arrests additionally enhanced 911 systems for self cell phones now use GPS technology to identify the caller's phone number and precise Geographic coordinates further improving the accuracy and speed of the emergency response.",
        "Emergency Medical Dispatch System": "The emergency medical dispatch system was developed to assist Dispatchers in providing vital instructions to callers until EMS Personnel arrive on the scene this system includes training and scripts that equip dispatchers with the necessary tools to guide callers through critical first date procedures Additionally the EMD system helps dispatchers select the most appropriately resourced units to respond to the emergency ensuring that the right level of care is dispatched however because dispatchers cannot see the situation at the scene the actual circumstances May differ from the information proved provided by the caller dispatchers must rely solely on the details relayed by the caller which can sometimes lead to discrepancies between the perceived and actual needs at the scene despite these challenges the EMD system plays a critical role in Bridging the Gap between the initial emergency call and the arrival of Professional Medical Assistant.",
        "EMS Communication and Organization": "Communication systems and Emergency Medical Services are vital for ensuring effective response to emergencies when a call is received the dispatcher uses the information provided to select and activate the appropriate parts of the emergency system EMS can be organized in various ways as part of the fire or Police Department as an independent public or private safety Service as contractors providing BLS or ALS services or as ambulance services offered by hospital-based programs advancements in technology such as cellular phones linked to GPS units assist responders in accurately locating patients however the rapid pace of technological change necessitates ongoing training and education to ensure the EMS Personnel maintain upto-date Knowledge and Skills additionally staying active within the community helps EMS providers remain informed about the best local resources enhancing their availability to deliver effective care.",
        "Equipment and Vehicle Preparedness": "In clinical care you will utilize a wide range of Emergency Equipment to provide effective patient care the aemt course will teach you how to use this equipment including understanding when its use is indicated and importantly when it's contraindicated before going on duty it's essential to check all equipment to ensure that it's in its assigned Place functioning correctly and that you are familiar with the specific model this preparation ensures that you ready to respond efficiently and effectively in emergency situations you may be required to drive the ambulance during your duties you should become familiar with the roads in your primary service area which is the main operational area for the EMS agency before starting your shift conduct thorough checks to ensure all equipment and supplies are present and functional verify that the communications equipment is operational and inspect vehicle fuel oil and other essential fluids ensuring the tires are in good condition check the driver's controls and familiarize yourself with each built-in unit and control in the patient compartment if it is your first time driving a particular ambulance it's advisable to take it for a brief drive before responding to a call so that you may become accustomed to its handling and features this preparation ensures that you can operate the vehicle safely and effectively during the emergency.",
        "Human Resources in EMS": "Human resources and EMS systems focus on managing the workforce Force within these organizations the overarching concept is to create EMS systems that Foster environments where talented individuals are motivated to work and can transform their passion into fulfilling careers the agenda promotes the development of systems that prioritize the well-being of EMS providers ensuring that they are supported and protected in their roles additionally the agenda encourages the creation of career ladders which provide Pathways for professional growth and long-term career opportunities for skilled providers efforts are also being made to facilitate the seamless relocation of EMS providers from one state to another ensuring that their credentials and skills are recognized across different regions thereby enhancing Workforce mobility and the continuity of care.",
        "National EMS Scope of Practice Model": "The national EMS scopa practice model establishes staple foundations for the roles and responsibilities of various EMS providers ensuring consistency and Clarity in their training and practice standards one significant benefit of this model is the National Registry certification which serves as a recognized standard of competence often facilitates the process of obtaining licensure in other states Additionally the recognition of EMS Personnel lure interstate compact or replica extends end privileges to EMS Personnel from member states allowing them to practice in a shortterm or intermittent basis across state lines this enhances the flexibility and mobility of the workforce ensuring that skilled providers can respond to emergencies regardless of their Geographic boundaries.",
        "Medical Direction and Control in EMS": "Medical Direction and control in EMS systems involve a physician medical director who authorizes EMS providers to deliver Medical Care in the field the medical director determines the appropriate care through the established standing orders and protocols protocols serve as a comprehensive guide outlining the scope of practice for EMS providers ensuring that they operate within defined medical and procedural boundaries standing orders which are part of these protocols specify the actions that an a EMT must take in response to particular complaints or conditions providers can Implement these standing orders without needing to consult medical control allowing for Swift and standardized care during emergencies the medical director serves as an ongoing liaison among the medical community hospitals and the providers in the service medical control as authorized by the medical director can either be offline or online online or direct medical control involves real-time physician directions given over the phone or radio these directions can be communicated by the physician's design knee protocols will specify an EMS physician who could be contacted by radio or telephone for medical control during a call this online medical control physician May confirm or modify the proposed treatment plan based on the situation offline or indirect medical control includes standing orders training and supervision authorized by the medical director this form of control ensures that EMS providers have a set of predefined guidelines and training to follow enabling them to deliver appropriate care independently of real-time physician input.",
        "Legislation and Regulation in EMS": "Legislation and regulation in EMS ensure that while each system medical director and training program has some latitude their training protocols and practices align with State legislation rules regulations and guidelines medical directors supervisors and other relevant Personnel develop service area protocols the state office is tasked with authorizing auditing and regulating all EMS systems training institutions courses instructors and providers within the state EMS Administration is typically overseen by a senior Ems official the daily operational and overall direction of the service is managed by an appointed chief executive officer and several subordinate officers in cases where the EMS unit is part of a fire or Police Department the Department chief usually delegates EMS management to an assistant chief or other officer solely responsible for EMS activities the chief executive of the EMS service handles necessary administrative tasks including scheduling personnel management budgeting purchasing and vehicle maintenance along with overseeing the daily operations of ambulances and crew this role functions similar to that of a fire or police chief but doesn't involve managing medical matters.",
        "Integration of Health Services": "The integration of Health Services ensures that the prehospital care provided by EMS is seamlessly coordinated with the care administered in the hospital when a patient is delivered to the ER they are transferred to another care provider facilitating a Continuum of Care this process helps to decrease errors increase efficiencies and most importantly ensure the patient receives comprehensive continuity of care additionally some EMS systems collaborate with local hospitals to enhance patient outcomes for time sensitive conditions such as heart attacks trauma and stroke these collaborations focus on streamlining the treatment processes ensuring that patients receive prompt and appropriate care that can significantly improve their chances of recovery and survival.",
        "Mobile Integrated Healthcare": "Mobile integrated healthc care represents a new system of delivering health care that leverages the prehospital Spectrum this approach evolved in response to the patient protection and Affordable Care Act aiming to provide better access to medical care for patient and communities with limited medical resources it enhances services for individuals who are homebound or disabled ensuring they receive appropriate care without needing to visit Health Care Facilities the community paramedicine is a key component of this system wherein experienced paramedics receive Advanced Training to equip them with the skills needed to provide a range of health care services within the community this model model promotes Better Health outcomes by making Health Care More accessible and tailored to meet the needs of the population.",
        "Quality and Safety in EMS": "Evaluating quality and safety in EMS involves multiple processes to ensure high standards of Medical Care the medical director maintains quality control ensuring all staff members meet appropriate Medical Care standards during each call this includes reviewing patient care reports auditing administrative records and surveying patients to gather feedback continuous quality improvement also known as quality assurance is a dynamic ongoing process involving both internal and external reviews and audits of all aspects of an EMS call periodic run review meetings are held to discuss areas of improvement and positive feedback fostering a culture of continuous enhancement refresher training and continuing education are crucial as skill decay can occur over time to address this the medical director May establish a cqi process to identify and correct deficits ensuring that all EMS providers maintain their proficiency and are up toate with the latest medical practices and protocols.",
        "Error Mitigation and Patient Safety": "Another key function of the evaluation process in EMS is to identify and Implement strategies to limit or eliminate human error thereby enhancing patient safety errors can occur at various times such as during communication with other aemts or when transferring a patient to the emergency department driving to the scene presents hazards that can lead to accidents and patients can be at risk of being dropped during lifting and moving aemt must strive to minimize Errors By understanding the circumstances in which they occur errors generally arise from three main sources rules-based failures knowledge-based failures and skills-based failures these types of Errors can occur independently or in combination to mitigate these risks EMS agencies need to establish clear protocols that are well understood by all amts Additionally the environment can contribute to errors with factors such as distractions or poor lighting playing a significant role by addressing these elements EMS systems can improve overall patient safety and Care Quality.",
        "Decision-Making and Continuous Learning": "When about to perform a skill it's important to ask yourself why am I doing this this question allows time for reflection and helps you make an informed decision about the procedure if you cannot find a solution seek assistance from your partner medical control or your supervisor utilizing cheat sheets can help minimize errors so always keep a copy of your protocol book handy during downtime refresh skills that are used less frequently to maintain proficiency decision-making AIDS such as algorithms can be valuable tools reflecting on actions taken during a call can serve as an informal critique to improve future performance additionally discussing challenging calls with your partner or your supervisor can provide insights and support to continuous learning.",
        "Information Systems in EMS": "Information Systems in EMS are essential for efficiently documenting the emergency medical care provided this documented information serves several purposes including constructing educational sessions for the Department data from ambulance activity logs help justify the hiring of additional Personnel by examining the types and frequency of patients the foundation can be established for purchasing new equipment and guiding continuing education sessions furthermore information gathered by the national EMS information system or nyus is instrumental in planning for the current current and future needs of EMS systems NSA dat up provides a comprehensive overview enabling better resource allocation training and overall system Improvement to meet evolving Health Care demands.",
        "EMS System Finance": "System Finance is critical for the sustainability of EMS departments ensuring they have the necessary resources to continue providing care funding systems are essential to cover operational costs including equipment training and Personnel in the United States EMS departments are categorized into several types based on their Staffing and funding models paid volunteer and a combination of both paid EMS departments employ full-time salaried Personnel while volunteer departments rely on individuals who offer their services without compensation combination departments incorporate both paid staff and volunteers balancing the benefits of both systems to ensure comprehensive emergency medical services EMS departments secure Financial Resources through various means including taxation fees for services rendered paid subscriptions donations and grants from federal state and local governments fundraisers and combinations of these methods also contribute to the necessary funding additionally aemts play a role in the financial operations of EMS by gathering insurance information from patients securing signatures on Hippa forms and obtaining written consent from patients to build their health insurance companies this process ures the EMS services are adequately funded and that patients receive the necessary care without Financial barriers.",
        "CMS Emergency Triage and Transport Program": "In 2020 the centers for Medicare and Medicaid services or CMS launched a pilot program called emergency triage treat and transport or et3 in select EMS agencies this program was designed to enhance the flexibility and efficiency of Emergency Medical Services it allows for the transport of patients to emergency departments when such a level of care is necessary additionally et3 introduces a payment model that supports the transport of patients to Alternative Care destinations including urgent care centers and doctor's offices or provides on scen treatment without the need of Transport this approach aims to improve patient outcomes by ensuring appropriate care while optimizing resource utilization.",
        "EMS Education and Training Standards": "The education system for aemts is regulated to ensure high standards of training and competence in Most states aemt course instructors must be approved and licensed by the state EMS office or agency which ensures that Educators meet specific qualifications and standards additionally most EMS training programs are required to adhere to National standards established by accrediting organizations such as the committee on accreditation of educational programs for the Emergency Medical Services professions or coamps and the commission on accreditation of Allied Health education programs or Kap these organizations set rigorous guidelines to ensure that the education provided to EMS professionals is both comprehensive and consistent ALS level instructors and directors are required to hold a 4-year degree ensuring they possess Advanced knowledge and expertise generally ALS training is provided in diverse settings such as colleges universities Adult Career Centers or hospitals Most states mandate the educational programs offering ALS training must receive state approval and have their own medical director to ensure quality and adherence to standards to maintain update and expand their Knowledge and Skills aemts are required to complete a certain number of hours of continuing education annually the foundation of being an effective aemt relies in a commitment to continuous learning and skill enhancement which is important and crucial for providing highquality care.",
        "Prevention and Public Education in EMS": "Care prevention and public education within EMS focuses on public health examining the health needs of entire populations to prevent health problems Public Health aims to proactively prevent illness and injury significant accomplishments include vaccination programs helmet and seat Bel laws tobacco use regulations prenatal screenings and the formation of the Food and Drug Administration EMS collaborates with public health agencies through primary prevention which aims to prevent events from occurring and secondary prevention which aims to reduce the effects of events that have already happened aemts May participate in the surveillance of illnesses and injuries additionally they can educate the public on a one-on-one basis after accidents teach teaching children in schools to call 911 work with Healthcare institutions to inform residents when to use ambulance services advocate for social media or mobile dispatch programs for CPR trained lay people and teach CPR choking Aid or delivery assistance.",
        "Evidence-Based Practice and EMS Research": "Traditional Medical Practice relies on medical knowledge intuition and judgment in the early years of EMS many standards for professionalism protocols training and Equipment were derived from EMS provids direct experiences currently ongoing EMS research provides a scientific basis for these standards virtually all aspects of healthcare today use evidence-based medicine which focuses on procedures that have been proven effective in improving patient outcomes and considers individual patient care istics and values EMS systems and States now consult the national model EMS clinical guidelines from the National Association of State EMS officials with guidelines based on current research and expert consensus EMS research may be conducted by EMS providers or others studying specific branches of medicine aemts are typically involved in gathering data it's important for those involved in studies to record all information meticulously as traditional Medical Practice is based on such research This research can also be conducted at each EMS facility and it's important for EMS providers to stay current with the latest advances in medicine as of 2015 it was determined that a 5-year cycle is insufficient to keep Pace with research and resuscitation science consequently the international liaison committee on res itation guidelines are now updated more regularly exemplifying evidence-based medical decision-making in progress when reading new research results it's important to understand their implications while research information can be powerful it is often relevant within a limited context therefore it's uh important to be skeptical ask questions and conduct your own research.",
        "Transport Considerations in EMS": "Transport considerations for EMS providers often involve the decision to transport patients to Specialty centers these centers focus on specific types of care such as trauma Burns poisoning psychiatric conditions or the care of specific patient populations such as Pediatrics specialty centers require in-house staff consisting of surgeons and other Medical Specialists and typically only a few hospitals in the region are designated as such centers transport time to these specialty centers may be slightly longer than to General hospitals however patients benefit from receiving definitive care more quickly at these specialized facilities which are better equipped to handle specific medical conditions EMS providers must be familiar with the locations of specialty centers in their area and understand the protocol calls for transporting patients to these facilities in some cases air Medical Transport may be required to expedite the transfer of patients to Specialty centers ensuring timely and appropriate medical intervention.",
        "Interfacility Transports and Hospital Coordination": "Inner facility transports involve the transfer of non-ambulatory patients or those with acute and chronic medical conditions requiring continuous medical monitoring these transport can occur between various Healthcare settings including hospitals skilled nursing facilities Board and Care Homes or the patients home residence during transport aemts are responsible for ensuring the Patients health and well-being this involves obtaining the patients medical history Chief complaint and latest vital signs as well as providing ongoing assessment throughout the transport in some cases a nurse physician respiratory therapist or other members of the medical team may accompany the patient and provide additional care and support ensuring comprehensive medical supervision during the transfer working effectively with Hospital staff is essential for providing comprehensive patient care becoming familiar with the hospital environment involves observing various aspects such as the equipment used and understanding its functions learning the roles and responsibilities of different staff members and familiarizing oneself with the policies and procedures in emergency areas additionally staying updated on advances in emergency medical care and learning how to interact professionally with Hospital Personnel are crucial components consultation with medical staff via radio is often necessary to coordinate Pat care during transport Physicians or nurses may be involved in teaching aemt training programs providing valuable insights and advanced knowledge the best patient care is achieved when there's a strong Rapport and clear communication between all emergency care providers including Hospital staff and EMS Personnel ensuring a seamless transition and continuity of care for patients.",
        "Collaboration with Public Safety Agencies": "Working effectively with Public Safety agencies is crucial for optimal patient care some patient safety workers such as firefighters and police officers possess EMS training which enables them to provide immediate medical assistance in emergency situations providers must understand the specific roles and responsibilities of these workers to facilitate seamless cooperation Public Safety workers may be better equipped or trained to handle specific tasks such as controlling down power lines or managing hazardous materials which absolutely fall outside the typical EMS scope recognizing and leveraging their expertise can enhance the overall emergency response the best patient outcomes are achieved through coordinated efforts and cooperation among various agencies ensuring that each team member skills are utilized effectively to provide comprehensive And Timely care.",
        "Professional Attributes of AEMTs": "Professional attributes are essential qualities that every aemt should possess to provide highquality patient care and work effectively within the system Integrity involves consistent actions and a firm adherence to a code of honest Behavior this means that aemts must be trustworthy and act ethically in all situations empathy is the ability to be aware of and considered about the needs of others aemts should show compassion and understanding towards patients and their families self- motivation is the ability to discover problems and solve them without someone directing you this involves being proactive and identifying and addressing issues as they arise appearance and hygiene are crucial as they reflect professionalism aemts should use their Persona to project trust professionalism knowledge and compassion self-confidence is knowing what you know and what you do not know it involves being confident in your skills and knowledge while recognizing when you need to ask for help time management is the ability to perform a delegate multiple tasks while ensuring efficiency and safety aemts need to prioritize tasks and manage their time effectively to provide timely care communication is understanding others and ensuring they understand you effective communication involves listening speaking clearly and confirming understanding teamwork and diplomacy involve being able to work with others knowing one's place within a team and communicating while giving respect to the listener aemts should collaborate effectively with other healthc care providers respect involves placing others in high regard or importance and understanding that others are more important than you are aemts should treat all patients and colleagues with respect and dignity patient advocacy involves constantly keeping the needs of the patient at the center of care and supporting the patient's rights aemts should act in the best interest of their patients and be an advocate for their needs careful delivery of care involves paying attention to detail and making sure that what is being done for the patient is done as safely as possible aemts should follow protocols and procedures meticulously an a emt's attitude and behavior must reflect knowledge proficiency and a sincere dedication to serving anyone who is injured or experiencing a medical emergency While most patients will treat aemts with respect some may not but every patient is entitled to compassion respect and the best care possible whether paid or volunteer aemts are Health Care Professionals Bound by patient confidentiality remember at the end of the day you are responsible for your behavior you are responsible for doing the right thing.",
        "Conclusion and Role of AEMTs": "Aemts play a critical role in the EMS system requiring a blend of professional attributes extensive training and a thorough understanding of both medical and Regulatory standards their lure is primarily a state function with variations in practice training and requirements across different states the national EMS scope of practice model provides over arching guidelines at the federal level while state laws regulate operational aspects local medical directors determine the day-to-day limits of EMS Personnel public basic life support training equips millions of lay people with essential skills such as CPR and bleeding control enabling them to provide critical care until professional responders arrive the use of aeds are designed for a lay person to use and are integral at every level of prehospital emergency training EMS research and continuous quality improvement are vital for developing evidence-based standards and improving patient outcomes traditional medical practices have evolved through direct EMS provider experience and ongoing research now underpins these standards aemts are often involved in research Gathering data and contributing to the scientific basis of EMS protocols effective communication systems including emergency medical dispatch ensure coordinated response efforts the integration of Health Services ensures that prehospital care is seamlessly coordinated with hospital care enhancing patient outcomes especially for time-sensitive conditions like heart attacks trauma and strokes additionally EMS providers must stay current with advances in medical science adhere to National training standards and maintain professional attributes such as Integrity empathy and patient advocacy to provide the highest quality of care and maintain the public Trust  a"
    },
    {
        "Introduction to Terrorism Response and Disaster Management": "chapter 42 terrorism response and disaster management planning and anticipating a response to terrorist events present significant challenges due to their unpredictable nature however several key principles can guide effective responses to such incidents terrorism is a global threat that poses risks to Nations and cultures worldwide impacting security and Public Health on multiple levels understanding the nature of terrorism is essential for developing effective strategies to mitigate its effects and enhance preparedness of among emergency response teams the prevailing concern regarding terrorism is not whether it will occur again but rather the timing and location of future attacks the US Department of Justice defines terrorism through several key points it involves violent attacks or actions that pose a danger to human life violating federal or state law the intent behind these attacks typically includes the the objective to intimidate or coers a civilian population influence government policy through intimidation or coercion or affect governmental conduct through means such as mass destruction assassination or kidnapping terrorism can be classified into two primary categories International and domestic International terrorism is perpetrated by individuals associated with or inspired by a defined terrorist organization or nation in contrast domestic terrorism is conducted by individuals aiming to advance ideological causes that are relevant to National issues understanding these classifications is vital for effectively addressing and responding to the diverse threats posed by terrorism although numerous groups exist with varying motivations only a small percentage resort to ter terrorism as a strategy to achieve their objectives among these violent religious groups and doomsday cults often seek to instigate apocalyptic violence or mass murder believing their actions fulfill a prophetic Mission extremist political groups including violent separatist factions aim to secure political religious economic or social freedoms through forceful means additionally cyber terrorists Target a population's technological infrastructure creating disruption and fear without traditional physical violence single issue groups also contribute to the landscape of terrorism these may include anti-abortion Advocates animal rights activists anarchists racists and eot terrorists each pursuing their agendas through acts of violence or intimidation a notable Trend in domestic terrorism is the emergence of the Lone Wolf terrorist attack which has been associated with some of the most devastating incidents on us soil in recent years these attacks can occur in various settings including schools music festivals and shopping centers making them particularly challenging to predict and prevent significant examples include the 2015 Emmanuel am Zion church shooting and Charleston South Carolina the PTZ nightclub shooting in Orlando Florida in 2016 and the 2017 shooting at the Route 91 Harvest music festival in Las Vegas Nevada an active shooter event is characterized as a lone wolf terrorist attack that employs Firearms rather than explosives the Hartford consensus outlines best practices for improving survival rates during mass casualty incidents particularly in the context of active shooter events key recommendations include a focus on threat suppression Hemorrhage control rapid extrication to safety assessment by medical providers and transport to definitive care this framework emphasizes that care begins with immediate responders highlighting the importance of early Hemorrhage control in re-evaluating the National practice of staging away from the scene of an incident to enhance response efficiency many Emergency Medical Service organizations have established rescue task forces which modify the roles and responsibilities of personnel responding to active shooter situations these teams are designed to operate in the warm Zone where there is a reduced risk compared to The Hot Zone and often consist of EMS Crews working in conjunction with law enforcement teams facilitated by inter agency training aemts play a critical role in these situations by maintaining a high degree of situational awareness preparing both mentally and physically for rapid response and supporting the education of immediate responders to maximize the chances of saving lives",
        "Weapons of Mass Destruction (WMDs) Overview": "weapons of mass destruction or wmds also referred to as Weapons of mass casualty are designed to inflict Mass death cause widespread casualties and result in extensive damage to property and infrastructure to categorize the various types of wmds tonics Bice and cbrn can be employed the Bice bonic stands for biologic nuclear incendiary chemical and explosive weapons encompassing a range of potential threats that can have devastating effects the cbrn memonic represents chemical biologic radiologic nuclear and explosive agents highlighting the diverse nature of these threats terrorist groups have historically favored tactics that involve explosive devices employing methods such as truck bombs and pedestrian suicide bombers to maximize impact and instill fear while there have been attempts to utilize chemical or biologic weapons these efforts have been largely unsuccessful in achieving their intended effects one significant concern is that weapons of mass destruction are relatively accessible as they can be obtained or created with a degree of ease moreover technical instructions for constructing wmds are increasingly available on the internet further complicating efforts to prevent their use",
        "Chemical Terrorism and Warfare": "chemical terrorism or Warfare involves the use of manufactured substances known as chemical agents which can have devastating effects on living organisms these agents can be produced in various forms be it liquid gas or solid depending on the desired route of exposure and the chosen dissemination Technique we can classify these chemical agents into several different classes vesicants also known as blister agents cause severe skin and tissue damage respiratory or choking agents lead to damage of the respiratory system nerve agents disrupt normal nerve function resulting in paralysis and potentially fatal outcomes and metabolic agents such as cyanides interfere with the body's ability to use o oxygen leading to Cellular asphixiation",
        "Biologic Terrorism and Warfare": "biologic terrorism or Warfare involves the use of biologic agents that cause disease these agents are often cultivated synthesized or mutated in laboratory settings for terrorist purposes enhancing their potency and Effectiveness the primary types of biologic agents include viruses bacteria toxins and each are capable of causing significant harm to Public Health",
        "Radiologic and Nuclear Terrorism": "radiologic and nuclear terrorism while historically less common poses a serious threat there are only two publicly known incidents involving the use of a nuclear device yet some Nations maintain close ties with terrorist groups this is referred to as state sponsored terrorism and have achieved varying degrees of nuclear capability moreover it's feasible for terrorists to acquire radioactive materials or waste enabling them to perpetrate acts of Terror the accessibility of these materials makes it easier for terrorists to secure them and requires less expertise for Effective use heightening the potential for catastrophic incidents",
        "Recognizing and Responding to Terrorist Attacks": "recognizing a terrorist attack is critical as most acts of Terror are conducted covertly making awareness of one's surroundings essential individuals should remain Vigilant and understand the potential risks associated with terrorism staying informed about the current Threat Level issued by the federal government can provide valuable context for assessing risk additionally being aware of information disseminated by the national terrorism advisory system is crucial for understanding specific threats and recommended safety measures when evaluating the potential for a terrorist attack several observations can be made to inform assessment and response efforts first consider the type of location involved as certain areas may be more likely targets for terrorism such as crowded public spaces Transportation hubs or symbolic sites next assess the type of call received as unusual circumstances or specific specific threats can indicate a heightened risk the number of patients can also provide critical insights a sudden influx of casualties may suggest a mass casualty incident linked to a terrorist attack pay close attention to the patient statements as their accounts May differ or offer clues about the nature of the event or the presence of a threat lastly be vigilant for pre-incident indicators which can include suspicious Behavior unusual activity in the area or any warning signs that may suggest an imminent attack",
        "Ensuring Scene Safety and Responder Protection": "when responding to a potential terrorist event ensuring scene safety is Paramount first stage your vehicle at a safe distance typically one to two blocks away from the incident site in order to minimize exposure to any Potential Threat threats remain in a secure location until law enforcement Personnel confirm that the scene has been made secure if there is any uncertainty regarding the safety of the scene do not enter Additionally the best position for staging is upwind and uphill from the incident as this helps protect against potential hazards such as chemical agents or smoke by following these actions emergency responders can Safeguard themselves and effectively coordinate efforts to assist victims while minimizing risks it's vital to remember several key points when responding to a potential terrorist incident first failing to park your vehicle in a safe location can endanger both you and your partner as exposure to threats may increase significantly always formulate an escape plan in advance to ensure you can exit the scene quickly if necessary if your vehicle becomes blocked by other emergency vehicles or sustains damage from a secondary device or event you may be unable to transport victims or evacuate yourself complicating the response effort responder safety is of utmost important particularly in the context of weapons of mass destruction the most effective method of protection is to avoid contact with the wmd agent altogether contamination and gross contamination represent the greatest threats to Personnel therefore maintaining a safe distance and utilizing appropriate personal protective equipment is essential in minimizing exposure risks",
        "Effective Communication and Command in Terrorist Events": "effective notification procedures are critical during a potential terrorist event when communicating with dispatch provide detailed information including the nature of the event any additional resources that may be required the estimated number of patients and the optimal route of approach again ideally upwind and uphill from the incident establishing a staging area is necessary in order to ensure that responders can operate safety and efficiently only trained responders equi with the proper personal protective equipment should handle incidents involving wmds it's important to request specialized teams as early as possible considering the time needed to assemble and deploy these resources additionally responders must remain aware that multiple types of devices or agents may be present which necessitates a heightened vigilance and preparedness initially it's important to establish command and maintain it until additional Personnel arrive on the scene in this capacity you may assume various roles including medical Branch director triage supervisor treatment supervisor Transportation supervisor logistic officer or part of the command and general staff if the instant command system is already in place seek out the medical staging officer to receive your assignment this approach ensures that roles are clearly defined and that the response efforts are coordinated effectively",
        "Continuous Scene Safety Assessment": "reassessing scene safety is an ongoing responsibility during a response to a terror incident remain Vigilant as terrorists have been known to plant additional explosives designed to detonate after the initial bomb with the intent to injure responders and secure media coverage these secondary devices can take various forms including different types of electronic equipment which may be difficult to identify responders must continuously assess and reassess the scene for safety remaining alert to any changes in conditions that could pose additional risks this proactive approach to scene safety helps ensure the well-being of all Personnel involved allowing for a more effective response to the incident",
        "Chemical Agents: Properties and Effects": "chemical agents can be characterized by their physical properties and may be classified as a liquid gas or solid material two important characteristics are persistency and volatility which describe the duration an agent remains on a Surface before evaporating persistent or nonvolatile agents can remain on surfaces for extended periods typically longer than 24 hours posing a sustained risk conversely non-persistent or volatile agents even evaporate relatively quickly when left on the surface particularly within an optimal temperature range the route of exposure is also critical as it indicates how an agent most effectively enters the body agents that pose a vapor Hazard primarily enter through the respiratory tract while those with a contact Hazard can penetrate the skin",
        "Vesicants (Blister Agents) and Their Effects": "vesicants also known as blister agents primarily affect individuals through skin exposure if these agents remain on the skin or clothing for an extended period they can produce Vapors that subsequently enter the respiratory tract the effects of vesicant include the formation of burn-like blisters on the skin and within the respiratory system leading to significant pain and injury common vesicant include sulfur mustard Lite and fosen oxine these agents typically Ally inflict the most damage on damper moist areas of the body such as the armpits groin and respiratory tract signs of exposure to vesicant can manifest in various ways indicating the severity of the chemical injury initial symptoms may include skin irritation burning and rening which can progress to immediate and intense skin pain particularly with agents like Lite and phos genen oxine a Hallmark sign of severe exposure to is the formation of large blisters on the skin alongside gray discoloration which signifies permanent damage particularly associated with Lite and fos gen oxine additional symptoms may include swollen and irritated eyes potentially leading to permanent eye injury including blindness if Vapors are inhaled the respiratory effects can be significant it may include horseness and Strider severe cough hemo typis and severe dnia sulfur mustard is a brown yellow oily substance recognized for its high persistency in the environment when absorbed through the skin it initiates an irreversible process of cellular damage this agent is characterized by its distinct garlic or mustard odor and is class classified as a mutagen capable of mutating damaging and altering cellular DNA ultimately leading to Cellular death patients exposed to sulfur mustard will exhibit Progressive rening of the affected skin area which can gradually evolve into large blisters these blisters resemble the shape and appearance of thermal second degree burns although they do not contain the agent itself it's important to note the skin remains contaminated until appropriate decontamination procedures are carried out moreover sulfur mustard targets cells within the bone marrow itself severely depleting the body's capacity to produce white blood cells which compromises the immune system Lite and fosen oxine produce blister wounds that are similar to those caused by mustard gas characterized by immediate intense pain and discomfort affected patients May display gray discoloration of the skin indicating significant tissue damage although this damage does not lead to secondary cellular injury as seen with sulfur mustard regarding the treatment of vesicant agent exposure it's important to note that there are no antidotes available for exposure to sulfur mustard or fos genene oxine however British anti-is it serves as the antidote for Lite although it's not typically carried by civilian EMS Services before any treatment is initiated thorough decontamination must be performed to minimize further harm once decontamination is complete establishing IV access is critical and initiating transport to a medical facility should occur as soon as possible burn centers are best equipped to manage the wounds and subsequent infections resulting from vesin exposure making them the ideal destination for affected patients",
        "Respiratory Agents (Choking Agents) and Their Effects": "respiratory agents commonly referred to as choking agents are gases that cause immediate harm upon exposure the primary route of exposure is through the respiratory tract where these agents can lead to significant damage to lung tissue this damage often results in fluid leakage into the lungs further complicating the clinical presentation exposure to respiratory agents produces various respiratory related symptoms including dnia tpia and pulmonary edema understanding the properties and effects of respiratory agents is crucial for emergency responders as prompt recognition and intervention can significantly impact patient outcomes in cases of exposure chlorine was the first chemical agent utilized in Warfare and is characterized by its distinct odor reminiscent of bleach often creating a green Haze when released into the environment upon initial exposure it produces upper Airway irritation and a choking sensation as the exposure progresses patients may experience a range of respiratory symptoms including shortness of breath chest tightness horse Ness Strider gasping and coughing in cases of serious exposure the situation can escalate significantly resulting in pulmonary edema as well as complete Airway constriction and potentially death fos Gene is a highly potent chemical agent known for its delayed onset of symptoms which can complicate the assessment of exposure unlike choking agents fene does not produce severe irritation upon initial contact the odor Associated is reminiscent of freshly moan grass or hay which may lead to a misinterpretation of its presence in cases of mild exposure individuals may initially experience symptoms such as nausea chest tightness severe cough and dipsia upon exertion however with severe exposure the clinical picture can deteriorate rapidly resulting in dipsia at rest and excessive pulmonary edema the treatment for exposure to fos Gene and other respiratory agents involves several critical steps aimed at ensuring patient safety and effective management of symptoms the first priority is to remove the patient from the contaminated atmosphere to prevent further exposure it's essential to keep the patient calm and inactive to minimize respiratory demand currently there are no antidotes available for fos Gene exposure so the primary treatment goals focus on managing the airway breathing and circulation emergency responders should gain IV access to facilitate fluid administration and medication delivery as needed it's also important to allow the patient to rest in a position of comfort ideally with the head elevated to Aid in breathing",
        "Nerve Agents and Their Effects": "nerve agents are among the deadliest chemicals ever developed characterized by their extreme toxicity and Rapid lethality exposure to these agents can lead to Cardiac Arrest within seconds to minutes making them particularly dangerous in any situation nerve agents belong to a class of chemicals known as Organo phosphates which are commonly found in household bug sprays agricultural pesticides and some industrial chemicals these agents work by blocking an essential enzyme in the nervous system leading to the over stimulation of organs which can ultimately cause them to burn out the G agents which were derived from early nerve agents include several types with varying volatility among them sarin or GB is a highly volatile colorless and odorless liquid that is extremely lethal with a lethal dose ld50 equivalent to just one drop sarin primarily presents a vapor Hazard making it particularly perilous in enclosed environments It's Quickly absorbed through the skin and evaporates rapidly and when it contaminates clothing it can produce off gassing further increasing the risk of exposure San and tabin are other significant G Series nerve agents each with unique characteristics s or GD is approximately twice as persistent as sarin and five times as lethal it has a fruity odor and is generally colorless GD poses both contact and inhalation hazards making it dangerous through multiple routes of exposure a unique aspect of s is its ability to bind to cells rapidly due to an additive that accelerates this action a process known as aging which results in faster and more severe toxicity compared to other nerve agents tabin or GA in contrast is about half as lethal as sarin but is 36 times more persistent like s it has a fruit odor and a similar appearance to GB increasing the difficulty of distinguishing between these agents tabin is notable for the relative ease with which it can be manufactured as its components are readily available it also presents both contact and inhalation hazards increasing its potential for widespread harm the V agent or VX is a nerve agent that presents as a clear oily liquid resembling baby oil with no discernable color while it shares some properties with the G Series nerve agents VX is over 100 times more lethal than sarin and is characterized by its extreme persistency unlike the G agents VX can remain relatively unchanged on surfaces for weeks to months significantly prolonging the risk of exposure VX is EAS easily absorbed through the skin making contact a primary Hazard and its oily residue is notably difficult to decontaminate due to its high potency and persistency it poses a significant challenge in emergency response and decontamination requiring specialized protective measures to efficiently manage exposure and prevent secondary contamination nerve agents produce a range of similar symptoms across different exposure types though the specific route of Entry lethal concentration or dose and volatility of each agent can vary significantly the severity of symptoms depends on both the route and the quality of exposure clinically symptoms of nerve agent exposure can be remembered using the mimics SL sudum and dumbbells slum stands for salivation lacrimation urine ation defecation gastrointestinal distress emesis meosis and muscle spasms while dumbbells stands for diarrhea urination meosis verto cardia bronchospasm Bron Oria emesis lacrimation and salivation one of the Hallmark signs of nerve agent exposure is meosis or excessively pinpoint pupils which is a rare presentation in most medical conditions this sign appears rapidly in cases of vapor exposure but may take longer to develop if the exposure is limited to the skin fatalities resulting from nerve agent exposure typically occur due to respiratory complications as these agents overstimulate the nervous system and impair breathing therefore Airway management and ventilatory support are critical for increasing the chances of survival medical treatment may include the doo doe auto injector which administers two key medications atropine and prid doxine chloride atropine serves to block the nerve agents effects on the body in military settings the combination injector is known as the antidote treatment nerve agent auto injector or atna this is designed for Rapid Administration in field conditions early recognition and immediate intervention are essential for effectively managing nerve agent exposure and improving patient outcomes",
        "Metabolic Agents and Their Effects": "metabolic agents such as hydrogen cyanide and cyen chloride disrupt the body's ability to utilize oxygen effectively causing cellular asphixiation cyanide gas is colorless and emits an odor similar to almonds although not everyone can detect this scent the effects of cyanide exposure begin at the cellular level and quickly manifest in major organs and bodily systems making its impact rapid and severe these agents are highly lethal with the potential to cause death within seconds to minutes of exposure cyanide compounds are commonly found in various industrial settings which increases the risk of accidental or intentional exposure at lower doses cyanides can produce symptoms such as dizziness lightheadedness headache and vomiting exposure to higher doses of cyanide rapidly leads to more severe symptoms which may include shortness of breath gasping respirations and respiratory distress or arrest other manifestations include teyia flush skin tacac cardia and altered mentation neurological symptoms May escalate to seizures coma and eventually apnea and then cardiac rest when cyanide is inhaled in large amounts the onset of symptoms typically occurs within minutes and without prompt and appropriate treatment the likelihood of death is very high treatment of cyanide poisoning involves several key interventions the use of specific medications as antidotes is Central to reversing the toxic effects however initial management also includes removing all contaminated clothing to prevent off gassing during transport in the ambulance for patients exposed to liquid cyanide thorough decontamination by trained and protected Personnel is is necessary before initiating medical treatment supportive care focuses on maintaining Airway breathing and circulation along with establishing IV access for patients with mild symptoms simply removing them from the source of contamination and administering supplemental oxygen may lead to symptom resolution however in cases of severe cyanide exposure more aggressive oxygenation and ventil support will be required if antidotes are not available on scene rapid transport to an appropriate medical facility is critical for definitive treatment",
        "Biologic Agents: Viruses, Bacteria, and Neurotoxins": "biologic agents responsible for causing diseases often present with symptoms similar to other common illnesses making their identification challenging in the initial stages these agents are typically classified into three main main categories viruses bacteria and neurotoxins they can spread through various mechanisms including direct contact Airborne transmission or vectors key Concepts associated with biologic agents include dissemination which refers to the method by which the agent is spread and the disease Vector which is any animal that facilitates the transmission of the dis disease communicability is a critical factor that indicates how easily the disease can be spread a person with a highly communicable disease is considered contagious fortunately routine standard precautions are often sufficient to prevent contamination for many biologic organisms another important factor is the incubation period which is the interval between exposure to the biologic agent and the onset of the first symptoms during this period patients may not exhibit any signs or symptoms yet they may still be capable of spreading the disease to others viruses are infectious agents that require a living host to multiply and survive as they cannot replicate or Thrive outside of a host organism once a virus invades a healthy cell it replicates itself spreading throughout the host body and often causing disease viruses are typically transmitted from host to host through direct methods such as respiratory droplets bodily fluids or through vectors while vaccines exist for some viruses offering a form of preventive protection treatment options are generally Limited in many cases specific antiviral medications may be used to mitigate symptoms or slow the progression of the infection but they are simply not Curative in 2020 covid-19 caused by a novel Corona virus underwent mutations that significantly increased its communicability leading to a global pandemic to mitigate the spread of the virus many countries including the United States implemented Public Health measures such as quarantine stay-at-home orders and the closure of non-essential businesses these measures aim to reduce the transmission rate and manage healthc care system burdens healthcare workers faced the Dual challenge of protecting themselves while simultaneously providing care for critically injured patients this required strict adherence to personal protective equipment protocols evolving clinical guidelines and often working in high stress environment ments to manage the rapid influx of patients small poox is a highly contagious viral disease requiring strict protective measures to prevent transmission healthc care providers should wear exam gloves a high efficiency particulate respirator and eye protection when managing a suspected or confirmed case clinically small pox presents initially with non specific symptoms such as high fever body aches and headaches before the characteristic rash and blisters appear the distinguishing feature of small pox is the size shape and location of its lesions which are different from other viral infections typically appearing uniform and progressing in the same stage across the body viral hemorrhagic fevers or vhfs Encompass a group of severe disease es caused by viruses such as Ebola Rift Valley fever marberg and yellow fever these viruses are characterized by their ability to cause damage to the vascular system leading to blood seeping out of tissues and blood vessels resulting in both internal and external bleeding patients typically present initially with flu like symptoms which can rapidly progress to more severe conditions including hemorrhaging as well as multi-organ failure and shock due to the highly infectious nature of vhfs providers should follow all standard precautions including proper use of PPE and isolation protocols mortality rates for vhfs can vary greatly and are influenced by several factors including the specific strain of the virus the patients's age and overall health and the availability of modern healthc care resources for supportive care and treatment bacteria differ from viruses in that they do not require a host to multiply and they can survive independently in various environments unlike viral infections bacterial infections can be effectively treated with antibiotics the early symptoms of many bacterial infections often mimic those with the flu including fever body aches and malaise an example of a bacterial disease is anthrax which can present in pulmonary cutaneous or GI forms Anthrax is caused by a bacterium that can remain dormant within a Spore a protective shell that allows it to survive in harsh conditions the routes of entry for Anthrax include inhalation skin contact and indigestion once exposure occurs antibiotics are the primary treatment option and their early Administration is critical for improving patient outcomes the plague exists in two primary forms bubonic and pneumonic each with distinct characteristics in routes of transmission the natural vectors for the plague are infected rodents and fleas which can spread the bacterium to humans the buban plague targets the lymphatic system leading to swollen and infected lymph nodes known as bbos which are large rounded and painful if the bubonic form is left untreated it can progress to sepsis and result in death however it is important to note that the plague is not contagious between humans the pneumonic plague in contrast is a lung infection and is often referred to as plague pneumonia This is highly contagious through respiratory droplets this form of the plague has a much higher mortality rate compared to the bubonic form and requires rapid isolation and treatment to prevent further spread and to improve patient survival neurotoxins are among the deadliest substances known to humans and can originate from various natural sources including plants marine animals molds and bacteria the routes of exposure to neurotoxins include ingestion inhalation of aerosols or injection unlike many other biologic agents neurotoxins are not contagious between individuals and tend to cause symptoms with a rapid onset after exposure one of the most potent neurotoxins is the botulism toxin which profoundly affects the nervous system's ability to function this toxin impairs voluntary muscle control causing progressive muscle paralysis which if left untreated can extend to the muscles that are responsible for breathing leading to respiratory arrest and eventually death rysen is a highly toxic neurotoxin approximately five times more lethal than VX but less deadly than botulism toxin it's derived from the mash remaining after processing the castor bean riceon exposure can lead to pulmonary edema respiratory failure and circulatory failure making it extremely dangerous across various routes of exposure particularly inhalation the toxicity is comparatively lower through oral ingestion the signs and symptoms vary based on the route of exposure the ingestion of rice may result in fever chills headache muscle aches nausea vomiting diarrhea severe abdominal cramping dehydration GI bleeding and necrosis of the organs including the liver spleen kidneys and GI tract conversely inhalation of rysen presents with fever chills and nausea irritation of the Eyes Nose and Throat profuse diaphoresis headache muscle aches non-productive cough chest pain Dipa pulmonary edema severe lung inflammation cyanosis seizures and respiratory failure treatment is primarily supportive focusing on maintaining the ABCs while managing symptoms during a biologic event a EMTs play a crucial role in syndromic surveillance which involves monitoring and recording trends that could indicate a public health threat this includes monitoring patients who present to emergency departments and Alternative Care Facilities with signs and symptoms that could be associated with the biologic agent or outbreak recording EMS call volumes as an increas in cause with similar complaints May indicate the spread of an infectious disease or biologic agent and tracking the use of over-the-counter medications as a sudden surge in the purchase of certain symptom relief drugs could signal the presence of an emerging illness aemts may also be involved in points of distribution which are facilities set up for the mass distribution of critical medical supplies including antibiotics chemical antidotes antitoxins vaccinations and other necessary medications and Equipment these facilities are part of the Strategic National stockpile which is a national resource of emergency supplies in response to a biologic event these supplies may be deployed in push packs which are prepackaged deliveries designed to arrive anywhere within the country Within 12 hours to ensure rapid access to life-saving medications and supplies aemts may be called upon to assist with various aspects of pod operations including the distribution of medications to the public in ensuring that the response is both efficient and effective in reaching all affected individuals quickly",
        "Ionizing Radiation and Radiologic Materials": "ionizing radiation is a type of energy released in the form of rays or particles and is commonly associated with radioactive materials these materials are inherently unstable and undergo a process known as decay where they change their structure to achieve stability during this Decay process radiation is emitted continuously until the material stabilizes there are several types of radiation emitted by radioactive sources each vary in their pen ative power Alpha radiation is the least penetrating form it cannot move through most objects such as a sheet of paper or human skin making it the least harmful externally beta radiation is slightly more penetrating than alpha particles and can be stopped by a layer of clothing or a few millimeters of a substance like plastic gamma rays are far faster and more powerful than both both Alpha and beta radiation they have significant penetrating ability and require denser materials such as lead or concrete to block them effectively Neutron particles are among the most powerful forms of radiation with a high penetrating ability making them particularly hazardous radiologic materials are widely used for various beneficial purposes including Medical IAL applications such as Diagnostic Imaging and Cancer Treatments irradiation of food to kill germs and extend shelf life and in construction work such as testing materials for structural Integrity these sources of radiologic material are commonly found in locations such as hospitals and other health care facilities that house Radiology departments for Diagnostic and therapeutic uses colleges and universities particularly those with research programs involving radiologic science or engineering chemical and Industrial sites where radioactive materials may be used in manufacturing quality control processes and nuclear power plants where radiologic materials are utilized for energy production radiologic dispersal devices are containers that are specifically designed to spread radioactive material material often through the use of explosive mechanisms one example is the dirty bomb which combines conventional explosives with radioactive substances the potential harm from a dirty bomb comes not only from the radioactive material it disperses but also from the explosive force used for dissemination however the actual destructive capability of an rdd is typically limited to the power of the explosives that are attached Ed as the radiation itself often poses more of a contamination threat than an immediate physical hazard consequently dirty bombs are often considered ineffective weapons of mass destruction in terms of causing large scale fatalities though they can still create significant Panic contamination and disruption",
        "Nuclear Energy and Weapons": "nuclear energy is produced artificially by altering or splitting radi active atoms in a process called nuclear fision this process releases a vast amount of energy primarily in the form of heat which can then be harnessed for various applications nuclear material has several key uses including medicine where it's utilized for Imaging and cancer treatment weapons particularly in the development of nuclear explosives Naval vessels such as submarines and aircraft carriers that use nuclear reactors for propulsion and power plants which convert nuclear energy into electricity nuclear weapons are typically stored in highly secure facilities worldwide with extensive safety measures to prevent unauthorized access or use the likelihood of a large-scale nuclear attack is considered extremely remote due to a stringent Global Security protocol and deterrence policy however there is ongoing concern regarding smaller nuclear devices known as special Atomic demolition Munitions or suitcase nukes the whereabouts of many of these devices remain unknown heightening fears of their potential misuse these suitcase siiz nuclear weapons were originally designed for tactical use specifically to Target and Destroy individual structures such as buildings Bridges tunnels or large ships their compact size and Powerful destructive capability make them a particular concern in discussions about nuclear security and potential terrorist activity",
        "Radiation Exposure and Medical Management": "the effects of radiation exposure can vary significantly based on two primary factors the amount of radiation received or dose and the route of exposure radiation can enter the body through multiple routes including inhalation indigestion absorption through the skin or wound contamination additionally exposure can occur through irradiation where the body is exposed to radiation without direct contamination from a radioactive Source medical management of radiation exposure requires an understanding of the difference between exposure and contamination if a patient is merely exposed to a radiation Source without physical contact with radioactive material they are not contaminated or radioactive however if a patient has radioactive substances on their body or clothing they are considered contaminated and must be initially managed by Hazmat responders once decontamination is complete and there is no remaining threatened responders standard treatment can begin focusing on ABCs and addressing any Burns or trauma sustained appropriate PPE should always be used when managing these patients to ensure safety from potential contamination body fluids obtained from contaminated patients should be placed in plastic bags for secure disposal when dealing with radiation it's important important to note that no suit or protective gear can provide complete shielding from radiation exposure the best protective measures involve three key principles first maximize the time spent near the radiation source to reduce exposure two increase your distance from the source of radiation as exposure decreases significantly with increased distance and third use appropriate barriers such as walls or leadline Shields to reduce exposure to radiation",
        "Incendiary and Explosive Devices": "incendiary and explosive devices come in a wide variety of shapes and sizes and it's critical for responders to be able to identify potential devices promptly notify the proper authorities and Evacuate the area safely additionally responders should be aware of the potential for a secondary device intended to Target those responding to the initial explosion the mechanisms of injury from an explosion are determined primarily by a patient's distance from the blast epicenter injuries are categorized into five types primary blast injuries are caused solely by the pressure wave from the explosion they typically affect hollow organs such as the lungs intestines and ears secondary BL last injuries result from flying debris propelled by the explosion and this can lead to penetrating or non-penetrating trauma tertiary blast injuries occur when the force of the blast displaces the entire body resulting in Impact injuries when the person is thrown against objects or structures quinary injuries Encompass any other injuries associated with the explosion including including Burns inhalation injuries Crush injuries or exacerbation of existing medical conditions lastly quinar blast injuries are related to exposure to toxic materials associated with the explosion such as radiation bacteria or chemicals the physics of an explosion involve a rapid and violent chemical reaction when a substance is detonated it converts a solid or liquid into large volumes of gas under high pressure which results in a significant release of explosive energy this release creates a pressure pulse that forms a spherical blast wave expanding outward in all directions from the point of detonation the force and energy generated by the explosion can Propel debris at high speeds while the accompanying high winds have the potential to cause both blunt and penetrating trauma to individuals caught within the blast radius certain tissues in the body are more susceptible to injury from explosions primarily due to pressure changes and their physical characteristics hollow organs such as the lungs intestines and stomach are particularly vulnerable to Rapid pressure shifts as they cannot easily withstand the force of a blast wave areas where tissues of different densities meet such as in between Airfield and solid tissues as well as exposed tissues are also prone to injury from blast forces the ear is the most sensitive to blast injuries as the sudden pressure changes can easily damage the eard drum and middle ear structures primary pulmonary blast injuries manifest as contusions and hemorrhages within the lungs a condition called Blast long is the most common cause of death among those who survive the initial explosion and identified by a clinical Triad of apnea bardia and hypotension solid organs such as the liver spleen and brain are typically less affected by the pressure wave itself but may be injured by secondary missiles or when the body is forcefully hurled against another surface hollow organs such as the bowel may be injured through mechanisms similar to those affecting lung tissue with the potential for rupture or bruising due to the pressure and forceful displacement neurologic injuries in head trauma are among the most frequent causes of death following an explosion these injuries may include subarachnoid and subdural hematomas which are forms of bleeding around the brain brain individuals may also suffer from permanent or transient neurologic deficits caused by concussions intracerebral Hemorrhage or air embolisms that interfere with normal brain function symptoms can range from instant but transient unresponsiveness which may or may not be accompanied by retrograde amnesia all the way to significant autonomic disruptions such as bra cardia and hypoten in addition to head and neurologic injuries explosions can cause extremity injuries including traumatic amputations these injuries result from the force of the blast flying debris or being propelled against solid objects which can then lead to significant blood loss and other complications involving immediate medical intervention",
        "Conclusion and Summary": "the US Department of Justice defines terrorism as acts of violence or actions dangerous to human life that violate federal or state law with the intent to intimidate or coer civilians influence governmental policy or impact governmental conduct through mass destruction assassination or kidnapping terrorism is broadly classified into International and domestic with International terrorism associated with Define terrorist organizations or state and domestic terrorism driven by ideological causes relevant to National issues although only a small fraction of groups resort to terrorism to meet their goals these groups can range from violent religious cults to single issue Cults terrorist tactics have increasingly involved individual Lone Wolf attacks and active shooter events prompting the development of strategies such as the Hartford cons census and rescue task force models which aim to enhance response and Care terrorists have historically employed Weapons of Mass destructions including explosive devices chemical agents biologic agents and radiologic nuclear devices each with devastating effects chemical agents vary by their state be it liquid solid or gas in their mode of exposure biologic agents such as bacteria viruses and neurotoxins can cause widespread disease and require close syndromic surveillance by providers in order to track and respond to outbreaks effectively radiologic and nuclear devices involve ionizing radiation and can come from various sources including industrial and Healthcare settings protective measures against radiation exposure invol involve minimizing the time spent near sources increasing distance and using shielding as there is no complete protective gear available in recognizing and responding to terrorist events scene safety is Paramount and the vehicle should be staged safely upwind and uphill from the incident awareness of the type of location call number of patients and pre-incident indicators are crucial in identifying potential terrorist activities aemts play a critical role in the initial assessment and triage of patients exposed to various threats such as chemical biologic and radiologic agents and must be ready to provide immediate life-saving interventions while protecting themselves from contamination and ensuring rapid transport to appropriate facilities understanding the mechanisms of injury from explosive devices and the diverse threats from various wmds is fundamental to ensuring effective response and patient care in these complex and evolving situations"
    },
    {
        "Introduction to Medical-Legal Issues": "chapter 2 medical and legal issues navigating the legal aspects of the healthc Care field can be particularly daunting and unfamiliar for Emergency Medical Services providers this challenges them in various ways emergency medical service providers typically receive extensive medical training but the legal realm is often overlooked their primary focus is on delivering emergency medical care and they may have little training or experience in understanding the complex legal landscape that governs their practice this Gap in education can make them ill acqui to handle legal issues that may arise during their work in the legal domain errors or an action can have severe repercussions both for individual providers and their agencies legal issues can lead to personal liability damage to professional reputations and legal actions against the agency itself the consequences can be significant making it crucial for providers to be well informed about the legal aspects of their practice the education most providers do receive regarding legal matters is often insufficient and may even be intermingled with incorrect or misleading information this can further contribute to confusion and uncertainty about legal responsibilities rights and obligations in the healthcare field the medical legal realm with emergency medical science experience is relatively underserved by subject matter experts there's a shortage of professionals who are well versed in both the medical and legal aspects of Health Care this shortage can make it challenging to access accurate and reliable guidance on legal matters specific to emergency medical science to operate effectively within this intricate legal framework healthc care providers and professionals must take steps to familiar familiarize themselves with legal Concepts and terms this includes understanding local laws they need to be aware of the laws and regulations that apply in the specific regions where they practice legal requirements can vary significantly from one jurisdiction to another protocols and their limitations a solid understanding of medical protocols and their legal limitations is essential providers must know what actions they can legally perform especially in emergency situations documentation skills accurate and thorough documentation is crucial proper recordkeeping helps protect providers legally and ensures they have a strong foundation for any necessary legal defense effective communication maintaining clear and appropriate communication with other providers Health Care Professionals patients and their family members is essential effective communication can help prevent misunderstandings miscommunications and potential legal issues understanding the various areas of law is essential for health care providers especially those in the field of Emergency Medical Services as it pertains to their practice and legal responsibilities here we expand on the key areas of law tort law plays a significant role in the legal landscape for healthc care providers it deals with harm inflicted by one person or entity against another in the context of Emergency Medical Services and health care this often relates to medical malpractice cases tort law enables individuals to seek legal remedies for harm caused by the negligence or wrongful actions of healthc care providers understanding the principles of tort laot is crucial for providers as they need to uphold a high standard of care and minimize the risk of legal actions common law sometimes referred to as case law is established through prior disputes in court these cases are published to guide future legal proceedings common law sets legal precedents that are vital for healthcare providers as it helps interpret statutes and regulations Emergency Medical Service Providers May encounter common law principles when addressing patient care standards and liabilities as these precedents inform legal judgments based on similar past cases criminal law pertains to wrongdoings against the rules of the state in the context of healthc care this may include criminal actions such as fraud drug diversion or even patient abuse healthc care providers including emergency medical science professionals must be aware of the legal boundaries defined by criminal law to ensure they are in compliance with regulations and ethical standards failure to adhere to these laws can lead to criminal charges and legal consequences civil law addresses wrongs between individuals or entities in healthc care this may involve disputes over contracts financial matters or disagreements between healthc care providers and patients emergency medical science providers May encounter civil law issues related to billing disputes contract negotiations or disputes with healthc care facilities or patients understanding civil law principles is crucial for resolving these matters through legal channels administrative law pertains to wrongs committed by individuals who are granted permission to practice by the state healthc care providers including emergency medical science professionals are subject to various administrated regulations licenses and permits that allow them to practice violations of these regulations can result in disciplinary actions and legal consequences knowledge of administrative law is vital for maintaining compliance and understanding the regulatory framework within which healthc care providers operate healthc care providers must have a working knowledge of these different areas of law their practice is intertwined with legal responsibilities and liabilities making it crucial to understand tort law common law criminal law civil civil law and administrative law by being aware of these legal principles healthc care providers can ensure that they deliver care within legal boundaries mitigate legal risks and maintain the highest standards of patient care additionally it helps them navigate legal challenges when they arise in their practice",
        "Understanding Negligence in Healthcare": "negligence a crucial aspect of tort law is a legal concept that healthc care providers including emergency medical science professionals must thoroughly understand stand here we expand on the key components of negligence and its implications negligence is a fundamental element of tort law in the context of Health Care it refers to instances where a health care provider such as an emergency medical science professional fails to meet the expected standard of care resulting in harm to a patient negligence forms the basis for many medical malpractice cases the principles of negligence largely find their basis in common law law which is derived from precedents set by previous legal cases these precedents help Define the standards of care and responsibilities of healthc care providers while common law forms the backbone of negligence law specific elements are codified in statutes these statutes can vary from state to state and emergency medical science professionals must be aware of the relevant statutes in their jurisdiction negligence cases are primarily governed by state law leading to the existence of a unique body of law in each state variations in statutes of limitations comparative negligence rules and Immunity laws can make negligence law markedly different from one jurisdiction to another to establish negligence four criteria must be met the healthc care provider had a duty to act the provider breached this Duty the patient suffered damages due to this breach and finally these damages were a foreseeable consequence of the breach one of the most critical points in negligence law is that it does not require the intent to cause harm negligence cases involve mistakes that lead to harm however if intent to harm is found it can lead to punitive damages in a civil lawsuit or criminal charges against the defendant a statute of limitations sets a time limit within which negligence cases must be brought typically this period is around two years but it can vary significantly by state some factors such as the patient being a minor or not knowing they were a victim of negligence May extend this time limit understanding negligence and its legal implications is Paramount for healthc care providers it involves grasping both the common law principles that underly negligence and the specific statutes that apply in their jurisdiction negligence cases can have far-reaching consequences so healthc care providers must maintain a strong commitment to delivering care within legal boundaries to to minimize the risk of legal actions and provide the highest standard of patient care",
        "Higher Standards and Immunity Laws": "expanding on the concept of other standards and Immunity laws in the context of Health Care offers insights into the legal framework that governs their actions and responsibilities in certain cases the law requires a higher standard to be met in order to find a healthc care provider responsible for an injury these higher standards often come into play when determining liability two primary standards are first re less conduct or gross negligence this involves consciously disregarding the known risks associated with a particular course of action it goes beyond ordinary negligence and suggests a willful disregard for safety and second willful and wanting misconduct this standard requires an intentional Act of misconduct demonstrating an even higher level of culpability many states have enacted immunity statutes that provide for one of these higher standards to be applied in provider cases these statutes often take a closer look at the specific type of action being performed in cases where the actions of providers are deemed Reckless or willful and wanting immunity laws may not Shield them from legal liability sovereign immunity is another type of immunity that may be afforded to Providers but it generally applies to governmental entities under sovereign immunity the government is immune from certain legal actions however it's important to note that the application of sovereign immunity can differ significantly based on the type of act being performed by the provider sovereign immunity can differentiate between two types of actions ministerial acts are actions that require a specific act to be performed given a set of circumstances in cases of ministerial acts providers are typically not protected by sovereign immunity as their actions are considered obligatory and not subject to governmental discretion in contrast discretionary acts involve situations where the provider has some latitude in decision making in cases of discretionary acts providers are generally protected by sovereign immunity as their actions are subject to a degree of judgment or Choice",
        "Insurance Coverage for Critical Care Paramedics": "let's shift gears for a second and discuss everyone's favorite topic Insurance understanding the insurance coverage and limitations for critical care paramedics is crucial as it directly affects their professional liability and potential legal protections the legal concept of respondi at Superior holds that an employer is responsible for the acts of its agents such as employees in the context of critical care paramedics this means that when a provider is performing their job duties their employer typically provides professional liability insurance this insurance is designed to protect the provider and their employer in case of legal claims arising from actions taken during the course of their employment there are two limitations of an employer's professional liability insurance first to be covered by their employer's professional liability insurance the act in question must occur while the critical care paramedic is employed by the organization insurance coverage generally does not extend to actions taken outside of the scope of employment or after employment has ended second the act in question must also be within the critical care paramedic scope of practice and relate to the reason for their employment if the action is considered outside the providers designated duties or unrelated to their employment it may not be covered by the employer's Insurance additionally there are several reasons an employer may not cover the employee if the employer believes that the provider acted beyond their Authority or duties they may choose not to cover the employee under their professional liability insurance actions that deviate from established protocols or standards could fall into this category in some cases employees may not have a legal duty to act particularly if they are off duty or not officially engaged in their work role this is where Good Samaritan statutes may come into play which provide legal protections to individuals who voluntarily provide assistance during emergencies outside their professional capacity in situations where the employer's insurance coverage is insufficient or inapplicable providers may consider obtaining private insurance this additional coverage can help protect them in cases where they're employer's insurance does not provide adequate coverage or when they engage in activities outside of their employment understanding the nuances of insurance coverage is vital for critical care paramedics as it impacts their personal liability and financial well-being in the event of legal claims or actions it's essential for providers to maintain a clear understanding of the scope of their duties act within their Authority and scope of practice and where necessary consider supplemental private insurance to ensure comprehensive protection legal consultations or advice from insurance professionals can be invaluable in navigating the complexities of insurance coverage for critical care paramedics",
        "The Importance of Consent in Medical Care": "consent is a fundamental Concept in the realm of medical care and is particularly significant within the context of the critical care paramedic course expanding on the concept of consent it is essential to understand that it serves as a common safeguard for individuals across all aspects of medical care including physical assessment treatment transport decisions and destination Choice here's a comprehensive explanation of these critical components one physical assessment in the medical field obtaining consent is a fundamental ethical and legal requirement for conducting physical assessments whether a patient is in an emergency situation or not it is essential for critical care paramedics to respect the autonomy of the individual by seeking their informed consent before initiating any form of physical assessment ment this includes basic assessments like taking Vital Signs and more complex assessments that involve a thorough evaluation of the patient's condition consent ensures that the patient is aware of the assessment being performed and voluntarily agrees to it two any aspect of treatment similarly consent is a Cornerstone of the treatment process whether it involves administering medications performing procedures or applying Advanced life support interventions critical care paramedics must secure the patient's informed consent this ensures that the patient has a say in their own care is aware of the proposed treatment and has the opportunity to ask questions or Express concerns consent extends to any aspect of treatment from minor interventions to critical life-saving procedures three transport decisions consent is not limited to the medical interventions themselves but also extends to decisions regarding patient transport when a critical care paramedic determines that transporting the patient is necessary they should seek consent from the patient if possible the patient has the right to understand the reasons for transport the potential risks and benefits and any available Alternatives in cases where the patient is unable to provide consent due to their condition paramedics must adhere to protocols and legal standards which may include obtaining consent from a legal guardian or family member four destination choice the choice of destination for the patient such as which Health Care Facility to transport them to also involves consent considerations paramedics should communicate destination options to the patient when possible and respect their preferences provided that the patient's clinical condition allows for such choices however there may be situations where the critical care paramedic must prioritize the patient safety and well-being over their destination preferences especially in cases of life-threatening emerc emergencies in summary consent is a Paramount principle that underpins all aspects of medical care in the critical care paramedic course it ensures that patients are actively engaged in their health care decisions allows for respectful and patient- centered care and upholds the ethical and legal standards that govern the health care profession Critical Care paramedics should be well versed in obtaining informed consent and be prepared to communicate effectively with patients to facilitate this import process",
        "Legal Aspects of Consent": "in the critical care paramedic course understanding the nuances of consent is imperative and several legal aspects play a significant role in this process these legal considerations are crucial to ensure that consent is obtained appropriately ethically and in accordance with the law here we delve into these legal aspects that must be considered when determining consent one legal competence in age of majority one key factor in determining legal competence for consent is the age of majority which is typically 18 years old in many jurisdictions at this age individuals are generally considered legally competent to make their own medical decisions Critical Care paramedics must be aware of the legal age at which patients are presumed competent to provide consent as this forms the foundation for many consent related decisions two Healthcare power of attorney healthcare proxy in case cases where a patient is unable to provide consent due to incapacitation or illness healthc care providers including Critical Care paramedics must be familiar with the concept of a health care power of attorney or Health Care proxy This legal Arrangement allows individuals to designate someone they trust to make Health Care decisions on their behalf it is crucial for paramedics to identify and communicate with the designated decision maker when obtaining consent from a patient who cannot provide it themselves free do not resuscitate or physician orders for life- sustained treatment these are critical legal documents that Express a patient's preferences regarding life sustaining interventions when encountering patients with these documents Critical Care paramedics must respect these legally valid instructions these documents May limit the extent of care that can be provided and paramedics must ensure that any actions align with the patients expressed wishes as per these directives understanding and navigating these legal aspects of consent is vital for providers it ensures that they are providing care within the boundaries of the law and respecting the rights and autonomy of the patient additionally they must be Adept at recognizing situations where consent may not be straightforward such as when dealing with minors patients with designated decision makers or those with existing Advanced directives this knowledge empowers Critical Care paramedics to deliver patient centered care while adhering to legal and ethical standards",
        "Assessing Decision-Making Capacity": "decision-making capacity is the ability of an individual to understand the implications of their health care decisions and provide informed consent this assessment is a fundamental aspect of providing ethical and patient- centered care orientation is a key component in evaluating decision-making capacity it involves assessing whether the patient is aware of their current situation such as the time place and their own identity an individual who is disoriented confused or unaware of their surroundings may have impaired decision-making capacity Critical Care paramedics must conduct a brief assessment to ensure the patient is oriented to their situation which is essential for making informed decisions regarding their care the influence of substances that alter mentation such as drugs alcohol or medications can significantly impact an individual's ability to make sound decisions Critical Care paramedics must consider whether the patient has ingested or is under under the influence of substances that may impair their cognitive function substances that affect mentation can Cloud judgment and impair the capacity to provide informed consent various clinical conditions can alter mentation making it vital for paramedics to assess and consider these factors conditions like hypoxia hypovolemia hypoglycemia and seizures can lead to altered mental States when evaluating decision-making capacity paramedics need to recognize the presence of these clinical conditions and address them promptly to restore the patient's capacity for informed decision- making the environment of care can also have a significant impact on a patient's decision-making capacity paramedics should be aware of environmental factors that may hinder communication and decision-making for instance language barriers the presence of intimidating or distracting individuals or a chaotic or stressful setting can impede the patient's ability to provide inform Med consent paramedics should take measures to mitigate these barriers and create a conducive environment for assessment assessing the patient ability to make competent decisions is a complex and multifaceted process and critical care paramedics must be Adept at evaluating these various factors to determine if a patient is capable of providing informed consent it involves not only clinical expertise but also effective communication and a keen understanding of the patient's mental and emotional state by conducting thorough assessments and addressing any impairments paramedics can ensure that patients are actively involved in their health care decisions and receive the care that aligns with their best interests",
        "Informed Consent and Patient Autonomy": "informed consent is a vital ethical and legal process in health care that involves proposing a course of action which can include assessment treatment or transport of the patient this process includes a comprehensive discussion of the potential risks and benefits associated with the proposed action as well as any available Alternatives ultimately informed consent empowers the patient to make an autonomous and informed decision regarding their care the Cornerstone of informed consent lies in the risk/benefit discussion with the patient this dialogue is crucial for ensuring that the patient comprehends the potential outcomes of the proposed action allowing them to weigh the risks against the benefits this discussion is the most critical element of informed consent as it ensures that the patient is fully informed about the implications of their health care choices expressed consent is a form of consent in which the patient clearly and unequivocally communicates their agreement after having been properly informed about the proposed course of action it is the standard form of consent and is legally required un th specific exceptions apply expressed consent is not just an ethical consideration but also a legal requirement in many Health Care scenarios patients must provide their expressed consent for assessments treatments and other medical actions the process of obtaining expressed consent is an essential part of ensuring patient autonomy and respecting their rights expressed consent is often established and documented by physicians when outlining the treatment plan in some cases Critical Care paramedics May obtain expressed consent when the patient is under their direct care this can include scenarios where paramedics are administering specific treatments or interventions and the patients explicit agreement is necessary implied consent comes into play when a patient lacks decision-making capacity is unconscious or is not legally competent to make decisions in such cases the law generally assumes that a person if capable of making choices would want life-saving treatment if it were offered implied consent typically applies when the patient has an emergency medical condition in most jurisdictions it is specifically relevant in situations where immediate medical intervention is necessary to preserve the patient's life or prevent severe harm when a patient refuses care it is essential to prioritize clear and respectful communication restating your suggestions in clearer terms or with increased urgency can help the patient understand the critical nature of their condition paramedics should use their communication skills to persuade the patient without compromising their autonomy in cases where the patient is hesitant to accept care appealing to their friends and family can be a useful strategy loved ones often have a strong influence on a patient's decisions and can help convey the importance of accepting Medical Care especially in emergencies if a patient adamantly refuses care it is important to reach out to medical control medical control can provide guidance and additional recommendations helping paramedics make informed decisions about the best course of action this collaboration ensures that the patient welfare remains a top priority paramedics should be aware that a patient may accept certain aspects of care while refusing others it's essential to respect the patients autonomy in this regard furthermore patients have the right to revoke their consent at any time paramedics must be prepared to adapt to changing situations and respect the patient's decisions throughout the course of care navigating situations where a patient refuses care is a delicate balance between respecting patient autonomy and ensuring their safety Critical Care paramedics must be skilled communicators able to adapt their approach based on the patients responses and needs implied consent on the other hand allows paramedics to act decisively in life-threatening situations ensuring that the patient receives the necessary care when they are unable to provide Express consent due to their condition",
        "Legal Risks of Failing to Obtain Consent": "in the critical care paramedic course it's emphasized that Critical Care transport paramedics must be diligent in assessing decision making capacity and obtaining informed consent to avoid potential liability on several fronts failure to do so can result in various legal consequences and it's crucial for paramedics to understand these risks negligence is the primary legal risk when Critical Care transport paramedics fail to assess decision-making capacity and obtain informed consent negligence in this context refers to the failure to provide the standard of care expected from a paramedic when a paramedic neglects their duty to assess a patient's decision-making capacity and obtain informed consent it can be perceived as a breach of their duty of care negligence claims may arise if a patient is harmed as a result of this breach battery is a legal concept that pertains to touching or performing a medical intervention on a patient without their consent it is considered both a civil tort and a crime in some jurisdictions if a paramedic acts without obtaining the patient's informed consent it could could potentially lead to a battery claim this is a serious legal risk as it involves a direct violation of the patient's bodily autonomy and can result in legal action against the paramedic assault refers to the unlawful Act of placing a person in apprehension of immediate bodly harm without their consent while it may not involve physical contact it can be a legal issue if a patient feels threatened or coerced into accepting treatment or intervention without their consent this is another risk that Critical Care trans support paramedics need to be aware of when failing to respect a patient's right to informed consent abandonment is a civil tort that arises when a clinician in this case a paramedic terminates a clinical relationship with a patient without obtaining informed consent and without transferring care to a clinically appropriate provider when a paramedic refuses care to a patient without following proper protocols it can be seen as abandonment this not only car carries legal implications but also ethical concerns regarding patient welfare it is essential that paramedics uphold ethical standards and follow the law when it comes to patient autonomy and consent by doing so they can minimize the risk of facing legal liabilities and provide highquality patient- centered care while respecting the rights of the individuals they serve",
        "Documenting Consent and Competence": "the patient care report is a critical tool for documenting all aspects of the competence assessment process this documentation should Encompass the entire evaluation of the patient's decision-making capacity and whether informed consent or refusal was obtained it is crucial that the patient care report includes any Associated documents relevant to the assessment this might involve notes on the patient's orientation substance use clinical conditions that can affect mentation and environmental factors that played a role in the assessment ensuring that this comprehensive information is documented Prov provides a legal record of the assessment process and any consent obtained the patient care report should adhere to the principles of using clear concise and objective language this is vital for accurate and unambiguous documentation Critical Care paramedics must employ language that is easily understood by fellow healthc Care Professionals legal authorities and other stakeholders who may review the patient care report additionally the patient care report should list the risks and benefit benefits associated with the proposed course of action by clearly outlining the potential outcomes of the medical interventions or treatments paramedics ensure that the patient their family and the healthcare team are fully informed as part of the best practice approach it is wise for paramedics to encourage patients to explain back in their own words what has been offered to them and the potential consequences of their decisions this serves as an additional layer of assurance that the patient fully comprehends the situation ation it not only provides an opportunity for clarification but also underscores the importance of patient autonomy and involvement in their care this meticulous documentation process serves multiple purposes it provides a legal record of the assessment and consent process helps an effective communication among healthc care providers and supports the continuity of care for the patient clear and comprehensive documentation in the patient care report is essential for transparency accountability and ensuring that the patients rights and choices are respected throughout their healthc care Journey",
        "EMTALA and Its Implications": "the importance of the emergency medical treatment and active Labor Act is underscored as it has significant implications for critical care transport paramedics passed by the US Congress in 1986 it is a federal law with primary goals that are essential for ensuring patient care equity and preventing discrimination in healthc care settings gala's foremost goal is to ensure that all all patients who need Emergency Medical Care at an emergency department receto without discrimination or delay this means that anyone who presents to an ER with an emergency condition regardless of their ability to pay insurance status or other factors should receive necessary Medical Care another fundamental goal of intala is to prevent hospitals from transferring patients to other facilities solely based on their insurance status or their ability to pay for services this provision is iCal for protecting patients from being denied care or subjected to inappropriate transfers due to financial considerations mtala places specific obligations on ambulances particularly in the context of hospital emergency departments these obligations are crucial for understanding the legal requirements when transporting patients the first obligation under antala applies to patients seeking treatment for an emergency medical condition in the emergency department of the hospital that accepts Medicare for payment this includes patients who arrive via various means such as ambulances in the nine to11 system and those who arrive at the hospital's ER directly for critical care transport paramedics this means that when they transport a patient to a hospital ER they must be aware of the intoler requirements the hospital is obligated to provide a medical screening examination and necessary stabilizing treatment to anyone seeking care for an emergency medical condition regardless of their insurance status or ability to pay paramedics play a critical role in facilitating this process by ensuring that patients in need are promptly assessed upon arrival mtala places specific obligations on ambulances particularly in the context of hospital emergency departments these obligations are crucial for understanding the legal requirements when transporting patients the first obligation under mtala appli lies to patients seeking treatment for an emergency medical condition in the emergency department of a hospital that accepts Medicare for payment this includes patients who arrive via various means such as ambulances in the 911 system and those who arrive at the hospital's ER directly for critical care transport paramedics this means that when they transport a patient to a hospital ER they must be aware of the Impala requirements the hospital is obligated to provide a medical screening examination and necessary stabilizing treatment to anyone seeking care for an emergency medical condition regardless of their insurance status or ability to pay paramedics play a critical role in facilitating this process by ensuring that patients in need are promptly assessed upon arrival mtala includes specific details about how and when these requirements apply including the concept of presentation on Hospital property presentation refers to the point at which the patient arrives on the hospital's property such as the ER entrance the use of Landing facilities for air medical units at hospitals is directly relevant to Critical Care transport paramedics an tala's requirements come into play when patients arrive via air Medical Transport it's important to note that current Medicare guidelines specify that inalla is not triggered for this scenario unless the critical care transport paramedic requests assistance from the hospital's ER or requires the hospital's resources for the patient's care this reflects the importance of ensuring that Anala obligations are met when air Medical Transport is involved understanding mtala obligations is essential for critical care transport paramedics as it ensures that patients receive the care they need and are not subject to discrimination based on their insurance or payment status paramedics play a crucial role in facilitating the initial assessment and stabilization process particularly when transporting patients to hospital and emergency departments compliance with mtala regulations is not only a legal requirement but also an ethical responsibility to provide Equitable access to Emergency Medical Care",
        "Medical Screening Exams": "medical screening exams are a vital component of ensuring that patients with emergency medical conditions receive appropriate And Timely care these exams are an essential part of the medical evaluation process and it's crucial to understand their characteristics and requirements medical screening exams are typically initiated when a patient presents with an emergency medical condition these exams are part of the broader and taller requirements and are designed to assess the patient condition and determine the nature and severity of their medical emergency it's important to distinguish between medical screening exams and triage exams medical screening exams are more comprehensive and focused on evaluating the patient's specific medical condition while treeage exams are often used for priority prioritizing care based on the urgency of the patient's needs medical screening exams are typically performed by qualified Health Care Providers which can include Physicians physician assistants or nurse practitioners these professionals are trained and authorized to conduct thorough medical assessments to determine the presence and severity of an emergency medical condition a comprehensive medical screening exam should include several key components to effectively assess the patient's condition these components can include a record of the patient's initial presentation and the reasons for seeking Medical Care recording the patient's Vital Signs gathering information from the patient about their symptoms medical history and any relevant details a handson examination to assess the patient's physical condition including any visible injuries or abnormalities utilizing diagnostic tools and tests such as Imaging or laboratory studies to determine the presence and severity of the medical condition cons Consulting with on call Physicians to Aid in the diagnosis and evaluation of the patient's condition and lastly recording Vital Signs again to ensure the patient stability and Readiness for discharge medical screening exams serve a critical role in the early identification and assessment of emergency medical conditions they help determine the appropriate course of action for each patient ensuring that those with significant medical needs receive timely and necessary care understanding the components and requirements of the these exams is fundamental for healthc care providers including Critical Care paramedics to meet their legal and ethical obligations to patients seeking Emergency Care",
        "Transfer Obligations Under EMTALA": "Critical Care transport paramedics frequently encounter and are involved in the transfer obligations outlined by the emergency medical treatment and active Labor Act these obligations are Central to ensuring that patients with emergency medical conditions are appropriately transferred between healthc care facilities the sending fac facility is responsible for arranging safe and appropriate transport for the patient this includes coordinating the transfer Logistics and ensuring that the patient's condition is stable enough for transport the sending facility must ensure that qualified Health Care Personnel such as critical care paramedics are available to accompany the patient during transport these Personnel should have the necessary skills and equipment to manage the patient's condition during Transit the sending facility should provide or ensure that the appropr medical equipment and supplies are available for the patient during transport this may include specialized equipment required for critical care patients the receiving facility is responsible for coordinating and Performing the actual transport in collaboration with the team this includes ensuring the patient safe transfer to the receiving facility mtala requires that the receiving facility must have the capacity and resources to accept and provide appropriate care to the patient this ensures that the patient is not transferred to a facility that cannot provide the necessary Medical Services it's important to understand the implications of intala violations which primarily Target hospital and physician conduct while the law was not originally intended to apply to the ambulance transport Community it's still essential to be aware of potential penalties and consequences in case of violations Anala as initially designed primarily focuses on regulating the conduct of hospitals and Physicians to ensure the Equitable provision of emergency medical care hospitals and Physicians found a violated the provisions of mtala May face several penalties hospitals that violate mtala may be subject to fines ranging from $25,000 to $50,000 per violation these fines are imposed to hold the hospital accountable for any failure to provide appropriate medical screening or stabilizing treatment to patients with emergency medical conditions Physicians who are involved in intala violations May face fines of up to $50,000 per violation Physicians are held accountable for actions or decisions that result in patients being inappropriately transferred or ried necessary Medical Care in addition to fines both hospitals and physicians may also face the possibility of being terminated from participation in the Medicare and Medicaid programs this can have significant financial and operational consequences for healthcare providers patients who suffer injuries as a result of an inala violation have the right to seek civil damages against the hospital or physician responsible for the violation this allows patients to pursue legal action to recover compensation for injuries and damages",
        "Legal Considerations During Transport": "there are several important legal considerations to keep in mind during transport operations let's take a look at a few organizing Personnel in the context of of critical care transport is a critical aspect of ensuring safe and effective patient care during inter facility transfers the qualification requirements for critical care transport paramedics are established by State Licensing authorities which dictate what each level of Provider can do and determine the necessary provider levels for specific types of Transportation compliance with State statutes and regulations is fundamental for providers to perform their roles within legal and clinical boundaries furthermore Anala which governs emergency medical care requires the sending physician to specify the qualifications of personnel accompanying the patient during transport this may range from paramedics nurses or even Physicians depending on the patient's condition and medical needs underpinning the entire process all Personnel involved in critical care transport function under medical Direction which provides protocols and standing orders to guide prehosp providers within their system in addition to personnel qualific apption ensuring that the appropriate equipment medications and supplies are within the scope of practice of the Personnel on board is essential this involves having the necessary medical equipment and resources to manage the patient's condition during transport especially in critical care scenarios moreover if a patient's condition necessitates it it's crucial to request additional ancillary Personnel for transport these ancillary Personnel may have specialized skills such as a balloon pump tech nician or a perfusionist and may play a critical role in ensuring the safe transfer of patients with specialized medical needs in some cases an ancillary Personnel member may assume overall responsibility for care such as a neonatologist for a neonatal intensive care patient effective organization of personnel their qualifications and the inclusion of ancillary Personnel when required our interal to providing the highest level of care during Critical Care transport operations",
        "Preparing for Patient Transfer": "preparing for a critical care patient transfer is a meticulous and critical process that requires thorough attention to detail the first step is to obtain pertinent patient information which serves as the foundation for the safe and efficient transfer this information encompasses various aspects including the reason for transfer the destination hospital and physici the level of care the patient requires during transport the treatment provided at the sending facility and specific medical treatment and Drug orders for the duration of the transfer additionally it's crucial to identify any necessary medical devices such as ventilators or infusion pumps and anticipate potential complications that may arise during the transfer before embarking on the transport several key steps should be taken to ensure a smooth and coordinated process these include obtaining the name of the receiving physician to facilitate seamless communication upon arrival at the destination providers should also thoroughly review the transport orders to verify that they align with their scope of practice and the patient needs furthermore if the complexity of the patient's condition warrants it additional Personnel should be requested to accompany the transport team ensuring that the patient receives the necessary level of care and expertise during a transfer this meticulous preparation is essential for the safety and well-being of the critical care patient and contributes to the overall success of the inter facility transfer",
        "Effective Communication During Transfers": "effective communication with the healthcare team is a Cornerstone of ensuring the safe and successful transfer of critical care patients Critical Care transport paramedics must communicate with their colleagues in a professional concise and clear manner to relay essential information this includes sharing the patient's condition any significant medical history the reason for transfer and specific care requirements in the event of a disagreement between the critical care paramedic and the sending physician regarding a transfer plan it's essential to address the issue professionally and clearly this can involve stating concerns discussing potential Solutions and seeking a Cooperative resolution if an agreement cannot be reached contacting the receiving facilities physician or the transport agency's medical director can provide further guidance and assistance in managing the situation all with the ultimate goal of ensuring the best care for the patient in some cases the sending physician May be unfamiliar with the protocols and capabilities of the transport team in such instances it's the responsibility of the critical care paramedic to communicate their skills capabilities and limitations effectively collaboratively developing a plan of care within the scope of practice is an excellent approach to aligning expectations and responsibilities if the sending physician is unwilling to participate in developing the plan of care it may become necessary to insist that the physician accompanies the patient to the receiving facility this ensures that the patient's care remains within the parameters of the provider's expertise and provides a proactive solution to potential disagreements effective communication both within the healthcare team and with sending and receiving Physicians is a crucial aspect of patient safety and the success of critical care patient transfers",
        "Medical Direction in Critical Care Transport": "Critical Care transport paramedics operate under two main types of medical Direction each with its unique considerations offline medical Direction involves using established written protocols and standing orders to guide patient care during transport these Protocols are based on standard practices and allow Critical Care paramedics to provide care within predefined parameters offline medical direction is particularly valuable in scenarios where immediate communication with a medical director is not feasible providing a framework for delivering care based on recognized guidelines on the other hand on online medical Direction becomes crucial when a patient's condition requires treatment Beyond established protocols or when consultation with a medical professional is necessary providers must ensure that online medical direction is available before initiating the transport as it can be essential for making real-time decisions that align with the patient's needs furthermore clear communication is vital and providers should ensure that both sending and receiving Physicians are aware of who will provide online medical Direction during the transfer in cases where immediate communication with the medical director is not possible it is important to have well-defined standing orders or protocols in place to guide decisionmaking ensuring that patient care remains consistent and within established boundaries throughout the transport",
        "Patient Handover and Documentation": "completing the transport and ensuring a seamless Handover of the patient to the receiving facility are crucial steps in the critical care transport process upon arrival at the receiving facility the critical care transport paramedic must prioritize continuity of Care by providing a comprehensive report to the designated receiving care provider this report should include essential patient information such as the patient's name age and sex as well as the names of the sending physician and facility the reason for transfer and a brief review of the patient systems furthermore the report should Encompass the patient's medical history medications administered during the transport fluid intake and a summary of the patient's condition during the transfer the key is to deliver this information in a clear concise and logically organized format to ensure that the receiving provider has a thorough understanding of the patient's condition and Care requirements in addition to the patient report providers should transfer any specimens medical records and laboratory and radiography results to the receiving provider this comprehensive transfer of information and data is essential for ensuring that the receiving facility can continue providing appropriate care seamlessly furthermore the providers should make themselves available to answer any questions or provide additional information to the receiving care provider after the transfer of care is completed effective communication and data transfer at this stage are vital not only for the patients's well-being but also for maintaining the Integrity of the patient's medical history and ensuring that the receiving facility can continue the care plan effectively accurate and comprehensive documentation is of Paramount importance when caring for critically ill or seriously ill patients during transport in these high-stake scenarios a patient's condition can change rapidly and without warning necessitating the modification of transfer orders during transport good documentation not only serves as protection for ens Personnel but is also a reflection of the quality of patient care provided its purposes extend beyond protecting caregivers it ensures Ur es continuity of care throughout the Healthcare System facilitates quality improvement efforts supports mechanisms for reimbursement meets regulatory requirements and establishes the legal defensibility of care incomplete documentation can lead to misconceptions about the quality of care provided it's crucial to maintain meticulous records especially as the implementation of electronic medical records reduces the margin for error and sloppiness teamwork is key in ensuring that documentation is both accurate and complete at the conclusion of a patient transfer critical elements that should be recorded include the times of vital signs and assessment findings details and Times of interventions including drug Doses and routes of administration patient responses to interventions any unored or adverse reactions Communications with medical control deviations from transfer orders or standing orders diversions to other hospitals and patient refusals of treatment if necessary amendments to run reports should be made in accordance with local protocols to maintain the integrity and accuracy of the patient's medical records overall comprehensive and meticulous documentation is a fundamental component of providing quality Critical Care transport and ensuring the best possible patient outcomes",
        "Conclusion: The Role of Critical Care Paramedics": "Critical Care paramedics play a pivotal role in the Continuum of Care for critically ill patients and their ability to provide exceptional care Hing on a profound understanding of both medical and legal issues a solid grasp of medical knowledge is essential as they often deal with complex and rapidly evolving medical conditions during patient transfers this understanding enables them to make critical decisions administer specialized treatments and ensure patient stability which is Paramount during transport furthermore medical expertise ensures that they can effectively communicate with the sending and receiving healthc care teams collaborate on care plan plans and advocate for the best interests of the patient on the legal front Critical Care paramedics must navigate a complex and litigious environment where mistakes can have serious consequences being well-versed in the legal aspects of their profession allows them to provide care within the boundaries of their scope of practice obtain informed consent and ensure all actions adhere to regulations and protocols it also safeguards them from potential liability as comprehensive documentation in adherence to Legal standards become crucial in any legal disputes in summary a strong understanding of both medical and legal matters is a Cornerstone of a critical care paramedics ability to provide Safe highquality Care to critically ill patients during inter facility transfers ultimately ensuring the best possible patient outcomes and protecting their own professional well-being thank you for your attention to this lecture"
    },
    {
        "Introduction to Patient Safety": "chapter three patient safety the patient journey within the Emergency Medical Services System represents a critical and intricate process that commences with the patient decision to seek Medical Care this pivotal decision initiates a chain of events that continues until the patient is safely handed over to hospital Personnel when the patient's condition demands Specialized Care during interf facility transport the domain of critical care transport comes into play this phase starts when a referring practitioner or a transfer call center contacts a critical care Transport service to request the movement of a patient requiring Advanced Care and monitoring the landscape of patient care particularly within the realm of critical care transport is marked by a constellation of complexities and variables these intricacies present numerous opportunities for various challenges including process failures errors and adverse outcomes in the highstakes environment of critical care where patients are often critically ill and unstable even the slightest misstep can have serious repercussions therefore the overarching goal of the emergency medical service system is to minimize the chance of error to as close to zero as possible achieving this goal necessitates a multifaceted approach encompassing rigorous training for critical care paramedics the establishment of well-defined and evidence-based protocols streamlined communication among all parties involved in the patient care and a commitment to ongoing quality improvement by addressing each aspect of the patient Journey with materal ulous care and attention the EMS system strives to fulfill its primary mission of delivering the highest level of care and safety to patients in need of critical care transport.",
        "Evolution of Healthcare Quality": "measuring and ensuring healthc Care Quality has evolved significantly over the years with the real awareness of its important staining Traction in the 1990s this change was precipitated by Landmark Publications at shed light on the previously minimal awareness of healthcare quality and the slow pace of quality measurement in the early 1900s Dr Ernest Codman a surgeon at Massachusetts General Hospital emerged as a pioneering figure in the Quest for healthc care quality improvement Dr Codman is credited with introducing the end results system a method aimed at monitoring the quality of physician and hospital care his work was not only instrumental in pushing for recording and Reporting individual Physicians outcomes but also led to the establishment of the American College of Surgeons in 1913 marking a significant step toward advancing the cause of healthcare quality the scope of the healthcare quality problem became apparent in the early 1990s when the Harvard Medical Practice study released critical findings this study revealed that a significant number of hospitalized patients almost 4% experienced substantial Adverse Events during their care even more concerning was the finding that nearly onethird of these Adverse Events were attributable to human error these Revelations highlighted the urgent need for improving Health Care Quality and patient safety prompting Health Care organizations and policy makers to prioritize the measurement and enhancement of quality in healthc care delivery.",
        "Institute of Medicine's Impact": "the emergence of healthcare quality as a central concern in the 1990s marked a pivotal moment in the history of Medicine it brought about a shift in the healthcare landscape prompting a more comprehensive focus on quality assurance patient safety and a development of methodologies to measure and monitor Health Care Quality at various levels of the Health Care system this transformation has since laid the foundation for ongoing efforts to improve Health Care Quality reduce medical errors and ultimately provide the best possible care to patients the groundbreaking findings of studies let the Harvard Medical Practice study along with other compelling research collectively spurred The Institute of medicine to delve into a comprehensive investigation of healthc Care Quality The Institute a renowned and influential organization in the field of healthcare recognized the critical need to address quality issues and ensure that healthc care delivery was not only effective but also safe for patients this pivotal step signaled a turning point in the healthcare industry leading to a series of initiatives reports and recommendations that have since reshaped Healthcare policies practices and systems in the pursuit of higher standards of quality and patient safety.",
        "To Err is Human Report": "in 1999 The Institute of medicine released its seminal report to air is human building a safer Health System a milestone publication that sent shock waves through the healthcare industry the report's findings were staggering revealing that nearly 100,000 Americans lost their lives annually due to Medical errors making these errors the eighth leading cause of death in the United States the report's impact extended far beyond the statistics as it urged a paradigm shift in the approach to patients safety rather than solely focusing on individual culpability The Institute advocated for a broader perspective that emphasized improving the systemic processes contributing to errors this pivotal report played a significant role in reshaping healthc care policy and practice emphasizing the urgency of addressing medical errors and setting the stage for a transformative error in healthc care quality improvement patient safety and the Relentless pursuit of a safer and more effective health system.",
        "Crossing the Quality Chasm": "in 2001 The Institute of medicine continued its pivotal role in reshaping Healthcare with the publication of crossing the quality Chasm the new health system for the 21st century this influential report outlines six core aims for Health Care declaring that Health Services should be safe effective patient centered timely efficient and Equitable these quality aims provided a framework for health care providers and systems to strive for excellence in patient care across a range of Dimensions the reports emphasis on these aims was a clear call to action urging the healthcare industry to deliver care that not only healed patients but did so with the highest standards of safety Effectiveness and patient satisfaction while these six quality ains have profound implications for healthcare in general theyd hold unique relevance and challenges within the Emergency Medical Services field achieving patient centered care for instance is essential but can be complex in the diverse and dynamic Critical Care environment healthc Care Professionals must navigate language barriers and address the needs of special populations including geriatric patients pediatric patients and individuals who have undergone bariatric surgery ensuring patient- centered care in these scenarios requires cultural sensitivity adaptability and the ability to deliver tailored care that respects the unique needs and circumstances of each patient furthermore addressing the six quality AIMS in critical care involves considering the constraints of the The Field's fast-paced times sensitive nature timely care is Paramount where quick and efficient responses can be life saving providers must continually find ways to deliver high quality Care under often challenging conditions ensuring that the patients well-being Remains the top priority the commitment to these quality aims reinforces the importance of not only delivering effective and safe care but also making it patient centered efficient and equitable even in the demanding Critical Care setting.",
        "EMS at the Crossroads Report": "the Institute of medicine's 207 report Emergency Medical Services at the crossroads was a significant milestone in the development and evaluation of the modern EMS system in the United States the report provided a comprehensive examination of the State of Emergency Medical Services at the time shedding light on the many challenges and limitations faced by the system it underscored the need for improvements in various aspects including the quality of care provided and the coordination of services one notable aspect of the report was its recognition of the unique challenges and responsibilities of critical care transport professionals these individuals often encounter patients with more critical conditions and complex care scenarios than typical 911 responders given the higher acurity of patience and the complexity of care required the potential for errors in the critical care environment was acknowledged to be significantly greater this highlighted the importance of specialized training protocols and quality control measures for providers to ensure the safety and well-being of patients during transport since the release of the 2007 report there have been several noteworthy advances in the field of Emergency Medical Services Research in the prehospital setting has increased leading to a deeper understanding of better best practices and the impact of prehospital Care on patient outcomes the role of medical directors has gained more prominence emphasizing the importance of medical oversight in ensuring the highest standards of care many agencies have also devoted resources to safety and quality improvement efforts aiming to reduce errors and enhance the overall quality of care provided these advancements demonstrate the commitment of the community to continuously improve and meet the involving needs of patients in the everchanging healthcare landscape.",
        "Recognition of EMS as a Subspecialty": "in 2012 a significant development in the field of Emergency Medical Services occurred when the American Board of emergency medicine officially recognized the profession as an official Subs specialty this recognition marked a pivotal moment in the evolution of the profession as it acknowledged the unique and essential role of Emergency Medical Services within the broader field of emergency medicine as a result of this recognition a specialty certification in Emergency Medical Services medicine was established which set clear standards for qualifications and training this included the definition of core content areas such as quality improvement and medical oversight of agency quality programs ensuring that Physicians were well prepared to provide highquality care oversight and leadership in the dynamic and critical environment this development helped formalize the expertise and professionalism of those working in the field ultimately contributing to the Improvement of patient care and the elevation of Emergency Medical Services as a vital component of the Health Care system.",
        "Disease-Specific Quality Measures": "in recent years various organizations have taken significant steps to enhance the quality of care provided by Emergency Medical Services systems particularly by focusing on disease specific quality measures these measures are essential to ensure that key criteria and standards are met to improve patient outcomes the American Heart association's Mission Lifeline program for example is dedicated to recognizing excellence in caring for patients with specific conditions such as STD elevation myocardial infarction this program acknowledges and honors agencies and hospitals that have demonstrated exceptional Proficiency in managing stemi cases thereby contributing to the timely and effective treatment of heart attack patients furthermore the American College of Surgeons has played a crucial role in establishing trauma measures for Emergency Medical Services systems promoting best practices in the prehospital care of trauma patients these measures are vital for improving the overall quality of care provided to trauma victims and optimizing the chances of positive outcomes additionally in 2016 the nationaly of Sciences engineering and Medicine released a report titled a national trauma care system integrating military and civilian trauma systems to achieve zero preventable deaths after injury this comprehensive report offers recommendations aimed at achieving the ambitious goal of zero preventable deaths due to injury by providing a road map for integrating military and civilian trauma systems the report addresses critical aspects of trauma care and highlights the importance of quality measures and protocols for Emergency Medical Services in reducing preventable fatalities these initiatives collectively contribute to advancing the quality of care and patient safety within the field.",
        "Defining Patient Safety": "the concept of patient safety is multifaceted and can be approached from various angles making its definition complex it can be viewed as a philosophy a discipline or an attribute of the Health Care system however the World Health Organization offers a concise and practical definition by stating that patient safety entails a freedom from unnecessary harm or potential harm that may be associated with health care services in essence patient safety is about protecting patients from harm throughout the entire Health Care process in the context of Emergency Medical Services this chapter defines patient safety as the proactive and comprehensive effort to reduce the risk of unnecessary harm associated with a care provider ided by professionals to an acceptable minimum this acceptable minimum is determined by several key factors including the best available medical evidence the quality and capabilities of the equipment used the level of Technology applied and the proficiency of human skills the aim is to set a standard that ensures that patients receive care that is both safe and effective minimizing the potential for harm to the greatest extent possible in doing so practition has worked within the boundaries of current knowledge and resources to uphold the principles of patient safety and promote the well-being of those under their care.",
        "Challenges in Patient Safety": "patient safety programs have gained significant momentum due to a wealth of evidence demonstrating that adverse medical events are both prevalent and often avoidable this evidence points to a Health Care system in which too many patients experience harm as a result of their care within the domains of emergency medicine Emergency Medical Services and critical care transport there is a unique set of challenges that contribute to the pressing need for robust patient safety initiatives in these fields practitioners are routinely faced with rapid decision-making under conditions of uncertainty often having to make critical choices with limited information at their disposal moreover the nature of their work is inherently complex involving a wide array of tasks and interventions each with its own set of risks and potential for errors coupled with this complexity are the long work hours often endured by emergency Health Care Professionals which can lead to fatigue and cognitive lapses further increasing the likelihood of mistakes these challenging characteristics inherent to emergency medicine and CCT environments emphasize the necessity for comprehensive patient safety programs that address the unique issues faced by Healthcare Providers ultimately striving to minimize errors and enhance the safety of patient care.",
        "Proactive Error Management": "in healthcare not all errors culminate in actual harm to patients but it is crucial for healthcare organizations to adopt a proactive stance in addressing errors even when they do not result in adverse outcomes this perspective aligns with the principles of continuous quality improvement and patient safety while certain errors may seem benign on their own collectively the can contribute to systemic weaknesses and vulnerabilities in the healthc care delivery process by acknowledging and investigating all types of Errors organizations can identify patterns and root causes shedding light on areas that need Improvement studying errors whether they are near misses or more significant deviations from Best Practices offers valuable insights into the intricacies of healthc care delivery it enables organizations to detect potential pitfalls bottlenecks or systemic issues that may otherwise go unnoticed through such vigilance Health Care Systems can Implement changes revise protocols and provide additional training to staff to prevent similar errors from evolving into patient harm in the future in essence the proactive analysis of Errors becomes a pivotal part of a healthcare organization's ongoing commitment to enhancing the quality and safety of patient care.",
        "Near Miss Events": "near Miss events often referred to as close calls or breakdowns in communication represent incidents where an error was narrowly averted and did not result in injury illness or damage despite having the potential to do so while near misses may seem indistinguishable from actual Adverse Events the critical difference lies in the outcome no harm occurred in near Miss situations it's worth noting that NE Miss events are believed to be significantly underreported in healthcare settings several factors contribute to this Under reporting including staff's view of disciplinary action their perception of a lack of support or empathy from supervisors and the belief that reporting is unnecessary if no patient harm ensues the Under reporting of NE Miss events is a concerning issue because these incidents carry immense value in terms of improving patient safety analyzing nisses provides Healthcare organizations with a unique opportunity to examine their their processes identify vulnerabilities and Implement proactive safety measures since no patient harm is involved in near Miss situations these events offer a more open and less threatening platform for discussion among staff it Fosters a culture of safety that encourages dialogue and learning from mistakes with fewer liability concerns since no patients were harmed consequently fostering an environment where near misses are actively reported and analy ized can significantly contribute to the continuous enhancement of Healthcare Safety practices.",
        "Historical Context of Error Analysis": "the study of errors in healthcare began as early as the early 1900s but it gained significant momentum when the safety of commercial Aviation came under scrutiny the aviation industry's exploration into safety practices led to a paradigm shift in the way errors were approached it became evident that a system level approach was the most most effective way to detect and prevent errors instead of solely blaming individuals for errors this approach recognized that errors were often a result of systemic issues such as flawed processes communication breakdowns or inadequate safety mechanisms this concept marked a turning point in understanding the root causes of errors in healthare and other Industries in healthcare medical errors are broadly defined as the failure of a planned action to be completed as intended or the use of the wrong plan to achieve a specific goal this definition encompasses a wide range of incidents from medication errors to surgical mistakes and diagnostic inaccuracies medical errors can be further categorized into various types including adverse drug events wrong site surgeries Falls Burns pressure ulcers and even mistaken patient identities these categories help healthc Care Professionals and organizations identify spefic specific areas where interventions and safety measures are necessary to reduce the occurrence of Errors the goal is to shift from a punitive culture of blame to one of proactive error prevention similar to the approach taken in aviation with the ultimate aim of enhancing patient safety and improving Health Care delivery.",
        "High Error Rates in Healthcare": "High error rates with serious consequences are most likely to occur in health care settings where patient Equity is high and interventions are complex recognizing errors and making them known is a fundamental step in the process of quality improvement in healthc care it allows organizations to identify areas where errors occur investigate the root causes and Implement changes to reduce the risk of recurrence open reporting of Errors helps Foster a culture of safety where healthc care providers feel comfortable acknowledging mistakes thus enabling a systematic approach to error prevention by learning from past errors Health Care Systems can continually improve their processes and enhance patient safety a safety culture in healthcare is a multifaceted concept with several key features firstly it involves recognizing that Healthcare organizations engage in high-risk activities where the consequences of Errors can be severe this understanding drives the importance of consistent safe operations to mitigate these risks a safety culture also entails fostering a blame-free environment within the organization where Healthcare Providers are encouraged to report errors without the fear of punishment this aspect is crucial as it promotes open and transparent reporting helping the organization identify areas where Improvement is needed furthermore maintaining a commitment within the organization to address reported errors and safety concerns is a fundamental component of a robust safety culture it ensures that once issues are are identified they are systematically addressed to prevent recurrence thereby enhancing overall patient safety.",
        "Safety Culture and Surveys": "validated surveys provided by the agency for healthcare research and quality play significant role in assessing and improving the safety culture within healthc Care organizations these surveys such as the surveys on patients safety and the safety attitudes questionnaire are administered to healthcare providers to evaluate their perceptions of the safety culture in their workplace and the entire organization they ask providers to rate various aspects of safety communication and teamwork the agency for healthcare research and quality provides benchmarking data based on these surveys enabling Healthcare organizations to compare their safety culture against National averages and identify areas where improvements can be made this data-driven approach is valuable for healthcare organizations as it allows them to focus on specific areas that need attention attention ultimately contributing to safer and higher quality care for patients.",
        "Just Culture in Healthcare": "a just culture is a critical element of an effective safety culture within Healthcare organizations it is a concept that aims to strike a balance between fostering open reporting of errors and maintaining individual accountability for reckless or unsafe behavior in essence it encourages the identification of issues and systemic problems that lead to errors or unsafe practices while distinguishing between different types of behaviors that can contribute to Adverse Events one of the key roles of a just culture is to differentiate between various types of errors or behaviors this includes recognizing instances of simple human error such as slips or lapses where well-intentioned individuals make mistakes due to momentary laxes in attention or memory it also addresses atrisk behaviors where individuals might take shortcuts or engage in practices that increase the risk of Errors even if unintentional lastly the concept identifies Reckless Behavior where individuals knowingly ignore required safety steps or intentionally engage in actions that put patients and their safety at risk by categorizing errors and behaviors in this way a just culture ensures that the response is appropriate to the nature and intent of the actions creating a fair and Equitable approach to addressing safety issues within the healthare system.",
        "Highly Reliable Organizations": "highly reliable organizations are another crucial concept that significantly contributes to the development of an effective safety culture within Healthcare organizations this concept is often associated with Industries such as Aviation and nuclear power which have a strong focus on error prevention and mitigation highly reliable organizations are known for sharing certain common traits and these principles have been applied to Health Care Systems as well one of the central tenets of Highly reliable organizations is their proactive approach to failures and errors in these organizations the emphasis is on managing failures internally to prevent them from reaching the public which in healthare means avoiding harm to the patient this approach is in line with a philosophy that is far better to prevent an error from occurring than to react to its consequences these organizations a aeve this by building redundancy into their systems involving rigorous training ensuring equipment reliability and maintaining a high standard of maintenance for instance in the airline industry these principles are evident in double checks and redundancy measures to ensure safety during every flight in healthcare adopting their principles involves implementing safeguards like double checks particularly with high alert medications to minimize the risk of medication errors additionally there is focus on designing systems that prevent a single failure from cascading into a series of errors that could lead to Patient harm by implementing these principles Healthcare organizations aim to create a safety culture where errors are identified and addressed proactively minimizing the potential harm to patients and promoting overall patient safety.",
        "Medication and Prescription Errors": "in healthcare medication and prescription errors are indeed among the most notable and concerning errors due to their potential to cause serious harm to patients these errors can involve the wrong drug wrong dose wrong route of administration or even the wrong patient such errors often occur due to factors like illegible handwriting similar sounding medication names or miscommunication during medication administration however Healthcare is a complex field with many opportunities for errors some of which are less common but equally significant wrong patient identification errors involve patients being matched with the wrong medical records medications or treatments these can happen during patient admissions transfers or handoffs transfusion errors refer to mistakes made during blood transfusions which can result in severe reactions due to incompatibility preventable suicides can occur in healthc care settings particularly in psychiatric units and highlight the need for proper patient supervision and safety measures Falls are also a significant concern especially among elderly patients and they can lead to fractures and other injuries burn injuries might occur during surgical procedures through the improper use of medical equipment or from hot fluids or surfaces wrong side procedures like surgeries or medical interventions performed on the incorrect side or sight of the patient can have serious consequences finally errors in the transition of care or handoffs between Healthcare Providers can lead to misunderstandings about the patient's condition treatment or medical history these errors underscore the importance of effective communication and coordination among Healthcare teenss to ensure patients safety and minimize the risk of Adverse Events.",
        "Preventing Medication Errors": "medication and prescription errors are a significant concern in healthcare as they have the potential to cause devastating and costly consequences for patients these errors can occur at various stages of the medication process including prescribing dispensing administering and monitoring a complex web of factors can contribute to these errors such as illegible handwriting on prescriptions similar sounding medication names or miscommunication during medication administration it's crucial to understand that not all medication errors result in actual harm to patients but the ones that do can lead to to serious health complications prolonged hospital stays and increased health care costs the study of medication related errors often revolves around examining adverse drug events which Encompass any harm or injury resulting from medication use this chapter focuses on the subset of adverse drug events that are considered preventable or related to medication errors in Emergency Medical Services settings medication errors can be particularly concerning children are at a higher risk of incorrect dosing because providers May struggle to accurately estimate their weight estimations of weight in children can significantly differ from actual weight which is problematic when weight-based calculations are needed to arrive at the correct medication dose additionally medications in emergency settings often come in more than one concentration further increasing the chance of error to mitigate the risk of medication errors Healthcare organizations employ various strategies including risk reduction measures to minimize the occurrence of lookalike sound alike medication errors these medication errors involve medications with names that look or sound similar and can be easily confused leading to mistakes in prescribing dispensing or administering these errors pose significant safety concerns and The Joint Commission and the institute for safe medication practices provide guidance on minimizing these errors these measures include using both the brand name and generic name on prescriptions highlighting differences between lookalike names ensuring prescription legibility and physically separating medications in storage areas overall efforts to prevent medication and prescription errors are Paramount in enhancing patient safety and reducing the occurrence of harmful events.",
        "Wrong Patient Identification and Site Procedures": "wrong patient identification and wrong site procedures are critical patient safety concerns in healthare accurate patient identification is vital in ensuring that the right patient receives the right care always using multiple patient identifiers such as the patient's name and date of birth is an essential practice to prevent misidentification this practice is particularly crucial For Crews during interfacility transports or when transporting patients home where patient Mix-Ups can lead to catastrophic consequences wrong site procedures are classified as never events indicating that there are errors that should never occur in health care and Signal serious underlying safety issues while these events are rare they pose significant risks to patients and erode trust in healthc Care Systems to combat wrong site procedures and misidentifications Healthcare organizations employ redundant mechanisms for ensuring that the correct patient procedure and site are verified before any intervention for example surgeons May Mark the surgical site before the patient's arrival providing a visible and unequivocal indication of the intended procedure site implementing a universal timeout is another strategy to improve patient safety and reduce the likelihood of wrong site procedures this involves a planned pause before the beginning of a procedure to facilitate communication among all Personnel involved and to ensure that all critical aspects of the procedure are revealed viewed EMS can also adopt a similar practice conducting a timeout for trauma and other critical patients upon arrival to ensure that no Vital Information is lost in the transition of care these measures collectively aim to minimize the occurrence of wrong patient identification and wrong site procedures safeguarding patients from harm and maintaining the Integrity of Health Care processes.",
        "Errors in Transitions of Care": "errors during transitions of care and handoff offs are critical patient safety concerns that can lead to Adverse Events if not managed appropriately transitioning care is an integral part of patient management in various Health Care settings including the emergency department and prehosp Care during a patient's Journey Through the Health Care System there are typically multiple handoffs where responsibility for the patient is transferred from one provider to another these providers can include Physicians nurses Medics and support staff each playing a crucial role in the patient care ineffective communication during these transitions can lead to misunderstandings misinformation and errors in patient management to mitigate this risk Healthcare organizations emphasize the importance of structured handoff processes that include key information such as the patient's medical history Vital Signs medication administration and any ongoing treatments standardized tools TOs and protocols such as the situation background assessment recommendation communication model are often used to facilitate effective handoffs and ensure that essential data is conveyed accurately recognizing the significance of handoff related errors healthc care providers strive to improve the quality and safety of care transitions this includes training Personnel in effective communication and teamwork skills implementing standardized handoff procedures and encouraging a culture of open communication and accountability by addressing these challenges Healthcare organizations can enhance the continuity of care and reduce the potential for errors during transitions ultimately improving patient safety and outcomes.",
        "Standardized Approaches to Transitions": "standardized approaches to Transitions in care play a crucial role in preventing handoff errors and improving patient safety one widely adopted technique is the situation background assessment and recommendation method which was initially developed by the US Navy in the 1990s and has become a best practice in healthcare this method offers a structured and concise format for communicating important information during handoffs the technique includes the following components one situation this is where the healthcare provider briefly describes the patient's current situation including the main issue symptoms or reason for the handoff it provides context for the rest of the communication two background in this section the provider provides relevant background information about the patient such as their medical history current diagnosis and recent events that led to the current situation three assessment the assessment part of this method focuses on the provider's evaluation of the patient it includes key findings clinical observations and diagnostic results that are pertinent to the patient's condition and four recommendation the provider offers their recommendations which may include suggested actions interventions or orders for the receiving Healthcare team this section helps guide the next steps in the patient's care in addition there are other standardized handoff formats tailored for specific scenarios for example the mechanism of injury injury SL inspection vital signs and treatment format is used primarily for trauma patients this structured approach ensures that critical information is conveyed efficiently reducing the risk of misunderstandings and errors during transitions of Care by using these standardized methods healthc Care Professionals can enhance the quality and safety of patient handoffs ultimately leading to improved patient outcomes and reduced medical errors.",
        "Decentralized Healthcare System": "the epidemic of medical errors can be attributed to various interconnected factors one of which is the decentralized and fragmented nature of the healthcare delivery system historically the medical community often viewed errors as a result of an individual's failure stemming from a lack of knowledge or skill this perspective framed errors as isolated incidents rather than systemic issues however governmental agencies that establish standards for a significant portion of the United States Healthcare System take a broader Viewpoint they see errors as indicative of the overall functioning of the entire Health Care system this difference in perspective highlights a fundamental challenge in addressing medical errors while Healthcare Providers May perceive errors as personal shortcomings government agencies and patient safety Advocates recognize that errors often result from systemic failures the decentralized and fragmented nature of the Health Care system means that information flow Co coordination and standardization are not always optimal leading to opportunities for mistakes to combat this epidemic of Errors there has been a shift towards adopting a more holistic and systems-based approach to patient safety recognizing that improvements need to occur at multiple levels within the healthc care delivery system to prevent errors and enhance patients safety this shift has led to initiatives and policies aimed at improving Health Care Quality and reducing Medical Errors.",
        "Systems Approach to Medical Errors": "A System's approach to addressing medical errors recognizes that most errors EO within the context of a poorly designed Health Care system this approach acknowledges that individual healthc Care Professionals may make mistakes but the focus is on understanding the systemic factors that contribute to these errors these factors can include various elements of the Health Care System such as processes procedures organizing ational culture and the physical environment in which care is provided for example long work hours a common occurrence in health care can lead to lapses in judgment and decisionmaking when healthc Care Professionals are fatigued due to Extended shifts their cognitive abilities may be impaired increasing the likelihood of Errors similarly less experienced staff members might make predictable mistakes when faced with complex decisions espe especially when the system lacks adequate support or standardization to guide them the system's approach aims to identify the specific conditions and situations that give rise to human error and then Works to remedy the underlying problems within the Health Care System it recognizes that most major accidents or Adverse Events result from a series of smaller mistakes that compound in environments with serious underlying system Flaws by addressing these system level issues the goal is to create a safer and more reliable Health Care system that reduces the opportunities for errors and ultimately improves patients safety this approach has led to various initiatives and strategies aimed at enhancing the quality and safety of healthcare delivery.",
        "Swiss Cheese Model": "the Swiss Cheese model developed by British psychologist James reasen is a key Concept in the field of systems analysis and patient safety this model provides a visual representation of how errors occur within complex systems and emphasizes the role of system failures in Adverse Events in the Swiss Cheese model systems are represented as multiple slices of Swiss cheese each with holes that vary in size and position the slices of cheese which symbolize layers of Defense within a system are stacked on top of each other individuals such as healthc Care Professionals interact with these systems errors occur and the holes in these defense layers align allowing an error to pass through all the layers and reach the patient most of the time the holes in one layer do not align perfectly with the holes in the other layers so errors are intercepted before reaching the patient however when the holes in multiple layers line up it can lead to catastrophic errors or Adverse Events the Swiss Cheese model illustrates that while individuals can make mistakes the primary focus should be on identifying and addressing the system vulnerabilities that contribute to these Errors By improving the design of these systems and addressing the holes in the layers of Defense Healthcare organizations can reduce the likelihood of errors and enhance patients safety this model has been widely adopted in healthcare and other high-risk Industries as a framework for understanding and mitigating errors.",
        "Active and Latent Errors": "James reason's concepts of active and latent errors are fundamental in understand understanding the different types of errors in complex systems particularly in the context of patient safety and health care these Concepts help differentiate between errors made by individuals or active errors and errors related to underlying system issues also known as latent errors active errors typically involve Frontline staff such as healthc care providers and occur at the point of contact between the individual and the larger system they are immediate and may result from fact factors like fatigue distraction or momentary lapes in judgment for example administering the wrong medication dosage due to a calculation error by a nurse would be considered an active error these errors are often more visible and directly associated with the individual's actions conversely latent errors are often rooted in organizational or system failures that may not become apparent until later when they contribute to Adverse Events these errors are not immediately obvious and may remain hidden within the system until a triggering event occurs latent errors are the result of design flaws inadequate policies or other structural deficiencies within the system for example a poorly designed medication ordering system that lacks proper safeguards to prevent dosage errors is a latent error while the error may not manifest until an active error occurs it is the latent error that allows the active error to lead to harm the concept of active and latent errors underscores the importance of addressing system level issues and vulnerabilities to prevent errors and improve patients safety but identifying and addressing latent errors organizations can create more robust systems that reduce the risk of active errors causing harm recognizing these distinctions is essential for a comprehensive approach to patient safety and quality improvement in healthare.",
        "Types of Active Errors": "Act Ive errors can be further categorized into two primary types slips and mistakes these distinctions are crucial for understanding how errors manifest within complex systems slips occur when an individual's intended action is Mis executed due to lapses in concentration often resulting from external factors such as distractions fatigue or stress a slip can be thought of as a mental hiccup where the person knows what they should do but they fail to execute it correctly for example a critical care transport paramedic May under the strain of a high stress situation inadvertently push the wrong button on a piece of equipment even though they are fully aware of the correct procedure these errors usually occur in real time and are strongly influenced by the immediate environment and the cognitive load on the individual in contrast mistakes involve taking the wrong action intentionally believing it to be correct cor mistakes often result from factors such as lack of experience insufficient training or even negligence unlike slips mistakes reflect a misunderstanding of the situation or a failure to recognize the correct course of action an example of a mistake might be a provide of administering the wrong medication dosage to a patient because they misunderstood the prescription or failed to check the medication label properly these errors are more deeply rooted in the individual's knowledge and judgment and they can have significant consequences both slips and mistakes are part of active errors that occur at the front line of care delivery understanding these categories helps identify the underlying causes of Errors which can then be addressed through strategies like improved training better system design and reducing environmental stresses this knowledge is vital for enhancing patient safety and reducing the occurrence of active errors in health care settings.",
        "Sentinel Events": "a sentinal event or serious adverse event represents a critical patient safety incident where an error within the Health Care system has reached a patient resulting in grave consequences these consequences may include death permanent harm or severe temporary harm that necessitates interventions to sustain life examples of Sentinal events Encompass a spectrum of medical errors such as ROM site procedures wrong procedures altogether cases of retained foreign bodies following surgery or medication errors with fatal outcomes these events serve as alarm Bells within the Health Care System prompting rigorous investigations interventions and quality improvement efforts to prevent their recurrence and enhance overall patients safety Sentinel events are designated as such because they act as vital indicators of systemic vulnerabilities within the Healthcare System system necessitating an immediate and comprehensive response in the wake of a sentinal event most hospitals employ a structured response system this system entails a formalized notification chain that promptly informs relevant stakeholders about the event it also involves an immediate huddle to assemble the necessary Personnel for timely response a debriefing to discuss the details of the event and a thorough root cause analysis process this Pro process is a critical step involving a systematic investigation to identify the underlying factors contributing to the event it often culminates with the endorsement and support of this analysis by senior leadership enabling corrective actions and the development of strategies to prevent future occurrences of such events thereby enhancing patients safety and the overall quality of healthc care delivery.",
        "Effective Communication in Patient Safety": "effective communication is a Cornerstone of patient safety event management it plays a pivotal role in addressing patient safety events helping Healthcare teams tackle competing priorities overcome human factors related issues and reduce errors several communication techniques and events are employed for this purpose ensuring that actual events sequences and timing are accurately documented to facilitate further analysis and corrective actions huddles are structured short meetings held on an ad hoc basis bringing together patient care teams during huddles teams share concerns discuss resource allocation anticipate outcomes and create contingency plans which are critical for recording the event accurately for subsequent analysis and corrective measures debriefing is a valuable inquiry tool led by a senior member that focuses on understanding what happened during the event and what can be learned from it to improve future practices it aims to collect insights from staff involved in the event not only for system changes but also to provide emotional support to staff and family determine reporting obligations and possibly visit the event site root cause analysis is a systematic approach that involves a multi-disciplinary team of professionals not directly involved in the event it is designed to identify the causes of a serious adverse event and pinpoint system flaws that can be corrected to prevent future harm most follow six steps identifying what happened determining what should have happened establishing the cause developing a causal statement generating a list of recommended actions to prevent recurrence and summarizing the results in a system that aderes to a just culture an algorithm is applied during the process to determine whether a similar person under similar conditions could or would have taken the same actions if the answer is yes the event is treated as a system failure rather than an individual failure persons with Reckless or malicious behavior are subjected to punishment while those with unintentional atrisk behaviors receive coaching and additional training this approach ensures a balanced response to events that considers both system factors and individual actions.",
        "Error Reporting Systems": "error reporting systems play a vital role in enhancing patient safety within emergency medical service agencies enabling the identification of issues and continuous Improvement in care delivery in 2012 the National Association of emergency medical technicians introduced the EMS voluntary event notification tool this system stands as an anonymous non-punitive and confidential platform that empowers professionals to report patient safety events and near misses it is designed to encourage open reporting and Analysis of Adverse Events enabling agency IES to identify Trends and areas for improvement without fear of reprisals the US Food and Drug Administration manages the adverse event reporting system which focuses on capturing information related to adverse medication reactions and device malfunctions providers can use this system to report incidents such as a failed defibrillator which is an example of a critical device malfunction when a provider or agency encounters such an event they have the to report it directly to the FDA or to the manufacturer in the case of Manufacturers they are obligated to notify the FDA of these events this system contributes to the overarching goal of improving patient safety within EMS by ensuring that such events are documented analyzed and addressed reducing the likelihood of recurrence and enhancing the quality of care provided.",
        "National EMS Culture of Safety": "in 2013 the National Highway traffic safety administration ens for children and the American College of Emergency Physicians jointly published strategies for a national ens culture of safety which represents a pivotal step in enhancing safety within the Emergency Medical Services sector this document recognized the imperative need for a secure and comprehensive National Database dedicated to reporting and cataloging Adverse Events in EMS this database would serve the purpose of identifying best practices Trends and areas for improvement while fostering a culture of safety within the EMS Community to establish such a system it was proposed that the national EMS information system database could be leveraged NIS is a standardized National Data repository for EMS patient care records that allows for the collection and sharing of valuable information across various EMS agencies and systems by integrating an adverse event reporting component into nemis the goal was to create a robust centralized resource that could capture and analyze data related to safety incidents and near misses in EMS this approach aimed to facilitate National level oversight Foster the sharing of Lessons Learned and ultimately Elevate the quality of patient care provided by EMS agencies across the United States.",
        "Use of Triggers in EMS": "the utilization of triggers has proven to be an effective approach in health care settings for identifying and addressing errors and safety issues reducing the Reliance on the voluntary reporting of employees trigger tools serve as systematic methods for identifying specific events or error rates that should prompt a more indepth evaluation of processes and workflows to enhance error prevention in 2018 a study conducted by Howard and colleagues adapted the institute for healthcare Improvement Global trigger tool specifically for the Emergency Medical Services System resulting in the creation of the EMS Trier tool this tool was designed to capture events or patterns that could signal potential safety concerns within the EMS system among the triggers free events stood out as particularly significant collectively accounting for 93% of the identified triggers these key triggers included significant changes in systolic blood pressure notably greater than 20% Which could indicate potential issues with patient management furthermore triggers included instances of elevated body temperature above 38\u00b0 C that did not subsequently decrease and oxygen saturation levels falling below critical thresholds these triggers provided EMS agencies with a clear and objective means of identifying high-risk situations that warranted further investigation and intervention thereby enhancing the overall quality and safety of care delivery in the field.",
        "Adopting Strategies from Other Industries": "in recent years the healthcare industry has increasingly turned to strategies borrowed from manufacturing and safety techniques from Aviation to enhance patients safety and improve the overall quality of care these strategies which include Six Sigma and lean have been successfully applied in various healthc care settings Six Sigma originally developed by Motorola in the manufacturing industry focuses on reducing errors and variations in processes it provides a systematic approach to process Improvement through the Define measure analyze improve and control methodology Healthcare organizations employ Six Sigma to identify and mitigate errors streamline processes and enhance the overall quality of care delivery lean inspired by the Toyota production system emphasizes the elimination of waste and the optimization of processes to enhance efficiency and reduce unnecessary costs in healthcare lean principles are used to streamline workflows eliminate inefficiencies and improve resource allocation this can lead to improved patient care reduced weight times and more efficient utilization of resources furthermore both strategies often emphasize the importance of teamwork collaboration and continuous Improvement making them valuable tools for healthcare organization striving to deliver highquality patient centered care Additionally the integration of Aviation inspired safety techniques such as the use of checklists further promotes a culture of safety within health care and helps prevent Adverse Events these strategies and techniques reflect the growing recognition that Healthcare can benefit from the successful practices developed in other Industries to ensure patients safety and improve outcomes.",
        "Six Sigma in Healthcare": "Six Sigma is a highly structured and data-driven approach to process Improvement that aims to eliminate defects and variations in any process whether it's in manufacturing transactional activities or Service delivery introduced by Bill Smith during his time at Motorola in 1986 it became a fundamental strategy for achieving excellence and quality in various Industries later it was widely adopted as a central tenant of Jack Welch's strategy at General Electric in the 1990s the name Six Sigma is derived from its primary goal which is to achieve a level of quality where there are six standard deviations between the process's mean and the nearest specification limit this level of performance corresponds to a very high degree of reliability with an error rate of only 3.4 defects per million opportunities Six Sigma has been associated with various Industries and its goal is to achieve a near perfect level of quality and efficiency few Industries have successfully reached Six Sigma reliability due to the high standards it sets achieving Six Sigma means that the process has a 99.99% non-failure rate an exceptionally low level of defects notably the aviation industry is one of the few sectors that has reached this ambitious goal as safety and reliability are Paramount in aviation making Six Sigma methodologies a perfect fit for their quality and safety initiatives the principles and methodologies of Six Sigma including datadriven decision-making continuous Improvement and the Define measure analyze improve and Control process are widely recognized for their effectiveness in enhancing quality reducing errors and improving overall performance in various sectors including Healthcare.",
        "Lean Principles in Healthcare": "lean a strategy initially developed by Toyota engineers in the mid 1990s is a comprehensive approach to process Improvement that aims to maximize efficiency minimize waste and ensure that all activities add value lean thinking goes beyond just manufacturing and is applicable to a wide range of processes and industries including healthare key principles of lean include the elimination of waste a focus on the customer and the commitment to continuous Improvement in lean thinking processes are analyzed in depth to identify and reduce waste waste is defined as any activity or resource that does not contribute value to the end product or service lean methods focus on a pull system where products or services are delivered in response to actual demand rather than being pushed onto the consumer this approach minimizes overproduction and excess inventory one of the fundamental aspects of lean is the concept of gemba which involves going to the workplace where the work is being done to observe and understand all the steps involved in a process by studying the process at the front line lean practitioners can identify opportunities for improvement once improvements are identified teams work together to create standard work which is essentially the best and most efficient way to perform a task this standardization helps reduce variation improve quality and minimize the chances of Errors the application of lean principles to healthcare has gained momentum with several hospitals and Health Care Systems adopting a lean Hospital approach in lean hospitals lean culture is integrated into all aspects of Hospital operations from Clinical care to administrative processes the goal is to improve the quality of patient care enhance efficiency reduce cost and create a safer and more effective Healthcare environment lean principles are particularly relevant in healthare where efficiency patient safety and quality of care are of utmost importance.",
        "Crew Resource Management": "crew resource management is a training and organizational culture approach that emphasizes the importance of effective communication teamwork and decision-making in high-risk Industries such as Aviation and healthare the introduction of CRM in healthcare is rooted in the lessons learned from the aviation industry particularly the tenith airport disaster of 1977 in the aviation industry CRM was developed as a response to a catastrophic event when two fully loaded Boeing 747 planes collided on the runway at tener airport resulting in 583 fatalities the analysis of this Collision brought to light alarming discoveries one of the most senior pilots in the airline was in command of the aircraft and had thousands of hours of experience flying the plane however a significant contributing factor to the accident was a breakdown in communication within the flight crew the captain believed that the flight had been clear for takeoff but the first officer and flight engineer had reservations however due to the hierarchal culture in the cockpit at the time the first off officer and flight engineer were unwilling to question or challenge the captain's decision this case highlighted the dangers of ineffective communication hierarchy and a lack of assertiveness in high stress situations as a result of the tenori collision and similar incidents the aviation industry recognized the urgent need to address communication and teamwork deficiencies CRM was developed to provide training that emphasizes the importance of effective communication a certif and teamwork among the crew this training which has been successfully implemented in aviation aims to prevent accidents by ensuring that all team members are actively engaged in decision- making and communication regardless of their position or seniority CRM has been adapted and applied to healthcare to address similar communication and teamwork issues that can have significant consequences for patient safety in healthcare CM training helps medical team means work cohesively and efficiently ultimately reducing errors and improving patient care.",
        "CRM Principles in Healthcare": "crew Resource Management places a strong emphasis on creating a culture of mutual support teamwork and open communication one of the critical principles of CRM is the expectation and requirement that any member of the crew regardless of their position or rank should feel comfortable and empowered to voice concerns regarding the safe operation of the aircraft this open and assertive communication style ensures that potential safety issues are promptly identified and addressed reducing the risk of errors or accidents the principles of CRM have been adopted by various Industries recognizing the significant improvements in safety and Effectiveness they can bring the military for example has integrated CRM principles into its training and operations to enhance communication and teamwork among Personnel in high press and complex situations similarly the nuclear industry has applied CRM Concepts to ensure that employees work cohesively to maintain the safety of nuclear facilities in the healthcare sector the importance of effective communication and teamwork in ensuring patient safety led to the adoption of CRM principles one of the notable initiatives in healthcare is known as team strategies and tools to enhance performance and patient safety safety which was created through collaboration between the US Department of Defense and the agency for healthcare research and quality the initiative provides healthc Care Professionals with a structured framework for improving communication teamwork and Leadership skills it offers various tools and strategies designed to enhance performance and most importantly patient safety Healthcare organizations and Facilities have increasingly Incorporated this training into their program s recognizing its potential to reduce errors improve patient outcomes and create a safer healthare environment by fostering a culture of mutual support respect and open communication CRM and programs like a helping Healthcare teams work more cohesively ultimately benefiting both healthc care providers and the patients they serve.",
        "Simulation Training in Healthcare": "simulation training has emerged as a pivotal component in team building within the healthcare industry this Training Method provides a controlled and safe environment for healthcare providers to refine their skills practice procedures and enhance their communication skills without the risk of causing harm to patients it offers a range of benefits that contribute to improved teamwork and patient safety one of the primary advantages of simulation training is the opportunity for healthcare providers to hone their clinical and procedural skills medical professionals from doctors to nurses to paramedics can practice a variety of medical procedures and interventions in a simulated setting that closely minimix real clinical scenarios this allows them to build competence and confidence in performing tasks they may encounter during Patient Care by practicing in a risk-free environment they can make mistakes learn from them and enhance their skills more effectively than through traditional on the job training alone additionally simulation training PR promotes effective teamwork and communication among Healthcare Providers many Healthcare situations require coordinated efforts from multiple team members simulation scenarios often involve interprofessional teams working together to manage complex cases make critical decisions and communicate effectively this hands-on experience helps healthc Care Professionals understand their roles and responsibilities within the team Fosters clear and concise communication and enhances situational awareness these skills are crucial for delivering quality patient care particularly in high stress or emergency situations overall simulation training has become a Cornerstone of healthcare education and training programs it not only offers healthc care providers the opportunity to refine their clinical and procedural skills but also equips them with the teamwork and communication skills needed to deliver safe and effective patient care by practicing in a controlled environment healthc Care Professionals can better prepare for real world scenarios ultimately improving patient safety and outcomes.",
        "Simulation Training in EMS": "simulation training has experienced a surge in popularity across various medical settings including traumacare obstetric and dynology and emergency departments in EMS this Training Method has proven to be invaluable in preparing Professionals for The Unique challenges they counter in the field the versatility of simulation training in EMS is evident through its application in various formats from basic task trainers to High Fidelity simulation mannequins that replicate life-threatening situations in more advanced EMS simulation training High Fidelity mannequins are employed to mimic complex and dynamic patient scenarios for instance High Fidelity Rhythm simulators are commonly used to practice the management of patients experiencing Cardiac Arrest or severe arrhythmias these simulators can replicate different cardiac rhythms allowing EMS providers to enhance their Diagnostic and treatment skills under realistic conditions by practicing with High Fidelity mannequins EMS professionals can improve their ability to respond effectively to cardiac emergencies and other critical situations they may encounter in the field simulation training in EMS is not limited to clinical scenarios alone it is also extended to driver training and retraining ens drivers play a crucial role in ensuring patients safety during transport to prepare them for the challenges of navigating ambulances through traffic handling emergency situations and understanding the limitations of their vehicles simulators can be used these simulators replicate the experience of driving an ambulance and help drivers develop the skills and reflexes needed to safely transport patients especially in emergency situations by incorporating simulation training into driver education and ongoing training programs em agencies can enhance the overall safety of their operations and reduce the risk of accidents during patient transport.",
        "Failure Mode and Effect Analysis": "failure mode and effect analysis is a structured approach to risk assessment and mitigation originally developed by military engineers in the 1940s and subsequently refined during the National Aviation and space administration's work on the Mercury gmany and Apollo space programs while it has a rich history in aerospace engineering this structured approach has gained importance in healthc care as a method for proactively identifying and addressing potential failures within Healthcare processes in healthcare this approach is used to systematically analyze potential failures within a health care process such as patient care delivery or medication administration the process involves constructing a risk Matrix for each identified potential failure which takes into account three critical factors the likelihood of the failure occurring the ability to detect the failure before it reaches the patient and the potential harm the failure may cause by assigning a risk score to each potential failure Healthcare teams can prioritize their efforts to mitigate risks and redesign processes to enhance patient safety this is instrumental in helping Healthcare organizations uncover vulnerabilities in their systems allowing them to focus on areas where improvements are most needed ultimately reducing the chances of errors and Adverse Events this proactive approach to risk management aligns with the larger goal of enhancing patient safety and the overall quality of care within the Health Care System.",
        "Challenges in EMS Care": "Em Care presents unique challenges compared to impatient or emergency department care as it occurs in Dynamic and often uncontrolled environments which can make it potentially more dangerous unlike the controlled environment of a hospital ens providers must deliver care in diverse settings from accident scenes to patients homes where they may encounter numerous variables that can impact patients safety given these challenges it's essential to develop and incorporate patient safety strategies and team training tailored to the specific needs of EMS in recent years the healthcare landscape has undergone significant changes partly due to the patient protection and Affordable Care Act this legislation led to the consolidation of many hospitals into larger healthc Care Systems which often resulted in sight specific specializations as a consequence of this consolidation and specialization hospitals have become more focused on specific types of care sometimes lacking the facility or expertise require for certain critical cases this has increased the need for transferring critically ill patients between facilities thereby elevating the importance of patient safety during interf facility transport as such ens systems have had to adapt to meet these evolving Health Care demands which include enhancing their patient safety strategies and implementing teen training to ensure that patients receive consistent and Safe Care throughout their journey within the health care system.",
        "Systematic Review of EMS Safety": "in 2012 bigam and colleagues conducted a comprehensive systematic literature review that aimed to shed light on patients safety within the realm of EMS this review Unearthed seven key themes Each of which serves as a crucial component in understanding potential pitfalls and guiding safety efforts for both individual providers and EMS agencies clinical judgment the First theme is fundamental to Patient Care within EMS it involves the ability of providers to make sound evidence-based decisions and assessments often under pressure and with limited information ensuring that EMS professionals possess robust clinical judgment skills is vital for maintaining patient safety the review also identified Adverse Events and error reporting as a significant theme this highlights the importance of recognizing when things go wrong and the necessity of reporting these incidents understanding errors and Adverse Events allows EMS agencies to learn from their mistakes and Institute measures to prevent their recurrence effective reporting systems are critical for fostering a culture of safety and continuous Improvement the themes of communications ground Vehicle Safety aircraft safety interfacility transport and field intubation reflect various aspects of patient care in the pre Hospital environment effective communication and Safe Transportation methods are integral to ensuring patients safety during All Phases of care delivery especially when responding to emergencies or facilitating interf facility transports similarly field intubation is a high-risk procedure that demands meticulous attention to safety protocols this comprehensive review illuminated the multi-dimensional nature of patient safety within EMS and emphasized the importance of addressing these distinct themes to improve overall patient care quality and safety in the prehospital setting.",
        "Enhancing Clinical Judgment in EMS": "clinical judgment is an essential aspect of EMS care as paramedics and other EMS providers are required to make critical decisions in high stress time-sensitive situations however the review by bigam and colleagues raised concerns that EMS providers might sometimes make decisions beyond their training and scope of practice this phenomenon is often referred to as scope creep and it may lead to Providers making decisions that could potentially harm the patient the review underscores the need for additional training in various areas to enhance clinical judgment and ensure that EMS providers are well equipped to make appropriate decisions additional training for EMS providers could Encompass several important aspects first it may involve improving their capacity for complex decision making in emergencies paramedics often face rapidly changing situations that require quick and accurate assessments and choices second training can focus on low frequency high-risk skills as emsa providers May encounter rare yet critical situations during their careers ensuring that they have the competence to handle such scenarios is vital finally training can address the use of Advanced Equipment and technology which are becoming increasing prevalent in EMS practice offering educational programs that familiarize providers with the latest tools can contribute to better clinical judgment and ultimately enhance patients safety in conclusion clinical judgment remains a Cornerstone of effective EMS care the potential for scope creep highlights the necessity of continuous training and education in the field emphasizing complex decision-making low frequency high-risk skills and Advanced Equipment utilization these measures can Empower ens providers to make sound decisions that prioritize patient safety even in the most challenging situations.",
        "Data Gaps in EMS Safety": "in the realm of em there is a significant Gap in the available data concerning Adverse Events and medication errors compared to other Healthcare settings like hospitals where systems for reporting and analyzing medical errors are more established enfs has been slower in developing comprehensive reporting mechanisms this lack of data can hinder efforts to enhance patients safety and identify areas that require Improvement inadequate data not only affects the ability to track and understand incidents but also impedes the development of preventive measures to mitigate the risk of errors and Adverse Events in EMS one of the prominent challenges in error reporting within EMS is the presence of patterns characterized by both Under reporting and non-reporting of events research and Survey data indicate that several factors contribute to this issue firstly em providers May fear reporting errors due to concerns about repercussions such as disciplinary action or damage to their professional reputation secondly there may be a lack of recognition among EMS Personnel regarding the significance of near Miss events which are valuable for identifying potential problems and enhancing safety measures combating this challenge necessitates the establishment of a culture that encourages open reporting without fear of Retribution and ensures that providers understand the importance of reporting all incidents including near misses in the interest of improving patients safety additionally improving reporting mechanisms and the overall safety culture within EMS organizations is vital for addressing these patterns of Under reporting and non-reporting.",
        "Communication in EMS": "communication plays a critical role in patients safety and is a central theme in Health Care Systems both in hospitals and prehospital settings let EMS effective communication is essential for ensuring that vital patient information is accurately and promptly conveyed between healthc care providers especially during transitions of care the handoff from EMS Personnel to emergency department or hospital staff is a crucial phase in patient care and where communication breakdowns can lead to Patient harm numerous Studies have focused on prehospital Communications specifically examining the handoff process between EMS and Hospital staff these Studies have revealed instances where important clinical information is not effectively transferred which can have severe consequences for patient safety for example changes in Vital Signs like transient hypertension may not be adequately communicated similarly details about medications administered including the type dosage and timing can be Lost in Translation during handoffs moreover changes in Ventilator settings which are vital for patients requiring mechanical ventilation may not be accurately conveyed these communication gaps can lead to misunderstandings errors in care and delays in treatment all of which could impact the patient well-being efforts to improve communication in EMS involve developing standardized communication tools and protocols such as the spa technique which have been widely adopted from other high reliability Industries such tools aim to ensure that vital patient information is accurately and efficiently communicated during the handoff process thereby reducing the risk of Adverse Events and enhancing patients safety.",
        "Vehicle and Provider Safety in EMS": "ensuring vehicle and Provider Safety is Paramount in the field of critical care transport the transport environment whether by ground or air presents unique challenges that require special attention to prevent vehicular harm to both patients and providers providers must adhere to specific safety protocols to guarantee their well-being during Transit providers in the passenger compartment should remain seated and secured at all times this practice is essential to protect providers from injuries that may result from Sudden stops starts or turbulence during transport securing providers also ensures they can effectively care for the patient without being at risk of becoming an additional patient themselves additionally providers should ensure that all equipment is properly secured loose equipment can become dangerous projectiles in the event of sudden movements potentially causing harm to the patient providers or both to support Provider Safety transport agencies should establish and enforce policy and procedures that promote and maintain maximal safety during transport these guidelines may include proper seating and restraint requirements equipment securing protocols and education on safe practices additionally agencies should conduct regular safety training and drills to familiarize providers with the specific safety measures and procedures they need to follow in different situations such as ground or Air transport during the day or at night and in VAR ious weather conditions maintaining a strong culture of safety within transport agencies is essential to minimize the risk of accidents and injuries allowing providers to focus on delivering highquality patient care.",
        "Air Transport Safety": "Air transport safety in critical care situations involves a series of critical steps to minimize risk and ensure the well-being of both the patient and the flight crew the goal of Air transport is to optimize the patient's condition before and during the flight while also ensuring that the necessary monitoring equipment is in place to address any unforeseen changes in the patient condition the foundation of Air transport safety is effective crew Resource Management which focuses on enhancing communication and teamwork among the flight crew and medical team clear communication is essential for ensuring that everyone understands their roles and responsibilities during the transport this includes assigning tasks such as patient care care monitoring Vital Signs and coordinating with ground Personnel or receiving facilities one of the key components of Air transport safety is the ability to make appropriate go/ nogo decisions before taking off the flight crew in collaboration with the medical team must carefully assess the patient's condition weather conditions and other factors that could affect the safety of the flight if any significant risk factors are identified the decision to delay or cancel the flight must be made to prevent harm to the patient or flight crew these go/ nogo decisions are crucial to Air transport safety and they require a high level of clinical judgment communication and teamwork among the crew the flight crew and medical team must work together to ensure that the patient is in the best possible condition for the flight that all necessary equipment is in place and that the flight itself can be conducted safely this emphasis on safety and risk reduction in Air transport is essential to provide the best possible care to critically ill patients during transport.",
        "Interfacility Transport Challenges": "interf facility transport plays a crucial role in the Continuum of patient care ensuring that patients receive the appropriate level of treatment in the right facility however Adverse Events during interf facility transport can pose a significant challenge as the patient's condition may change during the transfer research has shown that the rate of Adverse Events during transport can vary depending on the qualifications of the transport Personnel for instance a Canadian study found that transports staffed with specially trained Critical Care transport paramedics had a lower adverse event rate compared to those staffed with emergency medical technicians and paramedics Adverse Events reported during transport included incidents like hypertension initiation of vasopressor therapy and respiratory events the study also highlighted that certain patient populations such as pediatric patients are more susceptible to specific Adverse Events during transport such as hypothermia drug errors tachicardia procedure errors loss of IV access and cyanosis to mitigate these risks specialized teams with training and experience in pediatric care may be needed to ensure the safety and well-being of these patients during transfer the need for specialty trained teens in interfacility transport is becoming increasingly important particularly as advanced therapies like inhaled nitric oxide and extracorporal membrane oxygenation are used more frequently during transport despite the significant role of interfacility Transport in modern healthc care there is currently no mandatory regulatory oversight for transport teams emphasizing the importance of ensuring that these teams are well prepared and trained to to handle the unique challenges they may encounter during patient transfers.",
        "Strategies to Mitigate Adverse Events in Transport": "mitigating Adverse Events during interfacility transport is Paramount to ensuring patients safety and the delivery of high quality Care several effective strategies have been identified to reduce the risk of such events a study focusing on adult transports revealed that up to 70% of Adverse Events during transfers could have been avoided with better preparation before transport improved communication between the sending and receiving facilities and the utilization of checklists and protocols this underscores the significance of proper planning and collaboration in the transport process choosing the right crew configuration is one of the key factors in minimizing risks during transport ensuring that the transport team is well equipped and trained to manage the specific needs of the patient is crucial for more complex transports especially those involving ADV Advanced Equipment such as intra otic balloon pumps or extracorporal membrane oxygenation additional Personnel like Critical Care nurses respiratory therapists or Physicians should be considered as necessary to provide the appropriate level of care during the transfer checklists have also proven to be effective Tools in enhancing safety during interf facility transport using specific checklists that include sections for ventilator settings IV pumps and other equipment can significantly reduce the risk of Adverse Events and errors of emission these checklists serve as valuable guides for the transport team ensuring that all essential steps are taken to maintain patient safety lastly equipment Readiness and maintenance are critical in preventing Adverse Events ensuring that all equipment is available properly maintained and thoroughly checked before transport can help mitigate risks related to equipment failure or malfunction further enhance ing the safety of the transfer process.",
        "Conclusion and Emphasis on Patient Safety": "this lecture emphasized the significance of prioritizing patient safety in prehospital and critical care settings it delved into various strategies and methodologies including Six Sigma and crew Resource Management aimed at minimizing errors and enhancing the overall quality of care Six Sigma a systematic approach used to eliminate defects in processes was introduced as a valuable tool to ensure en the highest standards of patient safety the lecture highlighted how this methodology originally developed in manufacturing Industries is increasingly being applied to Health Care settings including prehospital care to reduce errors and prevent harm to patients crew Resource Management emerged as another critical aspect of the lecture emphasizing the importance of effective teamwork and communication in healthcare environments drawing lessons from Aviation CRM Fosters a culture of mutual support open communication and the expectation that any team member should voice concerns regarding the safety of patients the lecture stressed how CRM techniques can play a pivotal role in preventing Adverse Events and errors in the dynamic and high pressure setting of prehospital and critical care altogether this lecture underscored the ongoing commitment to patient safety integrating Six Sigma CRM and other adverse event mitigation strategies into the practice of critical care paramedics to enhance patient outcomes and minimize the risk of    harm"
    },
    {
        "Introduction": "physiology introduction Critical Care transport professionals often find themselves working in aircraft environments as part of their duties either on a permanent basis or during specific assignments to excel in these roles providers must be well versed in the unique intricacies of both rotor wing and fix wi operations understanding the differences and requirements of each type of aircraft is essential for ensuring the smooth execution of patient transport missions in an air medical environment the Paramount concern is always crew safety this critical aspect of their roles can sometimes be challenging for providers to fully comprehend especially when their primary focus is on patient care however it is imperative to emphasize that crew safety is the foundation upon which the success of any mission is built maintaining a high level of situational awareness adhering to rigorous safety protocols and recognizing the potential risks associated with aircraft operations are fundamental to the safe and efficient execution of their duties by instilling the principle that crew safety is the top priority flight paramedics ensure not only their well-being but also the ability to provide timely and effective care to their patients during critical transport missions a comprehensive understanding of flight physiology is indispensable for ensuring the airworthiness of the flight crew and averting transport related complications in critically ill and injured patients Critical Care transport professionals must have a strong grasp of the physiological effects induced By changes in altitude as they often encounter patients with Comm abilities or those who are already in a severely compromised condition for these patients the variations in barometric pressure during flight can exacerbate existing medical conditions and pose additional risks recognizing the potential challenges associated with altitude and being able to mitigate them is essential for the safety and well-being of both patients and the flight crew several gas laws come into play in Flight medicine and it is crucial for providers to understand their implications these laws can lead to Common problems arising from changes in oxygen levels and barometric pressure such as decompression issues as such providers need to be well-versed in recognizing the signs and symptoms associated with these problems and implementing appropriate interventions to maintain patient safety during Air transport moreover being aware of the primary stresses on flight crew members and understanding the factors that influence their tolerance to stresses is of Paramount importance flight crew including Critical Care paramedics should be be acquainted with various illusions of flight and spatial disorientation as these phenomena can affect their ability to operate safely in the aircraft environment by having a solid grasp of these aspects of flight physiology providers can ensure safer patient transport and maintain the air worthiness of the flight crew during Critical Care",
        "The Air Medical Role": "missions the air medical role even for providers primarily involved in ground-based services having a comprehensive understanding of flight physiology is vital this knowledge extends to the recognition and prevention of barometric maladies which can be relevant in various scenarios recognizing these maladies is important because they can affect patients both during transport and afterward especially if the patients have been exposed to changes in altitude barometric maladies such as decompression sickness or altitude sickness can occur due to changes in pressure during flight or high altitude ground transport providers need to beare aware of the symptoms and signs of these maladies including joint pain dizziness nausea and shortness of breath among others early recognition is crucial to provide timely interventions and mitigate potential complications for patients moreover understanding how to prevent these maladies is equally important providers should be knowledgeable about the preventive measures such as maintaining proper cabin pressure during transport and ensuring adequate oxygen levels for patients in some cases this may require taking precautions when patients have certain medical conditions or are exposed to Rapid altitude changes by having this knowledge groundbase providers can contribute to ensuring patient safety and well-being even when they are not directly involved in air Medical Transport when making decisions regarding air Medical Transport Critical Care transport professionals must carefully weigh the potential benefits for the patient against the associated risks this evaluation requires a thorough assessment of the patient to anticipate how altitude flight vibrations and other forces during transport might adversely affect the patient's condition for example in the case of patients with cardiac conditions and activity sensing pacemakers the flight vibrations could potentially disrupt the pacemaker normal function leading to severe complications the provider must consider the patient specific medical history and device settings when determining the appropriateness of Air transport there are several contraindications for air Medical Transport that providers must consider conditions like severe anemia hemoglobinopathy recent mardial inunction with complications in the past 5 days uncontrolled arithm pregnancies Beyond 24 weeks gestation recent eye surgeries that affect the globe and non-acute hypovolemia can all pose significant risks during flight in these cases ground transport or other methods may be more appropriate to ensure the patient safety exceptional care must be taken when deciding whether to proceed with Air transport to avoid exacerbating the patient's condition or creating additional health risks during the Journey Air Medical Transport despite its drawbacks and challenges offers several significant benefits making it a valuable component of the Health Care System numerous studies and real world data have shown that air Medical Transport can significantly reduce mortality rates especially for critically ill or injured patients the speed at which air ambulances can reach patients and transport them to Advanced medical facilities plays a vital role in improving patient outcomes this is particularly evident in cases where timey interventions are crucial such as trauma heart attacks or stroke the Swift response of air Medical Teams can provide life-saving care and significantly lower mortality rates air medal transport facilitates rapid access to highly specialized tertiary care facilities that might not be available locally for for patients with complex or rare medical conditions this access to Specialized Care can make a substantial difference in their treatment and Recovery the ability to quickly transfer patients to facilities with the necessary expertise technology and resources can enhance their chances of receiving Optimal Care leading to improved clinical outcomes air Medical Transport is indispensable for patients living in remote or geographically inaccessible areas these patients May face challenges in accessing health care services due to distance rough terrain or other logistical barriers air ambulances can overcome these obstacles and provide a swift means of transport to medical facilities this rapid access ensures that patients in remote regions receive timely and appropriate care preventing adverse outcomes that might occur due to",
        "The Atmosphere": "delays the atmosphere the Earth's atmosphere is a dynamic and complex layer of gases that envelops our planet it extends from the Earth's surface to an altitude of approximately 6,200 Mi which marks the beginning of space this gaseous envelope is essential for supporting life on Earth and plays a crucial role in regulating our planet's climate weather patterns and overall environmental conditions one of the remarkable characteristics of Earth's atmosphere is its variability the composition density and other properties of the atmosphere can change with respect to various factors including the time of day season and geographical latitude these variations are the result of complex interactions between the atmosphere the Sun and the Earth for instance during the day the atmosphere experiences changes in temperature pressure and humidity due to the sun's energy input seasonal variations on the other hand occur as a result of the Earth's axial tilt which leads to differences in solar radiation and temperature patterns between summer and winter geographical latitude also plays a significant role as different regions on Earth receive varying amounts of solar energy leading to Unique atmospheric conditions and weather phenomena understanding the dynamic nature of Earth's atmosphere is crucial for a wide range of applications including meteorology climate science Aviation and space exploration scientists continually study these atmospheric variations to improve our understanding of weather patterns global climate change and the impact of human activities on the atmosphere this tech knowledge is invaluable for making informed decisions about Environmental Conservation disaster preparedness and sustainable Resource Management on our planet the composition of the Earth's atmosphere is remarkably consistent and can be defined in terms of the percentages of various gases present although these percentages remain relatively constant the density of the atmosphere as well as the density of its constituent gases can vary with altitude the atmosphere is primarily composed of three major gases oxygen nitrogen and argon collectively these three gases make up almost 99% of the atmosphere's composition this composition remains consistent from the Earth's surface to altitudes as high as 250,000 ft oxygen is one of the most critical components of the atmosphere and plays a fundamental role in sustaining life on Earth it makes up approximately 21% of the atmosphere's volume oxygen is a bip product of photosynthesis a process carried out by green plants and algae during photosynthesis these organisms convert carbon dioxide and sunlight into oxygen and glucose releasing the oxygen into the atmosphere this process is essential for providing the oxygen necessary for respiration in many light forms including humans without an adequate supply of oxygen in the atmosphere Life as we know it would not be sustainable it's worth noting that although oxygen is vital for life it also supports combustion making it a crucial element for various industrial and technological applications nitrogen is the most abundant gas in the Earth's atmosphere constituting a significant portion of the total volume approximately 78% is often referred to as an init gas because is relatively unreactive under normal conditions nitrogen is odorless colorless and tasteless and these properties make it well suited for serving as a maj component of the atmosphere while nitrogen is not readily used by humans directly for metabolic processes it is still a critical element for Life nitrogen is present in the human body in substantial quantities as is a fundamental component of amino acids which are the building box of proteins proteins are essential to various biological processes and thus nitrogen is indirectly important for life in specific environmental conditions nitrogen can play a role in health and safety con concerns for example at high altitudes or after a rapid Ascent while scuba diving changes in pressure can affect the dissolved nitrogen in the bloodstream this can lead to evolved gas disorders like decompression sickness also known as the bends these disorders occur when nitrogen forms bubbles within the body due to changes in pressure as a result managing exposure to nitrogen is crucial for those engaged in activities at high altitudes or underwater environments and understanding its properties as essential for safe operations Argan on the other hand constitutes a much smaller fraction of the atmosphere's volume approximately 0.93% like nitrogen it is an inner gas meaning it is generally unreactive and doesn't readily participate in chemical reactions Argan is also odorless colorless and tasteless and it does not play a significant role in the metabolic processes of living organisms instead Argan is primarily used in specialized industrial applications such as welding and as a protective gas in various types of manufacturing processes where its ionic properties are advantageous while Argan makes up only a small part of the atmosphere it has valuable applications in specific technological and Industrial contexts beyond the primary gases in Earth's atmosphere several Trace gases are present in much smaller quantities each with its own unique properties and sources carbon dioxide is a critical Trace gas making up approximately 0.04% of the atmosphere it is produced by various natural processes such as respiration in living organisms and volcanic eruptions but its concentration has been increasing due to human activities primarily the burning of fossil fuels elevated levels of carbon dioxide are associated with global warming and climate change neon is a noble gas making up only about 0 18% of the atmosphere it is colorless odor and in it neon is most famous for its use in neon signs where it emits a distinctive orange red glow when electricity passes through it heum comprises a very small portion of the atmosphere roughly 05% it is the second lightest and second most abundant element in the universe helium is used in various applications including as a coolant and cryogenics and helium fill balloons and in medical settings for cooling superconducting magnets methane is another Trace gas making up about 0 2% of the atmosphere it is a potent greenhouse gas and is released into the atmosphere from sources such as natural Wetlands liuck digestion and the extraction and transportation of fossil fuels Krypton constitutes a minuscule fraction of the atmosphere approximately 0 1% It is a noble gas similar to neon and argon and is used in some specialized lighting and Laser applications hydrogen is present in very small amounts in the atmosphere about about 0.005% it is the lightest and most abundant element in the universe while there's not typically found in large quantities in the Earth's atmosphere hydrogen has important industrial applications including in the production of ammonia and as a fuel source for certain types of vehicles and Equipment these Trace gases while present in small quantities can have significant impacts on the environment technology and various Industries their study and management are essential for understanding their effects on the atmosphere and climate and for harnessing their practical applications the Earth's atmosphere is divided into distinct layers each characterized by unique properties and functions which are identified based on several factors one thermal characteristics these layers are categorized by temperature changes as you move higher in the atmosphere you encounter shifts in temperature that Define the boundaries between different layers two chemical composition the chemical makeup of the atmosphere varies with altitude different layers contain different concentrations of gases and this impacts the behavior of molecules and their interactions three movement the Dynamics of air movement including wind patterns and circulation differ in each layer these movements influence weather climate and other atmospheric phenomena and four density density refers to the concentration of gas molecules Within each layer the density decreases with height as you ascend because the weight of the molecules near the Earth's surface compresses the gases making them denser the first and closest layer to the earth's surface is the troposphere this layer extends from sea level to approximately 26,000 ft above the poles and around 52,000 ft above the equator it is commonly known as the lower atmosphere and it's where most weather events occur this is because it contains water vapor and experiences strong vertical air currents allowing clouds to form rain to fall and various weather patterns to emerge within the tropus gear there is a strong jet stream located above 35,000 ft where maximum wind speeds can average around 200 mph this powerful wind flow typically found at about 30\u00b0 latitude North and South plays a significant role in global weather patterns the temperature in the tropus gear varies with altitude it is generally warmer near the surface with temperature around 62.6 de fah however as you ascend the temperature decreases proportionally with increasing altitude reaching frigid temperatures as low as minus 68.8 de F the layers of the atmosphere are crucial for understanding meteorological phenomena air travel and climate Dynamics the troposphere in particular is of great significance because it hosts the weather systems and conditions that directly impact our daily lives as we move upward through the the layers we encounter distinct changes in temperature composition and other properties all of which contribute to the complex and dynamic nature of our atmosphere the second layer of Earth's atmosphere known as the tropopause occupies the region between the troposphere and the stratosphere this layer is characterized by several key features one altitude range the height of the tropes varies depending on geographical location at the poles it typically starts at an altitude of around 30,000 ft while near the equator it extends to more than 60,000 ft above sea level the significant difference in altitude is a result of the expansion and contraction of the atmosphere due to variations in temperature and pressure at different latitudes two altitude changes the height of the tropopause is not fixed but varies due to the expansion and contraction of air masses near the Earth's poles and equator as warm air rises near the equator it expands pushing the troper PES to higher altitudes conversely the cooler air near the poles contracts causing the troper to descend to lower Heights these altitude changes are reflective of the dynamic nature of the atmosphere and its response to temperature variations and three relation to the lower atmosphere like the troposphere the troper is considered part of the lower atmosphere it shares characteristics with the troposphere such as its proximity to the Earth's surface and both layers are vital for weather patterns and meteorological phenomena the differences in the properties and behavior of the troposphere and tropopause Mark the transition between the layers of the atmosphere and have a significant impact on the movement of air and the development of weather systems understanding the tropopause and its unique features is essential in meteorology and Atmospheric science as it plays a crucial role in the Dynamics of the earth's climate and weather the variation in its height and the relationship between temperature changes and all multitude shifts highlight the complex interactions within the atmosphere contributing to the formation of weather patterns wind currents and climate conditions in addition to the troposphere and tropes the Earth's atmosphere is composed of several other distinct layers each with its own unique characteristics and functions the stratosphere lies just above the tropes and extends to an altitude of around 30 Mi or 160,000 ft above sea level notable for containing the ozone layer the stratosphere plays a crucial role in protecting life on Earth the ozone layer absorbs and scatters the harmful ultraviolet UV radiation from the Sun unlike the troposphere where temperature decreases with altitude the stratosphere's temperature generally increases with altitude due to the absorption of UI radiation by ozone molecules the stratapore serves as a transitional region that separates the stratosphere from the mosphere its altitude can vary depending on factors such as geographical location and the time of year in the stratopause temperatures begin to decline with increasing altitude marking the boundary between the warming Stratosphere and the cooling mesosphere the mesosphere extends from the strator to an altitude of approximately 53 Mi or 280,000 ft above sea level this layer is characterized by a significant drop in temperature with increasing altitude making it one of the coldest regions of Earth atmosphere the mesosphere is also where meters entering the Earth's atmosphere burn up and create visible streaks of light commonly known as shooting stars the thermosphere stretches from the mesopor to the outer boundaries of the Earth's atmosphere marking the transition to the space environment unlike the troposphere or Stratosphere the thermosphere experiences a notable increase in temperature with altitude this warming is primarily due to the absorption of intense solar radiation however despite the high temperatures in the thermosphere it would feel extremely cold to humans due to the extremely low density of gas molecules at these altitudes the exosphere is the outermost layer of the Earth's atmosphere extending beyond the thermosphere it gradually merges with outer space and its upper boundary is not precisely defined in the exosphere the density of gas molecules is exceedingly low and the atmosphere becomes progressively tenuous this layer is where satellites and spacecraft orbit the Earth there is essentially no atmosphere in the exost and gas particles exist as individual atoms and molecules each of these atmospheric layers contributes to the complex dynamics of Earth's climate weather patterns and Atmospheric processes understanding the variations in temperature composition and behavior Within These layers is essential for comprehending how the Earth's atmosphere interacts with the planet's surface and outer space ultimately shaping the conditions for life on Earth the atmosphere can be divided into three distinct zones Each of which correlates with how the human body responds to hypoxia or a lack of oxygen these zones include the physiologic Zone the physiologically deficient Zone and the space equivalent Zone the physiologic zone is the portion of the atmosphere that contains the necessary levels of oxygen and barometric pressure required for a normal healthy person to live without any additional support this Zone extends from sea level to an altitude of approximately 10,000 ft it encompasses the barometric pressure which decreases from the standard 760 mm of mercury at sea level to around 523 mm of mercury at 10,000 ft within this range the barometric pressure remains sufficient to maintain an adequate partial pressure of oxygen or pa2 without the need for supplemental oxygen pressurization or specialized protective equipment however it's important to note that as one ascends to higher altitudes within the physiologic Zone several considerations come into play even in healthy individuals mild hypoxia can become evident at altitudes around 10,000 ft hypoxia tends to affect nearly all individuals with underlying medical conditions or commities to address these concerns Aviation regulations such as part 91 or part 135 of the Federal Aviation regulations mandate that commercial pilots must use supplemental oxygen when flying above 10,000 ft to maintain their health and well-being understanding these zones and the associated physiological changes is vital for ensuring the safety and health of individuals operating at various altitudes particularly in aviation where the use of supplemental oxygen is carefully regulated to prevent hypoxia related issues during flight the physiologically deficient Zone the second of the three atmospheric zones spans altitudes from 10,000 000 ft to 50,000 ft in this Zone the barometric pressure continues to decrease significantly as we Ascend above 10,000 ft the barometric pressure Falls to levels that can lead to a condition known as hypoxic hypoxia where the body experiences insufficient oxygen at the lower boundary of this Zone the barometric pressure stands at 523 mm of mercury while at the upper boundary of 50,000 ft it diminishes to a mere 87 mm of mercury as we progress higher into this Zone the effects of Trapped gases in the body become more pronounced and problematic these effects necessitate the use of protective equipment supplemental oxygen and pressurized aircraft to counteract the reduced barometric pressure the space equivalent Zone extends from an altitude of 50,000 ft to 120 m above the earth's surface in this Zone standard supplemental oxygen alone proves inadequate because of the extremely minimal barometric pressure to ensure the health and safety of individuals operating in this Zone specialized equipment becomes essential crew members and astronauts working in the space equivalent Zone require pressure suits and seal cabins to maintain the proper environmental conditions and oxygen levels in this zone two additional hazards come into play first exposure to atmospheric conditions at these altitudes can result in the boiling of body fluids due to the reduced boiling point of water in the low pressure environment second there is an increased risk of exposure to higher levels of solar radiation from the Sun presently there are no commercial aircraft used for air Medical Transport that operate within the space equivalent Zone as it is reserved for the domain of space travel and expiration barometric pressure also known as atmospheric pressure is a fundamental parameter in meteorology and has a significant impact on various aspects of our daily life lives including weather conditions it is essentially the direct result of the weight of the air in the Earth's atmosphere the amount and weight of air above any given location on Earth's surface can vary depending on factors such as time and geographical location as a result barometric pressure is not a constant value and can fluctuate the barometric pressure is intrinsically linked to the density of the air which intern is influenced by the temperature and the altitude above the earth's surface in other words it represents the weight per unit area of all the gas molecules present above a specific point at the time of measurement to calculate barometric pressure accurately factors like temperature and humidity must be taken into consideration as they influence the density of the air as altitude increases the weight of the air above decreases which means that barometric pressure decreases as you move higher above sea level this relationship between pressure temperature and altitude forms the foundation of how barometric pressure is measured and understood furthermore barometric pressure plays a crucial role in determining weather patterns changes in atmospheric pressure are among the most important factors in forecasting weather conditions when pressure systems shift it can result in alterations in weather patterns such as the development of high or low pressure systems that can bring about changes in temperature precipitation and wind patterns meteorologists use barometric pressure as an essential tool in predicting weather changes and issuing weather forecasts by monitoring these pressure changes they can provide valuable information about the development of weather conditions helping us prepare for upcoming weather events and respond to changing environmental conditions barometric pressure can be reported using various units of measurement and the choice of unit often depends on the region or the system used for meteorological observations the two most commonly used units for measuring barometric pressure are inches of mercury and mbars in United States barometric pressure is typically measured in inches of mercury this unit is derived from the use of a Mercury barometer which historically was a common instrument for measuring atmospheric pressure an inch of mercury represents the height to which a column of mercury is raised by the pressure of the atmosphere it's a traditional unit and is still widely used in meteorological reports and aviation in Europe and many countries using the metric system barometric pressure is measured in millibars the millibar is a unit of pressure equal to 1,000th of a bar it is widely adopted in the scientific community and is part of the International System of Units the use of mbars provides a more straightforward and internationally accepted way to represent atmospheric pressure additionally barometric pressure can be measured in atmosphere's atom which is another unit of pressure one atmosphere is defined as the average pressure at sea level equivalent to approximately 10 1325 mbars regarding standard atmospheres there are two widely recognized definitions the US Standard atmosphere and the international standard atmosphere the US Standard atmosphere is an atmospheric model developed by the United States that has been recognized for an extended period it provides a standardized representation of atmospheric conditions and is often used for Aviation engineering and scientific calculations within the United States the international standard atmosphere is a globally accepted reference for atmospheric conditions it's commonly used in international Aviation research and Engineering the international standard atmosphere provides a consistent and universally recognized standard for atmospheric properties such as temperature pressure and density these standard atmospheres are essential tools for Aeronautics meteorology and other scientific disciplines as they offer a baseline for understanding and comparing atmospheric conditions across different regions and",
        "Gas Laws": "altitudes gas laws boils law is a fundamental gas law that plays a crucial role in aviation medicine patient care and crew safety this law formulated by Robert Bole explores the relationship between the volume of a dry gas and its pressure while keeping the amount of gas and its temperature constant the key principle of Bo's law is that as the volume of gas increases its pressure decreases and when the volume of gas decreases its pressure increases this law has profound implications in aviation medicine and flight physiology one practical example of Bo's law in aviation medicine is the effect of altitude changes on gas expansion as altitude increases atmospheric pressure decreases this means that any gas trapped within a closed space such as the chest will expand for instance gas trapped in the chest can expand by approximately 35% when ascending from sea level to 8,000 ft at 18,000 ft it can expand to twice its original size this expansion has significant implications for patients with certain medical conditions for example a puma thorax can quickly progress to attention Lorax at higher altitudes similarly patients with an open skull fracture are at risk of developing pumilis a condition wet air accumulates within the skull gas is trapped in various body cavities such as the middle ear sinuses stomach intestines and even colostomy bags will also expand with increasing altitude potentially causing discomfort or equipment failure it's important to note that some medical equipment like cuff balloons on endot trial twos can be sensitive to changes in barometric pressure for example the cuff balloon on an endot tral tube can double in size when ascending from 5,000 to 10,000 ft which may lead to balloon rupture or tissue necrosis similarly patients with nasogastric or orogastric tubes should be transported with the tubes open or frequently vented to prevent over pressurization patients with colostomy bags may need to burp these bags periodically to release built-up gas and prevent bag failure understanding boils law is crucial in aviation medicine to ensure the safety and well-being of patients and crew members during flights at various altitudes Charles law discovered by Jack Charles in 7 1987 is one of the fundamental gas laws that have significant implications in aviation especially in the operation of aircraft and helicopters Charles law describes the relationship between the volume of a gas and its temperature while keeping the pressure constant according to this law as the temperature of a gas increases its volume also increases and when the temperature decreases the volume decreases all while maintaining a constant pressure in Practical terms this law means that when air heats up such as during hot weather the volume of the air increases this expansion of the air allows gas molecules to spread out making the air less dense conversely in Colder Weather the air is denser because the gas molecules are closer together these changes in air density have a notable impact on Aviation for instance when it comes to helicopter flight Charles law explains why helicopters tend to perform more efficiently in colder weather in cold weather the air is denser due to the gas molecules being more tightly packed this increased air density provides more lift as the rotor blades spin allowing the helicopter to carry a heavier load on the other hand in hot weather the air is less dense because the gas molecules are farther apart as a result the helicopter may experience reduced lift capacity and may be unable to carry as much weight pilots and flight Crews need to be aware of these temperature related changes in air density to ensure safe and efficient flight operations particularly in changing ing weather conditions understanding Charles's Law helps in optimizing aircraft performance and safety during flight Dalton's law discovered by John Dalton in 1800 is a fundamental gas law that explains the behavior of gases in mixtures this law states that the total pressure of a gas mixture is equal to the sum of the partial pressures of the individual gases in the mixture it is often referred to as the law of partial pressures because it deals with the partial PR pressure of each gas component within a mixture in aviation and Aerospace medicine Dalton's law is particularly relevant because it helps explain how the partial pressures of gases change with increasing altitude as one ascends to higher altitudes the atmospheric pressure decreases while the percentage concentration of gases in the atmosphere remains relatively stable the partial pressures of individual gases decrease proportionally as the total barometric pressure decreases one practical application of Dalton's law in aviation medicine is related to the use of supplemental oxygen when Flight Crews administer supplemental oxygen to patients or themselves at high altitudes they use Dalton's law to calculate the expected partial pressure of oxygen that should be obtained this calculation is especially important when checking arterial blood gas values to ensure that the patient is receiving adequate oxygen levels understanding Dalton's law is crucial for flight Crews as it helps them manage oxygen therapy effectively and maintain appropriate oxygen levels for both crew members and patients during air Medical Transport fix law established by Adolf Fick In 1855 is a fundamental principle that describes the process of gas diffusion across a membrane it states that the rate of diffusion of a gas is directly proportional to the difference in partial pressure of the gas on either side of the membrane directly proportional to the surface area of the membrane and inversely propor portional to the thickness of the membrane in essence this law quantifies how gases move across a barrier such as a biological membrane or a gas permeable material in critical care and Aviation medicine fix law is particularly relevant because it is the primary gas law used to describe the diffusion of oxygen across the alval membrane in the lungs this law helps us understand how oxygen is exchanged between the air in the alv and the bloodstream which is essential for maintaining adequate oxygen level in the body for example an older adult with chronic obstructive pulmonary disease who also has pneumonia may experience decreased gas exchange at high altitudes this is because at higher altitudes the reduced atmospheric pressure can make it more challenging for oxygen to diffuse into the bloodstream across the alv membrane consequently understanding fixed law is crucial for Aviation medical professionals to assess the impact of altitude and other factors on oxygen diffusion and to ensure the well-being of patients during air Medical Transport Henry's law discovered by William Henry in 1800 is a fundamental principle that explains the relationship between the pressure of a gas and its solubility in a liquid such as a solution or a bodily fluid it states that the amount of a gas that dissolves in a liquid is directly proportional to the partial pressure of that gas over the liquid in other words as the pressure of a specific gas over a liquid decreases es the amount of that gas dissolved in the liquid also decreases and vice versa this law has significant implications for understanding how gases behave in various contexts in the field of critical care Henry's law has particular relevance when dealing with decompression sickness also known as the bend decompression sickness is a condition that can affect individuals who experience rapid changes and pressure typically those who engage in activities like scuba diving or high altitude Aviation when ascending from the depths of the ocean or descending from high altitudes the reduction in pressure causes dissolve gases particularly nitrogen to come off a solution in the blood and tissues forming bubbles these bubbles can obstruct blood vessels leading to a range of symptoms and potentially life-threatening complications understanding Henry's law is crucial for managing and preventing decompression sickness as it helps to predict how changes in pressure will affect the solubility of gases in the bloodstream and it informs the protocols and procedures used to avoid this condition in high pressure environments gak's law named after the French chemist Joseph Lewis gusak who discovered it in 1809 is one of the fundamental gas laws that relates the pressure and temperature of a gas when the volume remains constant this law is also known as the pressure temperature law and is often expressed as a simple ratio the key principle of gay luex law is that there is a direct direct relationship between the pressure and temperature of a gas at a constant volume meaning that as one of these variables changes the other changes proportionally in the same direction to illustrate this concept consider the example of a sealed container of gas if you were to increase the pressure within this container while keeping the volume constant according to gak's law the temperature of the gas would also increase conversely if you were to decrease the pressure the temperature would decrease as well this law is a fundamental aspect of the ideal gas law and is crucial in understanding how gases behave under various conditions in critical care and Aviation medicine an understanding of gay luex law can be essential for professionals working with medical gases and pressure systems the law helps explain the behavior of gases within sealed containers which is particularly relevant in fields where gas storage and transportation are integral to Patient Care and safety acurate pressure and temperature control are crucial when handling Ling medical gases to ensure that they remain in their intended States and work effectively in medical applications Graham's law named after the Scottish physical chemist Thomas Graham is a fundamental principle in the field of gas diffusion this law describes the relationship between the rate of gas diffusion and the molar mass of the gas Graham's law states that the rate at which a gas moves through a small hole without undergoing interactions with other particles along the way is inversed ly proportional to the square root of the molar mass of one mole of gas molecules in simpler terms lighter gas molecules will diffuse more quickly than heavier ones through a small opening the practical application of Graham's law is evident to the process of gas exchange that occurs in critical care and the medical field in general for instance the exchange of oxygen and carbon dioxide in the bloodstream and the transfer of oxygen from the blood into the cells are prime examples of processes influenced by grams law in this context carbon dioxide molecules are significantly more massive than oxygen molecules additionally carbon dioxide is 22 times more soluble in blood than oxygen as a result carbon dioxide diffuses much more rapidly than oxygen this difference in diffusion rates has important clinical implications especially in scenarios involving respiratory and cardiovascular functions and is a key concept used in medical gas exchange calculations understanding Grahams law is critical for healthc Care Professionals as it helps explain the behavior of gases during respiration and gas transport in the human body Medical Transport",
        "Medical Transport Aircraft": "Aircraft Medical Transport Aircraft where the rotor wi or fixed Wing play a critical role in the timely and efficient transfer of critically ill or injured patients to appropriate healthc care facilities Critical Care transport professionals must be well-versed in the operations and unique considerations associated with both types of aircraft rotor wi aircraft such as helicopters offer several advantages in the realm of medical transport they are highly maneuverable capable of Landing in confined spaces and can provide rapid point-to-point transport these qualities make them particularly valuable for Missions involving urgent medical conditions trauma or Critical Care patients in remote or hard-to-reach locations rotor wi aircraft are also well suited for short range interf facility transfers where speed and accessibility are Paramount however helicopters have some limitations including lower cruising speeds reduced range and sensitivity to adverse weather conditions on the other hand fixed wi aircraft such as airplanes or Turbo prop planes offer distinct advantages for medical transport they can cover longer distances efficiently and rapidly making them ideal for long range interfacility transfers or repatriation flights for patients in remote or International locations fix six- wi aircraft provide a stable and comfortable environment for patients and Medical Teams reducing the impact of turbulence and allowing for a higher level of care during transport these aircraft are also less affected by adverse weather conditions compared to helicopters nevertheless they require suitable runways or airports for takeoff and Landing which may limit accessibility in some regions both rotor wi and fixed wi aircraft share the same fundamental principles of flight which are governed by four primary forces lift thrust weight and drag understanding these forces is crucial for flight safety and efficiency lift generated by the aircraft's wings or rotor blades opposes the force of gravity allowing the aircraft to become airborne thrust produced by engines or rotor systems propels the aircraft forward weight the gravitational force acting on the aircraft pulls it downward finally drag the aerodynamic resistance encountered by the aircraft opposes its forward motion to maintain stable and controlled flight Pilots must carefully balance and manage these forces throughout the entire Mission the balance between thrust and drag as well as between lift and weight is a fundamental Concept in aviation that directly affects an aircraft's ability to take off and land as well as maintain stable flight thrust is the force generated by an aircraft's engines or rotor system that propels it forward to achieve takeoff and aircraft must produce enough thrust to overcome the drag which is the aerodynamic resistance that opposes its Forward Motion in other words thrust must be greater than drag for the aircraft to accelerate down the runway and lift off the ground once the aircraft is Airborne it continues to produce thrust to maintain its speed and altitude when aircraft is in straight and level flight these two forces are in equilibrium meaning thrust equals drag the aircraft maintains a constant speed and altitude lift is the force generated by an aircraft's wings or rotor blades that opposes the gravitational force acting on the aircraft commonly referred to as weight for an aircraft to take off lift must be greater than weight when lift exceeds weight the aircraft accelerates upward and becomes Airborne during the flight in straight and level flight or during climb lift continues to counteract the gravitational force however when an aircraft is ready to land it must reduce its altitude and decrease its speed speed in this phase of flight lift needs to be less than weight to allow the aircraft to descend and touch down this phase is a critical part of the landing process known as the approach and Landing to ensure the safe operation of an aircraft Pilots constantly adjust thrust and lift to maintain equilibrium between these forces the balance between thrust and drag as well as lift and weight not only enables the aircraft to take off and land safely but also allows it to maintain stable flight at various altitudes and speeds this delicate equilibrium is an essential principle of Aviation that Pilots are trained to manage effectively rotor wi transport which primarily involves the use of helicopters offers several advantages that make it a valuable mode of medical transportation especially for critical care scenarios one of the most significant advantages of rotor wi transport is its ability to perform vertical takeoffs and landings this feature allows helicopters to access locations that are often inaccessible by ground vehicles or fixed wi aircraft remote rugged terrain rooftops or confined areas can be reached making helicopters an ideal choice for Emergency Medical Services search and rescue operations and transferring patients from these challenging locations helicopters are capable of sustained speeds in excess of 150 mph this speed combined with their ability to maneuver swiftly in various I directions ensures rapid response times to emergencies their agility is particularly useful in urban areas where ground traffic congestion can significantly delay the arrival of medical professionals helicopters are effective at operating at altitudes less than 2,000 ft above sea level this makes them well suited for Missions where patients need to be transported between medical facilities or for responding to emergencies in areas with varying elevations such as mountainous regions rotor WI aircraft can transport patients directly from one location to another without the need for runways or established airports this pointto point service is highly advantageous especially when time is of the essence in critical care cases trauma or transferring patients to specialized medical centers helicopters are adaptable to various population bases from densely populated urban areas to extremely rural locations a relatively small number of helicopters can serve a large population base effective ly their quick flight turnaround times and ability to cover distances swiftly are critical for reaching patients in emergencies providing timely care and reducing the time to definitive care facilities rotor wi transport while offering valuable advantages also has some notable disadvantages helicopters are more restricted than fixed wi aircraft when it comes to adverse weather conditions they are particularly sensitive to high winds storms and low visibility which can significantly limit their ability to operate safely this weather related restriction can impact the response time and availability of rotor wi transport during inclement weather conditions potentially delaying critical patient transfers the Interior Space of helicopters is relatively limited compared to larger fixed wi aircraft this constraint can POS challenges when performing complex medical procedures during flight for example the confined space may make it difficult for medical teens to access certain parts of the patient's body hindering their ability to provide comprehensive care Additionally the restricted cabin space can limit the availability of Advanced Medical Equipment and the capability to perform certain procedures like intubation due to space constraints operating and maintaining helicopters for medical transport is more expensive than ground transportation Alternatives the costs associated with helicopter ownership including fuel maintenance and train flight crews are considerably higher in fact helicopters are on average about seven times more costly to operate than traditional ambulances these higher operational expenses can contribute to the overall cost of healthare and may impact the availability of these services in some regions helicopters are subject to weight limitations which can vary depending on several factors including the type of helicopter and weather conditions weight limitations become more problematic during the summer months when the air is less dense reduced air density decreases the lift capacity of a helicopter making it challenging to transport heavier patients equipment or additional medical personnel these weight limitations can affect the operational flexibility of rotor wi transport in conclusion while rotor wi transport is a valuable asset in providing rapid Medical Response and critical care transfer services it does come with limitations such as weather restrictions interior space constraints higher operating costs and weight limitations Medical Transport agencies must carefully assess these factors to determine when rotor Wing transport is the most suitable option and to ensure patient safety and efficient use of resources fixed Wing transport including both air ambulance and medical evacuation aircraft offers several advantages for critical care and patient transport fixed Wing transport is generally considered safer than rotor wi transport due to its use of established airports runways and Landing areas these facilities are designed to meet strict safety standards minimizing the risk of accidents during takeoff and Landing fixed-wing aircraft often fly at designated cruising altitudes that help reduce Collision risks especially in controlled airspace additionally many fixed wi air medical transport aircraft are instrument flight rules certified and operated by two pilot Crews further enhancing safety fixed-wing aircraft are known for their ability to attain high speeds typically range ing from 250 to 600 mph this speed Advantage enables them to cover longer distances quickly making them well suited for interfacility transfers between medical centers especially when the distance is substantial fixed wi aircraft can efficiently transport patients across state lines or even to International destinations for Specialized Care when needed fixed wi Medical Transport Aircraft come in various sizes allowing them to carry a range of patient capacities smaller aircraft May accommodate two patients while larger military air medical aircraft can transport hundreds this flexibility makes fixed wi transport suitable for various medical scenarios from Individual patient transfers to mass casualty incidents unlike rotor wi aircraft fixed Wing transport does not have the same weight limitations related to Patient size or medical equipment this is advantageous when dealing with larger or heavier patients or when specialized medical equipment and teams are required for complex medical procedures fixed-wing Medical Transport Aircraft can accommodate multiple medical crew members including Physicians nurses and respiratory therapists they can also carry a wide array of medical equipment making it possible to provide Advanced Care during transport this flexibility ensures that critical patients receive the necessary interventions and monitoring and route to their destination fixed wi air Medical Transport while offering numerous advantages also comes with some notable disadvantages one of the primary challenges associated with fixed wi air Medical Transport is the high cost involved in obtaining and maintaining aircraft for medical purposes many air medical providers opt to contract with executive aircraft services to provide aircraft as needed these providers must cover not only the expense of using these aircraft but also the operational costs the cost can be substantial exceeding 10, ,000 for shorter distance flights and soaring to over $100,000 for international flights to mitigate these costs many fixed-wing air Medical Services secure reimbursement from patients or insurance companies before initiating the flight this financial aspect adds complexity to the coordination of such Services fixed wi air Medical Transport relies on established airports runways and Landing fields which must be wellmaintained and equipped to receive medical aircraft these facilities should adhere to rigorous safety standards to ensure the safe arrival and departure of aircraft this requirement limits the ability of fixed wi transport to access remote or undeveloped areas while this is not an issue in urban or Suburban regions it can pose a challenge when transporting patients from rural remote or disaster affected locations the size and type of aircraft used in fixed-wing air Medical Transport can dictate runway length requirements larger aircraft may need longer runways for takeoff and Landing which can limit accessibility to smaller or shorter runways Additionally the presence of hangers for aircraft storage is necessary to protect the aircraft from environmental factors and ensure their Readiness however hangers add to the overall operating costs of fixed wi air Medical Services creating an additional financial burden pressurized and non-pressurized aircraft present a crucial distinction iction in air Medical Transport particularly concerning patient safety and comfort during high altitude flights pressurized aircraft provide a controlled and pressurized cabin environment which is vital for protecting individuals from the physiologic effects of reduced barometric pressure at higher altitudes this pressurization is achieved by increasing the barometric pressure inside the aircraft above the ambient pressure thus maintaining a more stable environment most civilian and military aircraft employ the isobar system for pressurization ensuring that passengers and crew are less exposed to altitude related issues during the flight in contrast non-pressurized aircraft lack the control cabin pressure mechanism of their pressurized counterparts these aircraft such as many small Regional or private planes are unable to maintain a constant pressure in the cabin which results in a situation where the cabin pressure fluctuates with changes in altitude this limitation poses a significant challenge for air Medical Transport as patients are more susceptible to the physiologic effects of hypoxia and barometric pressure changes when using non-pressurized aircraft for patient transport medical professionals must consider these limitations and take measures to mitigate the potential risks associated with altitude exposure overall the choice between pressurized and non-pressurized aircraft is a crucial factor in ensuring the safety and well-being of patients during air medical transport a aircraft depressurization is a critical event that can occur during flight and is classified into two main categories slow and rapid depressurization rapid de pressurizations are dramatic and often accompanied by loud noises such as an explosion as well as various warning indicators including Master caution warning horns these events present immediate and severe risks to aircraft occupants the rapid decrease in cabin pressure can lead to several physiological consequences including hypox IA decompression sickness gastrointestinal expansion and hypothermia the most significant concern during a rapid depressurization event is the rapid drop in the partial pressure of oxygen which can reduce the eff of performance time and time of useful Consciousness by as much as half making it essential for passengers and crew to Dawn supplemental oxygen masks immediately to prevent hypoxia in response to a rapid depressurization the aircraft's emergency oxygen systems such as passenger oxygen masks should deploy supplying occupants with breathable oxygen to mitigate the effects of hypoxia hypoxia is the most immediate and critical threat as it impairs cognitive and physical functions which can lead to poor decision-making disorientation and incapacitation decompression sickness also known as the bendz may affect those who have recently engaged in activities like scuba diving and experienced rapid cabin decompression gastrointestinal expansion and hypothermal IA are additional risks associated with rapid depressurization and should be carefully managed during inflight emergency procedures rapid depressurization is a rare but potentially life-threatening event underscoring the importance of a well-trained and prepared crew to manage it effectively and ensure the safety of everyone on",
        "Primary Stressors of Flight": "board primary stressors of flight decreased levels of partial pressure of oxygen in the cabin air can pose a significant risk of hypoxia to both with flight crew and passengers as aircraft Ascend to higher altitudes the barometric pressure decreases causing a proportional decrease in the amount of oxygen available for example at an altitude of 15,000 ft the barometric pressure is approximately 429 mm of mercury under normal circumstances this reduced pressure may not be problematic for healthy individuals as they would still maintain adequate oxygen saturation levels and arterial partial pressure of oxygen oygen however these values are not necessarily representative of patients with critical medical conditions who may already have compromised oxygenation the most significant changes in barometric pressure occur during the ascent from sea level to around 5,000 ft While most non-pressurized aircraft may not fly at altitudes requiring supplemental oxygen or cabin pressurization it is important to consider the effects of pressure changes on board as such supplemental oxygen guidelines are in place to ensure the safety of crew and passengers during daylight hours it is recommended to use supplemental oxygen in non pressurized aircraft at 10,000 ft while during nighttime operations the recommended altitude for supplemental oxygen use is 8,000 ft certain military operations with flight durations Less Than 3 hours May permit operations at altitudes up to 13,000 ft these guidelines are critical to prevent hypoxia in individuals exposed to reduced partial pressure of oxygen during flight especially those who are vulnerable due to existing medical conditions thermal changes play a crucial role in the context of flight physiology especially as flight crew members are exposed to a wide range of thermal extremes these conditions can vary from very cold to very hot affecting crew members tolerance to hypoxia and overall performance temperature changes can lead to increased oxygen demands and make the body less tolerant of the effects of hypoxia potentially causing hypoxia to manifest at lower altitudes than expected one of the key factors is that temperature generally decreases as an aircraft ascends to higher altitudes for every 1,000 ft gained in altitude temperature typically drops byarm 3 to 5\u00b0 fah depending on humidity at altitudes ranging from 35,000 to 999,000 ft the temperature remains relatively constant at around - 32\u00b0 fah flight operation especially with rotor wi aircraft may take advantage of these cooler temperatures at higher altitudes during the summer to improve aircraft performance and engine efficiency ambient temperatures during flight can vary significantly due to the wide Geographic range that aircraft May cover changes in terrain from low-lying areas to mountainous regions or from northern climates to Southern climates can result in vast temperature fluctuations additionally the greenhouse effect can increase temperatures in the cockpit or cabin of small aircraft leading to increased heat stress the effects of heat stress include decreased short-term memory degradation of motor skills reduce performance irritability poor judgment motion sickness and heighten sensitivity to the effects of gravitational forces proper cabin temperature management is essential to mitigate these issues and ensure the well-being of flight crew and passengers decreased humidity within the aircraft can have significant implications for both the flight crew and patients humidity refers to the amount of moisture or water vapor present in the air and is usually expressed as a percentage this humidity level can vary significantly based on the temperature and the type of aircraft relative humidity increases with Rising temperatures and decreases as the temperature drops rotor wing and propeller aircraft generally have higher humidity levels compared to jet aircraft in jet aircraft the cabin air is continually recirc ated through filters which can remove moisture from the air consequently during high speed high altitude and long range flights the humidity levels can drop considerably after 2 hours of flight there may be less than 5% humidity in the cabin and after 4 hours it may drop to less than 1% the dry air within the aircraft during a long flight can lead to several issues including dry and cracked mucous membranes chapped lips Soul throats dehydration and a feeling of jet lag these these effects can be compounded in injured or ill patients making it essential to take measures to address this problem to mitigate these issues it's crucial to ensure patients are adequately hydrated before and during the flight provide humidified oxygen to patients receiving supplemental oxygen protect the patient's corneas from drying out through taping or artificial tears increase the rate of intravenous fluids or offer additional oral hydration if possible and encourage crew members to increase their fluid intake these measures help maintain comfort and well-being during long flights particularly for both the patients and the flight crew fatigue is a significant concern for critical care transport professionals and is often associated with various physiological challenges encountered during flight operations fatigue can arise from multiple factors including the lack of restful sleep jet lag in fixed wi environments constant vibrations in the aircraft and poor dietary habits crew members may experience reduced Sleep Quality due to the irregular and sometimes demanding nature of their work inadequate SE can lead to diminished alertness and overall well-being jet lag caused by Crossing multiple time zones can disrupt the body's circadian rhythm requiring time for adjustment the constant vibration of the aircraft can contribute to fatigue as it Paces physical stress on the crew and patients poor dietary habits including missed meals can further exacerbate fatigue affecting both cognitive and physical performance the consequences of fatigue are significant especially in the context of providing critical care to patients during Air transport fatigue can result in Delayed Reaction times when caring for patients and increase vulnerability to errors to mitigate these risks it's crucial to provide crew members with adequate opportunities for rest ensure that Duty days are not excessively long and establish a culture where providers feel comfortable requesting crew rest when they experience fatigue crew rest is a critical aspect of maintaining safety during air Medical Transport as it helps prevent fatigue related performance issues and ensures that the flight crew remains alert and capable of providing the highest standard of care regarding gravitational forces these forces have a profound impact on the human body during flight particularly during rapid acceleration or deceleration the intensity Direction duration and individual differences in response to gravitational forces all play a role in how the body is affected gravitational forces are measured in units known as key forces with one G force equal to the weight of an object the human body can experience positive and negative gravitational forces during flight negative key forces occur during a steep dive pushing blood toward the brain potentially causing a range of physiological effects positiv de forces are experienced during highspeed acceleration climbs or turns and can push blood away from the brain gravitational forces can lead to a series of physiological Sensations and effects on the body for example individuals may initially feel weightless or push down depending on whether the aircraft is accelerating or decelerating breathing may become labored due to the compression of the rib cage and lungs acceleration and deceleration can lead to exhaustion and air hunger hypoxia may occur as blood moves away from the brain potentially resulting in visual disturbances and even loss of consciousness further gravitational forces can lead to organ displacement and even unconsciousness signs and symptoms of gravitational forces on the body include p a rashes bruising Amnesia confusion and cardiac arrhythmias awareness of these effects is essential for providers to provide safe and effective care during air Medical Transport particularly when faced with rapid changes in gravitational forces spatial disorient orientation is a condition experienced by individuals particularly Pilots where they have an incorrect understanding of their body's position in relation to the Earth or the aircraft's orientation in space maintaining spatial orientation is critical for safe flight operations and it relies on the effect of perception integration and interpretation of sensory information from visual vestibular and propri acceptive cues one of the key challenges leading to spatial disorientation is sensory mismatch which occurs when the sensory stimuli from these three sources provide conflicting information this sensory mismatch can result in Illusions and spatial disorientation visual cues are particularly powerful in shaping our perception of spatial orientation often overriding conflicting Sensations from other sensory systems people may not even realize when their brain has received contradictory information because the visual system is so dominant to address these issues particularly for Pilots the concept of not relying on visual references becomes Paramount especially when flying by instruments the brain can become convinced that down is the bottom of the aircraft regardless of the actual orientation or angle of the aircraft spatial disorientation is classified into three types type one occurs when the pilot does not notice the existence of spatial disorientation type two occurs when the pilot realizes there's a problem but misinterprets it as a control malfunction and type 3 happens when the pilot experiences an intense illusion of movement and is unable to reorient themselves capets often play a crucial role in correcting type 3 spatial disorientation spatial disorientation is a significant concern in aviation safety leading to a considerable number of accidents to address this issue regulatory authorities like the Federal Aviation Administration have revised rules and training requirements to enhance pilot recognition of spatial disorientation and improve their ability to respond effectively Pilots receive training to recognize the sensations associated with spatial disorientation and the importance of trusting their instruments over their senses visual Illusions are a subset of spatial disorientation and involve deceptive signals sent to the brain by the visual system these Illusions can be more likely to occur during instrument meteorological conditions when the visual references outside the aircraft are limited visual Illusions can lead to misperceptions related to the aircraft's location altitude distance from other objects or aircraft speed and attitude for instance a sumor gravic illusion occurs when the brain misinterprets acceleration which can be particularly problematic when looking up or during abrupt changes in speed understanding and managing these visual Illusions are vital for flight safety especially when flying in challenging weather conditions or relying on instrument-based Flying Third spacing is a physiological phenomenon characterized by the loss of fluids from the intravascular space into the interstitial tissues this can occur in various situations including during flight in aircraft due to the effects of centrifugal force acceleration or deceleration when aircraft experiences abrupt changes in speed or Direction such as during Maneuvers the forces generated can push bodily fluids from the intravascular space into the extravascular space this loss of fluids from the intravascular space can lead to hypovolemia a reduction in blood volume hypovolemia is concerning as it can reduce the body's ability to maintain adequate blood pressure and oxygen delivery to vital organs in the context of Aviation hypovolemia can be particularly problematic because it may potentiate the effects of hypoxia making individuals more susceptible to the physiological challenges of high altitude flight to address the issue of fluid redistribution during flight specialized equipment known as gits or military anti-up trousers has been developed these garments apply pressure to the lower body particularly the legs during High gForce Maneuvers to help prevent excessive pooling of blood in the lower extremities by reducing the pooling of blood in the legs Hees suits help maintain adequate blood pressure and prevent hypovolemia ultimately improving a pilot's ability to tolerate High forces during aerial maneuvers third spacing and its consequences are important considerations for flight Crews and individuals exposed to high G forces as they can have a significant impact on overall physiological functioning during Aviation operations fi vertigo is a phenomenon characterized by an imbalance in brain cell activity resulting from exposure to lowf frequency flickering or flashing of relatively bright light sources the effects of fer vertigo can include symptoms such as nausea fiting seizures and fainting this condition may occur when an individual is exposed to bright light sources that flicker at specific frequencies usually between between 4 to 20 cycles per second one common scenario where flicker vertigo can occur is in the aviation environment in aviation individuals such as helicopter personnel and occupants of fixed wi propell aircraft may be susceptible to flicker vertigo due to the natural light or reflections of anti-collision strobe lights being distorted by rotating helicopter rotor blades or propellers the flickering effect can disrupt normal brain function and lead to the symptoms described to mitigate the risk of flicker vert to go safety precautions are often implemented such as modifying the design or positioning of bright light sources to reduce flicker especially in situations where the phenomenon poses a risk to flight safety and the well-being of Aviation Personnel exposure to fuel Vapors is a concern in aviation and can have various effects on flight personnel and passengers fuel Vapors are a mixture of volatile compounds that are released when aircraft fuel is handled transported or even just when the fuel tanks are opened exposure to fuel Vapors either due to leaks or during mment procedures can lead to several adverse health effects these effects may include headaches which are a common symptom associated with exposure to fuel Vapors the chemicals in fuel Vapors such as hydrocarbons and other volatile compounds can irritate the respiratory system and may result in discomfort and head pain prolonged exposure to fuel Vapors can also precipitate feelings of nausea the inhalation of these Vapors can lead to irritation of the Airways mucous membrane and respiratory tract which may contribute to a sense of nausea or discomfort aircraft maintenance Personnel ground Crews and even passengers might encounter fuel Vapors when performing tasks near aircraft fuel systems or during refueling procedures proper safety measures and personal protective equipment are essential to mitigate the risks associated with fuel Vapor exposure in aviation environments weather conditions play a significant role in aviation and rapidly worsening weather conditions or inadvertent flight into adverse weather can indeed cause stress for both flight Crews and passengers sudden changes in weather can pose operational challenges safety risks and potentially disrupt the flight schedule Pilots need to make critical decisions when faced with adverse weather including the use of instrument flight rules and diverting to alternate airports stress can arise from the need to adapt to changing conditions and make quick decisions to ensure the safe of the flight furthermore turbulence and severe weather events such as thunderstorms can result in discomfort and anxiety among passengers turbulence can lead to abrupt movements of the aircraft which can be unsettling for passengers who are not accustomed to such experiences inadvertent flight into conditions requiring instrument flight rules can be particularly challenging as it involves relying on onboard instruments for navigation and control instead of visual references it's crucial for flight Crews to receive training in handling various weather related scenarios and making sound decisions to manage the stress associated with rapidly changing weather conditions and ensure the safety and comfort of all on board anxiety is a significant aspect of flight operations that is often not openly discussed but plays a pivotal role in both flight crew members and sometimes even patients various factors contribute to anxiety in the aviation environment one primary cause is the release of cat econom which are stress hormones like adrenaline and noradrenaline in flight crew members and patients particularly in rotor Wing operations when flight crew members are new to the profession they often experience a high level of anxiety which can gradually diminish as they gain experience transporting patients with a range of conditions during different types of flights the aviation industry recognizes the importance of this learning curve and training programs are designed to help crew members adapt and manage their anxiety effectively the confines of the aircraft cabin can also contribute to anxiety especially impatience some individuals may experience claustrophobia when placed in a small enclosed space which can exacerbate their overall anxiety during the flight crew members need to be aware of this possibility and provide reassurance and support when dealing with anxious patients in some cases protocols may allow for the administration of a sedative to patients to help alleviate their anxiety managing anxiety in both flight crew members and patients is vital for ensuring a safe and comfortable journey in the aviation environment night flying presents its own unique challenges and flly crew members must be particularly Vigilant when assisting the Pilot's visual scan for other aircraft whether it's night or day lighting makes aircraft more visible at night and is often easier to spot them due to the specific lighting configurations the position of lights on all aircraft follows a standard protocol making it easier for Pilots to discern the direction of flight for instance if a pilot observes another aircraft with a red light on the left a green light on the right and a white light in the middle they can determine that the aircraft is moving away from them in the context of night flying flight crew members should minimize the use of white light sources that may affect the Pilot's night vision instead red lighting inside the aircraft is preferred because it helps maintain the Pilot's night vision flying at night presents specific challenges for the pilot including a limited field of vision added weight stress from wearing specialized equipment like helmets loss of depth perception monochromatic vision and a reduced sense of speed managing these factors and coordinating effectively as a flight team is essential to ensure safety and successful night flights in the aviation industry factors affecting tolerance of",
        "Factors Affecting Tolerance of the Physiologic Stressors of Flight": "the physiologic stresses of flight human factors play a crucial role in a provider's tolerance of flight stress the pneumonic I'm safe is a valuable tool that identifies key factors affecting a flight crew member's Fitness for Duty I stands for illness reminding providers to consider their physical condition before a flight sickness can impair cognitive function decision- making and overall performance M refers to medication emphasizing the importance of understanding the effects of any prescribed or over-the-counter medications on one's ability to operate safely medications can cause drug oiness impair judgment or induce other side effects that may compromise a provider's performance during a flight s represents stress acknowledging that stresses from both work and personal life can impact a crew member's ability to cope with the demands of the flight environment unmanaged stress can reduce concentration increase anxiety and lead to poor decision-making a corresponds to alcohol reminding providers that alcohol impairs judgment coordination and cognitive function the use of alcohol before or during a flight is strictly prohibited due to its adverse impact on safety F stands for fatigue recognizing that sleep deprivation and chronic fatigue can significantly reduce a provider's alertness and reaction times fatigue is a prevalent concern in the aviation industry and can lead to errors and poor performance finally e stands for emotion acknowledging that strong emotions such as anxiety or frustration can affect a provider's ability to remain focused and composed during a flight it's essential for providers to recognize and manage their emotions to ensure optimal safety and performance by considering these human factors flight crew members can better assess their Readiness for Duty and minimize the impact of stresses on their performance illnesses even seemingly minor ones like the common cold can have a significant impact on a flight crew member's ability to perform Le duties safely the symptoms associated ated with illnesses such as severe headaches fatigo and nausea can be especially problematic in the aviation environment severe headaches can affect cognitive function concentration and decision-making all of which are critical in Flight operations vertigo characterized by a spinning sensation can cause spatial disorientation leading to potentially dangerous flight attitudes nausea if prolonged or severe can be incapacitating making it difficult for a crew member to perform their task effectively given the fast-paced and often high stress nature of medical transport flights it's crucial for crew members to be in Optimal Health to manage the demands of the job medications whether they are prescribed or over-the-counter can have varying effects on a person's tolerance to hypoxia and other stresses associated with flight medications can impact cognitive function alertness coordination and judgment in aviation where split-second decisions can be a matter of life or death these effects can be a serious concern therefore it's essential for flight crew members to adhere to the Federal Aviation Administration guidelines regarding approved prescription and over-the-counter medications the FAA maintains a list of acceptable medications to ensure that crew members can operate aircraft safely while under their influence deviating from this list or using unapproved medications can jeopardize flight safety in essence the use of medications must be carefully considered to assess their impact on one's Fitness for Duty in the aviation environment stress is a common human factor that can significantly affect a flight crew member's performance stresses in both work and personal life can lead to distraction poor judgment and increased susceptibility to errors in the aviation environment where the margin for error is minimal it is crucial to manage and mitigate stress effectively unmanaged stress can impair cognitive function hinder situational awareness and reduce the ability to make key clear and timely decisions consequently stress management techniques and mental resilience are essential skills for flight crew members to ensure that their performance remains at the highest level even in high pressure situations recognizing the potential effects of illnesses medications and stress on flight safety flight crew members should prioritize their physical and mental well-being adhere to safety guidelines and effectively manage stress to perform their duties safely and efficiently alcohol consumption is strictly regulated in the aviation industry due to its profound effects on a person's physiological and cognitive functions when alcohol is consumed it can lead to histotoxic hypoxia a type of hypoxia caused by the interference of cell's ability to use oxygen properly in flight this can be extremely dangerous because it impairs the body's ability to efficiently extract and utilize The Limited oxygen available at high altitudes alcohol can also result in poor judgment and coordination two critical faculties that flight crew members need to ensure flight safety these impairments can lead to errors in decision-making and the execution of flight tasks both of which can have life-threatening consequences the Federal Aviation Administration closely regulates alcohol use for flight crew members and they are subject to strict guidelines outlined in part 91 of title 14 of the code of federal regulations violations of these regulations can lead to severe consequences including license revocation and legal penalties fatigue is a significant human factor that can compromise flight crew members performance prolonged wakefulness or inadequate sleep can result in judgment errors reduced attention span uncharacteristic behavior and even falling asleep on duty in the high stress and dynamic environment of medical transport flights where Split Second decisions and precise execution of tasks are required fatigue can be particularly hazardous crew members must remain Vigilant and capable of responding to emergencies at all times fatigue related errors can have catastrophic results making it imperative for crew members to prioritize rest maintain regular seat patterns and be aware of their individual fatigue tolerance the importance of mitigating fatigue risks and adhering to duty time limits and rest requirements is underscored in aviation regulations emphasizing the significance of maintaining alertness and Readiness during flight operations emotionally upsetting events can significantly impact a flight crew member's ability to perform their duties effectively when faced with such events individuals may experience heightened emotional stress and anxiety leading to impair judgment and overall crew performance in the demanding environment of medical transport flights where critical decisions often need to be made swiftly and accurately emotional disturbances can compromise one's ability to think clearly and respond to emergencies crew members must learn to manage their emotions and practice emotional resilience to ensure they can maintain their focus and professionalism throughout the flight even in challenging and emotionally charged situations tobacco products can have detrimental effects on flight crew members particularly in terms of their susceptibility to hypoxia and visual performance smoking tobacco introduces carbon monoxide into the bloodstream which can lead to hypemic hypoxia this condition occurs when carbon monoxide binds to hemoglobin more readily than oxygen reducing the blood's oxygen carrying capacity in a high altitude environment of Aviation this is a concerning problem as it further limits the already scarce oxygen available additionally tobacco products can have adverse effects on night vision making it more challenging for flight crew members to see and interpret the environment in low light conditions smoking in particular can damage the eyes and negatively affect visual accuracy which is essential itial for safe flight operations especially during night flights or in adverse weather conditions crew members are encouraged to obstain from tobacco products to ensure their Fitness for flight and to minimize the risks associated with hypoxia and impaired night vision hypoglycemia or low blood sugar can significantly impact a flight crew member's tolerance to the effects of hypoxia making them more susceptible to its detrimental consequences hypoglycemia can lead to symptoms such as nausea headaches dizziness and judgment errors which are particularly concerning in the aviation environment where clear thinking and precise decision- making are crucial when blood sugar levels drop too low cognitive functions are impaired potentially affecting a crew member's ability to respond effectively to inflight challenges or emergencies in the context of Aviation physiology the importance of maintaining stable blood sugar levels cannot be overstated as it is an essential aspect of of ensuring flight safety in addition to lowering tolerance to hypoxia hypoglycemia can be exacerbated by other stresses that flight crew members May encounter during their duties stress poor dietary habits obesity age and even physical exertion during flight can all contribute to blood sugar instability stress and the physical demands of flight can further depat blood glucose levels which in turn intensify the negative effects of hypoglycemia for these reasons flight crew members must prioritize proper nutrition Stress Management and regular monitoring of their blood sugar levels to ensure that they are in the best possible condition to handle the physiological challenges of",
        "Hypoxia": "Aviation hypoxia hypoxia the condition resulting from insufficient oxygen supply to body tissues is a significant hazard in aviation due to its potentially catastrophic consequences it's a risk not only for passengers and flight crew but also for individuals on the ground one of the most concerning aspects of hypoxia is that it can occur at relatively low altitudes even below 10,000 ft this means that pilots and passengers in general aviation or rotor wi aircraft which often operate at these altitudes can be at risk at such Heights oxygen levels are significantly lower than at sea level and without appropriate supplemental oxygen individuals may start experiencing hypure symptoms these symptoms can range from mild cognitive impairment to severe confusion disorientation and loss of consciousness which can be disastrous during flight furthermore patients with impaired pulmonary function are at even greater risk and the threshold for hypoxia is significantly lower for them their ability to efficiently oxygenate their blood is already compromised due to lung issues and exposure to lower oxygen levels at modest altitudes can quickly lead to severe hypoxia this heightens sensitivity ity to hypoxia is a critical consideration for air Medical Transport as patients with pulmonary conditions or other Cobi may experience rapid deterioration in Flight if not properly managed therefore the aviation and Medical Teams involved in air Medical Transport must be vigilant in monitoring and addressing the risk of hypoxia to ensure the safety and well-being of everyone on board the Insidious nature of hypoxia lies in the fact that its early signs are often subtle and not easily recognized even by experienced aviators impaired judgment is one of the earliest and most significant effects of hypoxia and paradoxically it limits an aviator's ability to recognize the condition and take immediate corrective actions as hypoxia sets in individuals become increasingly complacent and less aware of their deteriorating mental and physical state this false sense of well-being coupled with a judgment impairment can lead aviators to dismiss the symptoms or attribut Ute them to other causes making it challenging to recognize hypoxia in its early stages furthermore the symptoms of early stage hypoxia often mimic other conditions such as fatigue and hypoglycemia which can further complicate recognition fatigue and hund contribute to the confusion as they can independently cause feelings of light-headedness impaired cognitive function and dizziness this overlap of symptoms can make it difficult for aviators to pinpoint the specific cause of their discomfort delaying the realization that hypoxia is setting in hence Education and Training for aviators are critical to improve their ability to identify and respond to the early signs of hypoxia promptly ensuring their safety and the safety of everyone above the aircraft effective performance time and time of useful Consciousness are crucial Concepts when understanding the effects of hypoxia in aviation effective performance time refers to the limited duration during which an individual can function with an inadequate level of oxygen this time frame is highly dependent on altitude and can vary significantly as the altitude increases the amount of available oxygen decreases and the effect of performance time diminishes accordingly Pilots must be aware of these limitations to ensure they can respond effectively in the event of hypoxia time of useful Consciousness on the other hand is the period between the moment a person experiences a sudden deprivation of oxygen at a specific altitude and the onset of phys physical or mental impairment to the point where deliberate and effective functioning becomes impossible this window of time is critical for aviators to take corrective actions such as Dunning supplemental oxygen or descending to a low altitude to mitigate the effects of hypoxia the duration of time of useful Consciousness is alarmingly short at higher altitudes emphasizing the importance of rapid and appropriate responses to hypoxia in the aviation environment to ensure safety and successful flight operations the duration of both effective performance time and time of useful Consciousness can vary significantly from one individual to another and is influenced by several factors one critical factor is individual tolerances which can differ based on a person's physical condition overall health and atiz to high altitude environments people with higher Fitness levels and better oxygen carrying capacities might tolerate hypoxia for longer periods the method of hypox OA induction also plays a role gradual exposure to reduced oxygen levels might provide individuals with more time to adapt compared a sudden and Rapid onset of hypoxia Additionally the environment an individual is in before experiencing hypoxia can affect their tolerance with factors like fatigue dehydration or pre-existing medical conditions influencing the onset of symptoms physical activity is another crucial Factor as exertion increases oxygen consumption and shortens the the time of useful Consciousness for instance a person exposed to hypoxia at 25,000 ft might have an average of 3 to 5 minutes of useful Consciousness but if they've performed vigorous exercise like 10 Deep knee bends before the exposure their time of useful Consciousness might be reduced to 1 to 1 and a half minutes due to the increased demand for oxygen these variations highlight the complexity of hypoxia effects and the need for tailored training and safety measures for individuals in aviation and high altitude environments hypoxic hypoxia also known as altitude hypoxia is a type of hypoxia characterized by a deficiency of oxygen in the body due to insufficient oxygen entering the bloodstream this condition can result from various factors making it a significant concern in aviation and high altitude environments some common causes of hypoxic hypoxia include lung diseases that impair the ability to oxygenate blood effectively right to left shunts in the heart Airway obstructions that restrict the flow of oxygen into the lungs a reduction in the gas exchange area within the rvi low partial pressure of oxygen and increased altitude in the context of air Medical Transport cases of hypoxic hypoxia are primarily a result of the reduced atmospheric pressure that occurs at higher altitudes at higher elevations the overall atmospheric pressure is lower which leads to a decrease in the partial pressure of oxygen in the inspired air this means that with each breath there is simply not enough oxygen available to adequately oxygenate the blood in Practical terms clinical symptoms of hypoxia do not typically become noticeable until an altitude around 5,000 ft or higher however the process of developing hypoxia begins at much lower altitudes even within a few hundred fet above the ground emphasizing the importance of understanding and mitigating this risk in aviation and air medical operations histotoxic hypoxia is a type of hypoxia characterized by the inability of cells to effectively use the oxygen that is available in this condition there may be plenty of oxygen in the bloodstream but the tissues cannot properly utilize it this can occur for a variety of reasons such as the inability of oxygen to offload from hemoglobin or the tissue's metabolic dysfunction as a result the venous hemoglobin oxygen saturation remains higher than normal because oxygen is not adequately unloaded to the tissues histotoxic hypoxia is the most frequently encountered type of hypoxia by ER creu in Flight it is often a consequence of exposure to substances that interfere with cellular metabolism and it highlights the importance of proper oxygen utilization in the body regardless of the Oxygen's availability in the blood stagnant hypoxia occurs when there is a failure to transport oxygenated blood to the tissues this condition can result from a reduction in blood flow or although it doesn't necessarily mean a complete stoppage stagnant hypoxia is often seen in cases of heart failure and major myocardial infarctions heart attacks in the context of flight medicine it can also occur due to venous pooling impatients during accelerated Maneuvers or those that increase the gravitational load on the aircraft furthermore it may happen when blood pools in the lower extremities of patients and crew Who Remain seated in the aircraft for extended periods this type of hypoxia underscores the importance of maintaining proper blood circulation and oxygen transport throughout the body particularly in aviation and flight related environments the indifferent stage as the name suggests is characterized by minor physiological effects on the body when exposed to increasing altitudes this stage typically occurs between sea level and 10,000 ft above sea level although effects may start manifesting as early as 5,000 ft some of the effects in this stage include causing Nik Vision to deteriorate at altitudes above 5,000 ft as reduced oxygen levels impact the functioning of the visual system additionally electrocardiographic changes may be observed even at altitudes as low as 5,000 fet tachicardia and elevated heart rate is a common response and there may be a slight increase in alv ventilation which is the exchange of air in the alv of the lungs during the stage oxygen saturation in the blood can vary from 98% to 87% indicating a decreasing oxygen supply to the body's tissues the compensatory stage is so named because it reflects the body's initial attempts to provide short-term physiological compensation against the effects of hypoxia the body's ability to compensate in this stage depends on several factors including the physical shape of the flight crew member their physical activity level and the duration of exposure to hypoxic conditions during the stage respiratory rate and depth may increase which is a natural response to trying to intake more oxygen cardiac output also increases ensuring that the body's tissues continue to receive adequate oxygen supply the compensatory stage generally occurs between 10,000 ft and 15,000 ft above sea level if breathing 100% oxygen the compensatory stage may be extended to a higher altitude between 39,000 and 42,000 ft hemoglobin saturation during the stage can vary from 87% to 80% showing that the body is working to maintain oxygen levels in the blood within a functional range the disturbance stage is a critical phase in the progression of hypoxia it signifies that the body's tissues can no longer depend upon the initial physiological compensatory mechanisms to supply an adequate amount of oxygen this stage is experienced at altitudes ranging from 15,000 ft to 20,000 ft above sea level hemoglobin saturation during the stage falls to the range of 79% to 70% indicating a significant reduction in the oxygen carrying capacity of the blood the disturbance stage is characterized by both subjective and objective symptoms of hypox it's worth noting that during altitude testing some individuals did not experience subjective symptoms before becoming unconscious highlighting the rapid onset of cognitive impairment sensors are profoundly affected during the disturbance stage visual ability decreases as eye muscles become weak and uncoordinated sensations of touch and pain are diminished and eventually lost weakness and loss of muscular coordination are experienced and these symptoms become more severe with increasing hypoxia levels the loss of muscle coordination in conjunction with confusion is a dangerous combination cognitive impairment is one of the most dangerous Hallmarks of hypoxia during the stage individuals may find it impossible to comprehend their own disability due to the inability to make coherent judgments perform calculations slowed reaction times and impaired short-term memory impairments and cognition prevent a person from recognizing the ongoing effects of hypoxia personality manifestations during the disturbance stage are similar to those observed in individuals under the influence of alcohol and may include aggressiveness Euphoria irritability overconfidence and depression psychomotor functions deteriorate dur the stage with muscular coordination decreasing signs of impairment may include difficulty in speech elgible handwriting and poor coordination in tasks such as flying stammering and illegible handwriting are two Hallmark signs of impairment and as the severity of hypoxia increases delicate and fine muscular movements become impossible and gross motor movements are significantly impaired this stage is critical in the progression of hypoxia as it is marked by a deterioration in cognitive and psychomotor functions ultimately leading to a high risk of incapacitation if not addressed promptly the critical stage of hypoxia is the last and most dangerous phase occurring at altitudes of 20,000 ft and above during the stage the effects of hypoxia become severe and can have devastating consequences in a very short period within just 3 to 5 minutes at this altitude individuals experience a rapid deterioration in judgment and coordination reaching a point of inadequate or inappropriate function mental confusion becomes profound and if left uncorrected it quickly progresses to incapacitation unconsciousness and ultimately death hemoglobin saturation in the blood drops to less than 65% during the critical stage the lower levels of oxygen saturation in the blood mean that vital organs and tissues are not receiving enough oxygen to function properly this stage is particularly perilous because individuals may not be able to recognize the extent of their impairment due to severe cognitive and psychomotor deficits they may make errors in judgment and coordination that endanger the safety of the flight or medical Mission prompt recognition of the symptoms of hypoxia and the use of supplemental oxygen or descending to lower altitudes are critical actions to prevent catastrophic outcomes during the critical stage hyperventilation and hypoxia share similar symptoms which can make it challenging to distinguish between the two in the flight environment crew members must initially consider the possibility of hypoxia when they encounter symptoms such as confusion poor judgment and inappropriate corrective Maneuvers as these are common to both conditions hyperventilation is typically caused by a subconscious reaction to a stressful situation leading to an abnormal increase in the volume of inhaled and exhaled air resulting in Rapid breathing this excessive breathing causes respiratory alkalosis where the blood pH rises above the normal range disrupting cellular homeostasis when this happens cellular activity decreases or ceases hyperventilation initiates a series of physiologic changes including a decrease in the partial pressure of carbon dioxide which raises the blood pH thus in turn leads to vaser constriction of cerebral blood vessels reducing cerebral profusion and rapidly inducing unconsciousness when significant or prolonged hypoxia is introduced into cerebral tissue the symptoms of hyperventilation include light-headedness feelings of Suffocation driness tingling in the extremities painful muscle spasms Ataxia disorientation and in severe cases unconsciousness one of the most significant negative effects of hyperventilation is the potential for panic which can further exacerbate the situation it is vital for crew members to recognize and address hyperventilation promptly to prevent its progression and to rule out hypoxia as the root cause of the symptoms recognizing and treating altitude induced hypoxia is critically dependent on a thorough understanding of basic flight physiology when a person is subjected to hypoxia rapid recovery can occur when they are provided with sufficient oxygen this phenomenon is known as the oxygen Paradox a hypoxic individual who promptly breathes 100% oxygen may experience a sudden sensation of dizziness which is quickly resolved subsequently their function is almost entirely restored this paradoxical response highlights the critical importance of supplying adequate oxygen as soon as hypoxia is suspected or detected it demonstrates that even in a state of severe hypoxia the introduction of oxygen can lead to a Swift and often complete recovery of cognitive and physical function the most important principle in aviation safety regarding hypoxia is avoidance in event of hypoxia immediate actions must be taken to address the situation crew members should promp prly use supplemental oxygen and descend to an altitude below 10,000 ft to mitigate the hypoxic effects additionally if a crew member experiences hypoxia it is a valid reason to declare an emergency with air traffic control this action ensures that the necessary support and assistance can be provided promptly allowing for a safer and more effective response to the hypoxic emergency in aviation the avoidance of hypoxia and Swift well-informed responses are Paramount in preserving the safety and well-being of everyone on board the Federal Aviation regulations provide clear guidelines and requirements for the use of supplemental oxygen in aviation to prevent hypoxia part 135.8 n specifically governs the use of supplemental Oxygen by pilots and establishes rules for both pressurized and non-pressurized aircraft for non-pressurized aircraft and cubby helicopters Pilots are required to use supplemental oxygen continually ously when flying at altitudes ranging from 10,000 ft to 12,000 ft if the flight duration at this altitude exceeds 30 minutes above 12,000 ft continuous oxygen use is mandatory to ensure the safety and well-being of the crew this rule is particularly important as the altitude increases because the risk of hypoxia becomes more significant pressurized aircraft must adhere to similar rules requiring the use of supplemental oxygen when the cabin altitude exceeds 10,00 000 ft in situations where the cabin altitude is maintained between 25,000 ft and 35,000 ft Pilots must use continuous oxygen unless the aircraft is equipped with an approved quick Dunning type mask above 35,000 ft it is mandatory for Pilots to wear an oxygen mask continuously this rule is vital as Pilots at such high altitudes have mere seconds to respond to a sudden loss of cabin pressure emphasizing the importance of immediate access to supplemental oxygen in addition to regulations for Pilots Part 9 1. 1211 addresses the requirements for providing passengers with supplemental oxygen when cabin altitudes exceed 15,000 ft all occupants including passages must be supplied with supplemental oxygen to prevent hypoxia in pressurized aircraft a 10-minute supply of oxygen for each occupant must be available above 25,000 ft for patients who are sick or injured the provision of supplemental oxygen may be necessary at all altitudes to prevent hypoxia and ensure their well-being during the flight these regulations are in place to safeguard everyone on board and mitigate the risks associated with hypoxia during air",
        "Dysbarism and Evolved Gas Disorders": "travel disperis and evolved gas disorders various disorders related to altitude such as Barat trauma and disperis can impact individuals in aviation and may lead to discomfort and health issues barot trauma can result from the expansion and contraction of gases within the body due to changes in pressure this condition can lead to pain in different areas including the digestive tract sinuses teeth midia and lungs disparis on the other hand is a syndrome directly related to the effects of altitude as described by the gas laws it occurs when there is a difference between the barometric pressure and the pressure of gases within the body when gases expand at higher altitudes they can cause disc comfort and pain in enclosed cavities one common disorder related to altitude is barus Media which affects the middle ear and is one of the most frequently encountered trapped gas problems this condition results from the failure of the middle ear SPAC to equalize pressures during a transition from low to high atmospheric pressure as the pressure increases the middle ear May develop a negative partial vacuum leading to various issues like an inward depression of the tanic membrane and inflammation in severe cases this can even lead to a ruurd erdum to prevent or relieve barotitis media individuals can use techniques like swallowing yawning tensing throat muscles or pinching the nose and trying to blow through the nostrils however respiratory infections can make Equalization in the aein too challenging leading to severe pain and potential irum issues when experiencing these problems ascending to relieve the pain and equalize the pressure may be necessary these disorders highlight the importance of understanding how altitude affects the body and being prepared to manage such issues during Aviation activities baros sinus IUS is a condition that poses a risk to individuals exposed to ambient pressure changes particularly during Aviation activities it is defined as the inflamation of one or more of the Paran nuzzle sinuses and it primarily results from a pressure gradient between the sinus cavity and the surrounding atmosphere this condition is relatively uncommon but tends to affect the frontal sinuses when it does occur it is less common in children as the frontal sinus cavities are not fully mature until adolescence however individuals with upper respiratory tract infections are at a greater risk of developing this issue the clinical presentation of barosinusitis typically occurs during or shortly after exposure to barometric pressure changes symptoms include unilateral sharp Facial Pain and headache along with pressure-like Sensations and the sinuses in some cases individuals may experience nose bleeds the treatment involves pain management and decongestant with topical decongestants like nasal spray and oral decongestants such as pseudophedrine proving to be effective it's important to note that antihistamines should be avoided unless allergies are poorly controlled in which case they may have a preventive value barodontalgia sometimes referred to as Flyers toth8 is another condition associated with ambient pressure changes and affects individual exposed to such changes like scuba divers and Military Pilots this condition is characterized by pain and pressure in or around a tooth and typically resolves when returning to sea level baradia can occur due to various factors including gas bubbles trapped beneath the gums during restorative Dental treatments periodontal cysts and dental obsessors what is the rarest of the three conditions discussed it is the least understood most cases of are associated with pre-existing Dental issues and may be considered a symptom of those problems consequently maintaining good oral health and addressing any Dental issues before embarking on flights or Dives is crucial to prevent the development of this condition decompression sickness while not the most frequently encountered form of disperis is perhaps the most well-known due to its association with scuba diving and Aviation this condition is explained by Henry's law and occurs when init nitrogen gas bu bubbles form in one or more locations within the body the manifestation of symptoms depends on the location in the body where these bubbles form when a human body is subjected to a rapid decrease in atmospheric pressure such as during a rapid Ascent in aviation or a two rapid ascent and scuba diving capillaries in the body become super saturated with nitrogen this means that nitrogen gas starts to leave its dissolved State and forms bubbles these bubbles can develop in various tissues particularly those with a high factor content because fat can dissolve nitrogen 5 to six times more readily than blood the consequences of decompression sickness can be severe and include circulation problems pain and potentially death this is because nitrogen bubbles can cause blockages in blood vessels and interfere with normal circulation in the most extreme cases nitrogen bubbles in the arterial circulation can cause an arterial gas embolism a condition in which an air bubble obstructs a blood vessel leading to oxygen dep privation to the tissues and ultimately death if not promptly treated therefore preventing decompression sickness is essential in aviation and Diving by ensuring safe ascent and descent rates and adhering to proper decompression procedures when",
        "Operational Issues Related to Medical Transport": "necessary operational issues related to Medical Transport the concept of a sterile cockpit is a crucial safety practice in aviation it is a term used by the pilot in command to describe a specific mode of operation during critical phases of flight such as takeoffs and landings during these critical phases there should be no non-essential communication or activities that could distract the pilot in command or other flight crew members from their primary focus on the safe operation of the aircraft this practice is essential for minimizing distractions and enhancing flight crew concentration during the most critical and demanding moments of a flight the sterile cockpit rule is established to ensure that the flight Crews attention is is dedicated solely to flight critical tasks such as aircraft control navigation and communication related to the safe conduct of the flight non-essential conversations activities or distractions are deferred until the aircraft reaches a higher altitude or competes The Landing phase at which point the sterile restrictions are lifted this approach helps reduce the risk of errors and accidents during these high stress phases of flight improving overall flight safety adherence to the sterile cockit rule is a fun fundamental practice in aviation to maintain a clear and focused Flight Deck environment during critical moments of a flight air carrier standards and regulations dictate the enforcement of the sterile cockpit rule at all altitudes less than 10,000 ft while the sterile cockit rule is primarily associated with fixed wi aircraft where the majority of operations occur at altitudes above 10,000 ft it's worth noting that helicopters often operate at lower altitudes typically between 2,000 and 5,000 ft in such cases the pilot in command of the helicopter will determine the specific sterile cockpit times for their flights however the fundamental principle Remains the Same during critical phases of flight which typically include takeoff approach and Landing the sterile cockpit rule is strictly enforced to minimize distractions and enhance safety one important aspect of sterile cockpit compliance is related to communication with operation centers and dispatches in practice a rule of thumb is followed which dictates that Communications with operation centers should be relayed prior to liftoff or after the aircraft has reached its cruising altitude this means that critical Communications should be competed before or after the critical phases of flight during which the sterile cockpit rule is in effect if there's a need to declare a non-sterile cockpit during the flight indicating that it's safe to engage in non-essential Communications this can be done at the Pilot's discretion the sterile cockit rule also applies to interactions with patients during Medical Transport flights in this context the pilot may use the option of isolating the flight crew from non-essential conversations or activities this isolation helps maintain a focused Flight Deck environment during critical phases of flight even when there may be medical personnel or patients on board the ultimate goal is to ensure that safety Remains the top priority during takeoffs Landings and other high stress phases of the flight during a medical transport flight various issues may arise that necessitate Landing short of the original destination for the safety and well-being of all individuals on board mechanical problems with the aircraft can force the pilot in command to make an unscheduled landing at the nearest suitable airport mechanical malfunctions can Encompass a wide range of issues from engine problems to avionics failures in such situations the safety of the flight crew medical personnel and patients takes precedence and diverting to the nearest airport ensures that necessary inspections and repairs can be conducted promptly flight Crews should remain Vigilant and attentive to any signs of mechanical issues this includes monitoring for unusual conditions such as smoke in the patient care area unusual odors or smells unexpected vibrations strange noises or any indications of fluids leaking into the patient bulkhead prompt identification of these symptoms is critical for assessing and addressing the situation as needed in cases of significant mechanical problems or other emergencies on board the flight crew should declare an emergency to air traffic control this declaration communicates the severity of the situation and immediately triggers the implementation of the sterile Kut rule even if the flight was not in a critical phase of flight at the time this designation is crucial in emphasizing the need for clear and focused communication between the flight crew and air traffic control to facilitate a safe diversion to an alternate airport ultimately the safety of the flight crew medical team and patience is of Paramount importance diverting to the nearest suitable airport when issues arise is a proactive measure to address concerns promptly and ensure the best possible outcome in the event of an emergency or mechanical malfunction during a medical transport flight visual flight rules and instrument flight rules represent two distinct modes of flight used in aviation each tailored to specific weather conditions and regulatory requirements VFR is employed when weather conditions are favorable characterized by good visibility and minimal cloud cover allowing Pilots to navigate primarily by visual reference to the ground in some less populated areas Pilots may fly under VFR without constant communication with air traffic control however in more densely populated regions such as within controlled airspace maintain Ming communication with air traffic control is obligatory even when flying VFR in contrast IFR comes into play when weather conditions deteriorate and require Pilots to navigate and control the aircraft solely by reference to instruments and air traffic control guidance IFR is essential for safe and controlled flight when visibility is poor or adverse weather conditions Prevail ensuring that aircraft can operate safely even when external visual references are limited or absent the choice between VFR and IFR is made based on weather conditions with VFR allowing more pilot discretion and IFR ensuring a structured instrument guided approach to maintain safety and challenging environments instrument flight rules represent a critical mode of flight used when weather conditions preclude adherence to visual flight rules due to factors such as low visibility and cloud cover in IFR Pilots must rely heavily on the instruments inside the cockpit to navigate maintain control and ensure safety throughout the flight these instruments provide critical data such as air speed altitude heading and attitude enabling the pilot to fly with Precision even when external visual references are obscured to operate under IFR Pilots must obtain clearance from Air Traffic Control before takeoff which includes receiving a specific flight plan and instructions on how to safely navigate through controlled airspace and along designated Airways maintaining continuous Comm communication with air traffic control is essential for coordinating with other air traffic ensuring proper separation between aircraft and receiving updated route and altitude instructions as necessary to avoid adverse weather conditions or obstacles IFR is a fundamental component of Aviation safety enabling flights to proceed with reliability and Precision in various weather conditions that might otherwise pose a risk to Aviation operations identifying flight and seam locations is a crucial aspect of ensuring the safety and efficiency of air medical operations global positioning system tracking technology plays a pivotal role in this process allowing for constant monitoring of an aircraft's movement even when it is not in radio contact flight following centers rely on GPS data to track an aircraft's real-time position speed and altitude several commercial flight tracking programs are available which are particularly useful during flight emergencies as they provide immediate access to an aircraft's location and Status additionally computer software capable of converting physical addresses into GPS coordinates is essential for pinpointing specific locations in air medical operations rotor wi responders frequently use handheld devices to obtain precise Geographic coordinates of a scene or Landing Zone the accuracy of these coordinates is Paramount as it directly affects the efficiency and safety of the mission to mitigate inaccuracies two sets of coordinates are often obtained and cross referenced ensuring that the aircraft is directed to the correct location swiftly and safely overall GPS technology and accurate coordinate conversion are indispensable tools for air Medical Teams adding them in reaching patients and Landing zones with precision and expediency ultimately improving patient outcomes air medical",
        "Air Medical Safety": "safety air Medical transport is a critical and life-saving service but it comes with inherent hazards and challenges that air medical providers must navigate air medical providers often need to launch quickly in response to emergency requests this places significant stress on the flight crew to become airborne promptly the need for rapid response is particularly critical in situations where patients require immediate medical attention or are in life-threatening conditions responding to emergency calls may lead air medical Crews to chaotic scenes where Landing zones may be hastily prepared or have limited space this can be especially challenging in urban environments rugged terrain or adverse weather conditions requiring the crew's skill and experience to safely land the aircraft air medal teams are frequently tasked with treating patients who have sustained catastrophic injuries or are suffering from severe medical conditions these situations can exceed the capabilities of ground-based medical personnel the crew must provide Advanced Medical care while managing the unique challenges of the aircraft environment working in an aircraft environment presents physical and mental challenges the crew May face conditions such as intense heat dehydration motion sickness and physical exhaustion especially during extended operations the confined space of the aircraft can be mentally taxing for both the medical personnel and the flight crew addressing these challenges requires thorough training experience and effective communication among the air medical team members in addition to delivering Medical Care Providers must ensure the safety of the flight the patient and themselves this demanding work necessitates continuous training adherence to safety protocols and a de commitment to Patient Care in all circumstances despite these challenges air Medical Transport remains a vital service often making the difference between life and death for those in critical need of Rapid medical attention the causes of air medical crashes are often complex and multifaceted rarely attributed to a single isolated event these crashes are typically the result of a combination of various contributing factors that ultimately lead to the final catastrophic event when examining fatal EMS helicopter crashes between 2008 and 2017 a pattern emerges highlighting the most common contributing factors One Pilot decision- making pilot decisions play a pivotal role in the safety of air medical operations choices related to weather conditions road selection and operational decisions can significantly impact crash risks these decisions are often made in high stress environments where the pressure to respond rapidly to critical situations can influence the decision-making process two visibility or Darkness poor visibility especially during nighttime flights is a critical Factor contributing to air medical crashes reduced visibility due to weather conditions or night operations can pose substantial challeng es for even the most experienced Pilots the limited visibility can make it difficult to navigate and assess the environment accurately increasing the risk of accidents three mechanical problems with the aircraft mechanical failures or malfunctions within the aircraft itself can lead to catastrophic crashes ensuring regular maintenance and thorough pre-flight checks is essential to minimize such risks malfunctions can occur suddenly and if not detected early can result in tragic outcomes four Pyers attention SL orientation maintaining proper attention and orientation in the aircraft's cocket is Paramount distractions or disorientation can lead to a loss of control or incorrect decision-making which can be especially critical during emergency medical missions that demand precision and focus five organizational compliance adherence to safety protocols operational procedures and Aviation regulations is vital in air medical operations non-compliance with these standards can lead to accidents and jeopardize the safety of patients and crew six object SL terrain encounter collisions with obstacles or terrain can be a significant cause of air medical crashes these incidents may include striking power lines or impacting the ground which can result from navigational errors or challenging environmental conditions seven pilot experience the level of experience and training of the pilot is an essential Factor more experienced Pilots are generally better equipped to handle challenging situations making pilot training and continuous skill development a key component of safety and finally eight pilot flight preparation adequate flight preparation including thorough planning and pre-flight checks is crucial to Safe operations inadequate flight preparation can lead to issues during the mission increasing the risk of accidents given the high stress and critical nature of air Medical Transport addressing these contributing factors and enhancing safety in this field requires a comprehensive approach this approach should involve continuous pilot training strict adherence to safety standards rigorous maintenance procedures and a strong safety culture within air medical organizations regular safety assessments ongoing training and a commitment to safety Improvement are essential to mitigate these risks and ensure the safety of air medical operations when assessing the role of weather in emergency medical service helicopter crashes it becomes evident that weather related factors can significantly influence the safety and outcome of air medical missions key issues related to weather in these accidents often involve encounters with unpredicted instrument meteorological conditions MC refers to adverse weather conditions in which visibility is reduced cloud cover is pervasive and Pilots are required to rely on the instruments rather than visual references for navigation cloud cover can limit visibility and create a potentially hazardous environment for helicopter operations reduced visibility especially in the absence of cier reference points can make navigation and obstacle avoidance more difficult increasing the risk of accidents reduced visibility due to factors such as fod rain snow or Haze can be a major issue helicopter Pilots depend on visual cues for safe flight but when visibility is compromised it becomes essential to rely on instruments low visibility ility can affect situational awareness and decisionmaking weather is cited as a contributing factor in approximately 25% of EMS helicopter crashes what makes the statistic more concerning is that 2third of these crashes result in fatalities this underlines the severe consequences that weather related incidents can have in air Medical Transport when weather conditions deteriorate especially in situations where rapid response is crucial Pilots may be faced with difficult choices pressures to complete the mission and save lives can sometimes override safety concerns leading to tragic outcomes to mitigate these risks air medical organizations and Pilots must prioritize weather safety this involves rigorous pre-flight weather assessments adherence to instrument flight rules when conditions warrant continuous training on flying in adverse weather and fostering a safety culture where the decision to proceed with a mission is based on the safety of both the crew and the patients avoiding un necessary risks in poor weather conditions is a fundamental principle in enhancing the safety of EMS helicopter operations ensuring that patients receive the care they need while protecting the lives of those providing that care human errors Encompass a range of critical factors that can influence the safety and effectiveness of flight operations these errors are typically categorized into three main types skill deficiency perception errors and decision-making errors each type presents its own set of challenges and consequences for pilots and flight Crews skill deficiency is a fundamental concern in aviation as pilots and crew members are expected to possess the basic skills necessary to operate an aircraft safely when there are shortcomings in these essential skills it can lead to various hazards and compromise safety for example a pilot's inability to maintain proper control of an aircraft during takeoff or Landing can result in Runway accidents flying at improper speeds especially during critical phases of flight can lead to dangerous situations failure to follow standard emergency procedures can have di consequences in the event of an inflight emergency skill deficiencies highlight the importance of continuous training and the need for proficiency checks to ensure that all crew members can perform their roles effectively perception errors as discussed earlier can occur in conditions where visibility is reduced such as nighttime Landings or during flights and adverse weather these errors Encompass various forms of misperception including spatial disorientation somatogravic illusion and errors in judging distance altitude or a speed during these situations the human sensory system may be tricked into providing misleading information to the pilot leading to incorrect judgments and potentially hazardous actions decision-making errors are equally critical as they can have significant implications for flight safety poor decision-making can result in undesirable outcomes including selecting inappropriate emergency procedures and failing to take corrective actions when the aircraft is flying below the minimum safe altitude the ability to make sound judgments in High Press situations is a Cornerstone of Aviation safety and these errors underscore the importance of crew resource management and adherence to standardized operating procedures to reduce the risk of Adverse Events in essence understanding and addressing these three types of human errors is crucial in maintaining a high level of safety in aviation studies and investigations into air medical crashes have highlighted several areas within helicopter Emergency Medical Services operations that require Improvement these findings come from retrospective studies conducted by various organizations including the national Transportation safety board the Federal Aviation Administration and the air medical physician Association these areas include weather forecasting improving weather forecasting is crucial for enhancing the safety of air medical operations accurate and timely weather information is vital for making informed decisions about flight routs takeoff landing and inflight adjustments enhanced weather prediction and communication can help reduce the risks associated with unpredictable weather conditions flight operations during instrument meteorological conditions flight operations in instrument meteorological conditions are challenging and requires specialized training and Equipment ensuring that air medical crews are adequately trained to handle situations is essential to enhance safety during critical phases of flight personal training ongoing and robust training programs for air medical personnel including Pilots medical staff and other crew members are necessary to maintain a high level of Competency training should address specific challenges unique to helicopter Emergency Medical Services operations and prioritize safety protocols s design standards improving the design of medical helicopters and Equipment can enhance crashworthiness patient care capabilities and the overall safety of these aircraft adhering to Modern design standards and Technologies is crucial in reducing the impact of accidents crashworthiness ensuring that medical helicopters are crashworthy is essential to minimize the severity of injuries and fatalities in the event of an accident this includes the design of the aircraft its structural integrity and the safety features available on board operations management effective operations management and a culture of safety are vital in helicopter Emergency Medical Services organizations emphasizing safety protocols risk management and communication can help reduce human errors and improve overall safety Within These operations addressing these areas of improvement is essential to mitigate the risks associated with air medical operations and enhance the safety of helicopter Emergency Medical Services Personnel patients and the public helicopter Emergency Medical Services operations involve unique challenges and risks that can impact air medical personnel some of the other areas of risk factors identified in these operations include one unprepared Landing sites helicopter Emergency Medical Services missions often require Landing in challenging or unprepared locations such as remote areas accident scenes or confined spaces the lack of a dedicated Landing site can introduce hazards including uneven terrain obstacles and limited access proper sight assessment and Landing procedures are critical to mitigating these risks two complacency the familiarity of frequent flights to similar locations can lead to complacency among air medical personnel it's essential to maintain a Vigilant and safety conscious mindset even during routine missions to prevent lapses in judgment or procedures and three additional stress of responding to and caring for critical patients air medical Crews must respond to scenes with critically ill or injured patients which adds a layer of complexity and stress to their operations providing highquality patient care while managing flight safety requires continuous training and vigilance safety reports have highlighted the following problems in helicopter Emergency Medical Services operations that warrant Improvement effective communication with air traffic control is essential for safe flight operations improved communication protocols training and Equipment can help prevent misunderstandings and enhance safety during interactions with air traffic control the risk of colliding with CR objects such as obstacles or terrain features is a significant concern in Flight operations particularly during takeoff landing and low-level flight enhancing obstacle awareness and avoidance strategies as well as improving terrain awareness systems can help reduce these risks the time critical nature of of air medical missions is another risk factor that must be addressed emergency crews are often required to launch rapidly in response to emergency calls this may limit the time available for pre-flight inspection and weather assessment adherence to program policies that",
        "Making the Industry Safer": "include thorough PreFlight inspections even under time constraints can help ensure aircraft safety the goal in addressing these risk factors is to improve the safety of flight operations by implementing training procedures and equipment that enhance the ability of air medical personnel to respond effectively while minimizing risks making the industry safer reducing the number of air medical crashes is a Paramount goal to enhance the safety and effectiveness of these critical missions several Solutions and strategies have been proposed and implemented to achieve this objective one crucial step is to provide crew Resource Management training for all flight team members and mandate their participation crew Resource Management focuses on enhancing communication teamwork and decision-making skills among crew members new flight team members are typically required to attend initial training and many programs offer annual refresher courses this training Fosters a culture of safety improves situational awareness and equips the crew to work cohesively even in high stress situations to prevent helicopter shopping which involves transferring a mission to another provider for potentially unsafe reasons it is essential to encourage information sharing between competing air medal agencies medical providers should openly communicate and share decisions to decline certain missions based on safety issues with other nearby air Medical Services even if they are in direct competition this collaborative approach prioritizes safety over competition when a decision is made to decline a mission due to safety concerns it is vital that air medal program business administration and aircraft vendors fully support this decision this includes ensuring that there are no repercussions for crew members who prioritize safety by declining a mission providing the support reinforces the commitment to safety within the organization facilitating cooperation among various parties involved in transport decisions is crucial to enhancing safety joint agency training initiatives bring together air medical providers and different agencies such as EMS agencies fire departments and hosital providers these training programs encompass various aspects including aircraft familiarization Landing Zone requirements flight activation criteria and flight request training by promoting collaboration and understanding between these entities the likelihood of making safe and well-informed transport decisions is increased by implementing these Solutions and fostering a culture of safety the air medical industry aims to reduce the number of crashes and ensure that every mission is conducted with the highest standards of safety and professionalism ultimately benefiting both patients and flight Crews advanced technology plays a pivotal role in enhancing the safety of flight operations in the air Medical Transport sector night vision goggles are a GameChanger for air medical operations particularly during nighttime flights these specialized goles amplify available light and provide a clear view of the surrounding environment even in near complete darkness this technology significantly improves a pilot's situational awareness AIDS in obstacle detection and enhances safety during challenging night missions flight tracking software provides realtime tracking of aircraft ensuring that their positions are constantly monitored this technology serves multiple purposes from helping to quickly locate aircraft in the event of crashes or loss of radio contact to enhancing overall flight safety it may also include ground proximity Warning Systems and obstacle detection and alerting systems on aircraft commonly known as Terrain awareness and Warning Systems these systems offer crucial warnings to Pilots preventing controlled flight into terrain and enhancing situational awareness aircraft are equipped with weather display and alerting systems that provide Pilots with real-time weather data and warnings these systems play a critical role in ensuring that flight crews are informed about weather conditions during flight by monitoring weather patterns and potential hazards Pilots can make informed decisions to avoid adverse weather and maintain flight safety D operational control centers and flight dispatch and communication centers serve as hubs for monitoring and coordinating air medical missions these centers have access to real-time weather information and can notify Pilots of changes in weather conditions this communication allows for proactive decision-making to adjust routes altitudes or landing locations based on weather updates ensuring the safety of both patients and flight Crews by integrating these Advanced Technologies into air medical operations the industry can significantly reduce risks and enhance safety during critical flight missions these tools Empower flight Crews to make well-informed decisions and navigate a wide range of challenges ultimately improving patient care and outcomes crew Resource Management in air medical operations emphasizes collaborative decision- making and effective communication among the crew members but it doesn't imply that all decisions are made by committee without considering rank the extent of participation by subordinate crew members in decision-making can vary based on the specific situation and the crew's expertise here are some key points to consider regarding crew Resource Management in air Medical Transport the level of participation by subordinate crew members such as medical team members depends on the situation while the pilot typically makes technical decisions related to aircraft operation there may be scenarios where the input and observations of other crew members become crucial for instance if a medical crew member observes that the Pilot's flying skills have fallen below a safe standard they may need to intervene particularly in mercies such as avoiding collisions with obstacles or nearby air traffic medical crew members primarily focus on passive monitoring when it comes to crew Resource Management they are not responsible for providing flight instructions to the pilot or participating in technical decisions regarding the aircraft's operation however if they CE that a critical safety issue is imminent they have the responsibility to intervene to ensure the safety of the mission this intervention might include alerting the pilot if there is a risk of collision or other immediate hazards one area in which all crew members should hold equal empowerment is the decision to accept a mission many air medical programs use the all to go one to say no rule which gives every crew member the power to decline a flight this approach ensures that safety concerns raised by any crew member are taken seriously and if any crew member does not feel comfortable with the mission for any reason the flight should be aborted or not initiated this collaborative decision-making process helps maintain a high standard of safety in air medical operations in summary crew resource management is about fostering effective teamwork open communication and shared situational awareness among the crew members while certain responsibilities are defined based on expertise and roles safety is a shared responsibility and any crew member should feel empowered to voice safety concerns or intervene when necessary this approach contributes to a culture of safety in air Medical Transport crew safety precautions especially for critical care transport Personnel in air medical operations are essential to ensure the well-being of the crew members and by extension the safety and care of patients here are some detailed explanations of key safety precautions recommended by the commission on accreditation of Medical Transport Systems one crew rest and safety the commission on accreditation of Medical Transport Systems places strong emphasis on the importance of adequate crew rest and ongoing safety precautions recognizing their direct impact on the safety and effectiveness of providers and patient care crew members must be well rested to make critical decisions and provide quality Care during flights two shift length standards the commission suggests several standards regarding in shift lengths for all providers to prevent crew fatigue and ensure alertness these standards include discouraging shifts longer than 24 hours and mandating that Personnel have a minimum of 8 hours of rest before any shift longer than 12 hours additionally crew members should not be on duty for more than 16 hours within any 24hour span and those who must work longer than 16 hours should have the right to take an unscheduled break these standards are in place to address the risk of fatigue related errors and ensure that crew members are sufficiently rested for their responsibilities and F A3 pilot qualifications for air medical programs involving helicopters the commission outlines specific pilot qualifications to enhance safety these qualifications include a minimum of 2,000 total flight time hours with at least 1,500 hours in a helicopter and 1,000 hours qualified as pilot and command time furthermore Pilots should have 200 hours of night flying experience to enhance the safety of helicopter operations a minimum of 500 hours of turbine time is required although 1,000 hours are encouraged another important safety measure is a minimum of 5 hours of geographic orientation with another pilot before a pilot can accept a mission alone this orientation ensures that Pilots are familiar with the operational area and can navigate it safely overall these safety precautions and standards are critical in maintaining the well-being of air medical Crews and ensuring the highest level of safety in critical care transport operations they help mitigate the risks associated with fatigue unfamiliarity with the operating environment and lack of experience in conclusion Critical Care transport paramedic flight operations play an indispensable role in providing rapid and Advanced Medical Care to patients during emergencies however the key to successful air medical missions lies in a deep commitment to safety whether it's the importance of crew rest adherence to strict qualifications for Pilots or the implementation of Advanced Technologies safety precautions are the Cornerstone of this life-saving profession the safety of the air medical crew directly impacts the quality of care that patients receive by ensuring that flight teams are well rested well trained and supported by advanced technology we not only protect the lives of our dedicated crew members but also guarantee that our patients are in the best hands possible during the the most critical moments of their lives remember in air medical operations safety is non-negotiable and it must remain our unwavering priority thank you for your commitment to Excellence in critical care transport"
    },
    {
        "Introduction to Critical Care Transport": "chapter 1 introduction and overview of critical care transport recent shifts in the healthcare landscape have brought about significant Chang in patient Transportation traditionally patients with urgent medical conditions were automatically transported to the nearest hospital however a noteworthy transformation is underway with payers and healthc care providers increasingly directing patients to Alternative destinations this approach is driven by the desire to ensure that patients receive Specialized Care at facilities better equipped to address their specific medical needs for example trauma patients may be directed to level one Trauma Centers for Optimal Care.",
        "Growth and Complexity of Critical Care Transport": "One of the key outcomes of these changes is the exponential growth in the field of critical care transport or CCT CCT involves the transportation of patients who require Advanced Medical Care during Transit this growth in CCT is attributed to the rising demand for Advanced Care during transportation and the proliferation of specialized Health Care Facilities CCT is no longer a simple Transport Service it has become increasingly complex due to advances in medical Technologies and procedures highly trained medical professionals now play a crucial role in providing Advanced life support during Transit.",
        "Challenges and Requirements in Critical Care Transport": "Several factors Drive these changes including technological advancements that enable real-time monitoring and intervention the availability of specialized health Healthcare facilities and evolving Healthcare regulations that ensure the safety and quality of CCT Services however these changes also bring about challenges allocating resources for CCT Services is a vital consideration as as securing informed patient consent for alternative transportation methods healthc Care Professionals involved in CCT requires specialized training and certification to maintain competency and adapt to olving practices in healthcare.",
        "Interfacility Transport and Specialty Care Transport": "Interf facility transport or if plays a crucial role in facilitating the movement of patients between two Health Care Facilities this process has undergone significant changes and improvements in recent years it involves the transfer of patients from one Health Care institution to another often with the goal of providing Specialized Care or accessing specific medical resources not available at the originating facility a subset of if Specialty Care transport orct addresses the interfacility ground transport of critically ill or injured patients who require Advanced Medical Care and services that surpass the typical scope of practice of a paramedic SC Services go beyond the standard ambulance or medical transport involving a higher level of medical expertise and specialized equipment.",
        "Importance of Specialized Care in Patient Transportation": "The importance of these Transportation methods lies in their ability to ensure that patients receive the precise level of care they need the distinction between if and sat is essential because it dictates the level of expertise equipment and Personnel required for the safe and effective transportation of patients this has become especially important as Healthcare institutions continue to evolve and specialize necessitating a seamless and safe process for transferring patients between them the necessity for Specialized Care becomes evident when a patient's condition mandates ongoing care from health care providers in critical areas these areas Encompass emergency or Critical Care Nursing emergency medicine Respiratory Care and cardiovascular care patients with critical conditions such as severe trauma or life-threatening illnesses demand Specialized Care during transportation skilled providers with expertise in critical care play a pivotal role in monitoring and providing interventions during the transit considering the complex and specialized nature of these transports allocating the appropriate resources ensuring informed patient consent and adhering to regulatory guidelines are vital considerations these factors collectively contribute to maintaining the quality safety and efficacy of patient transportation services within the context of Specialized Care in patient Transportation.",
        "Configuration of Medical Crews": "The configuration of medical Crews can vary significantly based on the complexity and requirements of the cases these configurations are highly adaptable and Vary depending on the specific needs of the patient common crew members like emergency medical technicians paramedics registered nurses and respiratory therapists provide fundamental care care while specialized professionals such as perfusionists surgeons neonatologists and pediatric intensivists are brought in as needed to ensure that patients receive the most appropriate care during Transit the choice of crew members reflects the level of care required and the critical nature of the patient condition.",
        "Role and Training of Critical Care Transport Paramedics": "Critical Care transport paramedics play a pivotal role in patient care during high-stake situations these profession professionals are required to not only provide Care at a level equivalent to their non-ct counterparts but often at a higher level due to the complexity and acuy of the cases they encounter to achieve this Critical Care transport paramedics must be educated and skilled in the use of advanced practice procedures Critical Care transport paramedics are expected to deliver patient care that is on par with their counterparts in non- CCT settings such as 911 services this means that the fundamental skills of assessment basic life support and advanced life support interventions must meet or exceed the standards expected of their peers in traditional EMS roles beyond the Baseline competencies CCT paramedics need to be proficient in a spectrum of advanced practice procedures these Encompass a wide range of clinical skills and interventions that are vital for the care of critically ill or injured patients.",
        "Advanced Skills and Procedures for CCT Paramedics": "Some key elements include Advanced Airway management CCT paramedics are trained to manage Airways using various techniques including endral intubation superg glottic Airway devices and croomy when necessary ensuring adequate oxygenation and ventilation is Paramount in critical care cardiovascular support these paramedics are well-versed in advanced cardiac life support and are skilled in administering medications and interventions to manage aryas myocardial infarctions and other cardiac emergencies Advanced medication administration CCT paramedics are trained to administer a broad range of medications often including potent vasoactive drugs to manage blood pressure sedatives and analgesics for pain control and drugs to address specific medical conditions hemodynamic monitoring they are proficient in monitoring and interpreting hemodynamic parameters like blood pressure central venous pressure and pulmonary artery pressures which guide treatment in critically ill patients invasive procedures CCT paramedics may also perform or assist in invasive procedures such as chest tube insertion in certain cases to manage thoracic trauma or pneumothorax mechanical ventilation they possess the Knowledge and Skills to manage mechanical ventilators for patients who require artificial breathing support neonatal and Pediatric Care in some cases CCT paramedics need specialized training to care for critically ill newborns or children where procedures like umbilical catheterization may be necessary.",
        "Continuous Learning and Professional Development": "A commitment to continuous learning and professional development is Paramount to ensure that Critical Care transfer support paramedics maintain the highest standards of care and expertise most critical care paramedic programs have rigorous requirements to complete frequent continuing professional education classes often exceeding the minimum requirements necessary for maintaining state or national certification and lure which are essential for their employment in many cases these programs mandate annual training and continuing education to keep paramedics at the top of their game CCT paramedics are held to high standards when it comes to their Knowledge and Skills the rapidly evolving field of Health Care particularly in critical care demands that paramedics stay updated with the latest medical advancements protocols and best practices frequent continuing education classes are designed to address these Dynamic changes and help providers stay current many CCT programs make it Mand mandatory for paramedics to undergo annual training these trainings serve as a comprehensive refresher and an opportunity to learn about new techniques Technologies and research findings they may also include simulations and Hands-On practice enabling providers to hone their clinical skills and improve their decision-making abilities.",
        "Modes of Patient Transportation": "In the realm of patient transportation we rely on various modes to ensure patients receive appropriate care among these modes we have mobile or ground units rotary Wing aircraft known as helicopters and fixed wi aircraft such as airplanes understanding the roles and capabilities of these transport modes is essential in the field of healthcare ambulances are instrumental in patient Transportation they are typically utilized when patients need to be transported for distances of 50 Mi or greater particularly when time is not a CR critical Factor ambulances also come into play when patients have contr indications for Air transport such as unstable Vital Signs these ground units ensure the safe and comfortable movement of patients over longer distances and are a Cornerstone of Emergency Medical Services helicopters are invaluable in health care particularly in Rural and remote settings where accessibility to medical facilities can be challenging they excel at covering distances of up to 150 Mi swiftly making them crucial for situations where time is of the essence one of their key advantages is the ability to load patients from both the side and rear insuring versatility for various patient conditions and emergency scenarios fixed wi aircraft such as planes are used to transport patients over even longer distances typically exceeding 15 50 Mi these aircraft are essential for InterContinental or longdistance medical transportation they often work in conjunction with mobile Critical Care units ensuring that patients receive Continuous Care during air travel the ability to provide an enclosed and stable environment for patients along with a dedicated medical team makes fixed-wing aircraft a reliable mode for Long Haul patient transport.",
        "Factors Influencing Transportation Mode Selection": "Selecting the appropriate mode of patient transportation is a complex decision influenced by several critical factors the choice between ground air or fixed wi transport is a multifaceted process that Health Care Providers emergency responders and transport coordinators must navigate to ensure the safe and efficient transfer of patients these factors include patient Acuity the distance between sending and receiving facilities the responsiveness of the the transport service prevailing weather conditions and Regional topography one of the foremost considerations in determining the mode of transportation is the patient Acuity or medical condition for critically ill or injured patients particularly those with life-threatening conditions rapid transport via air is often the Preferred Choice For Less acute cases ground transportation such as ambulances May suffice the urgency of the the patient's needs and the interventions required dictate the mode chosen the geographical separation between the sending facility and the receiving facility is another significant factor for shorter distances within a city or town ground transportation is generally suitable as distances increase particularly for Rural or remote locations Air transport becomes a practical Choice fixed wi aircraft might be used for long distances or InterContinental transfers the availability of transport services including the responsiveness of air Medical Teams ground ambulance Crews or fixed wi flight Crews plays a pivotal role in areas with wellestablished and Swift response times transport mode decisions can be more flexible however in regions with limited transport infrastructure the choice may be more limited and heavily influenced by availability weather conditions significantly impact the feasibility of Air transport poor weather including Heavy Rain fog snow or strong winds can render helicopter or fixed Wing flights unsafe in such cases ground transportation is often the only viable option transport coordinators must consider weather forecasts and safety protocols when making Transportation decisions the geographic landscape including cluding mountains rough terrain and bodies of water can influence transport decisions ground transportation may be impeded in areas with challenging topography making Air transport a more practical solution conversely relatively flat and accessible regions May favor ground transport patient safety and clinical outcomes are the primary concerns in the decision-making process a comprehensive understanding of these factors is essential to ensure that patients are transported in the most efficient and suitable manner healthc care providers transport teams and coordinators must work collaboratively to make informed choices optimizing the patients chances for a successful medical outcome while considering the unique circumstances presented by each case.",
        "Role of Dispatchers in Critical Care Transport": "In the realm of critical care transport dispatchers are often unsung heroes performing a crucial role in coordinating and facilitating the transportation of critically ill or injured patients their responsibilities Encompass several key functions which collectively ensure that patients receive the appropriate care and resources in a timely manner the dispatcher's role involves initiating the treeage process Gathering patient information collaborating with clinical supervisors or utilizing algorithms to determine crew configuration and the most of transportation and ultimately dictating the use of a CCT team the process begins with the dispatcher who is typically the first point of contact when a referring facility or health care provider requests Critical Care transport for a patient dispatchers are highly trained to handle these initial calls with efficiency and precision they initiate the treeage process often Guided by established protocols and guidelines during this phase the dispatcher collects Vital Information about the patient's condition based on the details provided by the referring facility this initial interaction is crucial as it sets the stage for the subsequent steps in the patient transport process once the patient's information is collected the dispatcher collaborates with clinical supervisors or relies on algorithms designed to assess the patient needs and determine the most appropriate configuration for the transport team these clinical supervisors are typically seasoned Healthcare professionals often experienced paramedics or nurses who can provide expertise in evaluating the patient's condition and specific requirements algorithms on the other hand are decision support tools that help ensure consistency and efficiency in decision-making by Consulting with clinical supervisors or applying established algorithms the dispatcher can ascertain whether the patient requires a dedicated CCT team and what mode of transportation is most suitable whether that be ground or air determining the use of a CCT team the type of call and the patient condition as assessed through the trage process ultimately dictate the use of a CCT team if the patient's condition is critical necessitating Advanced Medical Care and interventions during transport the dispatcher will arrange for a specialized CCT team to ensure the patient safety and well-being the dispatcher's decision-making is critical here as it ensures that patients receive the level of care and transportation mode that aligns with their specific medical needs specialized units designed to provide the highest level of care to critically ill or injured patients during Transportation these teams are vital for situations where patients have complex medical needs that demand ongoing intervention and support.",
        "Scenarios Requiring a CCT Team": "Several scenarios necessitate the involvement of a CCT team including those involving mechanical ventilation vascular access devices vasoactive medications blood or blood product infusions mechanical circulatory support devices and instability requiring frequent interventions patients who require mechanical ventilation are often in a critical condition often due to respiratory failure transporting these patients requires a specialized CCT team that can manage and monitor the ventilator troubleshoot potential complications and provide the patient with the oxygenation and ventilation needed to support their vital functions during Transit patients with complex medical conditions may have multiple vascular access devices such as Central Venus catheters or arterial lines a CCT team is equipped to manage these devices ensuring they remain functional preventing infections and providing necessary medications or infusions through them during transport patients requiring vasoactive medications often have severe cardiovascular issues such as shock or severe hypertension a CCT team can expertly administer and monitor these medications making real-time adjustments based on the patient's condition blood pressure and cardiac performance to maintain hemodynamic stability patients in need of blood transfusions or specialized blood products are typically in critical conditions such as trauma or severe bleeding the CCT team can safely transport these patients while maintaining the Integrity of the blood products and providing essential support during the transfusion process patients with mechanical circulatory support devices like ventricular assist devices or extracorporeal membrane oxygenation require a highly specialized team for transportation the team ensures the proper functioning of these devices monitors the patient condition and addresses any device related issues promptly some patients are profoundly unstable requiring constant medical interventions monitoring and adjustment of treatments the these situations demand a CCT team capable of providing intensive care adapting to Dynamic clinical changes and ensuring the patient remains stable during transit in essence the role of a CCT team is to provide comprehensive care for patients with complex medical needs ensuring their safety stability and well-being during Transportation the situations requiring CCT teams typically involve patients with critical respiratory cardiovascular or hemodynamic conditions as well as those with complex medical devices or those who need frequent medical interventions understanding the unique demands of these cases is essential for health care providers and transport teams to ensure optimal patient outcomes during transport.",
        "Ground vs Air Transport: Advantages and Disadvantages": "The decision of whether to transport a patient by ground or air is a critical one in the realm of healthcare and it requires careful consideration of the advantages and disadvantages associated with each mode the choice between these Transportation methods has profound implications for the patients well-being treatment and overall outcome thus it is essential for healthcare providers and transport coordinators to weigh these factors judiciously there are many factors to consider for example one of the most significant advantages of Air transport is its speed helicopters and fixed wi aircraft can rapidly cover long distances making them essential for time-sensitive cases such as trauma or cardiac emergencies this speed can potentially save lives by Expediting access to Specialized Care however aircraft have limited space and may not accommodate larger teams or bulky medical equipment this can be a disadvantage in cases where multiple Health Care Providers or specialized equipment are needed additionally Air transport is susceptible to weather conditions which can lead to delays or cancellations poor weather including fog snow or strong winds can compromise safety and necessitate the use of ground transportation.",
        "Medical Oversight in Patient Transport": "There are two primary types of medical oversight a comprehensive set of trage treatment and transport protocols including standing orders and online medical control or consultation each of these approaches plays a critical role in ensuring that patients receive the most appropriate care during transport a comprehensive set of protocols provides a clear framework for healthc care providers and transport teams to follow when assessing treating and transporting patients these protocols outline the steps to be taken in various clinical scenarios addressing issues ranging from basic life support to Advanced interventions for example they may specify the procedures for managing Airways administering medications or responding to cardiac arrests staving orders are an integral part of this oversight system they are pre-established medical orders that allow healthc care providers and transport Personnel to take specific actions without direct physician consultation these orders are based on the protocols and are designed to expedite care in urgent situations standing orders Empower Medical Teams to make decisions and administer certain treatments without delay a well-structured set of protocols with standing orders enhances efficiency and consistency in patient care it ensures that healthc care providers have a standardized approach to managing various medical conditions and can initiate essential treatments promptly this is particularly valuable in emergency situations where rapid intervention is critical online medical control or consultation involves real-time communication with Physicians or medical experts who provide guidance and oversight remotely this consultation can be initiated by healthc care providers or transport teams when they encounter complex or challenging cases that fall outside the scope of established protocols the primary function of online medical control is to offer decision support Physicians can review patient data provide guidance on treatment options suggest medication adjustments or recommend interventions that align with the patient's specific clinical needs this consultative process ensures that the care provided during transport is tailored to the patient's condition online medical control offers a higher level of adaptability and customization in patient care it is particularly valuable for patients with unique or complex medical conditions through real-time consultations Healthcare Providers can seek expert advice and make informed decisions thereby optimizing patient outcomes both types of medical oversight are crucial in patient transport a comprehensive set of trade treatment and transport protocols with standing orders ensures that healthc care providers have clear and standardized procedures to follow especially in time-sensitive situations s on the other hand online medical control and consultation offer realtime access to Medical expertise enabling Health Care Providers to tailor care to the specific needs of each patient the combination of these approaches ensures that patients receive safe effective And Timely care during transport regardless of the complexity of their medical conditions.",
        "Standards and Regulations in CCT Programs": "Critical Care transport programs operate under a framework of standard and regulations although the specific standards can vary by location and type of service here we delve into the key aspects of standards and regulations governing CCT programs most the CCT programs aim to adhere to National standards to ensure a consistent and high level of care these standards are developed by national organizations and professional bodies to guide the practice of CCT they enccompass protocols equipment requirements safety procedures and patient care practices standards for CCT programs can vary significantly by state state governments often have their own set of regulations and requirements for the lure certification and operation of CCT services this can lead to some degree of variability in practice some states require CCT programs especially air Medical Services to obtain certific ation from the commission on accreditation of Medical Transport Systems this certification sets rigorous quality and safety standards for air Medical Services ensuring compliance with best practices State organizations govern licensure and certification of air medical services and practitioners these entities oversee compliance with State specific regulations contributing to the overall quality and safety of CCT services within their jurisdiction the scope of practice for individual Critical Care transport paramedics can vary significantly based on their level of certification and the state in which they practice paramedics with higher certifications often have broader scopes of practice allowing them to perform more advanced medical procedures and interventions the specific procedures and interventions that CCT paramedics are authorized to perform are often governed by state specific regulations it's essential for providers to be aware of the scope of practice in their state and adhere to these regulations while there are national standards for the practice of CCT there are no uniform national standards for CCT training courses the design and content of training courses can vary although they generally include didactic and Hands-On components a basic CCT training course typically involves a minimum of 80 additional hours of training beyond the initial paramedic or nurse training these courses cover essential topics such as Airway management Cardiac Care Pediatric Care and specialized equipment use the regulation of critical care transport programs is a multifaceted landscape While most programs aim to adhere to National standards there is considerable variability due to State specific regulations CMT certification requirements and the scope of practice for individual CCT paramedics Healthcare Providers CCT program administrators and providers themselves must be diligent in understanding and complying with the specific regulations and standards applicable in their area of practice to ensure the highest level of patient care and safety during Critical Care transport it's important to recognize that these standards and regulations May evolve so staying informed and upto-date is crucial for the most accurate and current information contacting the relevant state agency or organization is advisable.",
        "Well-being and Resilience of Critical Care Paramedics": "Critical Care paramedics are Health Care Professionals who play a pivotal role in delivering emergency medical care and transporting critically ill or injured patients their own well-being is essential to their ability to perform their high stress high stakes job of effectively well-being encompasses a state where individuals feel comfortable healthy and happy which is vital for both their personal lives and their professional performance the demanding nature of their work including exposure to traumatic situations and high-pressure decision-making necessitates a focus on maintaining well-being resilience is a key component in the maintenance of well-being for critical care paramedics resilience refers to an individual's ability to adapt and bounce back from adversity stress or traumatic events it is an essential quality for Professionals in high stress Fields like Critical Care resilience has three primary determinant that contribute to a paramedics well-being genetics attachment and control genetics play a role in an individual's innate ability to cope with stress attachment referring to the quality of relationships and support networks can greatly influence a paramedics resilience finally a sense of control or Mastery over one's work environment and decision-making processes can positively impact well-being by reducing stress and enhancing an individual's capacity to cope with the demands of their job by understanding and nurturing these determinant of resilience Critical Care paramedics can maintain their well-being and in turn provide better care to the patients they serve.",
        "Stress Management for Critical Care Paramedics": "Stress is an inherent part of the critical care paramedic profession where healthc care providers face a multitude of high stress situations daily stress can emanate from both positive and negative life events and understanding how these events impact well-being is crucial for critical care paramedics managing stress effectively is essential to ensure that paramedics remain fix physically and mentally healthy capable of delivering quality patient care and maintaining personal well-being it's essential to recognize that stress can result from both positive and negative life events positive events like a promotion significant life Milestones or personal achievements can lead to stress due to increased responsibilities or pressure to perform in contrast negative events such as patient deaths medical emergencies or workplace challenges can also induce stress acknowledging that stress can stem from various sources is the first step in addressing it to effectively manage stress Critical Care paramedics should assess the stress inducing value of each life event they encounter this evaluation involves considering the emotional and psychological impact of different situations by understanding which events are most stress inducing paramedics can allocate their resources and coping strategies more effectively some events are Beyond an individual's control but paramedics can manage controllable factors in their lives to reduce overall stress spreading out events that can be controlled such as scheduling personal and work-related responsibilities can prevent the accumulation of stress this can also help in avoiding overwhelming periods in one's life cumulative stress the stress that occurs over time due to repeated exposure to challenging events is a significant concern for critical care paramedics acknowledging the cumulative nature of stress allows paramedics to implement strategies that mitigate the long-term impact it's crucial to address the totality of stress experienced throughout one's career rather than focusing solely on individual stressors suggestions for a personal Stress Management program could include self-care prioritize self-care routines which include maintaining a healthy diet engaging in regular physical activity and getting sufficient rest adequate sleep in a balanced diet are foundational for managing stress mental health support access Mental Health Resources and support services such as counseling or peer support groups to address the psychological impact of high stress situations and critical incidents time management efficiently manage time and responsibilities ensuring a balance between work and personal life this includes scheduling regular breaks of vacations to recharge resilience training consider participating in resilience training programs designed to enhance an individual's capacity to cope with stress and adversity effectively mindfulness and relaxation techniques incorporate mindfulness meditation deep Brea breathing exercises or relaxation techniques into daily routines to help manage stress on a daily basis pure support establish and nurture a support network of colleagues and friends who understand the unique challenges of the profession and can provide emotional support positive coping strategies adopt positive coping strategies such as maintaining a sense of humor seeking Hobbies or activities that provide relaxation and a addressing emotional responses constructively Stress Management is an integral part of the critical care paramedic profession recognizing that both positive and negative life events can contribute to stress assessing the stress inducing value of these events and implementing a personal Stress Management program are essential steps for paramedics to safeguard their well-being and continue delivering highquality Patient Care by proactively addressing stress and utilizing effective coping strategies providers can not only mitigate the impact of stress but also thrive in their challenging and rewarding profession.",
        "History of Ground Ambulance Services": "The history of ground ambulance services is a testament to the advancement of Health Care and Emergency Medical Response throughout the centuries various events and Innovations have contributed to the development of the modern ambulance system this historical timeline highlights key milestones in the evolution of ground ambulance services during the Crusades the Knights of St John called hospitallers established a system for caring for wounded and sick soldiers on the battlefield they are often considered some of the earliest emergency medical providers the hospitallers provided essential care including triage medical treatment and transportation for injured Crusaders Dominique Juan Larry a French surgeon and chief surgeon of Napoleon's Army designed the ambulance Volante during the French Revolution these horse drawn carriages were equipped with medical supplies and staffed by trained Personnel this marked a significant step toward organized on-site Medical Care and transportation for wounded soldiers serving as a precursor to Modern ambulance services during the American Civil War Dr Jonathan Letterman the medical director of the the army of the pomac introduced an organized ambulance system he established a comprehensive medical plan that included the use of horsedrawn ambulances to transport injured soldiers from the battlefield to field hospitals this Innovation revolutionized Medical Care on the battlefield reducing mortality rates and providing a model for future ambulance services bellw Hospital in New York city became the site of America's First City Ambulance Service this marked a shift from Battlefield focused ambulance systems to Urban settings bellw Hospital service demonstrated the value of Rapid transportation of patients to hospitals and paved the way for the development of Municipal ambulance services in cities across the United States the turn of the 20th century marked a significant shift in the technology used for ambulances in 1899 the city City of Chicago Illinois developed the first motorized ambulance replacing horong carriages with automobiles this advancement greatly improved response times and the ability to transport patients rapidly to medical facilities in the early 1900s the structure of ambulance Crews began to resemble the modern model ambulances typically included a driver responsible for navigating through traffic and a trained Medical professional responsible for patient care this division of roles streamlined the response process and improved the quality of care Dr Francis pantridge a cardiologist in Dublin Ireland played a pivotal role in the advancement of prehosp care for cardiac patients he organized the world's first prehospital coronary Care Unit an innovation that significantly improved the survival rates of heart attack patients Dr pant 's work laid the foundation for modern prehospital Cardiac Care and Emergency Medical Services a groundbreaking development in the United States occurred in 1969 when the first Paramedic program was initiated in Miami Florida paramedics highly trained healthc Care Professionals were equipped to perform Advanced medical procedures and administer Critical Care in the prehospital setting additionally this period saw the introduction of prehospital defibrillation a life-saving intervention for patients experiencing Cardiac Arrest these Innovations marked a significant leap in the level of care that could be provided by ambulance Crews and ushered in the era of modern paramedicine these milestones in the history of ground ambulance services demonstrate a continuous drive toward improving patient care response times and the capabilities of ambulance Crews the the transition from horsedrawn carriages to motorized vehicles the specialization of roles within ambulance Crews the focus on prehospital coronary care and the establishment of paramedic programs represent critical steps in the development of Emergency Medical Services these advancements Have Been instrumental in saving lives and delivering highquality care during emergencies shaping the way Emergency Medical Services are structured and practiced today.",
        "History of Air Ambulance Transport": "Air ambulance transport represents a remarkable evolution in Emergency Medical Response enabling the rapid transportation of critically ill or injured patients to medical facilities this historical timeline highlights key milestones in the development of air ambulance transport from the late 18th century through the early 20th century the mulier brothers Pioneers in aviation conducted the first successful manned hot air balloon flight in 1783 the spectacle of human flight ignited the imaginations of Physicians who began to consider the potential benefits of Aviation for medical transport this period marked the Inception of aerial Medical Transport as a concept during the Prussian Siege of Paris an event occurred that would go down in history as the first documented case of air Medical Transport the French military used balloons to evacu uate wounded soldiers from the besieged city demonstrating the Practical utility of aerial transport for medical purposes during wartime in the Netherlands m deui a medical doctor explored the concept of using bbms for patient transport he recognized the potential of Air transport to quickly move patients to medical facilities particularly in situations where ground transportation was challenging in the early 20th century the US Army Medical corpse took a significant step toward the development of air ambulance transport they designed an aircraft specifically for carrying patients unfortunately during testing the plane crashed highlighting the challenges and risks associated with early Aviation Technology the development of air ambulance transport continued to progress in the early 20th century with advancements in aviation technology and the dedicated focus of military and medical organizations the following key Milestones illustrate the ongoing evolution of air ambulance transport in 1914 eigor Sikorski a pioneering figure in aviation designed and built the first successful helicopter the invention of the helicopter marked a revolutionary breakthrough in aircraft technology particularly for its vertical takeoff and Landing capabilities Cy 's Innovation would significantly impact the future of air ambulance transport in the aftermath of World War I the US Army recognized the value of air ambulances for transporting injured soldiers they redirected their focus toward the development of dedicated air ambulance units this marked a pivotal shift with military organizations acknowledging the benefits of air medical transport in both military and civilian contexts during the 1930s air ambulances continued to evolve and improve they were designed with features such as multiple engines to enhance safety and reliability heated cabins were integrated to ensure patient comfort and protection from the elements especially in cold climates additionally air ambulances were equipped with short Runway capability allowing them to take off and land in diverse and often constrained environments on April 23 1944 a historic event occurred during World War II that marked a transformative moment in air medical transport in Burma wounded Airmen were transported by helicopter for the first time this Innovation demonstrated the potential of helicopters for Rapid evacuation of casualties from remote or challenging terrains it marked the dawn of a new era in air Medical Transport emphasizing the speed and flexibility of rotary wi aircraft in providing life-saving care during the Korean war which began in 1950 air Medical Transport played a crucial role in saving lives on the battlefield wounded soldiers were transported to mobile Army surgical hospital units via helicopters including the Bell 47 and sakori s51 the introduction of air ambulance transport in a military context dramatically reduced mortality rates as injured soldiers received timely and specialized Medical Care in mobble surgical facilities this successful integration of air Medical Transport into wartime healthc Care Systems further solidified the importance of helicopters and fixed-wing aircraft in emergency response and patient care the Vietnam War from the late 1950s to the mid 1970s witnessed the WID spread use of helicopters particularly the Bell uh1 aoys commonly known as the Hui these versal helicopters played a central role in Battlefield rescues medical stabilizations and evacuations helicopters provided Swift and effective transportation for wounded soldiers often making the critical difference in the survival of these individuals the Vietnam War emphasized the indispensable role of air ambulance transport support in combat settings and significantly contributed to the development of modern aeromed techniques and systems during the late 1950s the concept of civilian air Medical Services began to take shape Etna California saw the organization of one of the first civilian air Medical Services this marked a transition from military Centric applications to civilian utilization of air ambulances enabling the rapid transport of critically ill or injured individuals from remote or underserved areas to medical facilities the 1960s saw a significant advancement in air ambulance services in the United States in Maryland the state police employed four paramedic staffed helicopters which were integrated into the public safety infrastructure these paramedic staff helicopters played a crucial role in providing Advanced prehosp Care and rapidly transporting patients to appropriate medical facilities the use of paramedics in the air ambulance setting represented a significant step forward in enhancing patient care during transport in the 1970s St Anthony's Hospital in Denver achieved a significant Milestone by establishing the first hospital-based air Medical Transport program in the United States this marked a crucial shift in air ambulance operations with h hospitals recognizing the value of having their own dedicated Air transport services hospital-based programs ensured the rapid and specialized transport of patients to the medical facilities best equipped to provide care significantly improving patient outcomes the 1980s brought increased attention to the safety and quality of air ambulance services a study by the national highway and Transportation safety administration highlighted the need for better equipment and specially trained crews in air ambulance operations in response to these findings the Federal Aviation Administration Regulators implemented more stringent requirements for Air ambulances including improved equipment and training standards these regulations aim to enhance the safety and quality of air ambulance operations reducing the risks associated with medical transport by air by the 2000s air ambulance transport had become an integral component of the Health Care system in the United States the number of air medical programs had expanded significantly with more than 100 programs in operation across the country this proliferation of air ambulance services ensured widespread access to Rapid Specialized Care for patients in both Urban and remote areas these historical Milestones underscore the growing recognition of air ambulance transport support as an essential component of Emergency Medical Response both in Military and civilian contexts the Vietnam War emphasized the critical role of helicopters in Battlefield Medical Care laying the groundwork for modern aerom medal systems the emergence of civilian air medical services such as the one in enna California further expanded the scope of air ambulance transport to serve civilian populations the integration of paramedics into air ambulance operations in Maryland exemplified the increasing sophistication of prehosp care with trained medical professionals providing Advanced treatments in Flight these developments collectively contributed to the continued growth and refinement of air ambulance services which today play a vital role in delivering timely and life-saving care to patients in diverse and challenging settings.",
        "Conclusion": "Your attention during this lecture on introduction and overview of critical care transport is greatly appreciated understanding the fundamental concepts and historical context of critical care transport is crucial for anyone involved in Emergency Medical Services or Health Care delivery the information covered in this lecture lays the groundwork for comprehending the evolution and significance of critical care transport in Health Care Systems worldwide"
    },
    {
        "EMS Operations": "Introduction: Practicing EMS within the law, keeping yourself safe, healthy, and sane, working on a team to resolve an emergency incident, operating an emergency vehicle, handling large incidents. What makes providers of emergency medical services (EMS) different from other medical personnel is where they practice \u2014 in people\u2019s homes, places of work, out in the street. Unlike medical professionals who work in hospitals, clinics, or doctors\u2019 offices, emergency medical technicians (EMTs) can\u2019t control the dangers that accompany unfamiliar environments. However, being aware of the safety issues and responding to them appropriately reduces the potential for harm. This chapter describes important aspects of EMS operations: following medical legal standards, staying healthy and safe, working well with others, handling an emergency vehicle, and being on the scene of a large emergency incident., Maintaining Medical Legal Standards: No matter where you engage your patient, there is a clear set of medical legal guidelines you should practice religiously, as you find out in the following sections. Ethics and \u201cdoing the right thing\u201d apply as well, but it\u2019s the law that will either protect you or, if you do the wrong thing, provide patients the ability to be compensated for their losses., Grasping the basic legal tenets of medical practice: The basics of understanding your legal role as an EMT are grounded in the following three legal terms: Scope of practice: Your state laws dictate what medical procedures you can perform, as well as what you cannot do. For example, you can ventilate a patient with a bag-valve mask and oxygen, but you can\u2019t ventilate a patient with an endotracheal tube. Standard of care: The way that you perform a particular procedure or technique is the way most other EMTs would do so under similar circumstances. The standards of care that apply range from being very regional (for example, system protocols that provide guidance while you are at work) to nationwide (CPR standards, for example). Duty to act: You are required to perform your scope of practice to the level of the standard of care. This includes nonclinical aspects of the job, such as keeping a vehicle stocked, responding to an emergency call, transferring the patient to receiving staff at a hospital, or allowing a patient to refuse medical care., Avoiding negligence: If you breach your duty to act (see the preceding section), the patient may be able to file a lawsuit against you for negligence. To prove negligence, the patient has to be able to prove four things happened: You had a duty to act. There was a breach of that duty. There was an injury. The injury (physical, emotional, or both) was a result of the breach, or causation. All four elements must be proven in order for a suit to be successful., Getting the proper consent: You must establish the right to render care to the patient. This can be expressed consent, where the patient is able to indicate he wants your help. Or, it can be implied consent, when the patient is unconscious or otherwise incapacitated and it would be reasonable to ask for help. Only adults are capable of providing consent; children must be judged by the legal system to be emancipated minors in order to give consent., Understanding slander and libel: Speaking poorly about someone\u2019s character is known as slander. Writing poorly about someone\u2019s character is libel. For example, stating that a patient is \u201cjust drunk\u201d to a receiving nurse could be seen as a slanderous statement; documenting that the patient was \u201cdrunk\u201d or \u201cintoxicated\u201d can be seen as a libelous statement., Dealing with refusals of care and/or transport: An adult, under most circumstances, has the right to refuse your treatment and transport. You have to determine whether the person is capable of making such a decision. This includes determining whether the patient is alert, oriented, and understands the consequences of not accepting your care. You also have to assess whether any existing circumstances are impairing the patient\u2019s judgment, such as intoxication or a language barrier., Maintaining confidentiality: You are required to protect the patient\u2019s right to privacy in matters related to treatment and personal information. Federal law known as the Health Insurance Portability and Accountability Act (HIPAA) sets strict guidelines (and financial penalties!) regarding who you can share information with, which is usually limited to other medical professionals directly involved with the patient\u2019s care., Respecting advanced directives: Patients with terminal illnesses may legally request that no \u201cheroic\u201d or aggressive interventions be done if they die, or are dying from, that illness. The request is in written form and is generically known as a \u201cdo not resuscitate\u201d (DNR) directive., Steering clear of abandonment: Once you have established contact with your patient, you are obligated to stay with the patient until you release the care to an equal or higher medical authority. This person may be a paramedic who intercepts your unit or the nurse at an emergency department. Releasing a patient includes making a verbal report with the person who is receiving your patient and following up with a written report., Complying with mandatory reporting: In most states, there are laws that protect the health and welfare of children and so-called dependent adults, usually older patients and adults who are unable to make independent decisions. As an EMT, you\u2019re required to report suspected cases of abuse or neglect to specific departments, such as child or adult protective services., Coping with crime scenes: EMTs often respond to situations where a violent crime has been committed, such as physical assaults, shootings, or stabbings. Your priority is to treat the patient to the best of your abilities; while doing so, try to avoid contaminating scene evidence as much as you can., Documenting your cases: You are required to document what you observed about the patient and the environment, the findings that you assessed, the care you provided, and any changes in the patient\u2019s condition while in your care.",
        "Staying Healthy, Sane, and Safe": "Introduction: EMS is a physically demanding profession and has more than its share of dangerous work environments. It requires you to stay in good physical shape, keep a positive attitude, and be aware of the dangers that surround you while you\u2019re working., Being fit for the job: Lifting and moving patients can be difficult. Unconscious patients are literally dead weight that is difficult to control. Injured patients may need to be immobilized to a long backboard and carried down several flights of stairs., Handling the stress of the profession: EMS is a rewarding career. You have the honor of being present at the beginning of a new life as well as the end of a life. In between, you experience situations that most people never will. These conditions can bring on emotional stress that can be difficult to acknowledge and deal with., Knowing that safety is job one: As an EMT, you enter people\u2019s homes or workplaces, work in the middle of a roadway, or handle patients affected by a hazardous materials incident or major catastrophic event. You must maintain a constant state of alertness to safety hazards that exist in the environment.",
        "Communicating Well with Others During an Emergency": "Introduction: With all the discussion about safety, stress, and physical activity on an emergency scene, things may seem to be a bit out of control \u2014 which they can be! EMS providers are trained to bring control to chaos., Working on a team: Working completely alone as an EMT is extremely rare. Even in those circumstances, you\u2019ll likely be interacting with other healthcare and public safety providers at some point during a call., Interacting with others on the scene: EMS providers deal with human beings. You need to be able to listen attentively and communicate clearly. These skills come naturally to some, while others need to work at them.",
        "Understanding Emergency Vehicle Operations": "Introduction: You may respond to emergency medical incidents in a variety of vehicles, such as ambulances, fire engines, or even your private vehicle if you volunteer as an EMT., Maintaining equipment levels and vehicle readiness: Professional emergency vehicles must be stocked with the appropriate type and levels of equipment., Driving an ambulance: Perhaps the most dangerous part of an emergency incident is responding in the emergency mode., Using air medical services: Many, if not most, EMS systems have access to an air medical service to transport critically ill or injured patients over distances that would take significantly longer to travel by ground ambulance., Performing light rescue: Depending on where you work, you may be required to know how to perform simple rescue operations.",
        "Managing Large Incidents": "Introduction: Incidents that overwhelm local, immediately available resources are commonly called mass casualty incidents (MCI)., Triage: Triage is a French word that means \u201cto sort.\u201d In mass casualty incidents, triage is used to decide which patient receives the most immediate care, who can wait to be treated, and, sadly, who is beyond help., Hazardous incidents: The modern world is filled with a near-infinite number of chemicals that are used to make our lives better, safer, and more convenient."
    },
    {
        "Introduction": "For the last 20 years \u2013 from the early days of urban search and rescue teams and the World Trade Center bombing in the early 1990s to the barrage of natural and man-made disasters we witness every year across an ever-shrinking globe \u2013 the field of professional emergency management has developed into a science as our knowledge of mass casualty incidents (MCIs) has grown. However, while round-table discussions of far-fetched \u201cwhat-ifs\u201d have evolved into best practices and doctoral dissertations, the fundamentals of disaster preparedness and response are essentially the same. Knowledge of these fundamentals is necessary for every EMS provider. A medical director who can proactively apply these fundamentals is crucial for effective disaster and MCI response and optimal patient care.",
        "Investment": "Early public safety strategies to bolster surge capacity and mass care centered on the development of extensive stockpiles of equipment. Since 9/11, excessive money has been spent on durable medical equipment, pharmaceuticals, and specialized vehicles and communications systems. Further money has been invested in tabletop exercises and training initiatives designed to support narrow policies and procedures specific to disaster events. This strategy of investing in insular disaster training has been echoed by EMS, hospitals, and other health care entities. Recent studies question the cost-effectiveness of this approach. Many leading health care coalitions now approach disaster management by investing in everyday infrastructure, personnel, protocols, and processes enhancing the health care system's all-hazards capacity. This approach follows the philosophy that a robust health care system with integrated everyday capabilities will be able to respond more effectively to disaster and surge events.",
        "Command": "Whether during MCI events or day-to-day operations, command can be used to organize individual assets and personnel or, on a larger scale, to manage a host of participating organizations and assets at the local, state, and federal levels. The National Incident Management System (NIMS) provides a consistent nationwide approach for federal, state, tribal and local government, the private sector, and non-governmental organizations to work effectively and efficiently together to prepare for, respond to, and recover from domestic incidents regardless of cause, size, or complexity. To provide for interoperability and compatibility among federal, state, tribal, and local capabilities, the NIMS includes a core set of concepts, principles, and terminology. HSPD-5 identifies these as the incident command system; multiagency coordination systems; unified command; training; identification, and management of resources (including systems for classifying types of resources); qualifications and certifications; and the collection, tracking, and reporting of incident information and incident resources. Command of individual resources for an event is best performed under the incident command system (ICS) paradigm as outlined by the NIMS. The ICS provides well-defined roles, responsibilities, and terminologies as well as a framework for response and recovery. Public safety personnel are well versed in the ICS. The medical director typically will not have a direct command or patient care function, but rather an advisory or consultant function as provided for by the ICS. The medical surge capacity and capability (MSCC) management system provides for coordination and command of large organizations and interoperability between health care organizations and local, state, and federal entities. It focuses on health care response and recovery, integrating public and private acute care providers into a larger architecture in order to support Emergency Support Functions (ESF) 4 and 8 of the National Response Plan (NRP). The MSCC management system describes an interdisciplinary coordination system that emphasizes responsibility rather than authority. Each medical asset is responsible for managing its own operations, as well as integrating with other entities in a tiered framework. This allows assets to coordinate more effectively than the individual, ad hoc relationships that otherwise occur during a disaster.",
        "Role": "In everyday operation of an EMS system, the medical director is responsible for such things as protocol development, equipment selection, and education. He or she also serves as a liaison and advocate for EMS within the rest of the health care system. The medical director is more akin to a chief executive or \u201cbig picture\u201d thinker than an individual provider or scene commander. The same holds true during MCIs or disasters. The medical director is most effective through the entire disaster cycle \u2013 mitigation, preparedness, response, and recovery \u2013 by fulfilling his or her day-to-day responsibilities well before the advent of a disaster. During the event itself, direct patient care and on-scene triage are best left to the street-level providers who train in those tasks every day. As described above, the medical director serves in the ICS command structure as a senior advisor and liaison between the scene commanders, health care facilities, and other agencies to facilitate the best care for the greatest number of people. In summary, the principles that should guide a medical director's approach to disaster management are investment in everyday infrastructure; integration into both individual asset command structure as well as the interagency structure; and adapting to a less operational and more advisory role. The remainder of this chapter focuses on applying these principles during the four phases of the disaster cycle.",
        "Mitigation and preparedness": "Mitigation and preparedness strategies are daily activities that health care facilities and personnel undertake prior to a disaster event that enable an effective response to and recovery from the event. Mitigation activities involve reducing the potential for a disaster to occur or reducing the potential impact of a disaster. Seat belt and other highway safety laws are examples of mitigating activities. Preparedness refers to activities that enhance an organization's capabilities to respond and recover if a disaster does occur. Examples include mass casualty training drills in hospitals. Both mitigation and preparedness involve similar principles. Historical events demonstrate that during true disasters, fundamentals such as communications systems, resource distribution, and organizational structure are common points of failure. Effective mitigation and preparedness strategies should focus on reinforcing these factors through enhancing these daily capabilities before the occurrence of an MCI. The EMS medical director is responsible for his or her agency's mitigation and preparedness strategy, which should focus on the following three areas. Identifying key resources, personnel, and agencies and establishing collaborative relationships between them. Developing policies and protocols that address daily operations as well as surge-level operations and training and evaluating personnel on these protocols. Implementing a data and communication infrastructure that addresses daily prehospital needs and is scalable during an MCI. Effectively implementing these areas in daily operations will affect multiple downstream components such as mutual aid agreements, hospital integration, patient distribution, and on-scene command, and will help prevent overwhelming on-scene and hospital resources during an MCI.",
        "Key personnel and resources": "Poor coordination between the multiple agencies affected by an MCI, as well as difficulties presented by resource sharing, lead to breakdowns in MCI response. As part of their mitigation and preparedness strategy, EMS medical directors should build collaborative and supportive relationships among the agencies that will be responding to or affected by MCIs. Under the auspices of patient care, the medical director is an ideal bridge-building envoy between agencies that rarely interact or sometimes compete in daily operations. In his or her role as a regional preparedness advisor, the medical director should identify and collaborate with every component of the patient care chain such as: hospitals and health care facilities, public health agencies, public safety agencies, fire departments, law enforcement, homeland security, animal control, regional health care networks, Veterans Administration hospitals, health care coalitions. Similarly, the medical director should identify local or regional resources and infrastructure that are operationally available on a day-to-day basis and that can be appropriately redistributed in the case of a disaster. He or she should collaborate with agencies responsible for these assets during daily operations so that the relationship can be called on in the case of a disaster. Mass casualty incident planning should also account for appropriate distribution of these resources. Classically, distribution has been defined either as a \u201cpush\u201d or a \u201cpull\u201d model. In the push model, resources are distributed to the community at large, as in the case of using postal workers to distribute vaccines during a biological attack. In the pull model, resources are centralized and patients are pulled toward the central infrastructure, as in the centralized makeshift facilities that saw the majority of patients during the Joplin tornado. We advocate a hybrid approach, using components of each model to address community-specific needs, based on the relationships established with various agencies.",
        "Policy, protocol, and training development": "Establishing protocols for response activities during an MCI is key to preparing an organization to respond effectively and uniformly during an event. Protocols establish key criteria, define roles, and establish best practices that can often be forgotten in the heat of the moment. Protocols should account for varying levels of training, amounts of available resources, and interoperability of accountable agencies. A well-designed MCI protocol should reinforce a first responder's ability to recognize and escalate an MCI, establish clear roles within the command structure, and appropriately allocate transportation resources (often resources are consumed immediately by lower-acuity patients, and thus transport of the sickest patients is delayed). Protocols and policies should address the following. Quantifying and defining an MCI (even small MCIs can overwhelm a busy prehospital service or an already overwhelmed emergency department). Dispatch of appropriate numbers of transport, communication, and supply assets. An emphasis on the role of triage and transportation officers in the ICS. Triage systems. On-scene transport decision tools that appropriately utilize BLS and ALS providers. Even patient distribution among local health care resources in order to not overwhelm a single system. Patient tracking. Continuity of operations for everyday 9-1-1 services. Mutual aid and interagency response. Medical directors should also consider and account for rare, but extremely disruptive events such as chemical, nuclear, or biological attacks, mass fatalities, or extreme weather events. Once protocols are in place, the medical director is responsible for awareness and education of the protocol for all key providers, not only various first responder agencies and personnel responsible for implementing the protocols but other stakeholders as well, such as hospitals, law enforcement, and public health agencies. As with any new protocol, buy-in by the stakeholders is key and the education component also serves a relationship-building role. Finally, the medical director must provide for training and drilling for first responders on the implementation of MCI protocols. Because of the infrequency of real-life events, we recommend using the daily multipatient events that EMS responds to as a substitute for large-scale events. Events such as multivehicle collisions requiring transport of multiple patients will likely not escalate to the regional, state, or national level, but they can allow street-level providers to prepare for larger events and to practice the protocols instituted by the medical director. This model trains providers on resource and partnership utilization, communication, ICS, and systems-wide decision making without placing stress on the system itself. Evidence-based improvement of MCI protocols requires periodic and formal evaluation of protocols and personnel responsible for their implementation. Various models for evaluation include computer simulation, tabletop exercises, and large-scale drilling. Studies show a trend toward increased robustness through large-scale drilling. An example of comprehensive drilling can be observed in airport-based EMS triennial response drills formally mandated by FAA part 139. Objectives learned from this type of drilling can be applied even at the small service level: preinspection review of policies and protocols, set calendar drill dates, outside review of policies and protocols, geographic response area movement inspection, equipment inspection, live drilling with timing and patient movement tracking, and postinspection, which highlights areas for improvement.",
        "Intelligence and communication infrastructure": "Communication and information sharing during an MCI rely on technology as well as on human beings interacting during a high-pressured crisis environment. Review of historic disaster events demonstrates the importance of communication as well as the likelihood of communication technology failure. For example, high-volume public inquiry can quickly overwhelm cellular systems during a highly publicized event. An MCI plan should account for the failure of cellular systems, wireless electronic medical record systems, and patient tracking systems and should prepare for 800 mHz and VHF radios and even paper and pencil back-ups as necessary. Similarly, human communication can be a weak point during an MCI, as response will typically involve multiple agencies that during routine operations will have little interoperability, occasionally competing interests, and often incompatible infrastructure. Actionable information and clear, rapid communication beginning with dispatch and ending with the after-action review are vital to the success of an MCI response and recovery. The medical director plays an important role in preparation and mitigation of communication systems during an MCI. As discussed previously, the medical director can serve as a liaison and envoy to other EMS agencies, health care leaders, state agencies, and emergency departments in order to advocate for patient care. This role can help to unify technology and policy across disparate venues. The medical director should facilitate a clear ability to collaborate and communicate bed availability, resource need and allocation, and patient flow. He or she should also serve as a consultant to translate the issues of staffing, diversion factors, surge capacity, and daily hospital operations between entities. So while the infrastructure is composed of hardware and software technologies, it is the collaborative implementation of these technologies, open dialogue between partners, and negotiated policies that make that infrastructure successful. These fundamental mitigation strategies of partnering, protocols, and infrastructure are the building blocks of effective MCI response.",
        "Response": "Large disasters can be daunting experiences for first responders and on-scene medical personnel. Even smaller scale MCIs such as multiple vehicle collisions, apartment fires, or weather-related events, which are the daily purview of EMS systems, can be highly unpredictable and quickly overwhelm response capacity. MCIs, by definition, produce a demand for medical care that may exceed the capacity of local or regional health care systems to effectively respond. It is vital that EMS systems rely on the protocols that the medical director has instituted for MCI response and on which providers have been trained and drilled. The protocols must provide for early recognition of an MCI so that the system may be ramping up \u2013 including resource availability, emergency department decompression, and mutual aid agreements \u2013 while on-scene providers are in the very first stages of response. This requires the ability of first responders to escalate an incident through dispatch, which will then trigger the escalation of further resources. This type of coordination requires clear and effective flow of information between the scene and downstream resources, which should be provided for by the formal protocols as well as the time invested in relationship building by the medical director. This systems-based approach is recognized as a critical component of catastrophic disaster preparedness and should be built in to the MCI protocols.",
        "The role of the medical director in MCI response": "The average physician medical director receives little formal training on guiding an emergency medical service. While medical directors may have a clearer understanding of developing protocols or integrating with stakeholder agencies, they will have variable experience with the incident command structure or actual MCI responses; most of their training will be on the job. This can leave the medical director uncertain of his or her role during an MCI response, which could lead to becoming more of an on-scene liability than an asset. It is important to realize that it is not the physician\u2019s role to assume on-scene command, which may be difficult for physicians who are used to being regarded as the ultimate authority in the clinical setting. This role requires specific training and knowledge that is better suited to fire and EMS commanders who practice this role on a daily basis. Nor should the medical director assume the role of primary medical provider, which should be assumed by trained first responders (including EMS physicians under certain circumstances). Ultimately, the medical director should fill an advisory role to the incident commander in the ICS. He or she should be available to consult on certain features of response, such as the most appropriate transportation destinations and resource allocation. For example, the medical director should know which hospitals would be able to provide pediatric trauma surgery or which hospitals may already be facing surge scenarios and be able to advise the transportation officer accordingly. The medical director should also be able to facilitate communication and the flow of information necessary between the various entities involved in the response based on his or her systems knowledge. This may include information sharing with medical directors from neighboring EMS systems, hospitals, alternative care facilities, or municipal leadership. Finally, as the senior medical person on scene, the medical director may be called on by the incident commander or the public information officer to address media questions about patient status or incident response. Because of the sensitive nature of the information \u2013 including protected patient data, the potential for law enforcement implications, and family notification issues \u2013 it is important that the medical director consult with public safety leadership and follow any guidelines set out by the incident commander or the public information officer.",
        "Incident command structure": "As an advisor, the medical director will likely be most heavily involved with the medical branch of ICS. It is in the three major components of the medical branch \u2013 triage, treatment, and transport \u2013 where a physician medical director\u2019s knowledge will have the potential for the most benefit.",
        "Triage": "Triage is a foundational function of MCI care. The primary goal is to quickly and consistently assess and catalogue patients. This should be a dynamic process that should be repeated as often as necessary until definitive medical care can be established. The process of triaging can also contribute to situational intelligence and downstream decision making. As part of the triaging process, patient staging areas should be established, including patient collection points and temporary treatment areas. There are many different triage systems used nationally and internationally. There is no clear evidence to support the efficacy of any one system over the others. However, studies demonstrate that many systems, especially START, tend to overtriage patients in real-life scenarios. Additionally, many triage systems do not take into consideration non-traumatic conditions such as myocardial infarction or stroke when triaging patients. Medical directors should be aware of the variations in the systems when selecting the appropriate system for their service and provide appropriate training. Mass casualty incident protocols should clearly define who is responsible for performing on-scene triage. The simplicity of all the systems listed above allows them to be taught to every level of prehospital provider. If taught effectively and followed by regular training, the lowest-level provider can perform this necessary assessment even in a large disaster. By allowing lower-level providers (EMTs) to perform triage, the higher-trained resources (paramedics) are free to handle the more complicated tasks of treatment and transport.",
        "Treatment": "Once triage is established and under way, the focus shifts to the on-scene treatment of patients. While the ultimate goal is to ensure that patients are transported to definitive places of care, on-scene initiation of care is necessary for both critical and non-critical patients while awaiting transportation. Recent MCIs such as the Boston Marathon, the Minneapolis Bridge collapse, and the Indiana State Fair stage collapse have demonstrated the need for the early initiation of advanced trauma care. ALS providers can perform much of the necessary primary treatment. If non-transporting ALS resources \u2013 such as paramedics on fire apparatus \u2013 are available, they should be directed towards treatment areas, thus freeing up the transport ALS assets to perform critical transfers. The medical director should be used for advanced medical procedures and guidance for treatment questions.",
        "Transport": "The transport section of the medical branch is one of the most important. It is not only necessary to transport patients quickly to appropriate locations, it is also important to deliver patients in a way that has the smallest effect on the overall health care system. For example, even in a small MCI, the transportation of just a few critical patients who would require surgery can overwhelm a single trauma center. When possible, the transport officer should attempt to divide patients between multiple trauma centers. Additionally, non-critical patients or patients with non-traumatic complaints should be directed to alternative sites (Level II or Level III trauma centers) in an effort to reserve the higher-level centers for the most critical patients. We anticipate that better distribution of patients will have a positive effect on patient morbidity and mortality. This distribution of patients requires adequate planning and coordination to avoid the easy default for an incident commander to send all patients to the closest hospital or the area\u2019s only Level I trauma facility. A key step in the preparedness portion of MCI transport is determining and codifying how hospital capacity and general preparedness information is gathered and pushed in real time up to incident command (and specifically the transportation officer). The communication response strategy should also account for a continuous feedback loop between the hospitals and EMS. Mechanisms should be in place to facilitate rapid updates between the hospital and pre-hospital environments that create an accurate common operating picture for decision makers both on the scene and in the emergency department. The specifics of how this is accomplished may vary depending on the specifics of the system, but they should be clearly spelled out in the MCI protocol. The medical director is responsible for training EMS and fire on this aspect of the protocol in order to avoid the negative downstream effect that patient surge can have on the local, regional, and national health care system.",
        "Resource escalation": "Mass casualty incidents often cause a large strain on available resources of the responding agencies. The most effective strategy for addressing resource shortages during a disaster response is bolstering everyday activities and forming collaborative partnerships with various agencies, as described previously. However, when need exceeds resources during a response, the medical director should serve as a senior medical advisor for the incident commander to help determine the need for additional personnel (BLS or ALS providers) or goods (medical supplies). The request for additional resources should be escalated through the ICS structure and if recognized early can be relatively seamless. When the need for resources and the ability to respond exceed the ability of a local system, other agencies may be called on for help. Mutual aid and the relationships it requires are an important part of the preparation and planning phase. Depending on the scope of the MCI, mutual aid may be called on to provide additional scene resources (for example, transporting units from a neighboring community) or to help maintain appropriate EMS services to the area surrounding the incident as local resources will be tied up with the MCI response. Supporting agencies can assume either routine emergency services in conjunction with the primary EMS agency or they can directly support the MCI, though the former is preferred as incorporating outside agencies into an already chaotic environment can prove daunting. The physician medical director should facilitate these agreements and advise fire and EMS leadership and neighboring medical directors.",
        "Recovery": "The recovery phase marks the transition period between a disaster event, including its immediate aftermath, and the return to normal operations. This is often the most protracted and challenging phase and is marked by financial and reimbursement issues, evolving interagency dynamics, medicolegal entanglements, and, maybe most importantly, discovery and learning of best practices. The health care system as a whole will struggle with different recovery issues than the medical director of an EMS system. Health care facilities must plan for long-term sustainability following an emergency event. This process might include mutual aid and assistance agreements with other agencies and jurisdictions, state and federal emergency waivers, and processes to maintain the revenue cycle during a disaster. Revenue and financial recuperation are particularly important in ensuring the availability of health care after an event. Given the scope of FEMA public assistance grants, reimbursement through federal health care programs such as Medicare and Medicaid is critical to a hospital's financial viability. The physician EMS medical director can play a role in assisting these efforts, but he or she will be required to play a fundamental role in a few key areas transitioning into the recovery phase and throughout this final phase of disaster management. These include patient tracking and reunification, mental health of the response team, and after-action review.",
        "Patient tracking and family reunification": "Early recovery efforts begin with comprehensive patient tracking and support of family reunification efforts. Patient tracking is within the purview of the medical director, and he or she should account for robust tracking mechanisms in the MCI protocol. It is necessary in the protocol to account for systems failure and to build in redundant tracking systems. The medical director should also work with local and national organizations \u2013 again with relationships built during the mitigation and preparedness phases \u2013 in order to assist in family reunification. There are a number of websites and apps that are useful for family reunification during a disaster, such as Google Person Finder, ReUnite, TriagePic, and Safe and Well. This is the final touch on comprehensive patient care for victims and families from the perspective of EMS agencies.",
        "Mental health": "It is well known that first responders suffer high rates of mental health issues and posttraumatic stress after responding to disasters. Many public safety and emergency medicine personnel cope poorly with everyday work-related stress, let alone extreme pressure situations such as disasters. EMS medical directors should be highly sensitive to the mental health needs of first responders and should consider immediately transitioning involved providers to employee assistance and crisis intervention resources. Additional mental health resources can be found at supporting hospitals, public safety agencies, state agencies, and labor unions. Medical directors can work with these mental health providers to identify at-risk responders who may need additional time and counseling before returning to work. Providers should also be trained in psychological first aid, not only in terms of immediate individual support but also workforce resiliency and strategies to reduce fatigue and proactively manage stress. It may be beneficial for responders\u2019 mental health to have a responders-only debriefing session to discuss the stresses and issues confronted during a large-scale MCI response. These sessions should be non-mandatory, closed to the public, and blame-free, supportive environments.",
        "After-action review": "The after-action review process is a critical component of MCI recovery. Even the most robust mitigation and preparation strategies cannot account for every obstacle, complication, or challenge that may be faced during an MCI. Decisions made during an event do not always align with those mapped out in the protocols, whether due to failed training or to recognition of the need for real-time modification. It is necessary to review in detail the events of each incident in order to learn from mistakes, guide future training, and adjust protocols as necessary. A well-run after-action review should answer critical questions such as \u201cWhat went right? What went wrong? Were standard operating procedures and protocols followed? If not, why not? What actually happened? What difficulties were unforeseen?\u201d As an example, the after-action review of the 1990 Avianca plane crash in New York identified that there were significant issues in pediatric triage and facility destinations. Depending on the nature of the MCI, it should be determined what information is needed to complete the review, who should be involved, who should lead it, who should attend, and how the review will be utilized. The leader should have the authority to use the results to improve future responses, but should also have the political sensitivity to discuss deficits in operations that might include multiple high-level agencies. In many cases the most appropriate person to lead the review is the medical director. The audience for the review should include all response personnel including fire, EMS, dispatch, mutual aid, and hospital personnel. Public safety officials, local government, and other public or private entities may also be involved. When initiating the after-action review process, the medical director should begin with fact finding and information gathering. He or she should gather and review the following data. All 9-1-1 and radio communications. The initial ICS structure. Changes to the ICS structure throughout the event. Patient contacts and times. Apparatus response. Patient transport and distribution. Adequacy of supplies. Hospital communications. The leader of the review process should also gather feedback from all involved entities, especially first responders and receiving hospitals. This feedback is crucial to recognizing different perspectives on the event as well as letting all parties air any issues they might have with the process. The actual review should happen quickly after an event so that the incident is fresh, and it should follow a defined agenda, including an introduction, review of the event, and identification of challenges, strengths, and future steps. All advanced work and findings should be summarized in a written report, which should be distributed to key stakeholders and used to refine future protocols. The key outcome of the review should be an actionable improvement plan. Whether or not the medical director is the leader of the review, he or she has a unique role as liaison between the hospitals, prehospital providers, and other involved agencies. The medical director should interpret or translate questions and concerns to help facilitate an understanding by all parties of the factors, decisions, issues, failures, and criticism that can arise in the review. Most importantly, though, the physician director should be the patient advocate and always put the patients\u2019 needs at the forefront when discussing best practices and protocols around triage, treatment, and transport to definitive care.",
        "Special considerations - Health care coalitions": "Large metropolitan areas are increasingly using health care coalitions as a critical piece of MCI infrastructure for planning and response. Coalitions serve to create a round table where all health care partners that would be affected by a mass casualty event can discuss, explore, and collaborate across a variety of issues. These coalitions make the integration between prehospital providers, public safety, public health, and individual hospitals seamless. Traditional health care emergency management strategy has focused on increasing the capacity of an individual hospital or program with the expectation of additional assistance from governmental sources during times of crisis. However, many resources lie primarily in the private sector. Moreover, the resilience of a single institution is necessary but not sufficient to effectively manage surge capacity, as it ignores the interconnectivity of the entire health care system. Catastrophic emergencies such as Hurricane Katrina and mass casualty events such as the shooting at Sandy Hook Elementary School demonstrate that an effective emergency response must be coordinated between the private and public sectors. Using a coordinated approach, established by health care coalitions well before an actual disaster, ensures a more robust initial response and allows for the provision of ongoing care during recovery; a coordinated approach shares the burden of surge during an MCI. Coalitions facilitate this coordination by establishing meaningful and supportive partnerships with hospitals and other health care providers, public safety entities, government agencies, and non-governmental relief organizations, and ensure an open line of communication with administrators and executives across these organizations. Generally, a health care coalition exists to bolster the daily operations of the entire health care system to best respond in times of crisis. It may affect this mission in any number of ways, including identification of alternative care sites, managing pharmaceutical and durable medical supply caches, and continuity of operations planning for various institutions. Operationally, some health care coalitions are responsible for maintaining a medical multiagency coordination center (MedMACC) as first described in Medical Surge Capacity Handbook. The MedMACC can serve as a real-time health care intelligence organization and as a conduit of necessary information between scene and hospital providers during an event. MedMACCs have also been used to help manage the distribution of patients from the scene, coordinate resources, and assist public health agencies to provide care to vulnerable populations. Whatever the role, the EMS medical director should be aware of the capabilities of local health care coalitions and work to form strong collaborating partnerships.",
        "Special considerations - Emerging technologies": "With nearly 75% of US adults using some form of social media (Facebook, Twitter, Instagram, Flickr, etc.), an EMS medical director needs to understand the effect that social media and related internet-based technologies can have on disaster mitigation, preparedness, response, and recovery. Because of the popularity of social media, the medical director should expect that in times of disaster, electronic media will be a primary mode that the public will search for information, to request aid, and find family and friends. This can especially be true in times of large-scale disasters when traditional systems such as 9-1-1 are overwhelmed. One in five survivors will contact emergency responders directly via social media, web sites, or email. According to a 2010 Red Cross Survey, if 9-1-1 call centers were busy, more than half of US adults would attempt to contact emergency services using digital media or SMS (texting). The Red Cross survey noted that most citizens would expect help to arrive within an hour of requesting assistance via digital media. During the hunt for the Boston Marathon bombers, the Boston Police Department\u2019s Twitter following increased seven-fold over the 5-day manhunt. This highlights the need for the medical director to have a robust plan to use social media strategies during daily operations so that in times of crisis, the public will be more likely to engage in dialogue with EMS services. The same technologies that the public use in times of crisis to request aid and share information can also be used by EMS and health care agencies to gather information to aid in preparation and response. This kind of health care intelligence can be divided into two phases. The first phase might be thought of as pre-event monitoring, which may include gathering information as diverse as weather patterns, terrorism trends, or disease and symptom trends, similar to epidemiological practices. The second phase is real-time intelligence gathering during an MCI event. Data mining from text \u2013 for example, searching for \u201churt,\u201d \u201ctrapped,\u201d \u201cinjured\u201d or using hashtags specific to an event from Twitter feeds \u2013 can assist in locating events or finding victims. Photos and videos from the public on the scene can provide information including crowd density, weather status, security threats, and larger environmental hazards. This type of scene information can be used to estimate hospital surge, locate victims, and estimate severity of illness, which can assist with scene staging, evacuation, and patient distribution. In the response to Hurricane Sandy, this type of health care intelligence resulted in at least 88 changes in ground operations. It is important to note that as with any technology during an MCI, social media will have failures and shortcomings. Any internet-based technology is prone to malicious attacks, for example, and scalability during times of crisis has not been formally tested. Most importantly, the quality of information has to be vetted. Online news sources may generally be thought of as reliable, but Twitter feeds and other public-driven sources rely on self-policing and can rapidly spread misinformation and rumor. The EMS medical director should account for the pervasiveness of social media in planning and response. During times of crisis, EMS and health care agencies should have a 24/7 social media presence for information distribution, and this should most likely fall under the purview of the public information officer. Ongoing intelligence monitoring should also be an integral part of mitigation and planning. Intelligence during a crisis response is more complicated as it requires real-time sharing of information between a chaotic scene, public health agencies, and hospitals. We recognize that most EMS systems likely will not have the infrastructure to support such a robust health care intelligence strategy. The EMS medical director should consider partnering with third-party resources such as health care coalitions, the Red Cross, or the Department of Homeland Security in order to build these intelligence capabilities.",
        "Special considerations - Vulnerable populations": "Mass casualty incidents frequently involve vulnerable populations. Planning for MCI response must include specific consideration for these subgroups. A 2007 survey of EMS agencies nationwide demonstrated that only 13.3% reported having pediatric-specific MCI plans, and that fewer than half had specific plans for individuals with other special health care needs. Recent events, such as the shootings at Sandy Hook Elementary School and the tornadoes in Moore, Oklahoma, highlight the need for these specific considerations. For example, children require significantly different resources during a large-scale event as they may lack both the cognitive and physical abilities for self-extrication, protection, or care. Even the uninjured child will require adult supervision in this setting. Planning must include strategies for identification and reunification with caregivers as well as identification of a safe environment to cohort well or minimally injured children. Additionally, children are more susceptible to environmental and biological hazards. Their pediatric physiological response to injury also differs from that of adults, which can lead to mistriage. Selecting triage models appropriate for children, such as JumpSTART or SALT, is an important part of MCI planning and training. These issues are not limited to children, and efforts have been made in recent years to address gaps related to supporting vulnerable populations in the face of crisis. Medical directors should also account for residents who are dependent on technology, those who require dialysis, the elderly, and patients with access and functional needs when creating MCI protocols and plans.",
        "Conclusion": "Mass casualty incident response for EMS is a complex and dynamic process that requires input, leadership, and oversight from EMS medical directors. Often overlooked and contrived haphazardly, a thorough approach to response involves: mitigation strategies focused on relationships and infrastructure; preparedness initiatives around protocol, planning, and training; response processes that facilitate the rapid flow of patients, intelligence, and resources; focus on patient care and partnerships; and end with patients distributed to the most appropriate facilities; recovery strategies that are flexible, support the network of providers, and facilitate resilience for both the providers and the communities involved. It is imperative that EMS medical directors build on everyday operational practices, protocols, and partners as much as possible. The roles of \u201cenvoy\u201d and \u201cliaison\u201d must be strongly emphasized through all phases of MCI response in order to build a network of partners and resources that ultimately works to ensure successful and repeatable response. The focus of this chapter has largely been around the EMS medical director as a leader in preparation, partnership, and infrastructure development; however, the MCI response is a dynamic and fluid process guided by a wide variety of local protocols and resources. And while the role of the EMS medical director is largely advisory and preparatory, there is also a role for the EMS physician, as now defined, in direct patient management and recovery phase care during MCIs. A growing number of regional strategies call for the EMS physician to serve in a clinical role that takes advantage of his or her background and experience in prehospital care. What is important in these settings is both the prior designation of that physician to these specialty roles and the separation of that clinical role from the EMS medical director\u2019s role as a command liaison or advisor during an MCI. When both roles are needed, neither is generally served well by one EMS physician, yet both of these roles are best served by physicians with advanced training and familiarity with EMS and MCI response. Therefore, additional planning and thought should be invested in the various roles EMS physicians will play in order to prevent one physician from taking on either too many roles or too much purview. This a priori delineation of roles facilitates the optimal utilization of EMS physicians in both the clinical and advisory roles. Local protocol development and agency training exercises should incorporate these strategies well before any actual response."
    },
    {
        "Introduction": "Disasters are natural or man-made events which cause such an overwhelming loss of life, injury, destruction of property, or loss of infrastructure as to prevent a community's ability to respond without outside assistance. Emergency medical services are vital for disaster management, and the administrative and medical leadership of EMS should be actively involved in all of its phases: planning, mitigation, response, and recovery. While all disasters are local, a national framework for disaster management has been defined by the Federal Emergency Management Agency to coordinate federal assets and to assist local communities to develop disaster management strategies that are effective and allow for cross-jurisdictional communication. The national framework is risk based, referencing the findings of the Strategic National Risk Assessment, which identifies the greatest threats facing the nation's homeland security, in three categories. \u2022 Natural hazards. This category includes floods, earthquakes, hurricanes, wildfires, human pandemic outbreak, animal disease outbreak, volcanic eruption, and space weather (solar flares with electromagnetic disruption). \u2022 Technological/accidental hazards. This category includes biological food contamination, chemical substance spill or release, dam failure, and radiological substance release. \u2022 Adversarial/human-caused threats. This category includes aircraft as a weapon, armed assault, bioterrorism, chemical terrorism, cyber attack, explosive terrorism attack, nuclear terrorism attack, and radiological terrorism attack. The list of risks considered on a national level is not comprehensive yet it helped to identify core capability requirements and contributed to the development of the federal framework for disaster management. Local and regional jurisdictions will conduct assessments that will identify other threats and hazards (drought, heat wave, tornado, etc.) that are appropriate for their preparedness planning and will largely be served by the core capabilities required to respond to all hazards.",
        "Federal framework for disaster management": "The federal framework for disaster management is based on Presidential Policy Directive 8 (PPD-8). Presidential directives are a form of executive order issued by the President of the United States that address the policy of the executive branch in relation to matters of national security, and carry the full force and effect of the law. PPD-8 aimed to strengthen the security and resilience of the United States through systematic preparation for all hazards. It established that preparedness is a shared responsibility of all levels of government, the private and non-profit sector, and individuals. PPD-8 defined a National Preparedness Goal: \u201cA secure and resilient nation with the capabilities required across the whole community to prevent, protect against, mitigate, respond to and recover from the threats and hazards that pose the greatest risk.\u201d It established a National Response System, which outlines the approach, resources, and tools for achieving the goal. It also defined National Planning Frameworks which define how to best meet the needs of individuals, families, communities, and states in their ongoing efforts to prevent, protect, mitigate, respond to and recover from any disaster event. \u2022 Prevention \u2013 avoid, prevent, or stop imminent threats \u2022 Protection \u2013 secure the community against man-made or natural disaster \u2022 Mitigation \u2013 reduce loss of life and property by curtailing the impact of disaster \u2022 Response \u2013 save lives, protect property and the environment, and meet basic needs \u2022 Recovery \u2013 return the community to a state of normality after disaster The frameworks address how the whole community works toward achieving the National Preparedness Goal across the five defined mission areas. Among these, the National Response Framework (NRF) defines the doctrine by which the nation responds to any type of disaster or emergency. The term response is defined to include actions which \u201csave lives, protect property and the environment, stabilize communities, and meet basic human needs following an incident. This includes the execution of emergency response plans to support short-term recovery. The core capabilities for response defined by the NRF are as follows. \u2022 Planning. A systematic process which will engage all community partners in the development of strategies for disaster response \u2022 Public information and warning. Delivery of timely, credible, and actionable information relaying the nature of the threat, actions being taken, and available assistance \u2022 Operational coordination. Organize and maintain a unified command structure which involves all stakeholders \u2022 Critical transportation. Provide transportation to meet mission objectives including evacuation of people and animals, and delivery of vital goods \u2022 Environmental response/health and safety. Provide guidance and resources to address all hazards in support of the responder and community \u2022 Fatality management services. Provide for body recovery, victim identification, victim processing, and counseling for the bereaved \u2022 Infrastructure systems. Stabilize critical infrastructure functions \u2022 Mass care services. Provide hydration, feeding, and sheltering to those most in need \u2022 Mass search and rescue operations. Provide search and rescue resources with the goal of saving the greatest number in the shortest time \u2022 On-scene security and protection. Ensure a safe and secure environment through law enforcement and security measures \u2022 Operational communications. Ensure communications in support of security, situational awareness, and operations \u2022 Public and private services and resources. Ensure essential services such as emergency power, fuel support for responders, and access to community staples \u2022 Public health and medical services. Provide life-saving medical treatment via EMS; prevent injury and disease through public health and medical support \u2022 Situational assessment. Provide leaders with decision-relevant information The NRF also describes \u201cemergency support functions\u201d which serve as a means to organize response resources and capabilities. These are used by the federal government and many states, and have been adopted locally to build, sustain, and deliver the core response capabilities. Response operations involve many partners and stakeholders. The NRF is aligned with the National Incident Management System (NIMS), which defines the command and management structures that allow for scalable, multijurisdictional response to any type of disaster. The NIMS provides templates for the management of incidents, while the NRF provides the structure and mechanisms for incident management policy development. The NIMS is based on the principle that use of a common incident management framework will give response personnel a flexible but standardized system for incident response and disaster management. The NIMS has five major components. 1 Preparedness. Assessment, planning, procedures and protocols, training and exercises, licensure and certification, evaluation and revision. 2 Communications and information management. A standardized framework for communications that provides a common operating picture for all stakeholders. Communications should be interoperable, reliable, scalable, and portable. The system should be resilient and redundant. 3 Resource management. Personnel, equipment, and supply flow must be fluid and adaptable to the requirements of the incident. 4 Command and management. Efficient and effective management through flexible standardized incident command structures. 5 Ongoing management and maintenance \u2013 of the NIMS via the federal government. The incident command system (ICS), well recognized by emergency responders and adopted by federal, state, and local governments as well as the private sector for incident management, is a component of this system. The ICS is structured to facilitate activity in five functional areas: command, operations, planning, logistics, and finance/administration. The ICS organizational structure develops in a modular fashion based on the size and complexity of the incident as well as the specifics of the hazard. As the magnitude and complexity of the incident increase, the organization expands as functional responsibilities are delegated. The Federal Emergency Management Agency (FEMA) provides an independent study program through its Emergency Management Institute that allows those with emergency management responsibilities and the general public to obtain training and education through distance learning, free of charge. The training supports the mission areas identified by the National Preparedness Goal. Over 125 training courses are available. NIMS introductory courses include the following. \u2022 NIMS 100 \u2013 Introduction to Incident Command System. This course describes the history, features, principles, and organizational structure of the ICS. It also describes the relationship between the ICS and NIMS. It serves as the foundation for higher-level ICS training. It is targeted at persons who are involved in emergency planning, response, or recovery efforts. \u2022 NIMS 200 \u2013 ICS for Single Resources and Initial Action Incidents. This course is designed to enable personnel to operate efficiently during an incident or event within the ICS. It is targeted at persons who are involved in emergency planning, response, or recovery efforts, particularly those who are likely to assume supervisory positions in the ICS. \u2022 NIMS 700 \u2013 National Incident Management System (NIMS): An Introduction. This course provides a basic description of the NIMS, the national framework that enables government, private, and non-governmental agencies to work together. \u2022 NIMS 800 \u2013 National Response Framework: An Introduction. This course provides an introduction to the NRF, specifically the national response doctrine, and the roles, responsibilities, and actions taken by the entities described.",
        "Catastrophic events": "All disasters are local. Police, fire, and EMS agencies, in concert with local government, non-governmental organizations (NGOs), and the private sector, manage most incidents locally. Incident command is established and emergency operations plans are implemented. The event\u2019s ICS is expanded as necessary to manage the event. If the incident commander determines the resources of the responding agencies are overwhelmed, he or she will communicate with the local emergency operations center (EOC) and emergency manager who may request aid from neighboring communities. If the local unified command, in concert with the local EOC, deems it necessary, state assistance will be requested, and when the state\u2019s resources are overwhelmed, a request can be made for federal assistance. The effectiveness of the local response depends not only on the preparedness of government public safety and public health officials, but on the integration of partners from the private sector, NGOs, and the preparedness of individuals.",
        "Non-governmental organizations": "Non-governmental organizations are organized corporate entities, separate from government and most often not for profit. These organizations are typically oriented to a particular purpose and type of activity, and can operate on a local, regional, national, or international basis. NGOs are important partners in disaster management. They assist the government and the whole community in planning for, response to, and recovery from disasters. They can make substantial contributions such as training and management of volunteers, provision of shelter, food, and water, transportation and logistics, identification of displaced survivors, interpreter services, and disability-related assistance. NGOs are a source of response core capabilities and as such should be included in community planning for disasters. Some NGOs are officially designated as support elements to national response capabilities. For example, the American Red Cross is chartered by Congress and has a legally defined and special relationship with the federal government for the provision of relief to survivors (ESF 6) and to help citizens prepare for and respond to emergencies. The National Voluntary Organizations Active in Disaster (VOAD) is a member organization composed of 55 state and territory VOADS and other NGOs committed to exchange of knowledge and resources in planning for, response to, and recovery from disasters. It is a combination of faith-based, community-based, and other non-profit NGOs representing thousands of professional staff and volunteers oriented to whole-community collaborative relationships and practices throughout the disaster cycle.",
        "Medical Reserve Corps": "The Medical Reserve Corps (MRC) is a national network of local groups of volunteers that include medical and public health professionals and others who are identified, screened, trained, and organized to improve the preparedness and response capabilities of their local jurisdictions by supporting routine public health activities and augmenting preparedness and response efforts. Activities of the local groups include training for emergencies, assisting to improve public health in the community, and participating in emergency response events. A local MRC unit coordinator leads the unit. MRCs work closely with the local health department, emergency management agency, hospitals, and other partner organizations. The MRC is a Citizen Corps partner program, federally funded to help build capacity for first responders through the use of volunteers. The Department of Health and Human Services administers the MRC, specifically the Office of the US Surgeon General, which serves as the clearing house for information and best practices for MRC units nationwide.",
        "The Community Emergency Response Team ": "The Community Emergency Response Team (CERT) program prepares people for disasters through education about the hazards that may affect their community, and trains them in basic disaster response skills. Through didactic and practical exercises, CERT members learn about fire safety, light search and rescue, team organization, and disaster medical operations, which allows them to assist others following an event when professional responders are not yet on scene. CERT members take a more active role in emergency preparedness projects in their community. CERT is another Citizen Corps partner program, and is administered by the Federal Emergency Management Agency.",
        "State response and assistance": "State governments support local efforts to respond by using in-state resources as coordinated by the governor, the state emergency management agency, department of public health, and others. The governor may activate elements of the National Guard with expertise in emergency medical response, communications, logistics, search and rescue, or chemical, biological, radiological, nuclear, and high yield explosives (CBRNE) incidents. Volunteers may be solicited from established registries. The Emergency System for Advanced Registration of Volunteer Health Professionals (ESAR-VHP) is a national network of state-based registries established to standardize volunteer registration programs and verify health professionals' licenses and credentials in advance of a disaster. Established by Congress in 2002, The ESAR-VHP is a state-managed health volunteer registration program administered by the Department of Health and Human Services, specifically the Assistant Secretary for Preparedness and Response (ASPR), which develops guidelines, policy, and requirements for the states to use in the development and implementation of their programs. The personal information collected is maintained and used in a manner consistent with all federal, state, and local laws governing security and confidentiality. State law and regulation guide workmen's compensation and liability coverage for registrants who actively volunteer. When the state's resources are strained, the governor may request assistance through the Emergency Management Assistance Compact (EMAC), which functions as a mutual aid agreement between states and territories. Congress ratified the compact in 1996, and states and territories may join by passing legislation that adopts the standard language of the Compact. All states are currently members of the EMAC. Upon a governor-declared state of emergency, the Compact allows states to send personnel, equipment, and supplies to help respond to disasters in other states. Through the legal foundation of the Compact, licenses, certificates, and permits are recognized as valid in the requesting state. The agreement also manages liability and responsibilities of cost. Personnel who are deployed are protected under the workmen's compensation and liability provisions of the affected state. The affected state also bears the cost of reimbursement for services. Requests for assistance through the EMAC have grown substantially since its inception. In response to the World Trade Center bombing in 2001, only 26 emergency management personnel were requested through the EMAC, while an estimated 40,000 people responded to the attack. In 2005, the Gulf states requested a much greater variety of resources through the EMAC, including 46,503 National Guard personnel, 6,882 law enforcement responders, 2,825 fire and hazardous materials responders, and 9,719 other responders, many of whom were local government assets deployed directly to the affected areas. The deployment of these resources is coordinated with local, state, and federal authorities. ",
        "Federal response and assistance": "The governor of a state may request federal assistance when a disaster exceeds the ability of the state to manage with its available resources, or special capabilities held by the federal government are needed to manage the crisis. The federal government can respond to the request by providing funding or by directly providing resources and services in coordination with the local, state, tribal, or territorial jurisdiction in need. The federal response is provided in a manner that respects the sovereignty of the local jurisdiction and its responsibility to manage the consequences of the disaster. The Robert T. Stafford Disaster Relief and Emergency Assistance Act was signed into law on November 23, 1988. This law created the system in place today in which a presidential declaration of an emergency or major disaster triggers assistance from the federal government to the states. It affords two types of declaration: an Emergency Declaration and a Major Disaster Declaration. The Major Disaster Declaration affords access to a comprehensive range of resources for response and recovery, which exceeds those available through an Emergency Declaration, but unlike an Emergency Declaration, can only be issued in the wake of a disaster. The Emergency Declaration, while more limited in scope, can be issued in advance of a disaster, with the goal of mitigating the impact of the event or avoiding the catastrophe altogether. States will mobilize their resources and implement their emergency response plans in response to an incident. When the resources of the state are overwhelmed, the governor may then request federal resources after jointly assessing the affected areas with FEMA to determine the extent of damage and estimate the federal resources required for an effective response. The state typically must also guarantee its share of the cost. The governor's request for a Stafford Act Declaration is addressed to the President, and considered by FEMA Administrator in conjunction with the Secretary of Homeland Security, who then makes a recommendation to the President. Federal agencies may also respond using funding sources other than those made available by the Stafford Act. In this case an agency's operating budget or funds designated by a trust or special appropriation may facilitate immediate life-saving assistance to states, such as firefighting support or support for a communicable disease outbreak or a cyber security event.",
        "National Disaster Medical System": "The National Disaster Medical System (NDMS) is a federal system coordinated by the Department of Health and Human Services (DHHS), in partnership with the Department of Homeland Security, the Department of Defense, and the Department of Veterans Affairs to provide disaster medical care to the nation. NDMS works with states and other local partners to augment their medical capabilities and capacity for response to disaster. The capabilities broadly include deployable response teams, patient movement, and definitive medical care. NDMS also supports the military and Department of Veterans Affairs medical systems by maintaining its network of civilian hospitals to receive and care for casualties that might be evacuated back to the United States in time of conflict or other type of military health emergency. National Disaster Medical System operations entail a highly coordinated, multiagency local, state, and federal effort. The federal partners are coordinated by DHHS, which has overall authority and responsibility for NDMS. \u2022 DHHS provides funding for training, exercising, and equipping all deployable teams. It coordinates the activities of NDMS with other public health and medical response activities (ESF 8) as well as the activities of the other ESFs. It also coordinates NDMS activity with the local and state entities. \u2022 The Department of Homeland Security, through FEMA, develops NDMS mission assignments in the context of the NRF, and funds NDMS operations supporting emergencies under predeclaration periods and those declared under the Stafford Act. \u2022 The Department of Defense (DoD) is responsible for patient movement using the US Transportation Command (USTRANSCOM). It also provides deployable health and medical resources required for the movement of those patients. The DoD funds NDMS operations supporting military contingencies and provides the necessary resources for receipt and distribution of patients for definitive care under those circumstances. \u2022 The Department of Veterans Affairs (VA) alerts and activates designated VA Federal Coordinating Centers for receipt of patients and coordinates definitive medical care in the designated receiving areas across the US. NDMS has medical, mortuary, and veterinary capabilities. Nearly 6,500 deployable personnel are organized into 90 teams. Team members are volunteers and maintain their readiness, education, and training without pay. They are required to maintain the certifications and licensure appropriate for their discipline. Personnel can be activated as intermittent federal employees, which affords them pay, workmen's compensation coverage, and protection under the Federal Tort Claims Act in which any civil complaints are defended by the federal government. Certifications and licensure are recognized in all states when members are federalized. National Disaster Medical System response team assets include the following. \u2022 Disaster medical assistance teams (DMAT). DMATs are composed of professional and paraprofessional staff organized and resourced to provide medical triage, treatment, and preparation for transport when needed. The teams are composed of 35\u201350 personnel, including physicians, nurses, mid-level practitioners, paramedics, behavioral health specialists, logistical support personnel, and others. The team is designed to be self-sufficient for 72 hours, with personnel typically deploying for 14 days. \u2022 National medical response teams (NMRT). NMRTs are trained and equipped to respond to weapons of mass destruction incidents. They are designed to provide patient decontamination and specialized treatment and care for survivors of CBRNE events. One team is dedicated to response within the National Capital Region. The typical team consists of approximately 50 people. \u2022 International medical/surgical response teams (IMSURT). IMSURTs deploy at the request of the Department of State to treat survivors of disasters outside the borders of the continental United States. The IMSURTs have also been deployed in support of domestic missions such as the World Trade Center bombings and Hurricane Katrina. The team configuration is flexible and may have 30 personnel including trauma surgeons, general surgeons, orthopedic surgeons, anesthesiologists, emergency physicians, midlevel providers, nurses, paramedics, logistical support personnel, and others. The teams can supplement or temporarily replace surgical and critical care capability, and stabilize and prepare patients for evacuation when needed. Personnel are typically deployed for 14 days or until local medical resources are supplemented or recovered. \u2022 Disaster mortuary response teams (DMORT). DMORTs are composed of individuals from a variety of disciplines who are deployed to provide technical assistance and personnel to identify and process deceased victims, under the guidance of local authorities. Disciplines represented include funeral directors, medical examiners, pathologists, fingerprint specialists, forensic odontologists, mental health specialists, and others. The federal government also maintains three deployable disaster portable morgue units (DPMUs), each of which contains a complete morgue with prepackaged equipment and supplies. DMORTs have deployed to mass fatality events such as the 2011 Joplin, MO, tornado (161 deaths), Hurricanes Katrina and Rita (~2500 deaths), and the 2010 Haiti earthquake (~212,000 deaths). \u2022 National veterinary response teams (NVRT). NVRTs provide veterinary care to ill and injured animals housed in federally supported facilities after a disaster. This also includes lab animal support, working animals such as US&R dogs, and assistance with USDA-led outbreaks among livestock and poultry. The 22\u201326 member team is composed of clinical veterinarians, veterinarian pathologists, microbiologists, epidemiologists, toxicologists, and others. When local medical systems become overwhelmed, NDMS provides the means to evacuate patients to the nearest participating hospital capable of supporting the needs of the patient. Local and state officials in coordination with federal authorities will identify patients requiring evacuation and initiate their movement. DoD has primary responsibility for coordinating the patient evacuation function of NDMS in conjunction with DHHS and FEMA. Various means of transportation can be used, including the resources at USTRANSCOM. Patients evacuated from a disaster area will arrive at a federal coordinating center patient reception area (PRA), where they will be triaged and staged for transport to a local NDMS participating hospital. PRA teams are often composed of local EMS personnel, local federal resources (such as VA Medical Center assets), local public health and health system personnel, and others. A local or deployed DMAT may also be assigned to PRA functions. The Federal Coordinating Center will track the location and status of all patients. Return movements home are coordinated by DHHS on a case-by-case basis, with those requiring continuing medical care returned when appropriate care is available at their point of origin."
    },
    {
        "Introduction": "Clinician-performed ultrasound has proven crucial for the evaluation of critical disease. Improvements in size, weight, cost, user-friendliness, and communications have allowed the enthusiasm for hospital ultrasound to migrate into the out-of-hospital arena. With increasing evidence that ultrasound can play a role in out-of-hospital emergency care, this diagnostic modality has been used in international explorations on all continents, in challenging high-altitude expeditions, on cruise ships, in hyperbaric chambers, and even in outer space on the International Space Station. Ultrasound-guided diagnosis of critical conditions in the field has the potential for improving triage decisions, hastening therapy prior to hospital arrival, avoiding unnecessary or harmful treatments, and expediting transport to correct facilities. Prehospital ultrasound has been described in advanced ground and flight EMS systems, in military medicine for both service personnel and civilians, in austere or underdeveloped environments, and in mass casualty situations. Non-physicians with limited medical backgrounds have demonstrated the ability to perform and interpret ultrasounds with adequate training. Despite the recognition of a need for field use of point-of-care ultrasound, its routine incorporation into prehospital algorithms has not yet been established.",
        "Why prehospital ultrasound?": "Bedside ultrasound performed by non-radiologists has been well described to accelerate diagnosis and patient management, ultimately decreasing hospital lengths of stay and reducing costs. Out-of-hospital ultrasound has facilitated improvements in diagnostic accuracy but outcomes research has not been performed within this setting. The potential for extrapolation of similar outcomes using prehospital ultrasound is intriguing. Prehospital diagnosis of a grave illness may lead to immediate procedural care, direct admission to relevant specialty centers, and prevention of secondary transfers. Ultrasound-assisted triage may allow more stable patients to be redistributed away from overwhelmed centers and visibly guide immediate resuscitative interventions in the field.",
        "Settings of field use": "In the United States, EMS crews are primarily staffed with non-physicians using a \u201cscoop and run\u201d transport philosophy, providing basic resuscitation while delivering patients to the nearest appropriate facilities. Some European countries, however, use physician personnel on board their EMS vehicles or mobilize specific physician units to direct medical management and allocate resources. EMS physicians are increasingly common in the US as well. These units may spend longer in the field providing treatment prior to transport. Therefore, the utility and feasibility of prehospital ultrasound may differ depending upon practice environment. The concept of ultrasound assistance enabling rapid, accurate care before hospital arrival remains the same regardless of which system is employed.",
        "Indications": "The 2008 American College of Emergency Physicians policy statement regarding emergency ultrasound lists the following examinations as core emergency ultrasound applications: trauma, intrauterine pregnancy, abdominal aortic aneurysm (AAA), cardiac and volume status, biliary, urinary tract, deep venous thrombosis (DVT), soft tissue and musculoskeletal, thoracic, ocular, and procedural guidance. Prehospital use in many of these areas is described in the following sections.",
        "Indications - Trauma": "The area of most extensive study regarding prehospital ultrasound is the Focused Assessment with Sonography in Trauma (FAST) examination to detect traumatic cardiac tamponade and intraperitoneal bleeding. The current standard is for the FAST exam to be performed immediately upon arrival to the trauma center during advanced trauma life support physical examination surveys. However, Walcher et al. demonstrated that performing prehospital FAST (PFAST) ultrasounds at the trauma scene changed management in 30% of patients with a 93% sensitivity and 99% specificity for detecting intraperitoneal free fluid. Identification of free fluid enabled providers to reduce patient blood loss by providing permissive hypotension, and non-essential therapies were avoided to shorten time to surgery. Advance notification of PFAST results was provided to receiving hospitals, which then activated surgical teams when needed. In 22% of patients, the choice of receiving hospital was changed based on the ultrasound findings. Due to the results of this study, one major German air rescue provider incorporated PFAST into its algorithm for trauma management. Other studies have demonstrated successful paramedic performance of the PFAST exam while en route, on ground or in air, without prolonging time to transport. Of note, ultrasound cannot distinguish blood from ascitic fluid or pinpoint exact areas of bleeding. It is not sensitive in the detection of retroperitoneal fluid, organ injury, or hollow viscus injury. These limitations of ultrasound may cause delayed or missed fluid detection on out-of-hospital or triage FAST exam. It remains to be seen whether positive findings on a PFAST exam in the United States would alter management as illustrated in the Walcher study, since many trauma centers in the US have immediate response by trauma teams and protocols in place to mobilize operating theaters quickly. The FAST detection of pericardial fluid may have more potential for prehospital intervention. A dramatic case report details the course of a 17-year-old 26-week pregnant female suffering from a stab injury. Despite field chest tube placement with evacuation of air and blood, the patient's vital signs declined. Ultrasound revealed a significant amount of pericardial fluid, which was immediately drained in the field and again in the emergency department. The patient ultimately survived, largely due to prehospital intervention. Similarly, another report describes how in-ambulance paramedic detection of traumatic pericardial effusion and subsequent alerting of the receiving team facilitated direct operative intervention. These cases highlight the potential for the PFAST exam to change prehospital practice and guide on-scene resuscitative therapies. ",
        "Indications - Pulmonary": "While the Extended FAST exam (eFAST), including evaluation of pleural sliding, has been imprinted into emergency department and trauma protocols, it has not become standard in the prehospital environment. Adoption of sonographic pneumothorax evaluation may be invaluable in the trauma setting, as physical exam findings and ancillary monitoring have proven insensitive or difficult to discern in a noisy ambulance or helicopter. Detection may facilitate prehospital needle thoracostomy and prevent development of tension pneumothorax. Additionally,Ruling out pneumothorax avoids unnecessary procedures and their sequelae, allowing focus on other resuscitative efforts. Equally, assessments of lung sliding and pleural effusion have become useful adjuncts in the management of acute dyspnea. Zechner et al. report a common scenario encountered by prehospital personnel: a patient with a history of both chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) presenting in severe respiratory distress with wheezing. When pulmonary edema was discovered via on-ambulance sonographic B-lines, treatment was immediately altered to discontinue terbutaline and proceed with urapidil (an alpha,-antagonist), enabling rapid improvement in the patient's clinical status. Subsequently, a German group developed a prehospital chest protocol to evaluate undifferentiated dyspnea. Using the subxiphoid cardiac view, bilateral coronal views, and bilateral anterior intercostal views, this protocol investigates pericardial or pleural effusion, pneumothorax, and right heart distension for pulmonary embolus. Providing supportive information in 68% of their patients and most useful for finding pleural effusion in decompensated CHF, prehospital ultrasound guided emergency physician management at the hospital.",
        "Indications - Cardiac": "Dedicated prehospital cardiac examination is very amenable to ultrasound. Brun et al. illustrate prehospital use of transthoracic echo for evaluation of shock in a patient with prior cardiac surgery presenting with dyspnea, tachypnea, crackles on exam, and hypotension. Ultrasound revealed pericardial effusion with thrombus in contact with the right ventricular free wall causing diastolic collapse of the right heart from a vitamin K antagonist overdose. The prehospital team notified the receiving hospital to prepare prothrombin complex concentrates in advance of arrival, and shortened time to drainage by the cardiac surgeons. Out-of-hospital groups have also diagnosed pulmonary embolus from acute right heart strain and examined cardiac output using non-physicians with tele-ultrasonography. The same challenges that affect interpretation of in-hospital echocardiography exist, such as differentiating between acute versus chronic right heart strain, epicardial fatty tissue versus small pericardial effusion, and stable versus unstable pericardial effusion. These physiological processes may require a more in-depth level of training. The main area of prehospital cardiac research stems from literature suggesting that absence of cardiac activity on bedside echocardiography predicts unsuccessful resuscitation in cardiac arrest. Thus there has been some focus on prehospital echocardiography performed by non-physicians for field pronouncement of death and avoidance of costly resuscitative efforts or misdirected allocation of resources. This has been further supported by a prospective study showing only a 3.1% (one patient out of 32) survival to hospital admission of cardiac arrest patients who displayed cardiac standstill on prehospital echo. In situations where uncertainties in decision to stop resuscitation are influenced by downtime, presence of bystander CPR, duration of resuscitation, ECG rhythm, age, or persistence of pulseless electrical activity (PEA), having a visible and reproducible prognostic parameter is useful. Although this study supports the idea that prolonged resuscitative efforts in the field may be futile when cardiac standstill is seen, there appears to be a small subgroup of people who survive to hospital admission, and the authors recommend not basing prehospital resuscitation on one single initial scan.",
        "Indications - Abdominal": "Within the emergency department setting, bedside ultrasound has been a rapid and accurate adjunct for diagnosis of AAA, renal colic, and cholecystitis. There are few reports of ultrasound for these disease processes in out-of-hospital settings. Prehospital ultrasound as a tool for investigation of abdominal or flank pain in the suspected abdominal aortic aneurysm may enhance admission decisions and reduce the potential for secondary transfer. An Australian helicopter retrieval team describe use of in-flight ultrasound in a man with suspected inferior myocardial infarction (MI). He had already received aspirin and enoxaparin prior to ultrasound-guided discovery of AAA. His management was changed to administration of fresh frozen plasma (FFP) for reversal of these agents and arrangements were made for direct transfer to the vascular team through advance notification to the receiving hospital. Other groups have successfully trained medic crews to evaluate the abdomen for AAA but the incidence of prehospital discovery and subsequent changes in patient outcomes have not been demonstrated. Out-of-hospital physicians utilizing ultrasound have changed management plans in hurricane disaster relief and in expeditions to the Amazon jungle when evaluating causes of abdominal disease.",
        "Indications - Obstetrics": "Evaluation of obstetric emergency is an area that may significantly benefit from prehospital ultrasound. A case series demonstrated the utility of ultrasound during air medical transfer where ambient noise creates difficulties in auscultating fetal heart rate. One case in particular highlighted the appropriate prevention of air medical transport in a patient displaying fetal distress due to premature rupture of membranes with prolapsed cord. When the flight team discovered intermittent fetal bradycardia on ultrasound, the transport was aborted and the patient went straight to the operating theater, averting fetal demise in this initially unrecognized condition. Diagnosis of ruptured ectopic pregnancy was confirmed by sonographic right upper quadrant free fluid in a patient with a reportedly normal pregnancy. Presence of free fluid heightened the suspicion of the prehospital team, who arranged immediate laparotomy during which a uterine rupture from myometrial implantation was discovered.",
        "Indications - Musculoskeletal": "Emergency medical technicians have successfully detected the presence of simulated fractures, and ultrasound detection of fractures has been useful in combat environments. These suggest diagnostic and therapeutic ultrasound implications particularly in remote environments where traditional diagnostic imaging is not available. Unstudied prehospital ultrasound applications include detection and reduction of shoulder dislocations, hip dislocations, pediatric fractures, and muscle and tendon injuries, and in nerve block analgesia.",
        "Indications - Prehospital ultrasound protocols": "Prehospital ultrasound protocols have been developed for the evaluation of life-threatening conditions. The Prehospital Assessment with Ultrasound for Emergencies (PAUSE) protocol includes a heart and thorax examination for pericardial effusion, pneumothorax, and cardiac motion with systematic guidance of resuscitative efforts. An integrative sonographic trauma survey has been proposed to identify multi-injury pathologies in the setting of mass casualty or combat. The CAVEAT examination assesses the chest for pneumothorax, hemothorax, and pericardial tamponade, the abdomen for FAST detection of hemoperitoneum, the inferior vena cava for qualitative volume assessment, and targeted extremity evaluation for detection of fracture. As each of the components within this protocol has been demonstrated using non-physicians, it is presumed that this protocol may be incorporated into the medic skill set. Supplementation of EMS training programs with easy-to-follow algorithms using pictorial aids may enable the implementation of prehospital ultrasound evaluation for resuscitation.",
        "Indications - Other": "In addition to detection of fluid in pleural, pericardial, and peritoneal cavities, Lapostolle et al. evaluated DVT and vascular flow disruptions in an out-of-hospital setting. This study found that ultrasound examination improved diagnostic accuracy in 67% of cases. Ultrasound has been used to diagnose high-altitude pulmonary edema and high-altitude cerebral edema in the Himalayas using thoracic and ocular ultrasound respectively, although with experienced physicians and not with mountain medics. Groups have explored prehospital transcranial Doppler use for assessment of brain injury and neurological disease. Procedural applications like peripheral intravenous access and abscess evaluations may also be useful in out-of-hospital scenarios. Ultrasound-guided thoracentesis and paracentesis are anecdotally common in settings without other radiographic capabilities.",
        "Disaster and mass casualty triage": "Mass casualty incidents require fast, reliable triage of large numbers of patients using limited resources. The chaotic environment, relative lack of medical personnel, and destruction of existing infrastructure can prevent early treatment of injured patients. The ability of ultrasound to identify patients who would benefit most from intervention could lessen uncertainties of physical exam findings in these situations. Placing diagnostic capability into the hands of first responders may be useful in future disaster strategies to augment triage accuracy, enhance mobilization of resources, improve allocation of scarce resources, and facilitate destination decisions. The few studies that have examined the above are understandably retrospective. Chart analysis of trauma patients at a Level I trauma center found that 20 of 286 patients triaged as in the simple triage and rapid treatment (START) method had positive FAST findings, with possible delayed hemoperitoneum identified in 7% of total patients. However, only six patients received operative management within 24 hours, with both over- and undertriage as significant problems. Because it is unclear if positive FAST findings would alter management in this setting, the study did not support the use of routine FAST as a secondary triage tool. Others have illustrated the usefulness of the FAST exam as a diagnostic and triage adjunct. Ultrasound was used as a screening modality for free fluid in the 1998 Armenian earthquake. Renal Doppler ultrasound performed at triage guided management of severe acute crush injuries in the aftermath of a 1999 Turkish earthquake, and ultrasound proved crucial in the identification of hemoperitoneum, hemothorax, intimal tear of the femoral artery, DVT, and deep tissue hematoma in both triage and middle-late stage assessment of patients admitted during the 2010 Wenchuan earthquake. The most recent case illustration highlights the usefulness of emergency department triage by ultrasound during the 2013 Boston Marathon bombing. An emergency medicine resident went bed-to-bed performing ultrasound and tagging results to the patient. The authors note that both triage and acute care for these patients were by the results of bedside ultrasound and recommended its implementation in disaster planning.",
        "Military": "The potential for out-of-hospital ultrasound use by military medics in the field is considerable, especially in the recognition of occult blood loss occurring in conditioned soldiers to prevent late-stage shock and in possible sonographically guided coagulation of internal bleeding. Army National Guard medics (EMT-B level) have successfully performed limited echocardiography for detection of cardiac activity. Military non-physician medics have performed fracture evaluation, FAST with pneumothorax examination, ocular, renal, vascular, and obstetric examinations. In addition, ultrasound training has been incorporated into the curriculum for special operator medics.",
        "Role of non-physicians/EMS training": "Multiple studies have established that non-physician personnel are capable of quickly learning and demonstrating proficiency with ultrasound in a wide variety of applications, in diverse environmental settings, and in differing modes of EMS transport. Training has encompassed a number of different methods including lectures, proctored hands-on sessions, before and after examinations, refresher sessions, OSCE assessments, web-based modules, flashcards, and tele-ultrasound guidance. Course times vary from as little as 2 minutes for fracture evaluation instruction to 1 day for FAST teaching, with cardiac and lung training reported from 10 minutes to 2 hours. Instruction for paramedics or ultrasound-naive physicians outside the United States appears longer, from 8-hour to 100-hour programs for the FAST exam and 2-day courses for the thoracic exam. Currently, there is no consensus on the optimal training time or method required to adequately train non-physician personnel, and no study to date has compared different training methods for EMS personnel.",
        "Tele-ultrasound": "Tele-ultrasound may become a valuable data transmission tool which takes advantage of a centralized expert's sonographic skills and disperses acquisition and interpretation of images to multiple unskilled providers. Tele-ultrasound has been described in remote locations and aboard the International Space Station. In an American study examining feasibility, 51 paramedics with no prior ultrasound experience received a 20-minute didactic session covering orientation and the FAST examination. With tele-ultrasound guidance, they performed complete FAST exams in a median time of 262 seconds. Although real-time clinical translation during EMS transport is required, this technology shows promise.",
        "Feasibility of ultrasound in the field": "Apart from operator skill and already known limitations of ultrasound as a diagnostic modality, several recurring limitations appear in field use which may prevent adequate completion of an ultrasound examination. Flight medics reported insufficient time to complete scanning. Screen visibility was hindered by bright ambient light, and physical restrictions arose from lack of space. Patient parameters such as obesity and combativeness prevented imaging, and battery or machine failure contributed to unsuccessful acquisition. Similar factors affect on-ground transport: difficult spatial arrangements, sunlight, battery problems, and a requirement for probe handling to be ambidextrous. In addition, harsh environmental conditions deprioritized ultrasound performance and optimal views were limited by presence of pacer pads, cervical collars, or splints. With ground transport, multiple examination completion times are longer and measurements may be less precise when completed in a moving vehicle, but these may not be statistically or clinically significant when compared with stationary performance. Other studies have shown that ultrasound can be completed without prolonging transport time. Despite these limitations, authors who have examined prehospital ultrasound feasibility have shown positive overall results and demonstrated the modality's utility in the field. Technological advances have allowed machinery to decrease in cost, weight, and bulk. Recent development of pocket-sized devices, wearable transducers, and in-clothing tele-ultrasound devices illustrates this, but perpetual improvements need to be made. Portable ultrasound devices need to be robust enough to operate in extremes of temperature while maintaining reasonable battery life, and inbuilt alternative power sources (e.g. solar energy) need to be considered. Displays that provide good visibility in bright light conditions with rapid boot-up time and simplified controls need to be incorporated. In addition, expanded image storage space and intrinsic capabilities for image transmission such as wireless internet or Bluetooth need to be included.",
        "Future directions": "European expert consensus groups have recognized prehospital ultrasound as one of their top research priorities. Recent literature has shown achievable diagnostic accuracy in non-physician hands and presented examples of patient care facilitation in treatment and transport decisions, thus supporting the use of prehospital ultrasound in varying EMS systems, in austere or impoverished settings, in combat and disaster environments, and in large recreational settings. Many of these studies involve small numbers of providers or small numbers of patients. The documented benefits of ultrasound in a hospital setting need to be reproduced in high-powered, larger-scale scenarios in the EMS literature. More permanent integration of ultrasound use within EMS systems, and development of longitudinal standardized curricula within EMS training, need to be established. Within this realm, questions surrounding the most efficacious way to teach first responders the most applicable ultrasound examination types to learn, and the optimal way to approach quality assurance of prehospital users, need to be answered. Ultimately, large-scale demonstration of the clinical improvement that prehospital ultrasound can produce in patient care needs to be established and patient-centered outcomes both within and outside the hospital need to be documented."
    },
    {
        "Introduction": "In 2006, the Institute for Medicine (IOM) described organization of EMS systems across the United States: \u201cIn states and regions across the country, there is substantial variation among emergency and trauma care systems. These systems differ along a number of dimensions, such as the level of development of trauma systems, the effectiveness of state EMS offices and regional EMS councils, and the degree of coordination between fire, EMS, hospitals, trauma centers, and emergency management.\u201d Each state and territory within the United States has a state EMS office \u2013 a functional entity that regulates various components of the EMS system. Like all other aspects of state government, there is often wide variation in where a state EMS office sits within governmental structure, personnel positions within a state EMS office, and scope of the office\u2019s activity in regulating EMS entities and providing non-regulatory support to the EMS system. Realizing that variations exist, this chapter will describe the general functions of a state EMS office with particular attention to functions that should be understood by local EMS agency medical directors and managers. Variation in the location of state EMS offices within each state\u2019s governmental structure can lead to confusion in terminology. For the purpose of this chapter, the term state EMS office will be used as a broad general term, understanding that a state\u2019s EMS office may be called an office, bureau, department, program, or other terminology. The National Association of State EMS Officials (NASEMSO) is a non-profit organization that is composed of EMS officials from every state and territory within the United States. NASEMSO goals include promotion of the orderly development and coordination of EMS systems across the nation, and the organization is also a forum for exchange of information and discussion of common concerns among state EMS officials. NASEMSO also facilitates interstate cooperation in areas such as patient transfer, communications, and reciprocity of EMS personnel. It has many opportunities for specialized collaboration among states through its councils of medical directors, data managers, trauma managers, pediatric emergency care, and educational and professional standards. The organization also has committees that address specific and unique EMS topics as they occur. Each state and territory has the opportunity to appoint a state medical director to the Medical Directors Council. In response to the 2006 IOM report describing fragmentation in EMS, and with support from the National Highway Traffic Safety Administration (NHTSA) of the US Department of Transportation, NASEMSO coordinated a project that developed a model for state EMS systems. Within this project, NASEMSO organized the model state EMS system into ten subsystems\n 1.System Leadership, Organization, Regulation and Policy Subsystem\n2.Resource Management Subsystems - Financial\n3.Resource Management Subsystems - Human Resources\n4.Resource Management Subsystems - Transportation\n5.Resource Management Subsystems - Facility and Specialty Care Regionalization\n6.Public Access and Communications Subsystem\n7.Public Information, Education, and Prevention\n8.Clinical Care, Integration of Care, and Medical Direction\n9.Information, Evaluation, and Research Subsystem\n10.Large-Scale Event Preparedness and Response Subsystem\n\nSections of this chapter will examine the subsystems of the model state EMS system in further detail with attention to issues that are of most importance to EMS medical directors.",
        "System leadership, organization": "System leadership and organization There are variations as to the lead agency where EMS resides within each state, and there is significant variation regarding placement of each state EMS office within the structure of its lead agency. NASEMSO\u2019s EMS Systems Model suggests that, ideally, each state EMS office should be located within a lead agency that has a cabinet-level department head who reports directly to and advises the governor. In the vast majority of states, the lead agency for EMS is the Department of Health or a similar department that oversees public health within the state. The second most frequent lead agency for EMS is the Department of Public Safety or similar department that typically oversees law enforcement, fire protection, or emergency management. In other states, the EMS lead agency is a separate EMS authority or commission or within some other department of state government. Whether in the Department of Health or some other agency of state government, the location of EMS within these lead agencies is also important. Departments of Health are frequently broken down into bureaus, which are further divided into divisions, and may be further divided into offices or programs. In addition to a cabinet-level department head, there are four required positions that must exist in an optimally functioning state EMS office. These positions may have official titles that differ but the specific functional roles are as follows. \u2022 State EMS System Director: a full-time individual responsible for the execution of statutory responsibilities charged to the lead agency regarding regulation of state entities included in the EMS system. This individual also leads and manages technical assistance activities that the state EMS office provides for the EMS system. \u2022 State EMS System Medical Director: a licensed physician responsible for medical oversight of the EMS system. The role of the state EMS medical director is described in a 2009 joint position statement from NASEMSO, the American College of Emergency Physicians (ACEP), and the National Association of EMS Physicians (NAEMSP). This document describes the qualifications and roles of a state EMS medical director, and suggests that this position should be officially recognized and full time within each of the states, District of Columbia, and each of the territories. This document describes the role as follows: \u201cThe state EMS medical director provides specialized medical oversight in the development and administration of the EMS system and is an essential liaison with local EMS agencies, hospitals, state and national professional organizations, and state and federal partners. The state EMS medical director provides essential medical leadership, system oversight, coordination of guideline development for routine and disaster care, identification and implementation of best practices, system quality improvement, and research.\u201d \u2022 State EMS System Advisory/Authority Body: a multidisciplinary board with an advisory role or authoritative role for the EMS lead agency. \u2022 State EMS Medical Committee: a body consisting of members who provide medical expertise to the EMS system lead agency. Membership within the group may represent regions within the state or specialty areas of medicine or the health care system. Under these positions that are required for an optimally functioning EMS office are personnel who accomplish regulatory and technical assistance tasks of the office. Regulatory tasks include licensing or certification, inspections, investigations, and discipline. Technical assistance operations may include planning, development, education, and disaster response. The ideal state EMS lead agency facilitates regular independent external assessment of the EMS system, and it develops and updates a comprehensive EMS system plan for the state or territory.",
        "Regulation and policy State": "EMS offices generally provide a combination of regulatory and technical assistance functions. EMS agencies and personnel within a state are regulated by a statute, or state law, that permits agencies and personnel to provide EMS to the general public of that state. Rules and regulations of a particular statute provide guidance in regulating and executing the specific law. Although not used liberally, states generally have the ability to waive or exempt an EMS agency or provider from requirements within its rules and regulations; however, requirements of a specific statute must be followed. Waivers of requirements within the rules and regulations are usually permitted only if a waiver will permit an agency or provider to continue to provide EMS when it is in the best interest of the public. Each individual state EMS statute or its attendant regulations may grant a state latitude in developing policies or procedures to assist in regulating EMS entities and to provide regulated entities with information related to their licenses. A policy is a principle or rule to guide decisions and achieve rational outcomes, for which decision makers may be held accountable. A procedure includes actions that are executed in the same manner in order to obtain the same result. A standard operating procedure describes and guides multiple iterations of the same procedure over multiple occasions and locations. It is important that EMS agency medical directors, EMS agency managers, and EMS providers understand the difference between standards and guidelines. Standards are generally requirements that must be met to achieve a designated purpose. These may be mandatory or voluntary but they are generally set by the government or by accrediting organizations. On the other hand, guidelines are generally rules that are set to guide behavior or offer best practice suggestions. They are often advisory and cannot be mandated by a regulatory body.",
        "Scope of practice": "The scope of practice \u2013 a description of what a licensed individual legally can and cannot do \u2013 is defined and limited by a state\u2019s statute or law. Defining a scope of practice for each level of licensed EMS provider is central to further state regulation of educational programs, medication formularies, required EMS vehicle equipment lists, state-wide protocols, complaint investigations, and reciprocity with other states. NHTSA published the National EMS Scope of Practice Model in 2007 to set consistent criteria for nomenclature and competencies for various levels of EMS providers across the United States. Consistency in the scope of practice of these individuals across states will improve professional mobility of EMS providers and enhance the public\u2019s name recognition and understanding of the providers within the EMS system. Within each state, an individual EMS provider is only permitted to undertake the skills and roles for which the individual has been: \u2022 trained \u2022 certified as competent \u2022 authorized by the EMS medical director \u2022 licensed by the state to practice. Trained While each state sets its standard for EMS education institutes that are acceptable for educating EMS providers, ideally this education takes place in an institution that is accredited by a nationally recognized organization like the Committee on Accreditation of Educational Programs for the Emergency Medical Services Professions (CoAEMSP). Accreditation helps to ensure that EMS providers are educated using well-organized and sound educational curriculum and techniques. Certified as competent Some states provide a certifying examination for some levels of EMS providers within their system, but reliable tests must be validated, including test bank development, test security, and expertise in test psychometrics. Most states have turned to nationally recognized certification organizations like the National Registry of Emergency Medical Technicians (NREMT) to provide reliable high-stakes examinations and certification for some or all of their levels of EMS providers. Authorized by the medical director This is synonymous with credentialing. The analogy for physicians is that, in addition to successfully graduating from medical school and passing the board exam process, the physician must be credentialed to receive privileges to perform patient care and procedures within a hospital. Through the credentialing process, the EMS medical director verifies that the provider is both qualified and competent. Licensed by the state to practice Every state has a process to formally permit individuals to deliver EMS care at each level of EMS provider that is recognized within the state. For the purposes of being formally recognized by a state to practice EMS within the state, states vary on whether they use the terminology of \u201clicensed\u201d or \u201ccertified.\u201d In some states, the EMS provider is licensed as an independent health care practitioner with licensing fees and requirements similar to those of other individuals who receive state licenses. Other states certify their EMS providers at the level in which the provider is educated, but this should not be confused with the certification process of an organization like NREMT. It is a common myth in the EMS community that the EMS provider functions under the medical license of the physician medical director \u2013 this is not true in the vast majority of states. Although the EMS medical director may bear some responsibility for ensuring the competence of an EMS provider within the agency, in most states EMS providers maintain their own independent licenses or certifications and are held accountable as separate health care practitioners.",
        "Resource management \u2013 transportation": "In addition to managing financial and human resources to ensure that the EMS system is healthy and able to provide continuous EMS service, the ideal state EMS office must assess transportation and vehicle needs of the system and provide technical assistance to ensure that these meet expected standards. In addition to inspecting and licensing ground, air, and water EMS vehicles, each state EMS office develops standards for equipment carried on each licensed vehicle. Every state EMS office should provide technical assistance to develop plans for transportation capabilities for mass casualty incidents and disasters.",
        "Resource management \u2013 facility and specialty care regionalization": "Gone are the days when conventional thinking held that all hospitals are created equal. Today, specialty hospitals are the norm, and as health care dollars have diminished, hospitals directly advertise their services to the consumer public. The result is a non-standardized set of descriptors including \u201cBest in region,\u201d \u201cHighest satisfaction,\u201d and \u201cHighest rated.\u201d This can lead to confusion among the lay public when individual preference and expectations collide with the modern EMS maxim of taking the patient to the most appropriate health care facility. There are an increasing number of specialty accreditations that hospitals can receive from various accrediting organizations. The American College of Surgeons (ACS) developed one of the first hospital specialty accreditations for trauma patients, and survival rates are improved for seriously injured trauma victims when they are treated at an ACS-accredited Level I trauma center compared to when care is provided at a non-trauma center. At accredited centers, commitment of resources, mandatory training, and performance improvement processes result in a standardized approach that improves the quality of patient care and survival. This successful format has been extended to other time-sensitive illnesses: stroke, coronary artery disease, pediatrics, burns, obstetrics, sepsis, cardiac arrest, and others. Most states formally recognize certain accredited hospitals as trauma centers to which EMS agencies should transport seriously injured trauma patients. Formal recognition of stroke centers and STEMI-receiving centers is still in development in most states. Third parties have also sought to reduce patient errors by standardization of care and integrating performance improvement. The Joint Commission and Norske das Veritas are two organizations recognized by the Centers for Medicare and Medicaid Services in their assessments of hospitals and other health care facilities. Likewise, the Centers for Disease Control and the American Heart Association, among others, have promulgated standards that may be voluntarily adhered to for stroke and heart disease.\n\nIn certain states, legislative authority is available for state EMS offices to assess hospital capabilities. Within the confines of state laws and regulations, state EMS offices must now give direction to EMS agencies and personnel regarding the appropriate triage for patients with time-sensitive illnesses and their transport to the most appropriate facility by the most appropriate means. States generally recognize a specialty receiving center by developing standards that may use the accreditation status provided by an organization or private entity, but some develop internal standards and verification processes to accredit facilities. As an example, most states recognize trauma centers that have been accredited by ACS but since 1984, Pennsylvania\u2019s EMS Act has recognized a separate process through the Pennsylvania Trauma Systems Foundation to accredit its trauma centers. State EMS offices may adopt wholesale the guidelines established by other agencies, states, or companies but often these must be modified to temper them to the realities within their own state. The geography, health care resources, weather, availability of air, ground, and water ambulances, and other local factors affect the ability to effectively use guidelines developed by national organizations. In addition, state guidance must permit alternative destinations when EMS resources or weather do not permit transport of critically ill patients to the specialty destinations that are typically available. These discussions should occur, as much as possible, before development of an individual patient\u2019s crisis. In our litigious society, the \u201cLocality Rule\u201d is no longer a primary defense and one cannot claim that there is no liability because a particular facility was not equipped to handle a particular event. This is captured in federal law with the 1996 Emergency Medical Treatment and Labor Act (EMTALA) clearly requiring hospitals to participate in the delivery of a baby whether or not they have obstetrics or pediatrics capability and to stabilize the patient to the best of the hospital\u2019s abilities. Public expectations also come into play and therefore knowledge of a particular hospital\u2019s, or other health care facility\u2019s, capabilities is pertinent information for any state EMS office attempting to do its due diligence in developing policies and protocols for these time-sensitive illnesses. Given the fluid nature of various categories of illness, their time sensitivities, required personnel skillsets, education, training, and modalities of transport, state EMS offices are in a unique position to formulate and give direction in the creation of criteria, policy, and procedures.",
        "Resource management \u2013 financial": "Funding to operate a state EMS office varies among states and territories. Funding may include the following. \u2022 General fund: state tax monies directly allocated by the legislature in the state budget. \u2022 Block grants: monies from federal or state programs. \u2022 Cash funds: monies collected by the state that are earmarked for EMS systems. For example, in some states, a portion of each motor vehicle registration or each fine for a motoring violation goes directly to the EMS system. \u2022 Licensure fees: monies from licensing EMS agencies or providers. \u2022 Federal funds: including funds from EMS for Children (EMSC) grants, highway safety funds, Homeland Security grants, or bioterrorism grants.",
        "Resource management \u2013 human resources": "To ensure adequate human resources to deliver EMS, state EMS offices must monitor the number of active BLS and ALS providers compared to provider needs of EMS agencies. Recruitment, education, and retention are critical to maintaining sufficient numbers of EMS providers within each state. Each state defines the necessary requirements for licensing or certifying providers at each recognized level. The state EMS statute or the state EMS lead agency is also responsible for setting requirements for continued certification or licensure and for reciprocity for providers from other states who wish to receive a license or certification within the state.",
        "Public access and communications": "Emergency medical services lead agencies should produce and maintain an EMS system communications plan that integrates the EMS agencies with the major communication system assets for day-to-day and disaster use. The EMS office should be aware of all voice, video, telemetry, and other data communications that can be used for real-time information management for patient care. The communications plan should include public access to the EMS system through 9-1-1, and the plan should consider state-wide interoperability of communications and communication through radio systems, cellular, voice-over-internet protocol, automatic crash notification, and patient alerting devices. The recent opening of broadband frequencies for public safety use will have dramatic implications for increased ability to share EMS-related data and to use telemedicine in real time in the future. State EMS offices should ensure that the EMS system users of communication devices understand the National Incident Management System (NIMS) and that interoperability is planned using the US Department of Homeland Security (DHS) SafeCom Interoperability Continuum. The EMS communications system plan should also address what medically directed emergency medical dispatch systems are in place and used to deliver patient care through prearrival instructions.",
        "Public information, education, and prevention": "It is important that the state EMS office develop the ability to effectively communicate with and educate the public and medical community on issues related to the EMS system. Developing relationships with the media, medical community, health care organizations, and local, regional, and state policy makers should occur before it is necessary to provide time-critical information to the public. The state EMS office should work closely with the state agency responsible for public health epidemiology to understand the top causes of death in the state. Public education and disease or injury prevention programs should focus on these causes of death and other issues important to the EMS system. The state EMS office can also use these media resources to educate the public, government officials, and health care partners regarding the capabilities and appropriate use of the EMS system and to provide just-in-time information related to EMS issues during crisis events.",
        "Clinical care, integration of care, and medical direction": "Every state EMS office is responsible for ensuring quality medical direction across all levels of the EMS system. In addition to a state EMS medical director, regional or county EMS medical directors may be required to assist in providing medical direction to regional EMS systems and to provide resources for local or individual agency medical directors. Emergency medical services providers generally care for patients by providing treatment that is either defined in written protocols or that has been ordered directly by a direct medical oversight physician. Protocols generally set the standard of care and are defined by the EMS medical director or a medical committee. These often define the expected care for a specific patient presentation, but also define points at which individual EMS providers are expected to contact direct medical oversight before proceeding with additional treatments. Some systems refer to protocols as standing orders. In contrast, guidelines are not necessarily mandatory or required treatments, but provide more general information that is not necessarily considered the system standard of care. The level of medical direction with authority to promulgate EMS protocols varies by state. While many states permit each local EMS agency medical director to develop his or her own protocols, other states require that these protocols are based at the county or regional level, and some states give statutory or regulatory authority to the state to mandate use of state-wide EMS treatment protocols. In 2010, ten states mandated state-wide BLS protocols and 11 states mandated state-wide ALS protocols. An additional ten and six states, respectively, had state-wide BLS or ALS protocols, but there was a process for a local medical director to alter or even replace these. Although not binding, at that time, 15 additional states had state-wide BLS guidelines and 17 had state-wide ALS guidelines that served as model protocols for local EMS medical directors. Mandatory state-wide EMS protocols have several potential advantages. \u2022 Uniform standard of care.regionalization: with increased emphasis on regionalization of care, and with the increasing transportation of patients with specialized needs and time-sensitive conditions to regionalized centers, receiving facilities can expect the same treatments and care for their patients from every EMS agency that they encounter. \u2022 Ease of EMS provider education/continuing education: mandatory state-wide EMS protocols facilitate uniform education and continuing education for EMS providers. \u2022 Up to date: EMS protocols can be more easily maintained and kept up to date if they are done with resources of a state EMS system rather than expecting each local EMS agency to continuously update local protocols. \u2022 Uniform response to disaster: state-wide protocols provide uniform expectations and improve communication with direct medical oversight when multiple unrelated agencies respond together to disasters, both within and outside a state. \u2022 Changes priorities of local EMS agency medical director: when a local EMS agency medical director does not need to place significant effort and resources into protocol development and updating, the medical director can redirect his or her time to education, quality improvement, or other priorities. \u2022 Evidence based: resources available at the state level can be used to ensure that state-wide protocols are as evidence based as possible. In Canada, Nova Scotia used an evidence-based process to develop its province-wide protocols. There are also some potential disadvantages to state-wide EMS protocols. \u2022 May not recognize local nuances in patient care needs: some have suggested that it is difficult to provide standardized protocols that meet the needs of all patients (for example, those in both urban and rural settings), although the states with current state-wide protocols all have these variations. Some use options within the protocol to address these variations. \u2022 Restricts \u201ccutting edge\u201d or \u201cprogressive\u201d care: while state-wide protocols are less likely to include unproven treatments, in some cases care that is considered to be progressive by some may actually be experimental. EMS systems need to ensure that they recognize the importance of research in EMS and need to have mechanisms to support such research. \u2022 May not be up to date: although it is possible that state-wide protocols can assist in keeping all systems up to date, if there is not an efficient process to update the state-wide protocols on a regular basis, then they may become \u201cstale\u201d and may jeopardize the opportunity for patients to receive the best care. \u2022 Medical directors may lose sense of control: while state-wide protocols may assist in redirecting medical director time to priorities of quality improvement and education, it is possible that medical directors who are not responsible for protocol development for an EMS agency may feel that they no longer have an important role in the system. The national movement in health care for evidence-based care that decreases unwarranted variation has not been ignored by EMS. In 1998, the EMSC program and NAEMSP published model pediatric protocols which were updated in 2000 and 2003. In 2006, the IOM report regarding EMS called for national protocol guidelines, and NHTSA has funded several recent projects to develop evidence-based protocols for specific emergency issues as well as to encourage the development and implementation of evidence-based EMS guidelines at a national level. Among other things, NASEMSO has suggested that the model state EMS system lead agency should \u201cestablish state-wide performance measures related to patient care,\u201d \u201cdefine medical director responsibility and protection of liability through statute,\u201d and \u201cenforce utilizing well-defined standards, policies and procedures (including protocols) for all prehospital clinical practice.\u201d",
        "Information, evaluation, and research": "The state EMS office should collect data from EMS agencies and other stakeholders, and these data should be used when developing state-wide EMS plans, when addressing EMS system issues, and when facilitating EMS research. In addition to collecting and analyzing information regarding EMS system performance using National EMS Information Systems-compliant data elements, the EMS lead agency should consider other data sources that may be useful in answering logistic, operational, and patient care questions posed at a system level. These additional sources may include information from death certificate data and other vital statistics, the Cardiac Arrest Registry to Enhance Survival, insurance carriers, trauma systems data, Crash Outcome Data Evaluation System, the Fatal Accident Reporting System, and hospital data. A state-wide EMS quality improvement plan should guide the use of data for the purpose of improving patient care and EMS system efficiency. NHTSA Performance Measures and additional measures can be used as performance indicators for system quality. The state EMS office should ensure that processes are in place to ensure confidential protection of records while allowing use of state EMS system data for quality improvement and research. State EMS offices should have a plan in place to engage EMS providers in understanding the value of data and its effect on quality patient care to help ensure better reporting of patient data by EMS providers.",
        "Large-scale event preparedness and response": "State EMS offices play an important role in medical preparedness and response to large-scale events, including disasters, scheduled mass public gatherings, and high-profile events. State EMS offices should participate in all levels of preparation for mass casualty incidents using an all-hazards approach. The state EMS lead agency should cooperate with the state emergency management lead agency and other agencies responsible for emergency response to analyze gaps, prepare the system, and assist with responses. State EMS offices should develop means to communicate with other jurisdictions, and plans should include provisions to facilitate both intrastate and interstate use of EMS resources. The Emergency Management Assistance Compact, NIMS, and other contracted agreements are necessary to facilitate many of these instances of resource sharing. The state EMS system plan must be rehearsed in an integrated fashion with other responsible state and local agencies using resources available to the system, including EMS vehicles, buses, and other vehicles equipped to move supine, wheelchair, and ambulatory patients, communications, equipment caches, mobile treatment facilities, and emergency personnel. The EMS preparedness planning must be integrated with hospital readiness and surge capacity. Non-traditional roles for EMS may be necessary during disasters or public health crises, and preplanning should consider how EMS resources would support objectives like mass public vaccinations and other non-traditional EMS roles.",
        "Conclusion": "State EMS offices are structured in many different ways, and play critical roles as both regulators of EMS and providers of technical assistance to EMS agencies and personnel. It is important that the lead agency for EMS has a director with cabinet-level access to a state\u2019s governor. NASEMSO has identified some ideal aspects of the organization and function of state EMS offices. In the future, health care reform will undoubtedly affect EMS agencies, providers, and systems. As the health care system uses more providers to the top of their scopes of practice to fill health care gaps, it is likely that EMS providers will be expected to provide more non-emergency care that is within their scope of practice but not traditionally within their roles in health care. More EMS providers may provide patient care in the hospital setting. EMS providers may be expected to make more decisions that do not lead to transportation to an emergency department and to integrate with systems that navigate some patients to alternative destinations. All of these potential changes from the traditional role of EMS will require state EMS officials and offices to be proactive as regulators and providers of technical assistance to the EMS system."
    },
    {
        "Introduction": "In the United States, transportation of ill or injured patients is typically accomplished by local, ground-based EMS, sometimes supplemented by air medical services. Routine patient transports generally involve point-to-point transfer, from point of injury or onset of illness to medical treatment facility, or direct from one medical treatment facility to another. For incidents requiring simultaneous transport of multiple patients, mutual aid agreements and contingency contracts may be used to access EMS resources from beyond normal, jurisdictional boundaries. This chapter focuses on the planning and execution required for large-scale or catastrophic events, when transportation of hundreds or even thousands of patients is necessary. Patient evacuation under such circumstances differs substantially from routine EMS operations. For example, destination medical facilities may be great distances away to find either specialty care or hospitals unaffected by the incident. Transport of the patients often involves a sequence of multiple transportation modalities, including some that may not be medically configured. It is useful to consider three overlapping phases in a cycle of planning for mass patient movement development of an estimate, using that information to generate a plan, and execution of the plan.",
        "Developing an estimate": "An estimate is developed to characterize specific threats, geographic and demographic information about an area, and populations that may require medical transport in order to identify requirements. The estimate includes potential casualty volumes, and is used to evaluate possible courses of action. Estimates for patient evacuation consider the nature of specific threats, with their inherent effects on patients and their ability to evacuate. The following categories are typically included. \u2022 Physical characteristics \u25e6 Weather \u25e6 Terrain \u25e6 Geology \u25e6 Hydrology \u2022 Transportation nodes, demands, and networks: ground, air, sea/waterway \u2022 Population density and demographics \u25e6 Population at risk \u25e6 Hospitals and other medical facilities \u25e6 Nursing homes and other extended care facilities \u25e6 Special needs (medical) \u2022 Casualties \u2013 numbers and types \u2022 Resources required to move patients \u2022 Resources available to move patients",
        "Threat": "Threats can be analyzed by identifying the most likely and most dangerous hazards that may threaten a given community. Fires or bombs can generate mass casualty events when they involve high-density occupancies or mass gathering venues. In the case of states along the Gulf Coast, the most likely natural threats may be hurricanes, while earthquakes are a greater threat along the west coast and New Madrid faults. Of all threats, which are most likely to occur and what are the consequences? How often do these events happen? Are they predictable or do they occur without warning?",
        "Notice versus no-notice events": "In recent years, mass evacuation and patient movement planning efforts have focused on two types of scenarios: responders are aware that an incident is imminent (e.g. hurricanes or major flooding), and responders have no warning prior to the incident (e.g. earthquakes, detonation of an improvised nuclear device).\n\nIn a \u201cnotice\u201d event, there is some opportunity to conduct preincident evacuation of vulnerable populations, including those in medical facilities, make preparations to shelter them in place if appropriate, and to prestage assets that will be needed during and after the event.\n\nLike the decision to order evacuation of a political jurisdiction, the decision to evacuate medical institutions and custodial facilities before landfall is difficult and multifactorial. The decision maker(s) must weigh the risk of moving patients out of the stable hospital environment against the threats posed. In the case of a hurricane, analysis of the threat considers the strength and direction of the storm, the survivability and sustainability of the facility, whether the facility is located in a known storm surge or flood zone, availability of supplies, and staffing.\n\nThe effects of a \u201cno-notice\u201d event tend to be immediate, causing instantaneous destruction, and may generate large numbers of casualties. Although notice and no-notice events share many similarities, the defining difference is preincident time to implement specific mitigation and response strategies. For discussion of patient evacuation, notice events can involve mass patient movement both prevent, where circumstances may be somewhat more controlled, and postevent. No-notice events may involve evacuation of large numbers of casualties as well as evacuation of damaged medical facilities postincident.",
        "Characteristics of the area": "In conducting the estimate, area characteristics need to be examined in relationship to the threat, the generation of casualties, and the effect on patients and medical evacuation.",
        "Terrain": "What is the terrain like? Where are the low-lying areas? What parts of the terrain are most likely to be affected by a storm surge or lowland flooding? Anything that places transportation networks or nodes underwater is going to hinder medical evacuation efforts. Areas prone to landslides are another hazard. In areas where the principal threat is from an earthquake, geology is key, including the location of fault lines, the types of soil and fill that exist in the area, and the location of bedrock, among other features. This information is critical because the amount of damage induced by an earthquake is somewhat predictable, and will be determined not only by the magnitude and location of the quake but also by the types of ground material under structures.",
        "Threat assessment": "One technique of evaluating the threat is looking at it from combined environmental, socioeconomic, and structural perspectives. For example, a hurricane can produce wind damage, storm surge flooding, debris, and water contamination. The types of injuries and effects on the population's health can be predicted. High waters will generate drowning and exposure victims. Flying debris may produce blunt trauma injuries. In general, however, hurricanes do not typically generate the numbers of injuries that other threats might. As the storm affects local infrastructure, utilities will be lost and transportation networks will be damaged or disrupted. Health care Facilities that are not primarily damaged or flooded may be placed at risk due to lack of utilities, supplies, and staff who cannot get to work.\n\nPublic health issues are also relevant to patient evacuation. Medically fragile populations living at home may need to be evacuated to facilities that can manage their conditions rather than typical school- or church-based shelters. After landfall, people who have been displaced may not have access to their medications or funds, thus exacerbating illnesses that existed before the storm. The lack of potable water can contribute to cases of dehydration, water-borne illnesses, and diarrhea. All of these circumstances can increase requirements for medical evacuation associated with hurricanes.\n\nIn an event such as an earthquake, the environmental factors are different. Given that earthquakes occur without warning, the population at risk may be significantly greater than in a hurricane, because there is little opportunity to seek shelter from structure collapse, falling debris, and in some cases fire.\n\nInfrastructure damage could be severe, depending on the magnitude and duration of the quake. Transportation networks may be disrupted due to collapse of bridges, buckling of roads, liquefaction of airfields, and breaks in rail lines. Medical facilities are at risk not only due to the lack of utilities, staff, and supply channels, but also direct structural damage or failure.\n\nPublic health concerns are similar since in a disaster of this nature and magnitude, populations would be displaced, property would be lost, and access to basic needs such as food, water, and shelter would be difficult.\n\nAfter examining the threat and its possible effects, the next step is to examine the community itself. The vulnerability and characteristic consequences of each type of threat need to be systematically analyzed to determine what needs for mass patient movement or evacuation may be generated in a community or region. FEMA\u2019s Community Planning Guide 201 (Threat and Hazard Identification and Risk Assessment) provides a useful format for performing such analysis [1].",
        "Weather": "Regional weather patterns are important since variances in temperatures and precipitation affect both emergency operations and human performance. High temperatures will contribute to patient dehydration and hyperthermia if patients cannot be sheltered from the environment. Weather can also affect evacuation operations, such as restricting flight operations or exacerbating flooding.",
        "Environmental factors": "How is the land being used? Is it urban or rural? What are the major industries in the area? Where are toxic industrial chemicals or materials likely to be used or stored? These are a few of the environmental factors that require attention as potential generators of casualties or hindrances to evacuation. An interesting environmental factor that altered the medical response by the People's Republic of China to the 2010 Yushu earthquake was the altitude of the Tibetan plateau. Over 75% of the emergency responders developed acute mountain sickness in the first hours to days on-scene, and the decision had to be made to evacuate the hospital patients and victims by air to hospitals at lower elevations.",
        "Population density and demographics": "Population densities and the demographics of the area are another significant characteristic to examine. US Census Bureau databases can help provide a macro-level view of a community. Additional considerations include locations of special populations such as the very old and the very young, since they are among the most fragile and may be more vulnerable to consequences of a disaster.",
        "Location of medical institutions": "The location of medical institutions, including hospitals, nursing homes, long-term care facilities, and hospices, must be identified along with their proximity to known hazard areas. These overlay maps can be conveniently generated using a variety of geographic information systems (GIS) products. If a facility is below the height of a predicted storm surge or located in a flood zone, then it may need to be evacuated before landfall, in the setting of a hurricane.",
        "Structural integrity of medical institutions": "The question here is whether a structure can withstand the threat at hand, whether it be the winds of a hurricane or the shaking of an earthquake. It is useful to document which facilities have been surveyed or rated by engineers for ability to withstand relevant hazards. Many structures may have been \u201chardened\u201d following previous disasters or in response to engineering surveys.",
        "Regional transportation": "Although most routine patient transport occurs by ground ambulance, in a mass medical evacuation, all alternatives must be considered, as demand will exceed available, standard medical evacuation platforms. Further, ground transportation may be limited due to damage to networks and the convergence of responders trying to enter an area while victims are trying to leave. Transportation must be examined from several aspects. First is the identification of transportation nodes, which are the primary locations that serve as access points, intermediary points, and destinations along the transportation network. In the case of medical evacuation, the primary nodes would be hospitals and other types of medical institutions. During a disaster, other points, such as casualty collection points and ambulance exchange points, would also serve as nodes. For larger operations, critical nodes may include airports, rail stations, landing zones, ferry berths, and other ports of embarkation and debarkation. Next, transportation networks need to be identified, including roads and highways, rails, airspace, waterways, and the infrastructure it takes to operate them. Postdisaster, determining which networks are intact and when the damaged ones may return to service is essential. In the event of a catastrophic disaster, all working transportation networks have to be evaluated as possible means for evacuation. Volume and demand will dictate that all viable means are used to move casualties and patients to safety. After identifying the nodes and the networks, planners have to predict how a given disaster such as a hurricane or an earthquake will affect transportation systems and consider ways to either mitigate or work around the likely disruptions. Finally, the demands that will be placed on the system have to be examined and the approach must be holistic. Responders, rescue workers, and various organizations and supplies will likely be coming into the affected area as victims are trying to evacuate the area. Who has priority? What networks will be used, and by whom? What demands will be placed on the system by medical evacuation? These questions have to be addressed in the estimate and in plans at all levels (local, state, and federal) in order for the system to work, but the analysis must begin in the local community.",
        "Estimating requirements for medical evacuation": "Prior to a disaster, patients are already present in various elements of the medical system. Many more are dependent on regular, frequent access to outpatient services, including dialysis, primary care, specialty clinics, narcotics programs, pharmacy, and others. There is also a homecare/medically fragile part of any community\u2019s population, with a substantial proportion being technology dependent and/or mobility impaired. The challenge regarding this particular group is to prospectively identify individuals as well as their residences. Typically the majority are elders living with family members. A catastrophic incident itself will generate casualties that must also be absorbed by the medical system. This rate will vary depending on the type of incident, its magnitude, the time of day, and the population density where it occurs. Medical evacuation requirements generated by a disaster will be determined by the following variables. \u2022 Compromised medical facilities \u2022 Incident-related injuries or illnesses \u2022 Preexisting conditions, including those of patients residing in medical facilities \u2022 Exacerbated problems resulting from the disruption of care or services \u2022 Impact of the incident on vulnerable populations such as the very young, very old, mentally and physically disabled. By knowing the population density, type of threat, average patient census in a community\u2019s medical facilities, and estimated number of casualties that may be generated, it is possible to predict the types of medical support that will be needed, along with transportation requirements for safe medical evacuation. Several factors must be considered when planning for modes of patient transportation. Such factors include, but are not limited to, the following. \u2022 Is the patient ambulatory? \u25cb If yes, does he or she need assistance? \u25cb Can the patient tolerate sitting? For how long? \u25cb Is support or restraint needed for the patient to stay seated? \u2022 Does the patient require a litter? \u2022 Does the patient require specialized equipment that requires oxygen or an electrical hook-up? \u2022 Does the patient require continuous medical care or interventions? \u2022 Does the patient pose a threat to self or others? \u2022 Is the patient chemically contaminated or infectious? These factors, together with total patient volume and distances involved, determine what mode or modes of transportation can best be used.",
        "Modes of transportation": "In the event of a catastrophic disaster where the demand for patient movement exceeds the availability of ambulances and paratransit assets in a local community or state, all modes of transportation have to be considered. Whenever possible, medical evacuation should be performed by standard medical transportation vehicles, with dedicated medical staff on board to move the patient and provide care en route. Ambulances may provide ALS or BLS care, carrying one or two patients per trip. The term paratransit formally refers to unscheduled transportation, provided by many communities for those who have disabilities that prevent them from using the public transportation system. In federal disaster planning, the term is used to indicate a vehicle that can accommodate wheelchair patients. This may be anything from a van or \u201cchair car\u201d to a coach bus equipped with a wheelchair lift. This variability means that planners must determine and request the number of paratransit seats that are required, rather than the number of vehicles needed. When patients or casualties have to be moved aboard non-medical modes of transport, such as high-water vehicles and other trucks, boats, trains, and airframes that are not medically configured, the risks to patient safety have to be weighed against the risk of staying in place. Buses are typically used for ambulatory patients in a mass evacuation. Depending on the patients involved, specific care providers may be needed to accompany patients on a bus. Some plans commit one empty ambulance for every bus convoy in case of emergencies en route. Alternatively, an EMT or paramedic with equipment may be stationed on the bus. Planning considerations for non-medical modes of transportation are shown in Table 33.2. The US Department of Defense (DoD) can deploy resources to assist in the process of medical evacuation during a time of crisis. This is done under the National Disaster Medical System and Emergency Support Function 8 of the National Response Framework. The DoD has a combination of dedicated medical evacuation platforms and non-standard evacuation platforms that can be employed if a state requests emergency assistance. These include military ground and air assets. To deploy these resources during a disaster, the Federal Emergency Management Agency (FEMA) tasks DoD with the mission assignment, and the Secretary of Defense must approve the operation. When a military, non-medical platform is used for evacuation, it is referred to as casualty evacuation (CASEVAC). This means there are no medical personnel or equipment aboard; it is simply a mode of transportation. By completing the estimate process, decision makers will understand the nature of the threat to the community, the demands that will be made on the medical evacuation system, the transportation networks that might be used, and the amount and types of transportation assets that may be required. This is a sufficient amount of information to develop an executable plan.",
        "Planning": "A good plan is simple and flexible. It sets the stage by laying out the situation, threat, and available resources. Such a plan is based on the facts derived from the estimate, and when facts are not available, valid assumptions. The plan provides organization, as it lays out how the mission will be accomplished, what agencies are responsible for what tasks, and how the responders will coordinate with one another. Resources and materials are identified as well as any existing shortfalls, based on the estimate. The medical evacuation/patient movement plan must address how mass casualties will be evacuated from point of injury/illness to definitive care, or how patients will be evacuated from threatened or compromised medical facilities. It must integrate all possible modes of transportation and the networks that enable them. It is also essential to factor in the time criticality of patient movement operations. In the case of a \u201cwarning\u201d event, patient evacuation may take place in a short time interval between the decision to evacuate and onset of conditions that preclude flight or ground transportation. The decision to evacuate is delayed as long as possible in the setting of an approaching hurricane to decrease the uncertainty of its path. Similarly, there is a finite window between wounding and effective medical care following a \u201cno-notice\u201d event. After-action analyses following the Bam earthquake and the Fukushima nuclear incident have correlated extensive delays in establishing processes for medical evacuation with degraded outcomes. Planning and sufficient resources to complete evacuation of the required patient volume before arrival of the threat or within a therapeutic window must be calculated and procured. Equally important, a good plan will clearly define command and control relationships and the ways in which communication will be accomplished throughout the operation. The plan must take the following considerations into account. \u2022 Operational considerations o Ingress and egress routes o Potential obstacles to evacuation o Loading and off-loading areas for ambulances o The need for casualty collection points (CCPs) and holding areas o Establishment of ambulance exchange points (AXPs) o Credentialing of ambulances and EMS personnel o Location and establishment of staging areas o Site access o Security o Medical and support staffing o Work/rest cycles \u2022 Clinical considerations o Triage o Emergency care o En route care o Time sensitivity and constraints \u2022 Logistical considerations o Support for essential operations and services o Medical equipment, supplies, and resources o Buildings of opportunity for CCPs and holding areas o Environmental control (heat, water, light) o Latrines o Blankets, litters, litter stands, straps, backboards o Provision for food and drink \u2022 Command and control (unified command includes interface among authorities having jurisdiction and emergency responders); facilitates coordination with: o Incident commander o Local dispatch o EMS provider(s) o Hospitals and other medical institutions o Local and state emergency operation centers (includes National Guard) o Federal ESF-8 staff (likely located in a joint field office; includes National Disaster Medical System (NDMS) federal partners) o Port authorities o Other agencies and organizations as appropriate Hospitals accredited by the Joint Commission or receiving payments from the Centers for Medicare and Medicaid Services are required to have plans in place for evacuation of their patients to safety when warranted by an emergency. This requirement includes the need for contracts or other agreements with transportation providers to execute them. However, large-scale medical evacuation of an entire region will likely require private, local, state, and federal assets to accomplish the mission. Reporting relationships and authorities of those tasked with coordinating these disparate forces must be clearly delineated in the evacuation plans, and must be practiced regularly or the operation will be problematic. Chaotic operations will be reflected in patient outcomes. Individuals with special medical needs have the responsibility to self-evacuate whenever possible. Experience has shown that many who are poor, elderly, or dependent on medical technology do not have the means to evacuate independently. Local government evacuation plans must provide for this population, including the potential need to request state and federal assistance if resources are inadequate to complete evacuation of these populations within the necessary timeframe. The patient movement component of the NDMS merges federal medical evacuation resources into a unified process. Originally established as a contingency plan for mass casualty incidents involving military troops serving outside the continental US, it was used for civilian patient transport for the first time after Hurricane Katrina in 2005. The largest prestorm patient evacuation using NDMS involved medical facilities along the entire Louisiana gulf coast prior to landfall by Hurricane Gustav in 2008. The major federal partners are the Department of Health and Human Services, DoD, the Department of Veterans Affairs (VA), and FEMA. The DoD has the lead for coordinating patient movement, and maintains the inventory of civilian hospitals that voluntarily participate in the system throughout the country. Both the DoD and the VA support the network of federal coordinating centers that are set up as triage and AXPs at or near the airports to which NDMS patients are flown en route to their destination NDMS hospitals.",
        "Casualty collection points": "Casualty collection points may be established at sites a safe distance away from the immediate threat, and with access to transportation networks. Casualties are brought to these locations, rapidly triaged, given immediate care, and prepared for evacuation. As patients are triaged and sorted, life-saving treatment is administered. Ongoing reassessment and therapy should be conducted as needed in this area. When possible, collection points can be divided into lanes based on triage categories. This will assist in the treatment and rapid transport of casualties from the scene. Ambulances are either colocated with the collection point or staged nearby where they can be called forward. Casualties are loaded onto appropriate vehicles as they become available. They are then evacuated to local hospitals, designated alternative care facilities, or AXPs for evacuation outside the jurisdiction. A system for communicating with destination hospitals and dividing patient volume according to their capabilities and capacity is critical.",
        "Ambulance exchange points": "Casualties are transferred from one mode of transportation to another at AXPs. As part of the planning process, it is important to preidentify locations that may function in this manner. There are several possible reasons for establishing an AXP. First, the situation may dictate that the type of transport asset has to change. Following Hurricane Katrina, casualties and patients were evacuated in boats to AXPs where ground vehicles could be used. Due to the high number of evacuees, it was generally necessary to do a second exchange from ground ambulance to regional holding areas where they awaited the next stage of evacuation via fixed-wing aircraft or buses. Second, when patients are evacuating from an entire region, time and distance factors may determine that the best way to maximize lift capacity is to establish an AXP. This way, local assets can make more trips between the incident scene and the AXP, where aircraft or other modes of transport can complete the evacuation. The federal coordinating centers used to transfer patients from evacuation flights to local hospitals are also AXPs. Local, state, and federal assets may be used at AXPs to facilitate transfer of patients across varying transport platforms. Third, an AXP may serve as a hub, maximizing evacuation capacity by receiving patients from multiple collection points for longer-distance transportation. This is a useful concept when an incident's footprint is very broad, and victims/patients may be triaged to destination hospitals with different medical specialty designations (e.g. trauma, burn, or bone marrow transplant centers following detonation of a nuclear device). Some factors to consider when establishing an AXP include the following.\n\n\u2022 Traffic flow. Whenever possible, the AXP should have easy access to the highway or road network. Vehicles should be able to come into the AXP, off-load the casualties, and then quickly leave without having to back up. The area should be well marked with directional signs and traffic cones. The entry and exit should be easily identifiable. Personnel assisting with traffic direction should be wearing high-visibility identification. Off-loading and on-loading areas. Appropriate areas where casualties can be easily off-loaded and on-loaded to another form of transportation should be identified and marked. If there is any delay between off-loading and boarding the second transport, then it is critical to establish a holding area, preferably in a building that is climate controlled. Medical support. Provisions must be made for establishing some type of medical treatment capability at the AXP if delays between off-loading and loading may occur. This function could be performed by a disaster medical assistance team, Medical Reserve Corps members, or a similar capability that can provide basic medical care. Communications. The local emergency operations center (EOC) must be informed when and where an AXP is established. The EOC should receive updates that include any requirements for logistical support as well as the casualty throughput and the number of casualties on site. Whenever possible, the AXP should have redundant communication equipment. Security. Law enforcement and crowd/access control must be addressed when establishing the AXP to ensure the safety of patients, families, and operational personnel at the site. Landing zones (LZs). If helicopters are used at the exchange point, a formal LZ must be established. When establishing an LZ, consider the following. The minimum requirement for an LZ is 30 m\u00d730 m, with an approach/departure zone clear of obstructions. Sufficient space must be allowed for hovering and maneuvering during landing and take-off. Whenever possible, approach zones should allow the aircraft to land and take off into the wind.",
        "Execution": "In the event of a major incident, local responders will be the first to answer the call and will activate emergency plans using the incident command system (ICS). Casualties must be quickly collected or extricated, triaged, stabilized, and evacuated. Responders must carry out the following tasks. \u2022 Assess the situation. \u2022 What type of disaster, how large an area does it cover, and what is its magnitude? \u2022 How many casualties are there and what types of injuries? \u2022 What are the ingress and egress routes into the area? \u2022 Implement ICS and activate regional contingency plans. \u2022 Communicate the situation to the proper authorities and request additional resources as appropriate. \u2022 Begin medical operations and evacuation. ",
        "Patient evacuation from medical facilities": "In a catastrophic disaster affecting a large geographic area, hospitals themselves may be damaged or destroyed, or may be overwhelmed by patient volume. In these scenarios, patients may have to be evacuated out of the jurisdiction, region, and possibly the state for appropriate hospital care. Based on their location, past experience, and predictions for an impending threat, some hospitals and other health care facilities may choose to evacuate prior to the incident. Medical institutions that have agreements with other facilities outside the affected area can activate their transportation plans, typically involving contracted ambulances and buses, although such resources may be limited during a major, regional event. These institutions must maintain communications with their receiving facilities until the transfer operations are completed. If the transport arrangements fail, then institutions can request assistance for patient evacuation through their local and/or state EOCs. In response to the specific request for assistance, EOC personnel can assemble medical evacuation assets from within the local area or through mutual aid agreements with neighboring jurisdictions. If the demand for evacuation resources exceeds these resources, then the request for assistance would be passed to the state. The state may coordinate deployment of resources from intrastate areas that are not threatened, execute contingency contracts with EMS providers, activate the National Guard, or request assistance from other states using the Emergency Management Assistance Compact (EMAC) or other interstate mutual aid agreements. If assets are still insufficient to meet the demand, it is likely that the state governor will already have declared a disaster and requested a declaration from the president. The Robert T. Stafford Disaster Relief and Emergency Assistance Act (PL 100-707) gives the President of the United States the ability to declare an area a national disaster and authorize the use of federal resources. Federal assistance for medical evacuation falls under Emergency Support Function 8; Public Health and Medical (ESF-8) of the National Response Framework. Medical evacuation for large numbers of hospitalized patients using federal assistance would likely be accomplished through the NDMS. Another transport option that can be used separately or in tandem with the NDMS is FEMA National Ambulance Contract. Among the specifications included in this contract are the capability to get up to 300 ambulances, 3,500 paratransit seats, and 25 medically configured aircraft (can be a combination of rotor- and fixed-wing aircraft) on scene within 12 hours of activation.",
        "Patient evacuation using the NDMS": "When it is determined that patients will be evacuated by the NDMS, a patient movement request (PMR) is generated at the threatened hospital and sent to the state EOC. The PMR identifies the patients by name, sex, age, category, and medical condition, and details any special equipment requirements. The state passes the PMR to the Global Patient Movement Requirement Center (GPMRC) located at Scott Air Force Base, Illinois. It is the GPMRC\u2019s responsibility to regulate the patients from a given hospital to an NDMS-member hospital. The GPMRC forwards the PMR to the Tanker Airlift Control Center (TACC) at Headquarters Air Mobility Command, which is also located at Scott Air Force Base. The TACC matches aircraft and crew with individual flight missions, and sends this information back to The GPMRC, which then relays the information to the state EOC and the receiving federal coordination centers. Once given the mission, military air medical forces are deployed to the airport of embarkation to establish operations in conjunction with local and state emergency responders. When alerted that an aircraft is inbound, the operational commander at the airfield dispatches ambulances to the hospitals to pick up the patients listed on that flight\u2019s manifest. On arrival at the airport, the patients are turned over to a mobile aeromedical staging facility (MASF) team. The MASF prepares patients for flight by exchanging hospital or EMS equipment for airworthy equivalents, ensuring that casts have been bivalved, providing blankets (since the cargo compartments of military aircraft that have been configured for patient transport are cold during flight), and other interventions. Patients are then loaded onto the aircraft with assistance from additional litter bearers. The plane departs the local airport for the designated FCC that will, in turn, arrange for local transportation to the appropriate destination hospital.",
        "Conclusion": "The keys to success in large-scale patient evacuations are: - to prepare an estimate that uses information regarding a threat, demographics, area characteristics, and regional resources to project consequences and response requirements - to develop detailed plans that incorporate potential courses of action and identify all logistics that will be crucial to successful implementation - evaluate, exercise, and periodically practice the plans to confirm that they are executable and effective. All responders involved in mass evacuation and patient movement operations must know their roles and responsibilities and perform them competently."
    },
    {
        "Introduction": "Law enforcement is an inherently dangerous occupation with 1,487 peace officers killed and 625,260 assaulted in the line of duty from 2000 to 2010. This does not include 72 officers who lost their lives during the September 11, 2001 terrorist attacks. Members of special weapons and tactics (SWAT) teams are at even higher risk, sustaining an injury rate of approximately 33 per 1,000 officer-missions. Although beginning as medical support to SWAT teams, tactical emergency medical support (TEMS) now encompasses the provision of preventive, urgent, and emergency medical care during such high-risk, extended-duration, and mission-driven law enforcement special operations.",
        "The TEMS environment and limitations of traditional EMS response": "An early survey of SWAT commanders found that the most common form of medical support for their team was a civilian ambulance on standby at a predesignated location with a crew that had no training in tactical movement or medicine. These findings suggested a need for established TEMS protocols, medical oversight, and specialized training, for several reasons. First, hostile conditions commonly encountered in the tactical arena place standard prehospital care providers at risk. Unprepared and unequipped to deal with these dangers, traditional EMS providers may become patients rather than caregivers. Second, entry into the operational area will be controlled, and access may be denied to non-law enforcement personnel. Also, typical EMS protocols prohibit entry of providers into unsecured environments, preventing timely medical evaluation and treatment of casualties in a tactical situation. Third, although the operational scene may be located in an urban setting, the treatment environment can be functionally austere. Recent military combat experience demonstrated improved survival with specially trained providers, with a 44% improvement in battle casualty survival despite a 46% greater rate of casualties sustained. Fourth, planning for medical contingencies requires knowledge of the planned operation of the tactical team, but law enforcement officials are reluctant to share details of their operational plan due to security concerns. Thus, a more integrated TEMS structure preserves the security of sensitive information while allowing for better planning and improved communication. An understanding of the unique TEMS environment and the proper training to operate in that environment are essential to a successful tactical medical support program to enhance mission accomplishment, avoid liability, diminish disability costs, and maintain team morale.",
        "History of tactical teams and TEMS": "The military has long recognized the value of early and definitive medical care in areas of operations. The success of its approach to embedded medical support has resulted in expansion to units other than special operations. Although they encountered situations similar to their military counterparts, tactical units in civilian law enforcement underrecognized the benefit of medical support, and its establishment remained underdeveloped until 1989 and 1990 when national, multidisciplinary conferences promoted the provision of medical support to civilian tactical teams. Today, the National Tactical Officers Association endorses and supports the incorporation of a well-trained and equipped Tactical Emergency Medical Support (TEMS) element into all tactical teams.",
        "Unique attributes of TEMS": "The medical support of law enforcement tactical operations creates an environment with unique attributes. Medical oversight enhances the development of appropriate protocols and teaching of additional skills.",
        "Zones of care": "The areas of operation for a tactical mission are usually based on the threat level. Traditionally, terms such as inner and outer perimeter have been used. While the concept of static inner and outer perimeters is useful in planning tactical operations, its application to tactical medical support is limited because as the incident evolves, areas of safe refuge or egress may rapidly change. Stratifying the medical areas of operations based on risk better reflects the dynamic process of treating the injured in the tactical arena. The area with the greatest risk is the hot zone, where an immediate threat is present. This risk may be secondary to a known threat or to hazardous conditions. Medical priorities in the hot zone must be limited to patient extraction or applying a tourniquet for life-threatening hemorrhage. Even these procedures may be delayed because of the potential risk for further injury to both the patient and the rescuer. The cold zone is the area with neither significant danger nor threat. Medical care in this area parallels that in the routine EMS world. The warm zone is the area of potential or indirect threat. Medical care provided in this zone is dictated by weighing the risk/benefit ratio and the perceived level of threat. Thinking in terms of graduated zones provides a basis to critically analyzing medical treatment options in a highly dynamic environment. The military, in its Tactical Combat Casualty Care paradigm, has developed a similar classification that also divides the area of care into three zones. Care under fire is analogous to the hot zone. Preventing further injury, tourniquet application, and retreating to safety are the only acceptable interventions. Tactical field care is similar to the warm zone and includes airway management, breathing and circulation intervention. Needle thoracostomy, vascular access, and other immediately life-saving procedures are part of this phase. Tactical evacuation care, or TACEVAC, includes more definitive management as the patient is evacuated away from the threat by any available means and is analogous to the cold zone.",
        "Weapons safety and less lethal weapons": "Tactical emergency medical support providers should be familiar with the specific weapons of the tactical team\u2019s arsenal, along with their associated medical risks and appropriate treatment strategies for patients exposed to them. Basic training in weapon handling is a minimum requirement for the TEMS provider since casual or improper handling can have tragic consequences. Handling of unfamiliar weapons poses an even greater threat, and a protocol for the safe transfer of such a weapon to a tactical team member is encouraged. Weapons designed to incapacitate suspects while minimizing the risk of death or serious injury are known as less lethal weapons (LLWs). They include chemical irritants, kinetic impact projectiles, noise/flash diversionary devices (NFDDs), and conducted energy weapons (CEWs). The term less lethal indicates that lethal effects are less likely than with traditional firearms but that death is possible.",
        "Chemical agents": "Chemical irritant agents are a common tool used for incapacitation and crowd control. They are usually highly effective, though some subjects are able to resist their effects. The most common agent used is oleoresin capsicum (OC) derived from hot peppers and commonly known as pepper spray. Ortho-chlorobenzylidene malononitrile is a synthesized chemical irritant commonly known as tear gas and abbreviated as CS. The agents are chemically unrelated but produce similar effects, with intense burning sensations on exposed skin and mucous membranes within moments of contact. Ocular pain, lacrimation, and blepharospasm are prominent effects. Rhinorrhea and dyspnea are also common although true bronchospasm is rare. Incapacitating symptoms last 10\u201315 minutes and resolve over 30\u201360 minutes. Medical treatment should include removal of contaminated clothing and irrigation with water (OC) or moving air (CS). Formal medical evaluation is rarely needed for either of these agents.",
        "Kinetic impact projectiles": "Kinetic impact projectiles, fired from specialized launchers, include rubber bullets, wood, plastic, and foam batons, and flexible fabric containers containing small metallic beads (beanbags). Kinetic impact projectiles are larger and heavier than traditional bullets and travel more slowly. They present a large surface area which distributes the force of impact, making them less likely to penetrate skin. Impact sites from these weapons should be evaluated carefully for unintentional penetration and for serious underlying injuries. Fatalities can occur with head, neck, and precordial impacts.",
        "Noise/flash diversionary devices": "Noise/flash diversionary devices are designed to surprise and temporarily disorient subjects in their vicinity by producing a bright flash and loud explosion. NFDDs are typically activated and placed by hand though launched projectiles are also used. NFDDs can produce major blast trauma, tympanic membrane rupture, and burns if they explode in tightly enclosed spaces or in close proximity to or in contact with a person. In addition, they are an ignition risk and can cause fires.",
        "Conducted energy weapons": "Although electrical stun gun weapons have been available for decades, modern CEWs are a relatively recent addition to the police arsenal of LLWs. CEWs are similar to pistols in appearance and deliver a series of brief electrical pulses that produce pain and involuntary muscular contractions. The low-current, high-voltage pulses are delivered either by direct contact with the weapon or via a pair of insulated wires attached to sharp metal probes that are fired by compressed gas and are designed to puncture and remain imbedded in skin or clothing to allow completion of an electrical circuit. The most commonly used CEW is the TASER, an acronym for Thomas A. Swift\u2019s Electric Rifle of storybook fame. The electrical pulses of the TASER X26 CEW each contain approximately 0.36 joules of energy at variable voltage up to 50,000 volts. Nineteen pulses per second are delivered for a period of 5 seconds, and the discharge can be truncated or repeated by the operator. Common risks of CEWs include puncture wounds from the sharp probes and blunt trauma from resulting falls, although the overall injuries from CEWs are very low. A large multicenter trial found that 99.7% of real-world suspects exposed to CEWs had mild injuries or none at all. Vertebral compression fractures from intense muscular contraction and ignition of flammables by electrical arcing have been reported. Great debate exists regarding the risk of ventricular dysrhythmias. Current research suggests a very low risk, at one in 2.5 million exposures. However, due to ongoing concerns about deaths in police custody associated with CEW exposure, its safety remains under active investigation.",
        "Hazardous materials": "Clandestine labs pose a special problem for both law enforcement and TEMS providers. Many of the materials used to produce illicit drugs are flammable or explosive, increasing the possibility of burn and blast injuries from ignition due to weapons fire, CEW deployment, or even light switches. Acute and chronic health effects from toxic exposure must be considered since illicit drug operations rarely use safe materials or practice safe handling procedures. Additionally, booby traps are a known hazard of clandestine operations with the potential to cause routine and unusual wounding patterns.",
        "Forensic evidence collection": "Loss of evidence because it was unrecognized, disturbed, improperly stored, or not maintained in a chain of custody can damage an investigation. One study concluded that emergency care providers often overlooked, lost, or discarded forensic evidence. The TEMS physician must have knowledge of the principles and procedures used to maintain evidence integrity. The patient care report should also document forensic findings, including evidence that may be lost in transport or continuing care of a patient, such as firearm soot on clothing or skin.",
        "Special patient populations and excited delirium": "Tactical medical providers may be faced with pediatric, geriatric, and/or chronically ill individuals with special medical needs. In addition, it may be difficult to determine if acute medical conditions are contributing to the behavior of some patients. An example that has received a great deal of attention in the professional and lay press is excited delirium. Excited delirium is a condition characterized by acute onset of bizarre and violent behavior often accompanied by paranoia, combativeness, extraordinary strength, hyperthermia, and incoherent shouting. This state of extreme physiological excitement has been associated with drug abuse, but also with psychiatric illness in the absence of drug intoxication. Police and TEMS personnel who confront these deliriously agitated subjects often require several individuals to help subdue them. Unaware of the underlying serious medical emergency, officers may not anticipate the cardiorespiratory arrest that can follow the physical act of restraining and controlling the subject. The mortality associated with this condition, up to 125 in-custody deaths per year, has sparked high-profile scrutiny of law enforcement procedures, resulting in allegations of excessive force or negligence. Ideally, patients suffering excited delirium should be approached with calm and caution. Standard verbal deescalation techniques or routine LLWs may not be effective given the irrational and altered state of these subjects. Use of CEWs has been proposed as a way to control such subjects while minimizing additional exertion that may contribute to metabolic acidosis and subsequent poor outcomes. Regardless of the control method eventually utilized, careful cardiorespiratory monitoring must follow as this is a medical emergency requiring ALS transport. These subjects should not be left unattended in police vehicles. Principles of management include avoiding the prone position, active cooling for hyperthermia, aggressive IV fluid hydration, and chemical restraint with benzodiazepines, antipsychotics, and/or ketamine.",
        "Preventive medicine": "While most tactical activities are of short duration, operations may last several days or longer. One of the most important but least appreciated components of a comprehensive TEMS program is the proactive skill set incorporating wellness and prevention activities. Because of their medical background, TEMS physicians are well situated to plan and provide for work-rest cycles, personal hygiene, meals, hydration, and the consequences of operating in extremes of temperature.",
        "Primary care": "A large number of injuries sustained in the course of tactical operations are minor in nature, and include sprains, strains, abrasions, and contusions. EMS providers are certainly familiar with these injury patterns, but their scope of practice generally does not allow for definitive care of such injuries. TEMS physicians can provide more comprehensive and definitive care for a wide array of injuries. In remote tactical team operations, where access to other medical care is limited, on-scene medical care of these seemingly minor issues can become critical to prevent further injury or lost work time.",
        "Special equipment": "Equipment for the tactical medical provider (physician or non-physician) can be divided into personal and medical. If providers are to deploy with the team, then they should have the same level of personal protection as the officers. Water should be carried to maintain personal hydration, and a radio should be provided to communicate with the team and local EMS assets. The TEMS provider must be fitted, trained, and familiar with the equipment and its use and must practice providing medical care while wearing the equipment, since it is substantially different from the traditional EMS uniform. Medical equipment must be functional and compact for a hostile environment requiring maneuverability. The amount and type of medical supplies depend on the provider level and should be tailored to the mission. Therefore, a method of carrying essential elements to provide initial treatment should be augmented by a resupply mechanism by maintaining a larger kit in a central location like the command post or vehicle. Emphasis should be placed on managing exsanguinating hemorrhage, airway, breathing, and circulatory support, or XABC. Thus, tourniquets, airway adjuncts, chest seals, and rapid vascular access kits are essential. The added danger of oxygen cylinder damage from projectiles, along with its weight, make its utility limited in the hot or warm zone. Fiberoptic laryngoscopes are also of limited utility in an environment requiring low or no light source. Thus, blindly inserted supraglottic airway devices are typically the airway of choice in the tactical arena. Various hemostatic agents are on the market to assist with hemorrhage control but are typically more useful for large, gaping wounds as opposed to smaller bullet wounds. Among the 679 casualty reports compiled from 4,139 incidents submitted to the Counter Narcotics and Terrorism Operational Medical Support (CONTOMS) database, none has included medical cardiac arrest. Thus, carrying cardiac and code drugs is typically unwarranted. Additionally, the hostile environment of tactical operations precludes resuscitation. If carried for cold zone operations, these medications can be kept at the command post or vehicle.",
        "Tactical training": "An understanding of tactical operations will assist the provider in appreciating the overall mission plan and the roles of each team member. Preplanning is made easier if the medic can adequately assess the direction and objective of the mission. TEMS personnel should have a working knowledge of the tactics and tactical movements of the team. A provider who is not familiar with stealth approaches, or who does not know when to use hand signals, may jeopardize not only a mission but also the lives of team members. Familiarization should be accomplished by participation in training and missions with the team. Attending a basic SWAT school will provide training in operations and tactics, but many civilian providers will not have the time or interest. Through tactical medical courses and on-the-job training, TEMS personnel can achieve the familiarity needed to function with a team.",
        "Unique TEMS skills - Commander\u2019s medical conscience": "Commander\u2019s medical conscience The health and wellness of the team and the public at large are a command responsibility. However, a good tactical physician can and will assist the commander in meeting this responsibility. In essence, TEMS is the tactical commander\u2019s medical conscience.",
        "Unique TEMS skills - Medical threat assessment": "The medical threat assessment (MTA) provides advice to the tactical commander about potential and expected health hazards inherent in an operation. It also evaluates the local medical resources and plans for evacuation of casualties. Information regarding terrain, site hazards, endemic disease, and forecasted weather should be included in the MTA. This information provides the commander with the ability to increase mission effectiveness, credibility, and team morale and may also decrease personnel attrition, costs due to injuries, and legal liability.",
        "Unique TEMS skills - Remote assessment methodology": "At times, wounded individuals may be located in an area inaccessible to direct medical care. Remote assessment methodology (RAM) is a method by which the care provider can attempt to ascertain injuries and condition by visualizing and talking to the victim from a distant location. The injured may be verbally directed in basic life-saving interventions like hemorrhage control, or may be instructed to proceed to an area that provides greater protection. The medical provider may also be able to determine lethal injuries, allowing the commander to obviate a futile rescue attempt.",
        "Unique TEMS skills - Direct physical assessment techniques": "Standard EMS assessment skills may not be applicable in a TEMS environment. The equipment worn by SWAT team members impedes palpation and visual assessment. Poor lighting and the inability to safely illuminate the patient due to restrictions on use of light may add additional barriers. Additionally, other stimuli from weapons fire, distraction devices, and radio communications may interfere with concentration. All of these factors will force the provider to use additional techniques to accurately survey the patient. Two methods, pioneered by the Uniformed Services University of Health Sciences and the US Park Police, include the sensory-deprived physical assessment and the sensory overload physical assessment. These techniques reinforce physical examination skills using senses other than vision.",
        "Unique TEMS skills - Medicine across the barricade": "The TEMS physician may encounter situations where medical problems are occurring in individuals separated from rescuers, and the only means of evaluating the patient is via telephone or radio. In this situation, assessments are made and instructions delivered to a caregiver on the other side, or across the barricade. A template for this activity currently exists in the form of EMS dispatch prearrival instructions. If negotiators allow a tactical medical provider to communicate directly with a perpetrator or victim/hostage, the provider should never agree to a demand, make a promise, or offer to enter the barricaded area.",
        "Unique TEMS skills - Hasty decontamination procedures": "Hazardous materials training is essential for any team raiding clandestine drug laboratories. Techniques for field-expedient decontamination should be practiced routinely and will reduce the risk of spreading contamination during patient treatment and transport.",
        "Tactical medical providers - The TEMS medic": "Competencies and skill sets have been defined for tactical officers and medical providers. However, the scope of practice of prehospital providers varies across the country as defined by state statutes or regulations. Whatever the desired range of skills, the training to properly perform skills in a safe and effective manner must be provided and clearly delineated in a written protocol. Preventive medicine, primary care, and advanced intervention skills will require particular attention, but not all providers will be able to provide these skills. Emergency medical services personnel trained to the first aid or EMT level currently provide most medical support to tactical operations. Regardless of the provider level, tactical teams will benefit from the proximity of dedicated medical support to the operational area.",
        "Tactical medical providers - The tactical physician": "Initial studies of SWAT teams revealed that most teams did not have physician medical directors, and only 10% had physicians as medical support personnel. While physician involvement in TEMS has steadily increased, physician role is varied. The majority of physician team members perform as volunteers. Therefore, time availability and practice constraints are significant determinants of how involved the physician will be. Generally, physician support falls into one of three categories: medical director, TEMS operational team member, or a combination of the two. In a primarily oversight role, the time commitment might be a few hours per month. Functioning as an operational team member, however, can be a much larger commitment since a call-out can last several hours or even days, and training with the team can be time-intensive.",
        "Tactical medical providers  - Medical oversight": "Supporting tactical law enforcement operations is a unique practice environment requiring skills beyond the scope of traditional physician education and even that of standard EMS systems. National educational programs exist to address TEMS, and completion of this training is highly recommended. Model protocols and recommendations for patient care in high-risk settings based on military combat casualty care guidelines have been developed, and these can be incorporated into existing EMS protocols. However, the dynamic environment of tactical operations necessitates greater flexibility in the management of casualties. The completion of a core curriculum course cannot guarantee concept and skill retention, so a continuing education curriculum as well as a prospective quality improvement plan should also be developed for TEMS personnel with oversight from the medical director. Tactical EMS programs are, with few exceptions, much smaller than their traditional EMS counterparts, providing a unique opportunity for a close relationship between the medical director and providers. Perhaps the best argument for physicians at the scene, in support of field operations, is the establishment and nurturing of this relationship. This interface is most rewarding to all participants and will have the greatest yield in improving the quality of care.",
        "Tactical medical providers - Operational team member": "An operational TEMS physician brings a broader scope of practice and experience to bear. Additionally, on-scene medical oversight can obviate the need to call for guidance, reducing the possibility of a security breach. The physician can also perform the more frequent routine care such as sick call, and perform preventive medicine functions. Keeping a team healthy will have a greater effect on team integrity and effectiveness than the thoracostomy or intubation rarely performed in the TEMS environment. Whether the medical director or any physician becomes actively involved operationally is a complex decision. Input from local EMS, law enforcement, medical, and legal communities should be sought as all of these stakeholders will be affected by the deployment of physicians on medical support teams.",
        "Controversies in TEMS - Sworn versus civilian medics": "The position that the tactical medical provider holds within the team will vary. Current models include using SWAT officers who are cross-trained as medics, non-SWAT officers acting as tactical medics, or civilian personnel trained to respond with and support the tactical team. Using a commissioned officer lessens concerns over personal security, evidence preservation, and weapons handling but may result in role confusion during an operation and pose logistical problems in skill maintenance. The concept of one role, one person in TEMS limits role confusion. Using civilian physicians and medics increases the medical knowledge available to the team, but will require a training emphasis on tactical movement, security, and weapons safety. The best balance of these issues should be determined on a case-by-case basis by each team. The use of civilian EMS physicians and providers without any tactical training, experience, or equipment to stand by during tactical operations is an inadequate and inappropriate method of providing medical support for law enforcement operations.",
        "Controversies in TEMS  - Armed versus unarmed": "If the TEMS provider is a sworn officer, carrying a weapon while on duty is usually a requirement. The area of concern is when a civilian is supporting the tactical team. The level of training to acquire firearms proficiency is difficult to maintain and liability issues will undoubtedly arise should an EMS physician or other provider be involved in a shooting. The approach to this issue should be defined locally and involve all of the involved EMS and law enforcement agencies.",
        "Conclusion": "Unconventional hazards are commonplace in tactical law enforcement. Barricaded suspects, hostage taking, clandestine drug lab raids, and high-risk warrant services are some of the missions that are carried out every day that put the law enforcement officers, perpetrators, and the general public at special risk. Manpower maintenance and appropriate medical support are essential to mission accomplishment. The tactical physician can play several important roles in ensuring such medical support."
    },
    {
        "Introduction": "Anyone on a journey of learning about quality will find the roadside littered with acronyms and mysterious terms; ISO, SPC, and Six Sigma are just a few. This chapter will provide the reader with an understanding of the evolution and types of quality initiatives that have appeared during the 20th century. In addition to literacy about common quality improvement (QI) systems in contemporary use, EMS system leaders and others involved in quality should have a fundamental understanding about the setting, concepts, and progression of quality initiatives in recent history. This chapter will highlight the origins and approach of quality systems found in the United States through the hospital, manufacturing, and government influences that shaped them into what they are today. Key differences between the approaches undertaken in the industrial and manufacturing settings and their resulting systems illustrate the opportunities from which EMS and other components in the health care system may benefit. This chapter will describe the genesis and \u201csystems\u201d of quality assessment and improvement that have been or can be adopted by organizations interested in enhancing their performance. To the extent that a person, agency, or tool was instrumental in the discovery or development of the system, they will be addressed in context.",
        "The evolution of quality concepts and methods": "Prior to the 20th century, activities most closely related to quality assurance emerged in medicine and manufacturing in very similar ways: societies or \u201cguilds\u201d of like practitioners or craftsmen formed on a community or jurisdictional basis. These societies set standards and reviewed the performance of individual members, acting against or expelling members for unacceptable performance or behavior. Early in their legislative formation (some as early as the late 1700s), many states yielded the authority to credential physicians to medical societies. Although this was largely an effort to protect the profession, it likely assured some level of quality through the development of community standards of care. The landscape of medicine and manufacturing began to change in different ways in the early 20th century. By 1900, in the United States it was common for states to establish boards and effect physician licensure as a function of the state. This migration marked the beginning of one approach to assuring quality in health care: regulation. The regulatory approach was marked by the states\u2019 decisions to mandate licensure of hospitals by their state health departments, beginning early in the 1900s. Licensure activities typically include some form of application, inspection to assure conformity with minimum standards, correction of conditions that fail to meet the minimum standard, issuance of a credential for a time-limited duration, and a cyclical repetition of these steps in order to perpetuate the license. During the same time frame, medicine in the United States was revolutionized by the work of Sir William Osler, attributed with the \u201clearning science\u201d approach to assuring quality in health care. While Osler\u2019s work did not label him as a quality pioneer per se, the nature of his work at the University of Pennsylvania and then as the first professor of medicine at Johns Hopkins University led to his recognition as an expert diagnostician who viewed consideration of the patient\u2019s state of mind and the underlying disease as equally important. His lasting effect was through changes in learning and curricula for physicians: increased patient contact while in medical school, use of laboratory findings, and authorship of his novel principles in a text that was considered a cornerstone in physician education through the 1920s. Dr Osler\u2019s work channeled the focus of medical institutions and physicians towards education as a means of improving quality evidenced by morbidity and mortality reviews, grand rounds, and clinicopathological conferences that abounded in the health care industry as a result. The field of medicine witnessed other advances in the early 1900s indicative of a learning science predilection. In 1910 the Carnegie Foundation published the Flexner Report, which accused the industry of educational malpractice through \u201cenormous over-production of uneducated and ill trained medical practitioners.\u201d Although this report has been questioned in more modern times in terms of both methods and comprehensiveness, the report is acknowledged as creating a significant focus on improving medical education quality and causing fundamental changes in medical education and practice structure. Another health care quality history landmark was a 1910 proposal by a physician named Ernest Codman. Dr Codman\u2019s concept, called the \u201cEnd Result System of Hospital Standardization,\u201d involved tracking every patient outcome by the attending physician and investigation into the causes of poor outcomes. This was viewed as an antagonistic evaluation of surgeons\u2019 competencies and Harvard University withdrew Codman\u2019s medical staff privileges at Massachusetts General, with the leadership refusing to implement the system. Although other publications describe Codman resigning in disgust and establishing a private hospital where the end-result system was aggressively implemented and published, assessments of the effect of Codman\u2019s concepts agree on one fact: they became a founding objective of the American College of Surgeons (ACS). The founder of the ACS, Dr Franklin Martin, was a colleague of Codman\u2019s who embraced his proposal; the concept of minimum standards for hospitals became part of the ACS\u2019 objectives at the outset. Within 5 years, the \u201cMinimum Standard for Hospitals\u201d was published and the ACS began inspecting hospitals; only 13% of the nearly 700 initially inspected met the five-point criteria. Presumably, hospitals were willing to undergo this form of peer review, and with a shift in focus from the individual physician to the facility as a whole, the ACS process met less resistance than Codman\u2019s system. Since hospitals were expected to modify their practices based on experiences exploring the minimum standards, this process is characterized as another example of a \u201clearning science\u201d tradition within the health care environment. In the meantime, a completely different approach to assurance of quality was evolving in the early 1900s in the manufacturing sector of the United States: treating management as a \u201cscience.\u201d As the Industrial Revolution entered its second wave of impact in the United States, formally trained engineers and other scientists were common in the workplace. Attention shifted from exclusive focus on mechanical issues such as conveyor belt function and scrap management to more elusive issues such as worker productivity and human motivation. Frederick Taylor, an American industrial engineer, made a compelling statement in his 1911 treatise: \u201cWe can see and feel the waste of material things. Awkward, inefficient, or ill-directed movements of men, however, leave nothing visible or tangible behind them.\u201d Frederick Taylor\u2019s work was considered a foundation for the field that is now referred to as scientific management. Manufacturing and other industries found value in the work of Taylor and his contemporaries, laying the cornerstone of scientific management deep within businesses. Their approach placed greater value on the scientific assessment of operations using quantitative approaches, including the use of mathematical models, rules of motion, and standardization of tools and implements. While there was recognition that cooperation had to exist between employees and supervisors, scientific management introduced change by observing work processes and redesigning the steps, tools, and human actions associated with the task. By 1920, the Flexner Report had been credited for medical schools having more tailored entrance requirements, more diverse medical student bodies, and refined curricula; more striking was the fact that 60 out of 155 medical schools in the nation closed during this period. Fundamentally, the contemporaneous efforts of both Mr Flexner and Dr Osler brought dramatic changes to the thinking and process associated with learning, and both yielded perceptions and beliefs that the quality of medical care was improved strictly as a result of the change in education that took place. Another milestone in the history of US health care that ultimately became a mechanism for assuring quality was the licensure of hospitals, evolving during this timeframe as a Department of Health function in individual states. The 1920s was the only decade of exclusive regulation (primarily in the form of police powers to protect the health and safety of patients) by the states before the federal government began preempting states\u2019 laws related to governance of hospitals. Meanwhile, scientific management rapidly grew as the favored approach in the post-World War I industrial environment that was experiencing increasing demand for goods and services and growing organizations. Fortunately, this predominantly engineering focus was complemented by the birth of the behavioral school of management thought when what is now known as the Hawthorne Studies took place at Western Electric\u2019s Hawthorne plant in suburban Chicago. The industrial sector of the United States was laying the groundwork for quantitative workload management and performance considerations tempered by an understanding of human relations and workplace psychology. In the 1920s, Western Electric was also incubating several other processes and pioneers that ultimately made significant contributions to quality science evolution. Primarily a manufacturer of electrical and telephone system components, Western Electric was one of the largest corporations in the United States and one of the few with international presence. Walter Shewhart, an engineer, carefully developed and tested methods that forced leadership to rethink inspection of finished products as the sole means of assuring quality. He devised a statistical method of monitoring and analyzing processes, allowing for the correction of conditions before a defective product was made. His original, elegantly simple concept proposal of a control chart was presented to Western Electric management on a single page of paper in 1924. Within 2 years, Western Electric had established a \u201cquality\u201d department, and appointed Joseph Juran, a young engineer, to lead the unit. Other Shewhart contemporaries were perfecting sampling techniques and by 1931, Shewhart published Economic Control of Quality of Manufactured Product. Regarded today as a foundational text for the study of quality engineering through statistical process control, the work had relatively little impact outside Western Electric and its research branch, known as Bell Telephone, in its first 10 years. Another scientist exposed to these principles during work at Western Electric ultimately carried the first banner on the value of quality management to the outside world: W. Edwards Deming. After his experience at Western Electric, Deming invited Shewhart to lecture with him in the late 1930s at the US Department of Agriculture Graduate School. Shewhart had continued his statistically centered focus on quality (which also led to his definition of the Plan-Do-Check-Act cycle) and published Statistical Method from the Viewpoint of Quality Control. Deming transferred to the US Census Bureau to assist with sampling techniques and in 1940, he implemented the first statistical process control use in an environment outside manufacturing as he managed clerical operations in the US Census Bureau during the 1940 census. Meanwhile, Juran continued his work in quality management in the Bell system, training and publishing handbooks for employees. In the 1940s Juran published his conceptualization of the \u201cPareto Principle,\u201d hypothesizing that management challenges could be classified and prioritized following an 80%/20% pattern. This principle had actually been published more than 40 years earlier in a series of texts on economics by the politically riddled economist Vilfredo Pareto, who postulated that a universal logarithmic formula governed the distribution of wealth. Professor Pareto\u2019s formula asserts that 20% of the people in a jurisdiction (any jurisdiction, anywhere in the world) hold 80% of the wealth. While empirical studies conducted since have reinforced this, the concept was adopted by Juran to distinguish between the issues (80%) over which supervisors had control, versus the reminder (20%) over which the workforce had control. Juran\u2019s and others\u2019 adoption of Pareto\u2019s assertion for other management beliefs drew criticism but Juran maintained that studies performed in the 1950s and 1960s also supported his application, which further evolved into the reference during root cause analysis to the \u201cvital few\u201d and \u201ctrivial many.\u201d These three already productive parents of quality management \u2013 Shewhart, Deming, and Juran \u2013 may have fathered a very different beginning for total quality management than they eventually did had their lives and the work of the US government not been detoured by the onset of World War II. The federal \u201cWar Department\u201d supporting the deployed armed services had two needs requiring them to reach out into the private sector: materiel and expertise. Subject matter experts were solicited from large businesses to assist with federal administrative functions, including Joseph Juran. Deming\u2019s transfer from census work to the War Department resulted in the concepts of sampling and control charting as requirements for materiel suppliers. These standards, essential for quality assurance and conformity of goods and services provided throughout the country, evolved into formal specifications that became commonly referred to as \u201cMIL STD\u201d (military standards) or MIL specs. These MIL procedures dictated sampling, machine calibration, schematic, and quality control practices in the interest of avoiding defects, or errors, in products or processes. The counterpart sentiment of employee value and involvement was evidenced by the introduction of the practice of \u201cquality circles\u201d on factory floors by the late 1940s. Medicine learned and benefited \u201con the job\u201d at war: physics and genetics (courtesy of the atom bomb), antibiotics, and unprecedented organized care behind the lines were key improvements but nonetheless individual discoveries or accomplishments, not the result of an overall strategy to improve quality per se. Military publications emphasize that the overall specialization of providers in subsets of skills, acceleration of training, and provider preparation for disease and trauma care not routine in typical practice settings became the focus as the military became the single largest producer or preparer of medical providers. In 1939 alone, the prewar mobilization of the \u201cMedical Department,\u201d a subordinate entity within the War Department, required an explosive increase of enlisted medical personnel and officers from less than 11,000 to 140,000. After the war, the American public\u2019s definition of quality health care was abundant health care. The ACS continued to assess hospitals\u2019 conformity to basic minimum standards, having assessed over 3,000 hospitals by the early 1950s. In a transition not unlike that of the shift for physician credentialing from societies to state regulatory bodies, ACS joined forces with the American Hospital Association, the American Medical Association, and others to form the Joint Commission on the Accreditation of Hospitals (JCAH) in 1952. The perspective was retrospective and geared towards confirming a standard of care through conformity of practices, not error prevention. It would be nearly 20 years before the JCAH retuned its standards to achieve \u201coptimal achievable\u201d versus \u201cminimum essential\u201d levels of quality. A more commonly known aspect of quality management history in the late 1940s was the impact of Deming on the Japanese manufacturing sector. Less commonly known is that Deming went there as part of an entourage sent by the War Department to help rebuild Japan\u2019s postwar infrastructure \u2013 by studying agricultural challenges! Another source cites the reason as assisting with Japanese population estimation for the US government but it is nonetheless often overlooked that Deming did not go to Japan as a quality guru initially. It was during his visits that he convinced a rising Japanese statistician of the value of using statistics in the industrial sector. Deming returned to Japan five times to teach and consult with the blessing of the Supreme Commander of the Allied Forces; Shewhart was the preferred instructor, but he was unavailable. Deming\u2019s presentations, ultimately referred to as the \u201cDeming Method,\u201d urged a statistical approach to managing quality. Juran followed, doing numerous presentations for Japanese executives as well. His training centered on his professional conclusions at that point: systems of quality management were an absolute necessity for a successful organization. \u201cMade in Japan\u201d had historically meant low-cost, shabby products. By the 1960s, the influence of Juran and Deming was clear as the Japanese achieved market leadership in the automobile and electronic sectors. Engineering schools in the US were incorporating statistical quality control classes into their curricula, but the US was behind the quality curve. While other new thinking evolved in the regulatory and industrial sector of the United States, such as \u201cgood manufacturing practices\u201d and \u201cmanagement by objectives,\u201d an international organization that would have a lasting effect on quality in the US was being birthed: \u201cISO.\u201d The International Organization for Standardization published its first technical standards (numbering in the hundreds) in the 1950s. The value and purpose of the ISO, presently composed of representatives of 148 countries\u2019 national standards institutes, are best stated in its own \u201cWhat if Standards Didn\u2019t Exist?\u201d literature: \u201cIf there were no standards, we would soon notice. Standards make an enormous contribution to most aspects of our lives \u2013 although very often, that contribution is invisible. It is when there is an absence of standards that their importance is brought home. For example, as purchasers or users of products, we soon notice when they turn out to be of poor quality, do not fit, are incompatible with equipment we already have, are unreliable or dangerous. When products meet our expectations, we tend to take this for granted. We are usually unaware of the role played by standards in raising levels of quality, safety, reliability, efficiency and interchangeability \u2013 as well as in providing such benefits at an economical cost.\u201d During the 1960s ISO issued thousands of standards using an elaborate but well-orchestrated system of subject matter experts and technical committees. Standards and requirements for hospitals took a dramatic turn in the 1960s as well. Congress enacted a requirement of JCAH accreditation for hospitals participating in Medicare and Medicaid. Soon afterwards, utilization review committees (staffed by hospitals\u2019 own clinicians) were mandated by Medicare. Intended to prevent fraud in reimbursement practices, this was the first vestige of performance assessment on a system-wide basis. These committees had no criteria to use in their evaluation processes, no incentive to thrive, and no mechanism for interfering with reimbursement. By 1970, despite resistance by the AMA, the federal government had introduced professional standards review organizations (PSROs). There is greater evidence of quality-related efforts in health care than manufacturing in the 1970s. Stagnation or poorly channeled energies in US manufacturing quality control efforts were apparent as focus on productivity and quotas was greater than customer preferences and satisfaction. Foreign producers (especially Japan) had eclipsed the US with design-based and systems approaches to quality. Manufacturing productivity in the US was increasing only half as fast as in Japan. American executives traveled to Japan in an effort to capture and replicate the Japanese success, but they returned with individual tools such as quality circles and missed the overall system underlying the industry advantage. The 1970s saw a quality thinking breakthrough in the healthcare industry as a physician named Avedis Donabedian introduced the paradigm of structure, process, and outcomes as a means of organizing and assessing quality. Beginning with an article in 1966 and with a pinnacle of three volumes in the early 1980s, Donabedian effectively refocused the questions on healthcare quality and provided a framework that would bring some order to an otherwise complex set of issues faced in hospital settings. Despite his death in 2000, his body of knowledge lives on in eight books, over 50 journal articles, and countless references to structure, process, and outcomes. The 1970s were also the formative years of EMS systems in the US. Congress acknowledged the value of EMS systems in 1973 in the EMS Systems Act (Public Law 93-154), which stipulated that one of the 15 essential components of an EMS system was review and evaluation \u201cof the extent and quality of the emergency health care services provided.\u201d In what may be the only administratively oriented EMS text published in the 1970s, Jelenko and Frey refer to process and outcomes in EMS as \u201ca little explored area.\u201d During this decade the first peer-reviewed articles specific to quality of out-of-hospital care were published in US journals, totaling 26 articles by 1979. In 1980 a documentary catapulted quality into the spotlight in the US as only television can do. If Japan Can\u2026Why Can\u2019t We? featured Deming and the quality methods he had taught the Japanese. His telephone ringing off the hook the next day indicated that Americans in the manufacturing sector finally understood that it took a systematic approach. The US Navy was awakened by two Navy Personnel Research and Development Center psychologists, one of whom saw the documentary and the other who went to a Deming lecture in 1981. Four years of planning ensued, and by 1985 a program was launched that was very successful, ultimately gaining considerable momentum. Even the name \u201ctotal quality management\u201d was born in the Navy; the label was recommended by a behavioral scientist as a more palatable alternative to the common reference in Japan, \u201ctotal quality control.\u201d Total quality management (TQM) enjoyed over a decade of heralding, book publishing, seminar offerings, and consultant opportunities. However, concrete definitions and applications were elusive, and while many organizations could embrace the concept and value of improved quality, training was likely to result in increased knowledge but no tangible skills. In addition to Deming\u2019s 14 points, akin to \u201crules of the road,\u201d other constructs emerged. A journal article describing TQM use in the public sector listed the principles as management commitment, employee empowerment (teams, training), fact-based decision making (the seven statistical tools, statistical process control, etc.), continuous improvement, and customer focus. The Joint Commission on Accreditation of Hospitals, about to change its name to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), influenced health care institutions in the 1980s as a quality \u201cassurance\u201d plan became part of the JCAHO inspection. Additionally, the PSROs evolved into regional professional review organizations with more binding standards and a contractual scope of work required to be updated periodically under contracts with the US Health Care Financing Administration. These efforts were largely retrospective inspection techniques, although in 1986 the JCAHO formed a not-for-profit consulting subsidiary, Quality Healthcare Resources. Both the JCAHO and the AMA published models for quality assurance processes and systems, although the AMA guidelines focused almost exclusively on peer review activities. The JCAHO has continued with additional performance improvement initiatives to present as a primary influence on hospital-based quality assessment. Little awakening to quality in EMS was evident in the 1980s. Only 36 articles related to quality in EMS were published between 1980 and 1989, up marginally from the previous decade. The comprehensive Systems Approach to Emergency Medical Care, published in 1983, devoted an entire chapter to the subject of operational and clinical evaluation. While the chapter thoroughly addressed program evaluation models, structure, process, and outcomes, and offered an exhaustive list of references, it probably was not ferreted out by EMS administrators interested in quality since it was buried in a voluminous textbook. The \u201cpop\u201d EMS administration text of the decade, Managing Emergency Medical Services by Newkirk and Linden, had a chapter entitled \u201cQuality Control\u201d but its focus was on employee appraisals and retrospective reviews of emergency responses. Most notable about the era was that both the National Association of EMS Physicians and the American College of Emergency Physicians conducted EMS-specific quality improvement conferences and published textbooks on the subject. The very foundation of quality efforts in the US was re-poured in 1987 as the result of two separate projects of national and international origin: ISO 9000 and the Malcolm Baldrige National Quality Award Program. As described earlier in this chapter, the ISO focused almost exclusively on manufacturing and product standards initially; it would have a profound effect on organizations interested in quality management when were issued. Some of the early reaction in the US was negative. Despite the influence and contribution of US work in quality to the ISO 9000 family of standards, misconceptions hampered its acceptance. Some of these myths included that these were \u201cforeign\u201d standards not appropriate to US businesses, a source of voluminous paperwork, and weak in their specificity about statistical methods. ISO 9000 can be thought of as a header or book title, with the underlying chapters (ISO 9001, ISO 9002, etc.) containing the details of quality systems, management, and elements characteristics. The standards were written generically in an attempt to make them applicable to any business setting. Following the 1994 revision of the standards, nearly 400,000 organizations worldwide met or exceeded the standards and proved themselves with external validation and registration. Given the complexity of quality management issues, the content of the of the standard had expanded to over 20 different standards and documents. When it was revised beginning in 2000, the standards\u2019 names and content changed accordingly. ISO 9000:2000 \u201cQuality management systems \u2013 Fundamentals and vocabulary\u201d ISO 9001:2000 \u201cQuality management systems \u2013 Requirements\u201d ISO 9004:2000 \u201cQuality management systems \u2013 Guidance for performance improvement\u201d For some organizations pursuing ISO 9000 and the associated registration was a necessity in order to do business in or with a European country; for others it was a programmed way to implement or formalize quality improvement initiatives. Several European governments chose to embrace quality as a national initiative, often endorsing or elevating that country\u2019s ISO 9000 equivalent as a national standard. In the United States however, a completely different initiative evolved: the legislation that ultimately became the Malcolm Baldrige National Quality Improvement Act of 1987 (Public Law 100-107) comprised only four pages of text. The original Act called for awards to be issued to small business and \u201ccompanies.\u201d In the late 1990s, the National Board for Quality Promotion (NBQP) responded to the education and health care communities by publishing criteria unique to those sectors. The core content is largely the same, however, with adjustments made to terminology to reflect what is typical in that sector. For example, the criterion labeled \u201cCustomer and Market Focus\u201d in the business criteria is named \u201cFocus on Patients, Other Customers, and Markets\u201d in the Health Care Criteria for Performance Excellence. The remaining categories in the health care criteria are: leadership, strategic planning, measurement, analysis, and knowledge management, staff focus, process management, organizational performance results. In his cover letter accompanying the 2004 criteria, the director of the BNQP addresses the value and utility of the criteria in efforts to \u201calign resources and approaches, such as ISO 9000, Lean Enterprise, Balanced Scorecard, and Six Sigma; improve communication, productivity, and effectiveness; and achieve strategic goals.\u201d This emphasizes that the Baldrige criteria are a framework or architecture, not a quality system in and of themselves. While that may have been the bone of contention for Deming, it speaks to the utility that the criteria may have for EMS agencies as a starting point when coupled with a body of knowledge about quality management. Motorola, one of the winners of the Baldrige Award the first year, had an important quality armament that led to its success in the BNQP application process: Six Sigma. An outgrowth of their TQM processes in the mid-1980s, Six Sigma was launched in January 1987 after a senior engineer made a proposal to the CEO in a manner reminiscent of Shewhart's one-page proposal about the concept of control charts. Motorola was committed to unprecedented levels of improvement, and a new system of achieving and measuring that degree of change was needed. Sigma is the name of the Greek symbol used in statistics to represent the standard deviation of the true population mean. Under a normal curve, about 65% of values will fall within one standard deviation on either side of the center, or average value, 95.5% will fall within two standard deviations, and so forth. Typically we don't refer to or calculate beyond three standard deviations, since 99.7% of values are captured at that point. The Six Sigma philosophy, however, is very concerned about the 0.27% beyond that boundary when it is an important process. While one-quarter of 1% may seem like an infinitesimally small number to worry about, it actually calculates as 1 out of 370. In high-stakes manufacturing and other public and private sector industries, ways of measuring and expressing 1 out of 1,000, 1 out of 10,000, and 1 out of a million would be a necessity. Leaving the specifics to more detailed texts on the topic, or are ranges that account for some common variation occurring in a process, but allow measurement at that greater level of specificity. So, at four sigma, our process is defective in 6,210 out of 1 million events or opportunities; at five sigma, only 233 out of a million fail to meet our expectations; and at the Six Sigma level, 3.4/1,000,000 events result in a misadventure or defect. The US airline industry is often used as an example of attaining Six Sigma level quality when evaluating fatality rates of passengers: the death of 19 passengers after one or more of the 9.8 million scheduled departures in 2003 equates to just over two deaths per million flights. Six Sigma is much more than its measurement system, however. It is a framework of pursuing quality solutions based on both process analysis and statistical analysis under the lens of the customer's expectations. This balance allows for true diagnosis of the problem an organization is trying to solve, and is applied on a project-by-project basis. Motorola discovered that its utility was not limited to the manufacturing floors. Its early utilization proved that Six Sigma could be leveraged for business, administrative, and service functions. Through an alliance with IBM, Texas Instruments, and Xerox, a system of executing Six Sigma projects was defined, allowing other organizations to adopt and deploy this powerful business strategy. This has created a common platform on which Six Sigma learning and comparison can take place across not only different organizations but even disparate disciplines. Somewhat evocative of Shewhart's Plan-Do-Check-Act cycle, Six Sigma projects follow a prescribed sequence of steps, entitled Define, Measure, Analyze, Improve, and Control. Each of the steps has important subprocesses that assure identification of characteristics critical to customers, thorough investigation of root causes, a complete understanding of the nature and frequency of the problem, mathematical modeling that allows for hypothesis testing, acceleration of detection and feedback loops, diagnosis of the condition, selection and trials of solutions, and control systems to assure the problem does not recur. The approach can be applied to any situation where an organization wants to accelerate a process, reduce the cost of a process, or reduce the number of events that do not meet a specification. General Electric brought Six Sigma into the national spotlight in the late 1990s with annual reports and speeches to shareholders revealing the extraordinary savings and successes the organization was enjoying as a result of its Six Sigma deployment. Two-thirds of Fortune 500 firms initiated Six Sigma programs during the same time frame. Six Sigma is gaining popularity among health care and other industries, including Johnson & Johnson, Cigna, Blue Cross and Blue Shield licensees, hospitals such as the Mayo Clinic, and many more since its disciplined approach translates well into virtually any setting. Its methodology is ultimately powerful in facilitating a transition for organizations to an evidence-driven way of doing business with technical advantages that distinguish it from TQM and other quality predecessors.",
        "Institute of Medicine": "Perhaps no other organization has had such a profound effect on health care quality in the 21st century as the Institute of Medicine (IOM). The IOM is the medical arm of the National Academy of Sciences (NAS) and is an independent, non-profit organization, whose mission is to give authoritative, unbiased information to decision makers and the public. The IOM convenes expert committees to critically evaluate and summarize information on issues central to health care, publishing their summaries.",
        "Primum non nocere": "To Err is Human \u2013 Building a Safer Health System was published in 1999 and documented the magnitude and effect of medical errors in health care. Identifying medical errors as the sixth most common cause of death in the US garnered tremendous media attention and, predictably, governmental scrutiny. Congress began hearings on this issue and other authors and countries embarked on further study to assess the scope of medical errors. A subsequent report by the World Health Organization identified that one in ten patients receiving medical care will suffer preventable injury. The IOM report called for the establishment of a Center for Patient Safety and other efforts to focus the attention of the health care system. This initial report fundamentally changed the dialogue of how medical care was assessed and provided in this country. Crossing the Quality Chasm: Creating a New Health System for the 21st Century, published in 2001, called for a fundamental redesign of the American health care system to improve quality. It focused on the need for a systems approach to optimize health care, and identified that \u201cthe nation\u2019s health care delivery system has fallen far short in its ability to translate knowledge into practice and to apply new technology safely and appropriately.\u201d It identified specific aims for a revitalized health care system, creating a system that is: safe: avoiding injuries to patients from the care that is intended to help them effective: providing services based on scientific knowledge to all who could benefit, and refraining from providing services to those not likely to benefit. patient centered: providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions timely: reducing waits and sometimes harmful delays for both those who receive and those who give care efficient: avoiding waste, including waste of equipment, supplies, ideas, and energy equitable: providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. The report identified ten rules for redesign based on the above care principles. It called for the Agency of Healthcare Quality and Research to develop care processes for 15 common health care conditions, to develop a listing of those conditions, and to work with stakeholders to develop action plans to implement this process. Other key principles espoused included the application of evidence to health care, expanding the use of information technology, and aligning payment policies with quality improvement. These topics have become the foundation of the philosophical, technological, and financial changes in the modern health care system. Much of health care has now coalesced around the core principle of evidence-based practice. The need for information technology has revolutionized medicine through the dramatic implementation of electronic health care records. Finally, the call for payment to be aligned with health care quality has been foundational in the evolution of payment for health care services to hospitals and other providers.",
        "Pay for performance and public reporting": "Public reporting of quality of care was a concept developed through a collaboration of hospitals, the Association of American Medical Colleges, and CMS. This \u201cvoluntary\u201d program\u2019s purpose was to invigorate quality efforts by allowing competitors and the public to compare selected quality measures of hospitals. It was linked to the annual Medicare update (payment adjustment) by CMS, and as a result 98% of all hospitals agreed to participate in the program. It allowed the public to access hospital process and outcome data through a public website. Initial data were reported in 2003 and compared hospital performance regarding the care of patients with congestive heart failure, myocardial infarction, and pneumonia. This program has continued to grow dramatically, and now includes measures of emergency care, patient satisfaction, and many other measures of health care performance. Pay for performance, also known as value-based purchasing, evolved through the first decade of the 21st century to improve the value for health care dollar spent. While it addresses the laudable goal of improving health care system efficiency, the driving force for this initiative was both economic (decrease waste and improve expenditures on necessary care) and political (legislators can demonstrate fiscal responsibility). Two subsequent IOM reports led the way for this rather fundamental change in health care quality initiatives. The first, a 2006 report on \u201cpreventing medication errors,\u201d recommended incentives to align patient safety goals with provider, industry and insurer profitability. The second, Rewarding Provider Performance: Aligning Incentives in Medicare (2006), identified that the health care system doesn\u2019t recognize or reward the coordination of care. Nor did it reflect the value of health care in patient care quality. The report recommended pay for performance programs as an \u201cimmediate opportunity\u201d to align incentives for performance improvement. A key driver for this economic initiative was Congress which, in enacting the Deficit Reduction Act of 2005, called for CMS to develop a plan for \u201cvalue-based purchasing\u201d by 2009. One example of this approach to reimbursement was to pay hospitals an incremental incentive for care of a specific type of disease. If patients sustaining myocardial infarctions received timely reperfusion (door to balloon angioplasty within 90 minutes) in a reliable manner (>90% of the time), hospitals would receive an incremental increase in CMS payment. In at least one analysis, Lindenauer et al. demonstrated a modest (2.6\u20134.1%) improvement in quality measures for hospitals participating in a pay for performance program, compared to those that did not. Though conceptually sound, clinicians, academicians, and administrators identified a host of concerns regarding relative value of interventions, appropriate measures of quality, additional administrative burden of data collection, and data accuracy. An additional concern was raised regarding case mixes and the relative effect that higher acuity, such as seen in tertiary care hospitals, might have on efficiency of care and on outcomes. Finally, a universal concern was raised regarding the ethical concern that programs focused on outcomes may misalign incentives for care between physicians and patients. A non-compliant diabetic with an elevated hemoglobin A1C, for example, may result in a decreased payment to their physician, who in turn may decide to refuse to care for that patient. Such concerns did not dissuade payers (primarily CMS) from implementing such programs and they have, in fact, continued to expand programs that require payment for meeting certain thresholds (e.g. 100% rate of aspirin administration for patients with acute myocardial infarction). To address concerns of providers, the US Department of Health and Human Services (DHHS) awarded a contract to the National Quality Forum (NQF) to establish a portfolio of quality and efficiency measures (core measures) that will allow the federal government to more clearly see how and whether health care spending is achieving the best results for patients and taxpayers. The contract is part of a provision in the Medicare Improvements for Patients and Providers Act of 2008. The NQF is a private-sector, consensus-based standard-setting organization composed of a variety of stakeholders whose mission is to define goals for performance improvement, standard setting, and public reporting of performance.",
        "The Affordable Care Act": "The Affordable Care Act (ACA) was enacted in March 2010 and promises to fundamentally change the American health care system more than any other legislation since the enactment of Medicare. The ACA will also result in a dramatic expansion in the use of electronic medical records in health care, which should facilitate data retrieval for quality efforts and improve access to outcome data for evaluation of care. As of this writing, the ACA has not become fully implemented, and the authors are speculating as to its future effect on health care quality, other than to opine that it will be profound.",
        "Conclusion": "Emergency medical services in the US are still in their adolescence of incorporating quality improvement as a mainstream activity. This historical review illustrates the strengths and effects of different approaches, including learning science, regulation, management science, and systems of quality assessment and performance improvement. Hospitals and manufacturing firms followed very different paths over the last century, allowing the reader to recognize origins and cycles in various systems and put them to use appropriately. Health care quality initiatives have now moved dramatically into the public view, and quality and reimbursement, through pay for performance initiatives, have become inextricably linked. EMS organizations will need to integrate quality principles developed in industry and medicine to improve system operations, financial viability, and patient outcomes."
    },
    {
        "Introduction": "Telemedicine/telehealth is the use of medical information exchanged from one site to another via electronic communications to improve a patient's clinical health status. EMS, with its pioneering use of radio for medical oversight and transmission of ECG telemetry in the 1960s, has and continues to have a leadership role in the use of telecommunications technology to provide medical care at a distance. This chapter will review the applications of telemedicine in EMS and the technologies which facilitate the provision of emergency prehospital care at a distance, discuss the effect of telemedicine on prehospital practice both in the emergency department (ED) and in the field, and provide a platform of knowledge which EMS providers can use as they develop solutions to current health care problems using telemedicine technologies.",
        "EMS telemedicine applications": "In the book Essentials of Telemedicine and Telecare, Norris categorized the practice of telemedicine into four types: teleconsultation, tele-education/telementoring, telemonitoring, and telesurgery. The different types of information being transmitted can include voice, video, and data. Any part of those types of communications can be one-way, two-way, or in multiple directions with multiple participants. The transmission of information can occur in real time (synchronous) or be interacted with at a later time (asynchronous or store-and-forward). In some instances, the exchange of medical information is between an EMS provider and physician, an expert EMS resource, or subject matter specialists; between a patient and a provider in an EMS setting; or between a patient and a provider in a health care setting that may significantly affect the utilization of EMS services.",
        "Teleconsultation": "The most prevalent example of teleconsultation is voice-only communication over telephone or radio. In the hospital, this is commonly seen when a physician consults another physician for a second opinion via telephone or when a radiologist reads a patient's imaging that is in a digital format. Outside the hospital, it is commonly seen when EMS providers contact a base station physician for advice and instructions. With the advancement of technology, teleconsultation now allows for patients, physicians, and EMS providers to have video in addition to audio communication with a physician in real time; for example, as in a telesstroke consultation helping EMS determine patient destination and prearrival preparation for the ED. Recent review of the evidence base reveals a number of avenues from which a patient or EMS provider may benefit with the use of telemedicine.",
        "Prehospital medications: thrombolytic use in cardiac events": "The 2013 ACCF/AHA guidelines for ST-elevation myocardial infarction (STEMI) transitioned \u201cdoor to balloon time\u201d of \u226490 minutes to the more rigorous \u201cfirst medical contact to device time\u201d of \u226490 minutes. First medical contact is typically defined as the first EMS provider on scene who can perform a 12-lead ECG, though some consider it to be the dispatcher answering the 9-1-1 call. It also describes the ability to reduce delay from symptom onset to treatment by administering prehospital fibrinolytics either by an EMS unit with a physician on board or in direct contact with a hospital-based physician. Multiple randomized controlled trials have demonstrated the safety and feasibility of prehospital fibrinolytics. The majority of these studies were performed in the UK or Europe and the use of thrombolytics in the prehospital setting for STEMI patients in the US is rare. Many EMS systems use telemedicine to obtain a 12-lead ECG in the field and transmit, usually by cellular phone to fax, to a receiving hospital in an effort to prenotify the hospital and activate the cardiac catheterization lab. Mavrogeni et al. reported the success of using telemedicine (remote transmission of ECGs) to supervise the administration of thrombolytics in six rural medical centers in Greece. Bj\u00f6rklund et al. showed that with the assistance of telemedicine (ECG transmission to hospital CCU and telephone review of indications with cardiologist), they were able to administer prehospital thrombolytic therapy and in doing so not only reduced time delay of treatment by approximately 1 hour but also reduced 1-year mortality by 30% compared to those STEMI patients who received in-hospital thrombolytics. Similarly in Scotland, Pedley et al. were able to use telemedicine equipment (mobile telemetry link with radio to emergency physicians) to assist in making decisions to administer prehospital thrombolytics to STEMI patients, and decrease time delay of treatment by 73 minutes in comparison to patients who received in-hospital thrombolytics.",
        "Telestroke": "Reports from the TeleBAT (Telemedicine for the Brain Attack Team) program at the University of Maryland in 2000 and 2004 demonstrated the feasibility of performing stroke evaluations by remote neurologists using cellular narrow bandwidth videoconferencing (one image every 2 seconds) in ambulances. A more recent pilot study has looked at the feasibility of prehospital transmission of real-time streaming video, vital data, and still picture transmission facilitating neurological evaluation. Initial conclusions have established the feasibility of teleconsultation while raising concerns over delays in care with patients managed using this system. An article by Liman et al. also raised concerns over the technical implementation and clinical usability of a typical telestroke \u201cevaluation in the ambulance\u201d system. A recent German study has shown that EMS stroke response with a computed tomography (CT) scanner equipped ambulance with an onboard neurologist and teleradiological support can potentially shorten times to stroke treatment with thrombolytics. It remains to be seen how the latest generation of telemedicine systems specifically designed for use in the ambulance setting, such as LifeBot DREAMS\u2122 and e-Bridge from General Devices, perform in facilitating examinations while preserving or enhancing timeliness to indicated thrombolytic care. Additionally, in the absence of a CT scanner in the field, the question arises whether telemedicine examinations by emergency physicians or neurologists are superior to examinations and decision making over stroke center referrals by EMS personnel with training in stroke assessment.",
        "Patient transport decision making": "Air medical transport is an integral component of the EMS system, allowing patients to be moved quickly to a suitable facility for appropriate medical care. Its introduction into the civilian world began in the 1970s after military air medical evacuation experiences during the Vietnam War had shown the effectiveness of helicopters for removing wounded soldiers from the battlefield. There is growing controversy about the overutilization and cost-effectiveness of air transport over ground transport. A retrospective analysis by Shatney et al. of 947 trauma patients transported by air in an urban setting showed that although transport time was decreased when using a helicopter, only 22.8% of the population benefitted from the quicker transport. Similarly, Bledsoe et al. performed a metaanalysis of 37,350 trauma patients transported by helicopter from the scene of injury. They measured the severity of the injuries using Injury Severity Score, Trauma Score, and Trauma Score Injury Severity Score and found the majority of the patients had minor or non-life threatening injuries (60.0%, 61.4%, and 69.3%, respectively). In order to determine if the routine use of helicopter EMS is cost-effective, Delgado et al. developed a decision-analytic Markov model to compare the costs and outcomes of helicopter versus ground EMS. Based on the model assumptions, the study showed that helicopter transport is cost-effective only if it reduces the relative risk of death in seriously injured trauma patients by at least 15%. This implies that the best way to increase cost-effectiveness of helicopter transport would be to reduce the overtriaging of minor injuries to helicopter EMS. Telemedicine should have a role in reducing overutilization, in concert with stricter guidelines for utilization. In Taiwan, Tsai et al. performed a prospective cohort study showing that when using video telemedicine to screen the patient, there was a 36.2% reduction in the use of air transport, resulting in a total annual savings of US $448,986. Similarly, in a study of interhospital burn transfers with relevance to a prehospital setting, Saffle et al. completed a review analyzing whether the use of telemedicine in evaluating burn patients would have altered the need for air, ground, or no transport from a community hospital. Of the 225 burn patients who were air transported, only 60% were deemed necessary for air transport, while 18% could have been treated at the outlying facility. In addition, 34% of the patients had air transport charges that exceeded their total charges for hospitalization. Telemedicine appears to be effective in reducing the overutilization of air transport and by doing so, increasing its cost-effectiveness and helping reduce unnecessary health care costs or risks to air medical crews.",
        "Refusal of medical care/treat and release": "Throughout the United States, it is common practice to have prehospital providers contact direct medical oversight physicians for further direction in situations where patients refuse medical care or would like to be released after having had some form of medical treatment in the field. Studies have shown that when a patient was able to speak to a physician, there was a higher likelihood (35%, versus 3% when the patient spoke only to the EMS provider) that the patient would ultimately be transported to a hospital. Other studies focused on the physician\u2019s assertiveness and showed that if the physician was concerned with the patient\u2019s clinical status, he or she was likely to be more assertive when talking to the patient, which would ultimately improve the patient transport rate. In the manner of Cukor et al., the addition of video promises to enhance these interactions by creating a \u201csocial presence\u201d in which the patient and provider can better discuss these complex issues.",
        "Community paramedicine": "Community paramedicine has been defined as an organized system of services, based on local need, provided by emergency medical technicians and paramedics, that is integrated into the local or regional health care system and overseen by emergency and primary care physicians. In these mostly pilot programs, EMTs and/or paramedics may be dispatched to calls not likely to need acute paramedic-level EMS intervention to assess for possible in-home treatments or interventions, find alternative modes of transport, or arrange referral to non-ED settings such as the patient's primary care provider. A recent review of the literature concludes that while the evidence suggest that paramedics are capable of learning and applying medical competencies, there is not yet consensus on what they should do or evidence supporting safety and effectiveness. There appears to be consensus on the importance of medical oversight for these programs, creating a tremendous opportunity for additional research into the role of telemedicine to fully realize the capabilities of these systems of home-based response and health care.",
        "Telemonitoring": "Telemonitoring is a form of telemedicine that uses computerized technology to track a patient's medical data, such as vital signs or electrocardiography, from a remote setting. The first case of direct transmission of patient data was that of an ECG in 1905 by the inventor of the ECG, Einthoven. However, the routine use of telemonitoring began in 1961, when the ECG, respiratory rate, electrooculogram, and galvanic skin response of the first human in space, Yuri Gagarin, were continuously monitored by doctors on earth. In 2000, Satava et al. described the use of telemonitoring of climbers on Mount Everest. They were able to monitor heart rate, three-lead ECG, skin temperature, core temperature, activity level, and GPS location in real-time from Yale University with minimal technical difficulty. Ideally, any physiological parameter that can be measured can be telemonitored and currently, there are a significant number of parameters ranging from vital signs to intracranial pressure monitoring, fetal heart rate, and pacemaker settings that are being telemonitored in a range of settings including homes, hospital intensive care units (ICUs), clinics, and in the prehospital setting. From the late 1970s onwards, EMS personnel started to use prehospital ECGs. At first, they were limited to the transmission of a single-lead ECG but as technology advanced, 12-lead ECGs were able to be transmitted to the receiving hospital using cellular technology to assist in initiating appropriate care for STEMIs. In a similar fashion, portable telemetry monitors were developed specifically for EMS providers able to display vital signs (heart rate, respiratory rate, blood pressure, pulse oximetry) and 12-lead ECGs, with the capability to defibrillate or pace a patient. Several commercial telemedicine platforms designed for EMS environments have been developed in collaboration with and tested by the military that offer the capability for real-time monitoring and transmission of heart rate, blood pressure, respiratory rate, pulse oximetry, glucose, end-tidal CO\u2082, and ECG. Using a simple method of inputting vital signs data and transmitting electronically to the hospital, Anantharaman concluded that real-time monitoring of patients in ambulances helped reduce the time to initiate appropriate treatment and allowed the receiving physician and staff to be better prepared for the patient's arrival. Hu and Chi have both demonstrated significant hypoxemic and hypotensive episodes occurring in trauma patients transported by helicopters and ambulances in a state-wide trauma system. Despite a demonstration of the capability to remotely monitor for hypoxemic and hypotensive episodes in head trauma, both proven to be associated with worse outcomes, the ability to show improved outcomes with remote telemonitoring has been elusive. Where the evidence base is limited is making the connection between the capability to monitor remotely and a proven benefit in outcomes, for example with brain injury, myocardial infarction, or stroke.",
        "Telementoring": "As applied to EMS, telementoring can be described as the aspect of telemedicine where an experienced provider (emergency physician or surgeon) assists or directs another less experienced provider (EMT or paramedic) who is performing a procedure at a distance. It was originally developed for use in the field of surgery (telesurgery) and practiced in two ways. The first, similar to what was just described, involved a specialist surgeon assisting another surgeon who was in a remote location with audio and video communication in real time. The second way, better known as telepresence surgery, involves the surgeon, assisted by on-site support teams, guiding robotic arms to carry out a procedure from a distance, either in the same room or across an ocean. Nevertheless, with the advancement of technology using real-time video and audio communications, telementoring can be used in any field that involves performing any medical procedure, including emergency medicine and EMS settings.",
        "Airway management": "One of the most important skills that paramedics learn is the ability to manage the patient's airway. From the basic nasal cannula to full endotracheal intubation, airway management is a crucial aspect of prehospital care. If the patient cannot maintain a patent airway, the paramedic may be required to secure the airway. This is often accomplished through oral tracheal intubation, a high-risk, low-frequency skill. Moreover, if the paramedic chooses to use rapid sequence intubation (RSI) and still has a failed intubation, the patient is now apneic and can succumb to hypotension, hypoxemia, hypercarbia, regurgitation, and cardiac arrest. Losssius et al. conducted a comprehensive metaanalysis of the intubation success rates of EMS providers (physician versus non-physician) and found that physicians have fewer prehospital endotracheal intubation failure rates than non-physician providers. The same held true when RSI was used and raised a concern for patient safety in the prehospital setting when managed by a non-physician provider. More specifically, a study done by Davis et al. showed that patients with severe traumatic brain injury who were intubated in the field had a 9% greater mortality and a 12% lower rate of survival when compared to patients with in-hospital intubations. Video laryngoscopy has become a vital tool for the intubation of patients with potentially difficult airways, and Bjoernsen et al. reviewed the usefulness of video laryngoscopes in the prehospital setting and suggest that they have the potential to become the primary modality of intubation for patients with cervical spine injury or limited jaw or spine mobility, and for difficult-to-access patients. Given that the procedure is performed in a video environment, video-assisted intubation lends itself well to telemedicine. In Korea in 2007, Chung et al. developed a tele-airway management system (TAMS) that allowed emergency physicians to remotely guide intubations performed by novice intubators. They showed that the success rate of intubation within 2 minutes was 94% in the group who were remotely assisted with telemedicine compared to 63% in the group only using videolaryngoscopy. More recently, the University of Arizona has established two telemedicine programs that have implemented the use of videolaryngoscopy and in 2007, they were able to demonstrate remote telemedicine assistance of a difficult intubation in a chronic obstructive pulmonary disease (COPD) patient in a remote emergency department. With video telementoring by an experienced trauma airway physician, the remote physician was able to achieve a Cormack-Lehane \u201cGrade I\u201d view of the airway with a videolaryngoscope which allowed for a quick intubation on the first attempt. In order to determine the feasibility of transmitting live video and audio data, Mosier et al. performed several intubations using different voice over internet protocol (VoIP) clients over both wifi and cellular networks. It was determined that VoIP over 4G networks or wifi allowed for superior audio and video images with the least data lag and image decay, further proving its usability in the prehospital environment. Whether \u201ctelebation\u201d, as coined by Mosier, is used for remote training of paramedic intubation skills with videolaryngoscopy or direct telementoring of intubation skills in remote locations, it has the potential to improve the success of prehospital airway management.",
        "Ultrasound": "The use of point-of-care or bedside ultrasound has gained wide popularity in emergency medicine over the last few decades, demonstrating its ability to reduce morbidity and mortality while adding efficiency to the patient\u2019s medical care. In the past few decades, this tool has been brought to the prehospital setting in an effort to assist in triaging, diagnosing, and treating the wounded soldier quickly. A recent review done by Sayed et al. described the current applications of prehospital emergency ultrasound. In the trauma patient, the most useful sonogram is the prehospital focused abdominal sonography for trauma (PFAST) and thoracic ultrasound to look for a pneumothorax. In cardiac arrest, prehospital providers used the focused echocardiographic evaluation in life support (FEEL) protocol to look for cardiac motion, ventricular function, right ventricular dilation, or pericardial collection. Echocardiography was also used to differentiate between true pulseless electrical activity (PEA) and pseudo-PEA. Ultrasoundography can make accurate diagnoses but has variability secondary to user skill. If the prehospital provider does not have appropriate training in obtaining images, he or she could potentially miss life-threatening diagnoses. However, multiple studies have shown that it is feasible for prehospital providers to acquire the necessary skills to obtain and recognize ultrasound images for life-threatening conditions. Sibert et al. looked at the feasibility of using ultrasound in a mobile telemedicine consult and found that the majority of the evaluators estimated that they could telementor an abdominal ultrasound examination, as long as there were no technical complications. As described in a study by Su et al., Taiwan is currently using an intricate telemedicine platform that aims to use tele-ultrasound in an effort to prediagnose and provide appropriate medical care to a patient who sustains a multisystem trauma. It remains to be shown whether, with continued advancement in technology, telemedicine will give prehospital providers, with the added mentoring of the ultrasound-competent physician, yet another more accurate tool in diagnosing the patient in the field in an effort to provide efficient and appropriate medical care.",
        "Combat and tactical EMS": "Around the world, the military has always been at the forefront with advances in remote, paramedical care and also telemedicine. A significant portion of prehospital medicine is adapted from what is being done on the battlefield. Academic centers, commercial companies, and different areas of the government have collaborated over the years in an effort to bring modern medicine to wounded soldiers overseas. In the civilian world, combat medicine is being applied to the police forces through tactical EMS. Examples include a tactical telemedicine project (Tac-Tel) developed in Palm Bay, Florida, in partnership with the regional trauma center that allowed the tactical medic to have direct audio and video communication with the trauma or acute care surgeon at the hospital. The surgeons were able to gain real-time information from the scene of the event and not only provide direct medical oversight to the medic on field, but also gain information on the patient status and circumstances of the injury.",
        "Mass casualty incidents/disaster medicine": "In any mass casualty incident (MCI) or disaster, after assessing scene safety and setting up incident command, the first priority is to triage patients. The majority of triage systems have used a paper triage system, where patient information, including basic assessment of Glasgow Coma Scale and vital signs, is hand-written and attached to a patient's wrist or clothing. As the patient is sent to a different triaging area and reassessed, the tag can be checked and updated information can be written. Over the years, there has been concern about the idea of having a paper-based triage system. Not only are the tags susceptible to harsh weather conditions, but there is often a redundancy in collecting patient information and the concern that illegible handwriting will make the initial triage information useless to the treating physician. Telemedicine provides a way to not only collect patient information electronically, but also track the patient and transmit all data wirelessly to downstream medical facilities. In Germany, Plitschke et al. described the development of a system using bar-coded triage tags that allow all the information collected to be transmitted wirelessly to the incident command center, telemedicine centre, or receiving hospital. This reduces the redundancy of collecting the same information as the patient goes from the scene to the ambulance and finally to a receiving hospital. It also can help notify the receiving hospital staff of the patient's status as they are able to see all the vital signs and initial treatment started in the field. More recently, Gao et al. have developed a platform known as the miTag (medical information tag) in an effort to enhance triaging and remotely monitor patients in an MCI or disaster event. The miTag is an electronic RFID tag that is placed on the patient with an initial triage priority number that allows all patient data collected to be wirelessly uploaded to a PDA/laptop to automonitor patients. Wireless blood pressure cuffs, ECG leads, and pulse oximeters have been developed that can be placed on a critically injured patient and automatically collect and transmit the data to the triage coordinator or incident commander's PDA/laptop. A pilot study with this platform showed that the group using this system was able to track and triage patients with effective communication of information more efficiently than in the paper group. All these developments in telemedicine allow a more efficient way to collect patient information, and triage and track patients as they go through each process of the disaster or MCI.",
        "EMS telemedicine technologies": "Telemedicine technology has evolved dramatically over the almost 50 years since EMS began using radio for medical oversight and transmission of ECG telemetry. Stand-alone CODEC (compression-decompression) digital video devices costing $150,000 apiece and from occupying half a room in the early 1990s, have evolved to software digital video algorithms making high-quality video transmission from cellphones and hand-held tablets possible. The last 5 years have seen the evolution of telemedicine equipment specifically designed for the EMS setting, incorporating features that support transmission over multiple modalities, many of which have already been mentioned in this chapter. Systems designed for the prehospital environment must also navigate different telecommunications modalities including public safety 700\u2013800 mHz systems, cellular, and even satellite transmission. Applications using videoconferencing and data transmission in areas such as urban environments with ubiquitous 4G cellular coverage may differ markedly from those in remote environments such as disaster response in areas where satellite or temporary mesh wireless are the only options. The efforts to advance EMS telemedicine and particularly videoconferencing have benefited greatly from the recent growth of wireless networking options fueled by consumer demand for mobile data. Bandwidth refers to the speed of transmission of data or the \u201csize of the pipe\u201d and speeds of at least 300 kilobytes per second on the wireless uplink and downlink are required for two-way videoconferencing. A streaming, one-way video link may be valuable in situations where only a view of the patient will suffice for evaluation, such as in teleskope. The current implementations of so-called fourth-generation wireless technologies (long-term evolution or LTE cellular and WIMAX wifi) may offer transmission speeds up to 100 megabytes per second to moving objects and up to a gigabyte per second to stationary objects, well within the range for high-quality videoconferencing. Public safety communications networks in the 700 and 800 megahertz range of the electromagnetic telecommunications spectrum may vary in their implementations of data transmission speeds capable of supporting videoconferencing. The most recent telemedicine systems designed for the EMS environment support the flexibility to use whatever communications networks are locally available, whether it be cellular, wifi, or 700\u2013800 mHz. In addition, more portable networking concepts such as mesh networking where devices deployed over a geographic area act as additional transmission nodes to other devices along with an increasing availability of satellite communications options enhance capabilities in remote or disaster situations. In July 1996, Dr Stephen Joseph, Assistant Secretary of Defense for Health Affairs, in a speech entitled \u201cTelemedicine in the Military Health Services,\u201d stated that \u201cAs an innovating factor for the military health services system, telemedicine will modify our conduct of operations, regardless of where we happen to be. The expanded capabilities facilitated by telemedicine will result in our combat medics being very different people than they are today. Their training will include use of helmet cameras to offer clear visuals of wounded or injured soldiers, readers to gain vital statistics from personnel status monitors, communication devices to send descriptive details and receive specific direction on how to handle each patient.\u201d Since then, portable, rugged telemedicine systems have been developed and deployed with several combat units. LifePro5 and Tempus IC Pro are both specifically designed for the military with civilian applicability. Each offers the entire telemedicine platform in a single unit that has the capability to wirelessly transmit data back to the hospital. The combat medic wears a video camera strapped to his or her head and a Bluetooth headset allowing direct communication with the physician on base. As the medic arrives on the field, the physician can see and hear everything that the medic sees and hears. These units provide remote physiological monitoring, telebation, telesonography, infrascanner technology (to look for intracranial bleeding) and electronic tactical combat casualty cards (TC3) which is all transmitted in real time to the physician at the base hospital. Not only can the physicians see the injuries and what kind of treatment was performed prior to arrival, but they can also offer further advice or direction so that the appropriate initial treatment is not delayed. At the same time, there has been an explosion of powerful tablet computers and hand-held devices designed to operate on 4G LTE networks and support high-quality videoconferencing and data integration including mobile applications. Health care providers including those in EMS are asking the question every day whether these devices which support connectivity in everyday life are applicable to their own specialty area of medicine such as the prehospital environment. The concept of a telemedicine-capable, video-equipped ambulance moved toward reality with federal grant support in 2002 from the Telemedicine and Technology Research Center (TATRC) and the Department of Defense. The DREAMS (Disaster Relief and Emergency Medical Services) concept ambulance was first deployed with the Liberty County Texas EMS and underwent 6 years of field testing. At the same time, a similar project with the University of Vermont Telemedicine Program, the FAST STAR (Fletcher Allen Specialized Telemedicine for Supporting Transport and Rescue), evaluated the systems in rural settings for airway management and ultrasound with prolonged EMS transport times in poor weather conditions. In 2007, Tucson AZ deployed a city-wide wifi mesh network allowing videoconferencing from ambulances to the university medical center that was ultimately limited by the wifi technology, in that the ambulances had to be stationary while transmitting video. LifeBot recently became the licensee for distributing the DREAMS ambulance technology as the state of the art in mobile ambulance telemedicine systems. Key components include ceiling-mounted cameras, continuous audio-videoconferencing communications, physiological monitoring, and a flexible communications hub that allows it to leverage available 3G, 4G, wifi, WiMAX, LTE, satellite, and military data radio. The ambulance contains three interior cameras which are remotely controlled by physicians in a hospital and a fourth portable camera worn by the prehospital provider, allowing live transmission of audio and video data during a teleconsultation. In addition, the ambulance offers full telemotoring of the patient in real time as well as telementoring of both ultrasound and videolaryngoscopy to the prehospital providers. During Hurricanes Rita and Katrina, DREAMS was used to assist in triaging patients over 375 miles away in New Orleans from the Memorial Hermann Trauma Center in Houston.",
        "Conclusion": "While the near future promises to be an exciting time now that we have telemedicine systems designed specifically for the EMS environment, there are very limited data on the effectiveness of these systems and on the performance metrics for telemedicine in general. It is important to think about telemedicine not just in a videoconferencing sense but also with the transmission of telemetry, ECG, voice, and store-and-forward contexts. Questions to answer include whether these systems are effective in improving the efficacy of prehospital airway management, preventing secondary insults of hypoxemia or hypotension in traumatic brain injury, enhancing the early identification of internal hemorrhage and shock, preventing patient deterioration over longer transport times, improving the management of stroke and myocardial infarction, and improving survival in MCIs and disasters, to name a few. These are exciting times for telemedicine with personal technology development and telecommunications, ubiquitous videoconferencing, and near-constant connectedness but it remains to be proven whether this is just technology in search of medical applications or a new age of connected patient care and medical effectiveness in the prehospital arena."
    },
    {
        "Introduction": "During the last 35 years, it has become apparent that the 9-1-1 dispatcher can rapidly elicit reasonably accurate sign and symptom information from frightened callers, allowing more accurate medical categorization of patients. In addition, the dispatcher can activate the configuration of responders optimally suited to deal with the specific emergency. It is not enough to mindlessly send paramedics or first responders on all cases; it is necessary to accurately determine the need for these highly trained individuals. If this is not done for all calls, the number of available providers will be reduced because of their inappropriate use. An available paramedic team located too far from the next patient may be ineffective solely due to excessive response distance.\n\nIn the 1970s, this dilemma stimulated the development of emergency medical priority dispatching and its essential training process. The goals are sending the right resources to the right person, at the right time, in the right way, and doing the right things until help arrives. Because the dispatcher is often the least medically trained provider in the chain of survival, these goals are accomplished through specific training in the careful use of a comprehensive protocol, including the items in Box 10.1.\n\nThe key role for the dispatcher was defined in 1978 when Salt Lake City Fire/EMS identified the medical dispatcher as the \u201cweak link\u201d in the chain of survival. Until then the average medical dispatcher had less than 1 hour of formal medical training. The emergence of structured emergency medical dispatch (EMD \u2013 this acronym is also used for the \u201cemergency medical dispatcher\u201d) protocols and training as vital elements of appropriately functioning EMS systems was a phenomenon of the 1980s. A number of factors contributed to the delay in recognition. Medical directors rarely observed the dispatch function because for most emergency physicians, a prehospital case begins when the radio or phone announces an inbound patient. The dispatcher\u2019s function regarding the mechanics of dispatch and the decision-making process was unknown to the medical community. Whether the closest appropriate unit was sent, or a paramedic unit was unavailable because of previous assignment to a \u201ccat bite\u201d call, or the first-assigned vehicle never arrived because it was involved in an accident in which lights and siren were unnecessarily used, remained hidden and continues to be unaddressed by many medical directors today.",
        "Myths of medical dispatch": "There are nine commonly held and virtually universal myths regarding medical dispatch that delay the development of sound programs. These myths are malignant rather than innocent misconceptions.\n\nOne of the more common myths is that most callers are hysterical. In 1986, Eisenberg et al. compared the emotional levels of 640 callers reporting cardiac arrest with those of callers reporting other complaints. A standard emotional scale from 1 to 5 was used, where 1 represented \u201cnormal conversational speech\u201d and 5 represented an individual \u201cso emotionally distraught that information (e.g. the address) could be obtained only with great difficulty.\u201d Of the 146 callers in non-cardiac arrest cases, the mean emotional score was 1.4. Contrary to popular belief, the mean emotional score of the 494 callers reporting cardiac arrest was only 2.1. In 1990 a study of 160 random callers in Los Angeles revealed an average Emotional Content/Cooperation Score (ECCS modified) of 1.2. No callers were rated at 5. More recent studies revealed a mean ECCS of 1.05 in 3,019 cases reviewed in British Columbia and 1.21 in 3,430 cases in Monroe County (Rochester, NY).\n\nA second myth is that the callers do not know the required information. In dispatch, the common classifications for standard callers are first, second, third, and fourth party. A first-party caller is the patient him/herself. A second-party caller is someone with the patient or intimately familiar with the patient\u2019s current condition. A third-party caller is someone who is neither with the patient nor knows the patient (e.g. \u201cI just saw a car accident out the window and it looks really bad!\u201d). Fourth-party programs for EMD training and use medically approved, scripted protocols. Thousands of dispatch systems provide prearrival instructions, with almost universally positive results medically, politically, and legally. The National Association of EMS Physicians stated in its initial consensus document on EMD that \u201cstandard medically approved telephone instructions by trained dispatchers are safe to give and in many instances are a moral necessity.\u201d\n\nDispatch prioritization is an essential element in any EMS system, as it establishes the appropriate level of care initially required, including vehicle response configuration and mode of urgency. All medical dispatch centers must institute and monitor adherence to dispatch prioritization protocols that clearly delineate calls that require lights-and-siren use and those that do not. All jurisdictions allowing the use of lights and siren by emergency medical vehicles must require training and professional EMD certification of their dispatchers and mandate the use of priority medical dispatch protocols approved by the local medical director that clearly delineate lights-and-siren use.",
        "Emergency medical dispatcher": "The role of the dispatcher in a modern EMS system is extensive, with at least seven sub roles: interrogator, radio dispatcher, triager, logistics coordinator, resource provider, psychological calmer, and prearrival aid instructor. A sound basis in generic telecommunication techniques is the first prerequisite for optimal EMD. The dispatcher requires specific training in what is commonly referred to as the dispatch priorities, an oblique cross-section of prehospital medicine unique to dispatch: appropriate interrogation, vehicle allocation, postdispatch instructions (PDIs) and prearrival instructions (PAIs) given to the caller, and concise information regarding the clinical situation and scene conditions given to the responding provider en route. Historically, the types of treatments performed over the telephone are generally more elementary, at least until recently when high-risk pregnancy, early stroke identification, and aspirin administration were added to the dispatcher\u2019s repertoire.\n\nThe basic components of EMD are chief complaint identification, key question interrogation, dispatch life support instructions, and prehospital medical care dispatch coding and response configuration set-up. They are covered in more detail in subsequent sections of this chapter.",
        "Medical oversight of EMD": "The concept of EMD obviously encompasses more than training. In fact, a practice standard has evolved that defines not only the role of the dispatcher but also the supervision, quality management, and risk management that must accompany it.\n\nIn order to prioritize calls properly, the EMD must be well versed in the medical conditions and incident types that constitute the daily routine. Training in these priorities must be detailed and dispatch-specific (not EMT or paramedic training per se). Since much of the knowledge and many of the skills required by the EMD are dispatch-specific, a curriculum for their training differs substantially from those used in the preparation of EMTs or paramedics. Training as an EMT or paramedic does not adequately prepare a person for the role of an EMD. Much of the required EMD curriculum cannot be found in standard EMS training curricula. It consists of content and emphasis which differ significantly from that used for the training of all other health professionals and public safety dispatchers.",
        "Quality management": "A quality management (QM) program is essential to the successful implementation and maintenance of an EMD program.\n\nThe 11 components of a comprehensive QM program are:\n1. selection\n2. orientation\n3. initial training\n4. certification\n5. continuing dispatch education\n6. medical oversight\n7. data generation\n8. performance evaluation or case review and feedback\n9. recertification\n10. risk management\n11. decertification, suspension, and/or termination.",
        "Continuing dispatch education": "Continuing dispatch education (CDE) is essential to reinforce initial concepts and build on the science of dispatch priorities. As the operational experience of new dispatchers expands, CDE becomes their link with the changing aspects of medicine. Traditionally, the major educational, occupational, and supervisory influences of dispatchers are related to public safety rather than medicine. An active CDE program is required to keep dispatchers current with medical standards and the ideas specific to their daily routine. A minimal CDE investment of 1 hour of education per month is now the national standard.",
        "Medical oversight": "Analogously, the dispatch response protocols are the \u201cmessenger RNA\u201d of the EMS system, putting planned desires of medical oversight into play for the desired \u201creplication\u201d of the response and treatment system each time a call is processed. NAEMSP states, \u201cMedical direction and control for the EMD and the dispatch center is part of the prescribed responsibilities of the Medical Director of the EMS system.\u201d This responsibility includes initial training, CDE, medical dispatch case review, and protocol review. The formal reviews should be performed on both the response assignments and the need for lights-and-siren responses.\n\nIt is essential that the medical director attend a full EMD training course taught by a credentialed instructor with, preferably, significant dispatch training experience. Once physicians understand both the knowledge base required for such training and the medical basis for dispatch priorities, they are significantly more able to provide adequate medical oversight for their dispatchers.",
        "Performance evaluation and case review": "The fundamental issue in the evaluation of dispatcher performance is protocol compliance. The goal of case review is to assist dispatchers in improving performance and protocol compliance. The case reviewer should score each section of the protocol used as the dispatcher navigates through the case. Case entry (primary survey), key question (secondary survey) interrogation, selection of correct dispatch code for appropriate unit response and mode, and correct delivery of PDIs and PAIs, including safety advice, must be carefully assessed. Case reviewers should also be specifically trained in this methodology so that variation among reviewers is minimized.\n\nCareful review leads to the identification of the \u201celements of success\u201d or to case-specific problems of compliance, understanding, policy, or protocol. Without adequate case review, dispatcher compliance to protocol generally falls below 50\u201380% (depending on the scoring category examined) even when mandatory compliance is a formal policy requirement. The level of compliance of every dispatcher should be collected and cumulatively compared with established levels of acceptable practice. Studies have shown that case reviews and the feedback of compliance levels directly to each dispatcher improve compliance dramatically.",
        "Decertification, suspension, and/or termination": "Disciplinary actions involving dispatchers should be progressive. Formal documentation of deficiencies and corrective actions are basic ingredients for successful remediation of individual dispatcher problems.",
        "Prearrival instructions": "Trained dispatchers are often the first, first responders. They provide the initial professional intervention, reducing the response time almost to zero for specific problems. There is no better justification for the provision of PAIs than the landmark legal opinion delivered by James O. Page to the Aurora (CO) Fire Department in 1981.\n\nAfter years of arriving \u201ctoo late\u201d at the scenes of hundreds of life-threatening emergencies, it is difficult for me to offer a detached and unemotional opinion. Throughout the United States, we have spent billions of dollars constructing systems to respond to medical emergencies and we have done little to cure the deadly 4-minute gap at the front of the system. While we race through city traffic to get to the scene, a brain dies from lack of CPR (oxygen). Frankly, I don't understand how any public safety or health care worker can accept these recurring tragedies without actively seeking a solution to the problem, which proves fatal in so many cases.\n\nThere are many recurring and predictable situations that must be uniquely addressed and corrected before terminating a call at dispatch. To the field provider, a cardiac arrest victim is a pulseless, motionless, non-breathing patient; however, the same patient initially presents to the dispatcher in the following fashion.\n\nThe funny noises, a common telephone description of the agonal respirations, must be correctly interpreted.\n\nPrearrival instructions are not only an essential dispatcher practice but are a clear public expectation. The failure to provide appropriate PAIs is described as negligent by a growing number of plaintiff attorneys. Although the notion that dispatch agencies will be successfully sued for providing PAIs has been a roadblock to their use, only one dispatcher negligence lawsuit has been filed following the provision of PAIs since that practice took form in 1975. (Ironically, that lawsuit occurred in Phoenix, AZ, where the practice of telephone PAIs was first initiated.) In contrast, an increasing number of recent lawsuits, completed or in progress, cite the omission of PAIs - or dispatcher abandonment, as legal terminology now describes it - as either the primary or the associated allegation.\n\nThe American Heart Association states: Emergency medical dispatch has evolved over the past 25 years to become a sophisticated and integral component of a comprehensive EMS response. Dispatchers provide the first link between the victim and bystanders and EMS personnel. Trained medical dispatchers may provide pre-arrival instructions to bystanders using standard, medically approved telephone instructions. Dispatchers should receive formal training in emergency medical dispatch, and they should use medical dispatch protocols, including pre-arrival telephone instructions for airway control, CPR, relief of FBAO [foreign body airway obstruction], and use of an AED.\n\n",
        "Dispatch life support": "Dispatch life support (DLS) provides the basis for defining the actual content and application method of the special treatment protocols used by dispatchers. In 1989, NAEMSP defined DLS as \u201cthe knowledge, procedures, and skills used by trained EMDs in providing care through pre-arrival instructions to callers. It consists of those BLS and ALS principles that are appropriate to application by medical dispatchers.\u201d\n\nFor example, although the chin lift is not a difficult psychomotor skill to teach in person, over the phone it becomes difficult, time-consuming, and ultimately not effective. However, the head-tilt method of airway control can be easily taught to the caller as follows: \u201cPut one hand on his forehead and your other under his neck. Lift up on the hand under his neck and push down on the hand on his forehead. This will open his airway.\u201d Dispatchers are instructed to be aware of hazards in neck manipulation if the patient has also incurred a significant mechanism of injury; this is rarely present in routinely encountered PAI situations. DLS more realistically incorporates the fact that, although many treatments that dispatchers provide are similar to BLS, they simply must be different in content, process, and real-time instruction.\n\nDispatch life support was formally defined to clearly establish the necessary, functional differences between the dispatcher processes and field care as understandably legitimate. EMD training contains many dispatch-specific methods of description and caller application found in neither field provider training nor protocol.",
        "Compliance with protocol": "Inherent in DLS is the necessity for medical dispatchers to adhere to scripted protocols for the provision of telephone treatment in a standard reproducible way.\n\nAlthough there is growing interest and effort among public safety agencies to provide telephone instruction to callers, only about 5\u201310% of centers provide correct, non-arbitrary, medically approved PAIs read directly from detailed protocol scripts.\n\nIn addition, it is not possible to comply with protocols when there are none present. Evenson and colleagues surveyed a relatively progressive state regarding the use of dispatch protocols or algorithms, and found that 45% of North Carolina communication centers had no guide or triage algorithms for dispatch.\n\nIt is essential for the medical director to understand the difference between PAIs and telephone aid. There are two very different methods of patient care initiated by dispatchers used at present.\n\n\u2022 Prearrival instructions are formal, telephone-rendered, medically approved, written instructions given by trained dispatchers to callers to aid the victim and control the situation before prehospital personnel arrive. The protocols for PAIs are used as word-for-word as is reasonably feasible.\n\n\u2022 Telephone aid is ad lib advice provided by dispatchers based on their own experiences and training regarding a procedure, diagnosis, or treatment, but not following a written PAI protocol. This method exists in a system either because no protocols are used or because protocol adherence is not required.\n\nTelephone aid often provides the illusion of PAIs without consistently delivering high-quality and accurate advice. The following are common errors seen during medical dispatch case reviews in agencies providing telephone aid.\n\n\u2022 Failure to correctly identify conditions requiring telephone interventions, and therefore PAIs. An example is \u201csaving\u201d an infant having a febrile seizure who was incorrectly identified as needing CPR because of the failure to follow protocols designed to verify the absence of breathing before the initiation of potentially dangerous dispatcher invasive treatment such as chest compressions.\n\n\u2022 Failure to accurately identify the presence or lack of interim signs and symptoms during the provision of telephone intervention. For example, dispatchers who ad lib CPR sequences often fail to ask important non-visual verifiers such as \u201cDid you see the chest rise?\u201d or \u201cDid you feel the air go in?\u201d\n\n\u2022 Failure to perform, describe, or teach multiple-step procedures such as CPR care in a consistent and reproducible fashion. For example, quality management reviews often reveal that dispatchers in the same center (or even the same dispatcher) perform care differently on each occasion if they do not follow the scripted PAI protocols exactly.\n\n\u2022 Lack of medically approved protocols for use as a template for evaluating dispatcher performance during the case review and quality management processes. Non-mandatory guidelines cannot be quality ensured.\n\nThe requirement for medical appropriateness within the dispatch center through effective medical oversight is an essential element for assuring the correct, safe, and efficient application of dispatcher telephone evaluation and intervention.",
        "Psychological aspects": "Although it may seem to the casual observer that the emotional or hysterical behavior of callers is random or unpredictable, there are very predictable, generic reactions present in most caller interrogation processes and PAI situations. The following are the most common.\n\n\u2022 The hysteria threshold. All distraught callers have a threshold of hysteria control that can be reached through repetitive persistence. Bringing callers below the threshold is usually quite easy if the appropriate techniques are used by properly trained dispatchers. Once below the hysteria threshold, callers are often in complete emotional control and can repeat the provided instructions in \u201cword-perfect\u201d form.\n\n\u2022 The repetitive persistence methodology. The most successful method of crossing the hysteria threshold is repetitive persistence, which is performed by the dispatcher repeating, in the same exact wording, a request to calm down or perform any other desired act. For example, \u201cYou\u2019re going to have to calm down, ma\u2019am, if we\u2019re going to help your baby\u201d should be repeated firmly to gain initial control of the caller. Usually this approach works after only two or three repetitions. Alterations in wording may be perceived by callers as signs of indecision or lack of control on the part of the dispatcher.\n\n\u2022 The \u201cbring the patient to the phone\u201d problem. It is striking how many times PAIs are initiated only to be interrupted by the caller yelling, \u201cBring him in here to the phone!\u201d Obviously this wastes time and interrupts the dispatcher\u2019s train of thought and provision of instructions. At the beginning of the telephone treatment sequence, the dispatcher should always ask, \u201cAre you right by her/him now?\u201d\n\n\u2022 The \u201cre-freak\u201d event. There are three points at which callers are reminded of the distressing state of the victim when they \u201cre-freak\u201d and cause the dispatcher to lose critical control. The first is when the victim is brought to the phone, and the caller is immediately reminded of how bad the victim appears. The second is when the dispatcher asks for verification of the absence of vital signs (breathing or pulse). The third is when the caller fails to revive the patient through the performance of CPR or the Heimlich maneuver, and becomes frustrated, and therefore may stop trying.\n\n\u2022 The \u201cnothing's working\u201d phenomenon. Average callers harbor the misconception that because they are following the dispatcher\u2019s instructions, the victim will positively respond or immediately be revived. This belief results in a specific type of frustration re-freak that can interrupt the treatment sequence. In despair, callers will commonly state, \u201cNothing\u2019s working!\u201d The dispatcher can easily overcome this with appropriate encouragement and repetitive persistence, and by mentioning that you are \u201ckeeping the victim going until the paramedics get there.\u201d\n\n\u2022 The \u201cparamedics aren\u2019t coming\u201d notion. During PAIs, callers may often wonder fearfully if help is truly on the way and will often repetitively ask, \u201cAre the paramedics coming?\u201d This may relate to the average citizen\u2019s skepticism regarding \u201cthe check is in the mail.\u201d The dispatcher need only confirm that the paramedics have left the station and are on their way. It is important that this be relayed in \u201clay terms\u201d for easy comprehension because the distraught caller may not understand professional terms such as \u201cen route.\u201d\n\n\u2022 The \u201crelief\u201d reaction. A less common but relevant situation may occur when a patient\u2019s condition actually improves. The reaction is caused when feelings of relief, guilt, remorse, or fear of what might have been strike the caller. When the patient apparently no longer needs the immediate assistance of the caller, the caller has the opportunity to vent built-up emotion and may begin crying. Tasking the caller with important monitoring \u201cchecks\u201d and reaffirming the patient\u2019s status are effective ways to deal with this event.\n\n\u2022 The gap theory. Temporary silences or gaps during the interrogation or delivery of PAIs can elevate caller anxiety and even create difficult callers. Gaps occur when dispatchers pause inappropriately. Callers may interpret such gaps as an indication that help is being delayed and that the dispatcher is hindering rather than helping. The caller may even perceive prolonged gaps as a lack of confidence or control on the part of the dispatcher. This encourages callers to insert demands and uncooperative statements into the interrogation or instruction process. In these cases, the call can cease to be dispatcher directed.\n\nCompliance with a medically approved protocol reduces the frequency and length of gaps by providing a consistent flow to the call sequence. When a gap is unavoidable, the dispatcher should simply inform the caller of the anticipated gap and the reason for the silence, and then return to the conversation as quickly as possible.\n\nUnderstanding the commonly predictable actions and reactions of callers, as well as those at the scene of a critical event, increases the effectiveness and confidence of the dispatcher when dealing with these stressful and difficult but predictable situations.",
        "Medical dispatch priorities": "The development of dispatch priorities was a pivotal event in the evolution of EMD. These priorities lie at the heart of optimal medical dispatch functioning; they are the sum basis of the knowledge, decisions, and treatment of the dispatcher. Dispatch priorities are not a new concept to the emergency physician. In fact, they are the subset of medical urgency science on which emergency department triage decisions are usually based.\n\nEvery question must satisfy one or more of the \u201cFour Objectives\u201d of interrogation.\n\n\u2022 It gleans information that is necessary to determine the appropriate response assignment.\n\n\u2022 It identifies and verifies conditions that require prearrival instructions.\n\n\u2022 It obtains information required by response personnel to preplan and address the scene and patient.\n\n\u2022 It provides for scene safety in minimizing the hazards and risks to patients, laypersons, and professional responders.\n\nA key question group that leaves any of these necessary indications uncovered will result in an unsound interrogation and an incomplete objective discovery. Often a system adopting a priority dispatch system is tempted to make pre-implementation modification to existing key question sets, PAIs, and dispatch determinants. This common error is the equivalent of buying a new ambulance and then changing the timing, wiring, and other parts without road-testing it first.\n\nTo a large extent, the primary reason for the structure of the key questions is identification of the most appropriate mobile response (i.e. the dispatch priority) that reflects predetermined distinctions in response urgency. For example, the dispatcher\u2019s determination of the level of consciousness in a diabetic problem case results in one of three basic determinants: \u201cconscious and alert\u201d or \u201cconscious but not alert\u201d or \u201cunconscious.\u201d\n\nUnfortunately, the effectiveness of using such lists was severely limited, because for the dispatcher to select the right response, the right problem had to be diagnosed first. Each of the problems on this list could present with chest pain as the chief complaint or an associated symptom. To require the caller \u2013 the least medically trained person in the EMS system \u2013 to initially diagnose the problem (before a full phone interrogation or professional scene evaluation) is flawed logic. Priority dispatch uses chief complaint indices that are symptom or incident based rather than diagnosis based. Because medical problems such as cardiac difficulties are usually reported either by the patient or a second-party caller actual symptoms are more readily obtained than in traumatic situations in which the determination of the type of incident or mechanism of injury is often the basis of the initial response; because these calls are often made by a third or fourth party; and access to individual patient symptoms may be limited.\n\nThe answers to key questions lead to the second component of the protocol, the provision of appropriate PAIs. One reason why key questions are asked is to identify and verify conditions that require PAIs. Before a problem can be treated over the telephone, it must be reasonably confirmed that it exists. PAIs therefore, cannot stand alone. They must follow as the result of proven interrogation scripts that identify those who actually need treatment and those who do not. Therefore, PAIs are only one component, albeit an essential one, of a competent medical dispatch system. Systems that provide telephone instructions without proper medically approved interrogation and evaluation of the patient\u2019s situation first are at significant medical and legal risk.\n\nIn medicine, planning and knowledge aforesought are crucial to the effective functioning of medical providers. Emergency nurses, trauma surgeons, and air medical personnel clearly have a medical advantage if they have some idea of the emergency they are about to encounter; prehospital providers are no different. Information that is succinct yet contains scene situation essentials (whether pertinent patient positives or negatives) is crucial to responders. Until someone actually arrives, no one knows more about the scene than the dispatcher, who is essentially the incident commander until someone else visually evaluates the scene. The dispatcher must determine the big picture and paint a verbal image for adequate en route and arrival preparation of the field providers.\n\nHazardous materials, the mentally disturbed, highway traffic, patients on drugs, and the \u201cjust plain mean and nasty armed to the teeth\u201d pose significant risks to responders, the caller, bystanders, and, obviously, the patient. Obtaining and transmitting, as a priority, information forewarning those who could benefit from such knowledge is required within the role of the dispatcher. Failure to uncover essential information during an interrogation, and relay it, has cost the lives of responders.",
        "Priority dispatch responses": "Emergency medical services resources are limited. This is increasingly evident as pressures to contain the costs of medical care escalate and elected officials agonize at the addition of even a single EMS unit to an already overtaxed fleet. Thus, the use of the EMS system must be judicious and balanced. Prioritizing calls is one way to effectively and safely accomplish this.\n\nPrioritization provides a logical way to deal with what appears at times to be the apparent chaos of response choices. Instead of having the system whirl in a version of EMS roulette, paramedic units are sent to appropriate calls rather than those that come in first. The dispatcher must adhere to clearly established, medically approved protocols to safely and effectively accomplish this essential task. It has been reasonably demonstrated that the science of medical dispatching requires non-arbitrary adherence to these protocols for response decisions made in the time-based environment of dispatch to be medically reliable.\n\nThe core purpose underlying the creation of EMD protocols was the need to control more rationally the process of EMS response. During the beginnings of modern EMS (circa 1970), the standard method of vehicle and crew deployment was what is now referred to as \u201cmaximal response.\u201d Nearly 40 years later, the need to regulate response has taken on greater implications. The issues include the following.\n\n\u2022 Response configuration (numbers and types of crews and vehicles)\n\n\u2022 Response mode (routine driving versus lights-and-siren use)\n\n\u2022 Referral to alternative care and evaluation methodologies (nurse advice, specialty center triage, non-EMS transport)\n\nEconomics of response\n\nPolitics of response\n\nPersonnel satisfaction and crew burnout\n\nResponder and public safety secondary to emergency response modes\n\nPrioritization risk management and legal concerns\n\nThe central issue from a patient care standpoint is getting 'the right resources to the right place at the right time in the right way.' The central issue from a systems standpoint is not running out of response teams by dynamically balancing needs with resources.",
        "The maximal response dilemma": "\n\nMillions of EMS responses occur every year. Before priority dispatch and call screening, virtually every response was run with lights and siren, not only to the scene but often to the hospital as well. This is an example of 'maximal response,' a combination of always responding with lights and siren or always sending multiple vehicles.\n\nMaximal response has its roots in three traditional myths. First, 'It's an emergency; we've got to hurry!' Years ago when hurrying was all that was done for the victim, speed had some value because it got the victim to the hospital for treatment. Second, many systems have confused EMS response logic with that of fire response. A fire gets worse by the second, but a single cardiac arrest does not spread geometrically in the manner of fire. Although medical problems do progress, the vast majority involve a single patient, usually in a less than life-threatening crisis. Third, and least acceptable, running lights and siren is fun and seems important. After the fire department management in Salt Lake City discussed sending first response engines without lights and siren ('cold'), a paramedic captain remarked, 'What are you guys going to do, take away the last thing on this job that's fun?'\n\nMaximal response has often been touted as the method of ensuring that those in dire straits rapidly get help. In the recent past, maximum EMS response was sent always to 'avoid errors in judgment.' Today, however, medical oversight may be unable to medically or legally defend a significant delay in arrival at a critical emergency because a paramedic team was sent to a minor call and was thus unavailable for the more serious call. Systems that still send a 'one of each' shotgun response, rather than use their first responder personnel or BLS ambulance crews efficiently, are not functioning at an appropriate level of medical responsibility. Fortunately, maximal response is a dinosaur in progressive systems; medical priority dispatching is the route to its extinction.\n\nMedical priority dispatching is an effective and safe method to determine the nature of the emergency at the time the call is received, eliminating the need for the classic maximal response in most cases. In EMS, the maximal response should be reserved for only the highest level of actual or potential crisis.",
        "Emergency medical vehicle collisions": "\n\nThousands of emergency medical vehicle crashes occur every year in North America as a result of lights and siren and multiple unit responses. According to US Department of Transportation statistics, 40% of all reportable accidents involve one or more injuries and 0.7% involve a fatality. In addition, 'hot' (lights and siren) responses cause many crashes that involve other vehicles when the EMS unit slips safely by. There are significant questions regarding the effectiveness and safety of lights and siren use.\n\nObviously, efforts made to appropriately limit 'hot' responses and extraneous responding vehicles reduce the number of accidents. The original premise of medicine, 'First to do no harm,' still applies. The EMS philosopher Page asks: What is the likelihood you'll get sued? Let's start by putting things in proper perspective. By far the greatest legal hazards facing EMTs arise from ambulance vehicle accidents. For some reason or other, we don't like to talk about ambulance vehicle accidents. Even though most of them are preventable. Instead, we are fascinated \u2013 in a morbid kind of way \u2013 with the whole subject of 'medical malpractice.'\n\nMore recently, the EMS literature has become replete with articles addressing emergency medical vehicle accident problems and various solutions to prevent and avoid them. Unfortunately, few of them suggest significantly reducing the use of lights and sirens. However, in 1994, NAEMSP published its position paper on lights-and-siren use in emergency medical vehicle response and patient transport. No data exist to prove that the use of lights and siren saves lives, although it may be reasonable to assume that this may be a factor in the rare but true time-life situation.",
        "Tiered response": "\n\nBefore discussing the steps in assigning dispatch priorities, it is crucial to understand the concept of tiered response. A tiered response is one of the most common methods of response deployment. The availability of more than one type of either response vehicle or level of personnel is required. Usually, tiered responses are found in larger municipal systems, particularly those that are fire department based. The various types of response components may include first response non-transporting units (such as police cars with police officers trained as EMRs or EMTs, or fire engines staffed with first responder firefighters or paramedics) and transporting ambulances staffed at various levels.\n\nTiered response systems make maximum use of dispatch priorities when the goal is to send 'the right thing in the right mode to the right patient at the right time.' Figure 10.8 presents a generic example of possible dispatch response choices in a tiered system using EMT fire engines, EMT ambulances, and paramedic ambulances. HOT indicates lights-and-siren response; COLD indicates routine travel.\n\nA popular response configuration alternative to a tiered response is the 'all-paramedic ambulance' system in which all transporting vehicles are paramedic ambulances, sometimes referred to as the \u201chigh-performance\u201d or Stout model. Unfortunately, few all-paramedic systems, even with the benefit of excellent system status management, can provide initial response times of under 5 minutes without integration of more ubiquitously located units such as fire engines. These all-paramedic systems often use priority response determinations through the addition of \u201cfirst responders\u201d when necessary and the determination of whether the initial ambulance response requires a \u201chot\u201d mode. When properly used through application of dispatch priority codes and medical oversight, the sometimes overlooked resource of public safety first responders and/or EMT-B units can markedly reduce response times for specific life-and-time-priority cases.\n\nGenerally coding levels are not related in an ascending linear order or urgency; the relationship is two-dimensional. The horizontal axis shows variations in the type of scene personnel required and the vertical axis separates cases requiring immediate first response from those needing only prompt but solitary secondary response by the appropriate vehicle and crew. Regardless of the type of response system used in a given jurisdiction, an accurate prioritization of conditions assists in determining the optimal use of those resources.\n\nThe benefits of medically approved dispatch response prioritization are many. By bringing more accurate information into the dispatch office through a more precise interrogation process, dispatchers are better able to recognize and understand the true medical condition. Therefore, such protocols allow for planned, safer responses (fewer units responding in the dangerous lights-and-siren mode), fuel and energy savings, reduced personnel burnout, and conservation of scarce paramedic teams for appropriate emergencies.",
        "Prioritization versus screening": "Unfortunately, there is a lack of distinction between call prioritization and call screening, and these terms are often incorrectly used interchangeably. The distinction is the inclusion of the \u201cno-send\u201d option as a dispatch choice in call screening; that is, some calls are actually \u201cscreened out.\u201d\n\nCallers have long been denied an EMS response (or non-mobile referral evaluation) and care by some large systems both with and without protocol; however, correct use of standard dispatch priority protocols does not include this option. Dispatch prioritization allows only for the decision of what to send, not whether to send. Screening out significantly increases the legal and media exposure of a system. A \u201clow-send,\u201d as opposed to a \u201cno-send,\u201d approach is legally, medically, and politically safer.\n\nRecently, attention has been given to the concept of alternative care rather than a traditional EMS response. For example, this has been done for many years with ingestions in children under age 12 without clinical symptoms. Such a response is accomplished by electronically transferring the caller to a regional poison control center for further evaluation and possible home care. EMS is promptly called back for a \u201csend\u201d if any unanticipated problems are encountered by the experts at poison control.\n\nThe area of alternative care warrants considerable discussion and review. Until significant progress is made regarding the modification of protocolized dispatch priorities to include routine alternative care tiers, as opposed to the \u201cno-send\u201d choice, significant risks remain. Certainly, documentation of very high compliance to protocol is a necessary prerequisite to implementation of an alternative care option.",
        "Response theory and local development": "At a certain point during initial priority dispatch implementation, a committee including medical oversight physicians, field personnel, managers, and administrators faces the task of designating the response assignments to each chief complaint/incident type protocol. The goal of local response setting is to match local EMS capability with the various dispatch determinant descriptors and codes found on each protocol. It does not change the protocol; rather, it allows each community to choose what resources to send for each of the determinant codes.\n\nThe political element of establishing localized responses for the dispatch determinants is probably the biggest hurdle an EMS medical director faces when implementing priority dispatch systems. Various EMS services within a region (each possibly a bit protective of its territory), different hospital base stations, and different medical directors may initially complain to priority dispatch advocates that \u201cthis concept may work elsewhere, but won\u2019t work here.\u201d\n\nThe more relevant point is to look at what these somewhat diverse entities have in common: a desire to serve the public, and a commitment to emergency patients and the safety of responding crews. They must eventually sit together and objectively assess the purpose and structure of priority dispatch and resultant rational control of system response. Implementation may be an initial challenge, but it has been accomplished successfully in the full range of EMS system designs and community sizes around the world.\n\nNot every EMS system resembles the examples shown in Figure 10.9 or Figure 10.10. Currently the diversity of response capability (not to mention response desires) from system to system is amazing. But each EMS system, with its unique characteristics, can maximize the efficiency of its response with correct use of a priority dispatch process.\n\nNearly all volunteer services can benefit from priority dispatch because it is no longer necessary for every available volunteer to respond on every call \u2013 which is not usually understood. Volunteer time and talent can thus be used more appropriately. Busy volunteer systems might configure their baseline responses as follows.\n\nECHO: Police first responders HOT; On-call EMTs HOT; Back-up crew HOT\nDELTA: On-call EMTs HOT; Back-up crew HOT\nCHARLIE: On-call EMTs HOT; Back-up crew COLD (for extra personnel if needed)\nBRAVO: On-call EMTs HOT; Back-up crew stand by at home\nALPHA: On-call EMTs COLD\nOMEGA: Referral to poison control center\n\nGeneral rules of the response planning process There are five rules for system planners to remember when assigning field responses to the dispatch determinant codes.\n\n1. Will time make a difference in the final outcome? In other words, is the patient\u2019s problem one of the few true time/life priorities requiring the fastest possible response time, with a goal of less than 5 minutes? Most systems identify the most time-critical calls as cardiac or respiratory arrest, airway problems (including choking), unconsciousness, severe trauma or hypovolemia, and true obstetrical emergencies. The early identification of these chief complaints means that a maximum response is sent. For the majority of other problems, planners should carefully consider using a less than maximal response.\n\n2. How much time leeway exists for this problem? In brief, what range of time is appropriate for the problem? In medicine, this ranges from seconds to days. However, the majority of calls lie in a range from those warranting prompt (but not breakneck) responses to those where there is significant time leeway for minor and clearly non-escalating problems.\n\n3. How much time can be saved by responding \u201chot\u201d? Accurate information about differences between \u201chot\u201d versus \u201ccold\u201d response times is uncommon but increasing. Response times from time of call to patient contact (versus arriving at the address) have not been well reported. Typical local traffic patterns, time of day, how fast local ambulances actually roll, typical roadway conditions such as stoplights, roads that demand frequent deceleration or acceleration, and local speed limit laws for emergency units should be some of the oversight committee\u2019s concerns. If an EMS unit has to respond within a mile or two, are the very few seconds saved running \u201chot\u201d worth the disruption to traffic and pedestrians, not to mention the safety of the motoring public and prehospital crew?\n\nNew studies regarding whether time is actually saved responding \u201chot\u201d versus \u201ccold\u201d reflect clinically minimal time differences, yet the relative safety of a \u201ccold\u201d response is well demonstrated and also medically appropriate.\n\nThe common perception of lights and siren is that their use indicates a real emergency situation. The principles of priority dispatch have resulted in a redefining of what an emergency really is. Reducing the use of lights and siren is, in itself, a concept that can save lives. When a person\u2019s life clearly depends on quick action and rapid motion, lights and siren is an important tool. However, there are many times when a situation that appears urgent in the field will not be helped by the use of lights and siren. The time saved using them (either going to the patient or to the hospital) is long gone before the patient benefits from definitive care. An ever-increasing number of public safety agencies are adopting the more responsible approach of limiting lights-and-siren use to potentially critical emergencies.\n\n4. What time constraints are present in the system? Each system design has limitations. In some areas, the crews are all-volunteer, and it routinely takes responders 10 minutes or more to get to the ambulance shed. There is a greater inherent time constraint in this context than in a set-up in which prehospital personnel await calls from inside an ambulance stationed on a street corner when the posting location is selected through use of a system status plan that fluidly redeploys available units based on call frequency predictive analysis. Their departure is immediate and their arrival significantly shortened overall.\n\n5. When the patient gets to the hospital, will the time saved using lights and siren be significant compared to the time spent awaiting care? This is the most ignored rule. When the critical needs of the patient warrant the fastest possible response to the scene and transport to the hospital, proper advance notification of the emergency department staff results in immediate, continuing definitive care after arrival. However, except for the most critical cases, patients do a great deal of waiting at the emergency department as hours are spent obtaining lab tests, x-rays, and specialist consults to validate the presumptive diagnosis before moving to any definitive treatment. Did the fast response and transport really help? In essence, was it medically (or publicly) ethical? In the majority of cases, the few minutes possibly saved responding and/or transporting \u201chot\u201d are irrelevant to the patient\u2019s actual care and ultimate outcome.\n\nResponse development is a process, not an event. The more data are harvested from the dispatch coding system, the more refined, effective, and safe it will be for patients, responders, and the EMS system in general. No one can expect to sit at a meeting table and hammer out every possible contingency. Something normally handled \u201ccold\u201d may \u2013 due to weather, traffic, or other unusual circumstances \u2013 someday at some particular time warrant a \u201chot\u201d or maximal response. The dispatcher can be given the flexibility to choose other options as clearly defined in locally written dispatch policies. Sound, reasonable judgment should be the hallmark of well-trained, protocol-equipped dispatchers. The process should obviously be backed up by strong, attentive medical oversight.",
        "Medicolegal issues": "The fascination with legal aspects of EMS has played a major role in retarding the development of EMD by perpetuating myriad inappropriate fears and supposed pitfalls. Specifically, there has been considerable concern about the potential liability that dispatchers might incur when giving telephone instructions or prioritizing calls based on formal protocol use. With the exception of the Phoenix case (related to incorrect advice in an infant CPR case: \u201cput your hand over the nose and mouth of the baby\u201d), there are no public records of any lawsuits (successful or unsuccessful) addressing either area, even though thousands of communities now perform both functions routinely.\n\nThe legal climate is getting warmer in all areas of medicine, and EMS is no exception. As the legal community has learned more about the workings of the prehospital care system, it has discovered the dispatch center as well; however, at this time failure to provide PAIs and \u201cscreening out\u201d stand out as the major areas of risk. Legal cases involving dispatch misadventures have become common enough that plaintiffs\u2019 attorneys have coined a term for it: dispatcher abandonment.\n\nThe medical director must understand the four essential components of negligence in a court of law: duty, breach of duty, harm, and causation. Most malpractice cases are won or lost in the area of causation by success or failure to show that acts of omission by the defendant were the \u201cproximate cause\u201d of the untoward result. However, the concept of duty may play a more prominent role as medical dispatching evolves. Prosser states in regard to duty, \u201cChanging social conditions lead constantly to the recognition of new duties. No better general statement can be made than that the courts will find a duty where in general reasonable men would recognize it and agree that it exists.\u201d\n\nIn 1981, Page wrote: I personally feel that the highly successful \u201cmedical self-help\u201d program introduced by the Phoenix Fire Department, may have started a process which will redefine a municipality\u2019s duty to its citizens. Similarly, the Emergency Medical Dispatch Priority Card System, created by Clawson in association with the Salt Lake City Fire Department, may have further advanced the municipality\u2019s duty. In other words, I can foresee a day when a citizen might allege that the municipality (which maintains a full-time public safety dispatching service) was negligent for failing to implement and operate such a service. In view of the fact that implementation of this new level of service does not constitute a major expenditure to the municipality and thus is basically an organizational/management/training issue, rather than a funding/taxation issue \u2013 I feel the case for a legal obligation (duty) to provide it becomes stronger.\n\nIn 1993, in the Journal of Emergency Medical Services, Cady reported that on the basis of the journal\u2019s annual 200-city survey, 94% of communication centers operated by EMS agencies were offering some sort of PAI. However, only 70% of fire departments and 68% of police-operated centers offered PAI.\n\nThe courts must decide whether or when such a duty \u2013 and therefore a standard of care \u2013 is actually created. This issue is moot in many states, as statutes and regulations require them. Legitimate concerns have been raised concerning PAIs. The common expression is, \u201cDoctors don\u2019t even give advice over the phone. Why should dispatchers?\u201d However, in thousands of cases, trained dispatchers have given excellent instructions via the telephone. Because the alternative is literally nothing, more intelligent concerns should focus on the questions listed in Box 10.3.\n\nThe answers to each of these questions play an important role in the risk management aspect of EMD. Because dispatchers are no less accountable than other EMS practitioners, the answers to these questions should be in the affirmative. In 1981, George stated in the EMT Legal Bulletin: An \u201cupfront\u201d clearly articulated written policy in support of telephone screening of emergency calls coupled with sound guidelines and protocols for use by dispatchers would provide a ray of legal light in an otherwise murky area of heavy potential liability. A reasonable system of call screening can provide a good legal defense for both the EMS dispatcher and his employer should a charge of negligent handling of emergency calls be raised by a plaintiff.\n\nThe absence of standard protocols makes it difficult to reproduce the same sequence of interrogation or the same answers in relation to a given chief complaint. As George further warned: EMS dispatchers must always avoid the appearance of responding to or categorizing emergency calls in a haphazard or arbitrary manner. A unified procedure will provide an excellent method of safeguarding against arbitrary decision making. Without a unified system, one dispatcher may decide that a crucial situation exists primarily on the level of emotion he detects in the caller\u2019s voice, while another may depend on his own \u201cgut\u201d reaction, without being able to articulate a clear reason for his decision [65].\n\nSome places provide various forms of legal immunity to public safety personnel. Governmental immunity may not always protect an individual or the employer from liability damage recovery, as in the Kazmerowski v. Chicago, Supreme Court of Illinois decision [70]. Immunity should never be provided to dispatchers without being clearly linked to appropriate training and certification, use of medically approved protocols, compliance with protocol, quality management mechanisms, random case review and feedback, continuing dispatch education, and recertification. If all these are not ensured, then public safety dispatchers and their employers should be responsible for negligent actions.",
        "Conclusion": "At times, application of common sense seems impossible in a world of self-protectionism, political correctness, and 'what if' mentality. Had EMS and EMD appeared in the 1930s, legal discussions would have been largely unnecessary. In those earlier times, actions themselves were considered more important than the imagined consequences. Today, however, these oft-mentioned concerns and fears have actually blocked more proactive interventions by dispatchers in many systems. Optimal dispatching requires the courage to practice medicine at dispatch the same way it is done in the field. Many of the key decisions and diagnoses in medical practice are based on statistical predictability or the likelihood of finding a specific problem using standard evaluations and tests. Medical priority dispatching concepts were born of this 'physician-based' process.\n\nThe dispatcher's role differs in major ways from that of the field provider. Street practitioners act as advocates for individual patients assumed to be dying until it is proven otherwise. Dispatchers are the advocates for the well-being of the entire system, and they must constantly juggle the concepts of 'allocate versus conserve' and 'hurry versus wait.' This requires a philosophy of training and protocol quite different from that of field personnel. The dispatcher's multiple roles of interrogator, prioritizer, and prearrival intervener are analogous to the physician's tasks of history taking, evaluation, categorization, and treatment. The advocacy of the system versus the individual patient is the dilemma faced in providing safe and efficient dispatch priorities. EMS physicians responsible for medical dispatch programs are repeatedly forced to deal with that dilemma.\n\nToday, many EMS systems lack the money and human resources to respond maximally to every medical request. The improvements in patient care and survival, and the appropriate tiering of response through structured call prioritization, provide one answer to the specter of political or financial self-destruction in EMS. Not paying appropriate attention to dispatch is analogous to picking up a deadly snake by the tail instead of just behind the head. The unexpected 'bite' of medical dispatch has injured a number of unwary medical directors.\n\nExcellence at dispatch encourages excellence down the line. Nursing QM expert Smith-Marker stated it well regarding telephone-based medical triage.\n\nTelephone triage can function according to defined purposeful expectations or by intuition. A medical dispatching system can operate in a designated manner or haphazardly. Patient care by phone can be delivered by design or by impulse and habit. Standards either exist or they do not. If they exist, they must be detailed, consistent, and comprehensive or they will be shallow, irrelevant, and worthless.\n\nIn conclusion, the core of EMD, as in most aspects of medical practice, is the provision of the correct medical interactions at the right time by appropriately trained practitioners. The critical functions of dispatchers in prehospital medicine are unique and crucial parts of the responsibility of medical oversight physicians."
    },
    {
        "Introduction": "There can be little doubt that EMS work contains more than its fair share of strain or that certain EMS calls are apt to produce a significant level of stress. This is not a calling well suited for those disposed toward the sedentary or the serene. The emergency side of the enterprise ensures EMTs a ringside seat, if not a central speaking role, in the majority of events listed on the classic Holmes and Rahe checklist of stressful life events. Even the most routine elements of contemporary EMS work (e.g. non-emergency transfers) can bring providers into repeated contact with demanding people in difficult circumstances.\n\nWhether looking from the health care side or the rescue viewpoint, the field provider often perceives himself or herself to have been relegated to a rather lowly position in the overall pecking order. When it comes time to pay the bills, there is no escaping the reality of limited pay for long hours. There probably couldn't be a better recipe for disenchantment, especially for people who studied hard and competed intently for positions in which they could help others and maybe save lives.\n\nBut do EMS workers endure radically greater stress than other health care and public safety workers? Are they grossly unsatisfied with their jobs? Are they falling victim to posttraumatic stress disorder (PTSD), suicide, and depression at epidemic levels? Do their careers \u201cburn out\u201d in just 4 or 5 years? Does unrelenting exposure to life's most poignant events lead to intractable harm? Can that harm be prevented or ameliorated by patent remedies and \u201cself-help\u201d programs? Does the absence of such programs lead providers to unravel and organizations to fail?\n\nA quick survey of the industry's folk wisdom could lead one to think so. Several years ago, articles in trade magazines and presentations at trade shows and conferences made sweeping claims about the risk of PTSD while a booming cottage industry arose to offer instruction in how to mount stress management programs. It all seemed reasonably simple, straightforward, and intuitively clear.\n\nHuman responses to life's many challenges are anything but simple. Those seemingly straightforward questions posed above are actually multidimensional and layered with nuance. EMS workers report more frequent and proximal involvement with objectively distressing events than do many others but this should be expected, given the nature of their work. Just when their reactions should be considered symptoms of dysfunction rather than signs of exposure poses another, considerably thornier set of questions. EMTs are well aware of the limitations their occupation presents but are also uncommonly attuned to its rewards. To whom should they be compared to determine whether their satisfaction with their careers is greater or lesser than one might reasonably expect of workers in any challenging enterprise? Rates claimed for PTSD and depression vary widely between studies, depending on criteria, methods, and assumptions employed. Those looking for high rates of disorder seem to find what they are seeking while those looking for resilience find it as well.\n\nThe question of whether prescriptive, prophylactic efforts at prevention and intervention can effectively mitigate these effects is no less complicated. Programs built around \u201ccritical incident stress management\u201d (CISM) and its signature intervention, \u201ccritical incident stress debriefing\u201d (CISD) permeated the industry and were typically well received as indicators of the organization's concern for the impact of work-related stressors on EMS personnel. Yet despite years of proclamation from promoters and purveyors regarding the effect of these efforts on job satisfaction, career longevity, and clinically significant sequelae, there is little evidence that these interventions have any appreciable effect on limiting PTSD and a disturbing trend in more extensive studies for debriefing to show paradoxical effects on natural recovery for at least some recipients. A number of authoritative guidelines for evidence-based practice now caution against the routine application of debriefing, and some list it as contraindicated.\n\nThis leaves the EMS manager with a troubling conundrum. It seems evident, on the one hand, that EMS workers have chosen to take on a challenging occupation and deserve to receive every effort the organization can muster to assist them in coping with its effects. It is also increasingly clear that what was once widely accepted as a de facto industry standard for addressing this concern has proven less than effective and might even become a complication for some persons in at least some situations.\n\nEven though traditional CISM interventions failed to live up to sweeping promises regarding prevention or mitigation of PTSD, they were generally well received as expressions of organizational support. Such expressions are indeed important, and it is only reasonable that some cogent set of supportive responses continues to be made following distressing events in the field. Fortunately, a widely growing research base containing increasing sophisticated information now offers useful suggestions.",
        "Occupational health approach: organizational systems perspective": "Traditional CISM programs were marketed and disseminated as \u201cgrass roots\u201d approaches designed to operate in a \u201cpeer-driven\u201d structure; the program and its operation were typically insulated from the usual structure and boundaries of daily operation and management. The original dissemination model was centered on two-day \u201cChautauqua-style\u201d workshops in which dozens of would-be interveners, typically dominated by prospective \u201cpeer\u201d providers, received training that was oversimplified with respect to underpinnings and overspecified with respect to intervention. While these teams were to include a mental health professional as \u201cclinical director,\u201d there was no qualification prescribed other than licensure or certification in some field related to counseling and attendance at one of these 2-day workshops.\n\nThese programs were ostensibly developed to address risk of occupational injury but have rarely been articulated with or supervised by the agency\u2019s occupational health provider. It is not uncommon, however, to find integration with an organization\u2019s employee assistance program (EAP). EAP programs are typically capitated delivery models, most usually from an external vendor, designed to provide limited basic counseling in areas such as substance abuse, depression, and family issues. \u201cCritical incident response\u201d is often provided as an add-on service.\n\nThe limitations of these types of insulation were addressed in recent revisions to National Fire Protection Association Standard No. 1500, Standard on Fire Department Occupational Safety and Health Programs. Changes recommended by a series of consensus groups convened through the National Fallen Firefighters Foundation as a part of its occupational health and safety initiatives included placing the organization\u2019s program for response to atypically stressful occupational events under the supervision of the occupational health physician and integrating elements of basic support into the daily structures and operations of the delivery system; changes were also made to provide more specific standards for EAPs. These consensus groups also adopted guidelines and recommendations for an integrated, stepped care approach to organizational support of employees and competent professional assistance where clinical issues arise, derived from current best practices and published guidelines.\n\nA basic outline of current recommendations is summarized below.\n\n\u2022 Immediate assistance should be proximal, non-intrusive, and ecologically intact, using principles of basic stress first aid as indicated by the situation and circumstances. The Combat Operations Stress First Aid program of the US Navy and Marine Corps was identified as a prototype combining evidence-based principles and organizationally integrated implementation.\n\n\u2022 Early, reliable, and non-intrusive assessment should be seen as an essential element in the process of resolution. While most EMS providers experience some level of distress following difficult duty, the greatest majority will not see that distress rise to levels that demand clinical treatment. The best approach in the early stages is generally one of practical support, compassion, and watchful waiting, referring any displaying obvious or profound difficulties for professional behavioral health intervention as indicated by their level of impairment. Easily utilized, non-intrusive screening measures are therefore an important element in tracking employee resolution and identifying those for whom more focused intervention is warranted.\n\n\u2022 Stepped care entails providing treatment specifically to those who need it at levels that match their clinical needs. While basic supportive assistance is generally appreciated by most who have experienced distressing events, it may not be of universal benefit and can feasibly prove detrimental to some. Indeed, studies of cardiac patients following major coronary events found that a significant minority actually fared better if not enrolled in seemingly benign interventions such as psychoeducational support and symptom education. Studies of early interventions based on debriefing techniques have also shown these sorts of paradoxical effects.\n\nExperienced EMS providers tend to be well acquainted with the transient discomfort that particularly poignant occupational experiences can bring and most have developed methods of regulating their discomfort that keep it from interfering with their lives and careers. Where transient but subsyndromic discomfort proves recalcitrant or troublesome, referral to EAP providers or reliable self-help resources can be beneficial in shoring symptom management skills and in addressing external stressors that may be compounding the provider's ordinary capacity for self-regulation. Where symptom manifestation reaches clinical thresholds, referral to specialty providers for evidence-based treatment of the clinical conditions manifested is warranted.\n\nEvidence-based treatment of clinical conditions by competent and credentialed specialty behavioral health providers should be considered the standard of care for cases that reach diagnostic thresholds. Just as we fully expect to refer orthopedic injuries to competent surgical specialists or occupationally engendered infections to appropriate specialists in infectious diseases, we should be prepared to refer cases of psychiatric syndromes associated with occupational exposures to the care of carefully selected behavioral health specialists employing evidence-based treatments consistent with current authoritative guidelines for appropriate intervention.\n\nThis can be especially confusing in the realm of psychological trauma, where (as noted above) there is little objective regulation upon which to rely for guidance and where \u201cfringe therapies\u201d that offer sweeping claims but little objective evidence abound. The treatment guidelines noted earlier converge on the well-documented efficacy of trauma-focused variants of cognitive behavior therapy using graded exposure. This approach has demonstrated efficacy in a range of applications, including treatment of PTSD in World Trade Center survivors. On the other hand, many treatments typically employed in routine therapy have been found to be relatively ineffective in treating conditions such as PTSD.\n\nwere transcribed, coded, and analyzed for common themes. Most of the providers\u2019 suggestions concentrated on very practical workplace steps, such as a half-hour to one hour \u201ctime out\u201d period to recoup and regroup (alone or with peers of their choosing, at their option) coupled to expression of support and interest from supervisors. Should professional intervention become advisable, providers indicated that they would prefer to exert greater influence over the nature, context, and sources for the intervention sought.",
        "Experience of a potentially traumatic event": "One provider\u2019s trauma may well be another\u2019s routine experience. The reaction is on many levels a subjective one, driven by the individual provider\u2019s experiences, sensibilities, and personal situations. Accordingly, the first question is, \u201cDoes the provider consider it significant?\u201d If so, he or she can request initiation of the protocol; if not, an expression of concern and the availability of help if needed may be all that is required.",
        "Supervisor \u201chot wash\u201d": "The \u201chot wash\u201d is an element of the military after-action review process that, especially if flavored as indicated with principles of stress first aid, can make the initial system response useful, helpful, and non-intrusive. Its basic structure is simple: What happened? What was successful? What could have gone better? How might we improve? Who should we tell about what we have learned? The hot wash is not reserved for complex, troublesome, or tragic events; it is most effective where it is a routinely practiced element of quality improvement, used to review routine events as well as complex encounters. The objective is \u201clocal learning\u201d that can identify and reinforce successful practices while noting opportunities for improvement.\n\nIf routinely practiced \u2013 not as a response to troubling incidents and equivocal outcomes but as a routine quality improvement exercise \u2013 this quick review becomes the default outline for response when confronted by trying events, making the transition to discussion natural and uncontrived. This discussion alone helps place the event into an appropriate occupational context and provides an easy segue into discussion of emotional reactions if sought or indicated. If that appears to yield sufficient resolution, the process may be complete; if serious issues are obvious, referral for assessment is prudent. If it still seems unsettled, a quick and non-intrusive screening may be employed at 3\u20134 weeks.",
        "Help-seeking predilections versus help delivery systems": "Building a system that can integrate seamlessly into the agency\u2019s standard organizational and incident management structures is vital to achieving an effective solution. Rather than imposing help delivery systems that are essentially insulated from organizational structures and patterns, and which may inadvertently run counter to the organization\u2019s occupational health objectives and practices, successful programs will ordinarily be built on analysis of the help-seeking patterns and preferences of its members as they encounter difficult occupational conditions and events. These efforts will generally be imbedded into standard operating practices that serve established organizational objectives.\n\nIn detailed qualitative interviews of Canadian EMS providers, Halpren and colleagues asked what types of assistance they felt to be useful and how they would want that assistance to be delivered. Paramedics, supervisors, and dispatchers were questioned in detail about their strategies for coping and their ideas for enhancing recovery. Systematic interviews were conducted in both groups and individual sessions where the responses Most of the providers\u2019 suggestions concentrated on very practical workplace steps, such as a half-hour to one hour \u201ctime out\u201d period to recoup and regroup (alone or with peers of their choosing, at their option) coupled to expression of support and interest from supervisors. Should professional intervention become advisable, providers indicated that they would prefer to exert greater influence over the nature, context, and sources for the intervention sought.\n\nFigure 24.1 provides a flow chart for a basic protocol addressing potentially traumatic events derived from elements outlined above, as developed by consensus groups matching leading research programs and industry constituency groups. It is not intended to be prescriptive but rather to serve as a basic schematic to be adapted to the needs, structure, and pragmatics of any given organization. It is built to accommodate stressful effects of more basic EMS encounters with full expectation that it will be treated flexibly and adapted as required for more complex incidents.",
        "Trauma Screening Questionnaire": "Brewin and colleagues reported on the development of the Trauma Screening Questionnaire (TSQ), a simple, straightforward, and non-intrusive short questionnaire that has demonstrated very good utility in identifying those for whom resolution is progressing well and suggesting who may require fuller assessment for clinical treatment of PTSD. Consisting of ten simple queries with \u201cyes\u201d or \u201cno\u201d responses regarding whether the indicated symptom has been experienced more than twice in the preceding week, it can be scored by rote counting of positive responses using a threshold of six or more affirmative replies as a positive screen for advancing to full assessment. It can accordingly be used with outstanding efficiency in primary care settings, workplace screening, and even as a self-assessment tool. Its capacity in various trials to screen out cases that will not experience clinical levels of impairment has been shown to be quite strong and its capacity to identify those who will require further intervention has shown acceptable sensitivity and specificity for use a screening instrument.\n\nIf six or more items receive positive responses, referral for a more complete assessment is indicated. Should a given provider screen as subsyndromic but still need assistance with symptom regulation or compounding life issues, appropriate referral for basic EAP assistance should be considered.",
        "Complete assessment": "A qualified EAP provider or other professional can typically accomplish this using appropriately validated instruments and procedures. Specialty treatment may not be indicated, but the EAP can help with symptom management or external stressors that are complicating the provider's usual capacity to deal with the circumstance. Where clinical treatment is indicated, referral should be made to a competent behavioral health specialist fully qualified in appropriate evidence-based techniques.",
        "Treatment by specialty clinician": "This should be a specialist (typically a board-certified psychiatrist, a licensed, doctoral level psychologist, or a certified clinical social worker) with advanced training and supervised experience in specific, evidence-based treatment models supported by current clinical guidelines (e.g. cognitive behavior therapy for PTSD, anxiety disorders, and depression). Occupationally related PTSD has typically responded to relatively short treatment cycles (12\u201325 sessions in the Levitt study), but is often accompanied by other issues that may benefit from further EAP assistance (e.g. family effects). Accordingly, evaluation for other needed or desired assistance completes the protocol.",
        "Building an integrated system": "It is important to keep in mind that successful approaches build on elements that are integrated into organizational and operational systems rather than invoked in response to limited and specific situations. Accordingly, critical elements need to be incorporated into those systems and used regularly to assure familiarity and appropriate utilization as indicated. The National Fallen Firefighters Foundation program generated training features for each element of the consensus protocol to assist organizations in putting key pieces into play. While developed from a fire service perspective, EMS applicability was a key consideration as medical response dominates the service profile of most fire service agencies and many are primary providers of ambulance service. Available elements include the following.\n\n\u2022 After-action review. Online training module regarding use of operational after-action reviews (hot wash) in daily operations.\n\n\u2022 Curbside manner: stress first aid for the street. Online training module presenting an abbreviated version of the Stress First Aid program emphasizing daily use of its basic principles in routine contacts, both enhancing patient care and priming these principles to facilitate their application in coworker interactions following difficult or trying events.\n\n\u2022 Trauma Screening Questionnaire. The TSQ is made available for download and use.\n\n\u2022 Developing an effective behavioral health program. Information to assist organizations in designing and contracting for employee assistance procedures that conform to revised NFPA 1500 standard.\n\n\u2022 Assistance to behavioral health providers. Online training in evidence-based intervention developed in partnership with the National Crime Victims Research and Treatment Center at the Medical University of South Carolina.\n\n\u2022 Stress first aid. This imbedded program of coworker assistance and referral, adapted for fire and EMS from the US Navy and Marine Corps Combat and Operational Stress First Aid program by the National Center for Post Traumatic Stress Disorder, provides training at awareness (all personnel), operations (officers and supervisors), and technician (designated peer support personnel) levels.\n\nAccess to all of these resources is available through an online portal at http://flsi13.everyonegoeshome.com; with few exceptions (classroom instruction in higher levels of stress first aid), all are accessible without charge through that portal.",
        "The final fundamental: personal wellness and fitness": "Resilience is ultimately determined more by the providers' capacity to absorb stressful exposures on the job than by either the nature of the exposures themselves or the responses to exposures after the fact. This requires a fundamental commitment from each EMS provider to his or her own health, wellness, and fitness, and a fundamental commitment from the agency to provide resources and support for maintaining those capacities in its members. While the nature and design of comprehensive wellness and fitness programs are beyond the scope of this chapter, it is important to emphasize their critical role in promoting the resilience of EMS providers. The International Association of Firefighters and the International Association of Fire Chiefs have developed a Joint Labor Management Wellness and Fitness Initiative that provides an excellent overview of the critical elements of effective programs for career agencies, while the National Volunteer Fire Council and the United States Fire Administration have published a similar initiative for volunteer organizations. A strong and effective behavioral health component that includes at a minimum assistance with marital and family problems, substance abuse, basic counseling needs, and capacity to assist or refer for specialty care, where indicated, is an essential element of any comprehensive wellness and fitness program.",
        "Conclusion": "Emergency medical services is a career that demands a great deal from its providers but also provides strong intrinsic rewards. Sound organizations realize these demands and build processes that promote personal and organizational resilience while providing access to intervention systems employing evidence-based best practices for providers who may require professional assistance following difficult occupational events. Contemporary best practices have shifted significantly based on evolving research. Traditional CISM approaches were adopted in an attempt to meet an important need but must be reconsidered and reconceptualized to reflect current understandings, advances in strategies and techniques, and emerging standards for evidence-based behavioral health care. Processes to provide both organizational support and access to professional care as needed are suggested as frameworks from which organizationally specific models can be constructed to fit the needs of particular EMS agencies."
    },
    {
        "Introduction": "Two principal legal issues are raised by performing quality improvement (QI) activities in any health care setting, including EMS. The first issue is the extent to which information generated by or for the body and individuals that perform QI may be kept confidential. The second question is whether participants in QI activities face liability as a result of their participation. These issues are addressed by statute in some (but by no means all) states, and the scope and nature of statutory protection differ significantly from state to state. By analogizing to the more fully developed law relating to QI in the hospital setting, however, it is possible to provide some practical suggestions aimed at protecting the prehospital QI process and those who participate in it.",
        "Confidentiality of quality improvement materials": "Reasons for confidentiality Those who perform QI reviews, and those who are the subject of such reviews, generally wish to protect QI data from public disclosure, including release for use in legal proceedings or to the media. Those legislatures and courts that have elected to protect the confidentiality of QI information typically are motivated by a desire to encourage candid review by assuring QI participants that the results will not be made public and may not be used in litigation against the subject of review. In other words, the purpose of confidentiality is to promote candid evaluation and protect the effectiveness of the QI process, thereby improving the quality of health care available to the public. The individual providers who are the subjects of QI activities are the ancillary beneficiaries of such confidentiality. The National Association of EMS Physicians has adopted a position statement endorsing statutory protection for the confidentiality of EMS patient safety and quality information because such protections promote learning and foster a culture of safety. However, courts and legislatures are also influenced by countervailing considerations. There are strong public policies in favor of giving consumers access to health care quality data, and making all relevant information available to the parties to litigation in order to enhance the likelihood of a just result. Each state attempts to reconcile these conflicting public policies in its statutes and court decisions relating to the confidentiality of QI records.",
        "State confidentiality statutes": "Participants in EMS QI should familiarize themselves with the statute, if any, in their state that governs the confidentiality of QI materials. Unless QI materials are made confidential by state statute, they are likely to be (a) subject to subpoena and other forms of pretrial discovery, (b) admissible as evidence at trial (assuming the materials are relevant and otherwise satisfy generally applicable requirements for the admission of evidence), and (c) subject to public disclosure under the state's freedom of information statute if they come into the possession of a state governmental agency. Who conducts protected QI? Emergency medical services QI may be conducted by hospitals individually, by EMS agencies individually, or by a centralized body responsible for the quality of care throughout an emergency medical system or on a regional or state-wide basis. The availability of confidentiality may depend on who conducts EMS QI. A majority of states have enacted statutes that grant hospital peer review records at least limited confidentiality. When EMS QI is conducted by a hospital, participants should confirm that the emergency medical care they review is within the scope of the statutory definition of \u201chospital\u201d QI. A number of states have adopted statutes that expressly protect the confidentiality of records of centralized review of EMS that is conducted by a private or governmental body that is responsible for monitoring the care provided by multiple prehospital providers. Such statutes typically also protect the records of QI activities that are conducted by providers themselves. For example, the Florida legislature has expressly provided that, \u201cThe investigations, proceedings and records of a committee providing quality assurance\u201d regarding EMS \u201cshall not be subject to discovery or introduction into evidence in any civil action or disciplinary proceeding\u201d conducted by the state or by an agency that employs emergency medical personnel. The same Florida statute provides that persons who attend a meeting of an emergency medical review committee are not permitted or required to testify in any such civil or disciplinary proceeding regarding information relating to the committee, except for information from external sources that was presented to the committee. A number of states have established state-wide or state-appointed EMS QI bodies, and have enacted statutes that grant confidentiality to the records of these statutorily mandated QI bodies. A significant number of states protect the confidentiality of QI conducted by a single EMS provider with respect to its own services. Often it is not clear whether these confidentiality statutes, which expressly apply to an individual provider\u2019s activity, also cover QI that is conducted on a centralized basis, such as where a committee of representatives of the state or local EMS authority performs QI. In states that protect only the records of individual providers, QI providers might attempt to bring themselves within the protection of the statute by having each participating provider sign a simple form that delegates the provider\u2019s QI functions to the centralized EMS QI committee. While this approach is largely untested, there is strong appeal to the theory that if QI is confidential when conducted independently by individual providers, it should also be equally protected when performed (perhaps more effectively and efficiently) on a centralized basis by a group of such providers. Research revealed only one reported court decision that addresses the confidentiality of EMS peer review materials. In McCoy v. Hatmaker, 135 Md App 693, 763 A2d 1233 (2000), the Maryland Court of Special Appeals upheld a lower court decision protecting the confidentiality of a fire department\u2019s records. The fire department employed an EMT who allegedly had violated state-wide EMS protocols when providing emergency care to a motorist who died. The motorist\u2019s estate sued the EMT and his municipal employer for wrongful death. In the course of that litigation, the plaintiff subpoenaed the report of an investigation of the incident/death that was conducted by the EMT\u2019s supervisor. The fire department refused to release the record to the plaintiff on the grounds it was confidential \u201cmedical review\u201d and protected against discovery by Maryland\u2019s medical review committee statute. The Maryland statute protects the confidentiality of the proceedings and records of committees that review the quality or necessity of health care or the competence or performance of providers; the statute is generic and does not apply expressly to EMS. The Court of Special Appeals agreed with the fire department and observed: Although medical review committees are most often associated with hospitals or other traditional health care facilities, a review by the Fire Department would constitute a protected action, when as here, the fundamental purpose of the review was the improvement of health care services provided by the Fire Department paramedics.",
        "Extent of confidentiality created": "State peer review confidentiality statutes also vary with respect to the scope of confidentiality each creates. The principal variables include the following. * Type of information protected: data submitted to QI body, body\u2019s deliberations, and/or its conclusions; written records only, or also prohibit oral disclosure of QI information (including testimony). * Type of QI protected: prospective (such as development of protocols and policies), concurrent, and/or retrospective review. * Whose records are protected: specified bodies only, or any individual and/or body that performs a QI function. * Type of disclosure prohibited: pretrial discovery, admission as evidence at trial, Freedom of Information Act (FOIA) requests, and/or voluntary disclosure by QI body. For example, the Rhode Island emergency medical transportation services peer review statute (General Laws 1956, \u00a723-4.1-18) prohibits discovery and admissibility of EMS peer review records in any lawsuit except \u201clitigation arising out of the imposition of sanctions upon a [sic] emergency medical technician,\u201d and peer review records may be used as evidence against an EMT to show the EMT furnished care contrary to a restriction or supervision that had been imposed with respect to the EMT. * An absolute prohibition against disclosure, or a \u201cprivilege\u201d that may be waived by the provider who is the subject of review and/or by the QI body. If disclosure is prohibited by law, the statute may prevent use of QI information in any and all proceedings or only in specific types of cases, such as professional liability actions and/or other types of personal injury lawsuits against providers. Participants in EMS QI can be effective advocates for confidentiality legislation that incorporates broad protection with respect to each of the variables outlined above.",
        "Federal confidentiality statute": "Confidentiality protection for EMS QI materials may also be available under federal law. Patient safety organizations (PSOs) were created under the 2005 Patient Safety and Quality Improvement Act (PSQIA) which amended the federal Public Health Service Act to improve patient safety and reduce the incidence of adverse events. The PSQIA creates comprehensive confidentiality for \u201cpatient safety work product,\u201d which is defined broadly to include virtually all information that is collected or generated by providers for submission to a PSO, or by a PSO. To qualify as a PSO, an organization must be an independent entity whose primary activity is to improve patient safety and the quality of health care delivery. A PSO must satisfy a number of requirements, including collecting and analyzing patient safety work product from multiple providers in a standardized manner for comparison purposes, and utilizing these data to provide direct feedback to providers and assist providers to minimize patient risk. An organization qualifies as a PSO only if it applies to and is certified as such by the federal government. Patient safety work product is made confidential by the PSQIA and is protected from discovery or admissibility in federal, state, and local litigation and protected against disclosure under the FOIA. Emergency medical transportation agencies and emergency medical personnel are not in the statutory list of examples of under the PSQIA. However, is defined broadly as all individuals and entities. This definition is sufficiently expansive to include emergency medical personnel and agencies. The PSQIA has been interpreted by the courts to provide significant protection to the confidentiality of patient safety work product. For example, reports of pharmacy dispensing errors submitted by a chain drug store to a certified PSO were determined to be privileged documents under the PSQIA and not discoverable even in a lawsuit filed by a state health professional licensing agency to enforce its subpoena for the drug store's relating to a specific pharmacist.",
        "Practical steps to enhance confidentiality": "The measures that will enhance the confidentiality of QI records will vary from state to state and will depend on the state's specific statute and case law. Nevertheless, the following general considerations are relevant in all jurisdictions. What are the defined elements of QI? The bylaws and written policies of individual prehospital providers and of centralized EMS agencies should include an expansive list of the committees and individuals who are responsible for QI (such as the centralized agency's chief medical officer, QI committee, and governing body). Bylaws and policies should also describe each QI function (such as retrospective reviews and provider credentialing) as constituting, or whatever alternative terminology the applicable state statute uses to define confidential records. A court is more apt to respect the confidentiality of QI materials if there is evidence that a clearly organized QI system exists and that the records in question were generated by that system. By whom are QI data collected and analyzed? Quality improvement data should be collected and analyzed only by individuals or committees that have been formally assigned a QI function, as described above. If, for example, providers are asked to prepare summaries or incident reports that will be utilized in QI, the QI policies should expressly state that these documents constitute QI materials. Access to QI documents should then be limited to formally designated QI participants. Neither state statutes nor reported court decisions address the effect on peer review or on confidentiality when the same patient is treated in multiple settings. For example, a patient might be transported to Hospital A by Ambulance 1, and then transferred to Hospital B for tertiary care by Ambulance 2. The individual hospitals and prehospital providers that treated the patient might be asked to share their QI records with one another, or a state-wide or regional EMS QI body might undertake review of the quality of care provided in all settings. Any transfer of QI records and any centralized QI activities should be supported by a written policy or other documentation that emphasizes the confidential and privileged nature of the records that are generated and shared. How are QI records maintained and distributed? As a general rule, courts are willing to protect QI records from public disclosure only if the health care provider who holds the record has also respected the confidentiality of the records. A court will not look with sympathy on a request, for example, that QI committee minutes be protected from subpoena if the minutes were freely distributed by the provider to those without a before receiving the subpoena. All QI documents that the participants hope to protect (such as QI committee minutes and reports) should be appropriately marked (for example, with the notation). The terminology chosen for the notation should track the language of the state's confidentiality statute. Some providers print each page of QI materials on special paper that contains such a notation. If the QI committee is required to report its activities or findings to other bodies that are not clearly covered by a peer review confidentiality statute, the committee's reports should be concise and should not contain information that the committee wishes to protect against subpoena or other public disclosure. Particular care should be taken when releasing QI information to public bodies, such as county and state agencies, because records in the possession of public bodies are frequently subject to public disclosure under a state freedom of information act, unless protected by a specific exemption. To reduce the chance that QI records will be inappropriately distributed and the privileged nature of such records waived, it is good practice to collect copies of all QI materials at the end of meetings of QI bodies unless it is essential that committee members take such materials with them. Responsibility for maintaining QI records should be centralized, and access to such records should be limited to individuals who need them in order to perform assigned QI functions. It is preferable if access to confidential records is governed by a written policy. Example The importance of clearly defining what constitutes QI data, and for whom the data are collected, is illustrated by two court decisions that arose under the same statute that makes confidential the granted a hospital peer review duty. A court held that this statute did not protect the confidentiality of data regarding the outcome of a form of hyperalimentation because the data had been collected independently by a physician and later turned over to a hospital QI committee. The court rested its decision on the fact that the data were not initially gathered at the request of a person or committee assigned a QI function. The court held that data (which were not created by or for a peer review body) could not be converted into confidential material by subsequently turning them over to a peer review body. However, in another case interpreting the same statute, the court held that hospital incident reports constituted confidential QI materials which could not be subpoenaed. The court based its decision in this second case on evidence that the reports were generated for the purpose of reducing morbidity and mortality and, pursuant to hospital policy, were submitted to the hospital's safety and/or QI committees. In short, the likelihood that data can be kept confidential is significantly enhanced if the QI body identifies in advance in written policies the types of data that are considered confidential and if access to such data is limited to those who have been formally granted QI duties.",
        "Liability": "Types of potential liability Individuals who submit information to an EMS QI body and those who serve as its members frequently express concern regarding the potential for liability as a result of their participation in QI. The following types of claims are the most likely to arise as a result of QI. \u2022 A defamation (libel or slander) claim by the provider who is the subject of review, particularly if QI information regarding the provider is disclosed in a manner contrary to a confidentiality statute. A successful defamation claim requires evidence that the defendant, knowing that the information was false or at least negligently failing to ascertain the facts, transmitted to a third party false information regarding the plaintiff which harmed the plaintiff\u2019s reputation. In other words, distribution of truthful information is not defamation. \u2022 An antitrust claim and/or claim of wrongful interference with business relationships by a provider who experienced license discipline and/or adverse publicity as a result of QI; for example, a claim that competing providers misused the QI process to eliminate the plaintiff from the market or to secure plaintiff\u2019s customers for themselves. \u2022 A claim by a patient who is injured while receiving emergency medical services that QI was performed negligently, as a result of which proper protocols were not in place or an incompetent provider was permitted to continue to practice. Immunity statutes In order to encourage candid participation in the QI process, a number of states have enacted statutes that provide immunity from liability arising from the performance of EMS QI. The principal variables among such immunity statutes include the following. \u2022 Persons covered: members of a QI body, those who furnish information to a QI body, those who investigate on behalf of or otherwise counsel or assist a QI body, and/or the body itself. \u2022 Prerequisites to immunity: no malice, good faith, and/or reasonable belief that action was warranted by facts known. \u2022 Types of claims protected against: claims for monetary damages only, all civil claims, or all civil and criminal claims. Immunity statutes do not preclude a plaintiff from filing a lawsuit against QI participants. The existence of an immunity statute does not even necessarily ensure that a lawsuit will be dismissed at an early stage (e.g. on motion for summary judgment) because there may be factual disputes as to whether the defendants satisfy the statutory requirements for immunity. However, immunity statutes increase the number of facts the plaintiff must prove in order to succeed in his or her lawsuit; for example, the existence of an immunity statute might require the plaintiff to prove that the defendants acted in bad faith while participating in QI. Most importantly, immunity statutes decrease the risk that a QI participant can be held liable for damages to a provider or patient as a consequence of the QI activity. Common law protection In addition to specific immunity statutes, the courts have developed certain principles that protect against liability in cases alleging defamation or interference with business relationships. There is common law protection (or, in legal parlance, a \u201cprivilege\u201d) against defamation liability for communications that are made in good faith and in the reasonable belief that the communication was necessary in order to fulfill a moral or legal duty, provided the disclosure is limited to appropriate individuals and proper subject matter. Similarly, where a person acts to protect a public interest or for other laudable purposes, he or she may be protected by the courts from a claim of interference with business relationships, especially if the defendant\u2019s actions were reasonable in light of the threatened harm. Common law privileges of this sort generally are not well defined and are highly dependent upon the facts of each case. Nevertheless, where QI participants act reasonably for the purpose of improving health care available to public, and are not motivated by self-interest, they may be protected from liability by common law privileges. Practical steps to reduce risk of liability The risk that those who conduct EMS QI or those who furnish information to a QI body will incur liability as a result of such participation may be reduced by the following measures. \u2022 Define broadly in the QI body\u2019s bylaws and procedures who is charged with QI duties, and comply strictly with these documents when conducting QI activities. This will enhance the likelihood that review activities will be deemed part of official quality improvement and therefore qualify for any available immunity and/or privilege. For example, the Rhode Island EMS peer review statute (General Laws 1956, \u00a723-4.1-18) limits statutory immunity to members of a 'duly appointed peer review board operated pursuant to written bylaws' and to those who communicate information to such a board. \u2022 Do not permit the QI process to be misused. QI participants should diligently avoid use of the QI process for any purpose other than improvement of patient care. In order to avoid even the appearance that QI is being used for anticompetitive purposes, try to avoid having providers participate in decisions from which they might benefit financially. \u2022 Preserve the confidentiality of QI records. By doing so, the QI body will reduce the risk that the reputation of a provider who is the subject of review will be harmed and thereby also reduce the risk of a successful claim of defamation or interference with business relationships.",
        "Conclusion": "Participants in EMS QI should familiarize themselves with the laws of their state regarding the confidentiality of QI materials and immunity from liability for QI participants. If the QI confidentiality and/or immunity statutes have been interpreted by state courts (whether in the context of QI conducted by an EMS organization or any other type of provider), QI participants should also be familiar with these rulings. The policies, minutes, reports, and other documents of the bodies that conduct QI should be drafted in a manner that maximizes the likelihood that confidentiality and immunity will apply to the QI bodies' activities and QI should be conducted with consideration for the consequences to confidentiality and immunity. QI participants in states that do not presently have confidentiality or immunity statutes covering EMS quality improvement should consider seeking enactment of such statutes."
    },
    {
        "Introduction": "This chapter reviews measures designed to minimize transmission of infectious diseases to EMS providers. EMS personnel and prehospital transport environments are specifically included as health care providers (HCP) and health care settings, respectively, in guidance published by the Centers for Disease Control and Prevention (CDC), the Health Care Infection Control Practices Advisor Committee (HICPAC), and the Occupational Safety and Health Administration (OSHA). The EMS medical director should be aware of state and federal regulations as well as current CDC guidelines and other standards for immunization of EMS personnel, circumstances requiring barrier precautions or notification of possible exposure, disinfection of equipment and apparatus, and both immediate management and medical follow-up of providers exposed to infectious pathogens in the course of their duties. An individual EMS provider service may be subject to enforcement of federal or state OSHA regulations, or may have adopted voluntary standards such as National Fire Protection Association (NFPA) occupational health and safety titles. These regulations and standards are generally derived from legislation, CDC guidelines, or other expert consensus processes, and should be considered minimal acceptable practices.",
        "Standards, laws, and regulations - CDC guidelines": "CDC guidelines Formal guidelines for reducing transmission of infectious diseases in hospital settings have been published since 1970, but the first to include prehospital providers in the definition of HCP were the \u201cuniversal precautions\u201d and \u201cbody fluid isolation\u201d (BSI) documents, published in 1985 and 1987, respectively. These were developed to address the risk of occupational exposure to hepatitis B and C, as well as the newly characterized human T-lymphotrophic virus-3 (HTLV-3), now known as human immunodeficiency virus (HIV). They defined which body fluids besides blood should be considered infectious, prescribed the personal protective equipment (PPE) that should be worn by care providers exposed to potentially infectious material, and offered guidance on safer handling of needles and other sharps in clinical settings. Most importantly, these guidelines emphasized the potential prevalence of unrecognized infections with blood-borne pathogens in all patient populations. They mandated the use of appropriate PPE any time procedures involving blood or body fluids are performed, regardless of whether a patient is known to have hepatitis or HIV. These CDC guidelines were updated in 1996, and expanded to include the broader isolation precautions aimed at preventing nosocomial infections in hospitals. At that time, the concepts of universal precautions for procedures involving blood or body fluids, and BSI that applies to all moist body substances except for sweat, including mucous membranes and non-intact skin, were synthesized to produce the \u201cstandard precautions\u201d that are still used. The introduction of standard precautions for all patient care, alone, is not sufficient to prevent all HCP exposure to infectious agents or nosocomial transmission in health care settings. Full implementation of standard precautions did, however, allow HICPAC to reduce the number of existing sets of isolation precautions to just three types, and these were based on the modes of transmission of the various organisms: air-borne, droplet, and contact. Each of these sets of precautions reinforces the use of standard precautions and then goes on to enumerate additional measures. Many pathogens are infectious through more than one route, so infected patients may require multiple sets of isolation precautions. The 1996 guidelines also emphasized hand hygiene as part of standard precautions. For the first time, hand washing was required after every patient encounter, in between procedures involving the same patient, and every time gloves and other PPE were doffed, regardless of known or suspected exposure to infectious pathogens. Other measures invoked as part of either standard or transmission-specific precautions addressed placement of patients within a facility, precautions that should be used when transporting potentially infectious patients through common areas, and the use of PPE including masks. The current guidelines, published in 2007, largely retained the format of the 1996 recommendations, with some important additions. First, the target audience was expanded to include providers in all health care settings, acknowledging the wide variety of venues other than hospitals in which acute patient care now occurs. Standard precautions were updated to include respiratory hygiene (cough etiquette). Precautions associated with infectious respiratory syndromes and direct patient contact were updated in the 2007 guidelines to reflect international experience with SARS-CoV and epidemic norovirus, and the increasing prevalence of multiply drug-resistant strains or species of staphylococcus, enterococcus, Clostridium difficile, and Mycobacterium tuberculosis. Transmission-based precautions that should be used when caring for patients with various clinical syndromes, even prior to identification of the infecting organisms, appear in Table 25.2. The other major addition to the 2007 guidelines from an EMS perspective was a brief presentation of the precautions that should be used for management of patients infected with CDC Category A bioterrorism threats. These select agents include anthrax, botulism, Ebola and other viral hemorrhagic fevers, plague, smallpox, and tularemia. The CDC periodically develops and publishes precaution guidelines that are specific to newly recognized infectious threats, or those that require isolation measures other than the more inclusive documents described above. A recent example that may be important to EMS providers, because clusters appear frequently in communities, pertains to norovirus. Key considerations for providers caring for these patients are how readily it is transmitted in health care settings, and the recommendation that hand hygiene include soap and water cleansing, as alcohol-based preparations may not inactivate the organisms. EMS medical directors, along with occupational health providers, need to be aware of current and emerging infections, maintain surveillance for occupationally acquired infections, and follow both general and specific guidelines for prevention as they become available.",
        "Standards, laws, and regulations - OSHA regulations": "Workplace protection of HCP against exposure to blood-borne pathogens was required by OSHA as early as 1991 with the introduction of 29CFR 1910.130 into its Safety and Health Standards. Expectations for PPE, engineering controls, training, and immunization against hepatitis B were consistent with the CDC guidelines. OSHA regulations also provided new definitions of infectious and regulated waste, along with rules for handling and labeling. Employee health records had to include exposure surveillance and documentation of clinical follow-up of known incidents. The Needlestick Safety and Prevention Act (PL 106-430, passed by the US Congress in 2000) compelled OSHA to revise this blood-borne pathogens standard in several ways. The 2001 revision, entitled \u201cNeedlestick and Other Sharps Injuries: Final Rule,\u201d mandated use of needleless systems and other innovations to decrease the risk of injury while performing medical procedures, documentation of employee involvement in determination of the risk of exposure to blood-borne pathogens, and maintenance of a sharps injury log detailing each incident together with the type and brand of device involved.",
        "Standards, laws, and regulations - Ryan White Act": "The Ryan White Comprehensive AIDS Resources Emergency (CARE) Act of 1990, Subtitle B Emergency Response Employee Notification (PL 101-381), required that each emergency response agency have a designated infection control officer (ICO) and a system for rapid postexposure notification of employees. The Emergency Response Employee (ERE) notification provisions were excluded from the Ryan White Act, which mainly addressed AIDS care funding when it was reauthorized in 2006, but the provisions were restored and updated in the Ryan White HIV/AIDS Treatment Extension Act of 2009 (PL 111-87). The new regulation broadened the scope, and more precisely defined the circumstances for obligatory notification of ERE following potential, infectious exposure. The list of potentially life-threatening infectious agents in the Ryan White Act Implementation document is similar to the CDC\u2019s list in the 2007 isolation precautions, and is also organized according to modes of transmission. Ways in which an ERE can be exposed to the various diseases are defined, and the responsibilities of medical facilities for reporting exposures to them are outlined in detail. The two situations mandating reporting by health care facilities are when an ERE believes an exposure has occurred, and when the health care facility identifies one of the listed infections in a patient who was potentially infectious when he or she was cared for by an ERE. In each of these cases, the health care facility is obligated to make one of the following determinations with respect to the ERE involved. The ERE has been exposed to a listed pathogen based on: the mode of transmission and the ERE\u2019s contact with the patient, AND the identity of the infectious agent has been confirmed through laboratory or clinical data. The ERE has not been exposed to a listed pathogen based on: the mode of transmission and the absence of a credible ERE exposure to infectious material OR there is sufficient information to conclude that the source patient did not have a listed infection. The medical facility does not know whether a putative source patient had a listed infection at the time of a suspected exposure. If the source patient was transported and/or treated by the medical facility for an unrelated medical condition, the patient may not have been tested for potential, occult infection. This determination should be revised appropriately if the medical facility acquires additional information relevant to the exposure. The facts of the potential exposure incident are insufficient for the medical facility to determine the plausibility of significant exposure. Emergency response employees should obtain appropriate follow-up for medical prophylaxis, testing, or acute care as indicated by the nature of the exposure. Postexposure prophylaxis (PEP) may include administration of vaccine, antibiotics, or other treatment to prevent acquisition of disease. For the Ryan White laws to be effective, EMS agencies, with their medical oversight and occupational health providers, must collaborate with hospital infection control and infectious disease specialists. Essential program elements include education, protocol development, and training at all levels to ensure appropriate evaluation and timely PEP for exposed EREs.",
        "Standards, laws, and regulations - NFPA standards": "The NFPA 1500 series of standards are voluntary, consensus standards relating to occupational safety and health in fire service environments. They are periodically revised by a multidisciplinary technical committee, and published by the NFPA. Adherence to these standards is at the discretion of the authority having jurisdiction, i.e. departments or municipalities choose whether or not to adopt them. As industry standards, however, they may be cited as expectations by OSHA or in litigation following occupational illness, injury, or death. NFPA 1582 (Standard on Comprehensive Occupational Medical Program for Fire Departments) primarily addresses medical evaluation of candidates for firefighter positions and fitness for duty determinations for members of fire departments. This document does include requirements for screening and surveillance for occupationally acquired infectious diseases, and requires immunization of members according to current CDC recommendations. NFPA 1581 (Standard on Fire Department Infection Control Program) outlines the duties of a departmental ICO as defined in Ryan White legislation, and proposes organizational mechanisms through which this function should be integrated in the department's administrative structure. According to NFPA 1581, the ICO also oversees all aspects of infection control in a fire department, including education and training of members, selection and use of engineering controls and PPE, cleaning of apparatus and equipment after potential exposure to infectious pathogens, prevention of food-borne illness and other potential exposures in fire department living spaces, and maintenance of records of these activities. Though written in standards language for departments that have adopted them, NFPA 1581 is a readily accessible single source of practical guidelines for infection control in fire and EMS agencies.",
        "Blood-borne pathogens - Hepatitis B virus (HBV)": "Because of widespread use of HBV vaccine, the risk of both occupational exposure and infection with HBV has diminished greatly. Agencies must have HBV vaccination programs in place, providing the vaccine free of charge to personnel at risk. EMS personnel should not serve as HCPs until they have received the first dose of vaccine or signed a declination form. If administration of the series is interrupted, the HCP should continue with the second or third dose; the only requirement is there should be at least a 2-month interval between the second and third doses. Any HCP who has contact with patients or blood and is at risk for percutaneous injuries should have anti-HB levels determined 1\u20132 months after completing all three doses of the HBV vaccine. Those who do not respond to the initial series with anti-HBV levels >10 mIU/mL should receive a second three-dose series and be retested. Historically, 25\u201350% of initial non-responders develop positive titers and are considered protected. However, any HCP who remains a non-responder to the HBV vaccine should be counseled regarding prevention of HBV infection if exposed, and the need to obtain hepatitis B immune globulin (HBIG) prophylaxis if exposed to HBsAg-positive blood. Early HBIG administration provides approximately 75% protection from HBV infection. Given HBV's stability in the external environment (it is known to persist in dried blood for at least a week), it is crucial to counsel the HCPs who are true vaccine non-responders. For others who have responded in the past, titers do decrease over time, but routine checking of titers following exposure is not recommended.",
        "Blood-borne pathogens": "The term blood-borne pathogens (BBP) is often used to refer to hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV), but pathogenic microorganisms.",
        "Blood-borne pathogens - Hepatitis C virus (HCV)": "Hepatitis C was first recognized as a distinct virus in the late 1980s. Although less efficiently transmitted than HBV as a BBP; exposure to HCV is a significant risk for prehospital providers because there is no vaccine or PEP available. Almost 4 million people in the United States are infected with HCV (75% chronically). Many are asymptomatic and not aware of their infections. Of those who develop acute HCV infection, 15\u201325% will clear the virus spontaneously and not develop chronic infection. The other 75\u201385% may have active disease (60\u201370%) or asymptomatic disease (30\u201340%). Therefore, it is essential that prehospital personnel use standard precautions with all patients. This virus is occupationally transmitted primarily by percutaneous injury. The average risk for virus transmission after percutaneous exposure to a HCV-positive patient is 1.8%. These data were collected before 2001, when use of safety-engineered IV catheters became required by law. Occupational transmission by mucous membrane exposure is rare, but infection via non-intact skin and conjunctival exposure have been documented. Despite occupational exposures to prehospital personnel, including first responders, paramedics, and firefighters, excess incidence or prevalence of HCV has not been observed in these populations. During initial evaluation of occupational HCV exposures, both the source patient and exposed HCP should be checked for HCV antibodies if possible. At the follow-up visit, and if the source patient is seropositive for HCV, the exposed HCP should undergo baseline testing for HCV and serum aminotransferase activity. Quantitative testing for HCV RNA should be performed again, subsequently, and if positive the infecting HCV should be genotyped. All assays used for serological and nucleic acid testing should be FDA approved. There is no known PEP that effectively prevents infection with HCV. If the profile of serological, nucleic acid, and liver function studies, with or without other clinical signs, suggests the presence of hepatitis C, the exposed HCP should be referred for specialty care to manage this infection. It is not always clear whether an exposed HCP has acute or chronic hepatitis C when tested following an exposure incident. A specialist experienced in making this determination and in subsequent management of the infection should be consulted, as this distinction is critical to treatment. Depending on many factors including comorbidities, size of inoculum, and potential coinfection with HIV, close to half of those with acute hepatitis C infection may experience spontaneous viral remission. It appears that increased evidence of acute hepatitis may correlate with a greater chance of viral remission. Treatment with pegylated interferons during the acute phase produces viral remission in up to 80% of patients. It is currently unclear whether it is preferable to begin therapy immediately upon recognition of the infection or to wait 12 or more weeks to avoid the side-effects in those who will spontaneously clear the virus without treatment.",
        "Blood-borne pathogens - Human immunodeficiency virus (HIV)": "The risk of HCP infection following percutaneous exposure to blood from an HIV-infected patient is roughly 0.3%. The risk ranges from 0.04% to 5% depending on whether there was deep injury by a hollow-bore sharp, visible blood on device, the device was previously placed in the source patient's artery or vein, and/or the source patient had a high viral load or had terminal AIDS. When exposure to mucous membranes results from splash or splatter of infected blood or body fluids, the risk of transmission to the HCP is 0.09%. Management of HCPs following exposure to blood or other potentially infectious material includes several steps. The HCP should be seen immediately to evaluate and document the exposure, provide local care of any wound incurred, complete cleaning if not already done prior to presentation, facilitate both source patient and HCP testing, start PEP if indicated, and arrange for follow-up by the appropriate occupational health service. Current CDC guidelines acknowledge that many exposures occur when occupational health services are not available, and recommend that the emergency department or other entities that provide postexposure services have clear protocols for accomplishing the testing, counseling, and medication required under these circumstances. If the HIV status of the source patient in an exposure incident is unknown, FDA-approved test methods that provide reliable results in less than an hour should be used. This CDC recommendation may be enforced by OSHA. According to current CDC guidelines, if the source patient tests negative for HIV, PEP for HIV should not be offered. If the source patient is known to be HIV positive, found to be seropositive on rapid testing, or has risk factors for HIV but cannot be tested, PEP is usually warranted. The preferred HIV PEP regimen at this time includes raltegravir plus the combination drug Truvada (tenofovir and emtricitabine). Medical directors should be aware when the guidelines are updated and defer to the revised recommendations. The current recommendations for HIV PEP and summary information on the recommended medications are available on the internet. The current recommendations eliminated attempts at correlating the severity of an exposure with the components of the PEP. If PEP is indicated, the same first-line or alternative regimens are used, regardless of any specific characteristics of the exposure incident. It should be started as soon as possible after exposure; it is thought to be less effective if started more than 72 hours later. The duration of PEP is 4 weeks unless contraindicated by side-effects, adverse reactions, or other developments. The HCP should be under the care of an infectious disease/HIV specialist during this period. Expert consultation is also recommended if the source patient is not known, if the exposed HCP is pregnant or breast feeding, or has significant, underlying comorbidity. In these cases, greater experience with the available PEP medications is necessary to counsel the HCP and manage ongoing care. Follow-up blood tests for HIV seroconversion should be performed at 6 weeks, 12 weeks, and 6 months following the occupational exposure. If a HCP was exposed to a patient who was coinfected with HCV and HIV, and the HCP seroconverts to the HCV, an additional blood test for HIV should be done 1 year after the exposure.",
        "Air-borne, droplet, and contact transmission of infection": "Table 25.2 outlines the precautions that should be used in the presence of various clinical syndromes, reflecting the likely modes of transmission of the responsible pathogens. Potential or documented exposure to specific pathogens requires further evaluation of the emergency responder involved, and in a few cases, some form of PEP. Meningococcus and varicella zoster are frequently encountered examples that are discussed in greater detail in Volume 1, Chapter 25. The responsibilities of the EMS provider, the agency, and the medical facility with respect to such exposures, as delineated under the Ryan White law, are enumerated above.",
        "Mycobacterium tuberculosis": "As part of the national strategic plan to eliminate pulmonary tuberculosis (TB), especially drug-resistant TB, the CDC TB guidelines were expanded in 2005 to include non-traditional health care settings such as the prehospital arena. Although TB cases have been decreasing, many areas within the United States have TB case rates higher than the national average. Multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB), although present in the US, are still treatable and are not more infectious than other strains of TB. Emergency medical services personnel can assist receiving hospitals by identifying potential TB patients early so they may be isolated. Prehospital personnel, both first responders and transporting HCPs, should maintain a high index of suspicion for patients with active, pulmonary TB. Symptoms may be non-specific but a patient who belongs to a high-risk group, has a history of TB, or has symptoms consistent with active infection should wear a surgical or procedure mask during transport, as long as this does not compromise his or her respiratory status. When the patient requires supplemental oxygen, the EMS crew (both the driver and the provider(s) attending the patient) should wear N-95 respirators. The ventilation system in the transport vehicle should be set to maximum non-recirculation, to draw as much fresh air into the patient care compartment as possible. Personnel should use the vehicle's rear exhaust fan or a HEPA-filtered, supplemental recirculating unit if possible. The Ryan White Care Act mandates hospital-initiated notification of personnel who may have been unknowingly exposed to a patient with suspected or confirmed TB. Currently, OSHA is enforcing the CDC 2005 TB guidelines for protection of health care workers. These guidelines require the health care setting to develop a risk assessment for TB infection. The results of the risk assessment will determine the need for a respiratory protection program. For example, many fire departments may no longer need to perform annual TB testing after initial screening. The TB risk assessment should be updated each year and added to the agency's exposure control plan. The ICO should compile the risk assessment data, in consultation with local and state medical and epidemiological officials. Medical oversight personnel should be aware of local data and any resistance patterns with the help of such consultations.",
        "Recommended immunizations": "Wellness programs are gaining more importance because they effectively reduce risk and become both an employee and employer benefit. EMS personnel should be offered hepatitis B vaccine, MMR (measles/mumps/rubella) vaccine, varicella vaccine (if not immune), TB skin testing in accordance with TB risk assessment, annual flu shots, and others as necessary (e.g. those required for travel for providers who are part of deployable teams). In 2005, a combination vaccine providing booster immunization against tetanus, diphtheria, and pertussis (Tdap) became available. Tdap is recommended for HCPs who have direct patient contact; if prehospital personnel have not already received Tdap, they should receive a single dose of Tdap as soon as possible. HCP who have received Td boosters recently may receive Tdap 2 years after the booster. Fire department personnel should follow recommendations outlined in NFPA 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments. Following these recommendations may reduce the incidence of diseases by offering vaccine to non-immune individuals. The medical director should emphasize that these programs are cost-effective; numerous studies have shown that immunization of unprotected HCPs is 50\u201360% less costly than postexposure medical follow-up and/or treatment.",
        "Reporting an exposure": "There are many reasons to report prehospital exposures. These include helping state and local epidemiologists document and report the risks of prehospital patient care, identification of dangerous patterns, and increased possibility of treating and transporting patients with unknown HBV, HCV, and/or HIV status. But the first responsibility lies with the individual who sustained the exposure. Proof of absence of infection at the time of exposure is important, because if the HCP later tests positive for a BBP, it is more likely due to the occupational exposure. Although the chance of disease transmission is small, complications from such disease transmission may be very expensive. Development of disease that is not documented as attributable to an occupational exposure can affect future employment and access to disability insurance coverage. Some states have laws regarding presumption of occupational exposure for EMS personnel. As many as 40\u201380% of HCP exposed to BBP do not follow up with occupational health services as required. Reporting an injury should be encouraged and remain uncomplicated. and are common reasons resulting in failure to document percutaneous exposures. The ICO and/or the occupational health service, not the HCP, should determine whether a given exposure constitutes a risk. In addition, the ICO should encourage and enable the exposed worker to obtain appropriate follow-up. OSHA requires completion of an exposure report form and that the information on the form complies with not only the BBP standard but also OSHA's medical record standard. An example of a fire department exposure form is available in NFPA 1581.",
        "Conclusion": "Emergency medical services medical directors should remain committed to use of evidence-based guidelines when developing and updating exposure prevention programs. ICOs should ensure that proper PPE, safety devices, and training for these items are provided and that their use is encouraged. Prompt reporting of any potential exposures must be enabled and encouraged. Exposure response plans should be complete, comprehensive, and updated annually. The risk of exposures is real, but can be reduced through use of appropriate precautions. The risk of disease transmission and subsequent morbidity in the occupational setting is low, and can be further reduced through appropriate PEP and follow-up."
    },
    {
        "Introduction": "For several years following the September 11, 2001 terrorist attacks on the World Trade Center and the Pentagon, public and government need for a greater sense of security conferred nearly unbridled spending on public safety. EMS systems enjoyed expanded budgets and little resistance to requests for resources aimed at homeland security preparation and response. Today anxieties about domestic safety are being overshadowed by concerns about a weak job market, an uncertain economy, and the as yet unknown effects of the Affordable Care Act. Cities as large as Detroit, Michigan, have declared bankruptcy and more are facing financial insolvency due, at least in part, to large public safety budgets and pension obligations. Myriad factors are putting pressure on public safety agencies and their leaders to be more accountable for their budgets and more cost-effective in their service delivery.\n\nA comprehensive discussion of managerial accounting, health care economics, and business decision making is beyond the scope of this chapter. An understanding of some basic principles, however, will help medical directors articulate their needs and justify the cost of care in their EMS systems. Medical directors who are able to advocate for clinically effective, fiscally responsible care through use of evidence-based medicine and best practices will establish themselves as an invaluable resource for their system and their community. This chapter will serve as an introduction to EMS finance, its common terminology, the assessment of productivity, and its effect on clinical and operational realities in a modern EMS system.\n\nTo understand EMS system finance, it is fundamental to distinguish between costs, charges, efficiency, and quality. These concepts are often misunderstood or used interchangeably.\n\nDo patient charges for an EMS response reimburse actual costs in providing that EMS response?: The charge, price, or fee of a service does not equal the cost of delivery. When describing the 'cost' of EMS, the fee to the consumer is often used interchangeably as the 'cost' of providing the service. For example, the price of treatment and transport to the hospital may be set at $1750. To a patient (consumer) or the payer, the $1750 charge is their 'cost' of the service utilized. However, that $1750 bill received by the patient is not the same as what it costs EMS to provide the service. That fee or charge may be determined by other factors independent of the real cost to provide the service. Where commercial payers (marketplace health insurance) or government (e.g. Medicare, Medicaid) have negotiated or legislated allowable reimbursements, the revenue received for providing EMS services may be substantially below the cost to provide the service. In 2013, for example, most Medicare reimbursements for EMS services in urban environments represented levels 6% less than actual costs to the EMS system for providing those services. Understanding the difference in these terms is critical when making decisions about altering response capabilities, talking with media or politicians, or negotiating with payers or hospitals.\n\nDo 'direct costs' equal full costs of providing service?: Direct costs such as labor, fuel, equipment, and medical supplies are easily identified as costs of providing service but do not represent the total cost. To fully understand the costs of an EMS system, all costs must be identified. For example, if an ambulance costs $550,000 in equipment and labor per year it is assumed that the cost of that ambulance running 1000 calls is $550 per call. What is overlooked is that legal support, continuing education, medical oversight, quality improvement, and billing services contribute to the total (full) cost. Failure to account for all additional expenses results in an understated assessment of the true cost of service delivery.\n\nDoes operational productivity or efficiency mean clinical quality?: Operational efficiency refers to meeting service expectations while minimizing the expense of delivery. It may be defined as achieving the local response time standard while operating at lower cost or higher unit utilization (productivity). These metrics do not describe quality of care but where clinical measures are not available, they often become the de facto measure of quality. Unfortunately, the pursuit of these goals can promote behaviors that may negatively affect clinical care. Myers et al. offered several evidence-based clinical performance measures to describe clinical quality. These provide a foundation for shifting quality measures to evidence-based clinical practice. It is paramount that medical directors champion clinical quality measures and that EMS leaders do not equate operational efficiency with quality.",
        "Understanding the cost of EMS": "Unlike manufacturing, which can risk falling short of production in favor of maximum efficiency, EMS systems cannot afford to run out of resources. EMS systems must maintain \u201cproduction\u201d capacity that exceeds demand despite the inherent inefficiency this creates. This is exacerbated by response time expectations that have been promoted independent of any proven clinical need. Response time expectations require additional units based on drive times rather than demand or capacity. The cost of deploying these resources, personnel, and apparatus, in excess of the demand, is the \u201ccost of readiness\u201d and is much of the cost of EMS.\n\nThe medical director\u2019s primary responsibility is to advocate for the clinical aspects of an EMS system, not its profitability. Therefore some medical directors may feel that the analysis of the \u201cbusiness\u201d of EMS is beyond their scope of responsibility. In reality, the contribution of healthy finances to the clinical success of a system prevents their separation. Through better use of resources, a fiscally savvy medical director creates opportunities to finance the clinical initiatives that ultimately determine the clinical success of a system. Medical directors should be able to conduct a basic financial impact assessment of a therapy and communicate their analysis and clinical need in terms familiar to those responsible for the finances of a system. To better illustrate and discuss the economics of an EMS system, the following are some of the commonly used terms and concepts.",
        "Full cost (total cost)": "The total cost is the sum of the direct, indirect, and shared costs of a particular service or product. Specific assignment of costs to direct, indirect, or shared is less essential than accounting for all costs incurred. Understanding and identifying all elements of the full cost is critical to budget requests, informed negotiations with payors or governing boards, and in utilization and expansion decisions.",
        "Direct cost": "Is a cost that can be traced to actual delivery of a particular service or product. Assignment of direct cost can vary between organizations but generally includes costs such as provider labor, vehicle purchase, operating costs such as fuel and fleet maintenance, medical supplies to include durable medical equipment and single patient use devices, and medical communications equipment. Direct costs can be fixed or variable.",
        "Indirect cost": "Is a cost that cannot be traced directly to a particular service or product. Like direct costs, assignment into one category or type may vary by tracking preferences of the organization. Indirect costs typically include administrative labor, building and facilities, taxes, debt interest, and support functions such as accounting, legal, human resources, marketing, and public education. Medical direction may be considered an indirect cost in EMS systems that do not account for the cost of physician oversight per response.",
        "Shared cost": "Is a cost that is shared among one or more operating divisions or departments within or between organizations. Shared direct costs include items or services such as loaned vehicles, loaned medical equipment, shared fleet maintenance services, and shared medical communications services. Shared indirect costs include items or services such as shared facilities, shared management functions, and shared administrative support functions.",
        "Marginal cost": "Is the cost of producing one additional unit of a particular service or product. Marginal cost is used to assess the cost of adding an additional unit of service or production. In many industries, including EMS, marginal cost is a non-linear function and depends on capacity. For example, if an ambulance has unused response capacity, then the marginal cost of it responding to one additional call is minimal. If that unit is operating at available capacity, the cost of an additional response includes the addition of another ambulance and all associated costs.",
        "Fixed cost": "A cost that does not change with increased production or business activity over a defined period of time, typically a budget year. They may be direct or indirect costs. For example, the medical director\u2019s salary, insurance, rent, and utilities are costs incurred by an agency whether they respond to one call or 100 calls. While fixed costs do not change, fixed cost contribution to the cost of each transport will decrease with increased unit production.",
        "Step costs (or step fixed costs)": "A means of capturing cost changes where production capacity has discrete limits. When the maximum production capacity has been reached, any additional demand results in the need to purchase additional capacity. The result is a non-linear cost curve with \u201csteps\u201d that result from abrupt changes in production costs. If an ambulance can respond to 4,000 calls per year, the fixed cost of that unit remains the same for 1 call through the 4,000th call. In order to respond to call 4001, the service must add an additional unit and incur the associated fixed costs.",
        "Variable cost": "Is a cost that changes with each unit of production or activity. Examples of variable costs include fuel, maintenance, and disposable medical supplies. Contribution of variable costs to total costs increases with utilization or increased production. All costs become variable if analyzed over a long enough timeline.",
        "Depreciation cost (amortized cost)": "Is an accounting technique used to track the loss of value in a tangible asset over time by subtracting residual value from the original purchase cost spread over the useful life of the asset. Amortized cost is often used interchangeably with depreciation but more often refers to intangible assets. In accounting, these terms are used to describe loss of value over time for tax or income reporting purposes. However, in managerial decision making this same concept is useful when accounting for cost contributions over the functional life of an item.",
        "Economies of scale": "A reduction in per unit cost that results from increasing size or scale of operation where the cost of producing the next unit of service is less than the average cost of previous units. For example, if a communications specialist can reliably manage up to 10 units, consolidating a five-unit EMS system and a neighboring four-unit system will result in reduced per unit costs of dispatch. However, economies of scale are not limitless. If the consolidation process created the need for a more complex logistics process to maintain field supervision and manage supplies, it may increase the cost of operation. If these costs increase faster than the communications savings, there is a diseconomy of scale.",
        "Opportunity cost": "Is a tool to assist in managerial decision making. Where there are finite resources there is a lost opportunity in choosing option A versus option B or C. Opportunity cost does not have to be in monetary terms, but can instead be in any term that reflects the foregone choice. To illustrate, assume a cost of $15,000 per hour to train providers in CPR (option A). The same amount of money would provide 240 unit hours of ambulance coverage (option B). If the best choice for the system is additional unit coverage (option B), it is at the expense of the providers knowing the latest CPR techniques (the value of A). Opportunity cost does not denote the relative value of the choice nor all the factors that went into selecting B over A. It merely acknowledges that even the best choice has a cost of foregoing the second or third best choices.",
        "Sunk cost": "A cost already incurred that cannot be recovered. In economic decision making, sunk costs should not be considered when deciding future expenditures. This is the axiom of sunk cost fallacy. For example, an electronic patient care record software system is purchased for $100,000. After implementation, it is discovered that billing information cannot be recorded and the software cannot be modified to do so. The prospective decision of how to address the agency's billing needs should address this problem independent of the money that has already been spent on the software. Another example is an agency that has taken delivery of a new ambulance for $100,000 in anticipation of increasing call volume in the coming year. Since accepting delivery, call volumes have actually declined. The prospective decision to staff and deploy the purchased ambulance should be made independent of the $100,000 purchase. It is worth noting that despite economists' desire for perfectly rational decision making, human susceptibility to loss aversion frequently prevents pure application of the principle of sunk costs.\n\nThese terms are useful in communicating with financial decision makers and when advocating for clinical improvements. When used in conjunction with an evaluation of the medical literature, these terms and the concepts they represent allow more accurate and informed decisions about the cost benefit of a clinical intervention.",
        "Productivity analysis": "Emergency medical services systems, regardless of structure or delivery model, are facing increasing cost accountability. Medical directors can expect to be engaged in discussions of costs and productivity. It is important that the medical director understands measures of productivity used to compare EMS systems or in decision making. Improper application can lead to faulty decision making, ineffective messaging, or loss of support for a needed initiative.\n\nThe measures covered here are some of the most common. None should be considered a comprehensive tool; each has its limitations. Over time, these measures have evolved to meet the needs of local systems. Definitions, inputs, and applications have changed but they are still useful as decision-making tools and for ongoing analysis of a system. If these measures are used to compare different systems it should be done with caution. The medical director must assess the commonality of definitions and assure that the systems are sufficiently similar to warrant direct comparison.",
        "Cost per capita": "This is determined by dividing total system cost by total population served. Its simplicity and ease of calculation make it attractive to policy makers when determining the overall cost of EMS to the community. When used to compare systems, this calculation fails to account for factors affecting the local cost of service delivery, including cost of labor, community demographics, call volume, geography covered, quantity and quality of services delivered, as well as political or legislative restrictions on revenue generation abilities. The inability to isolate these variables should, but often doesn't limit use of cost per capita in comparing one system to another. This calculation may still have value to the medical director as a tool for tracking trends within the system. Even when used in this capacity, the medical director should be cautious and evaluate changes in any system factors that may affect the fidelity of the analysis.",
        "Unit hour utilization": "Considered by many to be the basic measure of productivity in EMS and has become a critical tool for EMS decision making. Unit hour utilization is the ratio of utilization (U) to the number of unit hours (UH) produced. Utilization is the number of transports and a unit hour is defined as a fully equipped and staffed ambulance on a response or waiting for a response for 1 hour. The UHU ratio is calculated by dividing the number of transports by the number of unit hours produced, as follows:\n\nU(utilization) = Unit hour utilization UH(unit hours)\n\nAs a simple example of productivity, the number of transports completed by a unit is divided by the total number of hours the unit was available for response. If the unit completed six transports in a 12-hour shift, its UHU is 6/12 or 0.5. The same calculation can be applied to the entire system by dividing the total number of transports that day by total number of unit hours produced. If 300 transports were completed by 30 ambulances available 24 hours each (720 unit hours), the UHU is 300/720 or 0.42. By adjusting the parameters, the UHU can be used to track unit productivity over time or compare productivity between units or unit productivity to the system average.\n\nUnit hour utilization is critical to tracking productivity and the analysis of costs and profit margins. Because fixed costs exist regardless of utilization, increasing productivity distributes fixed costs across more transports. The use of UHU spread rapidly as EMS managers embraced the utility of the ratio. Many, however, found the original definition of utilization too limiting. They created their own definitions of utilization to analyze workload-related tasks such as patient contacts, post-to-post moves, or any other activity that made a unit unavailable for response. One of the most common modifications was to create a ratio of hours on task to available hours which is better at assessing unit \u201cwork\u201d while taking into account differences in patient care, drive, and transfer times. For example, assume the average task time for a transport is 90 minutes and a unit completed six transports in 12 hours. Using the traditional calculation, that unit would have a 0.5 UHU, but a task time UHU of (1.5 hours/transport \u00d7 6 transports)/12 unit hours or a UHU of 0.75.\n\nAs the use of UHU increased it began to be used as a means to compare systems. Like many metrics in EMS, the definition of UHU evolved differently in each system. Even where definitions appeared similar, the effect of population and call density, geography, and task times on UHU made comparisons dubious. An obvious example is the high UHU of most urban areas with denser populations and smaller geographic areas when compared with more rural systems. As a result, the term lacks precision and can lead to erroneous comparisons. Only if two systems define their utilization in the same way and are substantially similar in demographics, geography, population density, and task times can UHU be used to fairly compare the productivity of the two systems. The medical director is encouraged to assure significant similarities before using this measure to compare his or her system with others.",
        "Cost per patient transport": "This is determined by dividing the cost per unit hour of production (as defined in the UHU discussion above) by UHU to calculate the cost of providing the transport. The calculation is illustrated as follows.\n\nCost per unit hour / UH = Cost per transport\n\nSuch a calculation can reveal the effect productivity changes have on cost. If the full cost of placing a staffed, equipped ambulance in service is $100 an hour (cost per unit hour) and a patient is transported once every 3 hours (UHU = 0.33), then the cost per transport is $100/0.33 = $300. This measure can be useful when trying to quantify improved or reduced unit productivity. For example, if units in the system are spending 30 minutes waiting to transfer each patient at the hospital, this unit now completes one transport every 3.5 hours (UHU = 0.29) and the cost per transport is now $344.83. The $44.83 represents the theoretical cost to EMS of the delay at the hospital. Although the effect on productivity appears small, if that delay persists in a system that transports 12,000 patients per year, this cost could amount to $537,960. Presenting the cost of reduced productivity in this manner is useful when discussing the issue with hospital administration. The actual effect on cost is theoretical because it assumes that there is another call for that unit to respond to or that the inefficiency would result in a need for more resources. This will be discussed in greater detail later in the chapter.",
        "Applying cost theory to real-world decisions and analysis": "The medical director\u2019s primary responsibility is to supervise and lead the clinical direction of the organization. This will require thoughtful consideration of the current literature and the clinical value of an intervention to the local population served. The details of evaluating the clinical merits of an intervention will be described elsewhere in this text. If a change to the clinical practice is to be made the medical director must also consider its effect on the finances of the organization.\n\nWhen evaluating financial effect it is important to carefully account for all the costs of implementation. Some treatment options may initially appear to have minimal financial effects but have additional costs that must be considered. For example, the medical director wishes to improve the management of patients with atrial fibrillation and is considering the addition of diltiazem to the protocols. Assume the cost of the medication is $3 and the historical data show 100 treatable patient contacts per year. Superficial analysis suggests that this should cost about $300 per year for one dose and $600 per year if each eligible patient receives two doses. The training associated with implementation is expected to take 1 hour at roughly $10,000 per hour of training costs. The medical director is willing to absorb the associated training cost by foregoing 1 hour of ECG interpretation training this year \u2013 the opportunity cost of the decision.\n\nAt first, the financial effect appears pretty minimal at $6 per patient. On further investigation it is discovered that the medication requires refrigeration or will have to be discarded monthly. Refrigeration is not available on the 20 units currently deployed in the system. If 20 units require a minimum of two doses in the unit and two doses in the medication bag, the initial stocking cost will be $12 per unit ($3\u00d74 doses). Wastage due to lack of refrigeration will require monthly restocking of all the units at $240 per month or $2,880 per year. The total cost of restocking and treatment ($2,880+$600) will reach nearly $3,500 per year or $35 dollars per patient treated. Depending on the medical director's analysis, this cost may be justified by the treatment benefit.\n\nIt is important to remember that these clinical decisions come at the cost of foregoing another option. In this case let's assume it was the implementation of prehospital lactate monitoring to accompany a new sepsis protocol. The same 20 units will each need a lactate monitor which will require a capital outlay of $500 each or $10,000. The test strips cost $2 per patient and training will require the same $10,000 for an hour of training. Historical data show the system sees 1,000 patients per year with presumed sepsis. Assume the medical director is again willing to forego ECG training for a year. The financial effect of implementation in the first year is roughly $12,000 for lactate monitors and test strips. To better assess the per patient cost, let's assume the useful life of a lactate monitor is 5 years and there is no residual value in the devices. Now the depreciated annual fixed cost of the intervention is $2,000 ($10,000/5-yr life) for lactate monitors and $2,000 of variable costs for the test strips. The fixed cost contribution is now $2 per patient and $2 of variable cost or $4 per patient over the next 5 years. In this case the depreciation calculation does not eliminate the need to make the initial capital purchase but facilitates a better per patient cost comparison of the two therapies.\n\nFrom the medical director's viewpoint, the obvious solution is to implement both new treatments. Growing financial constraints, however, will likely make these types of choices both necessary and more common. The result of the financial impact analysis does not decide the clinical merit of an intervention. Therein lies the importance of the medical director's role in the decision-making process. The medical director's real decisions will be more complicated and subject to the pressures of operations, politics, and community demand. Many of these pressures are not captured in the purely clinical or financial review. Completing these analyses, however, contributes to better decision making and to advancing initiatives the medical director favors and defending against those felt to have little value.\n\nAlthough the medical director's primary responsibility is the clinical aspects of the system, one cannot ignore the effect of operational decisions on the clinical performance of the system. The system may be considering the addition of another ambulance to reduce clinically meaningless response times at the expense of the new a-fib and sepsis protocols. The medical director must understand how these financial concepts can be applied to the operational environment if they are to be successful in advocating for clinical performance.\n\nThe financial obstacles to providing care in rural or superrural areas are seldom appreciated by medical directors trained in urban environments. These systems typically deploy ambulances to cover enormous response areas with limited population and call volume. According to a study by the US Government Accountability Office (GAO), demand volume, or the lack thereof, was the key factor driving costs in non-urban areas. With fewer responses and transports, costs cannot be spread as easily and the cost per patient transport is predictably much higher. The GAO found that a rural system with three or fewer transports per day had almost double the cost of a system with 9\u201312 transports per day. Using the costs of the first unit in our model, it is easier to appreciate the challenges they face. In our simplistic (and understated) costing model responding to the first 1,000 calls per year resulted in an average cost of $480 per call. Our model does not account for what is also likely to be a large variable cost contribution in rural areas. Where the closest treatment facilities are 50\u2013100 miles away the variable costs will certainly be higher and compound the difficulties faced by these systems.\n\nMany cost analyses in EMS assume a linear cost of production curve. Variable costs will change with each unit produced but the fixed costs of ambulance deployment moves in production-related steps. This is an important principle because step fixed cost applies to both expansion and contraction in a system. In order to reduce the fixed cost of deployment, the system must increase efficiency or decrease volume sufficiently to be able to eliminate the need for a unit of production (transport ambulance).\n\nIn the current economic climate EMS systems are seeking to reduce costs. Many systems are using innovative techniques to reduce volumes such as managing frequent users without the need for transport. When directed at improved patient care these efforts have their own merits and represent the advancement of the profession. The financial analysis that drives these decisions should be considered carefully. A common justification is that the reduced call volume represents a return on investment that equals their average cost per call multiplied by the number of patients where transport was avoided. For example, if the average cost (to the agency) per transport is $400 then eliminating 100 transports would result in $40,000 of savings. This application of average costs risks overstating the effect of the intervention. Decreasing the number of transports performed by that unit reduces that unit's productivity. Reduction in costs will only be realized if there is sufficient decrease in volume to prevent the addition of another unit or reduce the numbers of units deployed. If a system is functioning near maximum capacity and is on the volume threshold of expansion or contraction, the benefit will equal the direct cost of an additional unit and may be substantial. To be complete, the analysis must also include the feasibility of actually reducing the number of deployed units. If units are not at maximum capacity but are deployed geographically to meet response times, the reduction in volume will not facilitate the elimination of a unit.\n\nThe status of EMS reimbursement as of this writing is in such a state of uncertainty as to preclude any specific discussion or risk being outdated by the date of publication. Revenue, however, should not be overlooked in any financial analysis. For example, if a system seeks to reduce volume the analysis in the previous paragraph must also weigh the effect on revenue. Reduced call volume may or may not reduce step fixed costs. It will reduce variable costs but also has the potential to reduce revenue from those same calls. In the manufacturing industry companies with excess production capacity will often lease that capacity to other manufacturers to offset their fixed costs. They understand that as long as the price they charge another manufacturer exceeds their variable costs, the revenue of each unit produced reduces the company's fixed cost liability. If a system wishes to pursue reduced call volumes, the leadership should complete a careful analysis of the ability to reduce fixed cost and the effect of reduced revenue. If alternative funding for non-transport can be secured through specialized contracts with payers, the effect of volume reduction will be minimized or potentially converted to an alternative profit stream.\n\nAlthough EMS is provided by for-profit and public utility models in addition to government agencies, many do not operate in strictly for-profit environments. Regardless of the system design, response time and service level requirements imposed on systems make it easy to see why EMS financing remains a challenge. To illustrate this using our system, assume a per transport reimbursement rate of $140. If all costs are accounted for in our simple costing model, the service would not be consistently profitable until it produced nearly 10,000 transports (where average cost of $132 is less than reimbursement of $140). In a free market where profitability was the sole driver, it would continue to add resources until the average cost began to approach the reimbursement rate (up to 28,000 transports). At that point there would be no financial incentive to add units. In the real world, EMS systems must respond to local pressures and demands that make such market-driven analysis difficult.",
        "Conclusion": "The medical director\u2019s role will increasingly involve bridging the often competing realms of system finance and clinical practice. With an understanding of the basics of EMS finance, the medical director has an additional tool to aid decisions about clinical changes to their system. Equally important is the application of these principles to illustrate the financial effect when debating the merits of operational or clinical changes or when addressing politicians, the media or administrators."
    },
    {
        "Due process": "Due process of law is a principle of federal constitutional law that gives every person in the United States the right to present reasons why the government should not deprive the person of life, liberty, or property. Due process of law plays a prominent role in modern public safety administration. The reach of due process of law underwent an explosive expansion in 1970 following the ruling by the Supreme Court of the United States in the case of Goldberg v. Kelly, 397 U.S. 254 (1970), which recognized a due process right to notice and a hearing before a government agency could terminate an individual's welfare benefits. Today, under certain circumstances (which in some cases are difficult to determine), due process of law can be required from a state or municipal agency, a volunteer fire department, a private ambulance company, and perhaps even a medical director. Due process of law extends to employment terminations, licensure and certification terminations, disciplinary actions, and the withdrawal of medical authorization and credentialing. It may also be required in a quality assurance or quality improvement review. Even in situations where due process of law is not legally mandated, it is a procedure that can serve to determine facts while instilling confidence in the process both in participants and observers. In addition to the constitutional doctrine of due process of law, there are several federal statutes that protect individuals from unfair treatment such as the Family Medical Leave Act, the Age Discrimination in Employment Act, the Americans with Disabilities Act, and Title VII of the Civil Rights Act of 1966. Employees may have additional individual employment rights under state statutes and employment contracts. Rights under such laws and contracts provide substantial benefits, and they must be complied with in any employment or licensing action involving EMS providers. Such additional rights, however, are not the subject matter for this chapter. This chapter will outline due process of law. It will briefly review the elements of due process of law that can affect the administration of EMS and the circumstances in which they are or may be required. Needless to say, when dealing with issues of providing and instituting due process of law, consult competent legal counsel.",
        "Law in the federal system": "First a word about the sources of laws that require and define due process of law.",
        "Case law": "Many of the requirements of due process of law in the United States arise from the written decisions of judges in various courts. In the federal system, the Supreme Court of the United States sits at the top of the judicial hierarchy, and its rulings are law throughout the United States. At the next level down are the US Courts of Appeals. There are 11 numbered courts, plus the US Court of Appeals for the DC Circuit, and the US Court of Appeals for the Federal Circuit, which has jurisdiction in specific subject areas not likely to involve EMS. The rulings of the US Courts of Appeal are the law in the circuits in which they sit unless overruled by the Supreme Court. In the next lower tier of the federal judiciary are the US District Courts. There are 89 of them \u2013 at least one in each state. Their rulings are primarily limited to the particular cases involved, but they often serve as precedent for other cases in the same district. In addition to the federal system, each state has its own state court system with a hierarchy of courts unique to that particular state. State courts have a hierarchy similar to the federal courts. The opinion of a state's highest appellate court is law in that state. The cases discussed and quoted in this chapter come from among all these various courts. The reasoning and conclusions are of interest from an analytical perspective. The extent to which they represent current law in a particular jurisdiction depends on their location and place in the judicial hierarchy, and whether the opinion continues in force or has been overruled by a higher court or abandoned by a subsequent opinion.",
        "State legislation": "Most contested cases involving EMS issues will take place before a state agency, such as a Department of Health. Every state has adopted a law known as an administrative procedures act that to some degree will provide for due process procedures in contested hearings in the cases to which those acts apply. Compliance with those procedures will be required. Those procedures can also provide a template for due process procedures that can be instituted in situations in which they are not required by law. State administrative law proceedings generally can provide an expeditious, inexpensive, and yet thorough review of the important issues in a matter without the potentially prolonged procedures involved in court proceedings. Among other things, certain rules of evidence can be relaxed. As an example, hearsay evidence, a written or oral statement made by someone not testifying, may be admissible in an administrative proceeding if it helps resolve an issue and is credible and the rules so provide. Such an approach allows the issue to be heard in a less formal format without being bound by the complex rules of evidence surrounding hearsay. At the same time a party who challenges a piece of evidence has the ability to present contrary evidence. Judicial review of administrative proceedings is usually quite limited. Ordinarily a ruling in an administrative proceeding will not be retried in a court on appeal. Generally any review by a court is limited to a determination of whether there was substantial evidence in the administrative proceeding to support the result. In addition to the state administrative procedures acts, many state constitutions have requirements for due process of law or its equivalent. There may also be other state statutes and regulations that detail due process requirements such as notice, hearing procedure, right to counsel, and similar subjects that may apply in specific cases. Those statutes and regulations must, of course, be complied with, and in some cases may provide more or different rights than the case law on the subject.",
        "Due process of law": "The present-day elements of due process of law have evolved to their current form from principles dating from medieval times combined with over 200 years of judicial interpretation by courts in the United States. The legal doctrine of due process of law in the United States is perhaps most directly derived from the 39th chapter of the English Magna Carta of 1215: No free man shall be taken, imprisoned, disseised, outlawed, banished, or in any way destroyed, nor will We [the King] proceed against or prosecute him, except by the lawful judgment of his peers and by the law of the land. (translated from Latin) The term \u201cdue process of law\u201d appears twice in the Constitution of the United States. The Fifth Amendment prohibits the federal government from depriving any person \u201cof life, liberty, or property, without due process of law,\u201d and the Fourteenth Amendment prohibits states from depriving any person of life, liberty, or property without due process of law. However, there is no definition of the term \u201cdue process\u201d in the Constitution. As Supreme Court Justice John Marshall Harlan II observed: Due process has not been reduced to any formula; its content cannot be determined by reference to any code. The best that can be said is that through the course of this Court\u2019s decisions it has represented the balance which our Nation, built upon postulates of respect for the liberty of the individual, has struck between that liberty and the demands of organized society.",
        "Due process \u2013 procedural versus substantive": "Although it may appear that due process of law clearly refers to a process or procedure, there are in fact two separate components to the due process of law doctrine. One component is \u201cprocedural due process of law,\u201d which deals with the process of procedural fairness. The second component is referred to as \u201csubstantive due process.\u201d The differences between the two are explained by the Supreme Court as: ... [the] Due Process Clause protects individuals against two types of government action. So-called \u201csubstantive due process\u201d prevents the government from engaging in conduct that \u201cshocks the conscience,\u201d\u2026 or interferes with rights \u201cimplicit in the concept of ordered liberty,\u201d\u2026 When government action depriving a person of life, liberty, or property survives substantive due process scrutiny, it must still be implemented in a fair manner\u2026. This requirement has traditionally been referred to as \u201cprocedural\u201d due process. To establish a violation of substantive due process an individual must show that: 1 the challenged action affects a fundamental right 2 substantial infringement of state law prompted by personal or group animus, or 3 government action is legally irrational in that it is not sufficiently related to any legitimate state interest. This chapter will primarily deal with the procedural aspects of due process of law. Some liberty interests related to employment are not protected by substantive due process in any event.",
        "Elements of due process": "The basic ingredients available for procedural due process of law were culled from existing court opinions and collected in 1975 in an article entitled \u201cSome Kind of Hearing\u201d written by Henry J. Friendly, a former Chief Judge of the US Court of Appeals for the Second Circuit. The inspiration for the title was a quotation from Supreme Court Justice Byron White: The Court has consistently held that some kind of hearing is required at some time before a person is finally deprived of his property interests. Judge Friendly set forth the requirements for procedural due process in relative order of importance as: An unbiased tribunal; Notice of the proposed action and the grounds asserted for it; An opportunity to present reasons why the proposed action should not be taken; The right to call witnesses; The right to know the evidence against you; The right to have decision based only on the evidence presented; Counsel; A record of the proceeding; A statement of reasons for the action taken. Not all of these elements are required in any given situation. Due process is a flexible concept that varies with the particular situation, or as the Supreme Court put it: Once it is determined that due process applies, the question remains what process is due. Generally, a decision on how many and which of the historical elements (or perhaps some new ones) to implement and how to implement them is based on: ...consideration of three distinct factors: First, the private interest that will be affected by the official action; second, the risk of an erroneous deprivation of such interest through the procedures used, and the probable value, if any, of additional or substitute procedural safeguards; and finally, the Government\u2019s interest, including the function involved and the fiscal and administrative burdens that the additional or substitute procedural requirement would entail.",
        "Governmental action": "The doctrine of procedural due process of law has a major limitation: it only applies to action taken by a government. For example, in ruling that the University of Nevada\u2013Las Vegas basketball coach could not complain that he did not receive due process from the National Collegiate Athletic Association (which was found to be a private organization and hence not involved in state action), the Supreme Court of the United States noted: Embedded in our ... [constitutional due process] jurisprudence is a dichotomy between state action, which is subject to scrutiny under the ... Due Process Clause, ... and private conduct, against which ... [constitutional due process law] affords no shield, no matter how unfair that conduct may be... . As a general matter the protections of [due process] do not extend to \u201cprivate conduct abridging individual rights.\u201d Although a person may have a right under the Constitution, what remedy does the person have if the right is violated? An important federal statute addresses that problem: the Civil Rights Act of 1871, 42 USC \u00a71983 (\u201cSection 1983\u201d). That statute provides that a person who is deprived of a constitutional right by a person acting under color of state law can sue the \u201cstate actor\u201d: Every person who, under color of any statute, ordinance, regulation, custom, or usage, of any State ..., subjects, or causes to be subjected, any citizen of the United States or other person within the jurisdiction thereof to the deprivation of any rights, privileges, or immunities secured by the Constitution and laws, shall be liable to the party injured in an action at law, suit in equity, or other proper proceeding for redress ... Although the issue is not entirely free from doubt in some cases, for our purposes at least, state action under Section 1983 and state action under the Fourteenth Amendment have the same meaning. Clearly a state or local government is engaged in state action. However, private parties, such as volunteer fire and ambulance companies, private ambulance companies, and even medical directors can be so closely entwined with governmental action as to be engaged in state action and thereby required to provide procedural due process. The analysis for determining whether a private party is engaged in state action for purposes of the Fourteenth Amendment is summarized by the United States Court of Appeals for the Sixth Circuit in Wolotsky v. Huhn, 960 F.2d 1331, 1335 (6th Cir. 1992) as: The principal inquiry in determining whether a private party's actions constitute \u201cstate action\u201d under the Fourteenth Amendment is whether the party\u2019s actions may be \u201cfairly attributable to the state.\u201d ... The Supreme Court has set forth three tests to determine whether the challenged conduct may be fairly attributable to the state ... These tests are ... [(1)] The public function test [which] requires that the private entity exercise powers which are traditionally exclusively reserved to the state, such as holding elections, \u2026 , or eminent domain, ... ... [(2)] The state compulsion test [which] requires that a state exercise such coercive power or provide such significant encouragement, either overt or covert, that in law the choice of the private actor is deemed to be that of the state.... ... [(3)] the symbiotic relationship or nexus test, [under which] the action of a private party constitutes state action when there is a sufficiently close nexus between the state and the challenged action of the regulated entity so that the action of the latter may be fairly treated as that of the state itself. If any of these criteria are satisfied by a person or entity, then state action exists and due process is required. Court opinions discussing this issue routinely engage in elaborate and detailed analysis of the evidence. In many cases predictability of the outcome is uncertain. However, many proceedings that will involve EMS providers and EMS agencies will involve direct governmental regulation and/or licensing and certification that constitute state action and thus will unquestionably involve the right to procedural due process of law.",
        "Ambulance companies": "Whether a volunteer or private ambulance company is engaged in state action and required to provide due process of law depends on the particular facts and circumstances under which the company operates. The courts that take up this analysis describe it as perplexing and difficult. The Supreme Court has avoided ruling on the issue: We express no view as to the extent, if any, to which a city or State might be free to delegate to private parties the performance of ... [fire protection] and thereby avoid the strictures of the Fourteenth Amendment. Determining whether an ambulance company is engaged in Fourteenth Amendment state action generally involves a review of all of the elements of all of the tests against all of the evidence in a particular case. Was the entity a private organization or corporation? How much funding did it receive from a governmental entity? Who owned the property that the organization used? What oversight did a governmental entity exert? Was the entity performing a governmental function? Was the entity performing a function that was traditionally an exclusive governmental function? Who was the entity's staff employed by? What is the legal requirement for providing the service? The results of this analysis have produced the following. \u2022 Six cases have found volunteer fire companies to be engaged in state action. \u2022 Two cases have held it is a question of fact whether a volunteer fire company has engaged in state action without deciding the issue. \u2022 Four cases have found volunteer fire companies not to be engaged in state action. \u2022 One case has found an ambulance company engaged in state action. \u2022 Six cases have found rescue squads and ambulance companies not to be engaged in state action. An interesting feature of the opinions holding that rescue squads and ambulance companies are not engaged in state action is a reluctance to find that emergency medical transport is traditionally an exclusive state function despite the fact that there are several cases that hold that providing EMS is a governmental function associated with the protection of health, safety, and welfare. One court remarked in 1983 that \u201cRescue squads are more akin to private functions that the State may be just beginning to assume than to public functions that are traditionally governmental\u201d. Perhaps after 25 years they have now become traditional.",
        "Medical directors": "One case has held that the medical director of an ambulance service of a state-created hospital was engaged in state action in connection with his failure to sponsor a paramedic employed by the ambulance service. Although the medical director did have an employment contract with the state, state action was found in part because state law required that an ambulance service have a medical director: (a) To enhance the provision of emergency medical care, each ambulance service shall be required to have a medical adviser. The adviser shall be a physician licensed to practice medicine in this state and subject to approval by the medical consultant of the Emergency Health Section of the Division of Physical Health of the Department of Human Resources... (b) The duties of the medical adviser shall be to provide medical direction and training for the ambulance service personnel in conformance with acceptable emergency medical practices and procedures. Code of Georgia, \u00a7 31-11-501(a).",
        "Medical review committees": "Medical review committees are a unique and valuable tool for conducting quality assurance and quality improvement reviews of EMS practices and procedures. They also are effective in conducting investigations into particular EMS events for purposes of disciplinary and credentialing procedures. Under laws in many states the proceedings of a properly constituted and operating medical review committee are confidential. Such confidentiality allows searching and through inquiry into events while shielding sensitive medical information from disclosure. Because such medical review committees are formed and function under state statutes and regulations, their actions can be held to constitute state action and therefore be subject to procedural due process: This court has held that \u201cthe requirement of due process of law extends to administrative as well as judicial proceedings\u2026\u201d Since the medical review committee is formed and functions pursuant to the terms of the regulatory act, it is a creature of the state, and like an administrative agency, is subject to due process rereview. The question then becomes the nature of the due process that is required in this setting. Medical review committees are one area that state administrative procedure acts may not cover. If not, and absent other statutory or regulatory requirements, it may be necessary to develop an appropriate process. Guidance in this area can be gleaned from the procedures suggested (but not required) for physician quality review procedures contained in the Health Care Quality Improvement Act of 1986 (United States Code: Title 42, The Public Health and Welfare; Chapter 117, Encouraging Good Faith Professional Review Activities; Subchapter I, Promotion of Professional Review Activities).",
        "National accreditation entities": "Action by private national credentialing agencies such as the National Registry of EMTs is probably not considered to be governmental action, notwithstanding the reliance that most states place on their credentialing of EMS providers.",
        "An opportunity to present reasons why the proposed action should not be taken": "The overarching principle of procedural due process of law is giving the party against whom action is proposed a fair and full opportunity to challenge the basis for the action and to present that party's own evidence. Generally a hearing of some sort will be required to provide an opportunity to present both sides of an issue. ... one may not be excluded by state action from a business, profession or occupation in a manner or for reasons which contravene the due process clause of the Fourteenth Amendment of the Constitution of the United States, and that due process means that there must be given notice of time and place of hearing, a reasonable definite statement of the charge or charges, the right to produce witnesses and to examine adverse witnesses and to have a full consideration and determination according to evidence before the body with whom the hearing is held. The form and procedure of the hearing process can be customized. \u201cDue process is not necessarily judicial process.\u201d\u2026 Nor does it entail one set \u201cof inflexible procedures universally applicable to every imaginable situation.\u201d Many states have statutes allowing hearings by electronic means. Consideration in the proper circumstances should be given to conducting all or part of a hearing by video conferencing or some other suitable means that will save resources and expand the participants who may be available to provide information. Whatever its form, the hearing must give the parties a fair opportunity to present their own evidence and examine the evidence against them. A critique of the requirements for a proper hearing comes from an EMS case. In that case the City of Chicago terminated a paramedic for her actions following 26 runs in 27 hours on duty during a heavy snowstorm that required her ambulance to park a block away from the patient's apartment. In the face of heavy criticism from the patient's family, the City terminated the paramedic despite evidence that was equivocal at best regarding the care she provided. Due process of law fundamentally requires a fair proceeding\u2026. Fairness is insured by procedural safeguards which require proper notice and an opportunity to be heard\u2026. Fairness also dictates that the procedure itself not be abused or misused. No matter how complete the panoply of procedural devices which protect a particular liberty or property interest,\u2026 due process also requires that those procedures be neutrally applied\u2026. Even if the procedures themselves are legitimate, it is impermissible to employ those procedures vindictively or maliciously so as to deny a particular individual due process\u2026. The record in this case demonstrates that the City misused its otherwise legitimate disciplinary procedures in a single-minded effort to discharge \u2026 [the paramedic] for her role in this unhappy sequence of events, and it thereby violated her right to due process of law. In Baxter v. Fulton-Dekalb Hosp. Auth., 764 F.Supp. 1510 (N.D.Ga.1991), a paramedic was terminated based on allegations that he failed to properly document the care he provided to a patient. Following a hearing and appeal it was determined that he had not incorrectly documented the care. However, the medical director disagreed with the outcome of the hearing and appeal and refused to allow the paramedic to practice under his direction. The court found that the refusal to reinstate the paramedic was \u201ca deprivation of the paramedic\u2019s constitutionally protected interest in continued employment without granting the paramedic any process of law.\u201d The more recent EMS case of Rinehart v. Greenfield further illustrates the concept of a meaningful hearing. In that case a firefighter/paramedic responded to a call for a choking infant who was not breathing and in asystole when the paramedic arrived. The infant did not survive, but there was no issue regarding the care provided by the paramedic concerning the treatment of the infant. However, there was an issue concerning the pressure release valve on the artificial respiration equipment. A dispute arose over whether the paramedic should have noted a problem with the valve in her patient care report. As a result of the ensuing dispute over the issue, the medical director revoked her privileges to practice under his medical direction. The firefighter/paramedic was employed by the City of Greenfield, which required that firefighters be capable of providing paramedic care. The City fired the firefighter/paramedic when the medical director withdrew her credentialing. The City was required to give the firefighter/paramedic a hearing before termination. At the hearing, no evidence was allowed concerning the revocation of paramedic privileges by the medical director. The only issue addressed was whether the privileges had been revoked, not whether they had been revoked for a valid reason. In ruling that the firefighter/paramedic did not receive due process, the Court stated: Under the City\u2019s theory, it did not matter whether \u2026 [the medical director] was right or wrong, prudent or hasty, fair or arbitrary. All that mattered was that he decided he did not want \u2026 [the firefighter/paramedic] to work as a paramedic or an EMT under his supervision. Under that theory, the Board of Works had nothing meaningful to decide. The Board\u2019s hearing on \u2026 [the firefighter/paramedic\u2019s] case was an empty formality. It was not a meaningful opportunity to be heard. Unless \u2026 [the medical director] changed his mind, nothing that \u2026 [the firefighter/paramedic] might show in the hearing could possibly have changed the decision to terminate her.",
        "Life, liberty, or property": "Courts make a distinction between life, liberty, and property interests. A life interest is primarily limited to capital cases and perhaps related clemency proceedings and has rarely if ever been applied outside of those areas. A liberty interest is described by the Supreme Court of the United States as: ... the term [liberty interest under the Fourteenth Amendment] ... denotes not merely freedom from bodily restraint but also the right of the individual to contract, to engage in any of the common occupations of life, to acquire useful knowledge, to marry, establish a home and bring up children, to worship God according to the dictates of his own conscience, and generally to enjoy those privileges long recognized ... as essential to the orderly pursuit of happiness by free men. A property interest arises when there is an interest in or right to \u201cproperty\u201d under law \u2013 generally state law. The interest in or right to the \u201cproperty\u201d must be reasonably definite and not limited by discretion. There must be an algorithm with no discretionary choices that will lead to the vesting of the right or interest. An interest in employment, a license, or a certification can qualify as a property interest under appropriate circumstance. The claims in the case of Med Corp. v. City of Lima, 296 F.3d 404, 411 (6th Cir. 2002), which holds that a private ambulance company has no property interest in being dispatched for 9-1-1 calls, illustrate the difference between a property interest and a liberty interest. Emergency 9-1-1 calls in Lima, Ohio, were received by a dispatch system located at the city police department. Depending on the type of call received, the calls were then dispatched to either the city paramedic service or one of several private ambulance companies licensed to operate in the city. The private ambulance companies were dispatched on 9-1-1 calls based on an unofficial unwritten policy of dispatching private ambulance companies on a rotating basis. One private ambulance service had difficulty locating addresses within the city and was suspended from being dispatched on 9-1-1 calls for one week. The private ambulance company filed suit against the city alleging deprivation of property and liberty interests without due process of law in violation of the Fourteenth Amendment. The company claimed that the suspension was a deprivation of its property interest in receiving 9-1-1 dispatches and in the property interest in its ambulance license. The United States Court of Appeals for the Sixth Circuit ruled that the private ambulance service did not have a property interest in being dispatched for 9-1-1 calls because dispatching a private ambulance to 9-1-1 calls was discretionary with the city. There was no policy, law, or mutually explicit understanding that conferred the right to receive 9-1-1 calls on the private ambulance service and that limited the discretion of the city. The suspension did not amount to a loss of the private ambulance company\u2019s property interest in its ambulance license because the extent to which the ambulance service might lose business through the loss of 9-1-1 calls would not render its license valueless.",
        "Employment and licenses as a property interest": "Employment relationships present a continuum of certainty. There are gradations of security \u2013 tenure, a contract for a fixed term, an employee at will, an employee serving \u201cat the pleasure of.\u201d Which of these qualify as property interests for procedural due process? To create a property interest, the state-law rule or understanding must give the recipient \u201ca legitimate claim of entitlement to [the benefit].\u201d ... For example, an employee may possess a property interest in public employment if she has tenure, a contract for a fixed term, an implied promise of continued employment, or if state law allows dismissal only for cause or its equivalent. Government employment that can be terminated at the will of the employer will not qualify. However, where there are rights to continued employment, governmental employment will qualify as a due process property interest. The same criteria apply to an EMS provider\u2019s license or certification. Does the EMS provider have a legitimate claim of entitlement to the license or certification? Where the state confers a license to engage in a profession, trade, or occupation, not inherently inimical to the public welfare, such license becomes a valuable personal right which cannot be denied or abridged in any manner except after due notice and a fair and impartial hearing before an unbiased tribunal. Were this not so, no one would be safe from oppression wherever power may be lodged, one might be easily deprived of important rights with no opportunity to defend against wrongful accusations. This would subvert the most precious rights of the citizen. Practically speaking, this means an EMS provider, having qualified for and having been awarded a license or certification, is entitled to procedural due process in connection with a proceeding revoking or limiting the license or certification. It also means that in certain circumstances due process applies to applying for a license. In a seminal case on licensing, the Supreme Court ruled that a person cannot be prevented from being licensed for invalid reasons reasons. However, an EMS provider is not entitled to procedural due process in obtaining a license if the provider does not meet legitimate criteria. In Lockhart v. Mathew the United States District Court for the Virgin Islands ruled that a former EMT whose license had expired and who could not lift the required 100 pounds required for licensure did not have a due process interest in an EMT license. Progressive disciplinary actions such as warnings, reprimands, reassignment, suspensions, and reassignment that fall short of revocation present another issue. When does the action become so insignificant that due process is not required? It depends. Some cases hold that a violation of constitutional rights is never insignificant. Others hold that a suspension of 3 days does not amount to a due process interest while a 5-day suspension may raise a due process interest. Placing a provider on probation may require procedural due process. A transfer with no pay change will generally not amount to a deprivation of a due process property interest. A warning probably does not raise due process interest, nor does a letter of reprimand that does not result in a loss of rank or pay.",
        "The liberty interest": "A liberty interest in employment arises when an employment action is taken that damages the employee\u2019s ability to obtain other employment. To the extent that charges of immorality, dishonesty, alcoholism, or incompetence affect the employee\u2019s \u201coccupational liberty interest\u201d then the employee may have a liberty interest that requires due process of law. Damage to reputation alone does not ordinarily present a due process interest. Statements regarding a provider\u2019s job performance or competence ordinarily do not rise to a level of stigma which creates a liberty interest. The Healthcare Integrity and Protection Data Bank (HIPDB) became operational in 2000, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Under that statute, state and federal agencies are required to report licensing and certification actions, including revocations, reprimands, censures, probations, suspensions, and any other loss of license, or the right to apply for or renew a license, whether by voluntary surrender, nonrenewability, or otherwise such action to the HIPDB. One reported opinion suggests that reporting to the HIPDB may not raise a due process liberty interest.",
        "Notice": "The first element of due process that a provider would ordinarily encounter in a matter would be notice of the proceedings against him or her. Generally the notice should advise the provider of the grounds for the action proposed to be taken, the type of action that is proposed, and the provider\u2019s rights (which may include the right to present evidence, to attend a hearing, to be represented by counsel, to subpoena witnesses, and other essential elements of the proceeding). The notice should be: ... reasonably calculated to apprise [the provider] of the proceeding and to afford him an opportunity to present his case. ... Due process does not require that notices of administrative proceedings 'be drafted with the certainty of a criminal pleading,' as long as the notice is sufficient for persons whose rights may be affected to understand the substance and nature of the grounds upon which they are called to answer. A notice must state all the facts and circumstances on which the proposed discipline is based. Additional incidents cannot be introduced at the hearing. In Ellins v. Department of Health, 505 So. 2d 74, 8 (La.App. 4 Cir., 1987), a paramedic was charged with a single incident of allowing a BLS provider to care for a patient on whom the paramedic had performed ALS procedures. At her termination hearing the city introduced evidence of other incidents of misconduct. The court reversed the termination of the paramedic stating: We find the hearing officer committed a reversible error in permitting the introduction of evidence concerning ... [the paramedic's] record of absences which was not the basis of her dismissal. While the rules of evidence may be somewhat relaxed at a Civil Service hearing, the lapse of formalities must not permit a violation of the employee's rights to a fair hearing with notice of the charges against her. A practical problem associated with notice is communicating the notice to the party who is the subject of the proceeding. The surest way for notice to be effective is to deliver a copy in writing to the individual to whom it is directed and to maintain proof of such delivery. Hand delivery to the individual followed up with an affidavit by the person serving the notice works well. Other generally accepted methods are certified or registered mail delivery with a return receipt signed by the person to whom the notice is directed.",
        "Time for hearing": "A procedural due process hearing should ordinarily take place before the provider is deprived of a protected property interest. However, where the public health, safety, and welfare may be significantly at risk, action may be taken before a due process hearing provided an opportunity for a hearing is given promptly after the action is taken: Not even an informal hearing, however, must precede a deprivation undertaken to protect the public safety. Starting with a case that authorized summary confiscation of potentially contaminated food products, North Am. Cold Storage Co. v. City of Chicago, 211 U.S. 306, 29 S.Ct. 101, 53 L. Ed. 195 (1908), the Supreme Court has consistently held that \u201cthe necessity of quick action by the State\u201d justifies a summary deprivation followed by an adequate post-deprivation remedy. A summary proceeding on the record in advance of the action or within a very short time afterward should be provided in such a case so that there is reasonable assurance that the situation presents a sufficient threat to the public health, safety, and welfare to warrant the revocation of a property interest before a hearing. Such a procedure could include the presentation of the evidence upon which the action is based to one or two officials who are independent from the prosecutorial personnel presenting the matter. The summary procedure should also be specified in advance in the statute, regulations, or rules that spell out the due process procedures that apply. Any procedural irregularities in a summary proceeding may be irrelevant if the suspended party has access to a timely post suspension hearing. The summary suspension of EMTs alleged to have falsified training records and issuing cards for training that never took place has been upheld where there were adequate post-suspension hearing provisions in place.",
        "Standard of proof": "In making the decision to deprive a provider of a property interest, the pivotal facts supporting the decision will need to be established. The side that must prove the pivotal facts in order to prevail bears the burden of proof of the issue. For example, it must be established that a provider committed a prohibited act in order to take disciplinary action against the provider. If there is no proof of the prohibited act, there will be no disciplinary action taken. In a case where there are conflicting accounts, a decision must be made by the body or individual charged with determining the facts. How much proof on an issue is required? The highest burden of proof in a contested matter is \u201cproof beyond a reasonable doubt,\u201d which is the standard that applies to criminal prosecutions. Although that degree of proof in an administrative proceeding could be required by statute or regulation, generally that is never a workable standard in an administrative due process proceeding. The available choices are \u201ca preponderance of the evidence\u201d or \u201cclear and convincing evidence.\u201d A preponderance of the evidence generally means that a matter is more likely than not. It is sometimes described as if the evidence for and against a matter is placed on a balance scale, if the scale tips ever so slightly to one side or the other, then the side to which it tips has the preponderance of the evidence. Clear and convincing evidence is somewhat more than a preponderance of the evidence and something less than beyond a reasonable doubt. Absent a statute or regulation to the contrary, most courts have held that requiring that facts be established by a preponderance of the evidence is sufficient for due process purposes in medical disciplinary proceedings. However, some courts maintain that the higher \u201cclear and convincing\u201d standard of proof is necessary to comport with due process for medical disciplinary proceedings.",
        "Right to counsel": "There is no procedural due process right to counsel before a government agency: ... the constitutional right to effective assistance of counsel reaches only criminal or quasi-criminal proceedings and does not extend to administrative license revocation proceedings. However, many administrative procedure acts and agency rules provide the right to representation by counsel, and any such requirements must be followed. The government, however, has no obligation to provide counsel in an administrative proceeding to an individual who cannot afford one, as would be required in a criminal proceeding. Although there is some authority that legal counsel may be prohibited in certain administrative proceedings (e.g. student discipline), such a prohibition is not recommended."
    },
    {
        "Introduction": "The potential for hazardous materials (hazmat) incidents is significant. More than 60,000 chemicals are produced annually in the United States. More than 4 billion tons of chemicals are transported yearly via surface, air, or water routes, with more than 500,000 shipments of hazardous materials made every day. In an attempt to define the magnitude of the nation's hazmat incidents, the Agency for Toxic Substances Disease Registry (ATSDR) developed the Hazardous Substances Emergency Events Surveillance (HSEES) system in 1990. Fifteen state health departments participate in the reporting system. In these 15 states, the system has shown the following: About 9,000 releases of hazardous substances occur annually, with 75% occurring at chemical facilities and 25% occurring during transportation. Most transportation-related incidents occurred during ground transport (85%), and 26% occurred in residential areas. Human error and equipment failure account for most releases. The most common substances involved were inorganic substances (24%) followed by volatile organic compounds (20%). More than 2,000 people are victims of hazardous materials releases in these states each year. Approximately 50% of these are transported to hospitals. Respiratory and eye irritation are the most common types of injury. Over a 4-year period, 132 deaths related to hazardous materials occurred. More than 7,500 people required decontamination during hazmat events over a 4-year period in these states. Of these, 2643 were decontaminated at medical facilities. Whether from household agents, industrial incidents, or acts of terrorism, EMS, fire, and law enforcement personnel face a variety of response issues related to hazardous materials.",
        "Developing standard operating procedures": "Every organization that has the responsibility to respond to hazmat incidents should develop standard operating guidelines (SOGs) that delineate roles, responsibilities, and pertinent response procedures. Ideally, responding agencies should coordinate their plans with neighboring jurisdictions to ensure interoperability. SOGs should address when and how to implement personal protective equipment (PPE) use, medical decontamination of ill or injured victims, and technical and emergency decontamination of responders. Individual agency SOGs should be part of a community response plan that provides the foundation for the overall incident response. Of particular importance from a medical perspective is the need for clarity on which agency (or agencies) will be providing medical support in the various work locations (hot, warm, and cold zones) and ensuring that they have the necessary protocols, equipment, and training to carry out their assignments successfully. This level of planning requires that representatives from the various agencies meet on a regular basis to write, train, exercise, and revise the plan. Once a plan is developed, training sessions and exercises should be conducted on a regular basis. All first responder agencies have multiple responsibilities that require ongoing training. Effective training is best conducted by expert personnel who create a rigorous training program for all aspects of response to these types of incidents. Individual agency training can provide important instruction on department SOGs. However, multiagency training conducted on a regular basis permits practice in the areas of unified command, integration of community resources, resource sharing, joint decision making, and information sharing. Effective training culminates with after-action discussions and reports, and revising plans, policies, and procedures.",
        "Identifying potential threats": "Hazardous materials are found in homes, businesses, industries, and transportation corridors. A comprehensive hazard vulnerability analysis should be conducted to determine what significant risks exist in the local community. The federal Superfund Amendments and Reauthorization Act became law in 1986. Title III of these SARA provisions is also known as the Emergency Planning and Community Right-to-Know Act (EPCRA). SARA Title III requires states to: promote outreach for developing local emergency preparedness programs to respond to chemical releases, receive reports from the regulated community, organize, analyze, and disseminate the resulting information on hazardous chemicals to local governments and the public. Specifically, this has required the establishment of state emergency response commissions and local emergency planning committees. The nationwide regulated community of manufacturers and non-manufacturers of hazardous chemicals must report concerning their emergency chemical releases; their Material Safety Data Sheets (MSDS); their facility hazardous chemical inventories (Tier I and Tier II reports); and their toxic chemical releases to the air, land, or water (Toxics Release Inventory). Because of this activity, businesses have reassessed their chemical inventories and their manufacturing processes. In addition, more businesses are working cooperatively with local governments to plan for and try to prevent accidental chemical releases. Fire department preplans and fire marshal inspection of commercial buildings and transportation centers, along with law enforcement intelligence information on high-risk targets and clandestine drug laboratories, should be considered when identifying response risks.",
        "Medical response planning": "After identification of potential risks, medical response procedures should be developed and published in conjunction with the department's medical director, emergency management, local medical facilities, and other appropriate community experts such as poison centers. Protocols for specific classes of agents or individual threats should be written and include information on signs and symptoms, personal protective measures required, need for decontamination, and treatment recommendations. Written publications on various agents are available from the Federal Emergency Management Agency (FEMA), Environmental Protection Agency (EPA), Occupational Safety and Health Administration (OSHA), and National Institute for Occupational Safety and Health (NIOSH) as well as non-government publishers. In addition, the American Association for Poison Control Centers offers 24-hour planning and response information assistance and can be reached at 1-800-222-1212. The Chemical Transportation Emergency Center (CHEMTREC), maintained by the Chemical Manufacturers Association, is another 24-hour resource for obtaining planning information and emergency response information, particularly for chemical releases, and can be reached at 1-800-424-9300. The Agency for Toxic Substances and Disease Registry (ATSDR) offers a 24-hour emergency number for health-related support in hazardous materials emergencies, and can be reached at 1-800-232-4636. Hotline services operated by government agencies such as the EPA and US Army Soldier and Biological Chemical Command (SBCCOM) can be contacted for assistance. There are several government web addresses such as those listed below that provide useful planning and response information. www.epa.gov/ceppo/cameo (computer-aided management of emergency operations), www.toxnet.nlm.nih.gov (chemical information), www.wiser.nlm.nih.gov (chemical information), www.bt.cdc.gov (CBRNE information), www.remm.nlm.gov (radiological information).",
        "Personal protective equipment": "After the events of September 11, 2001 and the anthrax attacks in 2001, increasing numbers of agencies have made various levels of PPE available to their personnel. Regardless of the user's profession, the correct type of PPE must be used for its intended application. The PPE must be appropriately donned and doffed. Understanding the operational limitations of wearing PPE such as limited dexterity, reduced hearing, and muffled voice is best experienced and surmounted through frequent training.",
        "Levels of protection for work involving hazardous materials": "Four levels of protection have been defined for work involving hazardous chemicals. Although these levels originally were intended for work at hazardous waste disposal sites, they have been adopted widely in other situations, such as rescue work. Level A is the highest level of protection. It is usually only worn by hazmat personnel and others working in areas of very high concentrations of toxic agents. A Level A ensemble consists of a fully encapsulating chemical-resistant suit, positive-pressure self-contained breathing apparatus (SCBA), double layers of chemical-resistant gloves, and chemical-resistant boots. The Level A ensemble will protect against vapor and splash threats. Most hazmat workers who enter the hot zone require Level A protection. This is very expensive, bulky, and requires specialized training in its use. The typical Level A hazmat suit costs several thousand dollars and must be properly cleaned between uses. Manual dexterity is poor and the suits retain heat. With the physiological stressors and the self-contained air supply, Level A ensembles are limited in the amount of time that they can be worn. Level B is used when full respiratory protection still is required but dangers to the skin are less. It consists of SCBA and a chemical-resistant suit with resistant gloves and boots. There is less vapor protection in a Level B ensemble. Level C is required when air concentrations are expected to be much lower and less likelihood of skin exposure exists. It consists of a full-face air purification device and a non-encapsulating chemical resistant suit with gloves and boots. Hazmat teams usually use Level B or C PPE when performing decontamination. This takes place away from the hot zone and when the amount of chemical present on a patient is significantly less than what exists in the hot zone. Also, quantities of chemicals that might present physical hazards, such as explosions, should not be present on a patient. Level D protection is used only when no danger of chemical exposure exists. It consists of standard work clothes and no respiratory protection. Structural firefighting clothing protects against extremes of firefighting, especially heat and steam. This attire is most suitable for firefighters and includes full protective clothing (turnout coat, hood, and bunker pants), SCBA, helmet, gloves, and boots. Despite the respiratory protection provided by SCBA, limited chemical protection is provided by structural firefighting clothing, and it is considered level D PPE.",
        "Available types of respiratory protection": "Self-contained breathing apparatus provides breathable air in an immediate danger to life and health (IDLH) atmosphere. The term self-contained means that the breathing set is not dependent on a remote supply (e.g. through a long hose). An SCBA typically has three main components: a high-pressure tank, a pressure regulator, and an inhalation connection (mouthpiece, mouth mask or face mask). Self-contained breathing apparatus may fall into two different categories: open circuit and closed circuit. The closed-circuit type filters, supplements, and recirculates exhaled gas. It is used when a longer-duration supply of breathing gas is needed, such as in mine rescue and in long tunnels, and going through passages too narrow for a big open-circuit air cylinder. Open-circuit SCBA are more common. The apparatus is filled with filtered, compressed air, rather than pure oxygen. Typical open-circuit systems have two regulators \u2013 a first stage to reduce the pressure of air to allow it to be carried to the mask, and a second stage to reduce it even further to a level just above standard atmospheric pressure. This air is then fed to the mask via either a demand valve (activating only on inhalation) or a continuous positive pressure valve (providing constant airflow to the mask). Supplied-air respirators differ from SCBA in that the air is supplied through a line connected to a source away from the contaminated area. SARs are available in both positive- and negative-pressure models. However, only positive-pressure SARs are recommended for use at hazmat incidents. One major advantage the SAR has over SCBAs is that it allows an individual to work for a longer period. In addition, SARs are less bulky than SCBAs. By necessity, however, a worker must retrace his steps to stay connected to the SAR, and therefore cannot leave the contaminated work area by a different exit. SARs also require the air source to be in close proximity (within 300 feet) to the work area. In addition, personnel using an SAR should carry an immediately operable emergency escape supply of air, usually in the form of a small, compressed air cylinder, for use in case of an emergency.",
        "Cartridge respirators and supplied air respirators": "Air-purifying cartridge respirators function by allowing the wearer to inhale air through a canister filled with a special sorbent material that binds chemical vapors. Cartridge respirators are inexpensive, portable, and easy to use and store. However, drawbacks to their general use exist. The type of cartridge used must match the chemical vapor in question. Different cartridges must be used to protect from organic vapors, acid gases, chlorine, ammonia, and methylamine. The sorbent materials also have a breakthrough phenomenon, in which chemicals elude off the sorbent after a period of use and then expose the user. Multisorbent cartridges are available that do not require matching with the vapor in question. In general, these have a shorter breakthrough period. These factors limit cartridge respirators to short-term use and to low concentrations of chemicals in the air. This is the situation that exists when patients require decontamination. Cartridge respirators depend on an airtight seal against the face. They require a good fit and cannot be used with facial hair. A moderate amount of work is involved when inhaling across the pressure resistance of the cartridge. All of this requires that any individual using this type of respirator be fitted properly and trained in its use. Cartridge respirators are very versatile for short-term use. They require adequate training of all personnel who may be expected to use them and require someone available at all times to decide which type of cartridge to use. Cartridge respirators are ideal for performing decontamination outside the ED. To overcome many of the problems with air-purifying cartridge respirators, battery-operated versions were developed. These use a battery-operated pump to draw air across the sorbent cartridge and pump it into a hood that surrounds the user's head. They do not require an airtight fit and can be used with facial hair. They do not require the user to work to draw air across the cartridge and, thus, are much cooler and less anxiety provoking. They also require less individual training. They still depend upon the cartridge to remove the vapor in question; thus, the cartridge must match the vapor. The time of use must be limited because of both chemical breakthrough in the cartridge and battery life. Since a clear shield surrounds the face, they provide better eye contact with the victims.",
        "Accompanying accessories and attachments": "In addition to the PPE described above, a number of accessories and attachments may be worn by public safety personnel including cooling and ventilation devices, flash garments, head protection, Nomex suits, and splash aprons. To address body heat concerns, cooling and ventilation devices can be worn under the PPE and against the body. Because of safety and effectiveness concerns, the use of these devices is not widespread. Most chemical protective suits are not flame resistant and should not be worn in situations where there is a risk of fire. Chemical protective suits can be worn with a flash overgarment. The overgarment only provides limited protection against a flash fire. Helmets can be worn when personnel are operating in situations with overhead dangers from pipes, tree limbs, and similar dangers. These products can be added to PPE to provide additional protection during operations.",
        "Implications of PPE use - Physical Limitations": "Personal protective equipment ensembles have limitations for the user. A primary limitation is the bulkiness of the suit. SCBA is heavy, especially when the user is getting fatigued. In addition, it can limit ingress and egress through tight spaces. Air-tank time limitations must be strictly adhered to so that the user does not run out of air. Chemical protective gloves can limit dexterity and tactile feedback. These limitations make traditional medical interventions such as IV access almost impossible while wearing a Level A ensemble and medical care may be limited to basic airway interventions, major hemorrhage control (tourniquets), and autoinjector antidotes.",
        "Implications of PPE use - Communications": "Standard radio use can be problematic. SCBA and respirators limit the volume and understandability of the user's voice. Personnel can use microphones worn around the neck to amplify voice box vibrations. SCBA and respirator masks can be modified to provide voice amplification so the user's voice can be better heard during conversation and when giving verbal instructions to the public.",
        "Implications of PPE use - Health risks": "One of the key health risks associated with wearing any type of PPE is heat stress brought on by additional clothing, weight, and physical activity. Heat emergencies such as dehydration, heat cramps, and heatstroke can be mitigated by allowing only properly trained persons in good health and physical condition to wear PPE. Pre- and postentry monitoring are important steps to providing situational health information on each responder. Proper hydration with electrolyte drinks and water along with good nutrition are also vital to limiting health risks. Other health risks include injuries from falls due to limited vision while wearing PPE. Hearing can be impaired when working around noisy equipment and is further affected by wearing protective ear muffs or plugs. Cold emergencies such as hypothermia or frostbite can occur if insufficient underclothing is worn during winter months or when working around cryogenic materials.",
        "Responding to hazardous materials - assess the situation": "Initial arriving units must consider the possibility that an incident involves hazardous materials. Adhering to the old adage \u201cevery call can be a hazardous material call\u201d has practical importance. When responding to a reported hazmat event, personnel should attempt to approach the incident from an uphill and upwind direction. This provides protection if the agent is being actively released into the environment. Providers should not get any closer to the potential danger than is necessary.",
        "Responding to hazardous materials - Determine threat risk and initial required actions": "Identification of the actual or likely agents involved allows determination of the threat risk and the initial required actions. Certain information should be ascertained on every event. Life safety: Risks to people and responders, Resources needed for immediate rescue, PPE requirements. Incident stabilization: Presence of fire, spill, or leak, Resources needed for containment, Effects of terrain, Population evacuation. Property conservation: Risks to property and the environment. The incident commander should communicate the strategies and tactics to deal with the incident to all responding personnel.",
        "Responding to hazardous materials - Establish a perimeter": "An inner and outer perimeter should be established rapidly based on the initial information. Starting with a large perimeter is preferable, as reducing the size of a perimeter is easier than expanding it. The US Department of Transportation\u2019s Emergency Response Guide (ERG) can be a useful tool to determine the size of the perimeter. Command personnel should determine whether personnel on the perimeter require PPE. While establishing the perimeters, ingress and egress corridors should be set up for response personnel.",
        "Responding to hazardous materials - Establish incident command": "The first arriving unit should establish single-agency incident command and transition to unified command as outside agencies respond to assist. The command post area should be cleared of secondary threat risks prior to establishment. Additional functions of the incident command system (ICS) should be established as needed, but high priority should be given to the staging sector to avoid disorganized arrival of responding personnel.",
        "Responding to hazardous materials - Product identification": "Identification of the product or products should occur as soon as possible. Placard or label information can be looked up in the ERG or other similarly designed reference texts including computer programs to identify the agent. Contacting CHEMTREC or the Poison Center can also assist with product identification. The arrival of hazmat-trained personnel with sophisticated monitoring and detection equipment may help to accelerate the identification of an unidentified product. Recognition and assessment of patient signs and symptoms may be the only initial information available to identify the class of hazard or agent. Product identity information should be shared among all response personnel and area health care facilities that may receive patients by EMS or self-directed transport from the scene. Treatment plans can be more completely detailed once the product identity is known, particularly regarding the need for specific antidotes.",
        "Responding to hazardous materials - Evacuations": "The incident commander will determine whether evacuations will be required. If an evacuation is necessary, then a plan must be quickly devised and specific assignments given to response personnel. Depending on the situation and resource availability, EMS personnel may be assigned to an evacuation center to assist with medical evaluation or to other on-site responsibilities.",
        "Responding to hazardous materials - Monitoring and detection devices": "Various forms of chemical agent detectors are available for monitoring initial contamination and screening contaminated patients. Devices may also be used to monitor residual contamination after decontamination of victims and equipment. Technologies used in detectors include infrared radiation (photo-acoustic infrared spectroscopy and filter-based infrared spectroscopy), ion mobility detection (spectroscopy), flame spectrophotometry (photometric detection), and enzymes (colorimetric tubes and detection tickets). Monitors may be handheld for personnel and equipment detection or stand-alone for area detection. A more basic method when screening for nerve and blister agents includes the use of detection paper, which uses dyes. Corrosive agents can be detected by the use of pH indicators. While detection paper is inexpensive and can be used to distinguish between different types of chemical agents, other substances, such as fats and oils, dissolve the pigments and cause false-positive results. The military currently uses the M8 and M9 chemical detector paper, which uses an enzyme method to detect nerve and blister agents. At an incident involving radioactive materials, a radiation survey meter is used to determine the type of radiation present (alpha, beta, gamma) and its level. Use meter readings and radiation safety guidelines to delineate safe and restricted zones. In addition to radiation survey meters, personal dosimeters can be used to estimate an individual\u2019s dose of radiation.",
        "Decontamination": "Most activities that involve handling hazardous materials or wastes will result in some form of contact with the hazardous materials. Contamination is described as the presence of an unwanted material or substance. Personnel may become contaminated in a number of ways including: contacting vapors, mists, or particulates in the air, being splashed by materials while sampling or opening containers; spray from releases, walking, sitting, or kneeling on contaminated surfaces, handling contaminated instruments or equipment. Fortunately, protective clothing and respirators prevent the wearer from being exposed to contaminants. Good work practices will reduce contamination on protective clothing, instruments, and equipment. Even with PPE and good work practices, hazardous substances can stick to personnel and equipment. Personnel will always have the potential to contaminate the equipment and clothing during site operations. If hazardous substances are not removed from workers and equipment exiting the hot zone, they could be spread to clean areas. The principles of decontamination are based upon an understanding of the two types of contamination. Primary contamination is the result of direct transfer of contamination from the source to a person or object. Secondary contamination is the transfer of contamination from a person or object to another person or object. Decontamination is the process of removing or deactivating harmful contaminants from surfaces of persons or objects by dilution and physical measures. This removal reduces exposure, regardless of the agent's physical phase (solid, liquid, or gas).",
        "Methods of decontamination": "There are many methods that can be used for decontamination. The method selected must be effective for the situation. The removal technique is based on: type, nature, and concentration of the contaminant involved, the amount of contamination, the levels of protection required, the type of protective clothing worn, the type of contamination (surface or permeated), the characteristics of the surface or equipment that will be decontaminated.",
        "Physical removal techniques": "Physical removal is effective for surface (adsorbed) contamination. Several methods may be employed. It is important to remember that some physical removal techniques may lead to air-borne contamination. Brushing. Loose particulate material can simply be brushed off protective clothing and equipment. Brushing should be performed starting at the top and sweeping downward. Using damp wipes may be appropriate to lower the potential of air-borne dusts. Scraping. Scrapers are effective in removing highly viscous liquids and solids from surfaces of boots, gloves, and equipment. Vacuuming. Vacuums equipped with HEPA filters may be used to remove and contain particulate matter from surfaces. Vacuums may also be employed for liquid spills. Special precautions for flammable liquids must be observed. Washing and rinsing. Washing and rinsing will remove surface and some permeated contamination. Pressure washers can be used to remove many contaminants from structures (not people). All water removal techniques require a plan for the collection and disposal of the waste water generated. Heat and steam cleaning. In some limited circumstances, heat can be used to drive off volatile contaminants. Heat is most effectively used with equipment decontamination. Steam jets can be used to liquefy viscous petroleum products and allow removal from equipment.",
        "Chemical removal techniques": "Chemical removal techniques change either the contaminant's form or properties. This makes the contaminant less hazardous or easier to remove. Absorption. Using pads or absorbent towels to wipe the chemical off an area. Adsorption. The use of activated charcoal or other adsorbents can minimize the effects of chemicals. Adsorption is a process where the product is chemically adhered to the adsorbent material. This is not to be confused with absorption in which the product is simply \u201csoaked up.\u201d Degradation. The use of one chemical to destroy the hazards of another chemical. Dilution. Using water or a solvent \u201cdilutes\u201d and lessens the hazards of the chemical. Evaporation. Some products will simply evaporate completely over a given period of time. Care should be taken regarding any residue that is left. Isolation and disposal. Many times the simplest method is to carefully remove the contaminated articles, bag them, and throw them out as hazardous waste. This is the idea behind disposable PPE. Dissolving contaminants. Chemical removal of surface contaminants can be accomplished by dissolving them in a solvent. The solvent must be chemically compatible with the equipment being cleaned. In addition, care must be taken in selecting, using, and disposing of any organic solvents that may be flammable or potentially toxic. Usually surfactants are used rather than solvents. Surfactants. A surfactant enhances physical cleaning methods by reducing adhesion forces between contaminants and the surface being cleaned. Household detergents are among the most common surfactants. Some detergents can be used in conjunction with solvents to improve the dissolving and dispersal of contaminants into the solvent. Neutralization. Although rarely done on PPE, neutralization can be used to render acids and bases non-corrosive. Acids can be neutralized with lime, limestone, or sodium bicarbonate. Bases can be neutralized with weak acids. These chemical reactions may result in a non-hazardous by-product that can be disposed of easily. Neutralization reactions give off heat and must be done slowly in a controlled manner by trained and experienced personnel. Chemical oxidation. Some chemicals, like cyanide, are easy to break down with oxidizing materials. Technically qualified personnel, who understand the reaction path, should supervise these activities. Solidification. Solidifying liquid or gel contaminants can enhance their removal by physical methods. Generally, solidification is used to remove moisture and bind the chemical so it will not be released from the solid. Disinfection/sterilization. Chemical disinfectants are a practical means of inactivating infectious agents. Unfortunately, standard sterilization techniques are generally impractical for large equipment and for PPE.",
        "Wet versus dry decontamination": "Wet processes may be used when the PPE worn has sealed seams. Wet decon on sewn seam suits will transport contamination into the suit and potentially contact the skin. In general, wet decon should be reserved for situations where: sealed seam garments are worn, the chemical presents a severe skin corrosion hazard, casual contact by the decon crew may be hazardous to them, run-off can be contained. Dry decon involves the careful and controlled removal of garments and can be a very effective technique. This method is preferred for disposable garments when chemicals are not pervasive and have low skin contact hazard.",
        "Decontamination implementation": "The initial technical decontamination plan should be based on a worst-case scenario. Decontamination procedures must be developed, communicated to personnel, and implemented before any personnel or equipment enters areas on site where the potential for exposure to hazardous substances exists (i.e. the hot zone). Technical decontamination processes can be determined by using the product\u2019s MSDS or other chemical reference material. The hazmat technician should be able to assist with basic chemical information as to which decontamination process would be most effective. Decontamination procedures must provide an organized process by which levels of contamination are systematically reduced. The process must include: standard operating procedures to minimize personnel contact with hazardous substances or with equipment that has contacted hazardous substances, decontamination of all personnel exiting contaminated areas, monitoring of all decontamination procedures by the safety officer to determine their effectiveness. When such procedures are found to be ineffective, appropriate steps shall be taken to correct any deficiencies.",
        "Personal protective equipment in decontamination area": "The decon corridor can be set up without wearing any PPE due to the fact that the warm zone is not contaminated until the decontamination process begins. The level of PPE worn by decon team members is related to what the entry team is wearing. Decon team members coming into contact with the contaminated entry team members should be in a level of PPE no more than one level below the entry team.",
        "Decontamination location": "Decontamination must be performed in geographical areas that will minimize the potential for exposure of personnel and the environment. Multiple locations can be used for performing decontamination. Indoor locations such as gymnasiums, swimming pools, and warehouses afford privacy, the potential for heated water, and environmental control. Disadvantages of indoor locations include lack of available space, air-borne concentration of the agent, limited ingress/egress and equipment access. Outdoor locations provide ample space for equipment and personnel, air-borne dilution, and shower run-off into a storm sewer. Disadvantages of outdoor locations include the potential lack of privacy, weather dependency, and potential access only to cold water. The size of the decontamination area will depend on the number of stations in the decon procedure, overall dimensions of work-control zones, and the amount of space available at the site. Whenever possible, it should be a straight path. All decontamination must be completed prior to any personnel or equipment entering the cold zone. The decontamination area should be conspicuously marked with signs for entry and exit.",
        "Rapid mass decontamination": "Rapid mass decontamination occurs immediately upon arrival to an incident where multiple patients are symptomatic. It is performed by incident responders trained to the awareness or operations level. Rapid mass decon can be achieved by \u201cwetting down\u201d patients as they walk past a fire engine. Decontamination solutions and systematic washing are not necessary at first. Dry decontamination should be considered as an alternative.",
        "Mass decontamination": "Mass decontamination is considered an extension of the rapid mass decon operation. As a decontamination operation develops, additional arriving resources provide the incident commander with the ability to control patients and direct their movement through decon to triage and treatment. The complexity of a decon operation also will grow from a single handline or clothing removal area to a well-coordinated decontamination corridor with multiple handlines and containment areas. Water pressure should not exceed 50\u201360 psi and the exposure duration should be approximately 3 minutes. Additional considerations should be made to accommodate separate corridors for males and females as well as ambulatory and non-ambulatory victims. When non-ambulatory patients are carried on stretchers through such flooded corridors, special attention should be directed to airway protection as supine patients on their backs are at risk of aspiration or near-drowning when large volumes of water are encountered in this position. Multiple divisions and groups will develop and the patients who have not left the scene already will be looking for direction. Assigning a decontamination officer will provide patients and firefighters with clear direction in a chaotic environment.",
        "Medical decontamination": "The decontamination of a patient is performed in a series of steps beginning with clearing the victims out of the hot zone as soon as possible and initiating the triage process in a safe environment. Triage for decontamination should be based on the victim's proximity to the release site: first those exposed to vapors or aerosols, followed by those exposed to liquid forms, and then those with severe complaints or injuries. It should be expected that some persons who were not in the immediate danger area nor are suffering any apparent ill effects will still seek medical assistance out of fear. Clothing removal prior to showering is recommended for chemical decontamination and may remove 80% of the secondary risk. This may require cutting clothes off non-ambulatory patients to minimize cross-contamination. Cutting down the center of the victim\u2019s clothing and rolling the clothing toward the sides is a generally accepted practice for minimizing contamination spread; removing contaminated clothing overhead can increase the harm risk. Removed clothing and valuables should be \u201cbagged and tagged\u201d and placed in a secure location pending an eventual decision as to whether the belongings can be returned to the victims with specific cleaning instructions. If a criminal act or terrorist attack is suspected, all clothing and valuables should be considered evidence. Law enforcement personnel presence in the decontamination sector is desirable to protect the chain of evidence. If mass casualties are involved, an initial or \u201cgross decon\u201d shower before clothing removal, especially for liquid exposures, will help to reduce toxic exposures. Patients should then proceed through a standard patient decontamination process as soon as additional resources are organized. Water used for decontamination should be high volume, low pressure, and tepid if possible to avoid shivering or skin vessel vasodilation. Ambulatory patients will often be able to perform decontamination themselves but need to be directed to wash themselves in a systematic head-to-toe manner. Non-ambulatory patients will require staff assistance. Non-ambulatory patients should be decontaminated in the following order: first airway, then open wounds, and then front and back from head to toe. The rinse-wash-rinse cycle should be continued until desired cleanliness is achieved. The process usually requires 3\u20135 minutes for non-viscous substances and 5\u20138 minutes for viscous or unknown agents. Only radiation detectors are currently available to screen for cleaning effectiveness in many communities. More complex meters and monitors may not be available at the decon site during large-scale events. Thus, in most cases \u201cclean as clean can be\u201d is usually determined by the clinical judgment of the decon team members. Decontamination protocols should address the possibility of pediatric patients requiring decon in addition to other patients with special needs, such as a patient with colostomies, deaf or hard-of-hearing patients, and poorly ambulatory patients using walkers or wheelchairs. A towel and redress supplies (clothing and foot covers) should be available for all victims once the decontamination is complete. The issue of water-reactive chemicals causing exothermic reactions during water-based decontamination is usually not an important consideration. Limited medical interventions may be required before the decontamination procedures commence, depending on the medical condition of the patient. Life-saving interventions implemented prior to or while awaiting decontamination should be limited to airway support, hemorrhage control, and administration of appropriate antidotes. Once decontamination is complete, the patients should proceed to the cold zone/support zone where they should be medically assessed and provided with medical treatment. Transport to the hospital may require personnel in an appropriate level of PPE. The receiving facility should be given an early notification of the incident along with periodic situational updates, including the identified agent or agents and type of decontamination being implemented.",
        "Additional considerations": "Specific statements regarding the numbers of ambulatory and non-ambulatory patients that can be decontaminated are actually estimated numbers. No models exist for gas, liquid, or vapor contamination that are consistent, reproducible, and measurable. Evidence to support what constitutes complete or even adequate decontamination does not exist. With multiple victims and responders, decontamination may be accomplished on a large number but probably not all victims before some begin to leave the scene. While serving the greatest number of victims reduces morbidity and mortality due to the likely agents and degrees of exposure, this fact reinforces the importance of first responders advising hospitals early and often regarding the actions taken at the scene to minimize the relocation of the disaster. It is often difficult to ascertain when to rotate staff performing decontamination procedures, especially when in Level B or C personal protection. Fatigue and heat exhaustion are risk factors, and it is sometimes unclear when staff need to be rotated out for rehabilitation. Thus, the safety officer and hazmat branch director must take into account temperature, humidity, and rigor of the activities being undertaken when setting up a rotation schedule.",
        "Technical decontamination": "Technical decon will be set up by the hazmat team to safely remove contamination from the PPE worn by the entry teams. They will also decon their tools and equipment in this area. Technical decontamination can be set up and staffed by operations-level responders. To prevent the spread of contamination, methods to reduce and remove contamination must be developed. These methods and procedures must be established before anyone enters the hot zone. The best way to eliminate problems with decontamination is to prevent or minimize contamination from occurring in the first place. Once decontamination procedures have been established, all personnel who may require decontamination must be given precise instructions. The safety officer should regularly inspect the process to determine its effectiveness. The time it takes for decontamination must also be ascertained, since personnel wearing SCBAs must exit their work area with sufficient air to walk through the decontamination process. In general, there are two types of processes: wet and dry.",
        "Personnel decontamination procedures": "The decontamination process should consist of a series of procedures performed in a specific sequence. Outer, more heavily contaminated items (e.g. boots and gloves) should be decontaminated and/or removed first, followed by the decontamination and removal of inner, less contaminated items of clothing. Each procedure should be performed at a separate station in order to prevent cross-contamination. Stations should be separated physically and should be arranged in order of decreasing contamination, preferably in a straight line.",
        "Decontamination of decon equipment procedures": "Decontamination of equipment, materials, and supplies is generally selected based on availability, and ease of decontaminating the piece of equipment versus disposability. Most equipment and supplies can be easily procured. For instance, soft-bristle scrub brushes or long-handle brushes are used to remove contaminants. Water in buckets or garden sprayers is used for rinsing. Large galvanized washtubs or stock tanks can hold wash and rinse solutions. A child's wading pool can also be used for employees to stand in when being decontaminated. Large plastic garbage cans or other similar containers lined with plastic bags are convenient for storing contaminated clothing and equipment. Contaminated liquids can be temporarily stored in metal or plastic cans or drums. Other gear includes paper or cloth towels for drying protective clothing and equipment.",
        "Emergency decontamination": "Emergency decon may be required when a responder dressed in PPE has a suit breach or suddenly becomes ill or injured. Hazmat teams are required to establish a means of emergency decontamination prior to entry unless there is an imminent rescue. Emergency decontamination can be handled easily by an engine company, but must be assigned early. Emergency decon should also be used for any first responders who are exposed to an undesired agent. In this situation the responders should be promptly transported to the technical decon corridor where they are washed quickly with soap and water before being taken to the warm zone\u2013cold zone border, where they are removed from their suits and receive required medical attention. If the technical decon area is not immediately accessible, then this emergency decon can be accomplished by using copious amounts of water from a nearby hose, shower, or pool.",
        "Medical monitoring of response personnel": "Medical providers including EMS physicians may play a critical role in maintaining the health and safety of response personnel on the scene of a hazardous material emergency. OSHA Standard 29 CFR 1910.120 mandates medical monitoring or surveillance for all hazmat team members. Many people may think that this is merely the act of taking a pulse and blood pressure before the entry team enters the hot zone. While this part is true, the medical monitoring of a hazmat team is actually an in-depth, four-part process consisting of a baseline physical exam before the member joins the team, annual physical exams while the member is part of the team, an exit physical when the member leaves the team, and any exposure-specific physicals or follow-up exams that are deemed necessary. These four steps are in addition to the medical monitoring done at the incident scene. The baseline physical includes a detailed, comprehensive health history that includes any previous chemical exposure. A complete physical examination is also administered that includes vision, hearing, and laboratory blood work. A comprehensive metabolic profile, urine analysis, heavy metal testing, and complete blood counts should be included in the blood work. These tests are used to obtain baseline numbers for future reference should the member undergo a chemical exposure. Electrocardiograms and chest x-rays should also be taken. The annual physical is a repeat of the initial baseline physical. It is used to update the medical history of the member as well as to verify the member\u2019s fitness for duty. A key role of medical personnel is the monitoring of personnel during an incident. The NFPA 1584, Standard on the Rehabilitation Process for Members during Emergency Operations and Training Exercises, provides fire and EMS personnel with guidance on how to establish and operate a rehabilitation program. It should be noted that this standard is based on consensus more than on evidence. Critical components addressed in the guidance are relief from climatic conditions, rest and recovery, cooling or re-warming, rehydration, calorie and electrolyte replacement, medical monitoring and treatment, member accountability, and release from rehab. A monitoring station staffed with medical personnel familiar with their roles and reporting to a rehab officer should be established in a safe and secure location. Chairs and cots should be available along with access to medical equipment and light healthy refreshments and fluids. Medical monitoring activity includes conducting pre- and postentry evaluation of personnel wearing PPE. Each individual should have an assessment consistent with the agency\u2019s SOG. Traditional examination elements include pulse, blood pressure, respiration, pulse oximetry, and body weight. Heat-related injuries are one of the biggest concerns that hazmat members face during entry into the hot zone. This is especially true when dealing with longer incidents or incidents where higher temperatures are involved. Brief information on current medical conditions and medications should also be sought and recorded along with the other data on a medical record for each responder, which then becomes part of his/her department medical record. Postevent, an exposure-specific physical can be given whenever a member is exposed to a chemical, whether symptoms are present or not. This includes a routine physical examination and laboratory tests geared toward the specific chemical involved in the exposure. The member also receives an exit physical when his or her assignment on the hazmat team comes to an end. This is also a repeat of the initial baseline physical and serves as an endpoint in terms of monitoring the member for possible chemical exposure. It helps to determine if later medical claims are related to his or her service on the hazmat team.",
        "Conclusion": "Working on an incident involving hazardous materials involves significant challenges and health threats to public safety personnel. A critical component of the response is medical support for personnel and the incident. The importance of having properly equipped and trained medical personnel conducting medical surveillance and managing on-scene emergencies involving response personnel or injured civilians has been reinforced by real-world events. Ensuring that the medical requirements of these types of incidents are met requires that the roles and responsibilities of personnel providing medical support be defined along with response SOGs. These SOGs should address PPE, medical monitoring practices, medical and technical decontamination, medical support, and treatment procedures."
    },
    {
        "Introduction": "Whether engaged as an on-scene EMS physician, as a practicing emergency physician, as a medical educator-researcher, or working in other capacities, an EMS system medical director may be called upon to interview with the news media, address public officials, or speak to community leaders. In addition to topics related directly to their rapidly evolving discipline, EMS physicians, as highly visible clinicians, often are solicited to render opinions about general medical issues facing the community, ranging from disaster management and environmental challenges to unusual disease outbreaks or day-to-day EMS incidents that become newsworthy or controversial. Often, the EMS physician must do this in a public forum such as a city council meeting or in spontaneous interviews on scene with the news media. In addition, due to its closer proximity to the world outside the hospital and the very public nature of many emergency medical events, the active EMS scene or the emergency department (ED) often becomes a ready focus for public information. Also, because they often constitute the medical leadership for a local community public service, EMS physicians also may become recognized, reliable, and readily accessible sources of medical information for the public. This accessibility often is amplified during weekends and nights when typical medical facility sources and their public information officers may not be as rapidly found. Because of these augmented opportunities for dealing with the media or providing public speaking, the EMS physician should develop special competencies in this unique political and very public arena of medical practice.\n\nThe primary purpose of this discussion is to provide EMS physicians with certain tools that may help them not only to optimize their public speaking skills in this unique environment but also to improve their effectiveness in delivering important public communications in general. More than ever before, with the various evolving challenges in the current world, such as diminishing health care resources, unforeseen epidemics, recurring risks of natural disasters, threats of terrorism, and potential scientific or procedural advances in emergency care, competency in public speaking becomes an imperative skill.\n\nWhen a crisis creates a widespread fear-generating sociological environment, trusted risk communication becomes a critical function for those practicing emergency medical care, particularly when medical threats predominate. During such crises, the EMS physician may have a unique responsibility for accurate and fact-based medical risk communication, not only to public officials but often to the public at large. This becomes a very special responsibility that other physicians are less commonly called upon to provide. Therefore, this special competency will be required more and more as EMS and disaster systems continue to mature in the future and particularly now that EMS has become a formal subspecialty recognized by the American Board of Medical Specialties. At the same time, these special competencies also will make EMS physicians more effective in their day-to-day communications and routine interpersonal interactions.",
        "Perspectives and caveats about public speaking": "Basic assumptions\n\nThe recommendations made in this chapter are stated with the consideration of some basic assumptions: that the EMS physician/public speaker is the appropriate spokesperson, and that he or she has received clearance to make public statements from his or her supervisor or applicable public information officer (PIO), either prospectively or just prior to the interview. Particularly during public health threats or major incidents of regional or federal significance, coordination with the jurisdictional authorities and their PIOs is not only wise to avoid confusing messages to the public, but also additional insights can be gained through those preinterview communications.\n\nLikewise, in cases involving specific patients, one should also make sure that the patient and/or the patient's family has been advised of any public comment. They should be apprised of and agree to the anticipated statements to be made as well as the likely answers to probable media questions concerning the patient's situation, especially those that may go beyond the typical disclosures that conventionally fall within the \u201cpublic domain.\u201d Although non-specific communications such as \u201ca 43-year-old man received a severe injury and is in critical condition\u201d may be public domain, generally it is still wise for the public speaker to prepare the related parties for the information to be disseminated in this era of patient privacy.\n\nMost patients, and families in particular, are very reluctant to have any information disclosed. Therefore, it is helpful to point out to them that, in most events that have drawn media attention, the media will report \u201csomething\u201d and that the proactive physician spokesperson may be able to help control and minimize the effect of whatever information eventually is disclosed to the public. It is important to recognize that, in today\u2019s world, the media are often more reactive when there is withholding of information. Analogous to a puppy that pulls even harder on a sock when the sock is being pulled away, the more one withdraws from the media, the harder they may look into the issue. More specifically, if they sense an attempt to conceal facts, they are more likely to pursue them more aggressively.\n\nIn that respect, no matter what public speaking challenge one encounters, it is crucial that the EMS physician approach the situation as a sincere patient advocate above all else. Self-promotion, insincere advocacy, or indiscriminate information dissemination soon becomes obvious to news media personnel, colleagues, and other patient advocates. Recognizing and appreciating these ethical and sociological concepts, one can become a much more effective, sought-after, and long-lived public speaker. Those simply seeking good \u201cPR\u201d will rapidly be seen as self-serving and not as public servants. Those sincerely promoting patient advocacy, public education, and public well-being, first and foremost, will be seen as true public servants and, in turn, good \u201cPR\u201d will ensue naturally.",
        "The challenges of bite-speak": "One of the more common public communication challenges of modern life is the task of finding the right \u201csound bite.\u201d With the evolution of mass media network teams, worldwide internet communications, and highly reactive information management systems, a massive amount of information is available to be delivered to millions of people. With the expanding availability of information and information sources, and with a growing competitiveness between news organizations as well as a \u201cfast-food\u201d society that prefers \u201cget to the point\u201d news, individual news stories are becoming \u201cbullets\u201d of information. In addition, the news media is a business. Air time or columns of print must be trimmed and \u201cbudgeted.\u201d\n\nThe continuing success of printed periodicals such as USA Today has been, in part, due to \u201ceconomies of scale,\u201d in terms of circulation, access, and \u201cefficiencies\u201d of individual articles. Likewise, many cable news organizations also cater to societal demands for bulleted information. In terms of easy access, the more recent proliferation of internet-based news sources now allows a person riding in a taxi in Cairo to get real-time scores of a professional sports competition in California on a handheld phone device or minute-by-minute election coverage on an office computer. The younger adult population primarily uses these messaged events as a primary source of news and information.\n\nEven more traditionally, the typical half-hour TV news program is actually only 10\u201315 minutes of news, once one excludes commercials, weather, and sports. To deliver 20 or more news items within that half-hour broadcast, the news producer for that show must keep each story extremely short. Also, stylistically, most network affiliates will still run at least two or three \u201cpackages\u201d per show, even during a late evening broadcast. A package usually is a more extended story including a taped segment provided by a reporter. Typically, the package is introduced by the reporter doing a \u201clive shot\u201d from some on-site location or from a desk in the newsroom, followed by the main videotaped story and, in turn, a departing live closure from the reporter, who may engage in some parting chat with the broadcast anchor. Although a package can run longer, it may be as short as 90 seconds and it still needs to include the story set-up, graphics, and several interviews as well as the live introduction and closure. This may leave only a few seconds for each of the individual interviews and less time for other news items. If a quarter or more of the news time is dedicated to packages, then each of the many other news pieces will be even shorter. Therefore, the other 15 (or more) items may be presented in much less than a minute each in formats such as a \u201cvoice-over\u201d (voice over tape), in which an anchor reads the narrative while videotape is run, or a \u201cV-O-bite\u201d (voice-over with a sound bite), in which a short interview with a relevant person is inserted.\n\nThe bottom line is that interview sound bites must be only seconds long, particularly if there is a need for a \u201cpro\u201d and \u201ccon\u201d position format. In the end, one could have been interviewed by a reporter for 5 minutes but what is finally aired, be it on radio or TV, might be only 7\u201310 seconds. Thus, one should choose one\u2019s words wisely and economically and, most importantly, one should stay focused on the overriding message to be delivered.\n\nLive interviews in certain broadcasts may run longer and may even extend for 2 or 3 minutes, whether on TV or radio. Nevertheless, typically one can expect 2\u20134 questions. Although the answers may not have to be limited to the 10-second sound bite, they still should be kept relatively brief (under 20 seconds) because listeners often fatigue in terms of attention span when the answers get lengthy. Brevity and \u201cbullets\u201d do it best.\n\nWhereas brevity and \u201cbullets\u201d are necessary for media interactions, they are just as applicable to other public speaking settings. For example, city council interactions only may allow for a minute\u2019s communication in a less structured presentation. Therefore, one must be prepared to get directly to the point or present relevant arguments cogently and briefly. This concept should not be a surprise to anyone who has sat through lengthy city council or legislative sessions in which hours of tedious comments are made and attention spans grow shorter and shorter throughout a long day of \u201clistening.\u201d\n\nTherefore, the sound bite may not be just a \u201cnecessary evil\u201d of modern society, but also an important format for communication in which one is challenged to make a point without short-changing accuracy in order to achieve the communicative objective.",
        "The effective sound bite": "Most public communications from EMS physicians are informational, but some also may need to address a point of contention. In the former case (informational comment), a simple (discussed later in more detail) may be effective. A different strategy, however, may be needed for a persuasive\u201d position. For example, if called upon to comment on a new helmet ordinance for youthful bicycle riders, the public speaker with medical expertise is more effective if he or she can anticipate the opposition\u2019s point of view. In theory, the proponents of the proposed ordinance already should have articulated and disclosed their rationale and supporting arguments. Generally, these have been cited in previous briefings. Therefore, it would be less effective to focus on the informational\u201d sound bite (e.g. \u201cUp to 90% of all serious head injuries to children can be prevented by bicycle helmets\u201d). Rather, one might want to focus on a strategy of defusing the opposition with a preemptive counterargument.\n\nIn the case cited, the EMS physician first may want to ascertain the opposition\u2019s arguments from someone such as an aide of the council member supporting the ordinance. If it turns out that the \u201ccon\u201d arguments consist of \u201cwe can\u2019t impose a financial impact upon families\u201d or \u201cwe can\u2019t interfere with freedom of choice,\u201d the EMS physician may want to recognize those concerns (at the council meeting or in interviews with the media) and, when appropriate, even address them somewhat sympathetically. For example, in the public statement to be made, the medical expert might say, \u201cWhen I first heard about this ordinance, I had a problem with the concept not only because we could be seen as \u2018forcing\u2019 a safety habit upon people, but also because we would be imposing a finite cost upon families less able to afford them. But, as I really looked into it more and more, I became convinced that it makes tremendous sense, both medically and economically.\u201d\n\nThat \u201csound bite\u201d alone could be the main statement for the city council. In fact, more than likely, it will invite further factual comment for the inquiring council or, subsequently, the media. The follow-up then can be the \u201cinformational\u201d sound bite in which the medical expert states: \u201cThe data are clear: up to 90% of all serious bicycle-related head injuries in children can be prevented by the children wearing a bike helmet. In a way, it\u2019s one of the best \u2018vaccinations\u2019 against such disabling injuries that we have \u2013 and we have no hesitancy about requiring other vaccinations for our children. Also, for every dollar we spend, we save several dollars in health care costs. So for an incremental additional cost to consumers already buying a bike, we not only protect the community from additional burdens in health care costs, but, more importantly, we are ensuring the safety of our children.\u201d\n\nThe media may or may not include the last part of this statement, but they may still use the information as part of their own narrative. Likewise, at the city council meeting, there probably is just enough time to include all of these remarks. In the end, the obvious points are addressed, but so are the counterarguments if they are prioritized and discussed initially.\n\nThree other points should be made about this particular statement to the city council. First, the statements about \u201ccost\u201d may be considered important in helping to defuse the specific opposing position, especially in this particular setting (the council meeting or, analogously, in a hospital boardroom when dealing with some cost-effectiveness issue). Such a tactic, however, may not be as appropriate for the independent media sound bite. In fact, sophisticated media reporters know that the public may not relate to \u201ccost-savings\u201d as much as to safety, and so they may not air or print that initial statement about the ordinance making medical and economic sense. For them the informational sound bite is most important. Nevertheless, in this particular setting, where freedom of choice and taxation anxieties can be concerning, the challenge should be anticipated and politely preempted to help to recruit the undecided council votes.\n\nSimilarly, it may be unwise to bring up the \u201cnegatives\u201d in the media interview because some people may only hear those points during a brief sound bite and not one\u2019s actual message, thus backfiring on the purpose at hand. Many media consultants even make this a hard rule \u2013 that one should not restate the negative issue if a reporter states it when asking a question. For example, if a reporter asks if it is possible to get a disease by doing CPR, it may be less strategic to reply, \u201cWhile it is always possible to catch a transmissible disease, it is unlikely, and the person you are most apt to save is someone you know or love.\u201d The first phrase may take hold in this instance and that is what the listener actually takes home. Accordingly, even in this day of compressions-only\u201d CPR, one might simply reply: \u201c70% to 80% of CPR cases occur in and around the home and another 10% to 15% in the workplace; so it\u2019s going to be someone you know or love \u2013 and doing CPR may be their only hope?\u201d The persuasive statement may be useful in some circumstances in which negatives should be addressed, but it may be unwise to do so in short media sound bites.\n\nThe third point to be made is the issue of what to say on each side of the \u201cbut\u201d in a statement. Take for example the verdict yielded by the judge on a typical prime time television drama. During the judicial verdict, the judge usually says something like, \u201cThe acts committed here were unconscionable and they go against every ethical and moral substance in my soul. But, the laws are clear in terms of the procedures for proper evidence collection and these procedures simply were not followed. Therefore, I am bound to rule in favor of the defendant.\u201d\n\nThe key concept here is that the counterargument starts with the sympathetic statement for the state (and victims/victims\u2019 families of the crime being judged). The true crux of the conclusions comes with the phrases following the \u201cbut.\u201d Similar considerations can be seen in day-to-day personal interactions. Take for example statements like: \u201cI\u2019m very sorry I snapped at you \u2013 I apologize, but I\u2019ve been under a lot of pressure lately\u201d or \u201cOh, I really would have loved to be there, but already have something scheduled for that evening.\u201d Both of these statements are more likely to be seen as insincere or, at best, polite responses when one considers what phrases come after the \u201cbut.\u201d Transposed, the statements translate more sincerely: \u201cI\u2019m sorry, I\u2019ve been under a lot of pressure lately \u2013 but that\u2019s no excuse to snap at you \u2013 I apologize\u201d and \u201cOh no, I already have something scheduled for that evening that I can\u2019t get out of \u2013 but I really would have loved to come to your place!\u201d Therefore, in the counterargument or persuasive sound bite (or any other public statement), one should appreciate how to transpose the \u201cpre-but\u201d and \u201cpost-but\u201d phrases.\n\nAs in the case of persuasive statements, for all the same reasons, the simple \u201cinformational\u201d message has to be succinct. As mentioned previously, a \u201cthree-part format\u201d might be recommended. First, the sound bite might start with a definitive word or phrase such as \u201cAbsolutely!\u201d or \u201cThere\u2019s no doubt about it!\u201d or \u201cIt depends!\u201d or (as in the previous example) \u201cThe scientific data are clear!\u201d After such \u201cdefinitive\u201d openers, then there should be a short core explanation such as: \u201c90% of all serious head injuries can be prevented by bike helmets.\u201d Finally, a parting resolve (which may or may not be cut by media editors) would be provided, such as: \u201c\u2026 in essence, it\u2019s one of the best \u2018vaccinations\u2019 against injury that we have!\u201d The exclamation points are placed here purposefully to emphasize the need for an upbeat delivery of those opening and closing words.\n\nIf one measures the time required for such a sound bite, it should be about 10 seconds or so. Take for example another sound bite about CPR. If asked whether or not it is important for everyone to learn CPR, the EMS physician might respond: \u201cAbsolutely! (opening exclamation) There\u2019s no way a professional rescuer can routinely reach our loved ones in the 4 or 5 minutes in which permanent brain damage can occur if their heart stops beating (core explanation). So it\u2019s up to each one of us to buy them precious time by knowing CPR!\u201d (parting resolve). That entire sound bite is just about 10\u201312 seconds, if executed well. The video editors may cut the parting resolve, but if said immediately, enthusiastically and with a sincere conveyance of advocacy, it will most likely stay in the final cut.\n\nA minor variation on this theme is to first answer the question asked during the opening exclamation. For example, if asked, \u201cIs it important for everyone to learn CPR?\u201d, the answer might be, \u201cIt\u2019s absolutely critical for each one of us to know CPR \u2026, etc.\u201d This approach can be highly effective in terms of reinforcing one\u2019s point, depending on the question. Still, just using \u201cAbsolutely!\u201d can work if the question is clear, particularly if brevity is needed.\n\nFinally, when the interview drifts, it is up to the \u201cpublic educator\u201d to keep it on track. Using the previous example, when an interviewer asks: \u201cWhat about the chance of getting AIDS or some other infectious disease?\u201d, the interviewee should stay on the mark and state: \u201cRemember: 70% to 80% of the cases requiring CPR occur in and around the home \u2013 and another 15% in the workplace \u2013 it\u2019s likely to be a family member or friend you will be saving!\u201d (Note: this takes about 10 seconds). Again, the suggestion here is not only to avoid repeating the negative aspects of the question but also to reemphasize to the audience that your own family members are the ones you most likely will be able to help if you learn CPR (your main point overall). In other words, if the question involves words that might flag something that is only a relative concern and a low risk, avoid repeating those words and focus on the communicative objective you wish to make. If there is a true and concerning risk (e.g. drug side-effect), however, it may be seen as disingenuous not to respond directly to the question. So a way to handle this problem may be to respond: \u201cLike everything else, there\u2019s always some risk involved (opening exclamation) but here the alternative is clearly worse. If it was my family, there\u2019s no question what I\u2019d do (parting resolve).\u201d",
        "Dealing with print versus electronic media": "Although there is a recent trend toward internet-based news transmission, the majority of older Americans in particular get their news information from the electronic media (radio and TV). Learning how to deal with the electronic media, therefore, should become part of the EMS physician\u2019s repertoire of expertise; however, printed (and internet-based) media can be of benefit as well. Printed media or printouts of internet-based interviews provide a permanent, easy-to-transmit copy that can be reproduced and disseminated rapidly as an attached email file or scanned into a transmissible computer file that can be shown in presentations. Also, print media often drive electronic coverage in trend reports and accompanying blogs. TV and radio \u201cassignments\u201d editors and researchers often tear out stories from newspapers or download printouts of internet-based newspaper reports that encapsulate the focus of information. In turn, they can pass on these \u201cprinted\u201d materials (or web-based transmissions) to their reporters for follow-up or even send them ahead of time to interviewees. With hand-held phones receiving this information, this allows the prospective electronic (radio/TV) media interviewee the opportunity to shape his or her response to an evolving story even better. It also allows the interviewees and interviewers alike to rapidly catch up on the issues being examined. Often, the print reporter already has distilled the latest information and gotten the interviews directly from researchers or the source of the story. At the same time, inaccurate information can also be passed along and propagate statements from others who are assuming that information is true. Initial reports of deaths or injuries at an incident may be exaggerated or underestimated accordingly. Therefore, the public spokesperson should always appreciate that caveat and coordinate information with official channels to ensure the public is given consistent information that can be trusted.\n\nIn general, print stories (newspaper, internet, magazine interviews) give prospective interviewees more time and information to assimilate their reactions to the subject at hand. Also, the tear-outs, printouts or PDFs can be filed away for future use or sent on to potentially interested parties and stakeholders, including elected and appointed public officials. In addition, important reports that relate to or affect one's own operations can be sent along to appropriate managers. Likewise, positive stories (e.g. about the EMS system or paramedics) can be disseminated as an \u201cobjective\u201d (i.e. someone else\u2019s) viewpoint about the performance of the emergency care staff members. Whether the recipients are bosses, city officials, or other \u201cstakeholders\u201d (including the emergency personnel themselves), the print story is readily accessible and readily transmissible.\n\nOne potential downside of print media, however, is that reporters can paraphrase the interviewee's comments because they are taking shorthand notes (unless they are directly recording it). Occasionally, the quotes may be imperfect. In contrast, with electronic media, the words that are broadcast are obviously the interviewee's actual words. Although they may be taken out of context or inappropriately edited, they will still be the actual words of the interviewee.\n\nTo that end, it is not entirely inappropriate, at the end of the interview, for the interviewee to ask the print media reporter to call back (after writing the story). The object here would be to hear the quotes that might be used and check them for accuracy, and also to see if the reporter really understood the point that needed to be emphasized. First, this means that the EMS physician must be readily available at the \u201con deadline\u201d time for the possible \u201cread-back.\u201d Second, when doing so, the interviewee has to understand that not all print reporters are entirely receptive to this request. Therefore, it is best to understand that such a request should be made in the spirit of the interviewee's limitations, not the reporter's. For example, the interviewee might say, \u201cI know I talked really fast \u2013 do you want to go over any point now or call me back later after you've had a chance to assimilate all of this stuff? In fact, I'd love it if you call me back to see if I was successful in articulating my points well and you can also double check your facts with me if you want.\u201d\n\nConsidering this concept, one also should budget time in an interview session to go back over anything that might need more detail. It would be advisable to be patient and ask if the reporter would like to go over his or her notes to see if anything needs to be discussed in more detail or modified. This is reasonable because most interviewees do, in fact, provide their facts and comment rather rapidly. Therefore, in addition to being available for deadlines, one should also switch gears with print reporters (talk slower) and reiterate certain points if they are key. Reporters want to get it right, but deadlines are often less forgiving.",
        "News conferences": "Traditionally, people have held \u201cpress conferences\u201d (also called \u201cmedia conferences\u201d and \u201cnews conferences\u201d) to announce new programs or initiatives. If responsible for setting up a news conference, the EMS physician and fellow PIOs should consider making it no longer than 10\u201315 minutes in terms of formal statements, and even shorter if there are not multiple speakers. Generally, the number of speakers should be limited to three or four at the most. Questions may be taken for a few minutes after the formal statements, but then more directed interviews with the individual speakers (or others), after closing the formal statement segment, should be offered as well. Also, a demonstration or other visuals are very helpful prior to those individual interviews. Photographers especially appreciate visuals! Formal statements should be limited to 2 minutes per speaker at most, if not shorter (e.g. 30\u201345 seconds). They should avoid obvious redundancies, but they still can be repetitive from different perspectives and refer back to each other to make statements complementary. The individual speakers should represent different sectors of stakeholders and should show broad-based support (see outlined example that follows). Prior coordination is therefore very important to ensure that each topic is a \u201cfresh perspective\u201d and not just a repetition of the same comments. For example, a news conference to announce implementation of a community-wide automated external defibrillation (AED) program might involve the following.\n\n\u2022 \u201cMaster of Ceremonies\u201d (a person who introduces everyone and fills in the very brief \u201ccolor commentary\u201d between speakers). In this case (about AEDs), this person could be the physician in a leadership position at EMS, a city official (mayor/city manager), an American Heart Association (AHA) representative, or a PIO or even a celebrity personality.\n\n\u2022 \u201cExpert Speaker\u201d (a person who gives the overview, facts, and rationale for the initiative). In this example, this speaker could be a cardiologist or EMS physician expert or an AHA representative who can provide the facts (number of weekly deaths in that community due to ventricular fibrillation, survival rates declining with each minute of delay, ease of use, etc.).\n\n\u2022 Possibly a \u201cCounterargument Expert\u201d (a person who preemptively addresses any potential opposition by providing an anticipatory counterargument). In this example, it might even be a lawyer. For example, if it is perceived that some employers are concerned that they may carry some liability if they install AEDs at their worksites, the lawyer addresses this perception by stating that today there may be more liability if they do not have one. He also states that this fact is the reason why he has an AED at all of his law firm\u2019s regional offices.\n\n\u2022 \u201cI'm a Good Example Person\u201d (a person who was saved or helped by the interventions or programs being discussed). In this example, a person saved by an AED (and maybe the person who operated the AED) can \u201cbear witness\u201d to the value of the initiative.\n\n\u2022 The How You Do It Person learn more about the process or become involved with the process being discussed). In this case, it can be someone who provides a clearinghouse number which the public can call to find out how to start an AED program and obtain a device and the respective training.\n\n\u2022 (this is the visual for the cameras). In this case, it could be a mannequin-CPR demonstration or a child using an AED. One could also pick a person at random from the audience to operate the machine.\n\nA media advisory sent by email and/or fax a day or two ahead of time should follow the very simple \u201cwho, what, when, and where\u201d format and be limited to one page. If necessary, a second page with more details and background can be attached if it adds indispensable information. Keep in mind that most information (media packets) can be provided at the actual news conference.",
        "Ten golden rules for public speaking or dealing with media": "Whether providing a \u201clive\u201d question-and-answer session for a radio broadcast, a state legislature address, or a taped TV interview, there are ten easy-to-remember axioms to keep in mind that should guide one\u2019s approach to each public speaking event.\n\nRule #1: Always tell the truth \u2013 but do it in a 10-second sound bite\n\nInformation is highly regarded, but false or inaccurate information is scorned and never forgotten by the media, the public, public officials, and even one\u2019s colleagues. In addition to the MD degree and expertise in many fields of medicine, credibility is the EMS physician\u2019s most important asset.\n\nSometimes, however, a fine line must be negotiated between the \u201ctruth\u201d and the \u201cwhole truth.\u201d For example, there are ethical issues and even government security concerns that must be taken into consideration. In the case of a famous person\u2019s sudden illness, the media will no doubt want to know why the celebrity was rushed by ambulance to the hospital. This scenario becomes an ethical concern. Aside from the family\u2019s or patient\u2019s reluctance to have anything said to the media (patient confidentiality issues), there is also the concern that information that gets out through indiscreet persons will not be accurate or will lead to inappropriate speculation. Therefore, a balance may need to be struck and, in some communities, the EMS physician may be the person who has to do so. Since something will need to be said, it is best done by a credible, trusted, patient-oriented spokesperson, and particularly one who can tell the truth but also knows where to draw the line on public disclosures.\n\nTake the case of the celebrity who has a probable gastrointestinal bleeding heralded by melena and severe hypotension, but also accompanied by transient ischemic electrocardiographic changes. The media, knowing only that the patient was rushed to the hospital after the 9-1-1 system received a \u201cman down\u201d call, may want to know if there was foul play or if the person had something serious like a heart attack or stroke. If the patient/ family spokesperson does concede to saying \u201csomething\u201d to the media, the preliminary public report can be more generic. For example, once cleared by the patient/patient\u2019s family, the initial report to the media might be that \u201cHe\u2019s having some abdominal pain, but since that is caused by a whole list of things, the hospital will be busy trying to figure out what\u2019s going on over the next few hours.\u201d The concept of Health Insurance Portability and Accountability Act (HIPAA) violations can always be invoked, but getting an \u201capproved\u201d generic statement can help to avoid further escalation of speculation.\n\nSpecifically, sometimes aggressive disclosure, either by the patient or by a physician with the patient\u2019s explicit permission, is also the best way to go. Take the case of President George Bush\u2019s pretzel swallowing incident in 2001. Much of the original flurry of media attention was rapidly defused, not only by full disclosure of the event but also by the president\u2019s assertive humor about the incident over the following day or so. In that case, the president\u2019s physician was immediately responsive and gave full disclosure about the cause of the incident and the care provided, as well as his high-profile patient\u2019s prognosis. At the same time, it must be put into perspective that the president is a very special case and such detailed disclosure is not appropriate for other persons, even those of great celebrity. Again, when it comes to the tricky issues of patient confidentiality, full disclosure is not always necessary, especially in the era of HIPAA.\n\nLikewise, there are other considerations regarding full disclosure, such as government security issues. For example, one must be cautious about releasing what plans are in place for dealing with terrorists. Once again, there is a fine line between making statements that assure the public that protective strategies are in place and statements that give away important security information. For example, one might state that there are multiple well-placed caches of chemical antidotes, but not disclose their exact whereabouts.\n\nRegardless of the issue, one must always tell the truth and always maintain credibility. If a reporter suddenly calls an EMS medical director or PIO to inquire about an anonymous report from a hospital regarding a misplaced endotracheal intubation by EMS personnel, it is important (for the appropriate person) to give a response. Even if the preliminary information does sound like some error was made, it is still reasonable to simply state: \u201cWe take all such reports seriously and you can be sure that we will be looking into this aggressively.\u201d In fact, giving too much detail generally is inappropriate and unfair to the \u201caccused\u201d in term of due process until the formal investigation is done.\n\nThese same caveats are important for the medical \u201cexpert\u201d in other venues, whether it is at town hall meetings, civic group gatherings, or other public locations. In addition, be it for city council or the media, it is important to keep one\u2019s truthful comments to the \u201c10-second sound bite,\u201d or at least as cogent and brief as possible, in the applicable situation. Thus, there is a challenge to the EMS physician to convey the information as quickly and succinctly as possible. That leads us to Rule #2.\n\nRule #2: Respond quickly and accurately, and become a readily available, familiar, and helpful resource\n\nWhen contacted by the media, rapid response is important. Most reporters are on some deadline unless they state otherwise. If an assistant to the EMS medical director answers the phone and takes the message from the media, it is important for the assistant to find out if there is such a deadline. Whether or not an immediate deadline exists, the reporter may still \u201cshop around\u201d to rapidly confirm an interviewee, even if the EMS medical director was the first choice. Although busy themselves, it is important for prospective media interviewees to be flexible enough to make some impromptu appointment time or get the media contact another good source right away. In that respect, the EMS physician (and the EMS community at large) is seen as the immediate, helpful, and familiar resource to go to in the event of an urgent situation. The same is true if it is a public official calling or other persons involved in important decision-making positions.\n\nBeing flexible and available is important in terms of future relations with the media or the public officials. This concept is important, not only to help \u201csoften the blow\u201d when a potential negative situation occurs but also to collect some \u201cbrownie points\u201d in the event that the EMS physician, or the EM community as a whole, eventually needs help with promoting some important public health issue. It is no promise, but if the EM community needs help with an injury prevention program or to promote a new life-saving campaign, it is always good for involved EMS physicians to have established responsiveness with the media or at city hall when the tables are turned.\n\nMore importantly, when the media (or council member) calls about a negative story such as the alleged unrecognized esophageal intubation or an unrecognized heart attack, it is important to respond quickly and accurately, even if initially in the dark. All the media may need is a quick sound bite to meet a deadline for the 10 pm broadcast or tomorrow\u2019s paper, such as: \u201cAt this initial juncture, I can\u2019t yet confirm what actually happened, but, as always, you can be sure that we will be looking into this aggressively.\u201d First of all, this statement is not hedging; it is appropriate. It is the fair thing to do in terms of due process for the \u201caccused\u201d EMS or ED personnel. Also, by the time the matter is formally investigated, the story usually is no longer as appealing to the media. This is because it may be long forgotten or it will no longer be \u201cnews\u201d regardless of the outcome of the investigation. Therefore, the quickly delivered sound bite (\u201cwe\u2019ll be investigating it aggressively\u201d) on the night of the event may be all that is ever required. Most importantly, by responding rapidly, the EMS physician is seen by both the media and the public as a trusted public servant who is very responsive and concerned. The public\u2019s trust and the public\u2019s safety will be maintained and that is the key point of the media inquiry in the first place.\n\nIn turn, in potentially negative future situations, the EMS medical director who is always responsive and helpful to the news media will be more likely to get a fair shot and not be as susceptible to the \u201cambush\u201d interview. Though it does not grant immunity from attack, being a reliable, familiar resource is an attribute that is taken into account under these circumstances and it may help to bring more balance to the media report when something sensational arises. Therefore, it is also wise for the EMS medical director to build prospective relations with local media and particularly assignments editors and segment producers at electronic media (radio and TV stations) or their counterparts at print media organizations. Often news directors, city council members, county supervisors, and the like are amenable to (briefly) hearing new information about exciting new ventures that benefit the program and so a short presentation of something innovative with which they can partner (e.g. new study, breakthrough training techniques, creative public safety program) can create a good rationale to meet face to face and start a relationship.\n\nAlthough one should attempt to schedule these often elusive appointments with those very busy media and government personnel, it must be remembered that the best way for EMS physicians to gain familiarity with the media or city/county officials is to do their job well as proactive public servants. For example, part of that job may be to establish safe community programs such as community-wide injury prevention activities or widespread public CPR training, and, particularly in the case of EMS physicians, to have high visibility and a friendly, competent demeanor at EMS scenes.\n\nAlso, because it is a pivotal public service role, part of the EMS medical director\u2019s job is to be readily accessible to those entities that represent the public or act as public advocates, even when it is inconvenient to do so. It is important to establish one's first interactions as positive interactions and not as adversarial ones. Responding quickly and accurately and becoming a helpful, reliable, competent, and (eventually) familiar resource is the best mechanism to accomplish that goal.\n\nRule #3: Be a human being \u2013 act like one and talk like one\n\nIn addition to being \u201cavailable, responsive, sincere, and truthful\u201d (in short sound bites!), perhaps the most important axiom to follow is to be a compassionate, friendly, and empathetic human being. The EMS medical director is ostensibly credible to the public just by having the medical degree or the position of \u201cER doctor,\u201d let alone EMS medical director. So, as a public educator, the physician spokesperson does not need to use technical terms such as \u201ccerebral infarction\u201d or acronyms such as \u201cCOPD,\u201d nor does he or she need to wear a \u201cSunday-best\u201d dress and accessories or a suit and tie for the spot media interview. When contacted by the media, rapid response is more important \u2013 as is realism. If the public speaker is in a scrub shirt at work, that is probably the best way to give the interview. In fact, this strategy is probably preferred to the image of an off-site\u201d physician in a suit or dress with textbooks in the background. Unless it is a pure medical information interview on a more esoteric subject, \u201cwork clothes\u201d are appropriate.\n\nLanguage-wise, the EMS physician may use terms like \u201cventricular fibrillation\u201d as long as it is immediately defined. For example, one might say, \u201cOne out of five people who will die today, will die from sudden ventricular fibrillation, an unexpected and abrupt short-circuiting of the heart\u2019s electrical system,\u201d or \u201cWe think that the officer involved has a pulmonary contusion \u2013 essentially a bruise in the lungs \u2013 that is giving him some breathing problems.\u201d At the same time, words like \u201csuffer\u201d and \u201csustained\u201d are too colloquial and even inappropriate, as in He suffered a cardiac arrest.\u201d After all, the medical community is supposed to keep you from \u201csuffering\u201d and, more importantly, in cardiac arrest, \u201csuffering\u201d is not accurate.\n\nWhen providing an interview, it is also important to avoid visual and auditory distractions, both in the background and on one's person. Dangling earrings or wild hair can be very distracting. Multiple colors or flashy nametags can also take away from the point of the interview, the sound bite itself. Chewing gum or fidgeting with some object can also be annoying, as is looking around aimlessly. Sometimes a simple, symbolic prop can be reasonable such as a steadily held stethoscope, chart, or walkie-talkie. Likewise, a background (emphasis on background) with an ambulance, a chest x-ray (inside the emergency department), or a lit-up 9-1-1 dispatch office display map can be effective as long as the background is not flashing or too busy with movement.\n\nRegardless of what one wears or what background one chooses, the critical factor is the demeanor that the EMS physician exudes. Nothing is more engaging in an interview than comfort and enthusiasm. Even in a serious, \u201cnegative\u201d story, a sense of sincerity and vivacity/strength still appeals to viewers and listeners. Likewise, in a print media story where a demeanor would not seem likely to be portrayed, many reporters may still comment on (or reflect) the interviewee's enthusiasm in their final copy.\n\nMost importantly, the key approach here is to do something similar to what the physician might do with patients when talking about informed consent. When necessary, and in applicable situations, a health care practitioner might say, \u201cIf this were my mom, this is exactly what I\u2019d advise her to do.\u201d Similarly, the EMS medical director may be able to use this technique in the sound bite or during public comment. For example, \u201cKnowing CPR is critical (the exclamation)! As a father, I can\u2019t think of anything more important to know for the protection of my children (core concept). It\u2019s one of those things we all need to know (parting resolve).\u201d This statement emphasizes that while the medical expert may be a physician, he or she is also a family person with whom the average person can identify. It also takes advantage of an important human motivator in which an otherwise disengaged and often inattentive male viewer will listen because he does see himself as the \u201cprotector\u201d in the family. It also says that CPR is something that all of us (not just health care workers) need to know for the sake of our families. In other words, from the basic human being\u2019s point of view, it is a basic social obligation. Bringing this subject down to the level of one dad\u2019s own advice to himself makes it more effective for the target audience.\n\nIn fact, considering what one would do for one\u2019s own family or loved ones not only is an effective sound bite, it is a smart strategy in terms of establishing credible policy and procedure or in day-to-day decision making. If a policy or position is good enough for the truthful, responsive, enthusiastic EMS physician and his own family members, then public trust is better gained. A comment such as \u201cIf this had been my own daughter, I would have wanted the paramedics to have done the same thing\u201d provides a very cogent and persuasive opinion. Likewise, one might say (about the need for a control group in pending scientific study of a new treatment), \u201cFor comparison purposes, the treatment will be provided strictly on an every other day basis, As a result, we\u2019ll all have a 50-50 fair shot at getting the new therapy\u201d or \u201cIt\u2019s a flip of a coin \u2013 and no matter who it is, your family member or mine, everyone gets a fair and even chance of getting either the new treatment or the well-accepted standard approach. Either way, our loved ones will now get better care than ever before.\n\nNot only does this make the concerns more palatable, it is ethically the correct thing to do. Moreover, if the EMS physician is sincerely willing to enter himself or a beloved family member into a study according to its rules (be it control or study arm), that probably handles 90% of any ethical concerns that most regulators would have, let alone the public at large.\n\nRule #4: The glass is half-full on issues, less optimistic on individual patients\n\nMost people do not want to hear pessimistic things. It is more appealing to stress an optimistic perspective, even if stating the same facts. For example, if asked: \u201cDoctor, isn\u2019t it true that if we don't get this new life-saving equipment, over the next year, many people will die unnecessarily? Absolutely! If we can get this new equipment, many lives will be saved. Therefore, in this \u201cnegative\u201d interrogatory (\u201c... many people will die ...\u201d), one would not use the direct \u201crepeat the question\u201d approach for the opening exclamation of the reply. Instead, one should use the reciprocal approach as in the example.\n\nThe \u201cglass is half-full\u201d approach is much preferred to the \u201csky is falling\u201d approach in getting viewers and public officials to listen. At the same time, the media, and particularly managing editors, still want to sell papers. They know that a compelling headline in the newspaper or an alarming break tease tends to get attention. In fact, despite what one says during the interview, the statements may still seem to be turned around when the morning paper headline reads, \u201cMany Will Die Unnecessarily Without New Device.\u201d Hopefully, the EMS physician\u2019s quote or sound bite within the article or news broadcast will still reflect the proactive position: \u201cmany more lives can be saved.\u201d\n\nIn contrast, when speaking about an individual patient, one should avoid terms like \u201cstable\u201d unless that is the unequivocal situation. A person with a gunshot to the abdomen should not be billed as \u201cstable\u201d just because he is conscious and oriented and his blood pressure and heart rate are currently \u201cnormal.\u201d Media statements should always anticipate the potential for complications as follows: \u201cAnytime someone is shot in the abdomen, we consider it a critical situation [because of the possibility of severe internal bleeding and infections] \u2013 but the good news is that he is in the best of hands at the trauma center \u2013 this is where I\u2019d want my family member taken \u2013 we\u2019ll let you know how he does!\u201d\n\nIn this case, if the patient is declared stable and then dies unexpectedly from an insidious iliac vessel injury, it appears very worrisome and affects future credibility. If it is made clear that all abdominal gunshot wounds should be considered critical, an unexpected death will not necessarily be seen as \u201cunanticipated\u201d whether talking to the family, the media, or anyone else. On the other hand, if the patient goes on to survive that critical injury, it makes the trauma center and EMS system look good, and appropriately so. Obviously, stating that the person is in a serious condition is inappropriate if the patient has a small laceration, but whenever doubt exists about complete stability or risk for serious problems, then a less optimistic (realistic) approach is more appropriate.\n\nRule #5: Make others look good \u2013 and you will look good\n\nComplimenting others is extremely important, even when the interviewee or person delivering statements was clearly the main person involved in some successful situation. For example, if an EMS physician is the first-in ALS provider and successfully manages an unusual multiple casualty circumstance and resuscitates several persons, it is still recommended to give credit to the first responder firefighters, and even later-arriving paramedics, especially for the lives that they save on a day-to-day basis. They will look good and, in turn, will appreciate you for your generosity. But also, in the long run, the EMS medical director working with an admired EMS agency looks good because of the enhanced reputation of that service.\n\nLikewise, if EMS personnel save a young boy awaiting a heart transplant who suddenly goes into ventricular fibrillation (VF), they should make sure to state that \u201call of the credit needs to go to the dad who did CPR\u201d even if the dad wasn\u2019t doing the greatest CPR and even though it was a protracted situation with persistently recurring or refractory VF. It not only shows sensitivity but, most importantly, it provides the public with another valuable example of why CPR is a critical life-skill that everyone should know. Intuitively, it is already clear to the public that the paramedics must have had something to do with the life saving. Therefore, if the person being interviewed states that \u201cwe were just doing our job and we wouldn\u2019t have been able to save him without the dad\u2019s actions,\u201d this tactic portrays humility and professionalism \u2013 it makes the EMS personnel look like they\u2019ve \u201cbeen there before.\u201d\n\nConversely, when bad things happen, the \u201cbuck stops here\u201d approach is just as appropriate. The leadership should say that, \u201cUltimately, this is my responsibility and you can be assured that I will be handling it.\u201d Even though people understand that the \u201cboss\u201d was not directly responsible for the unfortunate incident, the medical director or EMS leader who conveys a great sense of accountability for the incident helps to inspire public confidence that the problem is being taken very seriously and addressed accordingly.\n\nRule #6: Provide a good \u201chook\u201d \u2013 suggest a simple valuable lesson\n\nWhat generally catches the public\u2019s attention, be it in a news broadcast, the internet blog, or the city council chamber, is a simple \u201ctake-home\u201d point or something that gains their sympathy or attention. A good approach is to use willing persons as examples, such as those who survived because of CPR or the recent trauma patient who is now fully rehabilitated. As everyone knows, children and animals, either as subjects or as adjuncts to the story, always work well. Establishing relations with interesting survivors is important to do proactively. Many patients are extremely grateful or already innately willing to help with public health initiatives. The key word here is \u201cwilling.\u201d Referring the media directly to patients or former patients is inappropriate and, in addition, care must be taken to not take advantage of the \u201cdoctor-patient\u201d relationship and place patients in uncomfortable positions, either through overt solicitation or their own internal perceptions of pressure (\u201cI guess I owe it to my life savers, even if I don\u2019t feel like doing this\u201d). Often, this is a good situation for involvement of the PIO for the EMS system or applicable receiving hospital. They can be of great assistance and provide a buffer for the doctor-patient relationship.\n\nWith or without attractive, willing subjects, however, it is still important to make a simple \u201ctake-home\u201d lesson regarding the situation being discussed. For example, in a school bus crash involving another vehicle (in which an automobile driver is killed outright), an EMS medical director might be asked to catalog the number and age of school bus children injured (e.g., \u201c24 second-, third-, and fourth-graders\u201d), the types of injuries (various minor injuries), and where the children are being taken (five different area hospitals). However, an important \u201chook\u201d is to recognize that although the crash was bad enough to kill the driver of the car outright, an infant in the child safety seat in the back passenger area of the car was uninjured. If applicable, one might even do the interview at the scene with the child\u2019s car seat in the background (or nearby). This is a powerful image.\n\nLikewise, in a heat wave, one can provide a textbook account of heat exhaustion, heat stroke, and other esoteric \u201cdoctor\u201d information. It is much better, however, that a simple, valuable lesson be prioritized for the limited sound bite time. Therefore, it is prudent to focus on \u201ctake-home\u201d tips to prevent heat illness as stated before. Nevertheless, while preparing for the interview, one can provide some relevant background information to the reporter that will emphasize that prevention and treatment of dehydration is the key issue. One can also state preliminarily that, classically, the very young and old are considered to be most susceptible to heat illness because of their inability to sense a problem with heat or to fend for themselves (getting out of the heat or getting fluids). It is then also important to note that a large number of serious heat illness cases (in fact, the majority in some communities) may involve \u201cweekend warriors\u201d \u2013 young, healthy adults who work in super-cooled environments all week who then suddenly exert themselves out in the environment on a weekend day (e.g. playing tennis, jogging, doing yard work, working in the attic).\n\nAgain such preliminary background statements are probably relevant to setting the stage for the interview but most importantly, one should be focused on providing useful recommendations in the actual interview itself. As mentioned previously, in the example of heat illness, a few quick prevention tips can be provided in those four or five quick \u201cbullets as noted previously.\u201d One could also add a verbal tag-on: \u201cAnd if you do indeed go out in the heat, use a buddy system and look out after one another!\u201d\n\nRule #7: Provide simple statistics and graphics\n\nThe \u201ctake-home\u201d points are easier to take home if one uses simple statistics and graphics. For example, as stated previously, in the heat illness prevention interview, one could supply the media personnel with ready-to-run, short, bulleted graphics (displayed sequentially, as in a computerized slide presentation) to accompany your narrated tips.\n\n\u2022 Lightweight, Light-Colored, Loose-Fitting Clothing\n\n\u2022 Stay in Well-Ventilated Areas\n\n\u2022 Water, Water, Water\n\n\u2022 Avoid Alcohol\n\n\u2022 Use a Buddy System!\n\nActually, this can be considered a relatively long list (thus the concept of the verbal parting statement for the last bullet). Generally, a format with three lines of graphics is preferred. Also, the use of fewer words with capitalized first letters (except for articles and prepositions) allows for faster reading of the information. The idea here is that your sound bite will match this graphic and that it will be shown simultaneously with your interview and the respective statements. This works especially well in a live interview because it gives some structure and helps you to control the focus of the interview. Therefore, providing such bullets by email and/or fax can be very useful.\n\nProps and other visual aids are also useful. Today, with images readily available electronically on the internet or through scanners, one can rapidly send a television producer a picture of a deer tick and a typical Lyme disease rash if an interview on that disease is being requested. These images can be shown on the screen during a live interview or as part of a background during a taped interview. Likewise, simple props such as an AED or a vaccine bottle can be useful for the applicable interview. One should make sure such graphics are in the public domain or that permission has been obtained (preferably in writing). Photographers in particular are becoming more litigious and we must all be mindful of using other people\u2019s materials with permission, be they personal or professional images.\n\nIn other situations, it is how one says things that can capture attention. Saying that \u201cthere were 25 million EMS incidents in the US last year\u201d may be less effective than saying, \u201cevery other second, there is a call for EMS across the United States.\u201d \u201cA stroke occurs every 50 seconds in the US\u201d may be more powerful than \u201c600,000 a year.\u201d Simply said, the simpler the statistics, the stronger the impact. Also, for television (and print media), the display of simple graphics such as a bar graph with progressively increasing sizes over time can say more than a sound bite; clearly, a picture is worth a thousand words.\n\nIt is key to remember that such graphics may only be shown for 5\u20137 seconds (or less). Experience has shown that it takes at least 3\u20134 seconds for the average person to recognize and cognitively appreciate an image. At the same time, the attention span for that image may fatigue within another few seconds. Therefore, the timing and duration of such graphics and images need to be compatible with that type of schema. This is conventional wisdom not only for the television media but for other educational media as well. In graphic computer presentations (e.g. PowerPoint), similar considerations must be kept in mind. Instead of showing all the slide elements at once, each line might best be introduced and highlighted in sequential order, one at a time.\n\nRule #8: Stay on the mark \u2013 remember the three Rs of repetition, redundancy, and reiteration\n\nRegardless of technique, it is up to the health care practitioner being interviewed to relay a distilled piece of information to the public. As previously discussed, if the point to be made in a given interview is to get all members of the public to learn CPR and the reporter\u2019s questions begin to drift toward \u201cthe possible hazards of performing CPR,\u201d it is the job of the interviewee to get the interview back on track and remain focused on the objective.\n\nDepending on the interview setting, it is not necessarily inappropriate to repeat and reiterate the same point that one wants to make, particularly if it is not a live interview. In a live interview, repetition can be a little annoying. In the majority of other situations (such as a taped interview session with a reporter from which a sound bite will be extracted), some degree of reiteration is actually encouraged. The eventual sound bite that is used may come out better on a second or third try and the repetition can continue to reinforce your main point to the reporter.\n\nLikewise, if one is saying to the reporter that the \u201cglass is half-full\u201d and the reporter comes back and asks if that means that the \u201cglass is half-empty,\u201d the speaker must stay on the mark and not relent. If necessary, he or she must be repetitive.\n\nRule #9: Don\u2019t trust everyone \u2013 there\u2019s no such thing as \u201coff the record\u201d\n\nEmergency medical services medical directors should assume that any statement that they make today (or transmit via email), be it stated \u201cconfidentially\u201d or not, will appear in print tomorrow. In fact, that caution does not apply only to conversations with media personnel. The EMS practitioner should recognize the reality that their own employees, colleagues, supervisors, or supervisees may covertly tape-record/videotape personal conversations, especially with the widespread convenience of the hand-held phone video application. Likewise, it should be understood that any jokes, including those that were thought to be told in the privacy of a phone call or email, are subject to dissemination.\n\nEven the act of confidentially disclosing something in one\u2019s own home may, at times, place a loved one in a position to express sentiments inadvertently or to disclose information that should have been kept discreet. As most EMS systems and emergency departments are entities open and available for use by anyone, any time, there exists an unspoken public trust that the EMS system and the \u201cER\u201d is a public safety net and, in a sense, an entrusted type of public service. Therefore, the EMS medical directors/EMS physicians (and, again, any other health care practitioners) should maintain a sense of public trust and recognize that they are, in many ways, \u201cpublic\u201d figures. In turn, they should always assume that any verbal or written statement, made under any circumstance, could become public record.\n\nTherefore, one should not use the term \u201coff the record\u201d unless the interviewee wishes to test the reporter or confidant\u2019s discretion. In fact, the term \u201coff-the-record\u201d (OTR) should be considered a red flag when the reporter or person asking questions asks \u201cOff the record?\u201d One should always question what OTR means. Some reporters mean that they will not repeat the information at all, whereas others think that they can use the information for reporting but cannot print it or that they will print it without revealing the individual source. Oftentimes, the interviewee can disclose something OTR and then later find that the OTR information is still broadcast or printed using statements like, \u201cHowever, some high-level officials within the organization still tell Channel 9 that \u2026\u201d Therefore, it is best not to provide OTR information at all if one does not want to it appear anywhere. More specifically, those wishing to maintain absolute discretion should not trust anyone unless a long-term track record of trust has been established.\n\nThe issue of trust speaks to a larger point that learning to deal with the media is a marathon, not a sprint. Physicians will not perform perfectly their first time in front of the microphone and reporters will sometimes fall short in trying to tell a very complex story on a very tight deadline. Nevertheless, if both sides have the public interest and patient welfare as their top priority, and not just self-promotion or newspaper sales or ratings, then they can discuss, after the fact, how the story came out and what the reporter and interviewer could have done better. By talking about what they might do differently for the next interview opportunity, they can begin to build trust. From the reporter\u2019s perspective, covering a breaking news story is often like coordinating treatment of a patient in cardiac arrest; it is fast-paced and stressful, but if the reporter can look back at it with a critical eye, he or she can learn to be better on the next story. The best medical reporters are not only concerned about their reputation, but also their ability to deliver high-quality health information to their readers. In turn, this level of quality requires continuous and rapid access to a thoughtful and articulate emergency care physician and also a particular degree of trust.\n\nRule #10: Anticipate the worst \u2013 and expect the mediocre\n\nFrequently, rookie (or even veteran) reporters, full of enthusiasm, are sent out to quickly get an interview about a subject with which they are completely unfamiliar. Particularly when one must discuss a complicated ethical subject that the EMS physician may have studied or focused upon for years (e.g. triage systems or waiver of informed consent to study participation), it becomes difficult to reduce it all to a sound bite or an accurate print statement. As hard as he or she may try to understand and do so sincerely, the reporter may not be able to grasp, let alone accurately distill, a relatively abstract and multifaceted concept in a short period of time.\n\nMore concerning sometimes is the fact that, even if the interview goes well, the audience may not get the message or at least retain the specific message. One should be prepared for statements like, \u201cHey doc: saw you on Channel 11 last night (when you were actually on Channel 8) \u2013 you looked really good.\u201d But when asking, \u201cOh good, which one was that, what was it about?\u201d, one should not be surprised when the reply is, \u201cI can\u2019t remember, it was about some emergency thing \u2013 but you looked good!\u201d At least, in this case, the viewer got the \u201cgood\u201d vibe. Sometimes, it can also be \u201cI guess there was some kind of problem.\u201d\n\nAnother problem is the print story headline or the electronic media \u201clead-in\u201d (the news anchor\u2019s introduction of the story) or \u201cbreak-tease\u201d (\u201cWhen we come back \u2026\u201d). These are the \u201cheadlines\u201d that set up the upcoming story. Even if the reporter fully grasps the concepts and writes a wonderful piece, the headline, written by an editor, may portray something off-target. The editor may want to catch the reader\u2019s eye with something controversial or he or she may simply \u201cnot get it\u201d and focus on a minor point. In those respects, the headline writer may even say something that is perceptibly negative. Take, for example, a print media story originally written by a reporter to say that we need more AEDs and widespread public training on AED use because many people are dying unnecessarily without them. The actual text of the story relays that despite a great group of well-trained EMS personnel, the EMS system survival rates are low because bystanders are performing CPR infrequently and there are not enough AEDs available. Although the point of the story, originally, was to encourage bystander CPR and AED deployment, the editor still might write \u201cParamedic Survival Rate Low\u201d for the headline. Naturally, this will give the wrong impression despite a wonderful text below the headline. Likewise, for a break tease, the anchor may state, \u201cWhen we come back from our break \u2013 a new program to save lives may itself need resuscitation.\u201d In this case, a negative impression may be made despite an ensuing balanced story by the reporter.\n\nTherefore, one should anticipate the worst of an interview and, at best, expect the mediocre in terms of its ultimate effectiveness. In turn, one should not take it personally when the broadcast or printed output falls short of the mark. EMS physicians cannot always get their expert knowledge across in a matter of minutes and, at best, a mediocre representation of their key points may occur.\n\nIf there is a clear error in a report, one should immediately consider contacting the reporter. If the reporter is not reachable, then contact the \u201ccontent manager\u201d (section editor, executive producer, managing editor as applicable) and be specific about the issue. Also, it should be done in a respectful and constructive tone, not only to get a better reception about the \u201ccritique\u201d but also to ensure improved relationships and communications in the future.\n\nOn the other hand, sometimes the point does get across, especially if the speaker is given the chance to come back and speak again. Therefore, this realization makes it more incumbent upon the EMS medical director to become a responsive, familiar, helpful resource and to become extremely adept at preparing and producing those sound bites and printed bullets for the various potential subjects about which he or she will be asked to speak.",
        "Conclusion": "EMS physicians as public spokespersons subsidy are a large part of that operation. In turn, the EMS medical director must be prepared to deal with that public trust when it comes into question. This requires a special competency and ongoing experience in this unique political setting to become effective.\n\nIn addition, by virtue of the very nature of the business, the circumstances involving emergencies can be very volatile and emotional for families and patients alike. Furthermore, EMS activities and the door of the emergency department are in the fishbowl. Most EMS operations occur in the public domain in situations accessible to smartphones, cameras, microphones, and public observation. Similarly, the emergency department and its ambulance bays are adjacent to the outside world and therefore most easily viewed by the public and cameras alike. Therefore, the EMS medical director should not be surprised that media interactions can become frequent (if not daily in some venues).\n\nWhen the killer heat wave comes to town or the \u201cflu\u201d is filling up ambulances and emergency departments, the EMS medical director may be the person who can best address the media questions. Knowing about drowning events, skating injuries, hypothermia, choking, strokes, graduated driver licensing, gunshots, bioterrorism, food poisoning, and myriad other topics all must be a part of the EMS physician\u2019s repertoire.\n\nSome may consider the media \u201cfriend\u201d; some may consider it \u201cfoe.\u201d In fact, for the public health-oriented EMS physician, use of the mass media can be a powerful tool for effecting mass public education (regarding CPR, illness/injury prevention, etc.). Public speaking through the media can also have a major societal impact, if not a life-saving effect, in major disaster incidents such as a possible bioterrorism event. Therefore, becoming an effective and trusted public communicator is an important aspect of the job for an EMS physician.\n\nAgain, the recommendations made in this discussion do not in themselves guarantee effectiveness in public communication. It takes experience and, in some cases, lots of it! Like an ACLS algorithm, the ten axioms provided in this chapter establish a working guideline for success based on the experience of others. Just as the clinician needs to practice the ACLS algorithm over and over again, the public speaker needs to practice public speaking repeatedly, hopefully using the axioms outlined here. Individual EMS physicians also may want to explore and research their own styles of public speaking, based on their own experiences. There are also formal media training courses available which may further hone the communications efforts that should be considered and contrasted with this discussion\u2019s specific orientation on EMS practice. Regardless of the path taken, the EMS physician must follow the general principles of truthfulness, accessibility, reliability, and down-to-earth focused statements as outlined in the above discussions.\n\nAlthough making oneself always available to the media or public officials can be intrusive and even very uncomfortable when it involves a problem, the payoff is worth it. Being an effective public communicator is not only good for the public\u2019s health and advocacy and for the evolving new subspecialty of EMS, but it constitutes a large component of leadership roles in general. The EMS physician who always puts patient care first, and who can articulate it responsibly and cogently, will produce medical care achievements and thus will become a true public advocate. Particularly when one needs to be persuasive in terms of gaining more resources for the EMS system or for injury prevention programs or community-wide CPR training, effective communication is essential. To quote one of the original deans of EMS, Dr Norman Dinerman: \u201cBe the source and become the force.\u201d In other words, the EMS physician should be a fund of knowledge, a public communicator, and a patient advocate \u2013 one worthy of public trust."
    },
    {
        "Introduction": "Quality in EMS can be analogous to UFOs. Some are sure they have seen them and can describe them in detail. Others believe in their existence but have never seen them. Still others doubt their existence entirely or refuse to believe they are possible. But everyone agrees that, although often difficult to define, quality is an essential component of a vibrant EMS community. This chapter will describe current knowledge about quality and improvement, and then apply those principles to EMS. Throughout the chapter, examples will be provided to make the theory tangible, and specific suggestions will be offered to help medical directors and clinical leaders apply the principles to their own practices. The challenge for EMS leaders is to move quality in EMS, be it a state, region or a local EMS community, urban, rural, volunteer, wilderness, military, or interfacility operation, from a myth to a reality that continuously drives excellent, patient-centered care. In responding to that challenge, it will be important to remember that quality is a journey, not a destination; a process of assessment and reassessment, change, and adaption to continuously improve the delivery of the product (in this case, comprehensive and coordinated expert care) to the consumer. It is all about improvement, never being satisfied that the product is perfect.",
        "Quality in EMS": "Traditional descriptions of EMS quality have frequently had a narrow focus on specific objectives rather than overall system performance. For example: \u2022 patient-centric: administration of aspirin to chest pain patients \u2022 paramedic-centric: number of successful versus failed intubations monthly \u2022 community-centric: recognition of coronary ischemic discomfort for STEMI patients \u2022 organization-centric: percentage of patients cared for by an organization who received oxygen. In 2001, the Institute of Medicine published Crossing the Quality Chasm and described health care quality as safe, effective, patient-centered, timely, efficient, and equitable. Five years later, this same organization, in the seminal report Emergency Medical Services at the Crossroads, described EMS as fragmented and stated that EMS quality is \u201chighly inconsistent from one town, city, or region to the next.\u201d The report went on to assert that there is no agreed-upon national measure for quality and no consensus for who oversees or is accountable for quality.\n\nThe challenge for EMS leaders is to move quality in EMS, be it a state, region or a local EMS community, urban, rural, volunteer, wilderness, military, or interfacility operation, from a myth to a reality that continuously drives excellent, patient-centered care. In responding to that challenge, it will be important to remember that quality is a journey, not a destination; a process of assessment and reassessment, change, and adaption to continuously improve the delivery of the product (in this case, comprehensive and coordinated expert care) to the consumer. It is all about improvement, never being satisfied that the product is perfect.",
        "The science of quality and performance improvement": "The science of improvement had its origins in manufacturing, where quality is based on reliable execution of optimal processes. W. Edwards Demings was a statistician, professor, and consultant who spent a large part of his life teaching corporate leaders how to improve design and product quality. In the early 1980s, Deming was recruited to jump-start a quality movement in the failing Ford Motor Company. Within 3 years, Ford had undergone a massive internal transformation and surpassed General Motors in sales and profits. In 1987, President Ronald Reagan awarded Deming the national Medal of Technology for his contribution in improving quality workmanship within the technology sector of the United States. Deming believed that the ability to create improvement requires knowledge about the subject at hand (making cars or practicing medicine) combined with what he referred to as the System of Profound Knowledge. The System of Profound Knowledge asserts that improvement requires an understanding of the interaction of four factors that affect processes and outcomes. The descriptions below offer EMS examples for each. \u2022 Appreciation of a system: having an understanding of the interactions of a system and how they affect the outcome or quality measures. The EMS system is rather large, and includes dispatch, first responders, fire (including hazmat and special operations), hospitals, public health, mental health, and the EMS authority, as well as the health care provider and the patient. Any successful improvement effort must recognize the role each of these system elements plays in creating the outcome. \u2022 Knowledge of variation: understanding what is a \u201cnormal variation\u201d within a system compared to what is unexpected or unpredictable. Blood glucose levels offer a good example for describing the knowledge of variation. A patient whose daily glucose levels have fluctuated between 84 and 106 over the past 2 weeks does demonstrate variation, but the narrowness of the range suggests that it is the result of normal variations in diet and metabolic functions. This is referred to \u201ccommon cause\u201d variation because it affects all people and does not reflect a metabolic system that is \u201cout of control.\u201d In contrast, a patient whose daily glucose levels have fluctuated wildly between 84 and 320 during the same timeframe likely has what Deming referred to as \u201cspecial cause\u201d variation \u2013 not common to all people, and likely reflective of a system that is \u201cout of control.\u201d Successful quality efforts identify and focus on reducing special cause variation and DON\u2019T waste time and resources trying to \u201cfix\u201d common cause variation. Like all other systems, EMS has a lot of common cause variation: cardiac arrest survival, skills success rates by paramedics, or on-scene intervals \u2013 performance varies week to week or month to month. Statistical tools such as process control charts are used to identify variation that is not common cause (such as consistent differences in cardiac arrest survival between communities). Understanding and reducing special cause variation is what process improvement, and this chapter, is all about. \u2022 Building knowledge: understanding the system under consideration and using that understanding to predict what improvement efforts will successfully reduce special cause variation. The knowledge-building process not only refers to making informed predictions before beginning improvement efforts, but also the continued gathering of information on how interventions actually affected the system. For this reason, efforts to create system improvement need to be structured in a way that enables the effect of change to be carefully measured. The Plan-Do-Study-Act (PDSA) cycle is the strategy for systematically testing changes within the system and building additional knowledge, and will be discussed below. \u2022 Human behavior: how humans behave and react to given circumstances. What are the \u201chuman\u201d factors contributing to the special cause variation? And how will they respond to the proposed changes? Will there be resistance? Human behavior is often underappreciated when change efforts are undertaken, especially in a large and diverse system like EMS. Careful consideration of all four aspects of the System of Profound Knowledge will guide quality leaders in developing a change or improvement within the system.",
        "The Model for Improvement": "Application of Deming\u2019s principles to actually solve quality problems requires a structural framework that can guide the process and set parameters. Fortunately, there is a powerful tool available that can be used to guide and drive the process of quality improvement. The Associates in Process Improvement (Austin, Texas) developed this tool several years ago and it is currently used in education, health care, and public and private business to drive change and improvement. Although there are other guides and tools available, the Model for Improvement was adopted by the Institute of Healthcare Improvement as its \u201cweapon of choice\u201d to promote a balanced and healthy approach to improving quality within health care systems, including EMS. Use of this model within your system to define, measure, and ultimately improve quality is a major focus of this chapter. The Model for Improvement begins with three basic questions, each of which is foundational to understanding and defining the target of the improvement effort. 1 Aim: What are we trying to accomplish? Aim statements are very specific and address the topics of \u201cWhat,\u201d \u201cBy when,\u201d and \u201cFor whom?\u201d The aim should ideally possess qualities that will keep the intent of the aim on those things that matter. First, the aim should be patient-centered. The delivery of quality patient care is the driver of EMS and our quality initiatives should reflect that belief. Second, the aim should be focused on a practice with wide special cause variation, meaning that some providers (or communities) perform well while others do not. There is no benefit to patients in focusing improvement on practices that all providers do well (only common cause variation). While ultimately it is beneficial to address issues that virtually no one does well, it is a very difficult place to begin performance improvement efforts because there are no \u201cbest practices\u201d available to learn from. Instead, it is wise to begin with issues that have broad variability. Finally, the aim should be evidence based and backed by solid, foundational literature and best practices. Selecting aims that have an adequate evidence base reduces the controversy around the interventions that will be tested to improve performance. Consider the following EMS improvement aim that meets these criteria. To improve the percentage of patients in respiratory distress who are normally oxygenated to 95% by March 31st. 2 Measure: How will we know that a change is an improvement? The measure becomes the lens through which all potential change strategies are viewed to determine whether they will actually create the desired result. Like aim statements, measurement statements must be very specific and describe how the change will be measured. There are several characteristics of good measures. First, as with the aim, metrics should be patient-centered whenever possible. EMS metrics have traditionally been provider centered, but often there is a corresponding (better) patient-centered metric. For example, many EMS systems have long used the intubation success rate as an important measure; the patient-centered metric would be adequate ventilation and oxygenation as measured by EtCO\u2082 and SpO\u2082. Shifting to these measures takes the focus off the caregiver and shifts it appropriately to the patient, and also reduces the risk of unintended consequences associated with caregiver-centered metrics such as choosing to not attempt intubation in a challenging case in order to maintain a high success rate. Health care metrics have evolved to a focus on patient outcomes and patient harm related to the care provided by health care professionals. EMS metrics for quality must do the same. In addition, measures should be specific and numerical. Consider the following measures for the aims described in the previous section. To improve the percentage of patients in respiratory distress whose SpO\u2082 is >90% at the final assessment of the EMS encounter to a target SpO\u2082 of 95% at the final assessment of the EMS encounter by March 31st. 3 Change: What changes can be made that will result in an improvement? At its core, change is driven by a prediction about what change could be made within the system that would achieve the aim as evaluated by the measures. There are several attributes of effective changes. First, they require development, meaning that they have as their foundation the framework offered by Deming\u2019s System of Profound Knowledge: built upon an understanding of the system and knowledge of variation, influenced by knowledge, and informed by sensitivity to the human factors involved. They also must be amenable to evaluation, meaning that the change itself can be measured in addition to the outcome. For example, to improve the percentage of patients in respiratory distress whose SpO\u2082 is >90%, a change that might be predicted to achieve the aim might be administration of oxygen in a higher percentage of patients. In addition to the outcome (SpO\u2082), it would be possible to measure what percentage of patients actually received supplemental oxygen. Finally, successful changes require an effective strategy for implementation. To continue with the supplemental oxygen administration example, how will the goal of increasing the number of patients who receive oxygen be achieved? This may involve assuring that oxygen is available in all ambulances, training crews on how to administer oxygen and why it is important, and monitoring oxygen administration during the implementation phase to track progress. Unfortunately, many systems begin their attempts at quality improvement by going straight to implementation; they look for changes within the system or organization without having a clear understanding first of what they are trying to accomplish and if what they are trying to accomplish is measureable. If, however, the approach is first evaluated from a proper aim with measureable objectives, then the real fun can begin with brainstorming and a free flow of ideas that fills a whiteboard. For a system, provider group, or organization to be successful at implementing a robust, patient-centered, well-defined, and measurable quality project, there must be a champion, or leader, who has the focus and vision to accomplish what lies ahead. Often, but not always, that person is the medical director or another EMS physician. This individual needs to have oversight of patient care and have the knowledge, skills, and ability to drive change. But the champion is just the start. Once an aim is identified, it is important to identify additional individuals and groups who need to participate in order to effectively execute a change and measure the effect on the aim. These individuals will likely vary and might include representatives of the provider group, emergency responders, hospitals, public health, mental health, law enforcement, the local EMS authority, state officials, and others. Each aim will differ in participants, but each will require a leader, or champion, of the quality system.",
        "Tools for success": "The System of Profound Knowledge and Model for Improvement provide an excellent framework for guiding improvement, but their success is enhanced through the use of several tools that improve understanding of the causes of quality challenges, the drivers of successful improvement, and the process for testing and adopting change. These tools will be illustrated using the following sample aim: By August 1st, achieve a 10% reduction in the delay of transport of STEMI patients to STEMI centers. Diagramming cause and effect One of the elements of the System of Profound Knowledge is appreciation of the system: understanding the elements of the care delivery system and how they affect the quality of care provided. Before embarking on a quality improvement measure, it is helpful to take a moment and look at how inputs either directly or indirectly affect, or cause, an outcome. This is a good time to assemble all team members, go to the whiteboard, and brainstorm everything that contributes to the outcome. Kaoru Ishikawa, a Japanese industrialist who worked closely with W. Edwards Demings to redesign the Kawasaki shipyards and catapult Japan into becoming a world leader, developed the fishbone diagram. The fishbone diagram, also known as a cause and effect diagram, is an excellent tool for identifying factors that contribute to special cause variation. The fishbone starts by identifying the problem. This is listed as the \u201chead\u201d of the fish. As major causal categories are brainstormed, they are added as larger \u201cfishbones\u201d that make up the skeleton. As the discussion continues, factors that have influence over these causal categories are listed as smaller \u201cbones\u201d of the overall skeleton. If brainstorming begins to stall, consider some \u201cgeneric\u201d causal categories recommended by the American Society for Quality. \u2022 Methods \u2022 Equipment \u2022 People \u2022 Materials \u2022 Measurement \u2022 Environment Identifying opportunities for change Once cause and effect are better understood, it is time to identify how to drive improved performance. While fishbone diagrams are tools to clarify \u201cproblems,\u201d driver diagrams are used to organize \u201csolutions\u201d and are informed in many ways by the elements of the fishbone diagram. A driver diagram lists broad ideas that influence the aim. These are referred to as the \u201cprimary drivers.\u201d Under each primary driver are \u201csecondary drivers\u201d or those things that influence the primary drivers. Most driver diagrams list at least three primary drivers and can have a multitude of secondary and even tertiary drivers. Driver diagrams are important tools for answering the question what changes can be made that result in improvement? Opportunities for change that are relevant within a specific system can be quickly identified in the list of secondary drivers. For example, for communities that are early in their STEMI system development it might be important to focus on secondary drivers associated with the primary driver \u201cDevelop infrastructure to support STEMI care,\u201d such as increasing community awareness or designating STEMI centers. Other systems that have already developed the infrastructure may want to focus their improvement efforts on improving rapid STEMI care and transport or reliable hospital care. A well thought-out driver diagram can literally serve as a roadmap for improvement over several years as changes are instituted one secondary driver at a time. Systematically testing change: the PDSA model The driver diagram offers a strategy for selecting opportunities for improvement by identifying secondary drivers that theoretically affect outcomes and are relevant to the system under consideration. The next step is to systematically test these changes to see if they bring about the desired improvement. The key to conducting these tests is that they be performed on a smaller scale, with a limited number of participants or sites. This enables the change to be tested, measured, and modified as needed before rolling out any changes across a company, community, region, or state. The goal of this small-scale testing process is to identify if change to \u201cX\u201d produced improvement in result \u201cY.\u201d Western Electric employed Walter Shewhart, a physicist and statistician, and a mentor of W. Edwards Deming, in the 1920s. Shewhart used the scientific method of inductive and deductive reasoning to develop a very simple method to evaluate change. The process he developed is called the Plan-Do-Study-Act (PDSA) cycle. \u2022 Plan: identify the objective (aim and measure) and predict the outcomes or improvements of the change. Selection of which change to test is informed by the driver diagram. One of the keys to successful PDSA is to begin with small tests of change. For example, returning to the goal of shortened time to STEMI center, a small test of change might be to use a visual prompt placed on the cardiac monitor screen (\u201cACTIVATE STEMI CENTER\u201d) to see whether it affects time to activation. Of course, part of the planning is to identify what measures will be used to gauge success; in many cases during small tests of change the measures will be more focused around process (the crew remembered to activate the STEMI system) than outcomes (shortened time to STEMI center). \u2022 Do: execute the planned change. As noted before, execute on a small scale first. For example, it would be useful to try the prompt on the cardiac monitor screen with one crew for 1 week. \u2022 Study: gather information to determine the effect of the test. In the early stages this could be as simple as asking the crew if they saw the prompt on the cardiac monitor. Was it visible? Did it have the desired effect? Did they actually have any cases in which they activated the STEMI center and, if they did, did the prompt help? As the test progresses, the size and length of the test increase and usually the data collected become more outcome oriented. Ultimately, as the PDSA cycles evolve, the data will be the actual measure identified in the aim: reduction of time to STEMI center. During these later stages it will also be important to visually assess the data using tools like run and control charts. But in the early stages of testing, the data collected are more related to processes and crew effects. \u2022 Act: quality improvement requires action. At this point, decisions are made whether to make adjustments and send the process through another PDSA cycle, or to adapt/abandon the changes made. In the early stages of the PDSA process there will be tests that fail and need to be abandoned. Other tests may be somewhat successful but need to be adapted (for example, the font size in the on-screen prompt may need to be made larger). Successful tests are adopted. Adoption in early testing means that the test is broadened to more crews, while in the later stages adoption may result in creation of new policies and procedures for the system. Most process changes require multiple PDSA cycles. With each \u201cspin of the cycle\u201d fine-tuning and tweaking of the processes can be accomplished to maximize the desired outcome. Visual display of data to identify real change As noted previously, the world is filled with variation. One of the real challenges of process improvement and using PDSA cycles is mistaking common cause variation for real improvement; it can be tempting to ascribe a decrease in time to STEMI activation rates in a single week to a successful PDSA rather than common cause variation. Graphical display of data offers two tools to assist with longitudinal measurement of change, both short and long term. These graphic representations also help to reestablish or refocus a particular aim, and provide concrete input that can be used to show others and garner support for the particular direction a change is headed. One method of diagramming change is a run chart, which graphs a numerical change over time. On the x-axis is time (days, months, minutes, seconds, etc.) and on the y-axis is the measure of interest (temperature, ETCO\u2082, Glasgow Coma Scale scores, etc.), with the high and low cut-offs of the y-axis being 20% above and 20% below the highest and lowest measures, respectively. Once each data point is inserted in sequential order, common cause variation becomes evident, and when actual sustained improvement occurs it is visually apparent. Depending upon the aim, the slope of the graphical data will determine if change has occurred and if that change is desired. A neutral or random slope will represent that no real change has transpired. Once adequate data are available to demonstrate the mean and common cause variation, a control chart can be created. The control chart looks like a run chart (time along the x-axis, variable of interest on the y-axis), but also has \u201ccontrol lines\u201d that typically represent two standard deviations above and below the mean. These control lines create visual delineations between common cause and special cause variation; sustained change outside the control lines represents special cause variation, and may signal significant results from a process change.",
        "Putting it all together": "To better illustrate the material covered in this chapter, let\u2019s look at an example of a quality problem that exists in a fictitious EMS community. Dr Smith is the medical director of the sole transport provider for a large urban community. There are three trauma centers serving this community. Over the past several months the trauma quality council, chaired by Dr Smith, has noted multiple instances of field-activated patients arriving at the trauma center hypothermic. Dr Smith uses 2 years of historical data to construct a run chart and finds that, as suspected, a distinct negative slope has developed over the past 5 months, representing what he believes is a special cause variation. The quality council has convened to address this trend. In a brainstorming session, Dr Smith and his team construct a fishbone diagram to list as many causal factors affecting the patient\u2019s temperature as possible. Once this is completed, Dr Smith\u2019s team builds a driver diagram to begin to assimilate solutions to the hypothermia problem fleshed out in the fishbone diagram. Recall that the fishbone diagram evaluates the problem and the driver diagram organizes potential solutions. Next, the quality council, with the guidance and input of the provider educator, selects two simple and small changes to be introduced in 25% of the transport units (trialing the change in a small subset is key to flushing out hiccups or complications with the new change). Using the PDSA model, Dr Smith and the educator develop the following aim and measure: first measured core temperature on trauma patients delivered by EMS of 36\u00b0C within 4 weeks time. From the driver diagram, the team decides to add thermal blankets and use the heaters in the passenger compartments of the ambulance. The team then identifies a small group to test these changes, and develops provider training in the use of blankets and passenger compartment heaters on all trauma patients. Dr Smith decides to test this change in the northeastern section of the community, which transports 20% of the trauma calls. At the end of each week, Dr Smith gathers and plots the prior week's data. He also spends time discussing the effect of the changes with his providers involved in the evaluation. He might ask if the use of the heater is simple and if there is any effect on the care they deliver. He might also ask if the blankets are easy to access and if they interfere with patient care in any way. Dr Smith would most certainly provide feedback about the data he is observing, reinforcing the change and/or looking for new directions to head. At the conclusion of the study period, Dr Smith repeats the run chart to evaluate if any change has occurred. He discovers that in fact a positive slope has appeared on the run chart, suggesting the changes he implemented did in fact begin correcting the issue of hypothermic trauma patients and he could potentially accomplish his aim. Moving forward, Dr Smith institutes company-wide training on the new changes, and continues plotting his data on a run chart to assess progress. When enough data are available, Dr Smith constructs a control chart defining an average as well as upper and lower limits of normal. This completes the changes and provides Dr Smith with a method to track progress.",
        "Strategies for Success": "DO: \u2022 focus on the system, not individual caregivers \u2022 clearly identify things that matter (patient-centered objectives) \u2022 use run charts (or similar tools) to detect \u201cdisturbances in the force\u201d \u2022 develop aims with clearly defined goals and timelines \u2022 thoughtfully select measures that match the aim \u2022 get lots of input from front-line caregivers during the planning stage of the PDSA cycle \u2022 be patient. Change is sometimes slow \u2022 remember that most quality successes don\u2019t come from identifying what to do. The goal is reliability. The challenge is how to follow the evidence with every patient encounter, every caregiver, every day. DON\u2019T: \u2022 change too many variables at once (you won\u2019t know what changes had positive effects and what changes had negative effects) \u2022 build an improvement project around irrelevant aims \u2022 get discouraged.",
        "Conclusion": "In this chapter, we looked at a comprehensive, patient-centered, balanced, and highly effective approach to defining, measuring, and improving quality in an EMS system. The details outlined in this chapter are widely applicable to all types of EMS communities and systems. The journey of improvement has a beginning but has no end. The opportunities to improve are boundless but each positive change brings a multitude of rewards not only for the system but most importantly for the patient. We hope that the tips, tools, and techniques discussed herein will guide you in whatever role you play in your EMS community and that you will never stop looking for opportunities to introduce positive change."
    },
    {
        "Introduction": "Recognizing that the medical consequences of a disaster can exceed local, state, or regional resources, the federal government\u2019s response includes organizational frameworks, response resources, and legal authorities. The National Response Framework (NRF) guides the nation\u2019s response to all types of incidents. One of the NRF\u2019s Emergency Support Function (ESF) annexes, ESF-8: Public Health and Medical Services, specifically addresses the federal medical response. The US Department of Health and Human Services (DHHS) serves as both coordinator and primary agency for ESF-8. ESF-8 includes a concept of operations and response components, e.g. the National Disaster Medical System (NDMS) and the US Public Health Service (USPHS). Laws and presidential directives guiding the federal medical response to disasters include Emergency Management Assistance Compacts (EMAC), the Robert T. Stafford Disaster Relief and Emergency Assistance Act, the Pandemic and All-Hazards Preparedness Act and the Pandemic and All-Hazards Preparedness Reauthorization Act, the Social Security Act, the Homeland Security Act of 2002, Title 32 USC (National Guard), Presidential Policy Directive 8, and Homeland Security Presidential Directives #5: Management of Domestic Incidents and #21: Public Health and Medical Preparedness.",
        "Overview of federal medical response to disasters": "When an incident occurs, the local jurisdiction is responsible for organizing and managing the emergency response. Each sequential tier of response that may be required due to the size and complexity of the incident, whether mutual aid, regional, state, or federal, brings additional resources but takes time to fully deploy. Because of the delay involved in the formal process of requesting  and receiving federal medical assets, it is imperative that local medical responders consider the types of assistance required as early as possible in the response. In many cases, state and federal resources may not reach an incident scene in time to be useful. For example, a bridge collapse may seem like a disaster when viewed through the media, but the medical needs may not exceed local EMS and health care system resources. An infectious outbreak or large fire may involve fewer patients, but the patients may require specialized resources (e.g. burn center care) that outstrip local and state medical assets. The ability to perform a rapid needs assessment, matching emergency health care requirements to available resources, is imperative. Few initial assessments will end up being 100% accurate, but setting the process in motion will allow timelines for response to collapse, and future updates and reassessments may recast medical requests. For disasters requiring medical response, requests for assistance are made through the local emergency management agency (EMA). Many of these will be organized into emergency support functions (ESFs) using the federal model outlined below, such as ESF-8 for health and medical care. That desk will typically receive and collate requests for medical or other health care assistance. These requests would then be conveyed to the mayor or town manager, who would make a formal request to the state governor for assistance if unable to fill them locally. While the requests for assistance are being processed through political channels, the local EMA will typically also directly inform the state EMA. A governor may first look to see if he/she can provide the necessary resources by activating the EMAC and requesting help from other states. Only a governor or his/her designee (for example, the state public health director) may make a formal request to the President for a disaster declaration. Once a federal disaster is declared, the Stafford Act is engaged. The Stafford Act provides a funding and resource allocation mechanism. It allows the President, through the Federal Emergency Management Agency (FEMA), to direct federal agencies to support a local disaster response, and to establish the rates at which states or individuals share in the cost of response and recovery. The president appoints a federal coordinating officer (FCO) to oversee the response in the involved region. This officer, working with FEMA, will task medical support requests to ESF-8. At the federal headquarters level, ESF-8 is overseen by the Office of the Assistant Secretary for Preparedness and Response (ASPR) within DHHS. DHHS has ten regional offices and the ASPR has regional emergency coordinators (RECs) in each of the regions. These individuals coordinate the ESF-8 response under the FCO\u2019s FEMA staff. Once this federal framework is established for a specific incident, detailed requests for assistance are formally passed by the state\u2019s emergency operations center to FEMA\u2019s National Operations Center (NOC). FEMA, in turn, validates the requests and converts the requests into mission assignments that are forwarded with appropriate funding to the most appropriate federal agency for completion.",
        "National Response Framework - History": "In May of 2013, the second version of the NRF was released. The updated NRF is the latest version of the document that guides the nation\u2019s response to all types of incidents. It is one of five documents that comprise the National Planning Frameworks. The NRF started as the Federal Response Plan (FRP), which was initially written in 1992. The FRP described the roles and responsibilities of the federal government in a disaster. It was revised in 2002 to incorporate the increased capabilities required after 9/11; that document was called the National Response Plan (NRP). In 2004, the NRP was updated to reflect the roles of the newly formed Department of Homeland Security (DHS). To address the experiences of the 2005 hurricane season, a final revision of the NRP was released in 2006. Stakeholders had many complaints about the NRP, including that it was bureaucratic, internally redundant, and did not describe all parts of the nation\u2019s response. The first version of the NRF, released in 2008, was designed to address these concerns and replaced the NRP.",
        "National Response Framework - Organization": "The NRF is made up of four parts: the base document and three sets of annexes. The base document is a \u201chow to\u201d guide for responding to all types of disasters and emergencies. It uses the scalable, flexible, and adaptable concepts of the National Incident Management System (NIMS) to align key roles and responsibilities. The annexes are separated into ESFs, support, and incident topics and make up the majority of the document.",
        "National Response Framework - Base document": "Version two of the NRF focuses on a \u201cwhole-community\u201d concept for preparedness and response activities. Engaging stakeholders \u2013 from individuals and families to businesses, faith-based organizations, and all levels of government \u2013 is essential to creating a resilient nation. The focus of the response \u201cmission area\u201d is to use the most appropriate resources to save lives, protect property and the environment, stabilize the incident, and provide for basic human needs. To do this, the document is broken down into seven sections: Scope, Roles and Responsibilities, Core Capabilities, Coordinating Structures and Integration, Relationship to Other Mission Areas, Operational Planning, and Supporting Resources.",
        "Annexes - Emergency Support Function annexes": "Emergency Support Functions are the primary operational-level mechanism that the federal government uses to provide assistance in specific areas. There are 14 ESFs (ESF-14 was superseded by the National Disaster Recovery Framework), each listed with their coordinating agency and a description in Table 4 of the NRF document. The ESFs can be activated independently as needed for a specific incident. Pieces from ESFs can be combined into a single operational branch or grouped to accomplish needed tasks. Each ESF has a coordinator, primary agencies, and supporting agencies. The coordinating agency is responsible for management oversight of the ESF during the planning, response, and recovery phases. The coordinator is responsible for maintaining contact with all primary and supporting agencies. A primary agency has significant responsibilities and capabilities in a specific ESF. Supporting agencies have specific capabilities important to the ESF.",
        "Annexes - Support annexes": "There are eight support annexes: Critical Infrastructure and Key Resources, Financial Management, International Coordination, Private-Sector Coordination, Public Affairs, Tribal Relations, Volunteer and Donations Management, and Worker Safety and Health. Each one describes functional and administrative processes that are required for nearly every event. Each annex is managed by one or more coordinating agencies and cooperating agencies. A coordinating agency is responsible for implementation of the processes described in the annex. Cooperating agencies possess specific expertise and capabilities related to the tasks in the annex.",
        "Annexes - Incident annexes": "There are seven incident annexes: Biological, Catastrophic, Cyber, Food and Agriculture, Mass Evacuation, Nuclear/Radiological, and Terrorism/Law Enforcement and Investigation. Incident annexes discuss policies, the situation (planning assumptions), concept of operations, and responsibilities related to each of the events described. As with the other annexes, a coordinating agency and cooperative agencies are named for each annex.",
        "Emergency Support Function 8: Public Health And Medical Services - Policies": "The Secretary of Health and Human Services, through the ASPR office and its Office of Emergency Management, oversees the preparedness, response, and recovery activities of ESF-8. All supporting agencies still have control over their respective assets after receiving coordinating instructions from DHHS. An emergency management group (EMG) is established at DHHS Secretary's operations center to coordinate with supporting agencies and maintain communication with the NOC during an ESF-8 response. ESF-8 representatives are also assigned to the National Response Coordination Center, as well as the Regional Response Coordination Center or Joint Field Office as needed to assist with field operations.",
        "Emergency Support Function 8: Public Health And Medical Services - Concept of operations": "DHHS has regionally based, rapidly deployable incident response coordination teams (IRCTs) that are flexible and scalable to provide a continuum of capabilities from early reconnaissance and assessments to full command and control of ESF-8 services. The initial actions that DHHS can make available are broken into the following functional areas. \u2022 Assessment of public health/medical needs \u2022 Health surveillance, medical care personnel \u2022 Health/medical/veterinary equipment and supplies \u2022 Patient evacuation \u2022 Patient care \u2022 Safety and security of drugs, biologics, and medical devices \u2022 Blood, organs, and blood tissues \u2022 Food safety and security \u2022 Agriculture safety and security \u2022 Worker safety and health \u2022 All-hazard public health and medical consultation, technical assistance, and support \u2022 Behavioral health care \u2022 Public health and medical information \u2022 Vector control \u2022 Public health aspects of potable water/waste water and solid waste \u2022 Mass fatality management \u2022 Veterinary medical support",
        "Emergency Support Function 8: Public Health And Medical Services - Select response components of ESF-8": "DHHS and its supporting agencies provide assistance in the form of tactical response teams, logistic support, operational support planning, and after-action assessments. The response capabilities are designed to fit into the functional areas listed above. Response teams can vary from small technical advisory groups to large-scale care delivery groups.",
        "National Disaster Medical System": "The Department of Defense, Department of Veterans Affairs, and FEMA joined with DHHS to form the National Disaster Medical System (NDMS) in 1984. Initially established through a memorandum of understanding and enacted into law in 2002, the NDMS has three missions: response, patient movement, and definitive medical care. Among the assets the NDMS has available are disaster medical assistance teams (DMATs) which are response teams sent in to reestablish medical care or augment existing definitive care in a disaster theater. The teams consist of a group of professional and paraprofessional medical personnel, supported by a cadre of logistical and administrative staff. A DMAT is self-sufficient for 72 hours and deployable, often within hours of a request, anywhere in the United States and its territories. Other NDMS assets include disaster mortuary operational response teams, international medical surgical response teams, and national veterinary response teams.",
        "US Public Health Service": "Deployment of US Public Health Service (PHS) Commissioned Corps officers to disasters is envisioned as a tiered response. The Tier 1 response consists of three scalable assets: the regional incident support team (RIST), the national incident support team (NIST), and the rapid deployment force (RDF). The RIST is a rapid response deployment team capable of responding to a crisis in its assigned region within as little as 4 hours. Its job is to coordinate the federal response. Its deployments are short term and designed to be quickly relieved by follow-on teams of the IRCT. The NIST is similar to the RIST but deployable nationwide. The RIST and NIST teams coordinate the initial federal response of public health and medical assets until the full IRCT is in place. The first available multidisciplinary health and medical unit designed to arrive and treat patients is usually the RDF. Each of five RDF teams is composed of a multidisciplinary team of 125 members. One team is on call in a given month for deployment within 12 hours. RDFs are designed to staff federal medical stations (FMS) and NDMS facilities. An FMS is a scalable 50\u2013100-bed sub-acute care medical facility that is cached until needed and then transported and set up in buildings of opportunity, such as convention centers or athletic arenas. The IRCT, EMG support teams, and the RDF complete the Tier 1 response. PHS officers may be assigned to IRCTs or may support the EMG at DHHS headquarters. The Tier 2 response includes applied public health teams and mental health teams. Tier 3 response elements include all active-duty commissioned US PHS officers not previously assigned to Tier 1 and Tier 2 response entities. Tier 4 includes the inactive US PHS reserve corps.",
        "Pandemic and All-Hazards Preparedness Act (Public Law 109-417) and Pandemic and All-Hazards Preparedness Reauthorization Act (Public Law 113-5)": "The Pandemic and All-Hazards Preparedness Act (PAHPA) created the ASPR at DHHS. PAHPA also provided authority for the creation of a National Health Security Strategy and the development and acquisition of medical countermeasures. Its reauthorizing statute, the Pandemic and All-Hazards Preparedness Reauthorization Act (PAHPRA), continued and expanded the ASPR's role in administering the Hospital Preparedness Program and addressing/enhancing medical surge capacity, and authorized funding for Project BioShield and other critical public health and medical activities.",
        "Defense support of civil authorities": "When response or recovery needs or capabilities exceed those available from local, state, and federal civilian authorities, medical (and other) assets of the Department of Defense can be made available.",
        "Legal authorities": "Laws, policies, and directives permit, in certain circumstances, the provision of direct emergency assistance by the federal government. Perhaps more importantly, many of these provisions establish a common framework for how to prepare for, and operate during, a large-scale public health or medical incident. The next section provides a brief overview of some of the laws and directives related to health and medical responses.",
        "Social Security Act (Public Law 74-271, as amended, 42 USC 7, et seq.)": "In addition to authorizing Medicare, Medicaid, and other programs administered by DHHS, this law authorizes the Secretary of Health and Human Services to temporarily waive or modify certain provisions of those programs during a presidentially declared disaster or national emergency.",
        "Emergency Management Assistance Compact": "Created in response to Hurricane Hugo through efforts in South Carolina and Florida, the Emergency Management Assistance Compact (EMAC) now covers all US states, territories, possessions, and the District of Columbia. If a state's resources are overwhelmed, that state's governor will issue a declaration of emergency specifically detailing the circumstances and remedies requested from other states through the EMAC. Specific provisions of the EMAC relating to physicians and allied health care personnel include temporary recognition of licenses, certifications, and other permits from the sending state by the receiving state. Once the immediate state of emergency has ended, a gubernatorial declaration will be issued ending the emergency, after which these health care providers must comply with the usual licensing requirements of the affected state.",
        "Robert T. Stafford Disaster Relief and Emergency Assistance Act (Public Law 100-707)": "This Act establishes the policy of the federal government to provide an orderly and continuing means of supplemental assistance to state and local governments in their responsibilities to alleviate the suffering and damage that result from major disasters or emergencies. It is the primary legal authority for federal participation in domestic disaster relief operations. Under the Stafford Act, the president may direct federal agencies, including most cabinet-level departments, to support disaster relief operations. The federal government may be directed to provide assistance in one of three different scenarios: presidential declaration of a major disaster, presidential order to perform emergency work for the preservation of life and property, or presidential declaration of emergency.",
        "Homeland Security Act of 2002 (Public Law 107-296)": "This Act established the Department of Homeland Security and gave it the authority and responsibility to coordinate all federal homeland security activities in order to protect the United States against threats to the homeland. In order to better enable the overarching homeland security mission, Congress merged numerous agencies into this single department. FEMA had been primarily responsible for coordinating the federal response to major incidents, and was one of the entities integrated into the DHS.",
        "National Guard (Title 32 of the US Code)": "Title 32 USC authorizes the use of federal funds to train National Guard members while they remain under the command and control of their respective state governors. There are certain instances where, through very specific statutory or presidential authority, these National Guard forces are allowed to perform civil support operations that are funded by the federal government, while the National Guard forces remain under the control of their governor. Examples include weapons of mass destruction civil support teams (WMD-CST) and 32 USC 502(f) Presidential/Secretary of Defense approved operations (e.g. the Border Security Mission in the Southwest).",
        "Homeland Security Presidential Directive 5 (HSPD-5): Management of Domestic Incidents": "This directive assigned the Secretary of the DHS as the principal federal official for domestic incident management, and charges him/her with coordinating the federal government's resources in response to and/or recovery from terrorist attacks, major disasters, or other emergencies. HSPD-5 established that the federal government will assist state and local authorities when their resources are overwhelmed or when federal interests are involved. One of the most important provisions of HSPD-5 was the directive to establish NIMS, a single and consistent nationwide approach for federal, state, and local governments to work effectively and efficiently together to prepare for, respond to, and recover from domestic incidents. It also directed the development of the NRF that incorporates the NIMS to provide high-level policy, structural mechanisms, and operational guidelines for federal support to state and local incident managers.",
        "Presidential Policy Directive 8 (PPD-8): National Preparedness": "This directive recognizes the shared responsibility of the government (local, state, and federal) as well as the business community and individual citizens in fostering a secure and resilient nation. The national preparedness goal lays out the core capabilities required for preparedness and a national system to guide activities aimed at reaching that goal. The directive was released on March 30, 2011 and replaced HSPD-8.",
        "Homeland Security Presidential Directive 21 (HSPD-21): Public Health and Medical Preparedness": "This directive addresses preparedness for natural and man-made catastrophic health events that overwhelm the capabilities of immediate local and regional response and health care systems. Potential events include pandemic influenza and an event involving the use of a nuclear, biological, or other weapon of mass destruction. HSPD-21 addresses four main areas: biosurveillance, countermeasure distribution, mass casualty care, and community resilience. This presidential directive was released on October 18, 2007."
    },
    {
        "Introduction": "In the United States, and much of the rest of the world, medical direction of EMS is today widely endorsed and recognized as an essential component of any EMS system. However, this has not always been the case. In the landmark 1966 white paper Accidental Death and Disability, the Neglected Disease of Modern Society, the role of physicians in prehospital care was envisioned as that of potentially staffing ambulances to provide direct patient care, similar to the role that physicians play today in other countries, particularly in Europe. While there were a few efforts in the US in the late 1960s, in places such as Columbus, Ohio, to engage physicians in providing prehospital care, these efforts largely gave way to the use of 'physician surrogates' who soon became known as paramedics. These providers were initially trained and supervised by physicians to provide advanced prehospital care, especially to victims of sudden cardiac arrest or trauma. Within a few years, national standard curricula were developed by the US Department of Transportation, which standardized the training of paramedics and included requirements for physician oversight of the education of paramedics and the care they provide in the field.\n\nOf note, the Emergency Medical Services Systems Act of 1973 made no reference to the need for medical direction. When the EMS program at the Department of Health, Education, and Welfare (DHEW) subsequently developed the 15 essential components of an EMS system, they did not include medical direction as one of them. Despite these omissions, during the rapid development of EMS systems during the late 1960s and 1970s, medical direction of EMS became a de facto standard, especially for ALS providers. Although it was not considered one of the essential components, DHEW did eventually make medical direction for ALS a requirement for awarding grants. In 1988 the National Highway Traffic Safety Administration included medical direction as one of the ten essential components for state EMS technical assessments. The EMS Agenda for the Future in 1996 identified the need for medical direction for all levels of EMS providers, a principle that was thereafter incorporated into the US Department of Transportation's national standard curricula for EMS providers, including those for EMTs. Medical direction remains a component of the National EMS Education Standards today.\n\nOver the past 40 years, the role of the EMS medical director has evolved and has become more clearly defined through the efforts of the National Association of EMS Physicians, the American College of Emergency Physicians, federal agencies, and national organizations to encompass all aspects of an EMS system. Peer-reviewed journals, including one dedicated solely to prehospital care, have enhanced the science behind the provision of care to patients in the out-of-hospital setting, including the roles and effectiveness of an EMS medical director. Additionally, the cognitive and skills requirements for EMS medical directors have been refined through the publication of textbooks on EMS medical direction, guidelines for EMS fellowships, and, more recently, the development of an American Board of Medical Specialties (ABMS) approved subspecialty in EMS.\n\nThe role of the EMS medical director over the past decade has continued to evolve and, more recently, may be accelerating. The events of September 11, 2001 have drawn many EMS medical directors into a much more active role in disaster planning and response. More recently, H1N1 and other emerging infectious diseases have required medical directors to address issues ranging from EMS provider safety and surge mitigation, to the storing and dispensing of medical countermeasures. Recent efforts to utilize EMS providers in communities to address a broader range of medical care and public health issues have engaged EMS medical directors in discussions and planning on how to safely and effectively provide oversight for these emerging EMS roles. EMS medical directors have traditionally felt responsible for the emergency care provided in their communities and, therefore, have taken a public health- and population-based approach to what they do. These new and expanded roles for EMS will necessitate a reconsideration of the education and preparation of EMS providers, and perhaps medical directors, to take on these new roles and how to best ensure that EMS systems continue to function safely and effectively.",
        "The evolution of the subspecialty of EMS": "In the late 1960s and 1970s a relatively small group of dedicated physician mentors recognized the need for improvements in prehospital care to address major public health issues that were resulting in needless deaths. In cities such as Miami (Gene Nagal), Los Angeles (Michael Criley), Charlottesville (Richard Crampton), Baltimore (Peter Safer), Columbus (James Warren), and Seattle (Leonard Cobb and Michael Copass), they advocated for trained and supervised prehospital providers to care for patients with sudden cardiac arrest, trauma, and other life-threatening emergencies. These physicians were well recognized in their chosen specialties but, at the time, it is doubtful that they recognized that they were laying the foundation for what would eventually become a formal subspecialty in EMS.\n\nOver the ensuing years, as systems were required by grants or state rules to appoint EMS medical directors, a number of physicians assumed the role. Some did so out of interest or a sense of community service, others perhaps because they were asked to take on responsibilities that no other physician was willing to assume. Many of these physicians served admirably, but moved on. However, as the decades went by, an increasing number of physicians became EMS medical directors because they were genuinely interested in prehospital care. Many were (and still are) former EMS providers who wanted to get back on the street and take on the responsibilities of an EMS medical director.\n\nOver time these physicians came to view their medical director roles as the practice of EMS. A little over 100 physicians met in Hilton Head, South Carolina, in 1985 and subsequently formed the National Association of EMS Physicians. Several decades later, with the support of the American College of Emergency Physicians and other national specialty groups, they successfully petitioned the American Board of Emergency Medicine and the American Board of Medical Specialties to establish a subspecialty in EMS.\n\nAs with the specialty of emergency medicine, it is likely that the growth in the number of EMS subspecialists will not meet the demand for some time. There will continue to be challenges in recruiting EMS medical directors, particularly when a position is uncompensated and/or in a rural area. We should anticipate that EMS subspecialists will initially be employed by larger municipal systems, academic centers, state and regional systems, and national commercial providers. It is therefore likely that, for some time to come, we will continue to see physicians serving as local EMS medical directors who are not EMS subspecialty physicians.",
        "State requirements for EMS medical direction": "In the United States, the regulation of health care, including EMS, is by and large the responsibility of the states. While there may be national consensus on the need for medical direction, there is significant state-to-state variation on the legal requirements for it. States generally require medical direction for ALS, but there is considerable variation in the requirement for medical direction at the BLS level. Additionally, the role of the medical director and his or her qualifications vary from state to state. There are some states in which the state EMS agency has limited or no statutory authority over BLS providers and, therefore, even if they wished to mandate medical direction at the BLS level, they lack the authority to do so. Some states are also challenged with insufficient numbers of physicians willing to take on the role of the EMS medical director, particularly in rural areas.\n\nState laws and rules significantly affect the role of the medical director. Most states require a medical director to be engaged in education, credentialing, protocol development, and quality assurance. However, depending on the state, these functions may be performed variously at the local, county, regional, or state level. It is important for a medical director to be cognizant of the state laws and regulations for medical directors as well as the liability protections that may be provided through state law. Additionally, medical directors must be cognizant of federal laws and regulations that can affect their role and responsibilities.",
        "Barriers to effective medical direction of EMS": "Over the past four decades, the medical knowledge base and skills set required for EMS medical directors have been increasingly well defined. There are, however, other skills that are essential to the success and longevity of an EMS medical director, including, among others, leadership, administrative, and political skills. By the very nature of their role, EMS medical directors must be able to develop a vision, articulate it, and then effect change. Every EMS system poses its own unique combination of challenges whether it is a state, local, air, ground, fire-based, third-service, private, volunteer, rural, urban, BLS, ALS, or critical care system. It is the task of the medical director to recognize these challenges and effectively manage them.\n\nWhile the role of an EMS medical director may have been increasingly well defined and standardized at the national level, the authority and resources provided to an individual medical director by a given system or service most certainly have not. It is not uncommon to find a medical director with the title \u201cmedical advisor\u201d and/or with limited authority. Many medical directors lack response vehicles, communications equipment, or staff support. The title, authority, compensation, and resources provided to a medical director should be defined in a formal contract or job description and must be appropriate for the service or system that they serve and be commensurate with their responsibility for the patient care that is provided. A recent study suggests that EMS systems with engaged and compensated medical directors were more likely to have prehospital cardiovascular procedures in place. Volunteer EMS providers are less likely to have recent contact with their medical director than their counterparts in hospital-based and county/municipal services.",
        "Indirect medical oversight": "In most EMS systems, indirect medical oversight encompasses the majority of a medical director\u2019s activities and responsibilities. It is the process through which medical directors influence the practice of prehospital medicine in their communities. Credentialing of EMS providers, quality assurance and performance improvement (QA/PI), and protocol development are all examples of how medical directors engage in indirect medical oversight.\n\nAnyone in need of emergency medical services has the right to expect the highest quality evidence-based emergency medical care. From the initial 9-1-1 call to the medical care rendered on scene and even at the hospital, medical directors have the opportunity to positively affect the emergency medical care that is provided to each patient. Each EMS system is unique, and the medical director is responsible for providing clinical leadership that is tailored to the community\u2019s needs.\n\nThe delivery of EMS is influenced by many factors including the health of the population, the availability of resources, and the proximity of acute care hospitals. Medical directors must have a nuanced understanding of system needs and resources and use that understanding to ensure the delivery of the highest quality prehospital emergency medical care possible within that community. This section discusses various elements of indirect medical oversight and highlights the corresponding responsibilities of the EMS medical director.",
        "EMS provider education": "The system medical director must understand and be able to articulate a comprehensive vision for EMS provider education. In most systems the educational requirements for the licensure of EMS providers will be established by the state. Over the past decade, states have increasingly been adopting the principles of the EMS Education Agenda for the Future: A Systems Approach, which espouses the use of national EMS education standards, national certification as a prerequisite for state licensure, and the accreditation of EMS education programs.\n\nAt the local level, the initial and ongoing educational requirements for EMS providers may be affected by the local system. System medical directors may require additional initial and ongoing provider education to address local needs and ongoing QA/PI activities. These medical directors are frequently engaged in providing medical oversight for initial EMS provider training and, in such situations, may have the opportunity to address these needs prior to state licensure.\n\nThe medical director must have a strategy to ensure the retention of skills by EMS providers. An active continuing education program can address the challenges of knowledge and skills retention and ensure continued provider competency. Educational approaches are also essential to address QA issues such as deficiencies in 12-lead ECG interpretation or airway management, as well as the implementation of new protocols or the dissemination of the latest in evidence-based approaches to prehospital care.",
        "Verification of competency and EMS provider credentialing": "Other important components of indirect medical oversight include the verification of competency and credentialing. At its most basic level, competency equates with a provider\u2019s ability to safely and adequately perform patient care. Competency is predicated on the provider\u2019s ability to synthesize appropriate information, make effective medical decisions, and safely perform interventions. Credentialing is the process that grants an EMS provider the privilege to perform a prescribed role and specific skills within a service based on competency. A local credentialing process should include meetings with the medical director, chart reviews, field observation, and simulated patient encounters.\n\nThe medical director should establish criteria for initial and continued competency and conduct regularly scheduled provider reviews. The issue of competency is particularly important with certain low-frequency, high-impact patient care skills such as endotracheal intubation. Opportunities for intubations have been declining and it has been well established in the scientific literature that competency in the particular skill of endotracheal intubation is especially predicated upon frequent practice. In the absence of a clear national standard for minimum intubations, medical directors must develop an effective plan for maintenance of this core skill. Literature suggests that intensive physician oversight is associated with increased intubating proficiency.\n\nFinally, the medical director must have the authority to address the issue of EMS providers who are deemed to be incompetent or impaired to such an extent that they pose a threat to the public. To address this issue, the local credentialing process must enable a medical director to immediately suspend or limit the privileges of an EMS provider and to develop a plan for remediation, if that is deemed appropriate. In such circumstances, there should be a system of due process that is available to the provider.",
        "System quality assurance and performance improvement": "Quality assurance and performance improvement efforts comprise a large portion of indirect medical oversight responsibilities. Medical directors must actively monitor both provider and system performance to achieve and maintain a high standard of patient care. Quality assurance ensures that performance is as it should be. Performance improvement monitors processes and outcomes in an effort to augment and improve the overall quality of patient care.\n\nWhen deficiencies are identified through the QA process, the program must provide the necessary changes to the system and/or retraining and remediation of the providers. QA is not a punitive process. Indeed, a well-structured QA plan prescribes corrective action, elucidates root causes, and educates providers.\n\nPerformance improvement is an effort to improve patient outcomes, which requires that EMS patient care records be linked with hospital outcomes. Recent advances that EMS systems have made in improving historically poor outcomes from sudden cardiac arrest are demonstrative of the positive effects of PI. Over the past decade, medical directors in a number of EMS systems have established comprehensive processes for monitoring sudden cardiac arrest outcomes while making incremental changes to improve the delivery of prearrival instructions for CPR and the quality of CPR on scene. With such PI efforts, outcomes particularly for witnessed ventricular fibrillation arrests have been reported to have risen significantly in a number of jurisdictions.\n\nQuality assurance and performance improvement efforts may be performed in a number of ways. Retrospective activities include review of patient care reports, provider debriefings, incident reviews, and analysis of EMS data and outcomes. Concurrent activities generally include the monitoring of care in the field by the medical director, field training officers, or EMS supervisors, and through simulated patient encounters.\n\nElectronic patient care reports are increasingly more available, giving medical directors unprecedented access to both the patient care reports and system data. Additionally, electronic summaries from monitors/defibrillators permit a detailed analysis of vital data, such as CPR compression density and depth and the timing of critical interventions. The widespread proliferation of waveform capnometry affords a similar level of patient care surveillance. Providers now can confirm endotracheal tube placement with near 100% accuracy and immediately recognize tube dislodgment or migration. Incorporating new technologies and using electronic patient care reporting establishes a vital link between patient care and the QA/PI processes.\n\nSystem benchmarking is another useful tool in the QA/PI armamentarium. The ability to do benchmarking has markedly improved with the development and availability of electronic patient care reports and the establishment of the National EMS Information System (NEMSIS), which defines EMS data elements and is building a large repository of EMS data from all across the country. Benchmarking through NEMSIS, and other large databases such as CARES, enables medical directors to evaluate their systems against a template of system, clinical, and patient outcome data. In 2008 a position statement published by the US Metropolitan Municipalities EMS Medical Directors called for the development and use of patient-centered measures of system performance. Potentially useful clinical benchmarks include the administration of aspirin for suspected cardiac chest pain, minimization of on-scene intervals for victims of penetrating trauma, and the use of non-invasive ventilation for respiratory failure.\n\nFinally, QA and PI activities must include access to outcome data from hospitals. Patient outcomes are essential to understanding how prehospital interventions affect patient care. While prehospital data might indicate an increase in the return of spontaneous circulation, this is not the same as the percentage of patients who survive to hospital discharge and are neurologically intact. Patient care outcomes are affected by both prehospital and hospital care. The medical director must consider the entire continuum of care when evaluating the quality of care delivered to patients served by the EMS system.",
        "Field clinical supervision": "Field clinical supervision by the medical director is sometimes viewed as a component of the QA/PI processes but, in fact, it is much more. Medical directors in the field have an opportunity not only to assess the performance of providers and the system, they have an opportunity to mentor, engage in hands-on patient care, and learn firsthand about the challenges faced by providers. Medical directors who are active in the field uniformly report that the time that they spend on the street is not only productive, it is one of the most enjoyable aspects of their jobs.\n\nMany medical directors today functioned as EMS providers at some time in the past. This is a benefit in preparing a medical director for field clinical supervision. Medical directors who lack that experience should invest some time in getting oriented to \u201clife on the street.\u201d First and foremost, there are safety issues that must be considered as well as the many formal and informal rules and protocols that must be followed. Medical directors who understand these issues are able to insert themselves seamlessly into an incident and will garner significant credibility with EMS providers.\n\nMedical directors can perform field clinical supervision by riding with supervisors, but there are limitations to this approach. It is preferable for a medical director to have an assigned response vehicle that enables him or her to respond from wherever he or she may be to mass casualty incidents or unusual occurrences, or to focus attention on particular incidents that are a priority in the QA/QI process. Medical directors who have assigned response vehicles should meet the same training and performance requirements as other members of the service who drive emergency vehicles. The vehicles must be appropriately equipped for emergency response and have communications equipment and medical supplies, including a defibrillator, and should ideally undergo the same state inspections and credentialing as other EMS vehicles. The medical director must have appropriate personal protective equipment (PPE).",
        "Protocol development": "The specifics of any region\u2019s EMS system will determine the role of the medical director in protocol development. Some systems function under state-wide protocols, and others use regional or local protocols. Regardless, medical directors must be leaders in protocol development and continuous review.\n\nThe evolution of EMS as a medical subspecialty parallels the growing evidence base for the practice of prehospital medicine that has been published over the past several decades. Historically, EMS protocols were extrapolated from in-hospital practice. Today, they are more often developed using scientific literature derived from prehospital studies, with input from EMS physicians and prehospital professionals. Medical directors must ensure that protocols are relevant and appropriate for the local system by taking available resources and community needs into consideration. In developing protocols, the medical director needs to be familiar with the existing scientific literature and the evolving evidence-based guidelines and model protocols that are available today.\n\nAlthough protocols reflect the needs of any given EMS system, basic principles of treatment and transport destination should embrace the best available evidence. Protocol development is anything but a static process and medical directors must commit to regularly scheduled audits of prehospital practice and modify treatment protocols as appropriate. Finally, emergency medical dispatch protocols affect the first interaction between an EMS system and the citizens it serves. Physicians should be engaged in the implementation and quality review of dispatch protocols.\n\nWhile prehospital protocols have historically varied from system to system, there is a growing trend toward more standardization. Since 2008 the National Highway Traffic Administration and the EMS for Children Program have collaborated with a working group composed of prehospital providers, physicians, and administrators. The working group used the GRADE process to review current evidence with respect to field pain management and the air medical evacuation of trauma patients. It is anticipated that this project will form the foundation for a process to develop evidence-based guidelines in the future.\n\nMore recently, the Medical Directors Council of the National Association of State EMS Officials has been developing model protocols. Many agencies, both in the United States and abroad, post their protocols on the internet. The National Association of EMS Physicians addresses potentially controversial issues through its Standards and Clinical Practice Committee. Thus, there is an evolving set of resources available to assist medical directors in developing EMS protocols.",
        "Designation and oversight of base stations": "In most systems, direct medical oversight is delegated to \u201cbase stations.\u201d A base station is best defined as a hospital emergency department or health care facility that is designated to provide EMS personnel with direct medical oversight. In a centralized approach, one physician and/or one base station provides that direction for the entire system. More typically, depending on the system, there is more than one designated base station. In fact, it is not uncommon for all receiving facilities to be designated as base stations.\n\nThe designation of a base station involves much more than tasking an available emergency department with medical oversight for providers in the field. Typically, depending on the system, the local, regional, or state medical director will establish criteria for the designation of base stations and a process to ensure that base stations continue to function at an acceptable level.",
        "Designation and oversight of trauma and specialty centers": "Regionalization of care from an EMS standpoint is the transport of patients to the hospital that is most appropriate for a patient\u2019s condition. This may entail bypassing hospitals that are not staffed or equipped to provide timely definitive care to the patient. A well-known phrase, \u201cthe right patient, to the right hospital, in the right time, with the right care,\u201d is used to describe this concept. Since the early 1980s, regionalization of trauma care has been advocated to reduce deaths and improve outcomes by transporting selected patients to trauma centers. Since that time, the core principles learned in the development of trauma systems have been applied to the development of stroke, STEMI, and, more recently, cardiac arrest systems of care.\n\nAs with base stations, an EMS medical director may need to establish criteria and a process for the designation of trauma and specialty centers and ensure that the designated centers continue to function at an acceptable level and maintain good risk-adjusted patient outcomes. Fortunately, there are national standards available to assist in that function. The American College of Surgeons, Committee on Trauma publishes standards for trauma centers and has a process that will verify that the trauma center meets those standards. Similarly with stroke centers, the Brain Attack Coalition has published standards and the Joint Commission has a certification process for stroke centers. There are also standards for cardiac interventional centers for STEMI patients published by the American College of Cardiology and the American Heart Association as well as the Society for Cardiovascular Patient Care, which has an accreditation process for chest pain centers.\n\nTo implement regionalization of emergency care, medical directors must start with the development of protocols and thoroughly educate EMS providers on criteria for the triage of patients to trauma and specialty centers. To ensure that trauma and specialty centers are continuing to function with good risk-adjusted outcomes, medical directors must require that designated centers provide patient care and outcome data as a condition of designation. In Arizona, for example, hospitals designated as \u201cresuscitation centers\u201d share patient outcome information with the referring EMS agency and there is now a CDC-sponsored CARES national registry for tracking the both prehospital and hospital outcomes of patients with cardiac arrests. In Maryland and many other states, trauma centers are required to provide data to a trauma registry and the American College of Surgeons maintains a national trauma data bank. The American College of Cardiology has a STEMI registry and the American Stroke Association maintains a stroke registry into which hospitals may submit data. It is essential to ensure that the medical director has access to these registries and is able to link patients in the registries with prehospital reports.\n\nThe use of registries enables medical directors to benchmark system and hospital performance with risk-adjusted outcomes. These should be reviewed regularly by the medical director.",
        "EMS provider safety and well-being": "In most EMS systems the role of the EMS medical director does not include providing occupational medicine services. That said, medical directors must, nonetheless, prioritize EMS provider safety and well-being and advocate for these important issues. The medical directors\u2019 training and knowledge of EMS places them in a unique position to understand the health risks posed to EMS providers and then promote the development of a robust safety and well-being program for their providers.\n\nThe principal causes of work fatalities for EMS providers are transportation related; therefore, EMS medical directors should advocate for improvements in ambulance safety, including ambulance design, construction, and markings, as well as ensuring that there are policies that address occupant protection, driver screening and training, and the prudent use of lights and sirens. On-scene safety should also be addressed through the development of policies that are consistent with the Traffic Incident Management Systems program at the US Fire Administration, the Emergency Responder Safety Institute, and the US Department of Transportation.\n\nEmergency medical services providers are also at risk for assaults, back, and other injuries. Medical directors should work with administration to ensure that there are policies in place to minimize the likelihood of assaults and that ambulances and stretchers are designed to be as ergonomically friendly as possible. Medical directors should advocate for EMS providers to have access to appropriate PPE and be instructed in how to avoid exposures, especially to blood-borne and respiratory pathogens such as influenza and SARS.\n\nLast but not least, the medical director should advocate for a wellness program, which is known to reduce injuries, absenteeism, and even deaths through the promotion of healthy lifestyles. Such a program should, at a minimum, include initial health screening, ongoing monitoring, weight control, physical fitness, and access to stress incident counselors when necessary.",
        "EMS administrative issues \u2013 management and finance": "Though not a primary role, EMS medical directors have a vested interest in the management and financing of EMS systems. They should therefore be knowledgeable and informed on these issues and be given the opportunity to provide input into management and budgetary decisions that potentially affect patient care. Budgetary advocacy may extend beyond the EMS service and include advocacy directed to the public, local and state governments, and the media. These activities are best done in conjunction with administration and, when appropriate, other stakeholder groups including labor organizations.",
        "Legal and regulatory issues": "Both federal and state laws and regulations potentially affect the roles and responsibilities of an EMS medical director. At the state level, there may be state laws that place requirements or limits on EMS medical directors with respect to protocol development, EMS provider certification and licensure, quality assurance, reporting of suspected abuse, EMS worker safety, the registration and management of controlled substances, and others. The state may also impose educational requirements on the EMS medical directors themselves, including for continuing medical education.\n\nThere are several dozen federal laws and federal agencies that have a potential effect on or regulatory authority over EMS systems, and many of these can create responsibilities and pose challenges for the EMS medical director. A medical director should be familiar with all of these laws and know how they potentially affect his or her roles and responsibilities. Of particular concern to EMS medical directors are recent federal enforcement efforts related to controlled substances and reimbursement by Medicare.\n\nIn order to carry and administer controlled substances, EMS services must be registered with both the state and the US Drug Enforcement Administration (DEA). State laws related to controlled substances vary from state to state and this variation can, in turn, affect how federal rules are applied by the DEA in a particular state. Since it is common for an EMS agency\u2019s controlled substance registration to be held by the medical director, it is critical that the medical director be knowledgeable about these laws. In the past several years, the DEA has taken enforcement action against several EMS medical directors and some of these actions have resulted in large fines, the loss of medical licenses, and criminal charges.\n\nAnother issue of concern is the enforcement of federal laws regarding Medicare reimbursement by the Centers for Medicare and Medicaid Services (CMS). There are strict rules for the reimbursement of ambulance services provided to Medicare beneficiaries. Failure to observe these rules may result in fines as well as criminal sanctions. While medical directors may be only peripherally involved in billing activities of the service, one recent investigation resulted in the subpoena of the correspondences of the medical director to determine if he was complicit in the alleged improper billing practices of the service.\n\nBy law, the reimbursement for ambulance services by Medicare is limited to when ambulance transportation is provided and is medically necessary. CMS guidance defines medically necessary as meaning that transport by any other means is contraindicated. If the service bills for reimbursement at the ALS level, that level of care must be medically necessary as well. Medical necessity for an ALS reimbursement means that one or more ALS interventions were performed or that the condition of the patient warranted an assessment by an ALS provider, even if no ALS intervention was performed. The CMS rules for non-emergency transports are even more restrictive. Over the past several years, CMS has increased the number of audits of EMS services and several have included the participation of the US Department of Justice. Medical directors should be familiar with the CMS regulations on the coverage of ambulance services, which can be found in the Code of Federal Regulations (42 CFR 410.4).\n\nMedical directors needing guidance should approach their state EMS offices, regional or state EMS medical directors, or other experienced medical directors. Specific questions can be directed to the appropriate state or federal enforcement agency.",
        "EMS research": "Emergency medical services research is the foundation upon which the burgeoning EMS subspecialty was built, and has the potential to improve patient outcomes. Medical directors should have an understanding of how to design and conduct studies and educate EMS administrators and providers on the need for and benefits of prehospital care research. While not all EMS systems will have the resources and ability to conduct rigorous and comprehensive randomized prospective studies, most have the capability to participate in some way, be it publishing anecdotal case reports or case series, or participating in a regional or national study.",
        "Public health \u2013 public education, prevention, and response to catastrophic health events": "Emergency medical services has been described as the intersection of public health, health care, and public safety. EMS medical directors should provide the leadership to engage EMS systems in public health activities that have the potential to improve EMS outcomes as well as the overall health and wellness of the community.\n\nOver the past several decades, clear evidence has emerged that when EMS systems promote CPR training and AED use in the community, there are increases in the percentage of patients who survive prehospital sudden cardiac arrests. Similarly, EMS systems should engage in injury prevention education that has the potential to reduce the frequency and severity of injuries. Examples include education on the use of seat belts and helmets, fall recognition and interventions in the elderly, distracted driving, fire prevention and fire alarms, and childhood drowning. Public education on the signs and symptoms of acute stroke and STEMI and when to call 9-1-1 has been undertaken in an effort to reduce the time to definitive care.\n\nEmergency medical services data are useful in identifying trends in death, illness, and injury in the community and should be used and incorporated into the local public health system\u2019s surveillance data to identify where there is a need for public health education, investigations, and potential interventions. The EMS medical director needs to be prepared to monitor and support public health responses to major disease outbreaks such as pandemic influenza or SARS. Outbreaks have the potential to affect not only the public, but EMS and health providers as well. EMS providers may be some of the first victims of an outbreak, as was the case with SARS in Canada and Taiwan. Medical directors should work with their EMS systems to develop contingency plans to modify dispatch, on-scene, and transport protocols in the event that demands begin to exceed the availability of EMS and community health resources.\n\nSince the events of September 11, 2001, EMS and public health officials have worked together at the local, state, and federal levels to improve our response to catastrophic health events, be they man-made or otherwise. These planning efforts have been directed toward integrating public health, EMS, and health care resources to improve the overall response and to mitigate the impact of the incident. Medical directors are key stakeholders in planning and responding to such incidents.",
        "Direct medical oversight": "Direct medical oversight refers to real-time physician-directed care. Direct medical oversight may be provided by a physician who is either physically or remotely present. The majority of modern direct medical oversight occurs in the provision of online medical direction via telephone, radio, and, at times, video consultation. As opposed to indirect medical oversight, there is immediate feedback to the quality assurance and improvement program and immediate impact on patient care. Online medical direction is provided remotely but, although the technology facilitating this interaction continues to improve, it does not replicate the physical presence of the medical director.\n\nWhile the bulk of direct medical oversight is performed remotely, the necessity and value of a physician\u2019s presence in the field cannot be overstressed.\n\nAs EMS systems developed and the need for physician \u201csurrogates\u201d was recognized in the 1970s, medical direction was pioneered by a dedicated cohort of physicians who trained and continuously supervised a group of paramedics who would themselves become trainers and supervisors. These physicians had physical presence and medical authority with a close knowledge of the individual paramedic\u2019s training and skill level. Unfortunately, this level of physician involvement in both training and medical oversight proved extremely difficult to maintain. Many EMS systems developed without strong physician input or field presence. EMS systems and the role of direct medical oversight within them evolved in ways as varied as the communities which they served. Some, but not all, jurisdictions would legislate for a medical director although often without fully delineating his or her role or level of training. Regardless of the medical director\u2019s level of involvement, the constants remained: an expectation of competent and quality prehospital care, and of continuous and immediately available medical direction. The solution to limited physician interest and involvement, as well as the potentially crushing requirement of a constant presence for an ever-expanding service, moved direct medical oversight to the emergency department where the elements necessary for online medical direction could easily be established and were readily available.",
        "Online medical direction": "The most basic elements of an online medical direction program include an available physician and reliable communications, but there are a number of additional elements required to make that system functional. In the case of an EMS base station, the EMS Medical director delegates his or her responsibility for medical oversight to the online medical direction physician at the base station, and therefore must ensure that such direction is appropriate. The previous section on indirect medical oversight discussed the designation and oversight of base stations by the system medical director.\n\nThe online medical direction physician should have experience in the emergency department managing the acutely ill or injured patient and, as the medical authority who answered the call, have a clear understanding of his or her responsibility to the patient and provider. The physician must be familiar with local prehospital protocols as well as the design and operation of the entire EMS system, and be knowledgeable in the use of communications equipment and radio etiquette. He or she should have a thorough understanding of the quality assurance program and an ability to provide appropriate feedback to providers, the EMS medical director, and systems managers. These qualifications are typically obtained in the process of emergency medicine residency training and should be reinforced by the EMS system's medical director through a formal training program for physicians providing online medical direction.\n\nThe EMS system also depends on written policies, procedures, and protocols to develop and sustain an online medical direction program. There must be written policies that delineate the roles and responsibilities of physicians and prehospital providers. Evidence-based EMS protocols help to promote uniformity in care. Most systems have evolved from the practice of strict medical direction, which previously required base station contact for all patients. The safety and efficacy of 'standing order' protocols have been demonstrated and a vast majority of EMS transports occur without online medical consultation. At the same time, the benefits of online medical direction have not been clearly demonstrated outside limited instances of patient care refusals, with some potential in reducing emergency department overcrowding through transport destination decisions. Indications for online medical directions in a given EMS system should be clearly delineated. Written procedures inform both parties as to when consultation is necessary, when it is expected, and how quality assurance issues such as protocol deviations and skills shortfalls should be addressed. EMS medical directors and other EMS system managers depend on base station physicians to provide feedback on provider and system performance.",
        "Impact of communications technology on online medical direction": "There has been significant discussion about the importance of communication between the base station physician and the EMS medical director with regard to quality assurance and performance improvement, although developing this relationship would be less effective without reliable and recordable communications between base stations and prehospital providers. The technologies enabling these communications are continuously evolving, and this will most certainly have a significant effect on how online medical direction is conducted.\n\nIn the 1970s the federal government set aside a limited number of VHF channels for communicating by voice with the physician at the base station. The potential usefulness of these frequencies was significantly reduced by the limited range of transmissions and frequent interference. Eventually, these channels were supplemented by eight UHF channels, which reduced interference, improved reliability, and enabled an increase in the use of analog ECG telemetry. The number of available UHF channels for base station use has recently been increased through the actions of the Federal Communications Commission and a process referred to as narrowbanding.\n\nThe rapid development of cellular phone networks has led to their increased use as a method of contacting base stations for medical orders and 12-lead ECG transmissions. Maintaining a recording of these radio or phone consultations is essential to the QA/PI process and must be a consideration in system design. While the discussion of online medical direction to this point has focused on the emergency department base station, there are jurisdictions that may rely on the medical director or directors for online medical direction. While this practice may provide significant benefit to the system, communications should be routed through a central communications center where a recording can be maintained for QA/PI purposes.\n\nThe advent of broadband wireless technologies and the widespread utilization of smartphones by the lay and medical communities are naturally causing increased interest in advancing telemedicine applications in EMS. Telemedicine has been used by EMS since the 1970s when analog ECG telemetry was employed to send rhythm strips to the emergency department for physician confirmation. Today, the use of ECG telemetry has become much less common and has recently been supplanted by the transmission of 12-lead ECGs for prehospital cardiac catheterization lab activation. Cellular telephones equipped with cameras are often used to photograph crash scenes by patients and prehospital providers. Smartphones with photo and video capabilities and ubiquitous data connections present a simple and fast method of transmitting images of 12-lead ECGs, scene surveys, and patient assessments. The ease of increased connectivity must be tempered by the need to preserve the medical record while maintaining patient confidentiality and standards consistent with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).\n\nTelepresence is the next anticipated advancement for online medical direction and has been tested in a few areas of the United States. While initial successes have been noted in assisting with destination determinations in trauma and improved success rates with video-assisted intubation, budgetary constraints have been confounding factors. Technologies have been developed which allow for recorded video and audio streaming as well as real-time transmission of physiological data, pulse, respiratory rate, temperature, invasive and non-invasive blood pressure, capnography, and ECG telemetry. This has broad implications for the future of prehospital care and potential expansion of role of paramedics in the field.\n\nTelepresence would simulate the physical presence of the medical director or base station physician in the field, demonstrating a significant contribution to QA/PI programs.",
        "On-scene medical direction": "Despite these advances, the value of having the EMS medical director in the field cannot be overstated. As with our pioneer EMS medical directors, these interactions in the clinical environment provide opportunities for education and evaluation that cannot be simulated or provided remotely. Frequent physical presence of EMS medical directors on scene improves their understanding of the environment and allows them to develop a rapport with providers that ultimately facilitates educational and QA/PI activities.\n\nThe superiority of bedside teaching has clearly been identified in medical literature. All physicians have experienced the benefits of bedside teaching and should take a similar approach with prehospital providers. Familiarity, and the expectation that the EMS medical director is often on scene, will put the provider at ease and is a behavior that needs to be trained. Introductions to the patient, when possible, and to other individuals on the scene are recommended. While the EMS medical director is certainly responsible for the care of the patient, his or her primary role is to evaluate whether providers will come to a diagnosis and develop a treatment plan, assisting them with their assessment through Socratic questioning only if it becomes necessary. Similarly, treatment plans should be carried out by the prehospital providers, with positive or corrective feedback provided when necessary. There are also benefits to serving as a role model when teaching physical assessment and skills. The EMS medical director should step in when those rare instances of particularly difficult procedures occur or if additional support is needed, but only as a last resort. The EMS medical director should be provided with the appropriate tools and protections to facilitate this activity.",
        "Direct patient care in the field": "Although most of the on-scene responsibilities of the EMS medical director will involve the direct medical oversight of EMS personnel, there are instances in which it may be both appropriate and necessary for the medical director to provide direct medical care. Medical directors must be aware of the various potential scenarios in which their expertise in providing direct patient care is needed. These scenarios may present themselves without warning, so it is imperative that guidelines be developed that address this possibility and support optimal patient outcomes. While these scenarios may be relatively rare, contemporary EMS systems will incorporate the skills and experience of the medical director in direct patient care when necessary.\n\nThe on-scene medical director should consider providing direct patient care after unsuccessful attempts of a critical procedure by an EMS provider. Airway management, especially, has been shown to be a skill that is commonly challenging in the prehospital environment. Endotracheal intubation is performed relatively infrequently compared to other prehospital procedures. These findings provide support for strategies that involve having higher trained and more experienced providers assume care when field providers are unable to achieve success. If on scene, the medical director has the ethical and possibly legal responsibility to assume the task of performing such skills. The number of attempts that should be allowed before the physician takes a more active role must be dictated by the individual patient, field provider experience, time criticality of the procedure, and other factors that may contribute to the challenges being encountered.\n\nSkills that are beyond the scope of an EMS provider may also need to be performed by an on-scene EMS physician. For example, if BLS providers are caring for a patient who requires an ALS skill such as the administration of an IV drug, an on-scene EMS physician should consider performing these procedures if waiting for the arrival of an ALS provider would be potentially detrimental to the patient. A patient in the care of a BLS crew with unstable tachycardia who requires immediate cardioversion should have this procedure performed by an EMS physician who is already on scene, rather than wait for the arrival of an ALS provider.\n\nThere are also medical procedures that are beyond the scope of an EMS provider of any level. Patients with circumferential chest burns, for instance, who are developing worsening respiratory distress may need to undergo field escharotomy. The EMS physician should exercise judgment when deciding when to perform these extraordinary procedures. If a patient\u2019s condition is deteriorating rapidly, and waiting for transportation to an emergency department would put that patient at an undue risk, then the EMS physician should consider performing the necessary procedure. The use of extracorporeal membrane oxygen support may require direct physician care during transport between facilities.\n\nEMS medical directors should develop protocols for their individual systems that establish when an EMS physician should be dispatched to scenarios that would benefit from physician intervention. A prolonged entrapment following a structural collapse, for example, may benefit from a physician response to the scene to perform an amputation that facilitates the timely extraction of the patient. Although prehospital amputation is exceedingly rare, preparation for that possibility is recommended.\n\nThe potential benefit of an on-scene EMS physician is not limited to the procedures they may be able to perform. A physician's assessment and diagnostic skills may be useful in differentiating conditions that could affect both out-of-hospital care and the decision on hospital destination. On-scene physicians can also be beneficial in recognizing and treating potentially life-threatening conditions with prolonged scene times, such as a crush syndrome during a complicated extrication. The use of physicians in prehospital air transport has been associated with decreased mortality for patients with traumatic injuries.",
        "Contrasting European prehospital care with that in the United States": "Europe has had a long-standing experience of physicians in the prehospital setting. In Denmark, for example, physicians respond to the homes of patients, initiate treatment, and often are able to avoid transporting patients to the hospital. By treating these patients in their own homes, Danish prehospital physicians are able to eliminate the need to transport every patient who requests medical assistance, as is common in the United States. In Europe, physicians are more likely to be a part of helicopter-based EMS systems. Furthermore, some helicopter-based EMS systems in Australia provide physicians on every mission. In some regions of Germany, ALS units are staffed by physicians as part of routine prehospital care. In France, physicians respond to calls for medical service in the out-of-hospital setting, often separate from the ambulance services response system. By contrast, physicians in the US who respond to 9-1-1 calls generally do so as an integral part of the EMS system.",
        "Special situations requiring on-scene care by EMS physicians": "There are several special situations in which EMS physicians may be called upon to render care in the field. Urban search and rescue teams, for example, specialize in locating and extracting trapped patients following structure collapses. Physicians on these teams provide on-scene care to entrapped victims, in addition to providing medical support for the members of the team itself. These physicians must be proficient in treating patients with various types of trauma and crush syndrome, as well as confined space medicine and occupational medicine.\n\nEmergency medical services physicians may also be requested to deliver direct patient care at mass gathering events. The provision of care by physicians at these events has been demonstrated to reduce the need for patient transports, thus potentially reducing their effect on local EMS and emergency department resources. These findings suggest that EMS physicians can improve system efficiency by providing direct care at mass gathering events.\n\nFinally, during large disasters or mass casualty incidents, it may be necessary for EMS physicians to provide direct patient care. During such events, EMS physicians can augment the care being provided by overwhelmed field providers. EMS physicians may be helpful in performing other functions during a disaster response, such as providing triage and establishing field treatment facilities to reduce the surge burden on receiving facilities. In all these circumstances where EMS physicians operate in the field, it is crucial that responding EMS physicians operate within the incident command system structure, and avoid \u201cfreelancing.\u201d"
    },
    {
        "Introduction": "The dangers faced by today's emergency response personnel are steadily increasing in complexity, threatening the lives of emergency responders as well as their careers, health, and wellness. To protect their workers and comply with regulatory mandates, response agencies implement medical surveillance (medical monitoring) programs as part of their comprehensive occupational health initiatives.\n\nSeveral important federal regulations and consensus documents provide guidance on the design and operation of a medical surveillance program. They include but are not limited to OSHA 29 CFR 1910.120 \u201cHazardous Waste Operations and Emergency Response,\u201d EPA 40 CFR 311 \u201cWorker Protection,\u201d NFPA 1500 \u201cStandard on Fire Department Occupational Safety and Health Program,\u201d and NFPA 1581 \u201cStandard on Fire Department Infection Control Program.\u201d Individual states may also have pertinent medical surveillance directives that emergency response agencies should adhere to in operating their programs. Medical surveillance requirements may vary between firefighters, EMS, and law enforcement. Thus, those responsible for their agencies\u2019 medical surveillance programs should be intimately familiar with the rules and regulations affecting their departments, including the potential variation in requirements for various personnel. The Centers for Disease Control has created a technical assistance website, document, and training materials for emergency responder health monitoring and surveillance at www.cdc.gov/niosh/topics/erhms.\n\nCurrently, OSHA 29CFR 1910.120 requires employers to implement medical surveillance programs in the following situations.\n\n\u2022 For employees who may be exposed to hazardous substances or health hazards at or above permissible limits (PELs) for 30 days or more per year\n\n\u2022 In the absence of PELs, for employees working at levels above the published exposure levels for a given substance\n\n\u2022 Employees who wear a respirator for 30 days or more per year\n\nHazmat employees, defined as personnel who plug, patch, or temporarily control leaks from containers holding hazardous substances\n\n\u2022 All employees who are injured as a result of overexposure in an emergency incident involving hazardous substances\n\nThe Environmental Protection Agency\u2019s (EPA) standard varies slightly from the Occupational Safety and Health Administration\u2019s (OSHA) standard in that it includes volunteers who work for government agencies engaged in emergency response, such as firefighters. The EPA standard also applies to employees of state and local governments in states that lack OSHA-approved plans.\n\nMedical surveillance is the process by which the health of an emergency responder is maximized and risks are minimized. The process includes the systematic collection, analysis, and evaluation of health data in a defined population to identify patterns or trends suggesting adverse health effects or needs for further investigation or remedial action. Medical surveillance is applicable not just to hazardous materials (hazmat) entry team members but firefighters, EMS personnel, responders to large-scale mass casualty incidents (MCIs), and law enforcement officers. Members serving in specialty capacities such as dive teams, SWAT teams, and civil disturbance units may be subject to additional comprehensive medical monitoring programs. A 2009 report from the World Trade Center Medical Monitoring and Treatment Program (now operated by NIOSH as the World Trade Center Health Program) detailing the evaluation results of more than 20,000 emergency responders and ongoing medical treatment for 2,000 personnel with physical problems and 2,900 with mental health issues, reinforces that every response agency regardless of size should have a defined medical surveillance program to maximize responder health and safety.\n\nThe goal of the medical surveillance program is to promote:\n\n\u2022 early recognition of hazardous materials exposure-related occupational disease\n\n\u2022 early intervention and treatment\n\n\u2022 effective management of the occupational disease process\n\n\u2022 illness prevention.\n\nThe health hazards faced by today\u2019s emergency responders include chemicals such as carcinogens, toxins, irritants, and corrosives, as well as infectious agents and radiation-emitting substances. Psychological stress and temperature extremes are also considered health hazards. OSHA 29 CFR 1910.120 stipulates that the medical surveillance program be comprehensive and address all foreseeable risks. The program should be maintained by the employer and operate under the direction of an occupational medical director who is licensed in the state where the program is operated. This physician may be an employee of the agency or a contractor hired to fulfill this role. The physician must be familiar with occupational medicine, toxicology, and the job-related activities of the personnel he or she is overseeing. Hiring an occupational medicine physician to provide this service is often limited by funding, and operational medical directors are increasingly being asked to fill this role, or departments may contract with comprehensive occupational medicine service providers.\n\nThe effectiveness of a medical surveillance program requires definition of the mission of the program, its components, and operating procedures for surveillance activity before, during, and after an incident. The overarching purpose of medical surveillance is elimination of a responder\u2019s exposure to harmful, disease-causing situations. Thus, careful attention is paid to identifying potential health hazards as soon as possible and correcting practices that may jeopardize a responder\u2019s health and safety. The components of a medical surveillance program include:\n\n\u2022 having dedicated staff to conduct the program\n\n\u2022 suitable office space to operate the program\n\n\u2022 protocols for individual testing, biological monitoring, exposure monitoring, and determination of job-related risks and exposures\n\n\u2022 tracking systems\n\n\u2022 compliance with medical information privacy requirements.\n\nAvailable funding should be sufficient to provide competitive salaries for the staff, necessary office space and technology (including occupational health software programs), and examination equipment. Sufficient time and expertise should be available to allow for regular analysis of ongoing responder clinical data and review of incident reports to identify at-risk practices and recommend prescriptive improvements to reduce harm risks whenever possible.\n\nThe medical surveillance program also involves performing medical screening. This screening includes five categories of examination: post offer of employment, baseline, annual or periodic, job termination, and exposure- or injury-specific medical examinations. These government-required exams should be complemented by a medical monitoring program. Each of the surveillance elements is covered in more detail below.\n\nEmployers with medical surveillance programs must maintain responders\u2019 health records during the length of their service, and for a minimum of 30 years post resignation or retirement. Responders are entitled to access their records within 15 days of a request.\n\nMany medical surveillance programs have focused on injury prevention through implementation of rigorous physical conditioning programs, healthy lifestyle reminders, and work performance evaluations. These programs may operate under the oversight of the medical director or other designated physician, athletic trainers, physical therapists, or physician extenders.",
        "Initial employment examination": "The preemployment physical is performed once a conditional job offer has been made to a candidate and must be completed in compliance with the 1990 Americans with Disabilities Act. The examination typically includes a lengthy questionnaire inquiring about various aspects of the candidate\u2019s past and current health, pertinent family history, and off-duty employment and hobbies. Immunization and vaccination status may also be determined. The physical exam should be conducted by a licensed physician or physician extender. In addition, the following tests may be ordered and their results reviewed with the candidate:\n\n\u2022 Vital signs to include height and weight, blood pressure, pulse, and respirations\n\n\u2022 Chest x-ray to determine preexisting abnormalities\n\n\u2022 Pulmonary function testing including forced expiratory volume (FEV), forced vital capacity (FVC), and FEV:FVC ratio with the results taking into account the individual\u2019s height, weight, and age\n\n\u2022 Vision test for corrected and uncorrected vision along with color blindness and night blindness\n\n\u2022 Auditory testing to reflect hearing capacity at various ranges such as 500, 1,000, 2,000, 3,000, 4,000, and 6,000 hertz\n\n\u2022 12-lead ECG and stress testing depending on the age of the candidate and any abnormality seen on the original ECG\n\n\u2022 Blood chemistry for liver and kidney abnormality along with glucose and serum electrolytes\n\n\u2022 Complete blood count for anemia and other blood dyscrasias\n\n\u2022 Urinalysis for evidence of renal disease or signs of infection\n\nDrug testing, pregnancy testing, and more specialized biochemical testing (e.g. red blood cell cholinesterase, heavy metals, tuberculin) or physical exam testing may be required depending on responder duties and agency policy. Response agencies may also conduct fit testing for self-contained breathing apparatus (SCBA), air-purifying respirator (APR), and N95/N100 masks as part of the examination process. Physical capacity screening relevant to the physical demands of the job may also be conducted. Pertinent physical examination along with other test results are recorded on a standardized physical exam form that becomes part of that individual\u2019s written or computerized medical record. The results of the complete examination are then reviewed with the individual along with recommendations for fitness for duty, healthy lifestyle changes, and corrective actions for any specific problems.\n\nSome agencies have implemented the practice of freezing blood specimens. This allows the individual's original specimen to be compared to a postexposure specimen. However, the storage requirements, legal issues, associated costs, and reliability of results have made this practice controversial and not widely implemented.",
        "Baseline examination": "The baseline examination is conducted when an individual has been selected to join a specialized team that may put the individual at higher than normal exposure to hazardous situations requiring the use of personal protective equipment (PPE). The examination establishes baseline levels and the presence or absence of work restrictions. If a previous examination has been done within 1 year of the specialty team appointment, the results of the original exam may be used as the baseline, provided it meets the requirements of the specialty assignment. The responder should receive a written report summarizing the findings, identified problems, and recommended corrective actions. The report sent to the employer shall only address fitness for duty and whether there is any medical problem that should preclude the individual from being part of a specialty team; there should be no mention of any specific findings or diagnosis.",
        "Annual or periodic examination": "Depending on the age of the responder and any underlying medical conditions, the physical examination may be repeated annually or less often (but no longer than 2 years) as stipulated in the agency\u2019s medical surveillance program policy. The annual or periodic examination typically repeats the entire baseline testing except for the chest x-ray. An interval history is taken with particular attention paid to any exposure history since the last review or onset of new symptoms. Additional specialized testing may be done depending on the results of the interval history. The responder shall be given a copy of the exam results and any accompanying recommendations. The results of the examination reported to the employer, like the baseline exam, should only address fitness for duty and eligibility for team participation.",
        "On-scene medical monitoring": "On-scene medical monitoring of persons wearing PPE and/or operating under demanding conditions for extended periods is another critical component of an effective medical surveillance program. The abbreviated examination completed on scene is usually done by EMS personnel. NFPA 473 \u201cEMS Standards for Competencies for EMS Personnel Responding to Hazardous Materials/WMD Incidents\u201d provides details on how medical monitoring should be conducted. NFPA 1584 \u201cStandard on the Rehabilitation Process for the Members during Emergency Operations and Training Exercises\u201d includes a standard operating procedure for rehabilitation that includes medical monitoring steps and recovery criteria. It should be noted that this standard is mainly consensus based, as the evidence base is poorly developed.\n\nDepending on the incident and work assignment, response personnel may require a rest period spent in the rehabilitation (rehab) area. The amount of time worked before being rested in the rehabilitation area should consider several factors including the nature of the work being done, weather conditions, and level of PPE worn. The rehabilitation area officer should have sufficient personnel, equipment, and supplies assigned to meet the needs of the personnel rotating through rehab. The area should be adequate in size to accommodate large numbers of personnel as needed and located in an environmentally comfortable and convenient location on scene but \u201caway from the action.\u201d Chairs or benches should be available for rest along with access to drinking water. For prolonged events, sports drinks, healthy snacks, and/or light meals (fruit, soup, meal replacement bars, etc.) should be provided along with hand washing and lavatory facilities. Active cooling or rewarming adjuncts must be available when dictated by work or environmental conditions.\n\nThe 2015 edition of NFPA 1584 will reflect an evidence-based deemphasis on electrolyte replacement, will note a daily acceptable caffeine limitation of 400 mg per member, and will recommend against any consumption of energy drinks (not to be confused with sports drinks) by emergency responders. Additionally, it will outline responsibilities pertaining to rehab for the incident commander, company officer, rehab manager, and individual member.\n\nEmergency medical services staff should measure and record vital signs on all personnel reporting to rehab and utilize these, in conjunction with trained observation and locally derived protocols, to assess recovery and readiness to return to duty. Significantly abnormal vital signs (in context of the intensity of activity) or serious complaints must be evaluated in detail and given the necessary medical interventions (including ALS or transportation to a hospital, as indicated). Firefighters or rescuers exposed to smoke should be assessed for carbon monoxide toxicity. Status of personnel assigned to rehab should be tracked by the incident accountability system and final authority for release should be vested in rehab EMS staff.\n\nMedical monitoring is also necessary for personnel assigned to wear PPE (including hazmat suits, confined-space apparel, and dive suits). This practice assures that general fitness criteria are met before they are allowed to don the PPE. Such criteria should be developed as part of the medical surveillance program procedures, and published so that agency personnel are familiar with them. Thresholds should be established for blood pressure, pulse, respirations, temperature, and oxygen saturation. A baseline body weight should also be obtained when possible.\n\nSuccinct and pertinent health-related questions should be asked of each responder and a brief physical exam conducted, usually consisting of assessing breath sounds, heart sounds, and inspection for skin conditions. The answers to the questions, along with the other vital sign data, should be recorded on a standardized form for each responder. Individuals failing to meet the published criteria should be reevaluated and reexamined after a defined period of time (typically 15\u201320 minutes) while the individual rests in a quiet environment. If the criteria are still not met, then additional \u201cquiet time\u201d or reassignment to a task not requiring PPE should be considered.\n\nFollowing completion of the work assignment (and decontamination if hazardous materials are present), responders are then given a postentry examination. The new data are compared with the original information recorded on the preentry exam. Substantive changes in vital signs or general well-being should be treated in accordance with department protocols prior to or while the individual is in the rehabilitation area for an assigned period of time. Attention by the examiner to signs of stress in each responder is also important. This may be particularly important for incidents associated with marked horror, multiple injuries, deaths including to responders, or extended operations. When appropriate, provisions for specially trained personnel such as department chaplain or professional counselor at the rehab area should be in place.\n\nIt is important that responders have adequate rest periods. The practice used by some emergency response teams is to provide rest periods that are 2\u20132.5 times the work period (i.e. for every 30 minutes of work in PPE, personnel would rest for 60\u201390 minutes before being given another work assignment including redonning PPE). The NFPA 1584 document also provides guidance on rest\u2013work period ratios based either on number of SCBA bottles used or time worked intensely without SCBA.\n\nIn some situations such as prolonged urban search and rescue operations, team members receive their preentry screening when mobilizing out of their base camp at the beginning of each shift rather than at the work site. Depending on the assignment and continuing wellness during the work period, their postentry examination may be performed upon return to the base camp at the end of shift. During the shift, personnel use work\u2013rest cycles determined by environmental conditions, physical activity, and the need for PPE; medical screening is generally not performed unless deemed necessary by on-scene medical providers.\n\nIn large-scale incidents involving multiple agencies, one rehabilitation area may be established for all, or each agency may establish its own. Emergency response agencies should familiarize themselves with each other\u2019s rehabilitation practices, operating designs and medical monitoring. Familiarity will help to ensure continuity, shared staffing when needed, and completion of needed documentation on response personnel.\n\nFollowing termination of an incident, the completed medical monitoring documentation for each responder should be reviewed by qualified personnel in the medical surveillance program. An immediate review by the EMS branch director and/or safety officer should be followed within 24 hours by a review by the medical surveillance program medical director or his/her designee. This review will determine whether an exposure-specific examination is needed. The completed medical monitoring forms should be included with the incident record or entered into each responder\u2019s medical record file, depending on applicable regulations and agency policy.",
        "Exposure-specific examination": "Any time an exposure occurs, the affected responder should have a medical evaluation to determine the potential or actual presence of injury or disease. The medical surveillance program guidance should clearly specify when, how, and by whom an exposure exam should be conducted. The reporting process and response to a biohazard or blood-borne pathogens exposure are different from the response to a chemical agent exposure. Program guidance should clearly identify the steps for each situation. If the responder needs to be seen in the emergency department for acute assessment, management of the exposure, or postexposure prophylaxis, then the individual should be directed at discharge to follow up with the medical surveillance program staff. Depending on the agent involved, specialized testing may be required along with designated follow-up visits. Referrals to specialists (pulmonologists, cardiologists, etc.) should be coordinated by the medical surveillance program staff. The employer may only be informed of a condition that requires follow-up and/or treatment and whether the individual meets fitness-for-duty requirements. Appropriate worker compensation paperwork should also be completed by the medical surveillance staff in conjunction with the employee and risk management coordinator.",
        "Termination or exit exam": "The medical surveillance program guidance should outline when a termination or exit exam is to be conducted. The OSHA mandates that an exam be performed upon job transfer, team exit, or resignation, termination, or retirement from the department. The exit exam updates the history and physical exam and repeats all baseline lab studies. Any significant exposures since the last exam are also reviewed and specialized testing initiated if appropriate. The responder should receive a complete written summary of the findings. The employer is told of any medical problem that would preclude return/rehire or the likelihood of temporary or permanent disability.",
        "Conclusion": "Medical monitoring of emergency personnel has taken on greater importance because of increasing dangers experienced by law enforcement, fire, and EMS personnel. The primary purpose of medical surveillance is to preserve the physical and mental health of each member throughout his or her service to the community. Each agency should have a well-developed medical surveillance program, compliant with federal, state, and local requirements. The program should be led by a highly qualified medical director, complemented by a sufficient number and type of staff members to facilitate day-to-day operations of the program and meet the emergency needs of department personnel. Specific program procedures should be available to address 24-hour accessibility to qualified personnel, examination procedures, performance criteria, and documentation. These practices should be documented in writing for responders, and should be consistently employed and revised as needed."
    },
    {
        "Introduction": "Interfacility transport commonly refers to the transportation of a patient from one acute care setting to another. EMS personnel are frequently challenged with taking a patient to the \u201cclosest\u201d versus the \u201cmost appropriate\u201d receiving hospital and sometimes after initial work-up/treatment the patient needs to be transferred to another facility for further care. Additionally, patients may self-present to hospitals that are ill-equipped to provide necessary services and thus must be transferred. Reasons for transfer vary, but are often due to the need for specialized services based on a patient\u2019s medical condition or mechanism of injury. This chapter will address issues related to interfacility transports. Specifically, the focus will be on the level of care during transport, potential risks of interfacility transport, legal issues surrounding transport decisions, specific medical indications for transport to specialized facilities, and medical oversight for interfacility transport.",
        "Level of care": "The sending physician is responsible for choosing the appropriate transport personnel, vehicle, and equipment. The patient\u2019s condition, actual needs, and potential needs for care are essential for the sending physician to consider. The transporting service and the receiving facility also have some responsibility to ensure the transport is carried out in the best interests of the patient. Level of care determination needs to take into account human resource needs, economic considerations, space limitations, and legal requirements. When deciding on the level of care for the transport of a given patient, the sending physician must consider a number of things before making a final determination. He or she must think about what resources are available for the entire service area and the implications of using a resource that may be needed elsewhere. The availability of personnel and vehicles must play an important role in the decision-making process. The more advanced training and experience a transport team has, the more likely they are to be a limited resource, leading to prolonged response times to the sending facility. In a rural area, sending the town\u2019s only ambulance on an interfacility transport that will take hours may result in a serious degradation of available EMS for that period of time. Weather delays can affect personnel and vehicle availability. In addition to taking into account the total transport time, it is important to consider the out-of-hospital time. For example, one might have a BLS ambulance immediately available that will take the patient to the desired receiving facility with a 1-hour transport time; however, a critical care air transport team may have a 45-minute delay in getting to the patient but be able to perform the transport in 20 minutes, resulting in an increase in total transport time by 5 minutes but a decrease in out-of-hospital time by 40 minutes. In certain situations the total transport time is the most important factor and in others limiting the out-of-hospital time can have the most profound effect on the patient.",
        "Personnel": "Composition of the team should be based on the patient\u2019s needs. It can vary from non-medically trained transport personnel to specialty trained critical care transport teams. Whatever personnel are chosen should be able to handle all anticipated needs of the patient en route. They must possess the necessary critical thinking skills, procedural competence, and out-of-hospital care experience to effectively evaluate and care for the patient. All personnel involved in the interfacility transportation of patients must be able to adapt to a variety of situations. They must be able to work as a team, improvise when needed, and perform with limited resources. Crew members who are not regularly involved in out-of-hospital care, such as emergency department and intensive care unit nurses, must get adequate orientation and training so they can be comfortable in the unique situations that EMS professionals face every day. While the scope of practice of EMS providers is discussed elsewhere in this text, the following briefly reviews these concepts as they uniquely relate to interfacility transport.",
        "Non-medical": "Non-medical personnel can range from relatives or friends of the patient to cab drivers to police officers. While this is relatively rare, there are circumstances in which the patient simply needs to go from one location to another and will have no anticipated medical needs while en route.",
        "Basic Life Support": "Emergency medical technicians can perform the majority of low-acuity interfacility transports as the patients are often stable and have few anticipated medical needs and only require basic routine monitoring.",
        "Advanced Life Support": "Paramedics conduct most interfacility transports, as they are able to perform routine and advanced monitoring, administer many medications, and intervene in emergency situations.",
        "Critical care": "Critical care teams are often made up of specially trained paramedics and nurses. They are able to provide advanced and invasive monitoring, administer an expanded list of medications and therapies, and have refined critical thinking skills.",
        "Specialty care": "Specialty care teams are often made up of critical care teams who have training specific to a group of patients, such as pediatric, neonatal, obstetric, burn, extracorporeal membrane oxygenation (ECMO), intraaortic balloon pump (IABP). These teams sometimes also include other health care professionals such as respiratory care therapists, physicians, and perfusionists.",
        "Vehicle": "Several types of vehicles can be used to transport patients between facilities. In choosing the most appropriate vehicle, one must consider speed, space availability, equipment needed, weather, distance, cost, and other factors.",
        "Private vehicle": "While private vehicles are rarely used for interfacility transports, they serve an important role in moving patients who are not expected to require any medical monitoring or interventions while en route from one facility to another.\nExample: a pediatric patient with a fractured radius being transferred from a single-coverage community hospital ED to a children\u2019s hospital ED for reduction and splinting under sedation. As long as his injured arm is neurovascularly intact, his parents can safely transport him in their private vehicle.\nAdvantages: not waiting on medical personnel, inexpensive, keeps the patient with his or her family/friends.\nDisadvantages: no trained personnel or medical equipment are available if the patient experiences a decline in status.",
        "Cab": "Example: An adult patient who presents with metal shavings in her eye that could not be removed at the community hospital and needs to be transferred to a facility with an ophthalmologist available. The patient cannot drive her private vehicle because her vision is impaired, but can safely be transported by a cab as she is not expected to require any medical intervention or specialized equipment while en route.\nAdvantages: not waiting on medical personnel, inexpensive.\nDisadvantages: no trained personnel or medical equipment are available if the patient experiences a decline in status.",
        "Wheelchair/stretcher van": "Example: A patient 1 week out from a stroke who is being transferred from the inpatient neurology service to an acute inpatient rehabilitation facility for intensive physical, occupational, and speech therapy. The patient is bed-bound so must travel on a stretcher, but is not expected to require any medical intervention or specialized monitoring while en route.\nAdvantages: not waiting on medical personnel, typically readily available, inexpensive.\nDisadvantages: no trained personnel or medical equipment are available if the patient experiences a decline in status.",
        "Ground ambulance": "Example: A patient with a muffled voice presents to a community hospital and is found to have a peritonsillar abscess that needs to be drained by an otolaryngologist so she is transferred to the academic medical center 4 miles away. While the patient is not experiencing any airway compromise at this time, there is a fair chance her condition could change en route, so an Advanced Life Support crew that can manage potential airway emergencies must accompany her.\nAdvantages: there is a decent amount of space for the EMS professionals to care for the patient, typically more readily available than aircraft, less expensive than aircraft.\nDisadvantages: travels at speeds much slower than aircraft, may take a limited resource from a rural community and prevent that resource from responding to 9-1-1 emergency calls.",
        "Rotor-wing aircraft (helicopter)": "Example: A patient who presents to a rural critical access hospital after a motor vehicle collision, requiring intubation on arrival for airway protection, and is found to have a traumatic subarachnoid hemorrhage so needs to be transferred to a trauma center for further evaluation and treatment. The patient is critically ill and the time to the trauma center needs to be as short as possible, while ensuring that the personnel transporting the patient are able to manage a ventilator, monitor for signs of increased intracranial pressure, and offer appropriate interventions.\nAdvantages: very fast travel speed, typically staffed with the most advanced personnel, typically equipped with specialized and advanced equipment.\nDisadvantages: expensive, can be severely limited by weather, significant space limitations.",
        "Fixed-wing aircraft (airplane)": "Example: A 10-year-old boy with cystic fibrosis was on vacation with his family when he developed respiratory distress and on presentation to the local ED, he was found to have multilobar pneumonia and needed transfer to his pediatric transplant center 300 miles away for lung transplantation. He requires a highly specialized transport team and medical equipment and given the long distance he needs to travel, fixed-wing transport is the best option.\nAdvantages: very fast travel speed, can travel long distances, typically staffed with the most advanced personnel, typically equipped with specialized and advanced equipment, fewer space restrictions than in a rotor-wing aircraft.\nDisadvantages: expensive, somewhat limited by weather, has associated ground transports to and from an airport on both ends.",
        "Hazards associated with interfacility transportation": "The hazards associated with interfacility transport are similar to those experienced in scene response. The routine use of lights and sirens in interfacility transports is inappropriate, though there are select cases in which this may be needed, perhaps in the case of a STEMI patient being transported from a small community hospital to a tertiary facility for cath lab intervention. Prior to any interfacility transport, the patient should be stabilized to the extent that the referring hospital is capable. If the patient is expected to have a decline in airway status then it should be managed while the patient is in the sending facility where there are more people around with more equipment and resources available to work in an environment that has significantly more physical space than a transport vehicle. There are times when the risk outweighs the benefit and the interfacility transport should not be completed.",
        "Legal considerations in interfacility transportation": "Local and state legal issues vary from region to region. In general, the laws applicable to EMS were not written with the nuances of interfacility transfers in mind. Instead, they were crafted to apply to EMS response to a scene and the subsequent patient delivery to a hospital. Some state EMS regulations make no mention of interfacility transport whatsoever, while others are more inclusive. Laws and regulations that were written with interfacility transfers in mind may not always keep up with changing medical science, medical economics, the vast expansion of air medical services availability, and evolving federal law. Some specific questions have arisen that have not been fully answered. If a patient is to be moved from a hospital in one state to a referral center in another state, what are the licensing requirements for the medical crew, medical oversight physicians, and vehicle? When a transport team does not include a physician, when do observation and protocol-directed therapy turn into diagnosis and medical treatment? When has the transport team crossed the line and practiced medicine without appropriate protocols and medical oversight? If a patient loses signs of life during a transport, can he or she be pronounced dead? Does the pronouncement have to be done by a physician? Can the direct medical oversight physician make the pronouncement without seeing the patient? What is the time and location of death? Does the resuscitation need to be continued until the vehicle reaches the final destination? As a practical matter, most services find it more expedient to continue a fruitless resuscitation than to try to pronounce a patient dead while en route. Knowledge of the Emergency Medical Treatment and Active Labor Act (EMTALA) is essential for those involved in interfacility transportation. It is the responsibility of the sending physician and the sending facility to be sure they have met all of the requirements of EMTALA prior to transferring the patient. They must perform a medical screening examination to determine if the patient is stable or in active labor. If the patient is unstable or in active labor then the hospital is obligated to provide care (regardless of the patient's ability to pay) until stability has been achieved or active labor has resolved. If the hospital is unable to provide the necessary care, then the sending personnel must find a facility that can provide that care and arrange transfer. The hospital can legally transfer an unstable patient or a patient in active labor under the following conditions: the patient requests the transfer, after being fully informed about the risks and benefits of the transfer; the sending hospital is unable to provide a service that the patient urgently needs; the hospital has found a hospital that can provide the needed care and explicitly agrees to accept the patient; and the patient consents to the transfer after being informed of the risks and benefits of the transfer. The transferring service should be sure to bring all associated paperwork with the patient, including the transfer paperwork with explicit statements about the reason for the transfer and the name of the accepting facility and its accepting representative (typically a physician, although there is no actual requirement for the accepting staff member to be a physician; a burn unit charge nurse may be designated by the hospital as authorized to accept burn transfers, for example), the patient\u2019s medical record, any imaging studies completed (whenever possible the actual images should be transported with the patient), and results of any laboratory studies.",
        "Indications for interfacility transportation": "There are a variety of indications for interfacility transport, ranging from need for specialized services to insurance repatriation to patient request. The health care system is evolving into a network of regionalized medical resources to provide specialized care. Patients are most often taken from smaller hospital with limited resources to larger tertiary or quaternary care centers. In 2006, the Institute of Medicine report on emergency medical care contained a recurring recommendation for regionalization of emergency care for specific situations and patient needs. Some transfers are integral to the system design and as the health care system in the United States becomes increasingly regionalized and coordinated, efficient interfacility transport by EMS is becoming integral in the provision of specialized care in regionalized centers of excellence.",
        "Specific conditions": "There are several medical conditions in which interfacility transports are particularly common. These conditions share elements of requiring significant resources and staff with highly specialized training and equipment. Trauma systems are the first and most common regionalized systems in the country, but many other systems are also used or are currently being developed, including systems for cardiac, neurological, burn, maternal-fetal, and pediatric patients.",
        "Trauma": "The underlying theory of trauma system design is a focus on expertise, experience, and commitment. All EMS systems put considerable design effort into ensuring that patients requiring a trauma center will be appropriately triaged from the scene of the injury. Most of these systems provide for considerable overtriage. Thus, there should be many more patients with minor injuries transported to a trauma center than seriously injured patients taken to a hospital that is not a trauma center. Nonetheless, trauma patients are one of the largest groups of patients requiring interfacility transport. There are three main reasons for this: even a sophisticated triage system will still miss some patients with subtle injuries; some patients will find their way to the initial hospital outside the EMS system; in many rural areas the trauma system is designed with the expectation that many patients will be transported from a lower-level hospital to a higher-level hospital. In many of these systems a small hospital performs initial stabilization and retriage. Timeliness is usually the most important factor in the interfacility transport of trauma patients because the major killers of trauma victims are shock and brain injury. The goal of the transport is to bring the patient to definitive intervention before shock or neurological injury becomes irreversible. Sometimes the transport team provides some procedure that the local hospital personnel are unable to perform such as intubation, intravenous access, intraosseous access, thoracostomy, or cricothyrotomy. The ideal trauma system will designate the receiving hospital and transport system ahead of time. The system expectations should also be clear to the sending hospital, the receiving hospital, and the transport team so that the patient is prepared for transport before arrival of the team and minimal time is lost during transition from the sending hospital to the transport team.",
        "Cardiac": "A large and growing number of cardiac patients are transferred between hospitals. Many patients are transferred to designated heart centers early in the clinical course of myocardial infarction. Systems have been successfully described and must be in place locally to minimize time from recognition to reperfusion by speeding initial diagnosis, providing appropriate initial interventions, expediting transfer, and avoiding delays. With advance planning, ST-elevation myocardial infarction patients in shock can be safely and efficiently transferred to percutaneous coronary intervention centers with appropriate care en route. As there are technological advances in the life-saving devices used, interfacility transport teams need to be trained to handle patients who are being supported on ventricular assist devices, temporary pacemakers, ECMO, IABP, and other interventions rarely encountered by most medical professionals.",
        "Neurological": "The same general factors that relate to interfacility transport of cardiac patients can be considered when discussing the issues of interfacility transport of patients with acute neurological disease, such as stroke. A subpopulation of both of these groups may benefit from reperfusion therapies that are time dependent and may require specialized interventions that are not available at the sending facility. NAEMSP updated its position statement on the role of EMS in the management of acute stroke in 2007, and the associated resource document outlines the issues regarding the integration of EMS with stroke centers and the need for secondary interfacility transport to stroke centers. Recommendations have been made regarding the development of stroke centers and the triage of a subset of stroke patients to these centers for time-dependent treatments. The literature is evolving, but there appears to be a subset of patients who do better when treated at stroke centers, and a subset of patients who benefit from treatments aimed at immediate reperfusion. When a stroke patient may be eligible for reperfusion therapy but requires transfer to receive it, all the time required for transfer must be considered in order to decide whether or not a window of opportunity will still exist. The time to arrange transfer, for the transporting agency to respond and complete the transfer, and for evaluation and decision making at the receiving facility should be considered. Because of all these factors contributing to the overall times, many systems are being designed so initial testing and imaging can be performed at the small referring hospitals with remote decision-making support so that reperfusion therapy can be started prior to the patient leaving for the receiving facility. Once a patient is outside the time window for interventions aimed at reperfusing the brain, interfacility transport to a stroke center may still be beneficial but usually does not need to be accomplished urgently.",
        "Obstetric": "Almost all obstetric (OB) transfers are for the fetus. Some anticipated transfers for scheduled procedures could be done by private vehicle. Many transfers are for unanticipated conditions such as premature labor, preeclampsia, and placenta previa. Federal EMTALA laws define any woman in active labor as unstable. These patients can be transferred only when the expected benefits outweigh the risks of transfer. Premature infants delivered at neonatal centers are more likely to survive than similar infants delivered at other hospitals. Few systems proceed with transfer unless en route delivery is unlikely because few teams are expert at care of both the mother and the fetus, and there is rarely the physical space for both a high-risk OB and neonatal transport team to travel together. The most reliable indication that delivery will occur soon is cervical dilation of greater than 4cm. Fetal distress generally warrants cesarean section prior to transport. As en route time is critical, transport by helicopter transport is often the preferred method. Ideally, OB transfers are made in a vehicle with enough space and personnel to deliver intensive care to a newly delivered infant and to attend to the mother. Prior to managing OB patients in an out-of-hospital setting, the crews should be trained to handle the relatively large number of possible problems and complications that can occur in rapid succession.",
        "Burns": "Compared to other injuries, complications from burns usually progress more slowly. Burn centers have special expertise in wound healing and infection prevention. In the hours immediately following a burn, the main life threats are loss of intravascular volume and concomitant injury, among which are inhalation burn injuries to the airway, trauma, and poisonings. If inhalation burns seem likely, early intubation is prudent. A rare but dramatic complication is a sudden airway obstruction due to swelling after seemingly normal breathing. A moving vehicle is a difficult place to monitor for stridor and then intubate through a swollen airway, so if there are any signs of impending airway compromise it is most prudent for the airway to be handled at the sending facility. Carbon monoxide and cyanide are the most common poisons associated with burns. Cyanide works very quickly so it is unlikely to be an issue by the time a patient is ready for interfacility transfer. Carbon monoxide poisoning should ideally be treated with hyperbaric oxygen therapy, but in its absence it should be treated by providing high concentrations of oxygen at the local hospital and during transport. Significant increases in altitude during flight can be problematic for these patients and should be considered when the sending physician is choosing the type of transport vehicle. Calculations of fluid requirements depend on the careful estimation of burn size, measurement of urine volume and concentration, and hemodynamic monitoring. The transporting personnel should ensure the patient has a Foley catheter for continuous monitoring during transport. Sterile dressings help keep burns clean and reduce pain.",
        "Spinal trauma": "Spinal cord injuries are frequently associated with additional trauma, and these patients are initially managed as other trauma victims. Following stabilization, these patients may benefit from the experienced treatment and rehabilitation services available at spinal cord centers. Transfer is rarely time critical. Transfer arrangements will usually be determined by safety, convenience, cost, and mechanical stability. Depending on the nature of the injury and the time since injury, the main consideration may be preventing movement and extension of the injury. In cases of high cervical lesions the team should be proficient in airway management. Many otherwise stable spine-injured patients may be safely transported by BLS ambulance.",
        "Pediatric and neonatal": "As outlined above, even under the best of circumstances some mothers will deliver premature infants at hospitals without the equipment or trained personnel to care for them. Neonates require a disproportionate number of interfacility transfers, but some older children will also require transport. Many community hospitals can care for a child with uncomplicated illnesses or injuries; however, a much smaller number of hospitals are prepared to care for children with seizures, sepsis, or other severe forms of shock, and even fewer are prepared to perform surgical interventions or deal with metabolic and developmental conditions. Neonatal and pediatric patients require very specialized equipment and caregivers who are specially trained to take care of their unique needs. The current standard of care is to bring critically sick children to specialty centers designed to care for them. The American Academy of Pediatrics has published transport guidelines based on expert consensus.",
        "Medical oversight of interfacility transport": "The sending facility and sending physician bear the responsibility for determining the receiving facility, the mode of transport, the personnel to perform the transport, and the required equipment. The medical oversight physician for the transporting service plays a vital role in ensuring that the referring physician has the information needed to make the best choices in terms of the level of care. Many physicians in the community are not familiar with the various EMS agencies, resources, personnel, vehicle options, level of care, and capabilities that are available to them. It is the job of the EMS medical director of the transport service to educate community physicians so they can make informed decisions when the need for interfacility transfer arises. Medical oversight of interfacility transport can be complicated if a system or plan is not established in advance. Many interfacility transports are routine and uncomplicated yet when critical patients are involved, complex medical decision making and advanced therapies will likely be needed. Patients may require multiple medications with profound effects and potential interactions. They may need ventilator management, airway interventions, invasive hemodynamic monitoring, and maintenance of ongoing technologically sophisticated care. Understanding the risk/benefit ratio for interventions, or whether to transport at all, requires an in-depth knowledge of personnel and equipment issues in the out-of-hospital environment, as well as capabilities at both the referring and receiving facilities. Some services have multiple physicians involved as medical directors or to provide direct medical oversight during interfacility transport. It is essential that these physicians have knowledge of the protocols, the level of training and competence of all personnel, the transport equipment, and the medication formulary carried on the transport. While many services use emergency physicians from a selected ED, it is difficult to ensure that all individuals are knowledgeable about the nuances specific to each individual interfacility transport. Whoever is providing medical oversight should have expertise in the management of patients in the out-of-hospital setting and emergency care, as well as access to experts in pediatric and adult critical care, neonatology, ventilator management, trauma care, stroke care, and cardiac emergency care. Most transports need only limited direct medical oversight and more extensive audit and review later on. If policies and procedures were not followed, review should determine if the circumstances were quite unusual, remedial education is needed, or the policies need improvement. There is little downside to having physicians from multiple specialties involved with this form of indirect medical oversight. It may also be useful to have the participation of a multidisciplinary group of other involved parties, such as other EMS services, nursing personnel from sending and receiving facilities, and referring and accepting physicians, to help with the review process. Indirect medical oversight is often well suited to correct system problems associated with inappropriate transfers, delays in transport, or inadequate stabilization by referring hospitals. Indirect medical oversight should offer in-depth and deliberative analysis and recommendations to all participants involved. This should be well integrated into a quality improvement process."
    },
    {
        "Introduction": "Air medical transport includes scene transport (typically direct to tertiary care), interhospital transfer of high-acuity patients, and long-distance repatriation. Although most of the direct interactions between ground EMS and air medical services providers occur as a result of scene responses, the medical director must also consider the generally larger role that emergency interhospital air transport plays in the local and regional system of care. In both cases it is imperative to have a well-integrated and aligned system plan for air medical services. The primary objective of air medical transport is to give patients who are not proximate to advanced or critical care the same chance of survival as patients to whom care is immediately available. The role of air medical transport in time-dependent disease such as traumatic brain injury, cardiac emergencies, stroke, sepsis, and major trauma continues to evolve. The historical role of air medical transport in trauma \u201cmedevac,\u201d developed in the military, has transformed from primary \u201ctime critical\u201d to \u201ccare critical\u201d in which the use of a unique vehicle, team, and technology not tied to roads extends the reach of tertiary care by bringing specialized care not generally available from EMS directly to the patient with subsequent transport to tertiary specialist care. The geographic reach of air medical transport simultaneously decreases time to advanced resuscitation and needed procedural intervention and decreases the out-of-hospital time for a potentially unstable patient. The extent of the reach is profound, with studies both within the US and internationally highlighting a 1:6 ratio of helicopter EMS (HEMS) to ground ambulance in an urban US state, to a 1:50 ratio in the Western Cape of South Africa. In essence, the evolving air medical transport model supports both the rural safety net and regionalization through delivering the care and technology of the tertiary center direct to the patient, whether on scene or in a community hospital. The goal is to improve cost-effectiveness and outcomes for patients and the emergency care system.",
        "History to current situation": "Air transport of injured patients is documented to have occurred by fixed-wing aircraft as early as 1915, approximately 12 years after the Wright brothers\u2019 first flight. The US Army Air Corps initiated the first regular use of medical aviation in 1926, using a converted airplane to transport patients from Nicaragua to an Army hospital in Panama, 150 miles away. The routine use of air medical transport from hospital to hospital dates to World War II, as does the first use of scene evacuation of US soldiers from the site of injury, in what was then Burma. Although the helicopter was developed during World War II, it was not routinely used for patient transport until the Korean War, and even then not by design but in response to road travel conditions that prevented transport by ground ambulance. Injured soldiers were strapped to stretchers outside the aircraft with the intervention limited to rapid evacuation to a field hospital rather than en route stabilization. Air medical evacuation fully matured in the Vietnam War with over 800,000 injured soldiers cared for rapidly by field medics followed by a helicopter evacuation. Mortality decreased to the lowest rate of any major sustained conflict to that time. The forward operating medical units were then connected by specialized fixed-wing aircraft to bring injured soldiers to more centralized definitive care and later to specialized hospitals. The combination of rapid intervention near the battle zone, followed by rapid transport to a forward surgical hospital, and a continued chain of transport to specialized medical centers, is now the standard of care for military operations. From Iraq or Afghanistan, wounded US soldiers arrive via a flying hospital to centralized care, such as Ramsden, Germany, within 12\u201318 hours of injury. The greatly increased lethality of improvised explosive devices has dramatically changed the battlefield and increased the death to injury ratio; nearly 100% of these types of blast injuries would have been lethal in previous wars. The 1996 Accidental Death and Disability white paper brought home the potential use of helicopter evacuation in a formalized trauma system. The paper detailed a lack of coordinated response to injury, including the observation that \u201chelicopter ambulances have not been adapted to civilian peacetime needs.\u201d Building from this landmark paper in 1970, Dr R. Adams Cowley partnered with the Maryland State Police and obtained a National Highway Traffic Safety Administration grant to purchase a Bell Jet Ranger helicopter to transport injured trauma patients directly from injury scenes to the newly created shock-trauma unit at the University of Maryland Hospital, the first civilian unit of its kind. In 1972 the first hospital-based helicopter program was initiated at St Anthony\u2019s Hospital in Denver, Colorado. The primary goal of this program was to provide interhospital transport of critically ill patients, linking community hospitals with tertiary care, but scene medevac response was also incorporated into operations. In parallel with the evolution of specialized trauma centers, by 1978 almost 20 new helicopter services had been initiated across the United States, primarily operated by individual trauma centers. Each subsequent decade since then has seen a doubling of the US medical helicopter fleet. Growth has continued steadily in the United States and around the world, with a second era of rapid growth from the late 1990s and more recently in the period from 2003 in which the number of helicopters in the US has more than doubled, in large part due to improved reimbursement from Medicare and unaligned regulatory oversight between the federal Department of Transportation and state EMS and health agencies. Each rapid rise in helicopter deployment has tragically been associated with an increase in the number of fatalities. With the continued regionalization of tertiary centers, the advent of critical access hospitals in rural communities, and the extension of HEMS in rural areas, the numbers of air medical services programs continues to grow. By the end of 2012, the ADAMS database project identified 302 air medical programs in the United States operating 946 dedicated rotorcraft from 776 bases, and 314 dedicated fixed-wing aircraft operating from 171 bases. While the overall numbers are smaller, the rate of growth in Canada and Europe is similar to the US, with more rapid expansion in Eastern Europe, the Middle East, China, India, and Brazil. Based on data from the 2011 National EMS Assessment and the Government Accountability Office, collectively, air medical transport represents approximately 2% of all ambulance transports in the United States. Although individual HEMS programs\u2019 mission profiles vary widely by provider, on average (in the United States), a full-capability HEMS program will perform 54% interhospital transports, 33% scene runs, and 13% \u201cother\u201d mission types (e.g. neonatal, pediatric, transplant related). Growth is expected to continue in the years ahead due to other structural changes in the health care system, especially affecting rural areas. Factors affecting this growth include the following. Closure of hospital emergency departments, which have declined in number from just over 5,000 in 1992 to approximately 3760 in 2011, a trend that is expected to continue. A reduction in the number of Level I and Level II trauma centers from 600 in 2008 to 445 in 2011, a trend that is likely to continue despite the addition of new trauma centers in new growth urban centers. Reduction in the availability of specialist care in rural areas, particularly neurosurgeons. The continued concentration of specialist care into hub-and-spoke systems. Closure of rural hospitals due to financial pressures, conversion to critical access status, or decertification of critical access status. Emergency department closures and hospital overcrowding with increasing capacity issues for critical care and specialty beds often causing hospitals to divert EMS patients. These structural changes in health care systems are particularly problematic in rural areas with the least resources and infrastructure. A 2005 study identified that while 84% of all US residents have access to Level I or II trauma centers within 60 minutes, 27% of these residents require HEMS transport to achieve timely access. More problematic is that 42.8 million Americans live in rural areas without timely access to specialist care. The most current update from the Centers for Disease Control illustrates some progress, with close to 90% of the population now within 60 minutes of a trauma center, in part due to the addition of medical helicopters in previously unserved areas. Unfortunately, while 19% of the US population resides in rural areas, 55% of fatal motor vehicle crashes occur in rural areas, a rate nearly double that of similar accidents in suburban or urban areas. Despite the gains of modern EMS, \u201chighway fatalities are a major epidemic in this country; and most occur on rural roads involving rural residents. Only one-fifth of the nation\u2019s population lives in rural areas, yet two-fifths of all vehicle miles traveled and three-fifths of all fatal crashes occur there.\u201d",
        "Outcomes": "While there are unanswered questions about HEMS' cost-effectiveness, there is a body of evidence addressing HEMS' potential effects in a variety of situations. It is important to try to identify those cases in which benefit is most likely to occur, so that resources may be wisely used. Though classic evidence from decades ago has been bolstered by more recent demonstrations of HEMS cost-effectiveness, HEMS will likely continue to be perceived, correctly or not, as costly. At a minimum, HEMS constitutes a high-visibility allocation of resources. Because few would argue that HEMS benefit is always predicated solely on time and logistics, any consideration of HEMS outcomes evidence touches on the broader subject of advanced levels of care in the prehospital setting. The HEMS crews' extended practice scope offers circumstances well suited for assessing high-level ALS care and its potential benefits. For example, major analysis of prehospital intubation has provided important insight into, and unintended demonstration of, HEMS' salutary effect on outcome. Other investigation suggests advanced airway skills and hemodynamic management (such as fluid administration) combine to contribute to better HEMS-associated outcomes. The idea of HEMS utilization to expedite care for patients with time-critical injury and illness is not new. A significant body of literature exists that demonstrates HEMS utility for secondary (interhospital) transport of trauma patients. Loss of HEMS availability has been recognized as a potentially important factor causing increased trauma mortality in patients presenting to non-Level I centers. Additionally, emphasis has grown in the use of HEMS to expedite care for patients with time-critical medical problems. As for trauma patients, HEMS has been used to extend the reach of hospitals capable of delivering advanced time-sensitive care for acute myocardial infarction and stroke. With careful attention to training, some regions have successfully incorporated HEMS activation by scene ground EMS providers, for selected patients with acute coronary or stroke syndromes. Helicopter EMS has also been suggested to potentially improve outcomes for selected patients with other diagnoses, ranging from ill neonates to high-risk pregnant patients and cases of ruptured abdominal aortic aneurysms. While numbers of these patient populations tend to preclude robust outcomes analysis in retrospective studies, the occasional utility of HEMS for these types of patients is acknowledged by accepted consensus-based air medical transport guidelines.",
        "Extension of advanced care throughout a region": "Some of the above-mentioned benefits to patients also apply as advantages to regions and EMS systems. For example, HEMS may facilitate an EMS system's ability to provide for early ALS in isolated or difficult-to-reach areas that would otherwise be poorly covered. Analysis of the economics of covering a widespread region using a small number of aircraft, compared to a large number of ground vehicles dispersed in such fashion as to assure equivalent response times, is complex. Preliminary analysis has suggested that air medical transport is actually no more expensive than the multiple ground unit alternative. Helicopter EMS may offer benefits even to patients already at smaller hospitals. This is most likely true in rural settings where local facilities may be staffed by individuals with relatively little experience with managing trauma or other critical illnesses. In trauma, for instance, the lack of ready availability of surgical subspecialists is translating to an increasing inability of non-Level I centers to care for injured patients. The skills available among an air medical crew, including airway management, are sometimes called upon at small rural hospitals to help stabilize trauma patients prior to transfer.",
        "Provision of ALS 'back-up' for parts of an EMS system with limited ALS coverage": "In addition to providing ALS-level care to geographically remote areas, HEMS can offer a means for relatively isolated areas to get patients to tertiary care centers without necessitating removal of scarce ground ALS resources from the region. At least one paper has specifically identified that one major reason why rural areas use HEMS is that they perceive that they are unable to cope with losing their limited ground ALS coverage for what can be a 5-hour round trip. Use of air medical services for patients with non-critical illness or injury may not always be in the best interest of the system as a whole. However, some rural and frontier regions have come to rely on air transport as a means to assure they will not lose ALS coverage for hours every time a patient requires ALS-level transport to a distant receiving hospital. As an added benefit, the use of helicopters for longer-distance transports of critical patients can reduce the risks associated with prolonged lights-and-siren ground EMS transports.",
        "Minimization of transport times and direct transport to specialized centers": "The use of AMS for some transports, and its resultant streamlining of out-of-hospital times, can benefit EMS systems as well as individual patients. Examples of such benefits include faster turnaround and greater availability for transport. The overall reduction of transport time should also be viewed as a system benefit. One purpose of the EMS regional authority is to provide the optimal system intended to get patients where they need to be. In many cases, this will be the closest facility; in such circumstances ground transport will usually be a preferable alternative. However, some patient populations may benefit in selected cases from direct transport to specialized centers for trauma, cardiac, stroke, pediatrics, or other diagnoses. While decisions as to exactly which patients need to go directly to \u201cLevel I\u201d care are sometimes difficult, the fact remains that there are data suggesting that for some cases, HEMS direct transport to high-level care increases a regional system\u2019s ability to improve its patients\u2019 morbidity and mortality. ",
        "Transport flexibility in overloaded hospital systems": "The helicopter offers advantages of being flexible with respect to receiving center; not much time is lost in changing the receiving hospital destination if it is close by, and the helicopter\u2019s speed and range can bring distant hospitals into play if local facilities are overloaded. Though the obvious benefit to this (for EMS systems) relates to unusual circumstances such as disasters, the current environment of hospital and ED overcrowding renders the receiving hospital flexibility of HEMS a potentially useful thing. With the advent of increasing problems due to ambulance diversion, the transport flexibility provided by HEMS has additional advantages. Since ambulance diversion problems can result in a given ground EMS unit being out of service for an extended period (i.e. while it is performing a longer-distance transport), the aircraft may be able to \u201cback up\u201d the ambulance by either performing the transport or being available while ground EMS is out of service. With increasing evidence demonstrating that trauma mortality rates increase when trauma centers\u2019 EDs are on diversion, the HEMS unit can serve as a life-saving method for \u201cdecompressing\u201d the overtaxed ED. In fact, the utility of HEMS to distribute the patient load, already noted for its potential value in disaster and mass casualty incidents, may be applicable in some areas\u2019 Level I trauma centers on an increasingly frequent basis. The loss of availability of rotor-wing transport has been recognized as a potential mediator of increased mortality due to decreased capability to execute interhospital transports. ",
        "Integration": "Although an effective air medical services (AMS) system is now often assumed to be part of emergency care, from the outset, integration of air services into the larger EMS system has been problematic. Like hospital emergency departments, AMS represents a relatively scarce resource with a significant capital cost for infrastructure and maintaining readiness. A recent study indicates that fixed costs are on average 84% of total AMS provider costs. United States, costs are generally allocated per patient transport. The cost of AMS is expensive in comparison with ground ambulance transport, generally by a factor of 4\u201310 times. Hence integration and appropriateness of use are essential determinates for local system effectiveness. Further complicating the picture is the CMS 2002 national ambulance fee schedule which has driven much of the growth due to a significant increase in helicopter reimbursement concurrent with a much lower relative value units (RVU) for ill-defined ground specialty care transport. This has led in many areas to a loss of ground critical care capacity and an increase in helicopter capacity. Total cost of care from onset of injury or illness to discharge, however, is more important in the overall health care system. Consequently, it is often a mistake to make an isolated comparison and equate the lower charge with cost-effectiveness and the higher charge with cost-prohibitiveness. The challenge for the medical director, faced with uncertainty in an emergency patient, is to align and integrate the air medical services resource into the entire emergency care system in order to maximize outcome and cost-effectiveness benefit. This is often not a simple challenge. As noted in a 2007 national white paper: Integrated air medical resources are an essential component of contemporary EMS systems. Today, financial pressures, insurance issues, changing federal regulations, and competition all are forcing changes, consolidation, and in many cases reduced services or closure of emergency departments, trauma centers, hospitals, and specialty physicians. These factors have contributed to the increased use of AMS to move patients to specialty centers, particularly from outlying areas. As with EMS in general, there has been a general lack of overall system planning and design to guide the development and implementation of needed AMS. Mechanisms that might provide such guidance, such as state EMS or health regulations, certificate of need (CON) processes, and federal aviation and healthcare regulations, sometimes conflict with one another, providing a jumble of uncoordinated hurdles to AMS providers. The 2006 Institute of Medicine (IOM) report on EMS, Emergency Medical Services at the Crossroads, noted the challenges of federal and state regulatory jurisdiction, and calls for the integration of air medical services into regionalized EMS systems. This concept was solidified in a 2007 consensus document from NAEMSP, the National Association of State EMS Officials, and the Association of Air Medical Services. It suggests a course of action for integration of air services to become reality. Medical directors must prospectively and retrospectively manage the medical oversight and integration of air medical services. The consensus paper identifies seven principles essential to effectively integrating such providers into the prehospital and hospital emergency care system. States must assume regulatory oversight of the medical aspects of air medical services that advertise services and/or operate in their states, including dispatch and communication coordination. Air medical services are essential elements of contemporary EMS systems. EMS systems should strive to ensure that every patient having an emergent condition has access to air medical and ground critical care transport with transport type dictated by case-specific objective evaluation of distance, circumstances, and the logistics of transport. Air and critical care medical transport represent particular expertise in the delivery of acute emergency care, often with non-physicians practicing near a physician's scope-of-practice level. As such, clinical care provided by non-physicians should be overseen by physicians who practice and have expertise in emergency, critical care, and critical care transport medicine. All medical transport systems should use the national consensus medical guidelines for both dispatch and postmission use review. Air medical services should operate at a level consistent with the standards developed by the Commission on Accreditation of Medical Transport Systems (CAMTS). Air medical transport providers should operate at the highest levels of safety possible, and they should implement and maintain comprehensive risk management and safety systems management programs. As noted in Table 2.2, there is no ready correlation between the number of helicopters in a state and the land mass and population. Further, the number of helicopters is unrelated to improvements in reduction of motor vehicle fatalities. More problematic, the 20% growth rate is unevenly distributed and growth since 2003 has predominantly occurred in areas already served by HEMS. While there is no accepted calculation for the \u201cright\u201d number of helicopters to serve a population or provide geographic coverage, only two policy-level studies have been undertaken in the US to examine coverage, appropriate use, system design, and cost benefits. With ambulance reimbursement tied to patient transport, there is a significant incentive for supply to drive demand. As the current organization of the HEMS system is more tied to market forces than health care planning, physician medical directors need to pay close attention to appropriate use decisions in the face of clinical uncertainty. A 2009 study in Arizona found a combination of high rates of discharge from the ED following flight concurrent with high probability of survival and low Revised Trauma Score (RTS). Without thoughtful and consistent integration, helicopters can become the \u201cmedical centerfold\u201d in a system, increasing the costs of care without improving outcomes. Although historically \u201ctransport was treatment,\u201d the evolving model requires careful consideration of value added at each provider level. As with all medical interventions, an effective system recognizes that EMS and air medical transport are medical interventions and must be \u201cphysician proscriptive events.\u201d Essential elements of medical oversight include the following. Patient selection/dispatch criteria guiding the use of air medical services, to include explicit criteria such as NAEMSP guidelines with requirements for providers to measure and report compliance. Communications/integration of the AMS resource within the EMS system, to include a clear and consistent method for requesting a helicopter enhanced by regional protocols for early or simultaneous HEMS response. The provision of rapid information to the requestor regarding availability and estimated time of arrival in order to optimize field and interhospital care and transport. Comparing provider ETAs with actual arrival times is an essential system performance measure. Communication with HEMS center, EMS personnel at the scene, and emergency personnel who are establishing the landing zone. This should be available while responding to the scene and include stand-down criteria for the HEMS service. Regional education provided by the air medical service to all EMS agencies in their jurisdictions regarding the service, when and how to use it, and the management of scene safety. Determination of scene versus interhospital transport: the goal of an EMS system should be to transport patients requiring time-sensitive care directly to a regionally agreed tertiary destination. EMS providers must be given authority, with posttransport quality review, to initiate direct transport in order to optimize the effectiveness of time-dependent care. Measurement of time to definitive care as well as potential overtriage rates. Air medical services providers should participate in regional and state quality and performance reviews, including measuring the percentage of patients discharged in less than 12 or 24 hours after air medical transport, percentage with stable vital signs and low trauma scores, and those patients not requiring time-critical intervention.",
        "Clinical operations": "The majority of HEMS programs fly with a crew of two medical providers (93%), with a small number using either one (3%) or three (4%) medical providers. The most common medical crew configuration is one flight nurse and one flight paramedic (67%). Less commonly used configurations are flight nurse/flight nurse (8%), flight nurse/flight physician (5%), flight paramedic/flight paramedic (5%), flight paramedic only (<2%), and flight nurse only (<1%). A handful of programs limit their care solely to specialized interhospital transport, such as neonatal and pediatrics, and do not use personnel with prehospital training. The majority of programs that perform any scene response have a crew that includes either a flight paramedic or a flight nurse who has been cross-trained as a paramedic. Some air medical programs use supplemental staff with unique clinical skills on specific transports of patients with special medical needs. Depending on the space and lift capabilities of the particular aircraft, they may either take the place of one of the regular crew members or come on board as a third caregiver. Some examples of personnel who may be used in this fashion include perfusionists, respiratory therapists, neonatal transport nurses, pediatric transport nurses, and intensivists.",
        "Vehicles/mode of transport": "The decision to transport via rotor-wing or fixed-wing aircraft depends on a number of factors including disease diagnosis, destination, speed, distance, and weather. Helicopter flights tend to be for shorter-distance, more time-dependent emergency missions, whereas fixed-wing flights tend to be longer distance.",
        "Helicopters": "Recently, air medical services have transitioned to smaller single-engine visual flight rules (VFR; constant visual reference of the ground) aircraft. Less than 10% of the current US helicopter fleet operates with instrument flight rules (IFR), which is the standard for commercial airlines. Primarily this is a cost-driven decision as the increase in the number of aircraft has resulted in fewer patients per aircraft. While all helicopters are weight and range limited, smaller aircraft and cabin size are important considerations in the availability of specific in-flight therapy and availability of specialty medical equipment. The flight radius of a light- to medium-sized rotor-wing aircraft used for medical transports is 50\u2013175 miles, with a 100\u2013155 kph speed. Monitoring of actual response times and longer distance flights is essential in medical oversight due to the potential need for refueling with a patient on board, which is a time and safety consideration.",
        "Fixed-wing aircraft": "These aircraft have increased range when compared with helicopters, including speed (200\u2013300 k/ph) with 500 mile to transoceanic range. Launch time is generally longer than the 5\u201310 minute launch time for most rotor-wing aircraft, and both legs of transport require ground ambulance transfer. This negates speed and may present additional patient risk regarding dislodged invasive medical equipment such as airways or indwelling central catheters. Although fixed-wing aircraft have limited usefulness in truly emergency, time-dependent medical flights, they may play a role in certain emergency situations that would normally be handled by helicopter. Fixed-wing aircraft are more all-weather capable, IFR, and have deicing capability which is virtually absent outside of large military helicopters.",
        "Space": "Unlike some large military helicopters that can accommodate six or more patients, space is often quite limited in the aircraft used for civilian HEMS operations. Access to the patient is highly variable, depending not only on the model of aircraft, but also on the configuration of the medical interior of each individual aircraft.",
        "Weight": "Unlike ground transport, all aircraft are weight and space sensitive. The weight of the medical equipment, the providers, and the patients must be considered prior to every call. The weight, size, and electrical requirements of medical equipment are performance limitations. Certain models of ventilators, intraaortic balloon pumps, extracorporeal membrane oxygenators, and other medical devices may be readily adapted for use in ground interhospital transport, but may be too bulky and heavy for use on a helicopter. With the increasing girth of the average American, the provision of air medical services becomes more challenging, and a plaintiff in a recent court case in Florida has challenged a HEMS decision to not fly a patient due to weight.",
        "Auditory": "Aircraft are inherently noisy working environments. All necessary medical history must be obtained before loading the patient, as conversation will be difficult in flight. Breath sounds must be evaluated before transport, as auscultation on board will not be fruitful without the use of an amplified electronic stethoscope wired into the aircraft intercom system.",
        "Lighting": "Lighting can be an additional challenge in providing medical care aboard a helicopter. Although the driver of an ambulance generally is unaffected by what goes on in the patient care area, the pilot of a helicopter can have his night vision affected by the light necessary to provide patient care. It is therefore necessary to illuminate the patient care area with less distracting red or blue lighting at night, or to pull a heavy curtain to separate the cockpit from the helicopter service area. Most of the medical helicopters in the US now operate using military night vision, requiring additional certification of interior aircraft lighting. In the daytime, sunlight may make viewing of medical monitoring equipment difficult and can also affect the function of some medical equipment, such as the infrared sensor for certain end-tidal carbon dioxide monitors. Unlike ground ambulances, patients on helicopters may also develop \u201cflicker seizures\u201d by having sunlight shine directly through the moving rotor blades into their eyes, causing a strobelight-like stimulation and subsequent generalized seizure activity.",
        "Electronic medical equipment": "Electronic medical equipment must be evaluated for the effects of radiofrequency interference and electromagnetic interference before it can be used safely on an aircraft. The Federal Communications Commission limits use of any unapproved communication device. Medical equipment must be assessed for power requirements which may affect the aircraft and battery performance for transitioning patients to and from the aircraft. Physicians should be aware of what medical technology is available from any individual provider agency and have assurance that the equipment is regularly tested.",
        "Regulations": "Air medical services providers are regulated by both state and federal regulatory agencies, in addition to regional or local medical oversight. All aviation-specific issues are strictly in the purview of the Federal Aviation Administration (FAA), economic regulation is overseen by the federal Department of Transportation (prices, routes, and services), while medical issues are generally in the purview of a medical director and state laws and regulations. There is unfortunately a tremendous amount of gray territory in between. The complexity of regulation is beyond the scope of this chapter, but has been detailed by interested organizations. In 2006, the IOM noted that \u201cwhile the Federal Aviation Administration is responsible for safety inspections, helicopter licensure, and air traffic control, the committee recommends that states assume regulatory oversight of the medical aspects of air medical services, including communications, dispatch, and transport protocols.\u201d",
        "Federal preemption": "Understanding the various jurisdictional purviews of these regulatory authorities is a challenge for medical directors in the best of circumstance, and the Airline Deregulation Act of 1978, which created federal preemption to state regulation of interstate commerce, increases the complexity. Specifically, the Act states: (b) PREEMPTION.\u2014(1) Except as provided in this subsection, a State, political subdivision of a State, or political authority of at least 2 States may not enact or enforce a law, regulation, or other provision having the force and effect of law related to a price, route, or service of an air carrier that may provide air transportation under this subpart. As with the Emergency Medical Treatment and Active Labor Act (EMATLA), which is well known to emergency clinicians, the devil is in the details. Under preemption, air medical services providers have successfully overturned state regulatory efforts requiring aircraft-specific equipment, hospital destinations, certificate of need requirements, and CAMTS accreditation as a requirement for licensing. Although preemption continues to be debated, recent case law in many arenas other than air medical services has upheld the federal preemption position. The medical director must work to align the interests of patient care with often competing and conflicting regulatory and policy efforts.",
        "Federal Aviation Regulations": "The FAA solely governs aviation under Title 14 of the Federal Code. All air ambulances require air carrier certificate holders either directly responsible or contracted for aviation services. The two sections of the regulations that have the most bearing on air medical services are Part 91 General Operating and Flight Rules, which apply to all aircraft flying in the US, and Part 135 Air Carrier Certificates, Commuter and On-Demand Operations and Rules Governing Persons on Board Such Aircraft. These regulations basically govern such things as pilot rest and training, air space regulations, VFR/IFR, and aircraft maintenance. With the exception of public entities operating under Part 91, in order to provide air medical services, a Part 135 certificate holder must be present within the service. This can be a certificate holder that is contracted by a hospital or other entity to provide aviation services (\u201ctraditional model\u201d), a hospital becoming a certificate holder and owning the aircraft and hiring aviation staff, or a Part 135 certificate holder with a preexisting aviation operation that hires its own medical personnel (\u201ccommunity model\u201d). Note that the FAA Reauthorization in 2011 now requires that all air medical services with medical crew on board be conducted under Part 135. A hospital may own an aircraft and contract with a Part 135 operator who takes responsibility for all operations of the aircraft. Over the past several years the FAA has increased scrutiny of Part 135 operations to assure that operational control, the accountability and responsibility of the aviation component of the service, rests solely with the certificate holder. It is essential that medical directors clearly understand the FAA\u2019s definition of operational control because conflict between the air medical services mission (e.g. go/no go decisions, diversion of aircraft, medical equipment, etc.) and FAA requirements on the certificate holder must always defer to the certificate holder\u2019s operational control. Another area of FAA scrutiny is the use of brokered aircraft in which there is no clear line of operational control in the marketing and sale of service. This has primarily been an issue in the fixed-wing arena whereby brokers market fixed-wing services without owning aircraft, employing pilots, or employing medical crews. Physicians arranging for transport need to be cognizant that all is not what it seems in many of these operations.",
        "Quality, safety, and credentialing": "Most states license air ambulances as ambulances, but states have no jurisdiction over the aviation aspects of the program. This misalignment is challenging as safety issues, especially with regard to medical helicopters, have been a profound factor. Although accident numbers are relatively small, the consequences of accidents are enormous, with most accidents incurring major or fatal injuries. The Federal Aviation Regulations are based on safety, but are limited and do not currently address all of the best practice recommendations from the National Transportation Safety Board (NTSB). In addition to safety problems, including HEMS being on the NTSB \u201c10 Most Wanted\u201d list, air medical services quality is often opaque. Recent work by the American Academy of Pediatrics (AAP) and the Air Medical Physicians Association (AMPA) is in the early stages of establishing quality performance metrics. Table 2.3 highlights proposed national metrics illustrating both consensus and some divergence based on primarily adult patients versus neonatal and pediatric-specific transport and air medical services agency characteristics, with more information available at https://ampa.org/. In addition to state licensing, provider agencies may voluntarily submit to external accreditation from CAMTS. Currently CAMTS has 21 participating organizations, and has accredited about 154 air medical and ground services. The newest standards may be found at www.camts.org.",
        "Operational challenges": "The EMS medical director should have insight into the environmental factors that can affect the ability of an air medical program to support ground EMS operations.",
        "Weather and visibility": "With certain limited exceptions, timely scene HEMS response requires the pilot to be able to fly to the scene under VFR. In most EMS helicopter operations, this requires at a minimum a visibility of at least 1 mile with a cloud ceiling of at least 500 feet. Many programs use higher minimums in the interest of maximizing safety and increasingly, especially hospital-based providers are incorporating IFR to increase safety and reliability. Current NTSB recommendations include instrument flight currency for all pilots as marginal weather with low visibility/ night operations is the most common crash profile. Transition to instrument flight is a tremendous safety enhancement in the event the pilot inadvertently encounters changing weather and can no longer navigate by sight. Emergency medical services providers should anticipate that rotor-wing aircraft will be grounded during periods of freezing precipitation. Rain itself generally does not prevent scene HEMS response as long as visibility minimums are met; however, freezing/frozen precipitation can accumulate on the rotor blades and cause the aircraft to lose lift.",
        "Ambient temperature": "The ambient temperature can have a significant effect on the maximum weight that a helicopter is able to carry. The higher the temperature, the less dense the air, and consequently the harder the engines must push the rotor blades to achieve the same amount of lift. The effect of temperature on lift is magnified at high altitude, where the air density is already low. Each pilot, at the start of his or her work shift, calculates the maximum weight of fuel, cargo, and passenger weight the aircraft can carry on that day. In certain air medical operations, temperatures greater than 90\u00b0F may prohibit the transport of two patients or may limit the amount of fuel that is carried.",
        "Hazardous materials or infectious disease": "Unlike ground ambulances, helicopter pilots and crews are enclosed in the same small air space occupied by the patient and are at risk for exposure to fumes or communicable disease. Patients who are contaminated with hazardous materials should not be transported by air, and each service should have a pre-established plan for managing highly infectious patients.",
        "Ability to perform unusual and ad hoc activities": "The nature of the helicopter lends itself to utility in unusual circumstances. Some of these circumstances are mentioned here. These occasional uses do not justify the expense of procuring HEMS, but if the assets are already available, then these deployments can be helpful and contribute to overall utility of the air medical resource. EMS medical directors should have an awareness of the special capabilities of the air medical services in their area.",
        "Remote or difficult access areas": "Helicopters can be of great assistance for patients who are difficult to reach or remove from remote areas even if clinically they do not require critical level intervention. Hikers and hunters may become ill or injured a great distance from a roadway. Rural roads may be inaccessible long after a big snowstorm. Island inhabitants may be inaccessible due to rough or frozen waters.",
        "Search and aerial rescue": "Helicopters can be used effectively to assist ground EMS in locating patients in unusual situations. Some examples would include an overturned boat with persons swept downstream, a severely crashed vehicle found on an isolated stretch of road at night with evidence of bleeding and no patient, or a young child or an Alzheimer\u2019s patient missing in cold weather. Hunters and hikers may call from the woods via cell phone to report a serious injury or illness but may be unable to provide an exact location. On occasion, these patients are only located by staying on the line and telling the 9-1-1 center when they hear the helicopter getting close to them. All helicopters are capable of performing visual searches, and those that perform nighttime scene responses have searchlights and night vision. Hoist operations may be invaluable in dealing with a patient in a difficult access area where a landing zone cannot be established. Special equipment and training are required and currently, other than military, law enforcement, and fire/rescue providers, only Intermountain Healthcare LifeFlight in Salt Lake City provides this type of service. Hoisting is most often used to remove a patient from a dangerous, precarious, or time-critical situation, but on occasion may also be the only means of inserting rescuers to access the patient. Hoist operations are much more widely provided by HEMS internationally.",
        "Aerial reconnaissance and lighting": "Visualization of an incident scene from the air may provide important information as to the size of the event, the number of resources needed, and the best route for responding units to gain access. In regional disasters such as flash flooding and earthquakes, aircraft can locate imperiled persons who are not yet patients, and can alert responding units to impassable roadways. Most medevac helicopters have strong searchlights that can effectively illuminate an area the size of a football field. Although use of a helicopter searchlight is not a cost-effective method of routinely providing illumination, it can provide rapid, mobile visualization in critical situations. Beyond initially locating patients, the aircraft can provide lighting while rescuers access and provide initial care to patients who are scattered across a large incident, or are located in the water or in a difficult access area.",
        "Mass casualty incidents": "There are also instances in which HEMS flexibility has translated into myriad uses during disaster and mass casualty incidents. In incidents with multiple injured patients, air medical transport can be used to distribute patients among appropriate trauma facilities to prevent any one center from becoming overwhelmed. Depending on the incident location, the strategy may be to fly the most seriously injured patients, or alternatively to drive the most critical to nearby trauma centers, while flying less critical but serious patients to more distant trauma facilities.",
        "Mass gatherings": "Mass gatherings of people present EMS systems with unique problems. Normal traffic patterns throughout an entire city or region may be disrupted significantly. In addition to challenges in accessing and transporting patients associated with the event itself, access to health care facilities in the area may be obstructed. These facilities may also be overwhelmed with ambulatory patients from the event. Air medical transport may play roles in removing patients from the event itself, allowing non-event patients to continue to access health care facilities in the area, and distributing patients to more distant hospitals when local facilities are overwhelmed.",
        "Go teams": "In the rare case where a medical expert or team needs to be transported to the patient, the speed and logistical capabilities of the helicopter may be useful. Air medical programs may be able to support local EMS by transporting hospital-based physicians and other personnel who are specially trained and equipped for scene response. These responses typically involve incidents with protracted extrications in which there is concern that a field surgical procedure may be required. Such teams may also play a role in selected mass casualty incidents and disaster situations. \u201cGo team\u201d response requires much preplanning and coordination among local EMS, the sending hospital, and the air medical service. In addition to transporting people, helicopters have been occasionally used to rapidly transport vital supplies or drugs (e.g. prostaglandins to a neonate with a ductus-dependent lesion).",
        "Conclusion": "The successful integration of air medical transport into local EMS systems is dependent on effective preplanning and coordination at many different levels. Medical directors and EMS physicians play a pivotal role in ensuring that air services are used efficiently and effectively. Despite the projected substantial decreases in health care spending, the need for air medical services will continue to grow and evolve. The US Department of Health and Human Services projects a four-fold increase in the number of persons 60 years and older in the next two decades. The trend is particularly noticeable in the United States, with a rapidly aging population, especially in rural areas. The emergency medical needs of this population are reflected in the growing rates of trauma, as well as the increased occurrence of time-critical conditions such as heart attack, stroke, and non-trauma surgical emergencies (e.g. abdominal aneurysms and stomach/intestinal bleeding). Recent studies examining the response to elderly trauma patients have found that many of these patients do not currently reach trauma centers in a timely manner. As medical science creates new ways to intervene in medical emergencies with technology that must be utilized within a narrow window of time, the need for air medical services to bring that technology to patients, or to bring patients to that technology, will continue to grow but must be carefully medically overseen to assure appropriate resource use in time-sensitive disease."
    },
    {
        "Confined space medicine": "Confined space medicine (CSM) may be defined as the emerging body of knowledge concerned with the rescue and treatment of victims in collapsed structures or similar urban search and rescue (US&R) environments, with limited access and egress, and unfavorable environmental conditions. It has also been defined as \u201cthe unique body of knowledge concerned with the medical needs of the trapped individual.\u201d Confined spaces may be collapsed buildings, roadways, or other structures, or may be structures such as grain silos, utility tunnels, underground power vaults, caves, and other locations that are \u201cconfined\u201d in terms of limited ingress, egress, and ventilation even when intact and used as intended. Confined space simulators have become common training settings for US&R teams and other rescue services, including fire departments, that may be called upon to provide this type of technical rescue. Live training exercises on demolished buildings provide an additional level of realism, but also involve additional hazards.\n\nThe goal of CSM is to provide sophisticated medicine in an austere environment, despite limited space, personnel, and equipment. Unlike the \u201cconventional\u201d trauma environment, where \u201cscoop and run\u201d is the general approach, prolonged interactions between victims and rescuers \u201cin the rubble\u201d are to be expected, and it is often necessary to bring EMS, emergency medicine, and critical care capabilities to the patient, rather than bring only EMS and then transport the patient to emergency medicine and critical care. The potential lack of adequate medical back-up, due to compromise of the local medical system in larger events, may place further demands on US&R medical personnel, who may have to continue caring for victims after rescue.\n\nUrban search and rescue medical personnel can decrease morbidity and mortality through prompt assessment and stabilization of the victim, and can expedite extrication. For example, providing adequate pain control can decrease the apparent urgency of the extrication as viewed by rescue personnel, and improve patient cooperation. A careful examination of the patient in the rubble might also, for example, allow for extrication without a backboard, simplifying the mechanical process of patient removal from the confined space.\n\nSpecific components of CSM practice include the following: Gather patient data as early as possible. This can include getting information from bystanders, family, or coworkers before contact is even made with the patient. Once the patient has been located, a relatively sophisticated assessment can be made by simple voice communication, before physical contact is possible. Monitor the effect of the rescue efforts on the patient(s). Ensuring that atmospheric testing is completed before spaces are entered will contribute to rescuer safety as well as victim safety. Medical personnel should also watch for carbon monoxide (CO) production (from gas-powered tools or nearby vehicles) or dust created by rescuers, and should provide victims with dust masks, or oxygen by face mask if needed. Preposition equipment that is likely to be needed, to save time once the patient is reached. This may include the preplanning of strategies to deliver the necessary equipment by means of rope systems or other techniques. Begin physical assessment as soon as any physical contact is possible. A small amount of exposed skin or simple voice contact can allow for basic assessment of perfusion and overall neurological function. Victim report of injuries can allow for planning of care once access has been gained, including bringing the necessary equipment, medications, etc. into the rubble. Initiate stabilization. After taking universal precautions and ensuring victim and rescuer safety to the greatest extent possible, the rescuer should protect the victim from further harm by providing a dust mask, face shield, helmet, etc. as needed. The standard ABCDE approach to trauma care may need to be modified somewhat, but still provides a useful general format for identifying and stabilizing clinical problems as they are found. Unlike the conventional EMS setting, where a number of interventions such as IV access and supplemental oxygen are often provided in a \u201cprecautionary\u201d manner, such interventions should only be applied if clinically indicated, due to issues of space, equipment and line tangles, and time.\n\nProvide anatomical and physiological advice to the rest of the rescue team regarding moving the patient.\nReevaluate the patient after each significant move, particularly if advanced airway management (e.g. intubation) has been performed.\nPrepare the patient for hand-off to local EMS personnel, if available.",
        "Rescuer safety": "The Occupational Safety & Health Administration (OSHA), US Department of Labor, defines confined spaces as follows. Many workplaces contain spaces that are considered because their configurations hinder the activities of employees who must enter, work in, and exit them. A confined space has limited or restricted means for entry or exit, and it is not designed for continuous employee occupancy. Confined spaces include, but are not limited to, underground vaults, tanks, storage bins, manholes, pits, silos, process vessels, and pipelines. OSHA uses the term (permit space) to describe a confined space that has one or more of the following characteristics: contains or has the potential to contain a hazardous atmosphere; contains a material that has the potential to engulf an entrant; has walls that converge inward or floors that slope downward and taper into a smaller area which could trap or asphyxiate an entrant; or contains any other recognized safety or health hazard, such as unguarded machinery, exposed live wires, or heat stress.\n\nOSHA issues the following advice to employees at sites with permit-required confined spaces, and these seem reasonable precautions for EMS physicians and other rescuers as well. Do not enter permit-required confined spaces without being trained and without having a permit to enter. Review, understand, and follow employer\u2019s procedures before entering permit-required confined spaces and know how and when to exit. Before entry, identify any physical hazards. Before and during entry, test and monitor for oxygen content, flammability, toxicity or explosive hazards as necessary. Use employer\u2019s fall protection, rescue, air monitoring, ventilation, lighting, and communication equipment according to entry procedures. Maintain contact at all times with a trained attendant visually, via phone, or by two-way radio. This monitoring system enables the attendant and entry supervisor to order you to evacuate and to alert appropriately trained rescue personnel to rescue entrants when needed.\n\nNote the last phrase of the last item: appropriately trained rescue personnel. Regarding rescue services and their training, OSHA specifies the following. The standard requires employers to ensure that responders are capable of responding to an emergency in a timely manner. Employers must provide rescue service personnel with personal protective and rescue equipment, including respirators, and training in how to use it. Rescue service personnel also must receive the authorized entrants training and be trained to perform assigned rescue duties. The standard also requires that all rescuers be trained in first aid and CPR. At a minimum, one rescue team member must be currently certified in first aid and CPR. Employers must ensure that practice rescue exercises are performed yearly and that rescue services are provided access to permit spaces so they can practice rescue operations. Rescuers also must be informed of the hazards of the permit space.\n\nIt cannot be assumed that the local fire department meets the regulatory requirements for serving as the designated rescue service for a facility or site with one or more permit-required confined spaces, and an ambulance service that provides EMS but no rescue services does not meet the requirements. Indeed, OSHA notes that \u201cplanning to rely on the 911 emergency phone number to obtain these services at the time of a permit space emergency would not comply\u201d with regulations. The EMS physician should be aware of the complex regulatory issues involved in confined space operations and rescue, to avoid placing him or herself in danger. Training with a rescue service can help familiarize the physician with safe operating practices; however, the physician should never enter a permit-required confined space without complete training and authorization. Training in a confined space simulator or similar setting, in preparation for rescue work in structural collapses or similar emergencies, should not be confused with the site-specific training needed to perform rescues at permit-required confined spaces.\n\nEven outside the setting of the permit-required confined space, there are significant hazards to rescuers, some of which are not typically found outside the US&R environment. An oxygen-depleted environment can be found in mines, grain silos, and some other confined spaces. Oxygen depletion can also occur during structure fires. Self-contained breathing apparatus is needed to safely operated in these environments, until adequate ventilation and restoration of a safe breathing environment can be demonstrated through gas metering. EMS physicians should not wear and operate in SCBA without formal training and certification, and only in the setting of an organized response team or other authorized department.\n\nNitrogen asphyxiation is a subtype of oxygen-depleted environments. Nitrogen is used in some industries to displace oxygen, preventing rust/corrosion and decreasing fire hazards. Nitrogen-rich, oxygen-poor environments result in approximately eight deaths per year in the US, mostly related to industrial plants and laboratories, though even trenches and manholes can become nitrogen-enriched. Roughly 20% of these fatalities occur due to a mix-up of tanks of nitrogen and breathing air. EMS physicians should keep the possibility of nitrogen asphyxiation and oxygen depletion in mind, particularly when one or more rescuers has collapsed attempting to rescue a victim.",
        "Specific clinical problems": "Common injuries associated with collapsed structure victims include fractures/lacerations, closed head injuries, multisystem trauma, and dehydration. Many of these entities are familiar in routine EMS care; however, an array of atypical clinical conditions is likely to be encountered as well. These represent both clinical entities unique to the collapsed structure events, as well as unusual presentations of commonly observed illness/injuries. The \u201cclassic\u201d US&R/CSM medical problem is crush injury, which may be followed by compartment syndrome and/or crush syndrome. Blast injuries are also fairly common in this setting, particularly in bombings. Several other clinical scenarios are fairly specific to the US&R/CSM environment.",
        "Dust airway impaction": "Building materials contain a wide variety of factors that create dust when destroyed, such as silica, calcium, asbestos, wood, and mineral fibers. Masonry, sheet rock, plaster, tiles, and insulation all create dust when buildings collapse, and without adequate respiratory protection (for both victims and rescuers), dust can enter the airways and impair both ventilation and gas transfer. In addition to the cloud of dust that may be created during the event itself (particularly building collapses), rescue efforts (such as the use of power saws) can resuspend dust particles in the air. Dust airway impaction has been reported to be the cause of death in some earthquake victims.\n\nOf course, more conventional airway and respiratory problems can also been seen in the US&R/CSM victim, such as airway obstruction (due to blood, dislodged teeth, vomitus, facial fractures, etc.), debris limiting chest wall expansion, pneumothorax and hemothorax, and pulmonary contusions. Asphyxiation due to displacement (e.g. methane from ruptured gas line) or consumption of oxygen, thermal airway injury from hot gases, cellular toxins (CO, cyanide, and others), and a variety of noxious gases and particulates may also affect the US&R victim, although published data are lacking. US&R teams have air monitoring equipment to help ensure a safe breathing environment during rescue operations; the EMS physician should be careful not to enter areas and spaces that have not been tested and found to be breathable.\n\nThe US&R medical team must be able to assess and manage these problems both in the rubble and after rescue. General assessment of the airway and ventilatory status of the patient can begin before the patient is actually reached: a talking patient has a patent airway, and in fact likely has reasonably intact airway, breathing, and circulation. Humidified air or oxygen can be helpful for the patient with dried secretions and inhaled dust. When considering supplemental oxygen, a risk/benefit analysis must involve logistics (heavy tanks, oxygen tubing snaking through the scene), and the risk of fire.",
        "Prolonged care": "Patients who have been trapped for hours or days, without access to their usual medications, may already be developing acute exacerbations of chronic medical problems. Patients who rely on antihypertensives, insulin or oral hypoglycemic agents, psychiatric medications, antiarrhythmics, and seizure medications may be manifesting their chronic illnesses by the time US&R personnel reach them. While the federal US&R task force equipment cache includes a wide variety of such medications, local or regional teams are less likely to have extensive caches to rely on, so should consider either stocking such medications or developing plans to rapidly secure them when needed.\n\nAdditional information regarding care in austere environments can be found in Chapter 39, Tactical Emergency Medical Services, and Chapter 42, Care in the Wilderness, as well as in Volume 4, Chapter 14 of the prior edition of this textbook. There are a number of similarities between US&R/CSM and the other austere environments that the EMS physician must be prepared to work in, and flexibility, creative problem solving, and adaptability are among the keys to success in these situations and environments. Fortunately, many of the skills needed to operate effectively here are the same skills that help provide safe and effective patient care in the general out-of-hospital setting, and the more experience and expertise the EMS physician gains in working in the general field setting, the better prepared he or she will be for adjusting to an even more austere environment.",
        "Conclusion": "While US&R was initially defined by the Federal Emergency Management Agency as \u201cthe science of responding, locating, reaching, medically treating, and safely extricating victims entrapped by collapsed structures, it is widely recognized that the principles developed and formalized in the US&R domain can be applied to a wide array of other technical rescue disciplines, including rescuing victims from floods and swift water emergencies, high-rise fires, and confined space, trench collapse, transportation, and industrial machinery incidents. Much of the clinical experience acquired in the US&R/CSM realm has provided lessons in the medical support and management of other emergency domains, and vice versa.\n\nOne need not wait for a large-scale event to face the challenges of the confined space or collapsed structure event. Prehospital providers and EMS physicians may encounter these events following severe weather, mudslides, or earthquakes resulting in building collapse, during industrial or construction accidents, and even at what would be an otherwise routine motor vehicle collision. While large-scale events will typically result in the mobilization of additional resources in the form of regional, state, or federal assets, a smaller incident may be managed with only local regional or state resources. Each scenario with its unique scale brings a different set of challenges and differing response resources, but most of the operational methods and tenets will be the same. The EMS physician should be able to function safely and effectively in these circumstances."
    },
    {
        "Introduction": "While the primary environment in which EMS providers operate is an ambulance or the \u201cstreet,\u201d provision of medical care during an incident may necessitate the establishment of a temporary treatment facility, part of whose staffing and operation may fall under the EMS jurisdiction. The types and purposes of such facilities can vary based on the type of incident and available resources. While this is a common practice in EMS operations, most of what has been described in the literature has been focused on the response to disasters, which is also part of EMS's role. Throughout history, armies have commandeered existing structures to establish places to care for wounded following a battle. Baron Dominique Larrey, Surgeon in Chief of Emperor Napoleon's Grand Armee, is often credited as being the father of modern military medicine and EMS. One of his major accomplishments was developing a system by which wounded soldiers were collected from the battlefield and brought to a treatment area or field hospital, often set up in a church or other building and staffed by surgeons who provided care to the wounded. These temporary facilities were the forerunners of the battalion aid station in the US military medical system or the casualty clearing station used by Commonwealth forces. Similar types of units remain in service with militaries around the world and function to stabilize wounded personnel prior to evacuation to higher echelons of care. These are essentially self-sufficient systems that bring with them the necessary supplies and personnel to accomplish their mission of caring for the wounded after combat. This chapter will not focus on those types of facilities used in or associated with mass humanitarian events such as famines or refugee evacuations. Certain basic principles for temporary facilities do apply to these large-scale events, but the issues related to international operations and coordination are beyond the scope of this chapter. For guidance in dealing with such events, the reader is directed to the World Health Organization (WHO) website where more detailed information is available. Temporary facilities range from collection points all the way up to fully capable emergency departments (EDs) such as the \u201cRampart\u201d facility set up each year at the Burning Man festival in Nevada or the National Mobile Disaster Hospital, a 300+ bed transportable general hospital developed by the Federal Emergency Management Agency (FEMA) and currently housed in North Carolina. The type and design of a temporary facility are very much driven by the events that necessitate the creation or deployment of the facility. For planned events, temporary facilities are created to provide care on site, often with the objective of limiting demands on EMS transport and local medical facilities. By allowing persons to return to their activities after receiving care, a positive participant experience is also maintained. Another role for temporary medical facilities is the provision of responder health and rehabilitation. These can range from simple rest and rehydration areas on an incident scene with medical screening of providers prior to return to duty, to full-scale clinics set up to provide primary care and occupational medicine support at the base camps of prolonged events like large forest fires.",
        "Planned events": "The role of medical stations during planned events and their capabilities is covered in Volume 2, Chapter 27. Medical intelligence gathered from event planners and prior experience with the event helps guide the design and the capabilities of on-site facilities, including locations and level of care. Care given may be simple first aid all the way up to full Advanced Life Support staffed by physicians and nurses. They type of venue also affects the design of the facility. For example, an event with alcohol being consumed will have a different type of patient load from an event like a papal visit. Factors that must also be considered during planned event operations include ambient environmental conditions which can affect the participants, providers, and facility design. The facility must provide adequate protection from the environment. Minimal support requirements include power, water, lighting, and adequate space to provide the level of care that the leadership determines will be needed. Types of events will change the demographics of the expected crowds and can influence the numbers seeking care. Distances from and number and capabilities of facilities in the community also will influence design and operations and staffing of such units, as does whether there will be alcohol or other intoxicants served or used at the event. Finally, high-profile events such as political conventions or speeches by prominent individuals bring security-related concerns that must be addressed. Such large events are often multijurisdictional and this increases the need for coordination, and creates challenges with respect to staffing and accreditation. The key to success with planned events is beginning the planning process early and assuring that all parties involved in care are part of the process.",
        "Surge capacity": "Another area in which temporary medical facilities have a prominent role is in creating surge capacity for hospitals and EMS systems to deal with large-scale disasters or events. While this has been a long-standing component of US civilian disaster planning, the concept of non-hospital sites to address increased need for patient care came to the forefront with the 2009 influenza pandemic. The number of hospital beds available was felt to be inadequate to meet the demands anticipated, as the illness would spread across the country. Many medical facilities and health care systems developed temporary treatment facility plans as a component of their system surge planning. Surge capacity is defined as the ability to manage a sudden, unexpected increase in patient volume that would otherwise severely challenge or exceed the current capacity of the health care system. While numerous strategies exist to deal with this issue, the use of temporary facilities, often designated to provide care to the less acutely ill or injured, has been a component in many suggested approaches to the surge issue. Among the more common terms to describe these facilities is \u201calternative care facility (ACF)\u201d or \u201calternative care site.\u201d Hick et al. have presented a scheme to classify surge response and resources and classify such deployable assets under the heading of catastrophic surge. Keeping the less ill patients outside the primary hospital was felt to keep risk of spread down and allow the sickest patients to be cared for at the acute care hospitals. In events such as a pandemic influenza outbreak, it is anticipated that there will be a large increase in demand for medical services and that many of those needing services will not require hospital-level or ED care. By creating care sites at locations other than the ED, and directing patients with less acute symptoms and care needs away from the ED, these other care sites allow medical providers to focus scarce resources on those with the greatest need. While the level of care offered at an ACF may vary by system, the key component of the process is that it frees the ED and other in-hospital areas to see those patients who require a more advanced level of care, and allows those with less acute problems to be seen in a timely and effective manner. It is during such events that the scarce resources must be allocated to where they will do the most good. There is no consensus as to whether the ACF should be on the hospital campus or not. Colocating allows for easier logistical management, including resupply and adjusting of staffing, but does increase the risk of overwhelming the ED and main facility. Moving off-campus does decrease this last issue but brings other issues up, including how to inform patients of the location and transport of patients to and from the center, especially at a time when there may be a shortage of personnel at many essential community services due to illness. One of the disadvantages of temporary facilities is that they do require time and personnel to establish them, once the decision is made to deploy them. They are therefore more useful in events that have some degree of advanced warning, such as an approaching hurricane or an infectious disease event like an influenza pandemic. Temporary medical facilities associated with planned events also give the planners and providers a degree of time to design and plan the medical operations for the event. No-notice events such as tornados, hazmat and transportation accidents, and terrorist events, by their nature, do not have a lead time in which resources can be mobilized and deployed. Thus facilities used in these events have to be rapidly established, often with limited staffing, and flexible in design and capability. Individual health facilities may not have sufficient resources or personnel to staff such centers by themselves even if they adjust staffing patterns elsewhere in the organization. These types of facilities are often best created and deployed at the community or coalition level. Since the set-up and operation, supply, and staffing of such units may cross jurisdiction or corporate boundaries, it is important to develop collaborative plans for such care systems. These plans must address triggers for activation of the resource, staffing and supply of the resource, and operational guidelines. While many mass casualty incidents (MCIs) are of short duration, temporary care facilities are often operational for prolonged periods and often continue operations after the acute period, as was seen with both National Disaster Medical System and state-level assets deployed to events such as Hurricane Katrina. These temporary facilities often become the de facto health care system in an affected area until the local health care infrastructure can be restored. Many plans consider using facilities such as schools or coliseums or other large public spaces as treatment facilities or alternative care centers. Use of such spaces does prevent them from carrying out their primary role. If the site being used is outside the primary impact area, the facility may be looking to resume normal operations before the need for the facility has stopped, and this can have a significant effect on the finances of the chosen site. Schools are often considered for such sites, but many are already designated by emergency management agencies as shelters. Other potential sites that can be considered for use include fellowship or other large rooms or halls at churches. Credentialing of personnel to operate in this type of environment should ideally take place before deployment or activation. Utilization of the Medical Reserve Corps or obtaining staff from state databases developed under the Emergency System for Advanced Registration of Volunteer Health Professionals can help fill shortfalls in personnel. Ideally, training and exercise of the asset with these providers should occur regularly to maintain competency and test the system. There still must be some form of just-in-time training to be sure all can function safely in the temporary facility and that there is a system to verify credentials for volunteers not previously vetted.",
        "Characteristics of temporary facilities": "All temporary facilities have certain basic functions that must be addressed. There must be a way for patients, response units, and personnel to access the site and for egress for those patients needing transport to definitive care or discharge home. Depending on location and event, such transport may include ambulances, buses, and even establishing a helistop. Furthermore, there must be a way for participants or staff to easily identify the care facility location and hours of operation. There must be a system to track patients in and out of the facility as well as creating and maintaining medical records that can follow the patients. Communications capability to reach around the site as well as to off-site locations, including the local EMS system and both local and state emergency operations centers, is also a must. Such communications must include redundancy, especially as systems may go down during a disaster or MCI. In addition, there must be a way to communicate to the public and other responders the location of the facility, the hours when it is operational, and what services will be provided. The public information officer can assist with this task. Mass media are a useful tool, but loss of utilities may prevent the general public from getting the information, so alternative channels of information sharing must be considered. Staffing of temporary medical facilities is also determined by the mission of the facility and the anticipated duration and level of care. Personnel who are being asked to man a predetermined facility should receive training on operations in advance, but there should also just-in-time training to allow them to effectively operate in an environment that is different from their usual, in a safe and effective manner. A key consideration in the staffing is that providers, by law or rule, have a definitive scope of practice and cannot operate out of that defined range, just because it is an \u201cemergency\u201d or a disaster. Thus, the personnel assigned to the temporary facility must be capable of providing the level of care that the facility is designated to offer. During a major event, most health care facilities or systems do not have sufficient personnel available to staff a temporary treatment facility by themselves, especially if the facility needs to maintain or possibly expand operations to meet the needs of the incident. Certainly by the end of a few operational periods, they could exhaust the supply of personnel, even with adapting schedules. Furthermore, the resources necessary to equip, maintain, and train for such operations are extensive and may exceed the capabilities of any one EMS or health care provider. Therefore, temporary treatment facilities that are designed to augment surge capabilities for health care lend themselves to being \u201chealth care coalition\u201d level projects, as defined by the Office of the Assistant Secretary for Preparedness and Response at the US Department of Health and Human Services. Coordination of operations should follow the incident management system model to allow integration with the other areas of response to the event. All persons involved in the operation of the temporary facility should be familiar with this system. An essential component is defining the trigger points that would cause EMS or other components of the medical system to activate and establish temporary treatment facilities. These need to be clearly described in protocols or standard operating procedures, and the authority to activate these resources must also be defined and assigned. The plan should also include trigger points that establish when the facilities can begin to demobilize. Factors that affect this trigger include at what level the existing health care system is operating, and what resources can be brought online to meet the need. Finally, whenever temporary treatment facilities are activated and used, a detailed after-action report should be completed to identify those components that worked well and areas that require improvement. Often when temporary facilities are established, the event transcends jurisdictional and operational boundaries. It is therefore important that whenever possible, uniform treatment protocols, triage schemes, and medical records be used, to reduce risk of confusion and potential patient care errors. Exercises that incorporate such facilities are extremely useful in this process. Temporary facilities can be established in fixed structures, such as schools, exhibition halls, churches, etc. Shelter-based systems are also used, and many have been developed and cached around the US, often associated with medical response units. This is exemplified by the Disaster Medical Assistance Teams (DMATs) of the National Disaster Medical System, which are \u201cdesigned to be a rapid-response element to supplement local medical care until other Federal or contract resources can be mobilized, or the situation is resolved. DMATs deploy to disaster sites with sufficient supplies and equipment to sustain themselves for a period of 72 hours while providing medical care at a fixed or temporary medical care site.\u201d They are equipped to provide high levels of medical care. Similar programs are found at the state level including in Florida, North Carolina, Missouri, and Illinois, and even internationally. The use of fixed structures to house temporary treatment facilities can have certain advantages, especially with regard to protection from weather. Utilities may have to be restored, such as power or water. The challenge to the responders, dependent on the nature of the event, is in establishing whether the structure is safe for occupancy. Plans for temporary care facilities should include who is responsible for this structural assessment. For deployable or field temporary medical facilities, there are multiple design and structure options to choose from. They may range from a simple \u201cpop-up\u201d that might be used as an aid station at a planned event, to purpose-built tractor-trailer field hospitals. The mission and environment as well as mode of transport of the asset will influence what model is used. Large systems require more transport assets, more logistical support to establish and maintain operations, and may not be able to change transport modalities (ground to air as an example). These systems often take longer to set up and require the system to commit more resources to training and maintenance. If possible, arrangements should be made to rotate through or exchange perishable supplies (such as pharmaceuticals) with supporting hospitals or agencies so that they do not expire and have to be wasted. Supplies and the units should be stored in a controlled environment if possible to further reduce waste and damage. In addition, when possible, these assets should be used in support of planned events, so that personnel can become familiar with the set-up and operation of the transportable medical asset. Utilization of a planned or other event as a \u201clive fire\u201d exercise allows the unit to fill multiple roles. There are multiple systems that can be used for deployable facilities, each with specific characteristics. Intermodal containers can be converted into hospital and clinic structures and are rigid and lend themselves to long-term operations. Around the world, resources exist to move these shipping containers, allowing them to be easily transported. However, because of weight and size, they do require a robust logistics footprint. Other shelter/medical systems based either on air-inflatable or rigid-frame tent-like structures are available. Air-inflatable systems go up rapidly while the frame-based systems can be interconnected to expand facility size. Set-up should also allow for an area for some sort of emergency decontamination of patients and or staff. Another consideration for temporary treatment facilities (both fixed and mobile structures) is the provision of utilities. Electrical power may be disrupted by the precipitating event. Portable sources of power and trained staff to operate them must be provided. Inside the facility, there must be adequate lighting to permit personnel to carry out the necessary tasks. Even if food is not being stored on site, some medications require refrigeration. Lack of power may compromise the function of fire alarm systems in fixed structures. Portable smoke and carbon monoxide alarms should be part of any cache. Location of and ease of access to emergency exits, taking into account the conditions of persons who will be inside the temporary medical facility, need to be assessed. An evacuation plan should be developed during the set-up of the facility. Fire extinguishers should be placed in strategic locations. For support of medical operations, oxygen and suction are required. For larger scale facilities, medical-grade air may also be needed. Bottled gases are most commonly used along with portable suction devices to address these needs. Larger operations may include the ability to produce medical gases on site. Transport of pressurized gas cylinders in vehicles is subject to various transportation regulations and is often difficult on commercial aircraft. Potable water is an absolute necessity. If infrastructure is intact, public health support will be needed to test water systems before use. At a minimum, there should be 7\u201310 liters per day per person for drinking, cooking, and basic hygiene. For patients being kept in the facility, that number rises. While non-potable water can be used for some sanitation needs, hand washing will require potable water. Water must be brought into the temporary facility if there is no water supply system functioning, or the temporary facility must have equipment to purify its own water. Water can be challenging to transport in quantities. For water-intensive procedures such as dialysis, temporary facilities may not be adequate because of lack of water pretreatment equipment and other necessary components. Efforts should be directed to restoring dialysis center operations or consideration of transfer of patients as an alternative. Information on this issue is available from the Centers for Disease Control or the National Kidney Foundation, among others. Sanitation issues must also be addressed. For fixed structures, do they offer an adequate number of toilets to deal with the expected volume of persons? If toilets are not operational or if insufficient numbers are present or the temporary facility is operating in mobile structures, a source for portable toilets and servicing of them needs to be incorporated in the plan. Collection and storage of waste water, to prevent release into the environment, can consume a large amount of storage space. Management of trash and \u201cregulated waste\u201d is another concern. Material contaminated with blood or body fluids or other potentially infectious material, along with sharps, require special handling and disposal. Management of this must be part of the operations of a temporary facility with arrangements to store and safely dispose of such materials built into the plan. Other trash and foodstuffs must be stored in such a way as to prevent rodent and other pest infestation. Should feeding operations be carried out on site, then appropriate food handling and storage procedures must be followed. Public health personnel can assist in assessing needs for this and what steps must be followed to be both safe and compliant with regulations. Site security is extremely important. Prevention of entry of contaminated persons until decontamination is completed, if the event involves hazardous materials, assures safety for all. Tracking of personnel through an accountability system is also a requirement, as is a method to track patients. Consideration must be given to the fact that local law enforcement may not be able to commit personnel to support the medical facility. The same is true regarding decontamination assets from local fire services. Because the temporary facility may be involved in dispensing medication, especially if local pharmacies are rendered inoperative by the event, there must be a secure area to store pharmaceuticals that also meets environmental storage requirements for the medications. Contacting state pharmacy boards or other regulatory agencies when developing the operations plan will allow development of operational guidelines that keep the facility in compliance and reduce possibility of medication errors. If the temporary facility is serving as a shelter to support the medically fragile population, efforts should be made to assure that those persons being brought to the shelter bring their own medications, support devices, and other durable medical goods with them. A system must be in place to label these items and track them so that they accompany the shelter resident. In addition, it is advisable to have either a family member/caretaker or staff from the facility accompany the resident(s). In this situation, the facility may have to have a general population shelter colocated to handle needs for the families and staff who accompany the shelter residents. It is advisable for EMS and health care systems to preidentify potential sites for temporary care facilities and conduct site surveys in advance of events. These surveys should address the issues of space, access, environmental control, back-up power, access, and egress. If deficiencies are identified, modifications to the site can be made to improve its ability to support the temporary care facility. For deployable temporary care facilities, the footprint that such a facility takes, as well as the support needs, must be identified in advance and communicated to any agency or organization requesting the asset. Without that support, the asset will not be able to be utilized to its full potential. For any temporary medical facility, there is a lag period between the decision to utilize the facility and the actual bringing of the facility online. If such assets are community based, there may be multiple competing requests and needs for that asset. Advance planning must address these issues so that time and resources are not wasted. Guidelines exist for site selection for ACFs. When a site is predesignated, it may be subject to additional rules and regulations from agencies such as the Joint Commission or state agencies that oversee health care. This is a consideration if the organization establishing the temporary facility is a hospital or other health care entity. The US Department of Justice, which enforces the Americans With Disabilities Act, also has guidelines about shelter designation. Just because a disaster or major event has occurred does not mean that rules overseeing patient care, health care practice, licensure, etc. are suspended. At federal, state, and local levels, officials do have the ability to suspend or modify rules, usually after a disaster declaration, but such suspension is not a certainty. Thus temporary facilities may have to comply with applicable rules and regulations when in operation. Systems should check with the appropriate authorities in their jurisdiction and consider in the operational plan a step to request suspension of applicable rules and/or regulations, when necessary. If facilities will be able to provide x-ray services, then they must be set up to comply with the rules and regulations dealing with use of diagnostic x-rays, including any monitoring requirements. Qualified technologists may be needed, dependent on state regulations. Temporary structures often lack the level of shielding seen in medical facilities. Regulatory compliance is also necessary for laboratory tests performed in temporary facilities. The Centers for Medicare and Medicaid Services does permit certain tests to be performed without having a laboratory permit under Clinical Laboratory Improvement Amendments (CLIA) regulations. Facilities need to apply for a CLIA waiver in advance. Tests not on the waived list require a much more robust oversight program. Disaster declarations may allow various officials to suspend certain regulations or enforcement thereof, usually confined to the area of the event. Thus, a community that is receiving large numbers of evacuees or casualties in transfer from another community may not initially be covered by either the disaster declaration or the suspension of certain regulations, as they should not be located in the impact zone of the event. If the receiving community does become overwhelmed, it should consider asking to be added to the areas covered by the declaration.",
        "Conclusion": "Temporary medical facilities are as varied as the missions they are tasked with. Preplanning and coordination between agencies utilizing or deploying them are key to success. Effective use of these systems is based on matching the asset to the mission and developing in advance triggers for use and operating procedures. When used for surge they can increase sites for care, allowing more acute patients to be managed in hospitals and EDs. They can also be used at planned events to help decrease the load on an EMS system. It is key that appropriate planning and training on the systems take place so that staff can effectively use these assets."
    },
    {
        "Introduction": "Medical oversight in prehospital care is distinctly different from any other supervisory activity performed by a physician. Although it is acknowledged as an integral element of an EMS system, medical oversight has been a bit of a mystery to the law, the public, and the medical community. Despite their immense responsibilities in providing medical oversight, medical directors were rarely defendants in litigation during the first 30 years of EMS. Although weakening, this trend continues.\n\nThere have been obvious improvements in the sophistication of EMS systems since the early days of \u201cinvalid coaches\u201d staffed by \u201cambulance drivers,\u201d and a continued appreciation for \u201cthe speed with which the ambulances reach the sick and injured, bringing help that literally wrest the sufferer from the jaws of death, as the last flickering spark of life is leaving the body.\u201d However, prehospital medical care is often misunderstood, and consequently the role of the medical director is often not understood by lawyers, citizens, bureaucrats, and even some physicians. As recently as 1989 an appellate court judge referred to an ambulance as a \u201cmedical taxicab\u201d rather than a mobile intensive care unit.\n\nIgnorance and misperceptions affect medical directors. They face confusion, misconceptions and uncertainty in the day-to-day events of medical oversight and in the legal crises that may erupt from those duties. The medical profession has had decades to develop standards and predictability in legal rulings involving medical malpractice. However, only recently has a patchwork of legal decisions involving EMS activities solidified sufficiently to provide some predictability. In a few states, trends are evolving about liability issues that help define responsibilities of systems or prehospital care providers and interpret immunity statutes governing prehospital care. Medical directors may benefit from the few legal precedents established by other participants in this unique and developing area of medical care. However, any medical director, whether a novice or an expert, must keep in mind that there are many unresolved issues surrounding medical oversight.\n\nIn most states, the birth of EMS preceded the enactment of enabling legislation authorizing this unique delivery of medical care. When federal highway grant funds were offered, every state eventually enacted EMS legislation to qualify; however, intense physician supervision was not necessarily mandated in these early statutes, many of which remain in effect more than three decades later.\n\nDuring the development of EMS systems, immunity from liability for the rescuer gradually became a focus of many state legislatures. It was assumed that immunity was a prerequisite for volunteer (uncompensated), provider involvement in emergency response, although there was, and still is, no good evidence to substantiate this proposition. In a 1978 appellate court ruling absolving from liability rescuers who failed to oxygenate a patient in cardiac arrest, the court reasoned that immunity laws were essential because of the difficulty in obtaining insurance and because unlimited liability could \u201cbe enough to drive many providers of ambulance service out of business and greatly discourage others from entering.\u201d Immunity for the prehospital care provider became common and remains rooted in EMS law.\n\nEventually laws were passed to protect the trained rescuer and professional paid responder, as well as the \u201cGood Samaritan.\u201d Governmental immunity also became a strong shield from liability for the public agencies. Immunity for the Good Samaritan physician became commonplace, and immunity for the supervising physician was seen as early as 1976.\n\nMedical oversight as a necessary component of a system has not been recognized with uniform enthusiasm in legislation. Although physician participation (often side by side with paramedic personnel) existed in the early mobile cardiac care units, legislative mandates for physician involvement varied tremendously from state to state. Physician involvement commenced only at the hospital door for the majority of volunteer basic life support units that covered the expanse of highways and hillsides across the country. Even as EMS entered the 21st century, medical directors still were not required to supervise the medical care of many non-paramedic services, particularly in rural, nontransporting EMS services.\n\nDespite the years of muted development of medical oversight, the silence of the courts regarding the role of the prehospital medical director has begun to change. Medical oversight will become increasingly recognized in the legal arena as a fundamental component of quality prehospital care, especially as medical directors become more active and more informed, and the level of care delivered by EMS providers becomes more complex. Potential liability is the inevitable corollary that shadows the development of responsibilities in medical oversight.\n\nWith EMS becoming the sixth subspecialty of emergency medicine in September of 2010, awareness of the EMS medical director's role is becoming more high profile. The responsibilities of EMS medical directors are being taken seriously by both the medical and legal professions. A recent health law publication recognized the medical legal position of the EMS medical director and its importance. The role of the EMS physician as an expert witness in legal proceedings has been recently outlined in a position paper by NAEMSP.",
        "The legal framework of the physician/EMT relationship": "We have all heard that the relationship between the EMS medical director and the EMT is one in which the EMT is the \u201ceyes, ears and hands of the physician\u201d and that the EMT practices \u201cunder the license\u201d of the physician. Although these phrases still find their way into texts and sometimes court rulings, they do not describe the legal relationship. The legal relationship is one of supervision rather than agency. An \u201cagent\u201d is \u201ca person authorized by another to act for him.\u201d In a supervisory relationship, the physician has the responsibility to properly oversee the practice of another health care provider, whereas in an agency relationship the health care provider is an employee or representative of a company or governmental department which is responsible for what its employee does under the legal principle of respondeat superior (\u201clet the master answer\u201d) and the agency is liable for the actions of its agent. Although EMTs are agents of the EMS institution that employs them, they are not the agents of the EMS medical director.\n\nAgency relationships in the law began with the relationship between master and servant, with the master being liable for any harm caused by the servant. Also known as \u201cvicarious liability,\u201d this is not the relationship between the medical director and EMT, because the medical director does not employ the EMT or otherwise function in a manner that would implicate the physician for errors made by the EMT.\n\nThe term \u201cdelegated practice\u201d had been widely used to describe the relationship between the physician and the EMT. However, in most states, there are no statutes that authorize a physician to \u201cdelegate\u201d skills within his or her practice to another health care provider. Texas is a notable exception to this general rule.\n\nEmergency medical technicians are either licensed or certified by the state or county in which they practice. The terms \u201clicense\u201d and \u201ccertification\u201d have been muddled and cause a great deal of confusion in EMS. A license is \u201cpermission from a competent authority to do an act which, without such permission, [would] be illegal.\u201d Certification is \u201cthe formal assertion of some fact.\u201d Therefore, even when it is called certification, EMTs who are permitted to practice by states and counties are actually licensed. They do not practice \u201cunder the license\u201d of the physician, but instead under the physician\u2019s supervision, with the permission of the governing body. The notion of \u201cpracticing under a physician\u2019s license\u201d actually grew out of the fact that EMS developed quickly, and the legal system took some time to catch up to the existence of this completely new health care provider. Although paramedics began practicing in the 1970s, many states did not have enabling EMS legislation until the mid-1980s.\n\nThe EMS medical director has responsibilities that, in and of themselves, may open him or her to liability for negligently training, supervising, or retaining an EMT. Similarly, the EMS medical director has the responsibility to develop and update protocols so that they are in step with current EMS practice, the medical standard of care, and the law. The EMS physician who simply signs off on an EMT\u2019s competency without being intimately involved with medical oversight activities is opening himself to the scrutiny of the courts if an EMT under his supervision commits medical error.",
        "Sources of accountability - Federal law and regulations": "Although EMS is almost exclusively under state and local law as a health and safety concern, medical directors need to be aware of several areas of federal law. If medical directors are part of the employment hierarchy, their actions may allow them to be named in lawsuits based on employment disputes. The number of such lawsuits is increasing yearly.\n\nMedical directors should recognize the newer definition of sexual harassment. Formerly, overt inappropriate action was required. Now, the creation or perpetuation of \u201can oppressive or hostile work environment\u201d can constitute harassment.\n\nThere is continued tightening of safeguards against Medicare and Medicaid fraud and abuse. One of the areas being closely watched is the use of ambulance services, especially for transport. Physicians have been warned against easy certification of medical necessity for the use of ambulances when other avenues of transportation are available. Merely signing the medical necessity form stating the patient needs transport by ambulance could subject a physician to fines, damages, and civil monetary penalties under the False Claims Act and Medicare fraud and abuse regulations, which have been targeted by government investigators, including FBI task forces, in recent years. New regulations for ambulance reimbursement have been drafted that state acceptable reimbursement levels for ambulances based on the condition of the patient. Generally, the patient must demonstrate a need for ALS, such as abnormal vital signs or a need for medications, in order to qualify for ALS reimbursement. Additionally, final rules from the Department of Health and Human Services clarify \u201cmedical necessity,\u201d provide minimum staffing levels for ambulances, and revise rules for physician certification of the need for ambulance transfer of patients.\n\nThe successful plaintiff may recover punitive damages and attorney\u2019s fees. Often the individual charged does not have proper insurance coverage to indemnify him/her against the costs of the lawsuit, much less a damage award. A few examples demonstrate why these \u201c1983 actions\u201d can be significant in prehospital care.\n\nThe decision of Doe v. Borough of Barrington, rendered in 1990, ruled that a city violated a citizen\u2019s rights because it failed to train police officers about AIDS and the need to keep confidential the identity of a person infected with HIV. Reasonably extrapolated to EMS agencies, failure to train public employee prehospital care providers about the transmission of AIDS and patient confidentiality may result in liability if medical treatment and confidentiality are not managed correctly because of ignorance on the part of the prehospital care providers. New HIPAA requirements directly address these issues.\n\nIn Wideman v. Shallowford Community Hospital, Inc., an obstetric patient argued that she had a constitutional right to direct a county ambulance to the hospital of her choice. The patient contended that when an ambulance transported her to a county hospital that was the direct medical oversight facility for the ambulance service, she was deprived of her \u201cconstitutional right to essential medical treatment.\u201d However, the appellate court held that there is no constitutional right to prehospital treatment and transport to a facility of patient choice.\n\nFederal rules promulgated as part of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) require the protection of any information collected, in electronic or paper form, by a health care provider that may \u201crelate to the past, present, or future physical or mental health or condition of an individual; [describes] the provision of health care to an individual,\u201d or \u201cidentifies the individual; or \u2026 can be used to identify the individual.\u201d In response to these regulations, EMS services had to examine their record-keeping and consent procedures as well as those of the entities with which they commonly share information.",
        "Sources of accountability - Civil rights": "A federal civil rights statute, 42 U.S.C. \u00a71983, provides that \u201cevery person who \u2026 subjects, or causes to be subjected, any citizen \u2026 to the deprivation of any rights, privileges, or immunities secured by the Constitution and laws, shall be liable to the party injured in an action at law.\u201d The effect of this brief passage is significant. Any individual who believes that another has acted against him/her in violation of any law may choose to sue in federal court for a civil rights violation.\n\nCivil rights claims usually include claims of due process and equal protection violations as well. The Fourteenth Amendment of the U.S. Constitution states, \u201cNo person shall be deprived of life, liberty, and the pursuit of happiness, without due process of law.\u201d This has been interpreted to provide a right for fundamental fairness requiring, at the minimum, \u201cnotice\u201d and \u201can opportunity to be heard\u201d before some right, such as a license, is taken away. Equal protection is the constitutional requirement that similarly situated individuals are treated similarly \u2013 this is why discrimination lawsuits are civil rights questions as well.\n\nThese claims are significant for a number of reasons. State immunity statutes do not affect the ability of the plaintiff to sue and seek damages in federal court, and there are no absolute federal immunities that apply to these types of cases (though there are qualified immunities). State damage caps, which may affect the maximum recovery in malpractice actions, do not.\n\nMedical directors may face constitutional issues when a prehospital care provider contests termination from employment based on due process. Grievance procedures that involve the qualifications of personnel may involve the medical director. Understanding due process may prevent unnecessary review proceedings. For example, in Baxter v. Fulton-DeKalb Hospital Authority, a federal court ruled on the due process claim of a paramedic who had been cleared of misconduct in a hospital investigation of field performance. The medical director, who was employed by the hospital and supervised the paramedic who was employed by a public hospital, refused to reinstate the paramedic, even though the paramedic had been cleared of misconduct. The court ruled that the paramedic\u2019s claim against the hospital should not be dismissed because the hospital deprived the paramedic of due process by acquiescing to the decision of the medical director without holding a hearing.\n\nA New Mexico physician was charged with federal civil rights violations after he withdrew medical oversight from two providers who were suing him for medical malpractice. The providers claimed that they had a \u201cright\u201d to medical oversight just by virtue of being EMTs, and sued for civil rights violations. A significant problem for this physician was the fact that his malpractice insurance did not indemnify him for civil rights lawsuits.\n\nA Kentucky physician was named as a defendant in a state lawsuit alleging violation of rights under the Family Medical Leave Act as well as for civil rights violations, because he withheld medical oversight for a paramedic in a delegated practice state. The physician refused to extend medical oversight to the paramedic after the paramedic tried to return to work after treatment for alcoholism and depression; the medical director had a long list of prior complaints against this individual, unrelated to his illness, and was in the process of bringing them to the attention of the state licensing authority. Again, the physician\u2019s insurance did not clearly cover the costs of his defense. This case is somewhat interesting because the plaintiff chose to bring it in state, rather than federal, court. A federal district court had already dismissed a related case brought by the same paramedic against an ambulance service, citing that the plaintiff had not proven his case under the Americans with Disabilities Act (ADA). Individuals such as medical directors are not subject to the ADA unless they are employers.",
        "Sources of accountability - State statutes and regulations": "Although the role of the medical director is complex, the statutory provisions that directly address the role are often brief. Each state statute has supplemental regulations concerning the responsibilities of medical directors to the EMS personnel they supervise or the EMS system in which they function. There are different regulatory structures and varying degrees of specificity in different jurisdictions. For example, some state laws provide little more than a short definition of the medical director as a licensed physician responsible for the supervision and training of EMS personnel. Some regulations only state the responsibilities of the medical director in general terms, and it is assumed that the medical director will engage in certain supervisory activities. In other states, regulations identify the responsibilities of the medical director in detail. The Florida statute requires, for example, that the medical director \u201cestablish a quality assurance committee to provide for quality assurance review of all EMTs and paramedics under his supervision.\u201d Medical directors are encouraged to ride with the ambulance services in Oregon. In Washington, rules expressly provide that the \u201cmedical program director\u201d is certified by the EMS regulatory authority and can be terminated for failure to perform the duties of the position. Clearly, trends are emerging in the regulatory arena to abolish the \u201cpaper doc\u201d and mandate quality supervision and involvement.\n\nIncreasingly, states are attaching qualifications to the role of medical director beyond mere state licensure to practice medicine. In Oregon, the Board of Medical Examiners must review and approve an application for the position of prehospital medical director. Board certification in emergency medicine, family practice, internal medicine, or surgery or certification in both advanced cardiac life support (ACLS) and advanced trauma life support (ATLS) is required in Missouri. Now that medical director training is available at the national level, certain states now require their medical directors to be certified. New Mexico requires that new medical directors complete, within 2 years after appointment, either a nationally recognized EMS medical director course, a state-approved course, or local orientation provided by a regional or state medical director.",
        "Sources of accountability - Local ordinances": "The medical director will encounter additional layers of codifications in county and municipal government. City ordinances and county resolutions often target activities not addressed by state regulations. Such provisions can be very stringent and sometimes quite outdated. Although the sanctions imposed on ambulance services for violations are sometimes insignificant fines, misconduct may lead to revocation of an ambulance service permit to operate in the jurisdiction. These provisions may require proof of protocols, insurance, and proper staffing and may restrict the response activities of the ambulance service. Medical directors who give orders that conflict with local laws set their services up for trouble with city administrators. Local government politics can be a major source of consternation, and seemingly minor infractions can seriously complicate community relationships.\n\nCounty attorneys and plaintiff lawyers scrutinize the \u201cblack letter law\u201d of these various codifications and hold the physician accountable to the \u201cletter of the law\u201d and the \u201cspirit of the law\u201d as circumstances warrant. The medical director must know and operate within these legal statutes, regulations, and codes. Sound legal advice should be sought if there is a question of interpretation or application, preferably before a legal conflict has materialized. Competent private counsel, city and county attorneys, and state regulatory boards can provide valuable guidance in medical director decision making.",
        "Sources of accountability - Immunity laws": "Some states have statutes that provide immunity from liability for acts performed by medical directors as long as they act in good faith or in a non-reckless manner. The medical director immunity laws may therefore give a medical director a sense of comfort that the courts will forgive some misjudgments in medical oversight activities. These statutes have not yet been the subject of review at the appellate court level. However, the responsibilities of the medical director remain unchanged. Only the payment of damages is avoided; the medical director may still be responsible for attorney fees and court costs. Immunity laws are also venue specific: state immunity is good only in state courts. If the complaint involves a federal question, there is no immunity in the federal court system. There may be an ongoing tendency for courts to limit sovereign immunity.\n\nImmunity statutes for EMS providers have successfully shielded providers from liability for simple negligent conduct, but providers typically still remain accountable for \u201cgrossly negligent or reckless\u201d conduct. For example, Washington paramedics were sued when a patient died after arrival at a hospital with an esophageal intubation. They received immunity under Washington law, however, because \u201cthere [wa] s absolutely no evidence in the record to suggest that the paramedics acted without good faith.\u201d\n\nAn Ohio court recently upheld immunity for EMS providers when a bariatric patient fell from a stretcher as she was carried down some steps. The court found no \u201cwillful and wanton\u201d misconduct even in the face of a protocol deviation regarding the use of specialized bariatric stretchers. However, the existence of such immunity statutes can be a blessing as well as a curse. Medical directors should not be complacent in relying on the existence of immunity statutes to shield providers from liability for negligent acts.",
        "Sources of accountability - Sovereign immunity": "Many EMS services are run by a governmental subdivision such as a county or municipality. These generally benefit from sovereign immunity, which greatly limits actions for which governmental (that is, sovereign) agencies may be sued. Lawsuits generally require gross or willful negligence, although in some states, specific instrumentalities of the alleged negligence, such as the use of an automobile, may allow lawsuit. For example, a county and city ambulance service was sued by a patient who was allegedly rendered quadriplegic during a difficult extraction from a canyon. All of the defendants were found to be immune from lawsuit under a sovereign immunity statute.\n\nAlthough the statute stated that immunity did not apply to the negligent use of \u201cequipment,\u201d the court determined that this did not include the equipment used in this rescue. Similarly, sovereign immunity has shielded municipalities from lawsuits for crashes involving ambulances. A Tennessee court found that prehospital care providers were \u201chealth care practitioners\u201d because they were licensed under state law, and as such were specifically exempted from the state tort claims act, which read, \u201cNo claim may be brought against an employee or judgment entered against an employee for damages for which the immunity of the governmental entity is removed by this chapter unless the claim is one for medical malpractice brought against a health care practitioner \u2026\u201d",
        "Sources of accountability - Contracts": "The role of the medical director is complex and demanding. The days of volunteer medical directors working without contractual agreements are gone. A contract sets out the framework of your relationship with the EMS agency. The physician newly recruited as a medical director can benefit from predecessors and peers. Accepting a position of responsibility for an EMS system and all patient care rendered within that system should be preceded by a frank and detailed discussion of everyone's roles and responsibilities. The job is more manageable if medical directors have clear and unequivocal authority to accomplish the tasks with which they are charged. A contract in which the medical director's responsibilities and authority are delineated and agreed on is not an unreasonable formality; it is an important source of the medical director's legal authority. It is critical that medical directors have the authority to carry out their responsibilities. It is simply sound business practice.\n\nBeware of the service that approaches a physician for medical direction because its previous medical director left the position precipitously and it needs services immediately. These agencies will hand over a contract drafted by its own attorneys and ask for your immediate signature to remedy the situation. Be certain to take your time with the contract and have it reviewed by competent counsel \u2013 and find out exactly why the prior medical director left.\n\nMedical directors must acknowledge the fact that they are accountable regardless of how much time they devote to medical oversight and regardless of the number of field personnel they supervise. Medical directors must also realize the risks, the means, and the goals of the position and not hesitate to address these factors before accepting the position. Moreover, accepting the responsibility without any authority is an invitation for frustration, as well as risk. It is important to also recognize limitations that exist in the EMS system and negotiate the means and resources necessary to meet the goals of the job. For example, medical directors may insist that the fire department assume certain responsibilities in training and documentation and that practice restrictions invoked by the medical director be honored. They might insist that a coordinator position be established or equipment upgrades be made. If a private ambulance service has a contract with a city and has promised certain response times or other guarantees, potential medical directors must evaluate whether they can accept the constraints of that performance contract before they become the medical director for the ambulance service.\n\nIt is likely that the medical director has implied authority to impose certain restrictions and standards despite the absence of a formal written contract. He or she may accomplish some goals by using written protocols or establishing a quality improvement program with performance standards. The case of County of Hennepin v. Hennepin County Association of Paramedics and Emergency Medical Technicians was the first to address the relationship between an EMS medical director and a paramedic in the context of a collective bargaining agreement. A state court ruled it is a matter of medical judgment for medical directors to determine who they would supervise. The employer or the paramedic union could not force the medical director to accept a paramedic the medical director felt was incapable of practicing with reasonable skill and safety.\n\nAlthough many physicians have malpractice insurance coverage that may extend to certain of their activities as a medical director, they are unlikely to have coverage for all potential liabilities. Many of the insurance companies that provide insurance to ambulance services have begun offering secondary insurance policies that cover a physician for potential liabilities that may arise from his duties as a medical director. Secondary insurance policies step in only when the primary insurance, usually malpractice, does not cover an event or when the policy limits of the primary policy have been exhausted. This is in the interest of the insurance companies who know that having a medical director will improve the quality of the service rendered by the ambulance service and therefore reduce insurance claims. If this is not available, the medical director needs to find a source that will protect him or her for these duties, which are often classified as administrative rather than the usual patient care duties.\n\nThere is no standard contract, but there are certain minimum issues any contractual arrangement should address. Prospective medical directors should carefully scrutinize the EMS agency's strengths and weaknesses, the political tone and community support for EMS, and other factors that may affect achievement of their goals. The detail and complexity of the contract will differ if it is an understanding between the medical director and each EMS provider rather than between the medical director and the county commissioners or a municipality.\n\nThe substance of the contract may differ, depending on the agencies, the patient populations, the training and staffing of the prehospital care providers, and the different needs for immediate and long-range goals for quality improvement measures. The medical director's role must be formalized, because many systems consist of multiple management heads with decision-making authority spread among fire chiefs, company owners, city managers, and medical directors. Medical directors must identify the correct party or parties with whom they must negotiate. A contract with the city health department may be meaningless if the city fire department chief has unbridled discretion regarding who is hired, what level of providers are dispatched to certain medical emergencies, and whether attendance at continuing education sessions is mandatory.\n\nThe sovereign immunity of the US government is controlled by the Federal Tort Claims Act, which, on its face, seems to allow federal employees to be sued on the same basis as private individuals. Federal employees do have further protection, however. An additional section of federal law exempts \u201cany claim based upon an act or omission of an employee of the Government, exercising due care, in the execution of a statute or regulation, whether or not such statute or regulation be valid, or based upon the exercise or performance or the failure to exercise or perform a discretionary function or duty on the part of a federal agency or an employee of the Government.\u201d The boundaries of the Federal Tort Claims Act were examined in a recent California case in which the National Park Service and two of its providers were sued for failure to have neither the proper equipment nor training for proper c-spine immobilization and CPR. The court determined that any decision as to the training level of providers and what equipment they were provided was a discretionary function and therefore immune from lawsuit. On the other hand, the proper delivery of care at this scene was not a discretionary function and could be heard at trial.\n\nAlthough medical directors have yet to specifically benefit from sovereign immunity, lawsuits against EMS providers have been dismissed based on it. Without liability of providers, it would be impossible to derive liability against their medical oversight physician.",
        "Sources of accountability - Good Samaritan statutes": "Good Samaritan statutes are another possible source of immunity for the medical director, though they are more likely to be of benefit in limiting his direct liability from actions at a scene than by preventing vicarious liability by giving immunity to the providers. These statutes vary from state to state, so no blanket statements are possible. In general, however, Good Samaritan statutes usually are written to protect physicians, although others are sometimes included. California, for example, protects nurses, prehospital care providers, firefighters, and anyone attempting to aid a choking victim at a restaurant. Good Samaritan statutes usually apply to actions rendered \u201cat the scene of an emergency,\u201d which has been limited to the roadside in some jurisdictions and expanded to hospital rooms in others. They usually require that the care rendered is gratuitous and delivered in \u201cgood faith.\u201d The statutes vary in their protection, some offer complete immunity, whereas others excuse ordinary negligence. A medical director should understand the limitations of his or her state\u2019s Good Samaritan statute and how it might apply to medical oversight activities. The American College of Emergency Physicians has published a policy statement supporting Good Samaritan legislation.\n\nA Maryland decision temporarily extracted Baltimore firefighter/paramedics from the state\u2019s Good Samaritan statute because the city billed for their services and allowed a suit against a paramedic for an alleged esophageal intubation. This decision was overturned on appeal. The appeals court based the decision on another specific fire company immunity act and did not specifically address the Good Samaritan issue.\n\nThe Aviation Medical Assistance Act of 1998, a limited federal Good Samaritan law, immunizes qualified individuals from liability in state or federal court unless they are guilty of \u201cgross negligence or willful misconduct\u201d in their response to an in-flight medical emergency.",
        "Sources of accountability - Court decisions": "Case law is a source of law in which a written decision by a judge, or a panel of judges, interprets statutes or the applicability of legal principles to a case. Often referred to as \u201ccommon law,\u201d these rulings can determine the merit of a plaintiff\u2019s negligence claim or interpret a statute. For example, in recent years, interpretations of the working of immunity statutes and what conduct constitutes \u201cgross negligence\u201d have abounded. However, because of varying facts from case to case, varying interpretations from state to state, and passing years between the date of the incident and a court ruling, case law is sometimes an ineffective educator. Often, though, it is all we have.\n\nCourt decisions in one state are not binding on any other state; however, discussions of issues in state case law reveal the success or failure of legal theories proposed by plaintiffs, thereby highlighting the kinds of conduct that attract the attention of judges and juries. Courts also often look to see how other jurisdictions have handled new legal theories and are sometimes persuaded by their reasoning. An awareness of the legal arguments by plaintiffs seeking recovery from EMS agencies and prehospital care providers can guide the medical director in areas where acceptable protocols and negligent conduct have not been well defined. Specific areas of EMS case law important to the medical director are discussed further below. In areas where there is little law directly on point, analogous situations serve to show current legal reasoning.\n\nRemarkably, few legal decisions have discussed medical oversight or implicated medical directors in allegations of providers\u2019 misconduct. One of the few negligence actions that addressed the role of the medical director resulted in a ruling adverse to the medical director. In Florida, an appellate court upheld a jury verdict against a medical center, because the EMS medical director failed to properly supervise, train, and instruct the paramedics. After assessing a 5-year-old girl at her home, paramedics decided no emergency medical care was needed. The young patient died hours later of congestive heart failure. The EMS medical director admitted there was no written protocol for \u201chow to take a history or how to distinguish between an emergency and non-emergency situation\u201d or for taking pediatric vital signs. Instead, the medical director depended on the paramedics\u2019 schooling and experience to provide the necessary guidance. The jury concurred with the plaintiff\u2019s contention that the medical director was responsible for developing procedures \u201cand deviated from the standard of care by not having established such written procedures.\u201d Protocols addressing, or simply forbidding, non-transports might have protected the system and the medical director.\n\nDirector who rides along with the ambulance, but it is more commonly a failure in other areas. Through statute and regulation, medical directors are obligated to perform certain tasks, such as providing direct medical oversight, establishing protocols, and auditing the performance of field personnel. Despite many variations among EMS systems and state laws, standards of conduct in medical oversight have taken shape. When litigation arises, expert testimony by other medical directors is usually necessary to give substance and shape to the professional duties of colleagues. A malpractice action against a medical director could be a valid cause of action if the plaintiff can establish the requisite elements of malpractice including duty, breach, proximate cause, and damages. This was successfully argued in the case of Tallahassee, discussed previously.",
        "Areas of liability - Negligent supervision": "A claim of negligent supervision requires proof of a duty to supervise and a failure to do so that causes harm to another person. Negligent supervision might be argued if the medical director failed to take action to correct deficiencies in scenarios such as these: (1) the medical director observes a paramedic with poor intubation technique; (2) the supervisor of an ambulance service reports a series of patient care incidents involving a paramedic who verbally abused patients; or (3) the medical director fails to establish medication protocols consistent with current standards of medical practice, thereby letting the paramedic exercise unfettered discretion in the field. If a physician fails to act on knowledge, whether acquired from direct observation, field audits, patient complaints, or other sources, that a provider is lacking in skills or is practicing in a dangerous manner, the physician is duty-bound to remove, restrict, or otherwise prevent the prehospital care provider from continuing to render substandard care. This responsibility would likely be shared (although not necessarily equally) with the provider\u2019s direct employer. This duty to supervise arises from the statutory role of medical directors, as well as by virtue of the medical director's delegation of medical practice. It may be clarified in the medical director's contract. A jury would likely view medical directors, with their superior training and their authority to have taken corrective action, to be culpable because of failure to exercise their lawful authority. Although errors in judgment regarding the capabilities of a particular prehospital care provider can still occur, negligence claims against medical directors are less likely to materialize if the physician is active, informed, and involved. Until recently, no court in the country had held a private physician liable for injuries sustained by a person the physician has never treated, never met, and never agreed to treat. This has changed. North Carolina has found a non-traditional physician-patient duty formed between a physician and a patient seen only by residents the physician had contracted to supervise. Although the reasoning in this case has been criticized, its extension to medical director liability for patients seen by EMS providers he contractually supervises is a possible expansion of \n\nThis legal theory. There are several recent cases that follow the same theory. A Missouri surgeon agreed to be on-call for the emergency department (ED) at the same time he was attending a medical conference out of town. A patient was injured in a motor vehicle collision and the delay in obtaining surgical treatment for her due to the absence of the surgeon led to complications. A Missouri Court of Appeals determined that even in the absence of a traditional physician-patient relationship, public policy and the foreseeability of harm to patients supported finding a duty on the part of the on-call surgeon. An Arizona Court of Appeals has recently determined that a physician had a duty to a patient he had never seen nor treated just by providing an informal, or \u201ccurbside,\u201d consultation about an ECG. The court determined that the consultant physician was in the best position to prevent future harm to the patient by giving correct advice, no matter how informal the request. Again, extending this reasoning to creating a duty on the part of a medical oversight physician is not difficult.\n\nMedical directors usually do not have control over the employment or membership of a prehospital care provider in an EMS agency. However, although active involvement in the personnel aspects of an EMS service is important because the skills and judgment of prehospital care providers directly affect the quality of patient care, the physician should not become an \u201cemployer.\u201d The authority of medical directors to determine who they will supervise was the focus of County of Hennepin v. Hennepin County Association of Paramedics and Emergency Medical Technicians. A county paramedic who was a member of a union had been terminated by the county because of patient care-related conduct. After a hearing for reinstatement, an arbitrator ruled that the paramedic should be reinstated. The case was appealed and the testimony of the medical director was important because he had stated that he could neither trust the paramedic nor be certain that the paramedic would perform safely and appropriately even if on probation. The appellate court ruled that the medical director could not be forced to supervise a particular paramedic he did not believe was competent. The unique relationship of medical directors to the paramedic could \u201cimpose potential tort and disciplinary liability on the medical director for actions of unfit paramedics.\u201d Therefore the medical director may exercise \u201cmedical judgment\u201d to decide who should or should not work as a paramedic, according to the Hennepin County decisions. It is important to note that this court decision relied on the doctrine of delegated practice, which is not the way the law is structured in most states. The court noted that the paramedic could have been assigned to a position not involving direct patient contact.\n\nA more recent case in Pennsylvania outlines a situation in which a medical director\u2019s authority was undermined by additional layers of administrative appeals. An EMS medical director and the service he provided medical direction for challenged the Department of Health\u2019s finding that he had failed to present adequate evidence to support the withdrawal of medical control. The court found that the Department of Health could hold a hearing to review determinations regarding a paramedic\u2019s medical authorization. The case illustrates the importance of understanding what authority a medical director actually has in a given practice situation before engaging in medical oversight for a given service.\n\nThe case of Rinehart v. City of Greenfield illustrates the increasingly frequent scenario of EMS medical directors being sued after withdrawal of medical supervision results in an adverse employment action against an EMT. In that case, the EMS medical director withdrew medical supervision from a firefighter/paramedic and reported his action to the fire chief and the government licensing agency. In response, the fire chief placed the paramedic in an administrative position and subsequently terminated her. She filed suit against the city, the fire chief, and the physician. Interestingly, the court stated in a footnote that \u201cIt is not clear as a legal matter whether Dr. Rutherford actually had the authority to take this action, but the chief and other parties have assumed that he did.\u201d Subsequently, the court noted that the physician\u2019s contract provided that the fire department would terminate an individual paramedic\u2019s responsibility for advance life support upon receipt of written notice that the paramedic had failed to exhibit satisfactory performance, indicating that it was \u201ctroubled\u201d by the interpretation of this portion of the agreement.\n\nAs recently as 2012, suits continued to be filed in situations where a paramedic felt that employment consequences resulted from the actions of a medical director who restricted his or her practice. A paramedic was deemed no longer qualified for her job as a result of the suspension of her medical direction and a suit resulted.\n\nIf an employer such as a fire department fails or refuses to impose restrictions requested by a medical director, the medical director\u2019s ability to invoke conditions on the scope of practice of a prehospital care provider may seem complicated. Medical directors are not forced to continue extending their supervision to a prehospital care provider employed by an uncooperative agency, whether in a paid or volunteer service, if that provider has demonstrated incompetence in patient care. It is hoped that the employer would be persuaded to follow the medical director\u2019s recommendations for remediation. Such scenarios can be quite divisive and are best averted by being addressed before they occur, such as at the time of contract negotiation. The contract could state, for example, that he or she may, after reasonable investigation, limit, suspend, or withdraw medical oversight from any EMT.\n\nThe medical director should remember that EMS is fundamentally the provision of health care. At least one jurisdiction has determined that following a protocol is \u201cfollowing the instructions of the physician.\u201d Medical oversight should be just that \u2013 responsible oversight of patient care. No medical director should allow individuals to function under his or her oversight without the ability to completely supervise and, if necessary, limit their action. This oversight extends to direct medical oversight contact with prehospital care providers. Every radio contact between physician and provider is a potential source of liability. Failure to treat these interactions seriously and appropriately document them may result in problems.",
        "Areas of liability - Failure to perform responsibilities": "The clearest source of liability is a negligent act committed by the medical director. This could be a simple malpractice action for treatment rendered at the scene of an accident by a medical director who rides along with the ambulance, but it is more commonly a failure in other areas. Through statute and regulation, medical directors are obligated to perform certain tasks, such as providing direct medical oversight, establishing protocols, and auditing the performance of field personnel. Despite many variations among EMS systems and state laws, standards of conduct in medical oversight have taken shape. When litigation arises, expert testimony by other medical directors is usually necessary to give substance and shape to the professional duties of colleagues. A malpractice action against a medical director could be a valid cause of action if the plaintiff can establish the requisite elements of malpractice including duty, breach, proximate cause, and damages. This was successfully argued in the case of Tallahassee, discussed previously.",
        "Areas of liability - System concerns": "By definition, EMS is a network of resources; therefore, medical directors must construe their role and responsibilities jointly and cooperatively with the other components and players in the EMS system.\n\nModern EMS is often tainted with antiquated principles that define structures by political boundaries rather than patient needs. Medical directors rarely have an opportunity to implement the system of their choice; they are usually saddled with a machine that is in terrible need of repair, functioning suboptimally, and probably not up to code. Nonetheless, medical directors' responsibilities cannot be shirked; certainly they are no less accountable and perhaps over time even more so, if they acquiesce to unabated problems in their system.\n\nSystem problems such as regionalization, patient destination, and the use of paramedics or air medical transport can cause a damaging ripple effect in an EMS system. Competing agencies can compromise patient care if coordination and cooperation are not promoted by the medical director, who often has to remind everyone that appropriate patient care, rather than turf and egos, is the important factor. These politico-legal battles are among the most vociferous and most costly. Often, problems are the result of parochialism, competition for patients, or simply ignorance. Medical directors can be instrumental in correcting the errant habits and customs of a system, although it may take years of patience, debate, and befriending; if they do not make the effort, both they and the system are destined to fail.\n\nEntire EMS systems, not just individual providers, are increasingly under legal scrutiny. Although medical directors usually are not identified as the negligent defendants in these cases, they are not simply unwitting appendages to the system. They should be the quarterbacks for all EMS resources. Medical directors should have their positions in the system command structure defined by contract and implemented in standard operating procedures (SOPs). Interactions with, for example, fire department personnel who are used to using chains of command is facilitated by this definition. There should be no hesitation when the medical director appropriately assumes medical oversight of a scene. The following system concerns can become less daunting when addressed with protocols and policies founded on and driven by the principle of optimal patient care.",
        "Areas of liability - Dispatch": "Structured and prioritized emergency medical dispatch (EMD) has become the standard of care in most areas. The widespread use of commercial EMD products has fueled this expansion.\n\nAlthough dispatchers are often not EMTs, they are providing medical information and services as part of an EMS system, and they usually are required to have medical oversight. Their actions may implicate a medical director. The medical director bears the responsibility to ensure that the dispatch protocols and procedures are reviewed and updated at least as often as patient care protocols. This is especially true if protocols are obtained \u201coff the shelf\u201d from a commercial source \u2013 they should be reviewed and modified to ensure compliance with local protocols as well as provision of proper patient care.\n\nLawsuits have occurred over the issue of dispatch. Although none has yet implicated medical directors, they are worth reviewing. The suits have generally been based on dispatchers sending ambulances to the wrong address, delays in dispatch, or not sending one when needed. The results of these cases have been mixed, but usually the dispatch agency has escaped liability. There are two reasons for this. The first is sovereign immunity, which was discussed earlier.\n\nThe second theory blocking these lawsuits is somewhat complex and has to do with the concept of duty. Governments, and their agents such as dispatchers, have a general duty to provide basic, or \u201cessential,\u201d public services such as police, fire, and EMS to their citizens. This duty is owed to the population as a whole, not to specific individuals. Unless a court can find that a public service has established a \u201cspecial duty\u201d toward a specific individual, that individual may not sue for negligence. The key to finding a special duty is finding that a \u201cspecial relationship\u201d has formed that includes the open assumption by the municipality to act on behalf of an injured party, knowledge on the part of the municipality's agents that inaction could lead to harm, direct contact between the agents and injured party, and the injured party's justifiable reliance on the municipality's help. For example, a call to a dispatcher by someone with a headache who was advised to try aspirin and was later found to have a stroke was not sufficient to establish a special duty, where a series of two phone calls to another dispatcher was. Special duty has not been clarified in all states, and is more likely than other theories to vary between jurisdictions. New York and the District of Columbia, for example, have a series of cases discussing special duty, whereas in New Mexico the public duty/special duty distinction has been eliminated by the courts.\n\nA lawsuit from Chicago addressed both of these issues. A patient dialed 9-1-1 to request assistance for an asthma attack. The dispatcher indicated help was on the way, but did not keep the patient on the phone until the providers arrived. When the providers arrived, no one answered the door. The EMS personnel made no attempt to enter the apartment. The patient was found dead in the apartment the following morning. The city was sued for failing to keep the caller on the phone until help arrived, and for failure to either attempt to open the apartment or to use force to enter it. An appeals court initially found that the city had sovereign immunity from lawsuit as well as a defense under the special duty exemption, but this was overturned on appeal. The court specifically noted that conduct that is beyond the level of a paramedic\u2019s training is not immunized, whereas conduct that merely deviates from a paramedic's training and objectively the components and agencies within their systems; constitutes negligence is subject to immunity unless it is willful the goal of quality patient care must dictate system management and wanton. In the present circumstance, the court noted that decisions. the paramedics' failure to attempt to open the unlocked door Ambulance response should be timely. A Honolulu jury may have been a gross violation of the department's \u201cTry Before awarded nearly $2 million against the city for a 2-hour delay in You Pry\u201d policy.\n\nIn Ma v. City and County of San Francisco, the family of a patient who died from an asthma attack while EMS crews attempted to locate her after receiving incomplete directions sued for damages resulting from her death [80]. The court directly addressed the inter-play between duty and immunity, concluding that a duty of care was owed not with regard to the design or structure of the 9-1-1 dispatch system, but as to the manner in which the 9-1-1 emergency service procedures were implemented. The California Supreme Court ultimately found that San Francisco did not enjoy immunity from suit. A year later, the same court addressed Eastburn v. Regional Fire Protection Authority, a case in which a plaintiff alleged injury to her minor child resulting from a dispatch error and delayed 9-1-1 response [81]. The court found that no statute imposed direct liability on public entities in such situations and that vicarious liability is limited to cases involving gross negligence or bad faith, overruling portions of its previous decision in Ma.\n\nDispatch recordings that contain protected health information ment malfunctioned on-scene, and finally the ambulance broke down en route to the hospital with the patient. Ten minutes as defined in HIPAA must be handled as medical records, with from the school was a fire department with a paramedic unit confidential information protected. These are not public record that was never notified. Modern EMS will not tolerate such pro- and should not be distributed to news media or others without vincialism and uncooperative practices. appropriate medical release documents in place.\n\nInterestingly, many municipalities routinely make forced Volunteer systems are not immune to attack. Many commu- entrances at homes to which they are called, preferring to pay for a broken window or door, rather than face criticism for not finding a patient in extremis. \n\nOn the other hand, in late 1999, a Florida paramedic was shot vices. The volunteer spirit and contribution must not in the chest as he attempted to enter a locked apartment, where compromise patient care. A promise to provide EMS through he thought he would find a disabled woman who had dialed the formation of a fire department or fire protection district 9-1-1. He had inadvertently entered the wrong apartment. \n\nSpecial duty has also been addressed in federal court. In Virginia, a federal district court determined that a municipality had no \u201cspecial relationship\u201d with plaintiffs in a case that would support a claim brought under 42 U.S.C. \u00a71983 [83]. The court specifically noted that \u201cnot every death that results from the state\u2019s failure to act is a deprivation under the Fourteenth Amendment. Before an omission that leads to a death is actionable under the Fourteenth Amendment and \u00a71983, the Constitution must recognize an underlying duty on the part of the state to act ",
        "Areas of liability - Response": "How a fire department staffs rescue units or uses medical personnel to respond to a medical emergency is as much a medical decision as is the choice of intravenous solution. Optimal patient care is sacrificed by the poor placement of ambulances, the lack of coordination of tiered responses, and many other political, emotional, and business factors. Medical directors must study objectively the components and agencies within their systems; the goal of quality patient care must dictate system management decisions.\n\nAmbulance response should be timely. A Honolulu jury awarded nearly $2 million against the city for a 2-hour delay in ambulance arrival [85]. It is important to recognize, however, that even when the ambulance response is appropriate, patients often perceive that it took too long [86].\n\nThe type of response needed is worth exploring. It is imperative that the service, with the help of the medical director, develop clear and appropriate guide- lines for the use of lights and sirens in emergency responses and transfers. Crashes involving emergency vehicles represent more than half the claims paid by insurers of EMS systems [87]. Some providers do not even have an adequate knowledge of ambulance traffic laws [88]. Insurers often recommend special training for drivers of emergency vehicles, to protect both EMS personnel and their patients; medical directors are in a unique position to support this training.\n\nAn example of a system failure is Brooks v. Herndon Ambulance Service, Inc. The care of a patient was compromised when an EMT unit responded to a call. The patient, a student in a gym class, began seizing and then arrested [89]. The ambulance that received the call had difficulty finding the address, equipment malfunctioned on-scene, and finally the ambulance broke down en route to the hospital with the patient. Ten minutes from the school was a fire department with a paramedic unit that was never notified. Modern EMS will not tolerate such provincialism and uncooperative practices.\n\nVolunteer systems are not immune to attack. Many communities depend on the willingness of individual, uncompensated volunteers to respond to emergencies. However, such EMS services still must meet the same minimum standards as paid services. The volunteer spirit and contribution must not compromise patient care. A promise to provide EMS through the formation of a fire department or fire protection district supported by public funds creates obligations irrespective of the uncompensated status of the responders or the absence of charges to the patient. The duty for these providers to act reasonably is not altered by their gratuitous services. For example, a volunteer fire department with so few providers that there are no adequately staffed ambulances to respond to a call may invite liability if the delay in response was avoidable. This issue was raised in a Virginia case where a volunteer rescue service repeatedly had a shortage of personnel during early morning hours. The dispatcher was not notified of this problem and as a result did not request the assistance of a neighboring agency until the local rescue service failed to acknowledge the requests [90]. Unless medical directors are actively involved in these aspects of an agency, the care rendered in the field may be less than optimal, thus inviting legal complications. A volunteer service should not hold itself out to the community as having a level of care that it cannot promise 24 hours a day, 7 days a week. Medical directors must show prehospital personnel how such operations endanger or compromise patient care. They can encourage other options to be considered by the service and perhaps lead efforts for systemwide improvement that had not yet been recognized as necessary by the community. Mutual aid arrangements and insistence that only qualified personnel accept patient care responsibilities are examples of the input the medical director may offer to minimize legal risk.\n\nThe issue of several appellate court decisions has been the inappropriate use of personnel and equipment; liability has generally been defeated only because of the protections of immunity laws. For example, in Malcolm v. City of East Detroit, firefighters trained only in first aid were dispatched to care for a man complaining of chest pain, while available EMT firefighters stayed at the station. The patient arrested and the firefighters attempted to ventilate with a bag-valve-mask, although the patient was aspirating. The jury decided the city\u2019s action was willful and wanton, and therefore immunity protections did not apply. However, the judgment of $500,000 was vacated by the state Supreme Court, which gave an expansive interpretation to the governmental immunity statute. The message is that although the law may excuse substandard care from monetary damages, scrutiny and evaluation of EMS resources must still be pursued by the medical director of the system.",
        "Scene handling": "Besides the delivery of medical care, there are other scene issues the medical director should consider. These include the use of incident command (IC), and scene safety. Although neither of these is directly a medical concern, they have an effect on the efficient delivery of patient care.\n\nMass casualty incidents are a scene of confusion. There needs to be a command and control structure in place to ensure that appropriate use of resources is accomplished. A New Mexico lawsuit charged municipal, county, and private EMS agencies with negligence in failing to discover the body of a driver who had been thrown 200 feet from a crash scene. Plaintiffs alleged that the agencies had failed to implement a proper incident command structure (allegedly required in their SOPs), which might have required a search; the court disagreed, finding for the defendants. There are federal requirements for the use of IC in all hazardous materials incidents. NFPA 1500 requires fire departments to establish written procedures for IC.\n\nScene safety should be a concern for the medical director. Texas paramedics began applying a back- board and c-collar in the middle of an intersection to a patient who had been ambulatory for 10 to 15 minutes after an accident. They were forced to abandon the patient, still strapped to the board, when a vehicle careened into the intersection, ultimately running over the patient. The appeals court found that sovereign immunity did not apply. The paramedics\u2019 attention to their own, as well as their patient\u2019s safety, would have prevented this tragic error. The US Fire Administration has recognized that scene management is of primary importance in decreasing injuries for all types of emergency personnel.",
        "Destination": "The wrath of the courts has surfaced in decisions addressing the destination policies of EMS systems. When transport of a patient is not dictated by medical concerns and the patient\u2019s best interests, or is hindered due to non-medical reasons, juries have been harsh in their verdicts. In Hospital Authority of Gwinnett County v. Jones, the plaintiff convinced a jury that the transport of a patient who had sustained serious burn injuries was dictated by consideration of potential economic gains for the receiving hospital. The jury awarded punitive damages against the hospital in the amount of $1.3 million, and $5,000 against the ambulance service. A burn facility was approximately 15\u201320 minutes away by helicopter, and the defendant hospital was closer by ground. Rather than transporting the patient directly to the burn facility by the helicopter already en route to the scene, the patient was brought to the defendant hospital by ambulance, thereby necessitating another transfer of the patient to the burn facility. Arrangements for this second transport caused further delay. When lifting off from the hospital en route to the burn facility, the helicopter crashed, killing the pilot and crew but sparing the patient. The helicopter landing area had been used for years but was not approved by the Federal Aviation Administration. The jury returned its verdict with an additional powerful message: \u201cWe the jury find that there should be more stringent regulations of the ground and air ambulance services in the state of Georgia.\u201d\n\nThe authority of the patient to direct the ambulance to a specific hospital poses troubling issues. A state court found no liability against a direct medical oversight physician who advised EMTs to comply with a patient\u2019s preference to be transported to a Level II hospital. The providers had assessed the patient\u2019s injuries and felt that transport to a Level I facility was more appropriate. However, the patient\u2019s stated preference was honored, consistent with a protocol approved by the regional EMS authority. The patient died from a ruptured aneurysm while awaiting treatment at the Level II facility. The father\u2019s claims against the physician and hospital providing direct medical oversight were dismissed because the father failed to produce evidence that the patient would have survived the injury at the Level I facility. This state court ruling emphasizes the need for protocols that reflect sound medical principles; these are defensible even when patient outcome may not be optimal.\n\nAnother case illustrates the importance of clear direction and consistency in protocols for transport to specialty care hospitals. Stroke centers and STEMI centers have joined the trauma designation system to mandate EMS transport to the hospital best able to care for the patient despite family request for transport to a different facility. In Entrican v. Ming, et al. the mother of a young pregnant woman involved in a motor vehicle accident sued after EMS transported her to a hospital that was not capable of managing multisystem trauma. The court found a conflict in protocols titled \u201cChoosing a Hospital\u201d and another titled \u201cEmergencies.\u201d EMS had reasoned that the smaller hospital could have given blood to stabilize the patient, which it unfortunately failed to do. EMS providers need to be assured that their medical director will back up a decision to bypass a smaller hospital to get to a more specialized center.\n\nThe issue of hospitals placing themselves on diversion or bypass has begun to be addressed by the courts, which should influence how service protocols deal with the issue. In an early federal case, a hospital on bypass was found to have established a duty to a patient in an ambulance when it established radio contact with the ambulance to tell them to divert. The hospital escaped liability for simple negligence under an immunity statute. A related case from Maryland, however, supports bypass, stating that hospitals have no duty to accept persons when they are unable to treat them.\n\nThere is a potential complication for hospital-owned ambulances. The Emergency Medical Treatment and Active Labor Act (EMTALA) requires hospitals to provide a medical screening exam for any individual presenting to the emergency department, and, if an \u201cemergency medical condition\u201d is found, to stabilize the condition before transfer. \u201cComing to the emergency department,\u201d the action that triggers EMTALA, includes reaching hospital property or simply being in a hospital-owned ambulance. EMTALA does allow hospitals to refuse patients after radio communication if they are formally on diversion, but this applies only to ambulances not owned by the hospital, unless local EMS protocols dictate otherwise. In a Hawai\u2018i federal court case, the court considered \u201ccoming to the emergency department\u201d to apply to an ambulance in radio contact with the hospital heading toward the hospital, but this decision has not been followed by other courts. A recent opinion from the Center for Medicare/Medicaid Services has further made it clear that the practice of ambulance \u201cparking\u201d that has developed in recent years probably violates EMTALA, and that leaving patients on ambulance stretchers for extended periods of time is not a solution to ED overcrowding problems.",
        "Failure to transport \u2013 \u201cno loads\u201d": "Emergency responses in which the patient is not transported can seem like wasted effort. In some systems, these ambulance encounters consume time and resources; they constitute a significant patient population the medical director never sees, yet for whom he or she may still be responsible. These calls are a medicolegal quagmire involving issues of patient autonomy, consent, medical assessment, and ill-defined legal duties. Patients denied transport or convinced by field personnel to forego ambulance transport have been a source of numerous claims and case law.\n\nResearch indicates that a significant number of individuals who refuse transport are eventually seen by physicians, and a high number of patients who are refused transport by EMS personnel are eventually admitted to the hospital.\n\nThis area of liability is becoming more visible because some ambulance services are attempting to institute policies for alternative means of transport. Under this practice, paramedics determine if a patient needs ambulance transfer to an emergency facility or if an alternative form of transportation, such as a medical taxi, may be used. However, attempts by EMS agencies to identify \u201calternative means\u201d of transport for EMS patients have largely failed. Research has shown that EMS seriously undertriaged patients who later had critical events, even when paramedics received specialized training and protocols in field triage.\n\nWhen field personnel are called to a scene and do not transport a patient because they discover no medical reason for the patient to be taken by ambulance to the hospital, questions of liability are raised quickly if the patient suffers deterioration or demise. If the patient refuses the transport despite apparent medical need, the questions focus on whether patient refusal was \u201cinformed.\u201d The medical profession requires that refusal of treatment be informed refusal. Informed refusal requires that the patient have decisional capacity, and be informed of his or her diagnosis, the recommended treatment and alternatives, and what is likely to happen if treatment is refused. Claims of liability in either case depend on the following two factors: (1) the thoroughness or accuracy of the prehospital field assessment, and (2) the adequacy of the prehospital communication with the patient about the findings of the assessment and the need for medical treatment.\n\nIn Lemann v. City of Baton Rouge EMS, the EMS agency responded to a call for a fight in a bar parking lot. They found a 21-year-old man and treated him for a cut hand. He refused transport and the police took him home. Two hours later, EMS received another call for a \u201cman down\u201d and the patient was found unconscious at the top of a flight of stairs. He later died of a fractured skull and subdural hematoma. In Holt v. City of Memphis, a man called 9-1-1 on behalf of his mother, who was having trouble breathing. She refused transport, and the son signed the refusal form at his mother\u2019s request, only to testify later that he was coerced to sign it. The same EMS crew was called back 3 hours later, and the mother went into cardiac arrest and died during transport. The court found that EMS had performed an incomplete patient assessment, and found their documentation to be extremely deficient.\n\nAt least one court, however, has upheld a refusal of transport by a patient with decisional capacity even when the patient declined transport after EMS evaluation. In Kyser v. Metro Ambulance, the court refused to find abandonment when a 52-year-old man with abnormal vital signs and neurological deficits suffered a severe stroke after refusing EMS transport. The court ruled in favor of the paramedics because they had followed their protocol, had contacted medical oversight, documented the patient\u2019s mental capacity, and made persistent attempts to explain the risks and encourage transport. In deposition, a family member admitted that the paramedics had tried repeatedly to convince the patient to be transported.\n\nThe principle of consent is well known to the practicing physician. Adults of sound mind have the right to refuse medical treatment, even if the refusal of treatment may result in death. Refusal of transport is complicated by the fact that there are indications in EMS that there is no constitutional right for a patient to be transported to the hospital by a governmental EMS agency. In addition to outright refusal, there is some indication that the patient may insist on transport to a hospital less qualified to provide necessary emergency care.\n\nSeveral issues make \u201cno-transport calls\u201d or \u201cno loads\u201d troublesome. To minimize the risk in these situations, short of transporting every patient, the medical director must understand the legal pitfalls inherent in the protocols or absence of protocols for these calls. First, although it is repeatedly impressed on EMS providers that they cannot \u201cdiagnose\u201d illness, they are often directed by protocol to determine whether a patient is mentally \u201ccompetent,\u201d a determination which is both a diagnosis and arguably a legal conclusion. In fact, what EMS actually does is to evaluate a patient\u2019s decision-making capacity. Second, prehospital care providers have only basic training in assessing mental capacity or lucidity to evaluate a patient\u2019s ability to refuse treatment. Typically, they are instructed to ask only simplistic, routine questions about orientation such as \u201cawake, alert, and oriented times three.\u201d This training is insufficient for evaluating mental status and providing information to patients for purposes of informed refusals. Third, there is no clear standard of the validity of mental status evaluations made outside the clinic or hospital environment. These cases are further complicated by the lack of established legal standards regarding what constitutes informed refusal in the prehospital environment, to what extent consent is warranted for transport, and to what extent the duty to establish consent or refusal can be delegated by the medical director. Medical directors should make certain that their protocols are based on sound medical, rather than economic, grounds.\n\nAnother important issue is the scope of informed consent in the prehospital environment. Decades of case law in medical malpractice regarding the principle of consent involve patients seen in doctor\u2019s offices and hospitals, but the field environment is different. It may therefore be unrealistic to assume that the physician\u2019s duty to obtain informed consent or informed refusal applies to the prehospital care provider, particularly given the dearth of training in EMS for this task, and EMT\u2019s current poor record of informed consent practices.\n\nSimilarly, there have been no judicial interpretations of the relationship between a patient contacted in the field and a prehospital care provider or the medical director. Although arguably a physician\u2013patient relationship is created in both cases, several cases suggest that direct contact between a physician and patient is necessary for this to occur. A telephone call, for example, is not usually sufficient. Similarly, there is no judicial statement that the prehospital care provider must contact the base station to terminate the patient relationship in a no-transport situation. However, sound medical oversight dictates that the medical director consider direct medical oversight essential, or that very clear and precise protocols be in place if the patient\u2013prehospital care provider relationship can be terminated without such supervision.\n\nFactually, legal cases involving non-transport often involve glaring deficiencies in the assessment performed by the EMS providers; often, they reflect lack of discipline by the providers in adherence to protocols. Liability can befall prehospital care providers who leave the patient in the field without thorough and adequate assessment; medical directors may be responsible if they fail to provide sufficient protocols that detail the circumstances under which patients may be left in the field.",
        "Denial of ambulance transport": "Wright v. City of Los Angeles expounded on the paramedic\u2019s duty to assess in a costly incident of failure to transport. Police summoned EMS personnel for a man found lying on the sidewalk. He appeared to have been involved in an altercation. The paramedic did only a cursory assessment and decided ambulance transport was not necessary; he advised the police officers that the patient could be checked by a physician before booking. In fact, the patient was in sickle cell crisis. The court held that if the paramedic had conducted an examination consistent with the standard of care, he should have been able to determine that the patient was in need of immediate treatment.\n\nThere was no contact with the direct medical oversight physician for approval of the nontransport; the paramedic testified that he \u201csaw no symptoms indicating such a call was necessary.\u201d Minutes after the paramedic left the scene, the patient arrested and died. The paramedic thought the patient was simply intoxicated. The court found that the failure of the paramedic to provide \u201ceven a scant amount of care\u201d was an \u201cextreme departure from the standard of care for a paramedic in such a situation.\u201d Governmental immunity therefore did not shield the defendant from liability in this state court ruling, because the conduct was deemed grossly negligent. Although the medical director was not implicated, the case exemplifies how direct medical oversight might have averted a death and a costly lawsuit.\n\nThe medical director should evaluate the substance of the prehospital care provider\u2019s radio report when any request is made for a nontransport disposition. Although the prehospital care provider has the best direct view of the patient\u2019s situation, the direct medical oversight physician may have the medical expertise to evaluate the complications or implications of the patient\u2019s signs and symptoms; therefore, the need for consultation and careful supervision is certainly warranted. The medical director should also carefully monitor radio contacts and ensure that all physicians providing direct medical oversight know the protocols for nontransport situations.\n\nAn example is provided in Green v. City of Dallas, which involved paramedics who failed to transport a 35-year-old man complaining of chest pain. Because of the patient\u2019s age, the fact that he was on no medications, and the observation that he was exhausted from playing basketball, the paramedics reasoned that the pain was not cardiac in nature. Five minutes after the crew departed, the man arrested. The ambulance was sent back to the scene, but the man could not be resuscitated. The city avoided liability only through sovereign immunity.The decision in Hialeah v. Weatherford demonstrates that the time between the EMS contact with the patient and patient demise need not be brief to establish proximate cause [129]. In this case, the patient died 24 hours after the ambulance crew left. The patient\u2019s wife had called for assistance; the prehospital care providers observed her husband lying naked and stuporous when the ambulance arrived. The ambulance crew refused to transport the man, despite his wife\u2019s requests. The patient was transported 24 hours later when his wife again called for an ambulance; he died shortly afterward. The court held that there was sufficient evidence of proximate cause between the failure of the first crew to transport and his death more than 24 hours later, notwithstanding the wife\u2019s delay in requesting an ambulance the second time.\n\nProlonged scene times have also fared poorly under judicial scrutiny. In a case from Louisiana [130], a delay of transport due to prolonged scene time (20 minutes for someone with chest pain) was determined to be a cause of loss of a decedent\u2019s chance of survival and resulted in a jury award of damages against the paramedics involved.",
        "Patient refusal": "Sometimes a patient adamantly refuses transport, although the EMS crew feels transport is necessary. These cases are troubling for prehospital care providers when they feel it is in the patient\u2019s best interest to receive medical care. In addition, some prehospital care providers have been instructed by medical directors who would rather take the risk of forced transport than leave an injured patient. The rationale is that transport should be accomplished so a physician can evaluate the patient and establish informed refusal in the controlled setting of the ED. It can be argued that transport is warranted because the patient is unable to give informed refusal if, for example, circumstances or injuries appear to impair his or her ability to comprehend the risks and consequences of refusal. On the other hand, an adult of \u201csound mind\u201d is allowed to refuse medical treatment. Patients have the right to make medical treatment decisions that may result in deterioration and even death.\n\nIn some cases, a friend or relative has summoned the ambulance and wants the patient transported. Liability claims may still be argued against the EMS agency. In St. George v. City of Deerfield Beach an ambulance was summoned by a visitor of a man found bleeding extensively from a tooth extraction. The paramedics failed to transport the man who was \u201cobviously drunk and bleeding, but he absolutely and continually refused examination or treatment.\u201d The visitor called 9-1-1 a second time about 20 minutes later, but the dispatcher refused to send an ambulance. The appellate court rejected the defendant\u2019s motion to dismiss, ruling that sovereign immunity did not apply. Additionally, the court determined that the service owed a \u201cspecial duty\u201d toward the patient based on the repeated phone calls.\n\nAn interesting area of patient refusal arises in the context of children. Some states possess specific statutes that allow consent for medical treatment, and therefore refusal, to individuals as young as 14, but they often pose a dilemma. Frequently, ambulances are dispatched for a minor driver involved in a motor vehicle accident who does not need, nor want, transport. It is important to have protocols in place to deal with this situation. EMS medical directors should be familiar with their states\u2019 laws on emancipated minors and should educate EMS providers on issues involving minors and consent.",
        "Transport against will": "Transport against the patient\u2019s express desires, particularly if restraints are used, may constitute false imprisonment. It may also have Fourth Amendment implications for government EMS services. The pivotal issue is whether the detention of the patient is justified under the circumstances. There is some legal authority for a physician to forcibly restrain a person in need of treatment by virtue of a qualified privilege. The Shine v Vega case involved the involuntary restraint and treatment of an asthma patient in a hospital emergency room and resulted in the court cautioning physicians against imposing their will on patients with decisional capacity. Deprivation of a person's liberty is always a nontransport or patient refusal to identify deficiencies in assessments or information provided to patients.\n\nA flurry of lawsuits has occurred in the area of the death of individuals who have been restrained. These \u201cin-custody death\u201d cases have mushroomed in recent years and are often coupled with civil rights claims. These will require services to closely scrutinize any restraint policies they may us and to insure that policies are updated to reflect the current state of medical knowledge about conditions such as excited delirium.\n\nThe use of releases, waivers, and other such documents that the patient signs in the field have limited legal merit for several reasons. First, courts frown on documents that attempt to deprive a person of re-course to the courts through such language as \u201crelease of liability.\u201d Therefore, as a matter of public policy, these documents are construed against the party placing them in use. Some state court rulings have rejected medical professionals\u2019 efforts to contract away potential liability for negligent medical treatment. Release from liability for negligent care has also been rejected when the patient has little choice in where these services are obtained. Many of these forms are written in nearly incomprehensible legalese, which further invalidates their use. Therefore, documents purporting to relieve the prehospital care provider from liability might be invalid. Second, \u201cpromise not to sue\u201d language in these documents does not preclude the necessity to obtain an \u201cinformed refusal\u201d of treatment and transport from the patient.\n\nA few states have statutes that provide legal authority for peace officers to direct EMS personnel to take a person to a hospital if it reasonably appears that medical treatment is needed. Such statutes usually require the peace officer or transporting personnel to act in \u201cgood faith\u201d to gain the protections of immunity. In other states, the statute may allow EMS personnel this authority on their own. New Mexico allows transport upon a \u201cgood faith judgment\u201d by the EMS provider that it is needed. These types of statutes provide both authority and legal protection in the unwilling transport situation; however, medical oversight is no less important and may be evidence of \u201cgood faith.\u201d The medical director must understand the circumstances under which such laws may be used. Consultation with local law enforcement may be vital for the effective application of protective custody efforts. Immunity was not available for paramedics who forcibly took an allegedly suicidal patient to a Wyoming hospital against her will, although they were acting under the state\u2019s valid emergency detention statute.\n\nObtaining a patient\u2019s signature may be beneficial for simply demonstrating the patient\u2019s physical and cognitive abilities. Such a document may be appropriate if used as a written acknowledgment by patients of their voluntary refusal of treatment. It may serve as a testimonial of the efforts made to educate and persuade the patient to be transported. However, such forms should be supplemented with appropriate documentation of the patient\u2019s physical and mental condition as assessed by the prehospital care provider. The document should reflect attempts to warn the patient of the risks of delaying treatment and alert the patient that the prehospital care provider may not be aware of the full extent of the injuries. The medical director should not permit a release form to be used until it has been evaluated by legal counsel. Well-reviewed forms may be available from the insurance agency that provides liability coverage for the ambulance service.\n\nThe \u201creasonableness\u201d of their actions, carrying the patient, naked, uncovered, and handcuffed, to the ambulance, was left for the jury to decide. In a similar circumstance, the city of Louisville was forced, after an unsuccessful appeal, to go to trial to determine if its actions of transporting a patient to the hospital and inserting an IV against her will constituted false imprisonment and battery.\n\nMany EMS agencies and medical directors require that the provider contact direct medical oversight in every patient refusal encounter. This is useful only if the quality of the contact is not superficial. EMS providers must be thorough, accurate, and honest in their reports to physicians. The physician must be diligent in listening, questioning, and evaluating the soundness of the information. The medical director must tailor the protocol for patient refusals according to the EMS system and the prehospital care providers\u2019 skill and experience. Quality supervision by a medical director thereby diminishes claims of negligent failure to transport or patient abandonment.",
        "Transfers": "Interhospital transfers have evolved as one of the more lucrative profit centers for ambulance services. Transfers generally mean nonemergent use of ambulances. For many prehospital care providers, these patient contacts seem less exciting and less deserving of their medical skills. For example, these calls could include the \u201croutine transfer\u201d of a debilitated nursing home patient to and from a clinic appointment, a neonate in an incubator, or the cardiac patient with multiple intravenous lines infusing medications. Obviously, transfers can be as diverse and critical as 9-1-1 calls, and clearly require the attention of a medical director.\n\nA variety of problems can arise in the management of transfers. For example, the \u201ctransfer car\u201d may be staffed with less experienced personnel, which can create patient risk should the unexpected occur. In addition, research shows that physicians may fail to use the appropriate level of skill for the patient\u2019s medical condition and, more importantly, fail to stabilize patients adequately before transport. Transfers are often initiated by persons unfamiliar with EMS systems and ambulance service management. Transfer orders are often written by physicians who are unaware of the current scope of practice of the transporting personnel. This is evidenced by the requesting party directing the non-emergency response of the ambulance. It is also evident in the reimbursement problems that arise when the transport destination is based on physician convenience. Transfers can also be a source of liability for physicians and hospitals if a patient is unnecessarily put at risk because of the transfer. Efforts to decrease transport problems have led to the creation of patient transfer guidelines by certain critical care organizations. Medical directors should ensure that their protocols are consistent with these guidelines.\n\nThe case of Morena v. South Hills Health System involved the limited paramedic resources of the City of Pittsburgh. One issue in the case was whether paramedics were negligent in not accepting an interhospital transfer of a gunshot victim. The paramedics had responded and transported the patient to the nearest hospital. The patient then required transport to another facility where a trauma surgeon awaited. At that time, the City of Pittsburgh had only four paramedic ambulances for emergencies; private ambulances handled non-emergency interhospital transports. A nurse asked the paramedics to handle the transfer, but she did not explain that the transfer was an emergency that the unit was authorized to accept. Consequently, according to the protocols the paramedics declined the transfer. The surgical treatment had to be delayed until the transfer was ultimately completed. \u201cDue to this shortage of vehicles it was the policy of the service to not make inter-hospital transfers,\u201d the court noted. The court deferred to the policy and held that the duty of the emergency ambulance service was completed upon transporting the patient to the nearest facility; without knowledge that the transfer was of an emergency nature, there was no basis for negligence in the paramedics\u2019 refusal to accept the transfer. The message from this is that ambulances in an EMS system should not be used or viewed as an unlimited resource, and sound policies are defensible.\n\nWith the enactment of federal legislation that regulates interhospital transfer of patients in EMTALA, planning and preparation for transfers became serious business. The law may actually protect prehospital care providers from being \u201cdumped on,\u201d as well as create more paperwork for EDs. Although EMTALA does not directly regulate EMS, EMTALA pertains to the transfer of \u201cunstable\u201d patients and mandates that any transfer be \u201ceffected through qualified personnel and required transportation equipment.\u201d The law may also affect destination policies, because the patient must be transported to a qualified facility. The law can impose significant burdens on small ambulance services, which the medical director should attempt to limit. For example, in rural systems the need to transport an unstable patient to a higher level of care may be valid. However, the service may have only minimally trained personnel available and a limited number of ambulances. Nonetheless, \u201cqualified personnel and transportation equipment\u201d must accompany the patient. It becomes imperative that the medical director educate hospital staff about the transport capabilities of the ambulance service for transfers. A 2010 case in which EMTs were asked to transfer a woman in labor resulted in which a baby was born apneic at 25 weeks gestation in the ambulance. EMS was found liable at trial in Volusia County, Florida, with a jury finding that the service was \u201cnegligent by accepting the transport task\u201d and that the company showed \u201creckless disregard\u201d in rendering its services. The award of $10 million threatened to bankrupt the ambulance service.\n\nThe medical director should also be careful that \u201cconvenience transfers\u201d do not misuse ambulance resources, exposing the rest of the EMS system to risk. A recent tendency for patients who feel that ED waits are lengthy to call EMS from a hospital ED waiting room requesting transport to a different facility should be carefully managed. Additionally, political and economic decisions should not dictate the movement of patients. One court considered it egregious to refuse ambulance service to a patient because of political interests. A hospital that refused to allow use of its ambulance unless the patient was brought to its facility (where the patient\u2019s attending physician did not have privileges) supported a verdict of outrageous conduct in DeCicco v. Trinidad Area Health Association.\n\nThe medical director must vigilantly ensure that an ambulance service accept transfers only if adequately trained crews are available, or if the transferring hospital provides appropriate personnel to accompany the patient in the ambulance. This may entail careful examination of individual skills and prospective identification of specific medications that the prehospital care provider may monitor. He or she must also keep the Medicare reimbursement regulations on staffing levels in mind. In addition, there may be need for cooperative arrangements between the hospital nursing staff who accompany the patient in the ambulance and the ambulance personnel. The respective responsibilities of nursing personnel and the EMS crew should be clarified before transports are initiated. There should be no question of responsibilities in the back of a moving ambulance with a critical patient dependent on the attendant caregivers assigned to the transfer.\n\nAmbulance services have also come under increased scrutiny in recent years from government efforts to stem fraud and abuse. Many services have found themselves liable for large fines when they have submitted bills to Medicare for ambulance transfer of patients from home to dialysis centers when the patients were ambulatory and could have traveled by van or taxi. For example, in a recent case, the former owners of an ambulance company agreed to pay $2.25 million in damages and penalties for fraudulent ambulance claims submitted to Medicare and Medicaid after they had been found guilty of fraud in earlier criminal proceedings.",
        "Documentation": "Paperwork has been the bane of existence for many medical professionals otherwise skilled in the provision of patient care. Training in this critical area has been largely overlooked, and improvement has been dependent on retrospective audits. Poor documentation has persisted, and prehospital care providers tend to believe that PCRs are either an insignificant part of the medical record or routinely ignored by hospital health care providers. Lack of immediate feedback and tolerance of poor report writing by emergency department staff and medical directors undermine documentation efforts. Documentation is one of the first things reviewed by plaintiff attorneys. Sloppy, illegible PCRs reflect poorly on the service, regardless of the quality of care delivered. The use of electronic PCRs has led to a new legacy of unchecked boxes and incorrect keystrokes that leave much to be desired from the report.\n\nThe PCR is a measure of accountability for the EMS provider, just as the medical record substantiates patient care delivered in a hospital. The PCR should reflect the quality of patient care and assessment. Adherence to protocols should be evident in the report. Although the medical director may audit every PCR to monitor emergency care performance, lower-level EMTs have less training and are often less experienced both in patient care and documentation. Therefore, their PCRs warrant greater efforts toward improvement of report-writing skills. Many medical directors supervise providers who run just a few calls each month; thus, each PCR should be reviewed and used as an opportunity for improvement.\n\nThe PCR has another important function. It documents the severity of the patient's illness as a justification for reimbursement. Any exaggeration of a patient's condition done in order to increase the reimbursement for that patient transfer may be fraud. If the PCR is submitted to the federal government for payment of a Medicare claim, it may be Medicare fraud and abuse, a violation of the False Claims Act, or both. The former is investigated by the Office of the Inspector General of Health and Human Services, the latter by the Department of Justice. A medical director\u2019s approval of a fraudulent PCR many implicate him or her in the violation.\n\nPatience and persistence by the medical director can lead to improved PCR preparation and patient care. The medical director should develop useful PCR formats and discourage forms that impede quality documentation. Every PCR should address unique aspects such as scene factors or observations, patient positioning when first encountered, the apparent mechanism of injury, scene interventions, and extrication difficulties. Documentation of responses to interventions, justifications for interventions or for failures to treat, and the condition of a patient on arrival at the emergency department are also important on the PCR. The medical director should take a proactive role in the quality management efforts of documentation.\n\nFinally, legibility remains a critical factor in the usefulness of documentation. New computer-based paperless systems may help improve PCRs by providing a standard legible report format as well as creating a database for the service.",
        "Equipment": "To some degree, the skills and capabilities of EMS providers have been confounded by equipment or, more precisely, the compulsion to employ equipment in the \u201ctechnical imperative.\u201d The issue of proper equipment and procedures in EMS is compounded by the lack of significant evidence-based research on what works \u2013 many policies and procedures are, unfortunately, based on anecdote. From the insistence to dispatch a helicopter when rational assessment would obviate the expense and expedite patient care, to the forceful plunge of a 14-gauge IV catheter when an 18-gauge would suffice, the use and abuse of medical equipment have been implicating factors in many claims and lawsuits.\n\nAt least one court has ruled that use of equipment that is carried on an ambulance to provide patient care is a matter of \u201cmedical judgment.\u201d The medical director should impress on providers that new equipment, as well as skills, must have a demonstrated capability to improve patient care in order to be implemented. There is an aphorism that may be appropriate: \u201cBe neither the first nor the last to use a new medication or procedure.\u201d Medical directors should consider the legal protective measures related to the use of equipment by the personnel under their supervision.",
        "Conclusion": "The role of the medical oversight physician is complex and time consuming. It is a mixture of medicine, law, administration, public relations, and engineering. Careful delegation of tasks to field coordinators and hospital staff alleviates the burden quantitatively but does not lessen the physician\u2019s responsibility qualitatively. The benefit of interactions with field personnel is not merely risk management. Medical directors who exercise and practice meaningful medical oversight gain by knowing their system and its people, understanding its operations, and participating in its improvement. Passivity or acts of omission such as failure to provide protocols, failure to discipline, or failure to implement quality management audits place medical directors at great legal risk and deprive prehospital care providers and the community of the expertise and leadership that good medical oversight should provide. Medical oversight is seldom hazardous unless the medical director serves only by signature. The days of passive and uninformed medical oversight are over. Risks arise when the EMS physician fails to keep informed of accepted standards of prehospital medical practice, confuses politics or economics with good patient care, and acquiesces to inappropriate or inept actions by EMS providers. Through development of systemwide protocols, quality management systems, and personnel policies, the medical director should be secure.\n\nLegal hazards and pitfalls are nothing new to the emergency physician, who is constantly presented with the unexpected, the vagaries of caring for strangers, community pressures, and unrecognized sacrifices. The delivery of prehospital medicine is as complex and uncertain as emergency medicine, perhaps more so. Despite the medically and legally uncharted territories in prehospital care, the apparent variations and questions of duty in all aspects of medical oversight rely on the basic principles of medical practice \u2013 paramount concern for patient care and professionalism in the delivery of health care. The EMS medical director has a unique opportunity to serve innumerable patients, prehospital care providers, and EMS systems in a challenging and evolving arena."
    },
    {
        "Introduction": "Although there may be many ways to define wilderness, for the purposes of this chapter a wilderness setting includes any geographic area where typical medical resources are not adequate or available for the management of an injured or sick patient. Such settings may include deserts, mountains, rivers, oceans, space, caves, and other remote areas. In fact, urban areas during disasters can also be considered wilderness.\n\nThe definition of wilderness environment is critical when discussing wilderness EMS (WEMS). WEMS providers should be authorized to follow operationally specific protocols, so the environment where those protocols becomes activated (the \u201cwilderness\u201d environment) must be defined. This is best accomplished via local or regional definition. Nearly every jurisdiction has the potential for wilderness medical care, whether due to environmental factors such as weather (limiting transport capability or complicating care), fixed geographic factors such as absence of roads or presence of parks or bodies of water, or potential for natural or manmade disasters resulting in the sudden need for austere medical care (New Orleans during Hurricane Katrina). Currently, a patchwork of protocols and levels of care exists across the country, as states and services grapple with how to anticipate and manage WEMS operations. There is not yet a national standard regarding what should be included in WEMS protocols and what an appropriate scope of practice is for this subspecialty of EMS physicians and providers; yet the idea that WEMS or austere medical care will never be needed for any given jurisdiction is na\u00efve.\n\nWilderness EMS providers typically have to personally carry all of the equipment that may be needed for the care of the patient as well as for their own safety and survival. WEMS physicians and providers require knowledge in personal survival in austere environments, search procedures, advanced wilderness medical care, and geographically specific extrication techniques, for the safety of their patients and themselves.\n\nAlthough some authors define WEMS as any situation that involves a minimum 1\u20132-hour transport time, this definition does not encompass every WEMS experience. There may be situations that require specialized medical care prior to extrication or transport even if the area is near a roadside, such as a patient injured on the hill at a ski resort or a hiker in a large urban nature preserve. Due to the specialized skills required to manage these patients, the inability to get supplies to the patient easily, or a complex extrication without the aid of an ambulance, these situations must also be considered wilderness.\n\nIt is important to understand that WEMS is substantially more complex than the application of traditional medical training in a wilderness environment, and the indiscriminate application of traditional care and standards often proves to be dangerous to patients and/or providers in a wilderness setting.\n\nFinally, it is important to draw a distinction between wilderness medicine and WEMS. Wilderness medicine is the broad field addressing the general care of patients in a remote, austere, or wilderness setting. Most often in popular dialogue and training paradigms, wilderness medicine assumes unexpected and opportunistic care. If, however, one specifically trains for a particular type of emergency medical response to a particular set of environmental challenges, joins a team that has specifically configured itself to provide medical care in a specific locality, and maintains a formal wilderness medicine certification to do so, then the care has entered the realm of WEMS. There are significant consequences to the differentiation of general wilderness medicine from specific wilderness EMS, not least of which are an expectation for increased professionalism, increased or more specific training for that particular environment, potentially increased equipment and familiarity with local emergency services, and by definition the probable establishment of a different medicolegal expectations.\n\nOne good illustration of this difference is in the different didactic preparations. With a few exceptions, general wilderness medicine teaching focuses on the ad hoc use of materials at hand, which may or may not have been originally purposed for medical care. There is a recognition that minimal medical equipment may be available since medical care is only one consideration among many for recreational or professional trips. WEMS retains some of this ad hoc and improvisational spirit, but since the entire purpose of the WEMS operation is rescue and medical care, choosing the most appropriate equipment specifically for medical care, and absolute familiarity with that equipment, becomes paramount.\n\nA more concrete example would be the response and medical care one would expect to be offered by a backcountry skier out for a day with basic wilderness medical training and a standard day-pack who comes upon another skier with a broken leg and head injury in the remote backcountry. Then contrast the expectations of that caregiver with the expectations for the formal ski patrol unit that is dispatched to care for that same patient. This exemplifies the difference between general wilderness medicine and WEMS.\n\nOther terminology frameworks include programs with similar themes of austere and resource-deficient care (wilderness, disaster, tactical, military, remote) under an umbrella definition of austere medicine or resource-deficient medicine.\n\nTherefore, WEMS represents organized efforts wherein providers are assigned to specific geographic areas or missions with a specific duty to act. The purpose of WEMS is to provide care to an ill or injured patient in a wilderness setting while still recognizing that the providers are functioning within the defined health care system. It is the goal of WEMS to manage the patient in the field, extricate the patient, and transport to an acute care facility if needed. These goals are met with the concept that the patient should be receiving quality care with appropriate physician participation or oversight. The purpose of this chapter is to outline the structure of WEMS systems and define why and how health care systems that may need to provide wilderness care should consider developing or integrating formal WEMS programs.",
        "History": "Wilderness medicine is in some ways the oldest of the medical disciplines. The first time one human attempted to help another, with or without rudimentary tools made from the surroundings, could be considered the beginning of wilderness medicine. However, as a formal subfield of modern medical practice, wilderness medicine is very new, and WEMS is in its infancy.\n\nThe history of WEMS can be broadly divided into decades of evolution.\n\n\u2022 1940s\u20131950s: return of WWII 10th Mountain Division soldiers and establishment of the National Ski Patrol (NSP), probably the first non-military WEMS system. The NSP\u2019s first certification course was Winter Emergency Care, which evolved into Outdoor Emergency Care (OEC). The NSP\u2019s OEC textbook is now in its fifth edition and teaches WEMS skill sets and knowledge at a level exceeding the emergency medical responder curriculum but below the emergency medical technician level. Although the program is administered by the NSP, it is designed to cover material for all wilderness environments, and can be used by WEMS providers in a diverse range of wilderness environments in addition to ski areas.\n\n\u2022 1960s\u20131970s: publication of Medicine for Mountaineering, one of the first wilderness-specific medical texts; establishment of first wilderness medicine/WEMS proprietary schools, such as Wilderness Medicine Outfitters in the west, Stonehearth Outdoor Learning Opportunities (SOLO) in the northeast, and Peter Goth\u2019s NC Outward Bound-Linville Gorge Wilderness EMT courses in the southeast; development of many local search and rescue (SAR) teams.\n\n\u2022 1980s: establishment of \u201cSOLO West,\u201d the predecessor to the Wilderness Medicine Institute of NOLS (WMI-NOLS), and Wilderness Medical Associates (WMA). Other schools have proliferated, and for many decades such schools were the primary mechanism for obtaining wilderness medical training. Currently, over 100 different vendors or schools offer wilderness medical training, and over half a million individuals have received some sort of WEMS certification. This early dependence on private schools is an important differentiation between WEMS evolution and that of other EMS subspecialties. The 1980s also saw the establishment of the Wilderness Medical Society and first publication of Paul Auerbach\u2019s Wilderness Medicine, now considered the definitive textbook on wilderness medicine.\n\n\u2022 1990s: initial attempts at WEMS standardization. Development of Advanced Wilderness Life Support (AWLS) by the University of Utah, the first certification course generated by an academic institution, geared exclusively toward health care professionals, and marketed/taught outside the proprietary school model.\n\n\u2022 2000s: Stanford University established the first wilderness medicine fellowship. This decade saw the proliferation of academic programs, although most focused on wilderness medicine in general rather than WEMS. Examples of more rare WEMS-specific medical student/resident/fellowship programs include the UCSF-Fresno Wilderness Medicine/EMS fellowship (UCSF-Fresno also has one of the very few residency programs with a program-wide focus on WEMS); the University of Utah\u2019s EMS/Wilderness Medicine fellowship; and the Carolina Wilderness EMS Externship, a uniquely collaborative operational and educational project involving a major university, a community health care system, a county EMS system, and a community college. For paramedics, the University of Utah\u2019s baccalaureate degree program in EMS has specific WEMS training in its Remote Rescue Training program. Western Carolina University established the first distance-learning WEMS paramedic baccalaureate program in 2007, but it was inactivated only a few years after successful implementation, a victim of budget cuts. Other paramedic programs increasingly incorporate WEMS training into their traditional curricula. WMS and NAEMSP also endorsed the development of a specific Wilderness EMS Medical Director Course and associated curriculum, which is now offered annually at these organizations\u2019 conferences. This decade also saw seminal historical events that dramatically altered our thinking about wilderness and austere medical care, including the 9/11 terrorist attacks of 2001 and Hurricane Katrina in 2005, and the growth of regionalization in wilderness medicine.\n\nWilderness EMS is a field still defining itself, with new resources and programs appearing every year.",
        "Current operations and epidemiology": "Having generated data for many decades \u2013 longer than most WEMS systems have been in existence \u2013 the National Park Service has provided much of the best epidemiological information on WEMS operations. These data indicate that WEMS providers in national parks experience equal numbers of medical and traumatic EMS events (although more deaths are traumatic), and that the national incidence of EMS events is 46 per 1 million visitors. However, this incidence may be misleading, as it includes many park areas that would not typically be considered wilderness. Other studies only focus on specific highly visited locations or specific wilderness activities. One useful study examined all incidents over a 3-year period in eight of the \u201cmost wilderness-type environment\u201d national parks in California. This demonstrated an overall occurrence of 9.2 non-fatal events per 100,000 visits, with a mortality rate of 0.26 deaths per 100,000 visits. Men accounted for 78% of the deaths, with heart disease, drowning, and falls being the most common etiology. Other ParkMedic data exemplify many of the different operational elements of WEMS, including non-transport rates of 77%, base hospital contact rates of 28%, and rates for ALS care of 10% (with 16% of these ALS patients not transported).\n\nThese data amply demonstrate that WEMS providers have been working for decades in a very different operational environment than most traditional EMS authorities would recognize. As much as any other EMS subtype, WEMS argues for a redefinition of \u201cprehospital\u201d medicine\u201d as \u201cout-of-hospital\u201d medicine, since the majority of patients in some WEMS systems receive all their care in the field and are not transported to hospitals.",
        "Standardization": "Despite growing academic and commercial attention, standardization of WEMS training and practice has not yet been achieved to the degree it has in other EMS specialties.\n\nThe Wilderness Medical Society (WMS) was founded in 1983 and serves as the professional society for wilderness medical practitioners. WEMS has been actively promoted by this organization and it has made some efforts towards WEMS standards. In 1991, the WMS proposed a model mechanism to develop a curriculum for wilderness prehospital emergency care (WPHEC), with the intent of establishing a disciplinary standard for the WEMS field internationally. However, this was not widely cited or implemented in subsequent commercial or academic courses, and the term WPHIEC is no longer in widespread use. The WMS published minimum standards for wilderness first responder (WFR) certification in 1999. However, the maximum scope of practice may be the more controversial issue versus minimum curriculum standard. The WMS has also not yet defined the minimum curriculum or maximum scope of practice of wilderness EMTs (WEMT) or wilderness paramedics, which also is a potentially more controversial topic than WFRs.\n\nAmong communities that professionally require and utilize wilderness medical training, such as outdoor experiential schools, colleges, guiding organizations, and others, there is no industry standard regarding wilderness first aid (WFA) training and certification of outdoor adventure/education leaders. In 2013, leaders of many commercial wilderness medicine schools published a consensus document establishing minimum standards and scope of practice for WFA. However, as noted by the authors themselves, the document exclusively addresses first aid standards, not EMS responder standards, and sets a minimum, where a maximum scope of practice may be the more salient question. However, this bodes well for future initiatives establishing standardized or consensus standards and scopes of practice for true EMS certifications. In addition, the establishment of minimum standards for WFA and WFR also satisfies the requirements of EMS Education for the Future, which promotes the idea that there is a single level of minimum competency for each level of EMS credentialing, and that those labeled as EMS providers (presumably including WEMS providers) should be able to demonstrate ability at or above that level.\n\nHistorically, NAEMSP Rural Affairs Committee has pursued important work on WEMS protocols and practice, establishing clinical guidelines for delayed or prolonged transport involving spine injury, dislocations, wound care, and cardiopulmonary arrest. However, no new WEMS clinical position statements have appeared since 1993. In 2010, NAEMSP released a position statement on medical direction of operational EMS (including WEMS). This statement affirmed that WEMS programs and providers often require specialized skills, should function within and not outside the mainstream health care system, and should function with oversight from an appropriately trained, certified, and credentialed medical director. The position statement and an associated resource document address medical director and system standardization, but neither specifically addresses certification or scope of practice standardization except to say that it is multifactorial and all applicable regulations must be followed.\n\nThe American College of Emergency Physicians (ACEP) and the Society for Academic Emergency Medicine (SAEM) have formed wilderness medicine sections that have implicit interest in WEMS, especially as practiced by physicians, but no standardization positions have yet been formally taken by these groups.\n\nWilderness EMS also accounts for many of the field health care providers and organizations who sometimes, despite meeting all apparent criteria for being EMS providers, operationally fall outside EMS supervisory processes such as medical oversight, standardization, and regulated scope of practice. These may include some ski patrols, lifeguards, SAR teams, and wilderness guides, among others. The National Ski Patrol\u2019s OEC program, which is now commercially marketed as an all-seasons and all-environments wilderness medicine certification, has been particularly notable in this regard. There is at least one instance of a state specifically defining OEC practitioners as first aid providers regardless of their scope of practice, thus potentially bypassing EMS regulatory oversight. On the other hand, there is at least one instance of a state specifically declaring OEC as an EMS certification, thus explicitly putting it within the EMS oversight system. The interface of all these WEMS agencies and teams with traditional EMS systems can be a subject of both local and national debate and negotiation.",
        "Scopes of practice": "New scope of practice model\n\nThe National Highway Traffic Safety Administration published EMS Education for the Future: A Systems Approach in 2000 and The National EMS Scope of Practice Model in 2005. These were further refinements of a national standard for prehospital care promulgated by the 1996 EMS Agenda for the Future. The conceptual basis includes the application of the scope of practice of each of the four \u201clevels\u201d of EMS providers in all locations of the United States. Although these documents do not contain standards or sections addressing WEMS specifically, these concepts are still quite relevant to WEMS. Quite often in a wilderness event there may be a variety of levels of providers involved with the management of a patient. In addition, there may be times when a patient is managed by an EMS provider at the EMR or EMT level without the assistance of a provider at the level of AEMT or paramedic. While this suggests that scope of practice might need to be expanded in these circumstances, in a WEMS setting such expansion should be done only with appropriate indirect medical oversight well in advance of any anticipated need, and with the approval of the local and state EMS regulatory authority.\n\nAccording to the National EMS Scope of Practice Model, \u201c\u2026 state regulations must be clear as to the extent to which the State\u2019s EMS scope of practice applies to EMS personnel functioning in these non-traditional roles and settings. The employers of EMS personnel working in non-traditional roles and settings must also be aware to what extent the person\u2019s State EMS license permits or prohibits such activities.\u201d This scope of practice issue is two-sided: the state needs to understand the requirements of the austere and wilderness environment, and the providers and provider organizations need to understand that the state has regulatory authority.",
        "Levels of WEMS providers": "\n\nWilderness first aid (WFA)\n\nIn general, the WFA provider is someone who has limited training or experience in wilderness medicine. The typical WFA course is about 16\u201324 hours in length and is intended to provide the individual with basic first aid knowledge as it applies to a remote or austere environment. WFA-certified individuals may be part of an organized WEMS system in the capacity of search and rescue, but are generally not intended to be the medical component of a formal wilderness rescue. This is more often a \u201cgeneral knowledge\u201d certification that would be utilized in Good Samaritan circumstances. The wilderness first aider may also be a member of a local Boy Scout troop or a private citizen who happens upon someone in need. In 2013 a consensus panel primarily composed of wilderness medicine schools published a statement establishing minimum standards and scope of practice for WFA.\n\nWilderness first responder (WFR)\n\nThe WFR is the basic provider level serving in an organized WEMS system. There is also a growing standard for guided wilderness trips (e.g. rafting, climbing, and others) to have a guide certified to this level. WFR courses are generally about 80 hours in length. The WFR is trained to recognize potential life-threatening injury and stabilize the patient for transport out of the wilderness environment. At times, the WFR may be trained to administer life-saving medications such as epinephrine, oxygen, and glucose under appropriate medical oversight. The WFR may also be trained in protocols that include dislocation reductions, selective spinal immobilization, and termination of resuscitation. Although new EMS terminology would suggest that this should become wilderness emergency medical responder (WEMR), this has not yet been embraced, and this level of responder is universally still referenced as a WFR. As noted earlier, in 1999 the WMS Curriculum Committee published minimum course content guidelines for a WFR curriculum.\n\nWilderness emergency medical technician (WEMT)\n\nThe WEMT course is approximately 150 hours long and usually adds to WFR training by including more advanced techniques in manipulation of dislocations, administration of medications, and all components of traditional EMT training. Despite the absence of a standardized curriculum, the curricula of at least three of the major schools (WMI, WMA, and SOLO) have been found to be similar enough that they will recertify each other\u2019s students. As the majority of WEMS students are trained via the curricula from these three schools, an ad hoc comparison can be made between EMT and WEMT curricula, and when analyzed, that difference has been characterized as \u201cvast.\u201d In general, the wilderness modules appended to these WEMT curricula involve an additional 48\u201380 hours of training beyond standard EMT curricula.\n\nWilderness paramedic\n\nCommercial training companies, who generally train and certify at the WEMT level, do not generally recognize the wilderness paramedic as an independent certification level. However, numerous systems field paramedics who operate as wilderness paramedics. In general, the wilderness paramedic is able to administer medications with a similar scope of practice as the urban paramedic. In addition, some WEMS systems train providers at this level in procedures for prolonged care, such as the insertion of Foley catheters for urine drainage and nasogastric tubes for gastric decompression.\n\nWilderness physician\n\nThe wilderness physician is able to provide necessary care and advanced medical decision making within the limitations of the surrounding environment. Wilderness physicians may receive special training through fellowship programs and/or special courses such as the WMS\u2019s conference courses, proprietary professional school curricula such as Wilderness Upgrade for the Medical Professional, Wilderness Advanced Life Support, Wilderness Medicine for the Professional Practitioner, Remote Medicine for the Advanced Provider, or other similar coursework. As noted earlier, AWLS certification is available from AdventureMed, who license numerous instructors around the world to teach this course. The Wilderness EMS Institute has historically offered a Wilderness Command Physician course, although this has not been offered recently. In addition, wilderness physicians may also be tasked with providing medical oversight for other WEMS providers. In light of this, NAEMSP and WMS have jointly endorsed a new program, the Wilderness EMS Medical Director Course, which provides training for physicians involved as medical directors or medical advisors for WEMS systems. In addition, numerous fellowships now exist in EMS (with a very few, as noted earlier, specializing further in WEMS). As board-certified and fellowship-trained EMS physicians begin to enter the workforce, it would be expected that field care at the physician level, including wilderness physicians, would continue to rapidly expand and improve.\n\nEmergency medical dispatchers and telemedical providers\n\nAs telecommunications capabilities expand further into wilderness regions, the capability grows for remote medical care via telephone. It is worth noting that reliable 3G mobile phone coverage was established on the summit of Mt Everest, the highest point on Earth, in 2010. Emergency medical dispatchers (EMDs) may more frequently serve as the first point of contact with the subjects themselves for wilderness rescues. This puts a new emphasis on the importance of medical training for EMDs that includes novel protocols such as wilderness medical care. EMDs and other telecommunications services can provide life-saving wilderness medical instructions. For example, the most important intervention in the case of cardiac arrest from drowning or lightning strikes is immediate cardiopulmonary resuscitation (CPR), a skill that EMDs are uniquely prepared to facilitate via telephonic instruction, potentially hours before the first on-scene WEMS responder arrives.\n\nSome countries are also embracing novel telecommunication strategies to address austere and WEMS environments of care. In Bhutan, a Himalayan country in the unique situation of developing an EMS system within an entirely new health care infrastructure, the decision has been made to consolidate much of their field medical care in a central \u201chealth help centre\u201d (HHC), created in 2011. The HHC serves not only as a national public safety answering point, but also as a centralized source for telephonic medical care, potentially at the physician level. This addresses the reality that, outside the capital city, most of the country\u2019s evolving emergency medical system has characteristics of a WEMS system (>85% of the country is forest, jungle, or mountain, including the highest unclimbed mountain in the world), but excellent and nearly universal mobile phone coverage. This makes it easier and faster to have individuals call in for EMS consultation and care (essentially creating a national WEMS system), before dispatching a limited number of EMS personnel (<100).",
        "Direct medical oversight": "The process of direct medical oversight for WEMS operations can be quite difficult. Although it may be ideal to have the medical director or an EMS physician in the field with the EMS providers, this is typically not feasible. In addition, due to the reality that WEMS operations are often remote, it may be impossible to contact a physician by radio or cell phone.\n\nDespite the challenges of direct medical oversight for EMS providers in the wilderness setting, there is still a need for close physician involvement with WEMS operations. Therefore, EMS agencies that will be involved with WEMS operations should work with physicians who are familiar with their work. The challenges of WEMS are unique and the physician who has experience only in the more traditional urban EMS setting will typically not be able to provide adequate input to the management of a patient in the wilderness environment. Physicians who will be involved with direct medical oversight of WEMS operations should have appropriate experience and participate in field training exercises with EMS providers. They are encouraged to participate in actual rescue operations.",
        "Indirect medical oversight ": "\n\nIndirect medical oversight is the cornerstone of medical direction for WEMS systems. Mountain rescue data suggest that at least 95% of rescues are performed without physicians present. Because it is often difficult for WEMS providers to reach direct medical oversight in real time, it is important to have regular educational sessions for special field assessments and protocols.\n\nAlthough written protocols may seem too rigid for the wilderness environment, well-designed written protocols can largely eliminate the need for direct medical oversight. The key to developing wilderness protocols is to allow for a certain amount of flexibility in the application of the protocols by the EMS providers.\n\nBecause the case volume for WEMS operations is typically not as high as in the urban EMS setting, it should be possible to develop a program for regular case review. Case review can be the foundation for continuing educational activities and a rigorous quality improvement program.\n\nOrganized wilderness rescue can be quite complex. The most efficient method to manage the complexity is to apply a systems approach; hence the need for the development of WEMS systems. The organized rescue will often involve multiple agencies and personnel, each with their own areas of expertise. Although it may seem cumbersome to involve multiple agencies, the variance in levels of expertise is often quite important to a successful rescue. In a large-scale search there may be a need for individuals with expertise in high-angle or avalanche rescue and people with experience working with horses or snowmobiles. Large-scale searches will often require complex communications and logistical support for procurement of supplies and food. The best way to manage all of the different agencies and individuals that may be needed for a successful search is to use the incident command system. An example of the structure of a WEMS incident command is shown in Figure 42.6.\n\nIn addition to the operational concerns of maintaining command and control of the multiple agencies that may be involved in a WEMS event, there are legal, financial, and ethical concerns that should be considered. Many large-scale WEMS events will involve both paid and volunteer EMS personnel. Regardless of the costs of personnel, a search may require significant financial resources. Although the party that will ultimately be responsible for carrying the financial weight of a search will vary by jurisdiction, certainly it is advisable that each jurisdiction plan for this prior to an event.\n\nFundamentally, a primary consideration of any WEMS event is finding the balance between rescuing the injured person and making sure that all involved with the event are not placed in undue danger. One study of SAR operations in New Hampshire analyzed 321 incidents and found a 2.5% rate of rescuer injury.",
        "Protocols": "Wilderness EMS is emerging as a subspecialty in EMS that requires different approaches, protocols, and medical oversight. Any austere environment challenges the feasibility, practicality, and safety of traditional EMS protocols. There also may be major communication problems. Protocols that allow EMS professionals to care for patients in prolonged care environments must be designed with sound foresight and training. Development of such protocols has engendered a number of debates.\n\nFirst, some authorities have suggested that nothing about WEMS is sufficiently different to require separate standards, or that too much regional variation exists to establish national standards. In 2001, Goodman et al. argued that mortality rates would not be expected to change as a result of upgrading WEMS operations. However, each of these perspectives has been forcefully and directly repudiated in subsequent WEMS analysis.\n\nThe need for ALS, or equipment-intensive BLS such as automated external defibrillator (AED)-assisted BLS, has been heavily debated. Many WEMS operations benefit most significantly from outstanding BLS rather than ALS skills. As noted earlier, in some WEMS systems, only 10% of calls require ALS intervention. This potentially calls into question the need for ALS in the first place, or its appropriateness in the context of skill retention with low-frequency usage. However, evidence also suggests that less than 50% of calls in the most urbanized cities in the United States require ALS care. In addition, in some WEMS systems, providers keep skills active by also working in higher-volume systems when not working or volunteering on a WEMS team. Most importantly, to those patients who do critically need ALS interventions that may be life-saving in a remote setting, the fact that it is a low-frequency intervention is irrelevant. Some consensus guidelines are starting to appear regarding a standard of care and service expectation. For example, the International Commission for Mountain Emergency Medicine has concluded that all mountain rescue teams should have AED availability. All WEMS systems must evaluate the type of ALS care that is being provided, its necessity, and its cost to the system versus its benefit to the patient.\n\nWilderness EMS protocols are generally developed at the state level. Current practice demonstrates a mosaic of practices, ranging from states like Maryland and Alaska that have explicit WEMS protocols, to states like Maine that recognize the proprietary WEMS certifications of particular schools, to states like North Carolina that approve specific protocols on a county case-by-case submission basis, to many states that have no WEMS provisions whatsoever.\n\nAlthough WEMS is usually considered to be an extension of traditional EMS operations, multiple examples exist where protocols and practices first appearing in the WEMS environment helped drive changes in traditional EMS protocols. NAEMSP position statements first appeared in 1993 suggesting selective spine immobilization for remote/rural/wilderness patients, and protocols for this were taught in WEMS courses for many years before it became the subject of heavy scrutiny in traditional EMS. Other examples of WEMS driving traditional EMS operations include the development of the original prototype of our current incident command system by wildland fire teams.\n\nThe following are areas of focus of the major WEMS protocols that deviate from traditional EMS protocols and that are fairly consistent throughout many states' and schools' protocols and in national WEMS dialogue. It is worth noting that the first four are the same as those originally identified by NAEMSP in 1991 and 1993 position papers. However, despite their presence in the medical literature for two decades or more, some of these operationally specific protocols are still available to WEMS providers in only a few systems and remain controversial. This is particularly true for spinal motion restriction, joint reduction, and epinephrine availability for anaphylaxis.\n\nWound care\n\nSpecial training is needed to manage wounds over extended periods of time to maintain function and avoid infection. This goes well beyond the teaching of traditional EMS that generally deals only with bandaging to control bleeding and transporting to the closest emergency department. In wilderness settings, protocols should address wound irrigation and ongoing wound assessments. Sometimes impaled foreign bodies have to be removed, as they may limit evacuation and increase infection risk. For situations with prolonged extrication, there may be utility in having protocols for the administration of antibiotics for prophylaxis or treatment of wound infection. Control of bleeding with well-applied direct pressure is still a key principle.\n\nTermination of resuscitation (TOR)\n\nIf CPR has been performed in the setting of a cardiac arrest in the wilderness, it is helpful to give guidelines to out-of-hospital providers to enable them to cease resuscitation efforts. WMS practice guidelines indicate that CPR may be discontinued if there is no response after approximately 30 minutes, even if there is no monitor to demonstrate a non-organized rhythm, because there is virtually no chance of survival in the wilderness setting if return of spontaneous circulation (ROSC) has not occurred by that time. In 2011, NAEMSP similarly endorsed the concept that providers and medical directors, using evidence-guided methodology, could develop TOR protocols in non-traumatic cardiopulmonary arrest. NAEMSP's recommendation is that TOR protocols for non-traumatic cardiopulmonary arrest should be based on the determination that an EMS provider did not witness the arrest, there is no shockable rhythm identified, and there is no ROSC prior to EMS transport. The developed by Verbeek et al. demonstrates a sensitivity of 100% for identifying survivors and a negative predictive value of 100% for identifying non-survivors, with follow-up studies including rural regions showed a positive predictive value of 99.5% for death and specificity of 90% for recommending transport of survivors.\n\nThese are compelling data for TOR in the wilderness setting, where additional risks exist for providers performing CPR which must be measured against the putative benefit of continuing that CPR. Special considerations need to be made for patients with hypothermia, lightning injury, and drowning, but WEMS care of these patients without rapid evacuation to definitive care and without rapid ROSC is generally futile. Transforming a mission from rescue to recovery may be difficult for some rescuers, but the risk to rescuers of performing prolonged CPR in a wilderness setting outweighs the potential benefit.\n\nJoint reductions\n\nThese protocols are generally not taught in traditional EMS courses, because patients with dislocations are easily taken to a hospital where x-rays can confirm a diagnosis and practitioners can reduce them in a controlled setting. In the wilderness, a shoulder dislocation can make it difficult for someone to self-extricate, but with training the WEMS provider at even the most basic levels may be able to successfully reduce a shoulder dislocation, allowing the patient to evacuate himself or herself. This reduces the risk to the patient and caregivers while most importantly, still providing good patient care. Other joint reductions that are often taught are digits and patella. Most of these protocols are very specific to reducing dislocations caused by indirect trauma so as to minimize the manipulation of fractures.\n\nSpinal motion restriction\n\nSpinal immobilization is a very common procedure performed in the urban/rural EMS system, and although selective spine immobilization is now being more broadly accepted in traditional systems, almost every patient injured by blunt trauma with a significant mechanism of injury is still immobilized. In wilderness settings, however, placing someone on a backboard can drastically change the scope of a rescue/evacuation, with markedly increased potential for risk to both the patient (in the form of pain, agitation, respiratory compromise, local perfusion loss, and development of pressure sores) and rescuers (in the form of significantly increased operational complexity, physical labor for movement, possibility of secondary trauma, and longevity of operations). Selective spine immobilization and spinal motion restriction protocols are typically based on the same criteria that have become the standard for physicians deciding whether or not to order radiological studies on patients with potential spine injuries. These criteria have been validated in the EMS environment and are an important tool for WEMS providers.\n\nIn 2013, both NAEMSP and the American College of Surgeons Committee on Trauma adopted the position that the benefit of long board spinal immobilization is largely unproven. They both recommend that the utilization of backboards for spinal immobilization should be judicious, so that the potential benefits outweigh the risks. Some authorities make the case that no patient should ever be immobilized on a backboard in the WEMS environment unless needed for short-term extrication purposes rather than long-term transport.\n\nIn the wilderness environment in particular, there may be additional risks to immobilizing a patient, particularly if this may render him or her less able to avoid unexpected environmental risks. In a tragic case in Texas, a patient (who had been ambulatory for 10\u201315 minutes prior to this action) was immobilized onto a backboard in the middle of an intersection. A vehicle subsequently veered into the intersection, striking the immobilized patient but not the EMS personnel who were able to flee the danger. Even more likely analogues are apparent in a wilderness setting, involving flash floods, avalanches, or other unexpected environmental dangers, as well as simply the danger of a patient being dropped or control lost in precipitous environmental conditions like steep trails or near water. Any immobilization done in or around water requires particular attention to the necessity of immobilization given increased environmental risk, and continuous control of the patient to ensure that the airway is above water. Indeed, in swift water rescues where a rescuer is taking direct in-water control of a patient, subsequent loss of control of that patient can be construed as negligence, a principle which is not only axiomatic in swift water rescue training but which also has legal precedent.\n\nAnaphylaxis and severe asthma\n\nThis protocol primarily deals with the administration of epinephrine in life-threatening anaphylaxis and respiratory failure from asthma. Many guide services now require WFRs to carry epinephrine on long remote trips. Concerns have been raised about inappropriate administration of epinephrine causing significant side-effects in an older patient population with known or possibly unknown cardiac disease, as well as medicolegal issues with providers at the WFR or WFA level administering this prescription medication. However, most experts in the field, including the WMS, NAEMSP, and a wilderness medicine consensus panel convened in 2008 to address this question, have concluded that the benefits of treating life-threatening asthma and anaphylaxis with epinephrine by properly trained individuals at all levels of EMS providers outweigh the possible risks. Despite this, when last studied, only 12 states currently allow first responders/emergency medical responders to carry epinephrine. Other states put restrictions on EMT use of epinephrine that limit its actual availability, even if permitted for use, such as requiring it only be administered via expensive and short-lived commercial autoinjectors. Interestingly, 17 states require that epinephrine be carried by EMTs, speaking to its perceived importance. Studies have concluded that BLS providers correctly identify anaphylaxis and use epinephrine 95% of the time when compared to a physician review standard, and that their administration of epinephrine is safe.\n\nIn addition to the administration of epinephrine, it may also be advisable for WEMS providers to have protocols for the administration of albuterol multidose inhalers and prednisone for the treatment of both anaphylaxis and acute asthma. Wilderness protocols may also address the use of histamine blockers such as diphenhydramine for the treatment of anaphylaxis.\n\nCommunication in the WEMS environment is sometimes very limited or non-existent. In 2006 a robust debate appeared in the WEMS literature regarding protocol philosophy in the context of communication. One side argued for implementation of explicit, specific protocols and online direction; the other contended that well-trained providers could improvise, needed guidelines rather than strict protocols, and would rarely require online direction for consultation in difficult cases. This mirrors similar, earlier debates in the traditional EMS community regarding paramedic autonomy and strict versus loose requirements for online direction.\n\nUltimately, a consensus has evolved that EMS protocols requiring the provider to contact medical oversight for advice and approval, or that attempt to predict every WEMS operational situation explicitly, are not feasible in the WEMS setting. In the wilderness setting, many of the traditional communication forms often do not work. Even satellite phones and other sophisticated communication devices frequently fail. In the WEMS setting it is necessary to have a 'standing order' set of written protocols, and some recognition that WEMS providers need to have a higher degree of problem-solving and clinical decision-making ability in their field operations due to autonomy and operational complexity. As with any protocol authorizing EMS providers to perform skills, and especially those that promote some degree of autonomy in decision making, there should be a quality improvement program that assures that the training corresponds with proper medical decision making and that the decisions being made are sound.\n\nWilderness EMS medical directors must also consider the development of protocols and operational practices that are unique to wilderness environments. These include when to stop wilderness searches, how to build incident command-compatible operations that maintain command-and-control and appropriate medical care in the face of operations where the number of volunteers may exceed the number of formal responders, and many others.\n\nFuture areas of potential protocol expansion could include new pain medication modalities including intranasal fentanyl or oral opioids, field administration of agents previously limited to hospital use such as snake antivenin, and other innovations.",
        "Wilderness EMS-specific extrication, treatment, and transport equipment": "Wilderness medicine is often characterized as the provision of medical care with little or no availability of the medical technologies typically seen in health care. However, in some cases WEMS actually has access to (and must be familiar with) patient care equipment not available to hospital-based providers or traditional EMS providers. These can include tools such as:\n\n\u2022 Gamow bags for altitude illnesses\n\n\u2022 rescue helicopters capable of high-altitude/tactical/technical pick-off rescue operations, including short- and long-haul patient extrication and sometimes patient transport\n\n\u2022 Stokes baskets for high-angle and technical rescues\n\n\u2022 rope and rigging equipment for various environments including cave, water, and high-angle\n\n\u2022 atypical motorized and non-motorized transport platforms like boats, off-road ambulances, toboggans, rescue sleds, Mule Litter Wheels, and ATVs.\n\nAn interesting consideration regarding mechanized rescue vehicles is that formal wilderness areas in the United States ban motorized traffic. While this would seem to present an obstacle to rescue operations, in general, ethicists have suggested that preservation of human life takes priority over preservation of wilderness areas.",
        "Survival skills and capability for autonomous operation": "Wilderness EMS providers must be trained (and when appropriate/available, certified) to safely operate in their particular technical environment. Recognized certifications exist for many of the realms of WEMS including technical high/low-angle, swift water, cave, avalanche, dive, etc.\n\nTo a greater degree than traditional EMS providers, WEMS personnel must be prepared to operate autonomously and without the assumption that they will have constant access to medical oversight, back-up services, or additional resources. This may require not only additional training but also potentially additional equipment to safely operate within their particular environment. For backcountry operations, this could include map and compass and navigation skills and the corresponding equipment. For swift water rescue this could include rescue-specific personal flotation devices equipped with bailout options and swift water-appropriate helmets. For ski operations this can include cold weather gear, navigation skills in alpine/snow environments, and avalanche awareness. Many of these environments will have minimum levels of training and equipment without which no health care provider should enter the environment or attempt to deliver systematic (non-Good Samaritan) care. In addition, in many cases WEMS providers must have a fitness level and skill set appropriate to the operational environment that exceeds that of the general public or of traditional EMS providers.\n\nTeam and provider safety take on added importance in the austere and resource-deficient environments in which WEMS is often practiced. The illness, injury, or loss of a team member can have catastrophic effects on patient care and overall operations far beyond what would be experienced in a similar scenario in a traditional EMS environment. It is thus critical for both providers and administrators that appropriate steps are taken prior to deployment to ensure adequate training, certification, equipment, and fitness for the operational environment in which a team is delivering care.",
        "Challenges to WEMS systems": "Paramedic shortage\n\nThe Committee on the Future of Emergency Care in the United States Health System has expressed a perceived shortage of qualified paramedics in traditional EMS systems. It has been speculated that this will likely cause further stress on WEMS as a subspecialization.\n\nVolunteerism\n\nIn the United States, many if not most WEMS providers are volunteers. The sustainability of this approach is increasingly in question. Since the establishment of EMS, regulations and requisite certifications, along with corresponding training time and expenses, have skyrocketed from almost none to the complex regulatory environment we work in today. These time and money costs may become unsustainable for unpaid volunteers, many of whom also have full-time jobs elsewhere. This is similar to rural EMS, where time constraints are one of the most cited reasons for departure from a volunteer EMS system. In general, after a spike around the 9/11 terrorist events, the United States has seen a steady decline in volunteerism, with particularly dramatic declines in volunteer fire/rescue numbers (often the source of WEMS providers). This may have dire consequences for WEMS, which relies disproportionately on volunteerism for activities such as ski patrols, SAR teams, technical rescue teams, and mountain rescue teams.\n\nRanger shortage\n\nThe National Park Service also has a critical ranger shortage. There appears to be waning interest in employment as a park ranger, and about 50% of rangers specializing in law enforcement (which includes SAR and EMS) must retire between 2010 and 2015 under federally mandated age guidelines. Another challenge to ranger staffing is reassignment based on changing federal priorities following the terrorist attacks of 2001. In 2004 the National Parks Conservation Association released a report citing millions of dollars in fee receipts diverted for increased security requirements, with a system-wide shortfall of $600 million annually. A concerning disconnect between ranger staffing and attendance has been present for decades: visits to NPS parks have increased by more than 60 million people, but the number of permanently commissioned rangers dropped by 16% and the number of seasonal rangers dropped by 24% during this same period. This represents an ominous trend for WEMS care. A recent analysis of SAR operations determined that without the presence of NPS personnel responding to SAR incidents, one in five of those requesting SAR assistance would be a fatality.\n\nPhysician shortage\n\nWilderness EMS suffers as much as (or more than) other branches of EMS from a dearth of field physicians. As noted earlier, over 95% of mountain rescues are performed without a physician present, with the majority performed without direct medical oversight. This is less often the case in Europe and parts of Asia, where physicians are often heavily involved in mountain rescue and other wilderness rescue operations. A reinvestment on the part of physician-level providers in WEMS field operations would be appropriate, and is being actively promoted by many physicians active in WEMS.\n\nFunding\n\nAs with other elements of rural EMS and volunteer rescue services, inadequate funding is a continual challenge for WEMS teams. Many pursue strategies similar to rural EMS agencies (fundraisers and other direct appeals). Grant funding may be available but is extremely limited, in terms of both numbers and duration. Some teams obtain governmental funding. For example, most helicopter-based rescues involve state or federal assets and these operations are rolled into preexisting training budgets at no additional taxpayer cost, contradicting the myth that these are extremely expensive operations for the government to run. However, examples of non-profit helicopter-based WEMS/rescue services do exist, and funding for them may be extremely tenuous. For example, abrupt discontinuation of fuel and maintenance funding from the federal government in 2013 has required the Snohomish County (Washington) Search & Rescue Helicopter Rescue Team, a long-standing non-profit helicopter WEMS/rescue team, to turn to other sources for funding or discontinue its operations.\n\nQuestions regarding appropriateness of wilderness rescue\n\nInterestingly, the appropriateness of systematic wilderness rescue itself has been questioned. Some argue that the absence of formal medical care and rescue availability is part of the appeal of wilderness activities, and that individuals venturing into these areas should be self-sufficient and capable of treating and rescuing themselves. Further questions have been raised regarding payment for services rendered. Unlike most EMS operations in the United States, most rescues and WEMS medical care are usually either provided on a volunteer, uncompensated basis or by the government. (This is in contrast to Europe, where the standard is to charge for services rendered, with a consequence being that most individuals and groups purchase rescue insurance.) In large part, this uncompensated model is due to a concern that individuals injured or ill and in jeopardy in a wilderness environment will delay calls for help due to fear of cost. Also, despite the fact that state and national parks have no specifically mandated \u201cduty to rescue,\u201d such authorities do have an obligation to protect the safety of participants in their regions, which is often extended to rescue and thus uncompensated medical care. In some areas that are considered at particularly high risk, a prospective rescue fee is sometimes levied on visitors. For example, a $150 fee was required of climbers attempting Mt McKinley in 1995 to defray rescue costs. Although some felt this was appropriate and argue for expansion of such policies, others feel it inappropriately restricts access to public areas and disproportionately singles out certain sports that have not necessarily been demonstrated to be higher risk or more expensive in aggregate. For example, in 2001 only 5% of rescues involved climbers; the remaining 95% did not pay fees to defray rescue costs involving their activities, despite the fact that Alaskan Coast Guard rescues in aggregate are orders of magnitude more expensive than climbing rescues in aggregate. The National Park Service, the US Coast Guard, the Mountain Rescue Association, the American Alpine Club, and most SAR authorities do not support levying individual bills for mountain, SAR, or coastal rescues. Rare exceptions do exist, such as Telluride County, Colorado, where rescues may be billed to individuals who are pursuing \u201chigh-risk recreational pursuits.\u201d\n\nFinally, 'no-rescue areas' have been described where, upon entering, 'people put life and limb at risk while society condones and presumably enforces a requirement not to assist those in need.' Areas cited as examples of this include the moon landing, surely the epitome of a wilderness environment where no medical care would be available, or early mountaineers venturing above 8,000 m (26,247 ft). As rescue operations have become planned even in space and extreme high-altitude environments, it begs the question as to whether 'no-rescue areas' still exist today. Certainly remote areas have been cited in the literature where no organized rescue services exist and where rescues or WEMS services would need to be launched remotely or even from another country, such as the Brazilian Amazon east of Manaus and other extremely remote areas with no local or regional EMS rescue infrastructure whatsoever."
    },
    {
        "Introduction": "The World Health Organization defines public health as all organized measures used to prevent disease, promote health, and prolong life among the population as a whole. In contrast to this definition, the National Highway Traffic Safety Administration (NHTSA) defines EMS as a response that is activated by an incident causing serious illness or injury, focusing on emergency medical care for the patient(s). Despite the clear differences in these definitions, EMS and public health share numerous commonalities. Arguably, modern-day EMS was born after the 1966 Institute of Medicine report Accidental Death and Disability: The Neglected Disease of Modern Society. The white paper, as this publication is commonly known, concludes by stating that bolstering the EMS system as a whole would decrease morbidity and mortality, leading to improved public health.\n\nFollowing the publication of the white paper, federal funding flowed into cities, allowing EMS systems to rapidly grow in both form and function in the United States and around the world. Thirty years later, in 1996, a refreshed vision for EMS was formulated in the publication by NHTSA and the Health Resources and Services Administration (HRSA) titled The EMS Agenda for the Future. Federal funding supported the creation of this document, with the intent for it to be used by public and private organizations in planning for the future design of the growing EMS system. Within this document were numerous statements encouraging EMS and public health to strengthen their collaborations for the benefit of the community:\n\nEmergency Medical Services [EMS] of the future will be community-based health management that is fully integrated with the overall health care system. It will have the ability to identify and modify illness and injury risks, provide acute illness and injury care and follow-up, and contribute to treatment of chronic conditions and community health monitoring. This new entity will be developed from redistribution of existing health care resources and will be integrated with other health care providers and public health and public safety agencies. It will improve community health and result in a more appropriate use of acute health care resources. EMS will remain the public's emergency medical safety net.\n\nIn 2000, Dr Mohammad Akhter, then American Public Health Association Executive Director, challenged the National Association of EMS Physicians to work more closely with the public health community. Shortly after that challenge, the EMS and Public Health Roundtable was formed, bringing together leaders and practitioners in prehospital care and public health. The Roundtable provided a forum for prehospital and public health discussion, with the goal of developing guidelines to foster collaboration. During the Roundtable, many examples of prehospital public health efforts were identified, with injury prevention efforts at the forefront. The final meeting of the Roundtable, in August 2001 in Washington, ended with the intention of promoting demonstration EMS and public health projects and developing joint education and training efforts.",
        "Understanding public health": "Public health is composed of many subfields including environmental health, health care policy, occupational medicine, epidemiology, biostatistics, disaster planning, health promotion, and EMS. Two subfields require further elaboration here regarding overlap with EMS: epidemiology and health promotion/needs assessment.",
        "Epidemiology": "Epidemiology is \u201cthe study of the occurrence and distribution of health-related states or events in specified populations, including the study of the determinants influencing such states, and the application of this knowledge to control the health problems.\u201d The foundation of epidemiology was constructed by Dr John Snow, a physician in London during the cholera outbreak in the 1850s. By creating a dot map of over 500 cases of cholera by known address, Dr Snow discovered the common source of cholera was water retrieved from the Broad Street pump. Using this information, Snow was able to convince the parish counselors to disable the pump and soon thereafter, the cholera cases in that region subsided. The science of epidemiology rapidly outgrew its origins in disease outbreak monitoring to encompass chronic disease and injury. From ideal response times in emergencies to elderly EMS utilization, epidemiology encompasses the backbone of public health research and thus research in the field of EMS.",
        "Health promotion and needs assessment": "Health promotion is the process of enabling people to increase control over their health and its determinants, and thereby improve their health. Prior to beginning an intervention in promoting health, the researcher must first identify the deficiencies of health in the study community. Performing a community needs assessment represents one way of identifying health priorities in a community. Just as every individual's needs vary, those needs within individual communities fluctuate over time. For example, public education on sunscreen is important in all communities, but remains a greater health priority in the southern United States. The reverse may be the case for hypothermia precautions. Preparation of a community needs assessment occurs on the local level. Some of the information typically available in community needs assessments includes employment, emergency department utilization, EMS responses, home ownership, disease incidence, crime, social services, parks and recreation, transportation, etc.\n\nIn 2011, to highlight the importance of the topic of community needs assessments, the Centers for Disease Control and Prevention (CDC) convened a panel of over 50 subject experts to discuss best practices. Non-profit hospitals have been the greatest supporters of these assessments in the past. The Patient Protection and Affordable Care Act has ensured their support will continue into the future. Non-profit hospitals under section 501(r) of the Internal Revenue Code are required to perform community needs assessments every 3 years to maintain tax-exempt status. In addition, many community health care centers and non-profit organizations (such as the United Way) also perform community health assessments. This CDC gathering focused on the effect hospitals have on our communities. However, when considering partners for EMS public health initiatives, hospitals remain an important starting point. While the content of community needs assessments varies from state to state and county to county, seeking these documents remains an excellent first step in determining deficits within the community. However, in the report from the CDC conference, Dr Paul Halverson (then with the Arkansas Department of Health) warns that one should consider how interhospital competition negatively interacts with the desire to improve the health of patients and communities.\n\nI think it is not a given that hospitals want to come together and share accountability. It\u2019s not necessarily one of the things that comes natural. They are competing for patients. They are competing for physicians. They are competing for scarce resources. And then we ask them to come together and share. It\u2019s not something that they do naturally.\n\nWhen considering priorities in the community, one can also start with the Department of Health and Human Services (DHHS). Since the initial publication of Healthy People 1979, the DHHS has repeatedly set the country\u2019s public health objectives using 10-year benchmarks. The program not only sets the objectives but also challenges communities to collaborate to meet the goals. Healthy People 2020 launched in 2010 with overarching goals to promote high-quality lives and freedom from preventable health states while removing disparities from all groups.\n\nAn example of a process that communities and individuals have benefited from is injury prevention. The white paper in 1966 focused on these issues. In 1970 Dr William Haddon, Jr. developed the Haddon Matrix. This theory was specifically developed for crash data and stated that any crash required three factors: a host (human factors), an agent (vehicle), and environmental factors (often a fourth category of social factors is added). These factors are broken up into precrash, crash, and postcrash categories. While Dr Haddon\u2019s theory was developed for vehicular crash data, it has been used successfully over the years in a multitude of other public health problems.",
        "Programs highlighting the public health and EMS intersection": "It has been said that EMS is the intersection of health care (specifically emergency medicine), public health, and public safety. Examples of successful programs in public health that share an intersection with EMS and/or public safety include:\n\n- seat belt use and buckle-up programs\n- child car seat installation and parent training\n- bystander CPR\n- Vial of Life\n- bicycle helmets\n- elderly falls prevention\n- mass influenza vaccination programs\n- blood pressure/cholesterol screenings\n- frequent user case management\n- serial inebriate case management",
        "Surveillance and databases": "Surveillance is the collection of data about a community to monitor disease or health status [14]. Prehospital information contributes to case reporting by collecting information from individual EMS calls, grouping those calls into similar incidents, and then analyzing for trends to help in disease monitoring and surveillance in a community. Prehospital data have frequently been used in injury prevention efforts via surveillance. The Crash Outcome Data Evaluation Set (CODES) links prehospital motor vehicle crash data to hospital and discharge data.CODES describes the cost of motor vehicle crashes for those not using seat belts, and characteristics of different sets of drivers such as teenagers or older drivers. The effect of policy changes, such as primary seat belt laws or graduated licensing, can also be monitored through database surveillance.\n\nThe Cardiac Arrest Registry to Enhance Survival (CARES) represents another excellent example of public health surveillance in prehospital medicine. This registry was developed in 2004 as a joint collaboration between the CDC and Emory University with the goal of evaluating out-of-hospital cardiac arrest (OHCA) data across the United States. The registry uses an Utstein-style template to track cardiac arrests based on location, presenting rhythm, return of spontaneous circulation, and Cerebral Performance Category scores at discharge from the hospital. Many cities, counties, and even entire state organizations have joined the CARES registry since inception since 2004, which now includes over 40 sites. The data available from CARES assist communities in identifying areas for improvement and best practices in OHCA. For example, while bystander CPR has been considered integral in the chain of survival for OHCA, analysis of CARES data first confirmed the survival benefit that bystander CPR added.\n\nEmergency medical services data can also be used for the surveillance of respiratory illness. In New York, symptoms of influenza-like illness have been used in monitoring respiratory illness in correlation with emergency department illness. The European Emergency Data project also utilizes an EMS-based surveillance system. The objective of the project is to employ EMS data to assist in health status monitoring, early warning, prevention, and benchmarking.\n\nThe evolving National Emergency Medical Services Information System (NEMSIS) has begun to provide greater opportunities for the coordination of prehospital care with public health efforts on national, regional, and local levels. NEMSIS was developed from initial discussions involving NHTSA, HRSA, and NASEMSD in 2001 with the goal of standardizing prehospital information collection; the first dataset appeared in 2003. The standardized data elements number well over 500 today as version 3.0 of the project continues to evolve. In 2013, Wang et al. published a review of NEMSIS data describing over 7 million EMS responses in the United States to analyze response incidence type and outcome, clinical impression, patient characteristics, location type, time of day, and response mode. These data will become more granular in nature as more locations submit data to NEMSIS and more variables become available for analysis.",
        "Immunizations and prehospital care": "Immunizations are another example of prehospital public health activity with great potential. Walz et al. suggested in their 2003 article that paramedics could be a tremendous resource for bioterrorism and disaster response through vaccine administration. Paramedics receive training in the science and practice of intramuscular injections, pharmacology, and response to emergencies such as allergic reactions (as might occur with certain immunizations). The potential role and challenges for EMS participation in vaccinations are detailed in this paper. Also in 2003, Mosesso et al. reported on the MEDICVAX Project in Pennsylvania, describing the training and deployment of paramedics providing influenza vaccinations. The MEDICVAX program demonstrated the ability to cost-effectively deliver vaccinations to populations that had not been as effectively reached through the traditional system.\n\nIn 1999, the Chicago Housing Authority reported on its Pediatric Immunization Program (PIP) that extensively trained outreach workers in the recommended pediatric vaccination scheduling of the American Academy of Pediatrics and Advisory Committee for Immunization Practices. These outreach workers possessed a high school level of education and personal knowledge of the neighborhoods in question. Over the 3-year period of the project, in children 19\u201335 months at the time of enrollment, complete immunization rates increased from 27% to 50%. EMS providers could be trained in the vaccination schedule in a similar manner, thus representing an additional resource to reach into the community to improve vaccination rates.\n\nVaccinations by non-traditional health care practitioners hit the limelight during the H1N1 influenza season of 2009. The increased incidence and virulence along with significant media coverage of \u201cthe swine flu\u201d overwhelmed both the vaccine supply lines as well as those capable of delivering the life-saving vaccine. During the outbreak of 2009, or just prior to the 2010 influenza season, most of the 50 states created new language in their protocols allowing paramedics to administer the vaccine under varying emergency situations. Overall, prehospital providers have developed the skill of vaccination along with the setup of vaccination clinics in non-traditional settings, including the patient\u2019s home. An added benefit of increasing administration of vaccination rates in prehospital and other health care workers also must be noted. Health care workers in 2003 were vaccinated for influenza only 36% of the time. The 64% of health care workers who were unvaccinated were a potential source for influenza outbreaks in health care settings and the community. Health care sources can spread viruses such as influenza to patients and workers and affect staffing during critical outbreaks, as seen during the SARS pandemic in 2003.",
        "Community paramedicine and mobile integrated health care": "\n\nA measure of the success of public health is the reduction in the burden of disease. Prevention, health promotion, and disease intervention are important means by which public health improves. Prehospital care has significant opportunities in these areas. Garrison et al. noted in a review that prehospital provider counterparts in the fire and police services have been providing primary prevention for decades, through their successful efforts of fire prevention and decreasing drunk driving. In fact, fire prevention systems have been so successful that it is not unusual for the vast majority of a fire department\u2019s calls to be for medical assistance. This fact highlights the need for reforming preventive efforts in the medical sector, and for integration of public health and EMS.\n\nAttempts at EMS \u201cexpanded scope of practice\u201d have included public health and prevention activities. The Red River Expanded EMS Project (E-EMS), through increased training and protocols, sought to expand health care in a rural area. With the goal of reducing unnecessary transports to the hospital, E-EMS providers triaged patients into four categories: emergency transport, immediate physician consultation with treatment, referral back to E-EMS or other medical provider, and treatment via protocol alone. The E-EMS Project ended without reducing ambulance transports.\n\nThe Supporting Public Health with Emergency Responders (SPHERE) program in Seattle is targeting the secondary prevention of heart disease. The EMS system is used to identify patients with high blood pressure and high glucose readings. The goal is to provide these patients with information and guidance on what to do about it. As EMS providers are called in many cases when prevention has failed, prehospital care may provide a unique opportunity to identify high-risk patients and initiate preventive interventions.\n\nThese two programs were some of the earliest to highlight the possibilities of expanding the mission of paramedics. Often referred to as community paramedicine (citing origins in rural underserved communities), programs across the country and around the world are seeking creative ways to utilize the unique skill set of paramedics and the natural infiltration EMS has into the cores of the communities they serve. More broadly, the term mobile integrated health care is used to describe an interdisciplinary network of health care providers, including home health, nurses, case workers, etc. These programs can function in many ways. Examples include patient education of chronic health conditions, outpatient follow-up and coordination, needs assessments, medication reconciliation, advanced treatment protocols, and management of high utilizers of EMS. The International Roundtable on Community Paramedicine (IRCP) was formed in 2005 in the first of what would become annual meetings to discuss best practices, training programs and mission statements and future visions. The IRCP remains a key stakeholder in the community paramedicine movement.\n\nThe expansion of the paramedic scope of practice faces many challenges. The primary mission of paramedics limits functioning independently, instead placing paramedic care under the medical oversight of a physician. Technology advancements in telemedicine are rapidly progressing and allowing improved oversight of community paramedics; however, providing physician coverage of the program remains a challenge.\n\nFunding these initiatives, despite evidence of cost savings in the literature, has been difficult. Many EMS systems are hesitant to start programs, despite their benefit to the community, because of ever-shrinking budgets and funding streams. Developing support and partnerships with key stakeholders and hospitals in the communities served by these programs has been slow to catch on in the United States. However, the increased accountability of hospitals for their patients after discharge, encouraged by the Affordable Care Act, has opened opportunities for engaging hospitals in support of these programs.",
        "Conclusion": "Public health significantly overlaps with many of the goals of an EMS system, improving the health of the individual by strengthening the baseline health of the community. Identifying the deficits and needs in an individual community remains the first step. Referring to previous needs assessments while drawing comparisons and contrasts to other localities can help determine the needs of a particular community.\n\nDeveloping improvement programs can be a daunting prospect, but basing plans on other successful community interventions can be a starting point. Once an improvement program is in place, core concepts of public health such as epidemiology will track progress of these programs. Mobile integrated health care programs, to include community paramedicine programs, are challenging the traditional role of paramedics and bringing the public health interface to the forefront of EMS. The future likely will bring EMS and public health even closer together, with the prospect of the Affordable Care Act driving accountability outside the hospital walls to the community."
    },
    {
        "Introduction": "The delivery of prehospital emergency care by EMS personnel, including EMS physicians, is physically and mentally demanding. In contrast to many other occupations, the need or demand for prehospital care is not scheduled, and the amount of physical or mental work required for each patient is unpredictable. EMS workers must possess both physical strength and aerobic capacity to safely access and extricate patients. An EMS worker must lift and move patients onto stretchers, hospital beds, and other equipment, which requires core strength and flexibility. Many EMS workers are at risk of injury due to poor physical health and conditioning. Other common EMS activities, such as driving/operating ambulances, pose significant safety risks to both patient and EMS worker. A large proportion of fatal injuries while on the job are the result of driving ambulances or other EMS vehicles. Preventing fatal and non-fatal injuries in the EMS setting requires a multifaceted approach.",
        "Occupational fatalities": "There are few studies of EMS worker occupational fatalities. A recent study of the Bureau of Labor Statistics (BLS \u2013 this acronym will be used in this chapter for this agency, and not for Basic Life Support) Census of Fatal Occupational Injuries (CFOI), years 2003\u20132007, identified 65 fatalities and showed that the rate of fatalities for compensated EMS workers exceeds the rate of the general working public (6.3 per 100,000 full-time equivalents (FTE) versus 4.0 per 100,000, respectively). A recently published study using the same dataset for the same time period (2003\u20132007) identified six fewer fatalities (n=59). An earlier study by Maguire et al. involved a collation of events from multiple databases: the BLS CFOI, Fatality Analysis Reporting System (FARS), and National EMS Memorial Service database. Findings suggest that the rate of occupational fatalities among EMS workers may be more.",
        "Occupational injuries": "There are few studies exploring non-fatal injuries among EMS workers. A study by Reichard and colleagues identified an estimated 99,400 non-fatal injuries between 2003 and 2007 that were severe enough to be evaluated and treated in emergency departments. Based on standardized coding in the Occupational Injury and Illness Classification Manual (OIICS), 33% were linked to 'bodily exertion and exertion,' 21% to 'exposure to harmful substances or environments,' and 18% to 'contact with objects and equipment.' The most common non-fatal injury diagnoses were sprain/strain (38%), contusion/abrasion (17%), and laceration/puncture (14%). The neck and back were the most commonly cited body parts affected by non-fatal injury (31%), suggesting that lifting and moving patients and/or equipment are common causes of injury.\n\nResearch by Suyama and colleagues examined worker compensation reports for three public safety bureaus (police, fire, and EMS) in a large urban area. The study determined that the absolute frequency of reported injuries was higher for police and fire compared to EMS. When adjusted for the size of the workforce, however, the rate of injuries that led to lost work time was highest among EMS workers.\n\nEmergency medical services workers face repeated exposure to bodily fluids, including blood, elevating their risk of infection and illness from human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV). Findings from a 2002 survey sample of 2,664 paramedics determined that the rate of any exposure to blood in past 12 months was 6 per 10,000 calls and 3.7 per 10,000 patients. Most exposures appear to involve intact skin and were attributed to the higher frequency of uncontrolled bleeding in the prehospital setting versus in-hospital.\n\nThere is a high probability that a violent patient will injure EMS workers. Corbett and colleagues determined that >60% of EMS workers in a southern California urban system were assaulted while on the job. A separate study by Mock and colleagues determined that EMS workers are exposed to at least one violent patient or event every 19 calls/patients. A more recent study by Grange and Corbett determined that while violent patients accounted for <9% of patient encounters, more than half (53%) involved violence (verbal or physical) against EMS workers. While it is widely known that EMS workers are often exposed to violence and violent patients, few EMS workers report receiving enough training to respond appropriately and safely.\n\nOne limitation of previous research is underreporting of injuries through the required or standard channels within organizations. As many as 32% of injuries go unreported to employers due to a complex set of factors, including but not limited to stigma associated with being injured, worker-perceived low injury severity, and other unknown factors. Anonymous reporting via survey research may reveal that the proportion of EMS workers injured while on duty is greater than that counted based on injuries reported to the emergency department, employer injury logs, or worker\u2019s compensation databases. Recent research by the University of Pittsburgh\u2019s EMS Agency Research Network (EMSARN) shows that a large proportion of EMS workers are injured during shiftwork. When asked to reflect on the previous 2 months, nearly half of EMS workers (45.8%) self-report injuries occurring during shifts. Injuries while lifting or moving patients were the most common injury type reported.\n\nAmbulance crashes are not an uncommon occurrence, with somewhere between 4% and 9% of all EMS providers having been involved in ambulance crashes. Drivers involved in ambulance crashes are at increased risk for additional ambulance crashes in the future. Half of drivers involved in crashes have been involved in multiple crashes. Risk of an accident is also increased for younger/inexperienced drivers and those reporting sleep problems. Ambulance crashes represented the greatest source of tort claims against EMS agencies in one analysis of a national insurance company, comprising 37% of all claims. Crashes are also the leading cause of fatal injury.\n\nThere are few published studies that focus specifically on injuries incurred during EMS transport. Available data suggest that ambulance crashes occur in both emergency and non-emergency modes of transport. Becker et al. examined ten years of data from two national databases: the FARS registry and the General Estimates System (GES). The analysis from this national dataset included a comparison of EMS, fire, and police crashes. EMS crashes represented the highest proportion of crashes where emergency vehicle operators were killed or injured. Becker et al. also noted that restrained occupants were significantly less likely to be killed or seriously injured in ambulance crashes when compared to unrestrained occupants. This is consistent with findings from Kahn et al. Authors noted that improperly restrained occupants were 2.5 times as likely as unrestrained occupants to sustain serious or fatal injuries, and that serious or fatal injuries were nearly three times more likely to occur in the rear compartment compared to the front. Few EMS workers report wearing seat belts while providing care in the rear compartment of the ambulance, and providers report the need to be unrestrained in order to perform patient care tasks. Seat belt behavior may be modifiable with EMS agency policy intervention.\n\nOne method of mitigating the risk associated with ambulance response and transport is the use of 'drivecams' or onboard event recorders. These recorders are activated when the vehicle exceeds preset G-force limits. One large EMS agency conducted a prospective study, outfitting its fleet of 54 vehicles with onboard event recorders and observing the changes in driving behavior over time. They noted that the proportion of activations per mile and activations per response steadily decreased over time. The installation of these devices may influence providers to adopt more conservative driving behaviors.\n\nBrice and associates published a comprehensive report on the proceedings of a conference of ambulance safety experts. The authors implemented a Haddon matrix to conceptualize the problem of safety during ambulance transport and propose actionable solutions. A central tenet of several proposed solutions is the fostering of a culture of safety within the EMS agency.\n\nEmergency medical services worker injuries have been linked to poorer perceptions of workplace safety culture. Workplace safety culture refers to the aggregated beliefs that EMS workers create through their work and exposure to the safety conditions, policies, and practices within their EMS agency. Common domains of EMS workplace safety culture include safety climate, teamwork climate, perceptions of management, working conditions, stress recognition, and job satisfaction. There are few studies of EMS workplace safety culture. Recent research by EMSARN linked a higher number of EMS workers reporting recent injuries to lower (poorer) scores on five of six domains of safety culture. This association suggests that worker injuries are more common in EMS agencies where EMS workers perceive safety conditions as poor or 'less positive.'",
        "Injury prevention": "A large proportion of non-fatal EMS injuries are musculoskeletal and associated with lifting and moving patients or equipment. Carrying equipment and patients over long distances is Part of the daily occupational tasks of the prehospital provider. In spite of ergonomic improvements in patient movement devices, physical force must be applied to move patients in the course of prehospital care. Musculoskeletal injuries, including back injuries, hinder the job performance of EMS providers. To prevent back injury, it is essential for the prehospital provider to have adequate strength and flexibility. The core muscles of the hip and torso contain an individual\u2019s center of gravity and initiate movement. The muscles that attach to the core provide proximal stability for efficient upper and lower extremity movements. Activation of trunk musculature precedes any upper or lower limb movements and compensatory changes in trunk muscle recruitment have been demonstrated in people with low back pain.\n\nAdequate hip flexibility is also another important key for prevention of low back injuries. Tightness of the hip musculature can lead to reciprocal inhibition of the core musculature. For example, a tight iliopsoas (an important muscle for sagittal plane hip function) can lead to reciprocal inhibition of the gluteus maximus, transversus abdominis, internal abdominal oblique, and multifidus muscles. All of these muscles play important roles in spinal stabilization in the sagittal and transverse planes.\n\nImproving the biomechanics of patient movement has received considerable attention in recent years. One research group used an ecological model of musculoskeletal injuries in the fire service to identify targets for ergonomic interventions for moving and lifting. Focus groups were conducted with 25 firefighter/paramedics from 13 suburban fire departments. The participants identified lateral transfers, bed-to-stairchair transfers, and stair descent transport as areas needing improved technology. A separate study by the same group reported that a simple strap placed around the feet of the patient being transported down stairs while strapped to a long spine board reduced the strain on the EMS providers carrying the patient. Although more expensive, descending control devices, which alter a movement from a carrying-type configuration to a push-pull configuration, also reduce muscular activation and could reduce injury. Interventions for reducing muscle activation and strain during lateral transfers have been less successful.\n\nAmbulance stretchers have evolved over time from models requiring the providers to lift the stretcher from the ground to the ambulance deck to those requiring the provider to lift only the wheel carriage to fully powered stretchers that demand virtually no lifting. While there is a growing literature documenting a reduction in injuries after implementing mechanical patient movement devices in the hospital, little is known about the role of these devices for EMS workers. One study conducted in a large urban EMS system examined the rate of injuries before and after placing electrically powered patient stretchers on every ambulance in the system. The incidence rates for overall injury before and after the intervention were 61.1 and 28.8 per 100 FTE with a corresponding risk reduction of 0.47 (95% confidence interval (CI) 0.41\u20130.55) [33]. The subcategory of stretcher-related injuries had the lowest risk reduction (0.30; 95% CI 0.17\u20130.52) when comparing pre- and postintervention time periods.",
        "Comparing studies": "Few studies have been performed using directly comparable datasets, denominators, numerators, and methodologies. For this reason, there remains a great deal of uncertainty about the true magnitude of fatal and non-fatal injury rates and risks for EMS workers. Much of this uncertainty can be attributed to variation in the methods and data used to quantify fatal and/or non-fatal injuries, and it is worth highlighting for the benefit of medical directors charged with monitoring these data in their own systems. There are multiple appropriate methods by which to estimate rates. Subtle differences in the method used to calculate the rate can lead to substantial differences in the final estimate. One example could be differences in the selection of the denominator for an incidence density calculation. It is critical to report this information in full, and be mindful of the decision made by authors when evaluating and comparing relevant literature. The true rate of fatal and non-fatal injuries among EMS workers is undetermined due in part to the lack of a uniform database of EMS workers. Differences in data collection threaten confidence in the ability to aggregate data and accuracy in statistics.\n\nIn the broadest sense, an injury rate is calculated in the following fashion. The numerator is the number of events in a population for a given time period. The denominator is the number of people in the population at risk during the time period. The denominator of employed and volunteer EMS workers is poorly documented, as is often true with large and dynamic populations. Estimates of EMS workers in the US range from between 800,000 and 1 million.\n\nIn this chapter, we cite two studies that examine fatal and non-fatal injuries among EMS workers. Investigators in one study defined their population for determining non-fatal injuries as 'EMTs employed in the private sector with injuries resulting in at least one day of lost work time,' and for fatal injuries as 'private sector and government-employed EMTs.' Investigators of the separate study included compensated and volunteer EMTs, ambulance drivers and attendants, while excluding military workers. Investigators also included injuries among firefighters if it was documented that the firefighter was performing EMS duties at the time of the injury (e.g. patient transport/rescue). Differences in denominators and identification of numerators result in differences between seemingly similar studies involving similar worker populations. Differences in rates may then be misinterpreted as one workplace, agency, region, or other defined area having a much higher or lower rate of injuries or fatalities.\n\nEmergency medical services systems should have mechanisms in place to capture all injuries to workers within the system. Using the cumulative incidence rate (number of injuries per period of time divided by the number of workers at beginning of time period), the system can calculate the risk of individual EMS worker sustaining an injury over a given period of time and determine if that rate meets internal and external benchmarks. A uniform, centralized national reporting system has been proposed and would be very useful in refining the estimates of the risk of occupational injury in EMS."
    },
    {
        "Introduction": "The Emergency Medical Services Systems Act of 1973 was the first formal national initiative supporting and endorsing EMS in the United States. The Act defined 15 components of an EMS system, and this led to the development of the Department of Transportation's national standard curricula (NSC), in an attempt to standardize the training of prehospital personnel: the first responder, the emergency medical technician-ambulance (EMT-A, which evolved into the EMT-Basic in 1994), the EMT-Intermediate (1985, revised in 1999), and the EMT-Paramedic (1989, updated in 1999). These curricula essentially evolved from the existing practices of EMS providers in the 50 states. It was not until 2005, almost ten years after the publication of the Emergency Medical Services Agenda for the Future in 1996, that an educationally sound, scientifically based scope of practice process was implemented. The EMS Education Agenda for the Future: A Systems Approach was released in 2000 and called for the development of a system to support the education, certification, and licensure of entry-level EMS personnel that facilitates national consistency. The Educational Agenda is a vision for the future of EMS education, and a proposal for an improved structured system. To educate the next generation of EMS professionals, The Educational Agenda builds on the broad concepts from the 1996 Agenda to create a vision for an educational system that will result in improved efficiency for the national EMS education process. The system will enhance consistency, education, and quality and ultimately lead to greater entry level graduate competence. The Education Agenda proposed an EMS education system that consists of five integrated components: national EMS core content, National EMS Scope of Practice Model, national EMS education standards, national EMS certification, and national EMS education program accreditation. In 2004, the national EMS core content was released and defined the complete domain of out-of-hospital care. In 2005, the National EMS Scope of Practice Model divided the core content into four 'levels' of practice, defining the minimum corresponding skills and knowledge for each level of EMS provider, and established four levels: emergency medical responder (EMR), emergency medical technician (EMT), advanced emergency medical technician (AEMT), and the paramedic. Each level represents a unique role, set of skills, and knowledge base for which the National EMS Education Standards define educational content. The Education Standards define the minimal terminal objectives for entry-level EMS personnel to achieve within the parameters outlined in the National EMS Scope of Practice Model. Although educational programs must adhere to the Standards, its format allows for diverse implementation methods to meet local needs and evolving educational practices. The above five integrated components are intended to establish an educational system that, when fully implemented, provides the foundation to ensure the competency of out-of-hospital EMS personnel in a way that parallels other allied health care disciplines, as well as consistency from state to state. Note that the evolution and establishment of subspecialty recognition for EMS physicians intentionally and explicitly built on the same general structure. A survey published in November 2011 noted that there were 826,111 credentialed out-of-hospital care personnel in the United States. Until recently, there has not been a national system to aid states in the evolution of their EMS personnel scopes of practice and licensure. In 1996, there were at least 40 different levels of EMS personnel certification in the United States, with, for example, a number of different 'EMT-Intermediate' definitions and scopes of practice used by various states, many of which did not match either the 1985 or the 1999 NSC. This diversity and patchwork of EMS personnel licensure and certification created several problems, including public confusion, reciprocity challenges, limited professional mobility, and decreased efficiency due to duplication of effort. The National EMS Scope of Practice Model supports a system of licensure that can be recognized across all states, establishes a platform for reciprocity, allows for professional mobility, and reduces public confusion.",
        "Scope of practice is a legal description": "Scope of practice is a legal description of the distinction between licensed health care personnel and the lay public, and also among different licensed health care professionals, creating either exclusive or overlapping domains of practice. It describes the authority, vested by a state, in licensed individuals practicing within that state. Scope of practice establishes which activities and procedures represent illegal activity if performed without licensure. Scope of practice does not define a standard of care, nor does it define what should be done in a given situation; it is not a practice guideline or protocol. It defines what is legally permitted to be done by some or all of the licensed individuals at that level, not what must be done. Typically, scope of practice refers to the tasks and roles that licensed personnel are legally authorized to perform. In general, it does not describe the requisite knowledge necessary to perform those tasks and roles competently. As outlined in the EMS Education Agenda for the Future, the major responsibility for determining the knowledge necessary to safely perform tasks and roles falls to educators. The authors of the National EMS Scope of Practice Model offer a schema to provide guidance on the presumed depth and breadth of cognitive material envisioned for each level of EMS licensure. The interfacility realm of EMS is an expanding domain in which EMS providers play an ever-increasing role. With interfacility transfers of critically ill patients going from primary to tertiary care facilities, there is a need in some EMS systems to establish the core foundation of education, medical oversight, demonstration of competence, and licensure authorization for paramedics to participate in this interfacility critical care practice. The current National EMS Scope of Practice Model provides the floor capabilities for all paramedics, but does not specifically address this specialized domain. In some cases, specialty certifications may be used to respond to local needs for flexibility or to recognize continuing education. Specialty certifications may evolve to accommodate subtle differences in skills, practice environments (e.g. tactical EMS, wilderness EMS), knowledge, qualifications, services provided, needs, risks, level of supervisory responsibility, and amount of autonomy, judgment, critical thinking, or decision making. Although it is beyond the purview of the National EMS Scope of Practice Model to define the wide array of possible specialty certificates that may exist now or in the future, some states are venturing into the realm of establishing one or more 'specialty care' levels for the paramedic with additional training. A national model for this scope of practice has not been clearly defined, and currently the need is being addressed on a state-by-state basis.",
        "Regulation of EMS personnel": "Emergency medical services personnel are expected to care for patients who often have ambiguous and conflicting complexes of signs and symptoms, and are permitted to perform interventions and administer medications that can do considerable harm to patients if performed improperly or inappropriately. EMS personnel are also afforded a significant amount of public trust and are given access to a patient's property and person in a virtually unsupervised environment. Ensuring the competence and trustworthiness of EMS professionals is thus of paramount importance to ensuring public safety and welfare. \n\nIntellectually, we want to limit credentialing to individuals who can demonstrate the ability to provide safe and effective out-of-hospital care. Practically, it is a more complicated issue to ensure fairness when making credentialing decisions. In this context, it is valuable to remember the greater good. The desire to be an EMT or paramedic is simply not enough, and society as a whole is best served when those who cannot perform competently are denied the privilege of providing pre-hospital care. Herein is the premise for the credentialing of EMS personnel.",
        "Regulation of EMS personnel - Occupational regulation": "The provision of health care services is deemed a high-risk activity and is therefore highly regulated. In general, regulation is a \u201cstates\u2019 right\u201d because the US Constitution does not specifically identify a role for the federal government. There are a few exceptions (for example, aviation and over-the-road trucking) in which the federal government has a role in occupational regulation. Therefore, each state has the responsibility and authority for regulation that protects the health, safety, and welfare of its citizens. A state may regulate an activity without regard to the actions of other states. For this reason, virtually all licenses are issued by state governments (e.g. a driver's license, medical license, beautician's license, or hunting license). In our increasingly mobile society, professional mobility, reciprocity, and recognition of other states' licenses have become a considerable issue and placed pressure on states to adopt similar or nearly uniform regulatory infrastructures; however, the authority and responsibility for most regulation lie at the state level of government. There is a substantial body of literature on the theory and practice of regulation. It is beyond the scope of this text to cover the discipline in its entirety; instead, this chapter will describe basic principles and forms of regulating occupational groups in general, as well as the current and future of the credentialing of EMS personnel. Fundamentally, the purpose of occupational regulation is to protect the public. According to Schmitt and Shimberg, occupational regulation is intended to ensure that the public is protected from unscrupulous, incompetent, and unethical practitioners; offer some reasonable assurance to the public that the regulated individual is competent to provide certain services in a safe and effective manner; and provide a means by which individuals who fail to comply with the profession's standards can be disciplined, including revocation of the right to practice. As a secondary benefit, regulation also creates a mechanism for raising the standards of practice, ensuring quality of service, setting codes of ethical behavior, and disciplining for fraudulent, incompetent, and unethical behavior. Fundamentally, the only defensible justification for occupational regulation is public protection. This is a point often misunderstood by occupational groups that occasionally seek regulation as a way to elevate the social status of the group or to restrict competition.",
        "Regulating health care professions": "The regulation of health care professionals often involves complementary governmental and non-governmental credentialing activities that occur at the national, state, and local levels.",
        "Regulating health care professions - Regulatory options": "Licensure is the process by which a governmental agency grants time-limited permission to an individual to engage in a given activity or occupation after verifying that he/she has met predetermined and standardized criteria. Licensure is a mandatory process in that it is illegal to engage in an activity without the license. The licensure process also makes it illegal for an individual to present himself to the public as a qualified individual if he does not possess the credential (known as title protection). Licensure offers the greatest form of public protection and is consequently the most restrictive form of professional credentialing. Licensure extends from a state\u2019s police powers and involves granting legal authority to practice a profession within a designated scope of practice. Under the licensure system, states define, by statute, the tasks and function or scope of practice of a profession and provide that these tasks may legally be performed only by those who are licensed. As such, licensure prohibits anyone from practicing a profession who is not licensed. Licensing laws typically are referred to as \u201cpractice acts\u201d and define what aspects of the practice are legally regulated. Generally, the responsibility for the oversight of licensed professions resides in a regulatory board or a state administrative official. Certification is the process by which an agency grants a time-limited recognition and use of a credential to an individual after verifying that he/she has met predetermined and standardized criteria. In general, certification is used for one of two purposes. 1 A mechanism to identify specialty training and competence (e.g. CCRN, CEN) among already licensed individuals. 2 The competency assurance part of a state licensing process (e.g. CRNP, PA-C). Certification affirms a knowledge and experience base for practitioners in a particular field, their employers, and the public at large. Certification represents a declaration of an individual\u2019s competence in a specific area of professional competence, and can be performed by governmental entities (statutory certification) and private certification agencies (non-governmental certification). Statutory certification is a government-sponsored form of credentialing that is less restrictive than licensure. Statutory certification provides government with a regulatory option when an activity is not prohibited by law. For example, in many states there is no legal requirement that school teachers be certified; however, most teachers have undergone a governmental (state Department of Education) sponsored credentialing process that enables them to present themselves to the marketplace as \u201ccertified.\u201d Obviously, most school districts seek to hire certified teachers and may have local policies regarding the hiring of only certified teachers, but they are not prohibited from using uncertified teachers. Although they carry no legal weight, private certifications play an important role in professional regulation. Certifications issued by a private organization identify individuals who have successfully completed the certification process (usually entailing successful completion of experiential, educational, and testing requirements) and demonstrated their ability to perform their profession competently. Many professions use private certifications as either preservice or postservice requirements. Perhaps the most sophisticated system of postservice certification is in the medical profession, where board certification serves as an important complement to the medical license. The United States Medical Licensing Exam (USMLE) assesses a physician\u2019s ability to apply basic knowledge, concepts, and principles, and to demonstrate fundamental patient-centered skills that are important in health and disease and that constitute the basis of safe and effective patient care at the entry level. States require USMLE certification as part of the licensure process for physicians. Specialty board certification is used to identify physicians with specialty training. Specialty certification carries no legal permission to practice medicine or perform an otherwise restricted activity. For example, a physician can legally perform an operation in any state in which he or she is licensed, regardless of whether he or she is certified by the American Board of Surgery. Certification is an important complement to the medical license, because most hospitals will not permit physicians who are not board certified (or at least board eligible) to practice within their facility. A few professions (e.g. advanced practice nurses and physician assistants) have incorporated national certification as part of the state licensure process. In these professions, national certification ensures a consistent definition of entry-level competence and establishes eligibility and continued competency requirements. These are the most closely analogous systems to the role that national certification is given by most states in EMS. As mentioned earlier, regulatory terminology is often misused, even in state statutes, rules, and regulations. Due to the imprecision of the vocabulary, the courts tend to look at the structural elements of regulation, rather than its title. The distinction between certification and licensure does not depend on the \u201cindependence\u201d of practice, but rather on the legal authority to perform regulated tasks or roles. Fundamentally, when government vests certain individuals with legal permission to perform some act (function as an EMT or paramedic) that without said permission is illegal, it carries the legal effect of licensure. Following this logic, in the eyes of the judicial system, EMS personnel are licensed in every state. Unfortunately, confusion between the terms certification, licensure, and registration is common in EMS. Some states refer to their EMS licensure process as \u201ccertification.\u201d In every state, however, it is illegal to function as an EMS professional without governmentally issued permission to do so. Consequently, the proper term for the state governmentally issued EMS credentialing is \u201clicensure,\u201d regardless of what it may be labeled.",
        "Regulating health care professions - Occupational regulation": "The oversight of the licensure of health care professions is generally accomplished in one of two ways: by a regulatory board or as an administrative governmental function (typically within a state\u2019s Department of Health). Both have advantages and disadvantages, with independent regulatory boards more commonly used in medicine and nursing and governmentally administered oversight functions more common in EMS. Members of regulatory boards and administrative officials owe a duty of loyalty to the individuals served by licensees, not to licensees or to the profession regulated. It is thus the fundamental responsibility of the regulatory infrastructure to ensure that every licensee in a jurisdiction is and remains competent, and advocacy on behalf of individuals or the profession represents a conflict of interest. One of the ways in which regulatory boards remain vigilant on their primary responsibility is to include public members. Public members are able to more fully represent the interests of the consumer and often identify conflicts of interest that are difficult for members of the profession to recognize. The Pew Commission Taskforce on Healthcare Workforce Regulation recommends that professional boards should have at least one-third public representation.",
        "The regulation of EMS personnel": "Emergency medical services is a high-risk activity. EMS personnel treat millions of patients in one of the most challenging, uncontrolled, and unsupervised environments in all of medicine. The decisions they make have a significant effect on the health and safety of the patients they treat. Clearly, the competence of EMS personnel is a major public safety concern. Regulation of EMS personnel presents a number of challenges. There is a pervasive notion in the EMS community that \u201cEMS is different\u201d from other professions. Although important differences do exist, to be accountable to the public that we serve, the EMS profession should be regulated in a manner similar to, and just as rigorous as, other health care occupations. It does not matter if an individual is paid or volunteers, or practices in an urban or rural environment; incompetence represents a significant risk to the public. In many respects, the EMS profession is fragmented and tends toward a provincial perspective. This creates some additional regulatory challenges. First, some state EMS regulatory systems seem to operate in relative isolation and without regard to other states\u2019 regulation, frequently citing the uniqueness of the EMS environment in \u201cour state.\u201d Until quite recently, there has been little national consistency in the occupational titling of EMS personnel and the scopes of practice of various levels of EMS personnel vary, sometime considerably, from one state to another. For systems as complex, diverse, and decentralized as EMS agencies, multiple supportive layers of oversight help to ensure public protection. The EMS Education Agenda for the Future proposes three overlapping layers of regulation: national certification, state licensure, and local credentialing. Together, these three overlapping layers are complementary and form a comprehensive approach to ensuring patient safety. None obviates the need for the other two. The best systems work hard to ensure that all three are strong and work together in an integrated system of checks and balances.",
        "National EMS certification": "In 2000, the EMS Education Agenda for the Future recommended that a single certification agency be used to assess the competence of all EMS personnel nationwide. In 2006, the Institute of Medicine concurred with this recommendation and also recommended that \u201cstates accept national certification as a prerequisite for state licensure and local credentialing of emergency medical services providers.\u201d The task force that authored the EMS Education Agenda for the Future believed that there is a single definable level of minimum competency for each level of EMS credentialing and that only those able to demonstrate ability at or above that level should be permitted to carry the title of an EMS professional. The competency standard should not change by state, demographics, geography, rurality, agency type, or remuneration status of the individual being assessed. As the EMS community strives for more national unity, consistency, and integration, the EMS Education Agenda for the Future emphasizes the need for a single national EMS certification agency as essential. National certification ensures that all EMS professionals have demonstrated the same degree of competence, and licensure is the mechanism by which to implement state level statutory or regulatory requirements. The National Registry of EMTs is currently part of the licensure process in 47 states. In these states, national certification serves to verify entry-level competency of licensees. In the remaining states, local exams are used. It is important to note that even if required by the state credentialing entity, national certification, by itself, does not give an individual the right to practice; this is the role of state licensure. Although the National Registry of EMTs offers a recertification process, it is currently used in only 13 states.",
        "State licensure": "As discussed earlier in this chapter, the state bears the authority and responsibility to issue licenses. The oversight of the licensure process can be accomplished through a regulatory board or as an administrative function. In either case, the oversight is involved in a variety of activities related to the licensure of the individuals providing prehospital care. These can broadly be classified as rule making, initial competency assessment, entrance requirements, assuring continued competence, and discipline. Each responsibility is described below.",
        "Rule-making": "Some states have EMS practice acts that are very similar to those of other health professions, whereas others use different forms of legislation to enable the regulation of EMS in that state. In any case, some entity (regulatory board or administrative official) is granted the legal responsibility for oversight of EMS within the state. Legislation is usually general in nature and requires a group of EMS experts to develop rules and regulations that make the general statute more specific and measurable. The regulatory entity may not change or alter the law but has the responsibility to interpret and implement it. Additionally, the regulatory entity is often in the position of commenting on proposed legislation affecting the profession and recommending changes to statute as the profession evolves.",
        "Assessment of initial competence": "Emergency medical services, like most professions, requires that new applicants demonstrate knowledge and/or skill prior to the issuance of a license to practice. In order to be credible, the certification examination must be \u201cpsychometrically sound and legally defensible.\u201d According to Pope, the majority of legal challenges of exams are related to one of four areas: reliability, validity, fairness, and the passing standard. Reliability is a measure of how consistently the test measures the latent variable that is being assessed. Validity (in this context) refers to whether the test is measuring what it intends to measure. A fair test measures only the construct it was designed to measure, with no systematic advantage or disadvantage given to a demographic group or subpopulation. The passing standard is the methodology used to determine whether a candidate has demonstrated an appropriate level of knowledge or skill on the test.",
        "Establishment of entrance requirements": "Although theoretically possible, it is impractical to create tests and examinations that measure every aspect of professional competency. As a result, many states have entry requirements beyond simply passing. Educational and/or experiential requirements may be imposed to ensure that applicants have the necessary practical experience to justify the issuance of the credential. Entrance requirements may be imposed to ensure the safety of patients (for example, criminal background checks, history of drug abuse, age requirements, etc.). To withstand challenge, entrance requirements must bear a reasonable relationship to entry-level practice.",
        "Ensuring continued competence": "In addition to initial competency assessment, regulatory entities are increasingly expected to ensure the continued competence of licensed practitioners. Historically, this has been accomplished by requiring continuing professional education and \u201clife-long learning.\u201d Although these have numerous benefits, the accumulation of an arbitrary number of continuing education credits does not guarantee competence. The Pew Commission Taskforce of Healthcare Workforce Regulation recommends that \u201cstates should require that their regulated healthcare practitioners demonstrate their competence in knowledge, judgment, technical skills, and interpersonal skills relevant to their jobs throughout their career.\u201d Most regulatory authorities are still struggling with the practical, political, and economic challenges of ensuring continued competency.",
        "Discipline": "A major role of regulatory entities is the adjudication of allegations of professional misbehavior or incompetence. According to Roman, the purpose of disciplinary action \u201cis not merely to protect the public \u2026 but also to maintain high professional standards, and thereby, public confidence in the \u2026 profession.\u201d Therefore, it is imperative that regulatory entities take seriously their obligation to address professional misconduct. Disciplinary options include revocation, suspension, fines, consent orders, restitution, and reprimand.",
        "Local credentialing": "Emergency medical services personnel are not independent practitioners. In all states, EMS personnel function as part of an affiliation with an authorized EMS agency. Although some state variation exists, most states require a medical director to assume responsibility for the medical oversight and quality assurance of each EMS professional\u2019s practice. Therefore, EMS personnel provide services as agents of local EMS agencies. National certification and state licensure define the pool from which EMS agencies select their employees or volunteers. Local credentialing refers to the entire process by which an EMS agency permits an individual EMS professional to serve as its agent and is performed by local EMS leadership and medical directors. Local credentialing is perhaps the most important of the layers of protection, in that it offers the greatest opportunity for the direct and ongoing assessment of competence. EMS leaders and medical directors can be reasonably assured that applicants who possess national and state credentials have demonstrated entry-level competence in the cognitive and psychomotor domains, and have met statutorily required entry requirements and background checks. However, professional competency involves much more than can be assessed through the national and state credentialing processes. It is the responsibility of local EMS leadership to ensure that EMS personnel have and maintain competence in the non-technical aspects of EMS care. It is virtually impossible for national and state credentialing to reliably evaluate interpersonal skills, communication skills, honesty, integrity, the ability to work as part of a team, careful delivery of service, and commitment to patient care and quality improvement. In addition, some skills that are important parts of the job of an EMS professional are not evaluated as part of the national or state credentialing process. These include emergency vehicle operations and rescue activities that may be part of some EMS agencies\u2019 expectations for their employees or volunteers. Finally, local credentialing provides the mechanism for EMS agencies to ensure that EMS personnel are competent in agency-based medical and operational protocols. In general, local credentialing activities can be viewed as administrative, operational, and medical, and some overlap exists. Administrative activities include the application, selection, and hiring processes, new member orientation, supervision, agency-based continuing education requirements, continuous quality improvement, and various administrative policies (for example, uniform, appearance, and attendance). Operational activities include incident reporting, vehicle operations, staffing and crew configuration, deployment, and response. Medical activities include procedures, protocols, medical quality assurance, and precepting. Most states require that a licensed physician provide leadership over the medical aspects of EMS operations. The medical and administrative leaders of EMS agencies share the responsibility for the local credentialing of EMS personnel. For legal defensibility, it is extremely important to follow all policies and procedures and keep careful records regarding all credentialing activities.",
        "Summary: the synergy of three layers of public protection": "In summary, the National Registry of EMTs serves as the de facto national EMS certification agency. National certification is a distinct process separate from licensure \u2013 it identifies those individuals who have demonstrated the national entry-level standard for cognitive and psychomotor competence. State EMS offices (or regulatory boards) serve as the state licensing agencies. State licensure ensures that the applicant demonstrates any additional elements of competency as required by the state, meets educational and experiential requirements, and passes generally required background checks. Local credentialing is the ongoing process of ensuring that an individual demonstrates and maintains all aspects of professional competency. These three layers are complementary and together form a system of checks and balances intended to maximize the probability of safe and effective prehospital care."
    },
    {
        "Introduction": "The emergence and maturation of the specialty of emergency medicine has spawned and nurtured the development of EMS. In turn, EMS has become a subspecialty of its own, attracting a subset of emergency and acute care physicians whose focus of technical expertise and clinical acumen has been directed to the provision of care from the moment of system access to the arrival of the patient at the emergency department. The original EMS medical directors were those individuals fascinated by the possibility of extending 'sophisticated' methodology to the patient at the scene. Equally intriguing to them was the opportunity to provide this technical sophistication using individuals operating under the broad-based concept of 'extension' of the physician. Not surprisingly, and by the very nature of EMS itself, those physicians attracted to this subspecialty of emergency medicine were captivated by the eclectic and unique attributes of medical practice in this complex arena. They were soon faced, however, with daunting challenges concerning their own creativity in an equally complex arena, the political one. The multiple interfaces required of the medical director, within and outside the medical community, have created an especially challenging section of emergency medicine practice, where technical expertise by itself proved insufficient in creating a workable system. While the magnitude of this challenge is attractive for some physicians, the emotional energy required and the intense, continuous interaction in the political arena may cause an abbreviated career for even the most innately passionate physicians. As with most areas of medicine, if not life itself, an 'apprenticeship' is the means of conveying a 'practice' from veteran to neophyte. The growth and development of training programs in emergency medicine, while initially tentative in developing 'fellowships' in EMS, have now witnessed substantive progress. In turn, this has hastened the exposure of young physicians to the political realities incident to EMS system development and sustenance. While there are numerous structures within which the medical director may work (full-time academic; full-time public safety with academic affiliation; part-time volunteer), none guarantees success. The skillful political behavior of the physician in his or her role ultimately determines the success of system function, and may even alter the administrative structure within which the physician resides. Politics and economics are omnipresent forces with which the medical director must work as he or she attempts to craft and manage an EMS system. These 'forces' are usually not familiar, understood, nor embraced by individuals who originally entered the field of medicine in pursuit of the satisfaction derived from patient care. Many opportunities for frustration and disappointment thus await the unwary and idealistic physician who fails to acknowledge these forces, or is unable to master their elements. Similarly, those physicians who appreciate the 'leverage' to be gained from an understanding of politics and economics will be rewarded by the growth and development of their systems. Some thoughts and perspectives are herein shared with the interested reader to enable a means of creatively employing these forces for the ultimate benefit of the patient, and the community. For most physicians, the difficulty, indeed the resistance to comprehending the political climate in which EMS activities are crafted is deeply seated. How many physicians entered medicine because of a love of politics and economics? These are not motivating factors frequently identified by anyone in medicine. In addition, few individuals can provide an apprenticeship for the aspiring medical director that addresses the political realities requiring mastery. Residency programs are now committed to providing a formalized experience in EMS. Still, the attempted metamorphosis of the clinician into a political 'statesperson' is far more complex and arduous than the acquisition of technical expertise in the field. Further, the frequently misperceived position of physicians as 'superior' to other members of the health care team seduces them into behaving as such with non-medical individuals, with predictable and disastrous results. Political acumen, if not prowess, must be forged slowly, over time, and with a mentor (an \u201cObi-Wan Kenobi\u201d of sorts) who nurtures the individual physician. The disaffection for politics found inherently in most health care providers arises perhaps from the physician\u2019s affiliation with the precepts of the \u201ccraftsman.\u201d As one of four \u201ccorporate types\u201d defined by Maccoby in his seminal book, The Gamesman, the craftsman experiences perhaps the greatest disparity between the reality and the ideal. It is most difficult for this individual to juxtapose the desired medical goals of a \u201cperfect\u201d EMS system with the political realities found in any community. Friction between value systems surfaces. For most, the emotional cost produced by this paradigm discordance is high, and for some it is too great to sustain a career of permanence in this aspect of practice of emergency medicine. In the pursuit of quality, however, the craftsperson is handicapped by the lack of a definition easily communicated to the political veterans in the community. Quality, as with style, class, poise, and pornography, tend to be attributes of human behavior which are recognizable but poorly articulated. Political awareness is not usually found embedded in the \u201cgenetic code\u201d of the health care practitioner. At most, it remains a dormant gene which needs to be \u201cturned on.\u201d While many definitions of politics abound, it is based, practically speaking, on an attempt to engender, gather, manufacture, or express consensus. The relationship to the technically \u201cideal\u201d system, at best, is viewed as oblique, from the perspective of the scientifically forged physician. The genesis of EMS systems is not founded on logic and rationality. These attributes are not legal tender in the political community. He who possesses the power or the money, and who \u201csleeps\u201d with whom, are more often the determining factors. While the medical director may desire an arena devoid of political influences, this is as impossible to achieve as eliminating the vagaries of human behavior itself.",
        "Preparing yourself": "Goals of the organization, and the individual, require the achievement of excellence in five spheres: academic, operational, administrative, clinical, and community relations. The target audience of the medical director should be defined in the broadest possible context: that of other health care providers, citizens, and every other \u201ccustomer\u201d whom the medical director and his or her agency touch. Understand the concept of \u201cpolitical Darwinism\u201d: the political and economic topography define \u201creality.\u201d As the topography changes, you must adapt or perish; in other words, \u201cmutate or die.\u201d The individual who can seize upon innovative management and communication styles, and who is alert to changes in the \u201cbig picture,\u201d is able to adapt the needs of his/her agency to the vicissitudes of politics. Always keep reality squarely in your sights. Sadly, Darwinism is not pretty. Distinguish between a politician and one who is \u201cpolitical.\u201d A politician is loyal to his constituency. A medical director is free to be loyal to the principles of sound clinical practice. The director\u2019s demonstrated \u201cawareness\u201d of the political climate in which he must work does not impugn his motives, however; nor should he be an apologist for his insight. Systems evolve. The goal of system excellence will be well served, and the sanity of the medical director preserved, if she appreciates the glacial time frame within which change is accomplished. Perhaps the most for which any one individual can hope is to refine the system, in preparation for her successor to refine it still further. Yet another analogy is the \u201criver\u201d concept of individual efforts. Acute diversion of a river in one direction may beget spontaneous directional changes downstream for miles to come. Many, if not most of these distant changes are unforeseen. Nurture your colleagues. Patients and issues come and go. Long after your colleagues have forgotten the reason for your anger, they will recall the unpleasantness of the interaction. Expressed alternatively, friends may come and go, but enemies accumulate. Your colleagues outlast the issues and should be respected. Technical errors are more easily forgiven than those which are normative or behavioral. Strive to develop an ethical, emotional, and behavioral gyroscope within you. Like its physical counterpart in navigation, a similarly stable operational perspective will allow you to weather the buffeting vicissitudes of system change with constancy of purpose, enabling accurate tracking toward the goal you and our colleagues have identified. Attempt to create win-win solutions to problems. When this is impossible, ensure that both sides appreciate compromise. Be the source, and you become the force. Too often, the goal of the medical director is to become the power broker in the community. By striving to become the \u201csource\u201d (i.e. the consultative resource to whom people turn for guidance and problem resolution), the medical director soon becomes the force for change. Define quality in meaningful terms. Since the definition of quality is so elusive, choose those measurement parameters which are meaningful to the intended audience. Every transport of a patient is a political statement. Choose realistic mentors. Mentors who are great and flawed are more likely to be emulated than those who are perceived as great and perfect. The former are seen as \u201chuman,\u201d the latter are never able to reach the standard of the latter. Expressed alternatively, prescience is wisdom, omniscience is delusional. Choose mentors with the former skill. Observe why others fail. To be effective, you must have a good engine (innate talent), a good transmission (personality and communication skills), plenty of fuel in the tank (endurance), with a good set of windshield wipers to see where you\u2019re going. It also helps if you\u2019re on the most appropriate road. It\u2019s quite a waste to place a Ferrari on a jeep trail, and quite dangerous to run the jeep on the autobahn. When colleagues fail, observe the reasons. Develop a shared paradigm for your staff. Stress the provision of agency services with competence, compassion, class, creativity, credibility, connectivity, and collegiality. Strive to develop a demeanor and countenance which reflects an academic, intellectual, and collegial approach to solving problems. A special note of caution about bureaucracies is in order. Often, an adversary will remain camouflaged, if not silent and stealthy. While the remonstrative opponent is easy to identify if not to outmaneuver, the bureaucrat has proven more lethal to great ideas and system reform, if for no other reason than his resistance, persistence, and longevity. The bureaucracy will consume enormous amounts of energy on the part of the medical director. More reforms have been defeated in an attempt to navigate a bureaucratic quagmire than the withering verbal artillery of individual or collective opponents. Bureaucrats fundamentally perceive themselves as underappreciated, if not powerless. A bureaucrat, if provoked, can erect enormous obstacles, and subvert and condemn the most noble and meritorious ideas of the medical director, if only to demonstrate his power over the physician. Respect, acknowledgment, and interaction with the bureaucracy may not provide a dramatic victory but it will pave the way for one.",
        "Principles of action": "Unlike the provision of police or fire suppression services, EMS is inextricably tethered to hospital health care politics and economics. Every transport of a patient is thus a political and an economic statement. Institutional paranoia dictates that whoever controls ambulances controls the patients, and the revenue. Economically, ambulances thus become charged particles, to be gathered by some institutions and repelled by others, depending on their fiscal \u201cforce fields.\u201d Thus, stereotypically the trauma center may desire critically injured patients, regardless of insurance status (or despite the absence of third-party coverage), while the suburban community hospital may seek to avoid these patients in favor of the medically ill and third-party reimbursed clientele. Into this economic maelstrom is placed the medical director, for whom none of this fiscal agenda is inherently germane, but in which the service he is to provide exists. Is it any wonder that such an individual perceives the political and economic topography as foreign, if not hostile? To steer an academically neutral course becomes an ordeal that has daunted many. No wonder the physician advisor feels like a swash-buckling and heroic Harrison Ford slashing his way through the political and economic vegetation! To be effective in an arena which is inherently unfamiliar to the physician, a number of principles of action are herewith submitted. An understanding, if not a mastery of political judo is encouraged. As with its physical counterpart, the politically diminutive physician must understand the simple but effective maneuvers necessary to tumble opponents in the desired direction. The political agility of the medical director accrues from her allegiance to principles of medicine, and not to a political constituency or the egomaniacal forces of her opponent. With regard to adversaries, it is more effective to exploit their psychopathology than to persevere about it. Before pushing the first domino, know where the last one falls. Do not be tempted by the seductively easy \u201cwin,\u201d unless you are aware of all the political connections of your opponents. Better to be one who sets up the dominoes than the one who pushes them. Natural political forces will cause one to fall eventually. The wise medical director will have spent years establishing the desired direction in which they should fall, content that fate or circumstance will eventually tumble the first one. The movements of the chess game are instructive. The pawn, slowly moving ahead, can become as effective as any other \u201cchess piece.\u201d At any moment in time, the chessboard can be upset, moving all the pieces in different and unpredictable directions. For example, the regulatory bureaucracy may increase innovative torment for all or a new mayor may be elected. Public officials rapidly acquire a global perspective of each piece on the chessboard, as well. Like the professional tournament athlete, consistent performance over time will usually create substantial success. Covet identified problems. Complaints may be seen as \u201copportunities in drag.\u201d They permit creative manipulation of the system, and insight into behavioral issues which must be addressed. The medical director is a \u201cproblem solver,\u201d as much as any other single role he plays. Identify the relationships among people. The EMS system within the community is a complex political ecosystem, with myriad political connections among even the most far-flung members. A movement or alteration of the power at any end of the \u201cpond\u201d will move the \u201clily pads\u201d at the other by virtue of its \u201cripple effect.\u201d Become dispensable, but not openly so. As a wise physician administrator once demonstrated, place your finger in the middle of a glass of water. The finger represents your presence within the system or institution. Remove your finger. Notice the hole that is left. Learn to swim with the sharks. If bitten, do not bleed. Before recognizing another individual as a non-shark, ensure that you have witnessed docile behavior on more than one occasion. Rescue an injured swimmer with due regard for the external and internal reasons for his incapacity, lest you succumb during the effort. Periodically give a known shark a forceful punch in the nose to remind him that you have some power. Stage a crisis on your own terms. When a crisis looms, ensure that you orchestrate it to occur at such time that it will be optimal for you. For example, when funding for a poison center in the community was threatened by legislative inaction, the administrator notified the press that this clinical facility was about to lose an \u201c800\u201d line. This was timed for release shortly before Christmas, and coincident with public safety messages to parents concerning the potentially poisonous nature of Christmas foliage. The legislature quickly authorized the funding before recessing for the holidays for fear of constituent retribution at the next election. Be a political chameleon. It\u2019s helpful to have a full set of costumes to enable you to project a panoply of images, appropriate to the political moment. Identify all the stakeholders. Too frequently, only the patient is identified as the customer. Within any organization, however, internal and external customers must be satisfied. They are not necessarily direct supervisors of the medical director. Every individual within the system who must be satisfied, or at least acknowledged, should be identified, and never ignored. As expressed in the hallmark work In Search of Excellence, understand the business with which you are really engaged. The medical director is a choreographer of care. The challenge is to rise above the technical image of the physician as a provider of care to only a single patient. In providing the choreography for the entire system, one cares for thousands of people, and influences the well-being of people far beyond the limits of a single individual. This becomes one of the strongest motivating factors for the craftsman to continue the quest for system improvement. Project academic passion with political neutrality. In other words, craft the system to enable acknowledgment of and allegiance to medical imperatives while achieving political equanimity. Visible power is vulnerable power. The final decision maker enjoys the most ego gratification and the least potential for long-term survival. The individual who is invisible and informal in the use of power is most insulated from assault, but will not enjoy the adoration of the public or recognition from same. Strive for a position between these two extremes, to enable a \u201clow profile\u201d but with a somewhat formalized power base. Never satisfy a bureaucratic need completely. To do so will cause bureaucrats to forget you. Partial solutions enable an occasional reminder to the bureaucracy of your importance as a problem solver, and your inadequate funding. Control the key factors, but not all. For example, the medical director must retain the power to sign off the eligibility of each paramedic to sit for recertification. The power to \u201chire and fire\u201d is thus focused into an clinical arena, rather than a political one. Avoid the use of fear, embarrassment, anger, frustration, intimidation, and guilt. They are transparent and managerially myopic means of motivating behavior. They are also anti-academic, anti-intellectual, and anticollegial. Survival alone defines a certain success of design, and merits your respect. Individuals who have existed within a system for some time have evolved successful forms of political adaptation. Do not ignore what may appear to be conservative postures or clever camouflage. Remain vigilant, but not suspicious. The latter is an emotionally draining posture with which to confront life. Subject projects to the OREO analysis. Identify Opportunities Identify Resources Identify Expectations Identify Obstructions Linguistics are important. Develop and refine your language skills with the goal of achieving precision, brevity, and elegance. In particular, avoid public expressions of profanity at all costs (a recommendation of the Stoic philosopher Epictetus which remains as valuable as ever). There is nothing more compelling than genius presented with style, grace, and class. Cultivate this vision of self throughout your career.",
        "Sustaining the drive": "It is said in physics that all energy is devoted to overcoming friction and gravity. This is true of human behavior as well. The energy of the EMS system medical director is expended on overcoming the resistance (friction) of the status quo in order to move the system to higher performance and greater accountability. The gravitational forces of tradition and bureaucracy exert a profound influence to restrain new ideas. While there is no substitute for having the raw strength of merit, it is frequently, by itself, insufficient. Innovative tactics and strategies, coupled with endurance, prove more effective in the long term. It is perilously easy to impugn the motivations of adversaries. More durable is to approach each individual or group with a respect for their position and an understanding of why a particular position is held (we all have religion, but we worship at different altars). Publicity should be used advisedly, deliberately, and with due regard for the law of unintended consequences. The use of the media is worth mastering. As often as possible, give credit to others for the success of the system. Always strive to achieve medical imperatives with political equanimity. History belongs to the person of letters, the student of language, but most of all to the master of the synthesis. The individual who can amalgamate the various resources of the community, and weave a tapestry involving many threads, will be the individual who contributes the most to any system. Remember that institutions, professions, and communities are platforms for your creativity. Respect them, and ensure that they are used wisely. Each medical director must consider his or her own personal evolution. The goal should be to leverage your creativity at every opportunity. Assist not a limited population of patients, but an entire community. In the process, contribute to the knowledge base of the specialty and assist an entire nation. Key to this personal evolution is the need to become \u201cmore than a physician.\u201d To this end, medical directors should consider acquiring knowledge, skills, and abilities from other professions such as teaching and business, to augment their own innate talents. Such education may be acquired by either informal (apprenticeship) or formal (MBA acquisition) methods. Borrowing from other professions to augment the persuasive talents of the physician can be extremely powerful. Likewise, adding non-medical literature, such as the Harvard Business Review and the Wall Street Journal, will suggest a multitude of approaches which are effective in the non-medical venue of business and government, in which the medical director must forge her vision of the high-performance EMS system. System development and maturation are non-linear and anything but smooth. They do not follow the measured, predictable tempo of a Strauss waltz as much as that of a reggae rhythm. The EMS medical director must be a seasoned clinician (practice champion) who is able to move beyond the bedside and choreograph the system. It is important to appreciate that the choreographer need not be the best dancer, but must recognize those who are gifted with superior talent. Always have an exit strategy for yourself. The frustration of system choreography over the years may be lessened by identifying the myriad other venues in which your creativity can be expressed. Be substantive. Figureheads soon become hood ornaments, and the first to be sacrificed when the system crashes.",
        "Conclusion": "Though politics and economics may appear abrasive to the physician, they act as sand within the oyster, which produces the pearl. Remain professionally satisfied by performing meaningful work, identifying and placing yourself proximate to role models to emulate, keeping things eclectic and capturing a childhood fantasy on a daily basis. Most of all, identify your own vision of the medical director to enable each of the above. Finally, know when your effectiveness has waned, and your tenure is drawing to a close. A timely, gracious, and dignified exit will nullify the harshest critics, and establish your accomplishments in the institutional memory of EMS."
    },
    {
        "Introduction": "The term triage means to sort or select. EMS personnel and other health care providers use the principle of triage at different times for a variety of reasons during the provision of emergency care. Examples range from determining whether an injured patient needs the resources of a trauma center to identifying which emergency department patient needs to be placed in a treatment room first. During a mass casualty incident, triage decisions must be made more rapidly; EMS providers have less time to gather information and decide who to treat first. Further, the emphasis shifts during a mass casualty incident from ensuring the best possible outcome for each patient to ensuring the best possible outcomes for the greatest number of patients. Military organizations were the first to develop the concept of mass casualty triage and these concepts have been adopted for use in the civilian setting. Mass casualty triage occurs when there is more than one casualty and the available resources require a provider to initiate care for one patient over another. In a synthesis of available evidence, Frykberg found that during mass casualty incidents there is an almost linear relationship between overtriage and poor patient outcome. This finding indicates that the methods used to prioritize victims of a multicasualty event for treatment and transport may have a significant effect on patient outcome.",
        "Triage systems": "There are many triage schemes that are used around the world. In the United States, the decision of which triage system to use has typically been made at the local agency level. However, this could lead to poor interoperability in situations where multiple agencies must respond to the same incident and are using different triage systems. In an effort to correct for this issue and to encourage evidence-based practices, the Model Uniform Core Criteria (MUCC) were developed. The criteria lay out a list of minimum standards that triage systems should incorporate to ensure interoperability, and they identify the evidence that is available to support each criterion. In July 2013 the Federal Interagency Committee on EMS approved an implementation plan for establishing the MUCC as a national guideline. This document recommends that state and local EMS agencies use triage systems that comply with the MUCC, and allows for the use of federal funds for the transition. There has not been sufficient time since this plan was published to describe the results. Further, it is currently a transition period so each medical director and EMS physician should be familiar with all the mass casualty triage systems that may currently be in use. A review of existing triage systems was conducted by a multidisciplinary panel sponsored by the Centers for Disease Control and Prevention (CDC) prior to publication of the MUCC, and they identified nine existing mass casualty triage systems, including two pediatric-specific systems. These systems include Simple Triage and Rapid Treatment (START), JumpSTART, Homebush, Triage Sieve, Pediatric Triage Tape (PTT), CareFlight, Sacco Triage Method (STM), military triage, and the Italian CESIRA (Coscienza, Emorragie, Shock, Insufficienza respiratoria, Rottureossee, Altro) protocol. These systems have been described in detail in other works, and are relatively similar in that most use a four- or five-category scheme that is grounded on basic physiological criteria. A notable exception is the STM, which uses a proprietary computer-based algorithm to generate a numeric treatment priority score based on physiological criteria and available community resources. Several secondary triage tools, such as Secondary Assessment of Victim Endpoint (SAVE) triage and System of Risk Triage (SORT), also exist. These systems allow responders to further prioritize patients once they have been placed in the four or five groups.",
        "Triage categories": "The goal of mass casualty triage in the prehospital setting is to prioritize patients for treatment and/or transport. Most triage systems accomplish this by placing patients in one of five categories: immediate, delayed, minimal, dead, or expectant. Immediate casualties, designated by the color red, are those who need immediate medical attention due to an obvious threat to life or limb. Patients in this group can include those who are unresponsive or have altered mental status, respiratory distress, uncontrolled hemorrhage, amputations proximal to the elbow or knee, sucking chest wounds, unilateral absent breath sounds, cyanosis, or rapid weak pulses. Delayed casualties, designated by the color yellow, are those who are in need of definitive medical care but are not likely to decompensate rapidly if care is delayed. Examples of patients in this group include those with deep lacerations with controlled bleeding and good distal circulation, open fractures, abdominal injuries with stable vital signs, and head injuries with an intact airway. Minimal casualties are designated by the color green; these patients have self-limited injuries and can tolerate extended delays in treatment without increasing their risk of mortality. These patients have minor injuries such as abrasions, contusions, and small lacerations. Their vital signs are normal and stable, and while they require medical attention, it can be delayed for days if necessary without significant adverse effects. Dead casualties, designated by the color black, have no respirations following basic airway maneuvers. Expectant casualties, designated by the color gray, are still alive but have little or no chance for survival despite maximum therapy. Initially, resources should not be directed toward this group as they will be needed to care for patients who are more likely to survive. As the event progresses and resources become available, attempts should be made to resuscitate these casualties and/or provide them with comfort care. These five categories and specific color codes are recommended in the Model Uniform Core Criteria.",
        "SALT triage": "A CDC-sponsored expert panel used aspects of existing mass casualty triage systems that were supported by the best available evidence and expert opinion to develop SALT (Sort, Assess, Life-saving interventions, Treatment and/or transport) triage. SALT triage was developed as an all-hazards mass casualty initial triage standard for all patients (adults, children, and special populations). SALT begins with a global sorting of patients to prioritize them for individual assessment. Patients who are capable are asked to walk to a designated area, and these patients are assigned last priority for individual assessment. Those who remain are told to wave and are observed for purposeful movement. Those who do not move and those with obvious life threats (e.g. uncontrolled hemorrhage) are assessed first since they are the most likely to need life-saving interventions. Individual assessment begins with limited rapid life-saving interventions, which include the following. Controlling major hemorrhage through the use of tourniquets or direct pressure provided by devices or other patients. Opening the airway through positioning or basic airway adjuncts and, if the patient is a child, giving two rescue breaths. Chest decompression when indicated for suspected tension pneumothorax. Autoinjector antidotes when indicated. These interventions are performed only if they are within the scope of practice of the responder providing triage, and if necessary equipment is immediately available. Next, patients are prioritized for treatment and/or transport by assigning them to one of five categories: immediate, delayed, minimal, expectant, or dead. The mnemonic ID-MED is a simple reminder of the triage categories. Patients with mild injuries that are self-limited if not treated and who can tolerate delays in care without increasing their risk of mortality are triaged as minimal. Patients who are not breathing even after attempted life-saving interventions are triaged as dead. Patients who do not obey commands, lack a peripheral pulse, are in respiratory distress, or have uncontrolled major hemorrhage are triaged as immediate. However, if any of the immediate patients have injuries that are likely to be incompatible with life given the currently available resources, they are instead triaged as expectant. The remaining patients are triaged as delayed. Currently, SALT triage is the only triage system that is known to be compliant with the MUCC.",
        "START triage": "The START triage method is currently the most widely used method of mass casualty triage among first responders in the United States. This algorithm, used for the triage of adult multicasualty patients, is based on respiratory function, quality of perfusion, and mental status. JumpSTART is similar to START but it is intended to be used to triage child casualties. Once patients are triaged and sorted using START, life-saving treatments are administered as needed. Casualties are loaded onto appropriate vehicles as they become available and transported to hospital facilities in the area.",
        "Triage tags": "Once a patient has been assessed and assigned a prioritization category, a means of rapidly identifying the patient's category is useful. This is traditionally done using commercially available triage tags, which come in a variety of designs. Regardless of the type of tag, it should allow for bidirectional changes in triage category as the patient's clinical condition changes (either worsens or improves). If tags are not available, a marking pen can be used to identify the assigned triage category on each patient's forehead. Alternatively, casualties can simply be physically placed in separate locations based on the triage categories to which they have been assigned.",
        "JumpSTART Pediatric MCI triage": "After initial triage It is important that casualties be retriaged at each phase and level of care and whenever clinically and tactically allowable, because the initial triage category may change as clinical status changes. The prioritization process should be considered dynamic, and may be altered by changing patient conditions, resources, and scene safety. In general, treatment and/or transport should be provided for immediate patients first, followed by delayed patients, and then minimal patients. Expectant patients should be provided with treatment and/or transport when resources permit. Efficient use of transport assets may include mixing categories of casualties and using alternative forms of transport, so rules for transport order should not be unduly restrictive. A system for communicating with destination hospitals and dividing patient volume according to their capabilities is also critical.",
        "Conclusion": "Triage is an important aspect of scene management during a mass casualty incident that, if done properly, may have a positive effect on patient outcome. The Model Uniform Core Criteria are intended to standardize the mass casualty triage process across the United States. SALT triage was developed based on a systematic review of the literature and is compliant with the Model Uniform Core Criteria. As the body of scientific evidence continues to grow in the area of mass casualty triage, this evidence should be further integrated into triage methodology."
    },
    {
        "Introduction": "Every medical director and EMS physician is an educator. Since the earliest days of EMS, physicians have been instrumental in the initial and ongoing education of prehospital providers. Whether one is an agency operational medical director or heads an accredited EMS education program, teaching is an essential component of the position description. As EMS has continued to evolve and mature, it is both reasonable and appropriate that educational systems have been developed that maximally utilize the capabilities of all members of a multidisciplinary team of educators, but the pivotal role of the EMS physician remains unchanged. In 1997, the National Association of EMS Physicians (NAEMSP) and the American College of Emergency Physicians (ACEP) released a joint position paper that formally recognized the criticality of the medical director's role in EMS education. The paper identified the following tasks for the physician medical director: to approve the medical and academic qualification of the faculty, the accuracy of the medical content, and the accuracy and quality of medical instruction given by the faculty; to routinely review student performance and progress and attest that the students have achieved the desired level of competence prior to graduation; and to have a significant role in faculty selection and curriculum development, authority over presentation of medical content, and authority to assure that faculty teach established medical practices. As the position paper notes, the successful medical director must be intimately and actively involved in all aspects of the EMS system, from administration and education to standard-setting, quality management, and research. Collaborative, collegial relationships between medical directors and their multidisciplinary teams of administrators, educators, and allied health professionals have strengthened many EMS systems by enabling medical directors to maximize their time and efforts. While the EMS medical director should have a sound understanding of educational principles and methodology as well as knowledge of the national standards for curricula and accreditation, it is imperative to appreciate that vast amounts of learning take place outside the traditional classroom setting and that education doesn't have to be highly structured or employ the latest iteration of simulation technology to be effective. Emergency medical services physicians teach by example as well as by carefully crafted lectures. They teach when they create and sustain an environment that enables the prehospital providers to do their jobs safely and effectively. They teach when providing clinical care in the emergency department and have incidental interaction with providers during the bedside transfer of care. They teach when conducting case reviews around the station kitchen table. They teach each time they respond to a query from a provider that begins with \u201cHey Doc, got a minute?\u201d They teach by holding themselves to the highest standards of patient care and demonstrating a commitment to lifelong learning. They teach by recognizing that education is intrinsic to system and provider development and performance improvement. They teach when they collaborate with organizational leadership and community health care partners to implement health and safety initiatives, interagency continuing education, and multidisciplinary advocacy programs. Given the breadth of the core content that the EMS physician must master, it is not surprising that some feel ill-prepared to teach, as educational design and methodology are rarely included in terminal professional degree programs except those leading to degrees in education. This lack of formal preparation should not dissuade one from this important task. Just as EMS medical directors indirectly touch each patient who receives care from their providers, so too does the legacy of a teacher extend indirectly to the countless lives of those touched by each person they teach. The intent of this chapter is to provide a foundational understanding of the role of the physician in EMS education, including theories of adult learning and the language of learning as well as the evolution of EMS curricula and accreditation standards. As EMS challenges continue and systems evolve, the EMS medical director must continue to play an integral role in this process to ensure that resources are identified and appropriately applied to improve patient care and increase provider competency through education and training that is integrated with quality improvement initiatives. In addition to this textbook, a valuable addition to your professional library would be the National Association of EMS Educators' Foundations of Education: An EMS Approach, written by and for EMS educators.",
        "Theories of adult learning": "Learning theories represent an ideology surrounding the art and science of learning. Pedagogy, the art and science of teaching children, had its origins between the seventh and 12th centuries modeled on the approach used in monastic and cathedral schools where priests taught basic skills to young people. This teacher-centered approach was largely unchanged for much of recorded time and is still evident in most traditional educational settings. This teacher-centered learning assumes that the learner has a need to know and is dependent on the teacher to fulfill that need. \n\nSocial learning theory and self-efficacy In social learning theory, Albert Bandura states that behavior is learned through the process of observational learning and imitation, and is influenced by being rewarded and/or punished for these actions. Effective modeling teaches general rules and strategies for dealing with different situations. Just as children learn by modeling the behavior of those around them, so too do adults learn in a similar fashion. This model has been replicated time and again in medical education as \u201csee one, do one, teach one.\u201d The seminal research in social learning theory, proposed by Neal Miller and John Dollard, posits that learning relies heavily on modeling performance for learners as an integral component of the learning process. Their operating premise was that if one was motivated to learn a particular skill or behavior, learning could be enhanced through clear observation of that skill or behavior, and by imitating the observed behavior the individual would solidify the learned behavior and be rewarded by positive reinforcement. While the visual model of effective performance is foundational to social learning theory, Bandura embellished the Miller and Dollard model by adding the relationship of model to the learner (symbolic coding), more robust practice, and a rich feedback component. Bandura also noted that people\u2019s beliefs about their ability to deal with different situations affect learning by influencing their actions \u2013 what they choose to do, how much effort is invested, how long they persist in an activity when faced with adversity, and how they approach challenges. Self-efficacy, the belief in one\u2019s own ability to complete tasks and reach goals, arises from four primary sources: mastery experiences, social modeling, social persuasion, and psychological state. It is not surprising that success enhances self-efficacy, while failure tends to diminish it. Failure is particularly likely to lower self-efficacy when it occurs early in learning new skills and behaviors. Seeing others perceived as similar to one\u2019s self or one\u2019s circumstances succeed enhances self-efficacy, as does positive external reinforcement. A person\u2019s perception about his or her emotional state or physical reactions and stress level can also affect self-efficacy in certain situations. \n\nSelf-directed learning While the term andragogy was in use in Germany in the early 1800s, it is Malcolm Knowles who popularized the concept in the United States after introducing the term and the concept that children and adults learn differently in the late 1960s. In Knowles\u2019 view, andragogy, the art and science of helping adults learn, is the antithesis of pedagogy in that it is student-centered and it relies on the teacher as a facilitator of learning. Knowles identified six core principles of adult learning that place the learner at the center of the learning process and exhibit basic respect for the inherent worth and dignity of each individual learner. Learners need to know the reason for learning. This concept is easily related to EMS education as the provider must know and understand not only the what but also the why and how of all aspects of prehospital medicine. Self-concept of the learner. Autonomy and self-direction are essential aspects of adulthood in our society. Adult learners need to be responsible for their educational decision making and when possible, should be included in planning (identifying learning needs and setting goals) and evaluation (evaluating learning outcomes). Prior experience of the learner. Prior experiences, both positive and negative, serve as a foundation for learning; this is particularly true of the experienced EMS provider. Readiness to learn. Adults tend to be most interested in learning subjects that have immediate relevance to their work and/or personal lives. Orientation to learning. Adult learning is problem-centered rather than subject-oriented, which speaks to the immediacy for application of new learning. Motivation to learn. As people mature, the motivation to learn is internal. These principles should be taken into account when planning adult learning activities. However, it is critical to remember that educational planning is a dynamic process and depending on the goal or purpose of an educational activity, some of these principles will be of lesser importance. As always, situational awareness is a necessity; for instance, when conducting classes for initial certification of EMS providers, prior experience will have less significance than when conducting continuing education activities for experienced providers. \n\nTheory of margin Howard McClusky, an educational psychologist at the University of Michigan, described the theory of power-load margin in the 1960s. The formula (margin=load/power) states that the key components of adulthood are load (the internal and external demands made upon the learner by self and society) and power (a combination of interacting support and coping factors and strategies that the individual possesses to sustain the load). This formula clearly suggests that the greater the power in relationship to the load, the more margin will be available, and the greater the margin, the greater the likelihood the learner will be able to manage the load. This model is particularly relevant in adult education as it focuses on the pressures that may affect the individual during the learning process, the competing demands for one\u2019s time and attention that can distract the learner from learning. An area of study that has emerged from McClusky\u2019s theory is the degree to which adult educators increase learner load, pioneered by Michael Day and Jim James at the University of Wyoming. Their qualitative analysis categorized instructor-generated load into four areas: attitude, behavior, tasks (structure and content), and classroom environment. \n\n Jack Mezirow\u2019s work in developing the transformative learning theory is the belief that \u201ca defining condition of being human is that we have to understand the meaning of our experience\u201d and that learning is a change process. His premise is that meaningful learning occurs most readily when learners are actively engaged and use critical reflection and discourse to challenge their frames of reference, and that adult educators have an obligation to facilitate such understanding and encourage autonomous thinking. Frames of reference (mind schemes) are the structures or assumptions through which we understand our experiences. Based on the totality of an individual\u2019s experience over a lifetime, there are three components that serve to set and shape one\u2019s expectations and attitudes: cognitive (perception, knowledge, memory, judgment, reasoning), conative (drive, impulse, action), and emotional (expression, feelings, beliefs, attitude). We tend to reject ideas that fail to fit our frames of reference. Transformation is the \u201cprocess by which we transform our taken-for-granted frames of reference (meaning schemes, habits of mind, mindsets) to make them more inclusive, discriminating, open, emotionally capable of change, and reflective so that they may generate beliefs and opinions that will prove more true or justified to guide action\u201d following an activating event that exposes the limitations of one\u2019s current knowledge or approach. The adult educator can foster transformative learning in professional training programs by creating an open and safe environment that in the face of an activating event allows the learner to identify and assess current assumptions, encouraging critical reflection and discourse, giving students an opportunity to test new perspectives and fostering openness. Context-based learning The core principle of context-based learning is that adult learning takes place in context where tools and the context intersect with interaction among people. Devised at McMaster University in Hamilton, Ontario, in the 1960s, context-based learning (formerly known as problem-based learning) was initially used to prepare medical students by replacing the traditional lecture approach to teaching with a student-centered approach that emphasizes self-directed learning, placing the adult educator in the role of facilitator. Context-based learning is a teaching strategy organized around scenarios that are relevant to desired learning outcomes, but it is not organized by topics or disciplines. Students work in groups to resolve real-life scenarios or situations. Through a student-led process, the group identifies relevant learning needs, which are then explored by the students using current research and resources to consolidate information and develop a strategy to resolve the situation based on the necessary concepts and principles. Clinical scenarios processed in this manner encourage research, critical thinking, and the development of lifelong learning skills. \n\nEvidence-guided education While Glick\u2019s model for evidence-guided education is not truly an adult learning theory, it does warrant inclusion as foundational material for the EMS physician. Glick\u2019s concept builds on earlier efforts to combine outcome data with education and to correlate outcome data with practice improvement. Evidence-guided education focuses on patient outcomes rather than best practices, and Glick posits that there is benefit to the systematic integration of such information to augment all aspects of medical education, although it may be most easily integrated into continuing medical education initiatives or postadverse event remediation activities. Sources of outcome information may be based on a single adverse event or a system-wide practice analysis, the key being to identify those topics or scenarios that are most generalizable. Evidence-guided education recognizes that a continuum exists in which education, clinical care, patient outcomes, and performance improvement are inextricably linked.",
        "Language of learning": "Education delivery systems\n\n There are predominantly three education delivery systems: traditional (face to face), distance education, and blended/hybrid models. In traditional education, learning is a synchronous activity that occurs at the same time in the same place and typically involves a teacher-centered classroom setting. While one might think that distance education is a by-product of the late 20th century, its earliest beginnings were pen and paper exchanges via the postal service. Distance education is student-centered and in its purest form occurs in different times and at different places. Learners choose when and where to learn and when and where to access instructional materials. Simonson et al. identify four components of distance education: institutionally based (academic institution, corporation, etc.), separation of student and teacher, interactive telecommunications (synchronous or asynchronous), and learning experiences (instructor-student sharing of data and resources). Hybrid or blended learning combines face-to-face classroom interactions with distance learning techniques to disseminate information to members of a learning community. This type of learning blends the use of technology-based asynchronous teaching methods and traditional teaching methods. This model may be seen in cohort postgraduate programs where each semester is launched by a short (5\u201310 days) face-to-face session and the balance of the learning and student-teacher interaction is conducted via distance education. Given the proliferation of technology and social media options, the opportunities available to enhance even the most traditional educational delivery are only limited by one's imagination. Regardless of the chosen educational delivery model, the challenge for the educator is to create a safe, supportive environment based on mutual respect where a community of learners can explore ideas, master concepts, and learn new skills. \n\nDomains of learning Bloom's taxonomy is a classification of learning objectives, named for Dr Benjamin Bloom who chaired the committee of educators that developed the taxonomy. They identified three domains of educational activities or learning: cognitive (knowledge), affective (attitude), and psychomotor (skills). A goal of the taxonomy was to motivate educators to focus on all three domains, creating a more holistic form of education and promoting a higher level of thinking. Bloom also proposed a taxonomy of six levels within the cognitive domain, ranging from the simple recall or recognition of facts (knowledge) as the lowest level, through increasingly more complex and abstract mental levels to comprehension, application, analysis, and synthesis, ending at the highest order, which is classified as evaluation (judgment). When designing learning activities, the instructor should remember that rarely does learning take place in a vacuum or a single domain. Just as prehospital care requires EMS providers to demonstrate mastery of the appropriate combination of cognitive, affective, and psychomotor skills to meet the needs of a given patient, so too should the design of our educational activities prepare them for that eventuality. Understanding the domains of learning is an essential consideration when writing goals and objectives as part of the instructional design process for any learning activity. Well-designed learning activities are progressive and sequential, allowing the student to demonstrate success at one level of cognition before moving on to the next. Learning styles Learning styles are a popular concept in psychology and education which seek to identify how people learn best. The concept that there are three dominant learning styles (auditory, visual, kinesthetic) had widespread popularity during the 1970s and 1980s, although there is no evidence that learning styles actually influence learning results or that one style is better than another. While there are many ways to categorize learning styles, Neil Fleming's model is among the most popular. In 1987, Fleming developed an inventory designed to help students learn more about their individual learning preferences. This model is sometimes referred to as the VARK learning styles (visual learning, auditory learning, reading/writing, or kinesthetic learning). While the validity of VARK as well as other learning style theories has been questioned and even criticized, the premise remains popular. As noted earlier, education takes place in many venues and by many methods. The instructor who actively seeks to engage the learner through a variety of modalities that stimulate the senses and captivate the mind conducts the most effective educational activity.",
        "Early EMS education": "Education and training for EMS personnel began much as EMS care began, uncoordinated and fragmented. The American College of Surgeons developed training programs for ambulance attendants in the mid-1950s and the American Academy of Orthopedic Surgeons conducted courses with the first EMT textbook Emergency Care and Transportation of the Sick and Injured. The 'orange book,' as it was commonly known, was published in 1967 and was edited by Dr Walter Hoyt. As pockets of emergency prehospital care were developed, training of these personnel occurred in various forms. The National Academy of Sciences and National Research Council also attempted to standardize ambulance attendant training with the text Training of Ambulance Personnel and Others Responsible for Emergency Care of the Sick and Injured at the Scene and During Transport. In 1966 Congress passed the National Highway Safety Act and funds were provided for the development of educational programs for EMS personnel and to pilot advanced-level program development. The first EMT curriculum was written in 1969\u20131971 and delivered to the National Highway Traffic Safety Administration (NHTSA) in 1971. The first paramedic curriculum was developed in 1977. The need for standardization in EMS education was recognized and a third-party contractor (Dunlap and Associates) was awarded the contract for this curriculum development. The curricula provided much detailed information such as how to plan a course, structure, amount of time to deliver, detailed lesson plans, and content. As states adopted NHTSA recommended model, EMS legislation, which included curriculum, scope of practice, and other curricula specifics, became tied to these curriculum documents. NHTSA continued to support updated curricula as well as an additional level between EMT-Basic and EMT-Paramedic that was known as EMT-Intermediate. New clinical evidence such as American Heart Association guidelines did not necessarily show up in curricula as the revisions were expensive and could not be done often. The first meeting of the National Registry of Emergency Medical Technicians (NREMT) was held in 1970 to provide uniform standards to credential ambulance attendants. In 1975, the American Medical Association gave the paramedic profession recognition as an allied health occupation and subsequently worked with the Joint Review Committee on Education Programs for the EMT-Paramedic (JRCEMT-P) to develop standards or essentials for paramedic education programs seeking accreditation. Although most developing allied health professions created a tie between graduating from an accredited education program and taking national credentialing exams, EMS did not at that time. EMS education and training issues were the topic of a consensus workshop in 1990 and representatives of the EMS community discussed and determined training priorities for the 1990s. The Education Agenda builds on broad concepts from the 1996 Agenda to create a vision for an education system that will result in improved efficiency for the national EMS education process. This system will enhance consistency in education quality and ultimately lead to greater entry level graduate competence. The new EMS education system is intended to include infrastructure that promotes national uniformity and is still responsive to local and regional needs. Five components of the new EMS education system are the National EMS Core Content, National EMS Scope of Practice Model, National EMS Education Standards, National EMS Program Accreditation, and National EMS Certification. National EMS Core Content The first component is the National EMS Core Content, a broad content base for the education agenda. The intent of the Core Content is to describe the entire domain of knowledge and skills of out-of-hospital care. This component is similar to physician education programs to define the scope of a specialty discipline. This project was led by physicians from NAEMSP and ACEP who worked with other stakeholders. National EMS Scope of Practice Model This second component identifies \u201clevels\u201d of EMS providers and designates specific skills for each of the provider levels. The project was led by the National Association of State EMS Officials (NASEMSO) and what was the National Council of State EMS Training Coordinators, working with a broad group. The EMS Education agenda for the future: A systems approach The universe of EMS knowledge and skills Delineation of provider practice levels Replaces the current national standard curricula National EMS core content National EMS scope of practice National EMS education standards National EMS certification National EMS education program accreditation A single agency for each function-standard exam, minimum competence, consumer protection The scope of practice skills that were identified in this project are a floor for each practitioner level. Since states set scope of practice for their EMS providers, this project is a model for the states to adopt to promote consistency and reciprocity between them. \nNational EMS Education Standards The third component is the EMS Education Standards, which identify competencies, clinical behavior and judgments, educational infrastructure, and the depth and breadth of content to include in each level of education. This section was led by the National Association of EMS Educators (NAEMSE) with cooperation from various stakeholder groups. Physician involvement in the development and review of education standards was prominent. Content identified is broad and less proscribed than the former national standard curricula, so that changes can more easily occur as evidence is collected. Instructor creativity and flexibility are encouraged and local needs must be considered. The EMS community responded to the broad-brush strokes of the Education Standards by saying that they were not adequate and more direction was still needed in EMS education. Consequently, companion documents of content outlines were developed for each level to provide some framework for programs to develop the curriculum. These documents are called Instructional Guidelines and are available on NHTSA website. The Education Standards and Instructional Guidelines were released to NHTSA in January 2009 and as of this writing, no updates have been made. Consequently, it is imperative for educators and medical directors to keep abreast of what new evidence in clinical practice should be taught in the EMS classroom. \nNational EMS Accreditation National EMS Accreditation is sometimes called one of the Education Agenda \u201cbookends.\u201d National certification is the other bookend. According to the Education Agenda, accreditation is defined as a non-governmental, independent, collegial process of self and peer assessment. The purpose of accreditation is to provide a system of public accountability and continual improvement of academic quality. The Agenda further states that a single national accreditation agency will be identified and accepted by state regulatory offices. NASEMSO designated the Commission on Accreditation of Allied Health Education Programs (CAAHEP) and its Committee on Accreditation of EMS Professions (CoAEMSP) as the agency in 2010. Currently there are 14 organizations that sponsor the CoAEMSP. Each organization has two representatives on the CoAEMSP board. The sponsoring organizations are listed in Box 19.1. Accreditation\u2019s primary purpose is to protect the student by ensuring that programs meet minimum standards. Additionally, accreditation protects the program and institutions by assisting in quality assurance. Accreditation is either institutional or programmatic. Programmatic is sometimes called \u201cspecialized\u201d or \u201cprofessional.\u201d The US Department of Education or the Council for Higher Education Accreditation (CHEA) must recognize accreditors. Institutional accreditation assesses the entire institution without evaluation of any specific institutional programs. A regional accreditation agency such as the Southern Association of Colleges and Schools is an example of institutional accreditation. Programmatic accreditation relates to a specific academic program that prepares students to practice in a specific profession. The CAAHEP is an example of this programmatic accreditation. It has 18 committees on accreditation for various health professions, and is CHEA recognized. The CoAEMSP is one of the committees that functions under the CAAHEP. The CAAHEP only accredits programs that are longer than one academic year or two semesters, and consequently EMT and EMR programs are not accredited in this system. The CoAEMSP is currently evaluating the need for accreditation of Advanced EMT programs. The accreditation process As in most accreditation systems, paramedic program accreditation involves the self-evaluation and then peer evaluation of programs reviewed against Standards and Guidelines that follow a prescribed CAAHEP template, and are developed in conjunction with the EMS community. The standards are reviewed every 5 years and adjusted to move forward with the profession. A program wishing to become accredited first completes and submits a self-study document that responds to a series of questions about the program to facilitate self-evaluation. Once the self-study document is submitted, the program receives feedback and then a site visit takes place with a team of paramedic educators and a physician involved in EMS education. Once the site visit is completed, the program receives a report concerning compliance with Standards and Guidelines to assist in making changes if necessary. Changes are documented and may take a period of time to come into compliance based on the length and frequency of the paramedic course. Programs are often required to submit progress reports for the CoAEMSP to monitor movement toward compliance of standards. The CoAEMSP reviews programs and those meeting the standards or making progress toward compliance are recommended to the CAAHEP board for accreditation. This sequence occurs every 5 years, and a report is submitted annually with outcome data from the program, such as graduate and employer satisfaction, state or NREMT exam pass rates, job placement rates, and other factors. Medical direction required for accreditation Accredited paramedic programs must have documentation of an active medical director. The CAAHEP standards include qualifications and responsibilities of a medical director. According to Standards interpretations, the medical director is responsible overall for medical oversight. The medical director needs to interact with students in some manner, whether it is teaching a class lecture or lab instruction or instruction in the emergency department. The medical director must review high-stakes exams for accuracy and relevance. Content of the course should be frequently evaluated to identify any information or practice issues that should be added. A sample terminal competency form for the medical director to sign off student competency is available on the www.coaemsp.org website. Medical directors are typically the EMS champions in the medical community and advocate for student involvement in the operating room for airway clinical practice and other locations that may take some special encouragement. Connecting students with patients, patient assessments, and patient pathologies is a special talent medical directors can bring to their students. One should never minimize the learning that can occur in the clinical setting with an enthusiastic physician who teaches in the clinical area. Comprehensive information on accreditation can be found at www.coaemsp.org. \nNational EMS Certification National EMS Certification is the other \u201cbookend\u201d of the National EMS Education Agenda. The Education Agenda calls for a single, national certifying organization to be identified and accepted by state regulatory offices. NASEMSO designated NREMT to be that agency in 2010. NREMT has been credentialing EMTs of varying levels since 1970 at the recommendation of President Lyndon Johnson\u2019s Committee on Highway Traffic Safety. The mission of NREMT is to provide a valid, uniform process to assess the knowledge and skills required for competent practice required by professionals throughout their careers. NREMT holds accreditation from the National Commission for Certifying Agencies (NCCA), which is the accreditation arm of the National Organization for Competency Assurance. NCCA is recognized as the authority on accreditation standards for professional certification organizations and programs. NCCA accreditation means that the standards set by NREMT have been reviewed by NCCA and deemed credible for ensuring the health, welfare, and safety of the public. Regulatory terms Confusion exists among the general public, as well as among state agencies, concerning words related to regulatory concepts. Certification is issuing a certificate by a non-governmental private agency (such as NREMT) based on adopted competency standards. Certification affirms a knowledge and experience base for individuals who practice in a particular field, as well as their employers and the public. This is different from licensure, which is granted by a legislative entity such as a state government, giving an individual permission to do a job or task that requires such permission. A driver\u2019s license is an example of such permission. Generally speaking, a licensed individual in health care has a certain amount of autonomy in delivering that service. Registration is a list of individuals who have attained a specific professional status, so that NREMT keeps a list of persons who have met the criteria for practice. Registration does not allow an individual to practice in a state, but may be a prerequisite for such permission to practice (licensure). NREMT certifies that individuals who pass the skills and cognitive exam are entry-level competent; states take that information and award licensure if deemed appropriate. In EMS as in other health care fields, an additional step to verify competency is a local credential, which may verify other criteria for practice such as professional behavior or local protocol exams. The local EMS agency and medical director typically accomplish this step. Certification tied to accreditation The Education Agenda further clarified the relationship between accreditation and certification. The document states, \u201cA graduated phase-in plan will be developed for implementation of national accreditation. Each state should identify a graduated time line for adoption. After the phase-in date, only graduates from accredited programs will be eligible for national certification to qualify for state licensure.\u201d In 2007 NREMT board of directors made a bold move: effective January 1, 2013, a paramedic candidate must graduate from a CAAHEP-accredited program in order to take NREMT paramedic examination. As of this writing, over 365 paramedic programs are accredited, and 275 more are in the process of becoming accredited. For successful applicants, NREMT grants 2-year registration. At the time if this writing, 47 states require NREMT registration at one level or another for state licensure. In some states, continuing registration using NREMT criteria for re-registration is required for continued state licensure. The medical director of individuals who are attempting to re-register their EMS certification are required to verify online that requirements are met in order for the individual to be re-registered. NREMT stays busy keeping exam item databases updated and adding new items. Exam items are based on a practice analysis at each level completed every 5 years as required by NCCA. NREMT hosts approximately ten item-writing meetings annually to manage the databases. EMS physicians are important contributors to the item-writing sessions, and EMS fellows also participate. \nContinuing Education Coordinating Board for EMS Accreditation The Education Agenda did not address continuing education issues except to say a systems approach should be developed for continuing education and continued competency assurance in EMS. Although such a system is not currently in place in EMS, continuing education courses do have a national accreditation agency. The Continuing Education Coordinating Board for EMS reviews and accredits EMS-related continuing education. This national accreditation makes it possible for students to obtain credit outside their state and to receive credit through distance education. For more on CECBEMS accreditation, see www.cecbems.org. \nRemediation and workforce reentry The EMS physician who serves as an agency medical director should collaborate with organizational leadership to develop policies regarding remediation and workforce reentry for the authorized providers in that system. Such policies should address identification, strategies, and evaluation criteria in accordance with existing agency human resources policy. Workforce reentry policies are often time-based and usually correlate with prolonged absences from operational status due to illness, injury, maternity leave, or military deployment. If the EMS provider returning from military deployment served in a medical capacity during deployment, it may be reasonable to consider an abbreviated reentry strategy. \nIdentification Identification of EMS providers needing remediation will likely arise from two areas: failure to successfully complete an orientation/internship process, or as a result of a patient care error, such as medication misadministration, inability to recognize patient acuity, or errors in 12-lead ECG interpretation. When provider deficiencies are related to a patient care event, it is usually easy to identify the specific area of weakness and develop a strategy for remediation. However, the inability to complete orientation/internship is often a more global issue and will rely heavily on documentation of deficiencies, as well as ongoing efforts at remediation that were noted throughout the daily evaluation during the orientation/internship to lay the foundation for the remediation plan. \nStrategies Once a provider has been identified as needing remediation, the EMS physician should meet with the provider and his/her supervisor as well as whoever will be responsible for conducting the remediation activity; ideally this will be someone in the training division. The following information should be available at this meeting: the identified deficiency, remediation plan objectives, what method of evaluation will be used to verify completion, the time frame for completion, and the consequences of failure. The EMS physician should also be prepared to solicit input from the provider about additions to the remediation plan. As noted earlier, human resources should be involved in remediation plans in the event that failure to successfully remediate may affect a provider's authorization to provide care or their employment status. In some cases, the remediation activity may only involve a case review with the crew and/or single provider conducted by the EMS physician in a setting where the errors in judgment can be reviewed and discussed in a non-threatening manner. In other situations, when specific cognitive or psychomotor skill deficiencies have been identified, there may need to be a more structured schedule of activities such as attending a presentation on a particular topic or a specific number of practice scenarios or skills sessions with a trainer before being allowed to be evaluated. Objectives for remediation should be specific, measurable, achievable, realistic, and time bound (SMART). Workforce reentry planning should be guided by the same principle of SMART objectives with the intention of providing a structured opportunity for the EMS provider to demonstrate competency in all aspects of his or her position prior to being returned to full duty. Content areas for reentry plans should include insuring that all required certifications are current, as well as providing the necessary resources and practice opportunities to acquire or refresh technical skills or master new protocols prior to being returned to full duty. \nEvaluation Evaluation activities associated with remediation or reentry should be clearly delineated at the outset of the remediation or reentry period. Depending on the circumstance for each individual provider, evaluation activities may include cognitive testing, practical scenarios, psychomotor skills performance, and/or oral interview/case reviews. It is imperative that evaluation activities be consistent with existing organizational standards; evaluation standards should not be more stringent for the EMS provider who is completing remediation or reentry processes than they are for any other provider.",
        "Conclusion": "Emergency medical services education is essential to the provision of prehospital care and its continued evolution into the 21st century. As a medical director, the EMS physician is first and foremost a patient advocate, so it is critical that physicians be actively involved in all aspects of the education process for their providers and knowledgeable about the structure and process of educational program accreditation."
    },
    {
        "Introduction": "The irreversible cessation of life may be difficult to determine with complete confidence, particularly in the austere environment of out-of-hospital emergency care. As a result, clear protocols should be implemented in each EMS agency outlining when to attempt resuscitation and when to terminate resuscitation efforts. When distinctive protocols do not exist, decision making is left to the discretion of the paramedic and the direct medical oversight physician at the point of care. The literature suggests that this leads to bias and inconsistency in care across similar patients. There is limited evidence to guide when to start resuscitation. Yet a large body of work, including external validation across different geographical regions, exists to guide the development of local protocols to provide a consistent approach to termination of resuscitation in adult out-of-hospital non-traumatic cardiac arrest.",
        "Adult out-of-hospital cardiac arrest - When to start resuscitation": "There are three criteria that must be met to start resuscitation in the prehospital setting. 1 Provider safety is assured. 2 The patient is not obviously dead. 3 The patient does not have a \u201cDo Not Attempt Resuscitation\u201d directive (DNAR) that meets local policy. The issues related to provider safety and policy and directives governing provider safety are dealt with in other chapters. The Uniform Determination of Death Act, which has been adopted by many states, and endorsed by both the American Bar Association and the American Medical Association, states that \u201can individual who has sustained either: 1) irreversible cessation of circulatory and respiratory functions; or 2) irreversible cessation of all functions of the entire brain, including brain stem, is dead. A determination of death must be made in accordance with accepted medical standards\u201d. Although this statement attempts to define death, it still leaves the determination of the condition to the vague criterion of \u201caccepted medical standards\u201d as well as the provider\u2019s definition of \u201cirreversibility.\u201d",
        "Adult out-of-hospital cardiac arrest - When to withhold resuscitation": "In most jurisdictions, obvious death with no need to attempt resuscitation is defined by legislation or by medical directives. An unpublished survey of the Resuscitation Outcomes Consortium (ROC) services was completed prior to establishing the ROC Epistry data set. Definitions of obvious death were similar across the >280 services. As demographics continue to shift toward an aging population, end-of-life decisions may be made in advance more commonly in patients calling EMS. A study in 2008 of cancer patients suggested that 37% had had these discussions in advance, which resulted in decreased ventilation, rates of resuscitation, and ICU admission, and increased hospice enrollment for end-of-life care. Most importantly, these conversations resulted in better quality of life for patients and their caregivers. The various platforms facilitating patient decision making need to be considered when establishing medical directives concerning attempting resuscitation. These include living wills, health care advance directives, or (when combined) comprehensive health care advance directives. Seattle medical directives have been altered to include verbal DNAR as well as written DNAR. Employing a before-and-after design, Feder demonstrated 50% reduction in resuscitation rates when the directive enabled paramedics to not attempt cardiac arrest resuscitation in patients with a history of terminal illness, under the care of a physician at the time, and with a written DNAR or family requesting a DNAR. This would have a positive effect on the survival rates from out-of-hospital cardiac arrest as these patients would be removed from the denominator. In a system with explicit medical directives pertaining to obvious death and prescribed end-of-life autonomy in decision making, all other victims of out-of-hospital cardiac arrest (OHCA) should receive full resuscitation.",
        "Adult out-of-hospital cardiac arrest - When to terminate resuscitation in adult non-traumatic OHCA": "To understand the evidence for termination of resuscitation (TOR) rules, one must understand the definition of medical futility. Objective criteria for establishing medical futility were defined in 1990 as interventions that impart a <1% chance of survival. In adult non-traumatic OHCA, there is a validated decision rule to guide TOR for BLS. This rule has been externally validated in the United States, Canada, Europe, and Japan. The BLS rule has also been proposed and externally validated as the \u201cUniversal Rule\u201d for all levels of providers, for all non-traumatic OHCA. This reduces confusion in a service with a tiered response and enables simpler implementation strategies. The rules have been validated under the 2005 and 2010 resuscitation guidelines without any change in their performance accuracy. It makes sense that any intervention in the prehospital setting (new drug, new device, or new step-by-step process of care) that potentially increases survival would first and foremost increase the rates of return of spontaneous circulation (ROSC) or enable ventricular fibrillation (VF) more often and increase the potential to receive a shock. Either of these outcomes would make the patient ineligible for TOR, and the rate of transport to hospital would rise. Thus, as scientific advances improve resuscitation outcomes, more patients will meet the criteria for transport instead of termination. Adult patients with cardiac arrest attributed to an obvious cause such as lightning strike, mechanical suffocation, poisoning, near drowning, etc. should be treated via the prehospital resuscitation protocol and transported to ensure they are given the full benefit of interventions unique to the etiology of their arrests. These arrests were routinely excluded from all the studies pertaining to TOR rules.",
        "Adult out-of-hospital cardiac arrest - Implementation issues related to termination of resuscitation": "The 2010 Guidelines from the American Heart Association and the 2011 position paper from the National Association of EMS Physicians advocate for the implementation of the TOR rule to reduce the transport of futile resuscitations and provide a more consistent approach to all non-traumatic OHCA patients. EMS medical directives relating to TOR need to be tailored in how they are implemented locally, taking system nuances into consideration; however, the medical directive must include the rule as validated with all three components after full prehospital resuscitation by a resuscitation protocol which is guideline compliant. For example, if medics did not remain on scene to complete their resuscitation protocol and instead took a scoop-and-run approach, there would be insufficient time to complete the resuscitation protocol. Thus, there is insufficient time to adequately assess if the patient achieves ROSC or received a shock at any time. Termination of resuscitation would be premature and not compliant with the rule. Another example pertains to a medical directive that removed the first and third criteria, instructing the providers to terminate if no ROSC was achieved in the prehospital setting. This was explored in an analysis of the Toronto ROC data and it was found that resuscitation should not be terminated for patients who did not achieve ROSC but did receive shocks or had their arrests witnessed by EMS. The survival rate in this group was 3.5%, which exceeds futility. It would be cavalier to reduce the TOR rule to no ROSC as it denies potential survivors the opportunity for transport and continued resuscitation. Sasson et al. published a number of barriers to TOR protocol implementation, including changing legislation and local EMS remuneration practices to enable EMS services and their medical directors to implement the TOR decision rule. It is essential that both of these barriers are addressed and corrected locally prior to implementation using the body of science and current position statements. Education should include a consistent approach to the use of TOR rules, and include sensitivity and grief counseling for providers who will be providing death notification to the families. Helping medical directors and colleagues understand the current body of knowledge should address the fear of litigation for medical directors and myths relating to the ability of EMS personnel to provide death notification and the effects on family members. Numerous studies have demonstrated that providers are comfortable with terminating resuscitation in the field, comfortable with conveying the news to family, and effective at doing it. Furthermore, it has been established that family members are receptive to this approach to care and do not suffer any long-term emotional or psychological effects.",
        "Pediatric out-of-hospital cardiac arrest - When to start resuscitation": "In the case of children (aged 17 years or younger), decisions regarding when to resuscitate, how long to continue, and when to terminate resuscitation are based on fewer available data than we have for adults. Nevertheless, the available data indicate that, with the exception of posttraumatic arrest, EMS providers should attempt to resuscitate any pediatric patient who does not have obvious signs of irreversible death (e.g. lividity, rigor mortis or decomposition) or in the special circumstance of a valid DNAR order. Due to the low occurrence and increased stress involved in pediatric resuscitation, it may occasionally be difficult for paramedics to reliably discern clinical signs of futility. In fact, in many cases that were later found at the emergency department (ED) to have already developed signs of lividity or rigor mortis, paramedics had found it difficult to truly discern these conditions in the field and therefore attempted resuscitation. Recent literature has shown that survival to hospital discharge in pediatric patients greater than 1 year old is higher (9.1% for children aged 1\u201311 years and 8.9% for those aged 12\u201319 years) than survival in both infants (<1 year, 3.3%) and adults (4.6%), suggesting that pediatric OHCA survival is improving.",
        "Pediatric out-of-hospital cardiac arrest - When to terminate resuscitation": "With regard to the decisions to terminate efforts in pediatric patients, no reliable clinical predictors have been sufficiently evaluated in the out-of-hospital setting to accurately predict pediatric resuscitation success or failure, and no decision rules derived for adult prehospital TOR have been evaluated in the pediatric population. Furthermore, compared to adults, pediatric patients have been shown to have increased rates of survival from non-shockable rhythms, a cornerstone of many TOR decision rules used in the adult population. Published studies of pediatric OHCA have demonstrated that unwitnessed cardiac arrests, arrests without bystander cardiopulmonary resuscitation (CPR), and arrests with initial non-shockable rhythms are associated with decreased survival. However, none of these variables alone or in combination has been shown to accurately predict futility. A lack of prehospital ROSC is also strongly associated with mortality, suggesting that, as with adult cardiac arrests, prehospital providers should focus on the delivery of high-quality CPR during initial resuscitation efforts instead of resorting to a scoop-and-run approach. In a prospective study of about 300 consecutive pediatric OHCAs, on-scene ROSC was never achieved in 267 children despite aggressive attempts at ACLS for more than a half hour, and none of these children survived. The exact duration of CPR prior to recommending TOR is unknown. The absence of spontaneous circulation within 20\u201330 minutes of ACLS initiation has been associated with poor survival (unless there is hypothermia or persistent VF). However, current data are inconsistent and further research is needed to determine any specific cut-off values. A recent study of 138 pediatric OHCAs showed a median duration of CPR of 18.5 minutes in survivors compared to 41 minutes in non-survivors; however, survivors were reported with up to 64 minutes of resuscitation. Cut-off values and predictive factors must be interpreted cautiously as emerging in-hospital treatments such as postarrest therapeutic hypothermia and the use of extracorporeal membrane oxygenation (ECMO) may result in good neurological outcome in patients who were once considered futile. The concept of on-scene termination of resuscitative efforts for children is further complicated by the psychosocial effect on the family and the psychological discomfort of the EMS providers. Health care professionals often find it more psychologically challenging to withdraw CPR attempts rather than not starting resuscitation in the first place. A blinded survey of EMS personnel regarding comfort levels with on-scene pronouncement was reported using a rating scale of 1 (not comfortable) to 10 (very comfortable). The study found that veteran paramedics (n=201) are very comfortable (average score 10) with the pronouncement of an adult on scene, but not with pronouncement of a child (average score 2). Accordingly, with the greater availability of in-hospital support services for the families of pediatric patients and the EMS providers\u2019 potential concerns with on-scene pronouncement, termination of resuscitative efforts for children may be best performed in the hospital. Nevertheless, it has also been emphasized that once medical futility is determined, EMS personnel should take care during transport not to create additional risks in traffic, and in-hospital personnel might adopt modified procedures that limit further resuscitation and resource use. In addition, in some cases of suspected sudden infant death syndrome, unwarranted resuscitative efforts and hospital transport may compromise a potential crime scene investigation. With limited and inconsistent evidence to terminate resuscitation, current guidelines do not recommend the use of TOR rules or specific criteria for pediatric OHCA. In the absence of clear criteria, EMS providers should employ explicit definitions of obvious death to dictate when to start resuscitation and to continue resuscitation while transporting to the hospital, seeking consultation with direct medical oversight as required.",
        "Adult traumatic cardiopulmonary arrest": "Among the greatest challenges in EMS is decision making around the patient who is found to be experiencing a traumatic cardiopulmonary arrest. Whether traumatic arrest is the result of blunt or penetrating trauma, the prognosis for survival (approximately 2%) is dismal, but not futile as defined by an overall survival rate <1%. The decision whether to withhold or terminate resuscitation of the traumatic arrest patient is fraught with emotion since patients are typically young and the circumstances surrounding the event often occur unexpectedly in public and unsecure settings, and can be subject to intense immediate and prolonged public and media scrutiny. In addition, there is a need for EMS providers to act quickly and decisively in an environment where it can be difficult to determine whether the patient has a detectable pulse. Contrary to non-traumatic cardiopulmonary arrest, there are no prospectively derived and validated clinical decision rules to guide EMS providers on whether to withhold resuscitation of the traumatic arrest patient, or circumstances where it might be reasonable to terminate resuscitation after failed attempts to achieve ROSC in the field or during transport. Nevertheless, some observational studies have identified factors that are associated with futility such as the absence of organized electrocardiographic activity often described as asystole and EMS provider CPR for greater than 10-15 min without ROSC. Whereas, other observational studies suggested an increased survival was associated with the presence of normal sinus rhythm, pupillary responses, or visible respiratory effort, especially in penetrating trauma patients. The challenge in making recommendations is that the literature reports >1% survival rates for victims of blunt and penetrating trauma even in the presence of dire clinical findings such as asystole. It appears as if no single criterion unequivocally distinguishes between survivors and non-survivors of traumatic arrest. Despite these challenges, NAEMSP and the American College of Surgeons Committee on Trauma (ACSCOT) have published joint position statements and supporting resource documents (initially in 2003 and updated in 2012) to provide guidance on withholding resuscitation and termination of resuscitation of adult traumatic arrest patients. The 2012 position statements provide separate recommendations for withholding resuscitation and TOR. The components of the position statements are a combination of operational design recommendations that are largely common sense, as well as a number of patient care assessment and intervention recommendations that resulted from a structured literature review focusing on clinical factors that are associated with outcomes of traumatic arrest. Experience with the 2003 position statements has shown that there is a wide variation in their application, with several large EMS systems transporting traumatic arrest patients contrary to the recommendations. Specific factors leading to this variation were not reported; however, this observation has resulted in a call to identify and address barriers to implementation as a way to increase compliance with these recommendations. This is important since the consequences of non-compliance have resulted in high rates of transport of futile patients, as evidenced by one study from a single center that reported only a single survivor amongst 294 transported patients who met criteria for withholding or termination of resuscitation. This patient survived with a neurologically compromised state.",
        "Adult traumatic cardiopulmonary arrest - When to withhold resuscitation": "The withholding resuscitation recommendations are unchanged from the 2003 position statement and are meant to identify blunt and penetrating trauma patients who by consensus have no meaningful chance (with the previous caveats) of survival and therefore do not warrant implementation of resuscitation procedures or transport. Ultimately, these patients can be left at the scene in the custody of authorities, thereby preserving forensic evidence to support investigations into the cause and circumstances related to the death. Clinical application of the recommendations on withholding resuscitation requires sufficient assessment to determine the presence or absence of vital signs, pupillary response, respiratory effort, and spontaneous movement. It also requires the application of a cardiac monitor to determine the presence or absence of organized electrocardiographic activity. The lack of a precise definition in the recommendations as to what constitutes organized electrocardiographic activity reflects a similar lack of precision in the literature. Conservatively, one would interpret this to mean asystole, although it has been proposed that any heart rhythm at a rate less than 40 is uniformly associated with non-survival. Importantly, these recommendations fall within the scope of practice of BLS and ALS providers. From an operational perspective, it is important to establish that this assessment does not constitute initiation of resuscitation; otherwise, there will be the potential for disagreement as to what constitutes withholding resuscitation. Of note in these recommendations is the added requirement for penetrating trauma patients to have no other signs of life. This relates to reports of survival in penetrating trauma patients with asystole who exhibited other signs of life.",
        "Adult traumatic cardiopulmonary arrest - When to terminate resuscitation": "The clinical aspects of the position statement regarding TOR are meant to identify traumatic arrest patients who meet the criteria for resuscitation but do not achieve ROSC after adequate trials of CPR and other resuscitative procedures as dictated by the EMS providers' scope of practice and medical protocols. This is because both blunt and penetrating traumatic arrest patients who do not achieve ROSC have close to zero probability of survival despite further attempts at resuscitation in the hospital, including resuscitative thoracotomy. The duration of an \u201cadequate trial\u201d of CPR is not precisely defined. Traditionally 15 minutes has been supported as a cut-off; however, as reported in the 2012 position statement, the collective literature suggests that only 0.75% of traumatic arrest patients with more than 10 minutes of CPR survive to hospital discharge with good neurological status. This low rate of survival suggests 10 minutes is a reasonable trial of CPR. It is somewhat difficult to conclude whether penetrating trauma patients (especially those with thoracic injuries) should have a longer trial of CPR before considering TOR since many studies do not differentiate between penetrating and blunt trauma in their patient populations. Yet, reports of survival in patients with CPR for greater than 10 minutes tend to favor penetrating trauma patients. It should be noted that contrary to 2003, the 2012 position statement does not specifically mention whether TOR should be considered in patients with EMS-witnessed traumatic arrest who fail to achieve ROSC after 10\u201315 minutes of prehospital resuscitation. The reason for this is not mentioned; however, it is important to acknowledge since about 37% of traumatic arrest patients fall within this category. Unfortunately, most literature regarding prehospital traumatic arrest simply describes the presence or absence of arrest in the field but not its timing. Given only one neurologically compromised survivor out of 110 patients with EMS-witnessed TCPCA, it seems reasonable to apply the TOR recommendations to this group as well. Prehospital TOR of traumatic arrest patients is operationally challenging because CPR (and most other procedures) should typically be performed during transport (scoop and run). Therefore, application of TOR protocols under these circumstances would likely lead to many patients qualifying for TOR during transport. Moreover, many patients in urban settings would likely arrive at trauma facilities prior to \u201cadequate\u201d trials of CPR being completed. Development of TOR protocols during transport predictably will require consultation and support from a wide variety of stakeholders including the EMS agencies, medical oversight physicians, trauma centers, regulatory agencies, law agencies, and the medical examiners. Local protocols would also have to include the specific destination (e.g. morgue, coroner's office, emergency department) once TOR has been implemented. In urban settings, it may be that the best local solution once transport has been initiated is to continue resuscitation and leave the decision for TOR to the receiving trauma center. While the 2012 position statement advocates for active physician oversight in developing and locally implementing TOR, there is no specific statement indicating the need for direct (online) medical oversight. While identifying patients who qualify for withholding resuscitation seems reasonably straightforward and ostensibly could be implemented without direct medical oversight, TOR appears more complex, especially since other resuscitative measures beyond CPR are typically performed. To ensure compliance with the recommendations and EMS provider comfort with implementing TOR, it may be that direct medical oversight would provide additional value to making the final decision. A number of patient groups experiencing extenuating circumstances are noted in the guidelines which are not specifically addressed. This may be largely because the available literature has excluded them from study or the available information is scant and incomplete. Examples of these patient groups include pediatric patients, patients with environmental injuries, pregnant patients, and patients where the mechanism of injury does not correlate with the clinical condition. Many services will implement resuscitation and transport of these patients without regard for TOR recommendations, which is appropriate given the lack of literature. For patients who are transported to trauma centers in accordance with the position statement, it is important for EMS providers to appreciate that arrival at a trauma center does not dictate that a resuscitative thoracotomy will be performed. Rather, the recommendations identify patients who may qualify for resuscitative thoracotomy, and transport to a trauma center gives the option to the trauma team. It should be noted that the literature on resuscitative thoracotomy is largely based on reports from Level I trauma centers that have experience and expertise in performing this procedure. It is logical to conclude, despite the absence of supporting literature, that the survival of traumatic arrest patients would be <1% in those who must be transported to non-Level I trauma centers. This would suggest that prehospital traumatic arrest TOR protocols may be more appropriately applied in rural EMS settings.",
        "Conclusion": "The decision of when to start or terminate resuscitation is fraught with inconsistency if left to the discretion of the individual provider or direct medical oversight. There is a body of knowledge that guides medical directors on an approach to TOR in adult OHCA of non-traumatic origin. The TOR rule is sanctioned by NAEMSP and AHA. Implementation includes addressing legislation and remuneration barriers, employing targeted education techniques, local planning with local authorities who share responsibility for death notification in the community (police, ambulance, fire, emergency departments, primary care physicians, and coroner\u2019s office) and engaging the physicians involved in direct medical oversight to assure common understanding, agreement, adoption, and adherence. All other cardiac arrests of a unique and obvious non-traumatic etiology such as near-drowning or overdose who fit the criteria to start resuscitation should be transported with ongoing resuscitation to benefit from etiology-specific interventions. In the case of pediatric OHCA, there is a paucity of literature informing when to start and when to stop. Without signs of obvious death as defined by a medical directive, EMS personnel should attempt resuscitation in all cases of pediatric cardiac arrest. Factors such as unwitnessed arrests, non-shockable rhythms, and longer resuscitative efforts are all associated with poor outcomes; however, there are currently no accurate determinants of futility in pediatric cardiac arrests. Adult TOR guidelines have not been validated in the pediatric population and current cardiac arrest guidelines do not support the use of specific criteria to terminate resuscitation. Due to a lack of research examining pediatric TOR, each case should be examined on an individual basis in consultation with medical oversight, or transported to the hospital with continued resuscitation. The science on when to withhold or terminate resuscitation of traumatic patients is less defined than for non-traumatic OHCA. All evidence is observational and has not been subjected to a clinical decision rule analysis. There appears to be no single clinical finding that universally distinguishes between survivors and non-survivors from either blunt or penetrating traumatic arrest. Recently updated guidelines have been published that provide a working tool for EMS medical directors to develop protocols to address these issues."
    },
    {
        "Introduction and brief history": "The history of EMS in the United States is remarkably brief. Many regard the report Accidental Death and Disability: The Neglected Disease of Modern Society in 1966 as the foundation from which organized EMS systems emerged throughout the country. Shortly thereafter, the US Department of Transportation released its first curriculum for training personnel as Emergency Medical Technician-Ambulance in 1969. The National Registry of EMTs (NREMT) was formed in 1970 to certify the entry-level competence of EMS personnel. The EMS Systems Act of 1973 provided critical support for states to begin organizing their EMS systems. More recently, the 1996 National Highway Traffic Safety Administration-sponsored EMS Agenda for the Future (the Agenda) described a futuristic vision of EMS as 'community-based health management that is fully integrated with the overall health care system.' In the context of systems that are not yet 50 years old, it should come as no surprise that the legislation, regulation, and ordinance governing these systems are still maturing. In 2010, the National Association of State EMS Officials (NASEMSO) published a Model Statutory and Regulatory Content for State EMS Systems. This document was created in response to a report by the Institute of Medicine, titled Emergency Medical Services at the Crossroads. Among other subjects, the report cites various problems with the state regulation of EMS systems. NASEMSO piece is intended to be a guide that states can use as a model for improving or reforming the content of their existing statutes.",
        "Physician oversight of EMS systems": "Emergency medical services systems provide emergency health care to patients in the out-of-hospital setting. Services are typically performed by non-physician personnel who are not independent practitioners. EMS personnel operate with defined scopes of practice using physician-approved protocols for care. Such personnel typically provide services on behalf of an EMS agency. The quality measures, relationships of system participants, education requirements, competency verifications, documentation expectations, and many other elements of the EMS system structure are usually defined in some form of legislation, regulation, or ordinance. Integral to the provision of quality out-of-hospital emergency medical care through EMS personnel has been physician medical oversight. This physician involvement is relatively simple to understand and more complex to put into action. Emergency physicians have the legitimate role and responsibility to determine and guide the management of patients requiring emergency care, whether in the hospital or outside the hospital. An April 2009 joint statement by the American College of Emergency Physicians (ACEP), the National Association of EMS Physicians (NAEMSP), and NASEMSO on the subject of state EMS medical direction reads: Dedicated and qualified medical direction is required to ensure safe and quality patient care. Medical direction is a fundamental element of the emergency medical services (EMS) system. It is essential that the lead agency for EMS within the fifty states, the District of Columbia, Puerto Rico, the territories of Guam, the Virgin Islands, American Samoa, and the Commonwealth of the Northern Marianas Islands, has a state EMS medical director. The state EMS medical director provides specialized medical oversight in the development and administration of the EMS system and is an essential liaison with local EMS agencies, hospitals, state and national professional organizations, and state and federal partners. The state EMS medical director provides essential medical leadership, system oversight, coordination of guideline development for routine and disaster care, identification and implementation of best practices, system quality improvement, and research. The state EMS medical director is essential to the comprehensive EMS system at the local level by promoting integration of direct and indirect medical oversight for the entire emergency health care delivery system. The state EMS medical director should be a physician with extensive experience in EMS medical direction and an unrestricted medical license within the state. Ideally, the state EMS medical director will be a board-certified emergency medicine physician. State EMS medical direction requires political, administrative, and financial support to achieve these goals. The foundation of the relationship between the state EMS lead agency and the state EMS medical director, including the job description, responsibilities and authority, should be clearly defined within legislation, regulation, or a written contract. The state EMS medical director should be provided with mutually agreed upon compensation for services, necessary materials and resources, and liability protection specific to the unique duties and actions performed. In summary, ACEP, NAEMSP, and NASEMSO strongly encourage the establishment of a regular full-time position for a state EMS medical director in all fifty states, the District of Columbia, Puerto Rico, the territories of Guam, the Virgin Islands, American Samoa, and the Commonwealth of the Northern Marianas Islands. The same concepts of essential medical leadership, system oversight, coordination of guideline development for routine and disaster care, identification and implementation of best practices, system quality improvement, and research apply to physicians involved in EMS medical oversight at a regional or local level. Understanding the medical oversight model and the statutes, rules, or other authorities that enable it is important for every physician who provides out-of-hospital emergency care or is involved with the treatment of patients who may be served by the EMS system. It is equally important for physicians to become aware of the procedures and opportunities to influence these bodies of public policy. Chapter 8 of this volume addresses this subject more extensively. Emphasis in this chapter is put on statutes at the state level because these often drive the arrangements for managing EMS systems down to the local level.",
        "The role of legislation, regulation, and ordinance": "The foundation of EMS legislation, regulation, and ordinance is protection and specifically the protection of patients served by EMS. This is a legitimate and important consideration, particularly in light of the setting in which EMS occurs. When patients select primary care physicians, they have many options for learning about practitioners. Most states provide publicly accessible databases that include information about licensure status, academic background, practice specialty, hospital affiliations, and malpractice experience. The public can see this information, speak with trusted friends and neighbors about their experiences with a particular physician, talk to other health care providers, or pursue other means to learn about a physician in advance of establishing a doctor-patient relationship. When a person dials 9-1-1 with a medical emergency, the experience is very different. Patients have no choice about who arrives to provide their care. Patients in an emergency environment are poorly equipped to protect themselves against incompetent practice. Often, they open their homes to EMS personnel they have never previously met and about whom they know nothing. These EMS personnel are given access to the patient's medications and sensitive information about their medical history, all at a time when the patient may be unable to observe the EMS personnel's actions. The EMS experience often takes place with virtually no advance notice. Patients count on these people to safely and effectively provide life-saving interventions, many of which carry significant risk if not done properly. It is easy to see in this circumstance why there is a public interest in the cautious and conservative regulation of EMS. The role that physicians are assigned in statutes, rules, or other authorities to oversee and assure the quality of EMS in the out-of-hospital setting is an important public protection responsibility.",
        "The language and structure of legislation, regulation, and ordinance": "Terminology surrounding the subjects of EMS legislation, regulation, and ordinance can sometimes be confusing. States may use slightly different titles for similar bodies of public policy. The Minnesota Legislature's website provides a useful discussion of terminology regarding laws, statutes and rules that is broadly applicable to most states. Statutes, also called laws, codes, or sometimes legislation, are federal or state laws that have been created by acts of publicly elected members of Congress or a state legislature. Most state EMS statutes tend to be written in fairly broad language. Often their purpose is to describe the duties and authority of a responsible state EMS agency. State statutes frequently establish structures such as EMS advisory committees or councils. Rules, sometimes also called regulations, are typically created by a state agency under authority provided in a state statute. Rules often have similar enforceability as statutes. They are usually created through an administrative procedure where notice of the rule-making process is given and there is an opportunity for public input. Rules are often more technically detailed than statutes and frequently are longer. Ordinances are municipal or local laws. They may be created by a city, county, town, village, or borough under an authority delegated in state statute. Ordinances often deal with matters of public safety, health, and morals. Communities may establish noise ordinances, leash laws, or building codes that define local standards for the subject of the ordinance. At the community level, ordinances often deal with important EMS matters such as cost, level of service, response times, vehicle and equipment specifications, quality management provisions, quasi-legal documents that affect the provision of EMS. Contracts may exist between private EMS providers and counties, cities, or towns for the provision of EMS. Contracts are agreements between parties for compensation in exchange for goods or services delivered and sometimes penalties for failure to perform. Policies exist within all forms of EMS agencies to describe expectations or requirements for all matters of daily operations. Emergency medical services legislation, regulation, and policy evolve constantly. Federal statutes are the most difficult to change. State statutes represent the next level of effort to modify. State rules or regulations are normally easier to amend than state statutes. Local, county, or municipal ordinances or policies may be less complicated to change than state rules or regulations. Contracts often have periodic opportunities to be amended or renewed. Local EMS agency policies and procedures are generally the easiest to modify. One strategy for establishing standards in statutes and rules is incorporation by reference. An example of this is the National EMS Scope of Practice Model (Scope Model). The Scope Model was established as a component of The EMS Education Agenda for the Future: A Systems Approach (Education Agenda). The Scope Model is a voluntary form intended for use by individual states to establish their specific scopes of practice for EMS personnel. It was developed through a consensus process that included broad input from all elements of the EMS community. The Scope Model represents a floor rather than a ceiling, with the intent that all states who use it assure that EMS personnel licensed in their state are authorized to perform at least the specified skills and interventions. While a state can elect to add more education and skills to a particular level, the Scope Model sets a common expectation that states can have when EMS personnel move between one state and another. Some states have begun to incorporate the Scope Model by reference in their laws or rules. The Scope Model is intended to evolve in the future as more evidence for safe and effective EMS practice is established. States that have incorporated it by reference do not need to reopen their legislative or rule-making processes to make updates. This is an important strategy that enables the debate and discussion of best practice and scientific evidence to occur among the relevant professional EMS organizations rather than within the halls of elected officials who often have little technical knowledge of medical practice. Incorporation by reference has gained popularity with the proliferation of technology that enables most source documents to be easily accessed through the internet. The incorporation of the Education Agenda is a good example of successful policy implementation using the concept of incorporation by reference as well as other concepts mentioned above. In 1998, at the request of NASEMSO, NHTSA supported the development of the Education Agenda. This document followed the original EMS Agenda for the Future with a specific focus on establishing a national system of EMS education that would parallel other allied health professions. The Education Agenda has five components: core content, scope of practice model, education standards, national certification, and national EMS program accreditation. Implementation of the Education Agenda has been a significant national undertaking that was completely voluntary by states. Many implementation efforts are still ongoing. As states have moved to implement the Education Agenda, most have had to amend components of their EMS statutes and/or rules. The majority of states now require NREMT certification to become state licensed, although this is not all states and not for all levels of licensure. Eligibility to hold NREMT certification as a paramedic now requires graduation from an accredited program of education. Accordingly, states that require NREMT certification for paramedics have also either directly or de facto established a requirement for national paramedic program accreditation by the Committee on Accreditation of Educational Programs for Emergency Medical Services Professions (CoAEMSP). As many states adjust their statutes and rules to reflect adoption of the Education Agenda, the language of each state's statutes and rules is not standardized but the concepts behind these licensing and certification authorities are becoming more aligned. National implementation of the Education Agenda is also helping to standardize terminology about the authorization for EMS personnel to function. The Education Agenda calls the verification of entry level competence by NREMT a The document issued by the state EMS authority enabling a person to function is called a Some have felt that the term license implies an independence of practice that is not accurate for EMS personnel given their relationship with medical oversight. In reality, states are free to enact any requirements they wish on the practice of licensed EMS personnel, including requirements to function under medical oversight. This concept parallels the licensure of other allied health professions and reflects the increasing professionalism of EMS personnel. As states incorporate by reference requirements for NREMT certification and CoAEMSP program accreditation into their statutes and rules, they are establishing a standard that will periodically update automatically as the EMS profession evolves without the need to adjust a state's individually created standard.",
        "Authorities established by states and examples of state-specific language": "The language, content, and structure of state EMS laws and rules vary considerably. To date, there has been little effort to standardize the approach states take to regulating EMS, although there is some evidence to suggest that pattern may be changing. A state EMS statute with broad authority will commonly address the following system components. System leadership, organization, regulation, and policy System financing Human resources and requirements for education, certification, and licensure Transportation by ambulance services Systems for regionalization of facilities and specialty care Public access and communications Public information, education, and prevention Clinical care and medical oversight System evaluation and research Large-scale event preparedness and response In some cases, these topical components are addressed in other statutes rather than a single comprehensive EMS statute. One example is large-scale event preparedness and response which is sometimes established in the state\u2019s emergency management statute. Here are some state-specific examples of statute language that represents some of the subjects commonly found in state statutes. These examples illustrate the diversity of approaches state legislatures have taken in assigning responsibilities for EMS oversight, medical direction, exemptions from liability, and other subjects. This is the language in the Nebraska EMS statute that establishes authority for their state EMS office to create rules and the scope of subjects those rules may address. The board shall adopt rules and regulations necessary to: (1) (a) For licenses issued prior to September 1, 2010, create the following licensure classifications of out-of-hospital emergency care providers: (i) First responder; (ii) emergency medical technician; (iii) emergency medical technician-intermediate; and (iv) emergency medical technician-paramedic; and (b) for licenses issued on or after September 1, 2010, create the following licensure classifications of out-of-hospital emergency care providers: (i) Emergency medical responder; (ii) emergency medical technician; (iii) advanced emergency medical technician; and (iv) paramedic. The rules and regulations creating the classifications shall include the practices and procedures authorized for each classification, training and testing requirements, renewal and reinstatement requirements, and other criteria and qualifications for each classification determined to be necessary for protection of public health and safety. A person holding a license issued prior to September 1, 2010, shall be authorized to practice in accordance with the laws, rules, and regulations governing the license for the term of the license; (2) Provide for temporary licensure of an out-of-hospital emergency care provider who has completed the educational requirements for a licensure classification enumerated in subdivision (1)(b) of this section but has not completed the testing requirements for licensure under such subdivision. Temporary licensure shall be valid for one year or until a license is issued under such subdivision and shall not be subject to renewal. The rules and regulations shall include qualifications and training necessary for issuance of a temporary license, the practices and procedures authorized for a temporary licensee, and supervision required for a temporary licensee; (3) Set standards for the licensure of basic life support services and advanced life support services. The rules and regulations providing for licensure shall include standards and requirements for: Vehicles, equipment, maintenance, sanitation, inspections, personnel, training, medical direction, records maintenance, practices and procedures to be provided by employees or members of each classification of service, and other criteria for licensure established by the board; (4) Authorize emergency medical services to provide differing practices and procedures depending upon the qualifications of out-of-hospital emergency care providers available at the time of service delivery. No emergency medical service shall be licensed to provide practices or procedures without the use of personnel licensed to provide the practices or procedures; (5) Authorize out-of-hospital emergency care providers to perform any practice or procedure which they are authorized to perform with an emergency medical service other than the service with which they are affiliated when requested by the other service and when the patient for whom they are to render services is in danger of loss of life; (6) Provide for the approval of training agencies and establish minimum standards for services provided by training agencies; (7) Provide for the minimum qualifications of a physician medical director in addition to the licensure required by section 38-1212; (8) Provide for the use of physician medical directors, qualified physician surrogates, model protocols, standing orders, operating procedures, and guidelines which may be necessary or appropriate to carry out the purposes of the Emergency Medical Services Practice Act. The model protocols, standing orders, operating procedures, and guidelines may be modified by the physician medical director for use by any out-of-hospital emergency care provider or emergency medical service before or after adoption; (9) Establish criteria for approval of organizations issuing cardiopulmonary resuscitation certification which shall include criteria for instructors, establishment of certification periods and minimum curricula, and other aspects of training and certification; (10) Establish renewal and reinstatement requirements for out-of-hospital emergency care providers and emergency medical services and establish continuing competency requirements. Continuing education is sufficient to meet continuing competency requirements. The requirements may also include, but not be limited to, one or more of the continuing competency activities listed in section 38-145 which a licensed person may select as an alternative to continuing education. The reinstatement requirements for out-of-hospital emergency care providers shall allow reinstatement at the same or any lower level of licensure for which the out-of-hospital emergency care provider is determined to be qualified; (11) Establish criteria for deployment and use of automated external defibrillators as necessary for the protection of the public health and safety; (12) Create licensure, renewal, and reinstatement requirements for emergency medical service instructors. The rules and regulations shall include the practices and procedures for licensure, renewal, and reinstatement; (13) Establish criteria for emergency medical technicians-intermediate, advanced emergency medical technicians, emergency medical technicians-paramedic, or paramedics performing activities within their scope of practice at a hospital or health clinic under subsection (3) of section 38-1224. Such criteria shall include, but not be limited to: (a) Requirements for the orientation of registered nurses, physician assistants, and physicians involved in the supervision of such personnel; (b) supervisory and training requirements for the physician medical director or other person in charge of the medical staff at such hospital or health clinic; and (c) a requirement that such activities shall only be performed at the discretion of, and with the approval of, the governing authority of such hospital or health clinic. For purposes of this subdivision, health clinic has the definition found in section 71-416 and hospital has the definition found in section 71-419; and (3) The requirements for licensure for all vehicles, persons and services subject to this chapter, including training and testing of personnel; and (4) Fees to be charged for licenses under this section. E. With the approval of the commissioner, the board shall appoint a Director of Maine Emergency Medical Services. This portion of Montana statute specifically exempts civil liability for local EMS medical directors with limited compensation for their services. (1) A physician, physician assistant, or registered nurse licensed under the laws of this state who provides online medical direction to a member of an emergency medical service without compensation or for compensation not exceeding $5,000 in any 12-month period and whose professional practice is not primarily in an emergency or trauma room or ward is not liable for civil damages for an injury resulting from the instructions, except damages for an injury resulting from the gross negligence of the physician, physician assistant, or nurse, if the instructions given by the physician, physician assistant, or nurse are: (a) consistent with the protocols and the offline medical direction plan approved by the department in licensing the emergency medical service; and (b) consistent with the level of licensure of the emergency medical services personnel instructed by the physician, physician assistant, or nurse. (2) An individual who volunteers or who is reimbursed $5,000 or less in any 12-month period for providing offline medical direction is not liable for civil damages for an injury resulting from the performance of the individual's offline medical direction duties, except damages for an injury resulting from the gross negligence of the individual. Maine\u2019s EMS structure is interesting in that it is one of only a few states where the state EMS agency is a stand-alone entity that is attached to the Public Safety Department for administrative purposes only. This statute defines the powers and duties of Maine\u2019s EMS Board. In Maine\u2019s case, the EMS Board appoints the state EMS director and state EMS medical director, and oversees the functions of the state EMS office. 1 Powers and duties. The board has the following powers and duties. A. The board shall conduct an emergency medical services program to fulfill the purposes, requirements and goals of this chapter. The board shall adopt the forms, rules, procedures, testing requirements, policies and records appropriate to carry out the purposes, requirements and goals of this chapter. B. Notwithstanding any other provision of law, any rule-making hearing held under this chapter and required by the Maine Administrative Procedure Act, Title 5, chapter 375, must be conducted by the board, the director or other staff as delegated by rule or a person in a major policy-influencing position, as defined in Title 5, section 931, who has responsibility over the subject matter of the proposed rule. C. The board shall appoint a licensed physician as statewide emergency medical services medical director and may appoint a licensed physician as statewide assistant emergency medical services medical director. These physicians shall advise Maine Emergency Medical Services and shall carry out the duties assigned to the medical director pursuant to this chapter, or as specified by contract. A person appointed and serving as the statewide emergency medical services medical director or statewide assistant emergency medical services medical director is immune from any civil liability, as are employees of governmental entities under the Maine Tort Claims Act, for acts performed within the scope of the medical director's duties. D. Rules adopted pursuant to this chapter must include, but are not limited to, the following: (1) The composition of regional councils and the process by which they come to be recognized; (2) The manner in which regional councils must report their activities and finances and the manner in which those activities must be carried out under this chapter; Here is an example of the New Hampshire statute that describes the function of a state medical control board that includes the appointment of a physician as the state\u2019s EMS medical director. Emergency Medical Services Medical Control Board; Chair; Duties; State Medical Director. \u2013 I. There is established an emergency medical services medical control board which shall consist of: (a) A minimum of 5 physicians representing different geographic areas of the state who shall be nominated by the councils established under RSA 153-A:6 and confirmed by the board and a physician representative of the trauma medical review committee. (b) The commissioner, or designee, who shall serve as a nonvoting member and as executive secretary. II. The terms of each member shall be 3 years. The chair shall be appointed by the commissioner, and the appointed chair shall become the state medical director. The emergency medical services medical control board shall nominate one of its members to the governor for appointment to the coordinating board established in RSA 153-A:3. III. The duties of the emergency medical services medical control board shall include, but not be limited to, the following: (a) Assisting the coordinating board in the coordination of a system of comprehensive emergency medical services and the establishment of minimum standards throughout the state by advising the coordinating board on policies, procedures, and protocols. (b) Providing technical services required by the division pursuant to RSA 153-A:7, I and the coordinating board. (c) Serving as a liaison with medical personnel throughout the state. (d) Submitting to the commissioner standardized protocols concerning patient care to consider for adoption as rules, which shall address prerequisites within protocols governing their use by providers, living wills established under RSA 137-H, durable powers of attorney for health care established under RSA 137-J, and patient-requested, physician generated orders relative to resuscitation. (e) With the concurrence of the state pharmacy board, specifying noncontrolled prescription drugs that emergency medical care providers licensed under this chapter may possess for emergency use as authorized in RSA 318:42, X. (f) With the concurrence of the state pharmacy board, specifying controlled prescription drugs that advanced emergency medical care providers licensed under this chapter may possess for emergency use as authorized in RSA 318-B:10, V. (g) Approving the protocols and procedures to be used by emergency medical care providers under their own licenses or through medical control. (h) Adopting statewide adult and pediatric resuscitation protocols for licensed emergency medical care providers. This Missouri statute defines the role of regional medical directors. Regional EMS medical director, powers, duties. 190.103. 1. One physician with expertise in emergency medical services from each of the EMS regions shall be elected by that region's EMS medical directors to serve as a regional EMS medical director. The regional EMS medical directors shall constitute the state EMS medical director's advisory committee and shall advise the department and their region's ambulance services on matters relating to medical control and medical direction in accordance with sections 190.001 to 190.245 and rules adopted by the department pursuant to sections 190.001 to 190.245. 2. A medical director is required for all ambulance services and emergency medical response agencies that provide: advanced life support services; basic life support services utilizing medications or providing assistance with patients' medications; or basic life support services performing invasive procedures including invasive airway procedures. The medical director shall provide medical direction to these services and agencies in these instances. 3. The medical director, in cooperation with the ambulance service or emergency medical response agency administrator, shall have the responsibility and the authority to ensure that the personnel working under their supervision are able to provide care meeting established standards of care with consideration for state and national standards as well as local area needs and resources. The medical director, in cooperation with the ambulance service or emergency medical response agency administrator, shall establish and develop triage, treatment and transport protocols, which may include authorization for standing orders. 4. All ambulance services and emergency medical response agencies that are required to have a medical director shall establish an agreement between the service or agency and their medical director. The agreement will include the roles, responsibilities and authority of the medical director beyond what is granted in accordance with sections 190.001 to 190.245 and rules adopted by the department pursuant to sections 190.001 to 190.245. The agreement shall also include grievance procedures regarding the emergency medical response agency or ambulance service, personnel and the medical director. The language in this portion of Vermont's EMS statute is an example of a state that incorporated by reference the National EMS Scope of Practice Model. (10) Establishing, by rule, license levels for emergency medical personnel. The commissioner shall use the guidelines established by the National Highway Traffic Safety Administration (NHTSA) in the U.S. Department of Transportation as a standard or other comparable standards, except that a felony conviction shall not necessarily disqualify an applicant. The rules shall also provide that: (A) An individual may apply for and obtain one or more additional licenses, including licensure as an advanced emergency medical technician or as a paramedic. (B) An individual licensed by the commissioner as an emergency medical technician, advanced emergency medical technician, or a paramedic, who is credentialed by an affiliated agency, shall be able to practice fully within the scope of practice for such level of licensure as defined by NHTSA's National EMS Scope of Practice Model consistent with the license level of the affiliated agency, and subject to the medical direction of the emergency medical services district medical advisor. This Vermont EMS statute language illustrates the trend towards conversion of nomenclature for the authorization to practice from certification to licensure. Transitional provision; certification to licensure Every person certified as an emergency medical provider shall have his or her certification converted to the comparable level of licensure. Until such time as the department of health issues licenses in lieu of certificates, each certified emergency medical provider shall have the right to practice in accordance with his or her level of certification.",
        "Federal legislation, regulation, and policy affecting EMS": "It is beyond the scope of this chapter to address all of the relevant federal statutes, rules, and policies that play a role in governing EMS. However, EMS physicians may wish to become familiar with the following examples as they contemplate their role in EMS system oversight. Health Insurance Portability and Accountability Act Rules (HIPAA). HIPAA requirements are familiar to most physicians. The same provisions that apply in other areas of health care are in force for most EMS operations as well. Emergency Medical Treatment and Active Labor Act (EMTALA). This link connects to the Centers for Medicare and Medicaid Services website and has a number of resources to assist in understanding EMTALA and its relevant federal rules. OSHA Standard 1910:120. The Occupational Safety and Health Administration\u2019s standards regarding hazardous materials. Employers are responsible for protecting the health and safety of their employees who may be exposed to hazardous materials through a variety of means, including personal protective equipment, planning, and training. The OSHA website describes these obligations in detail. The OSHA standards are an example of federal protection for EMS workers that also serve to protect EMS patients through good infection control practices. Medicare Claims Processing Manual Chapter 15 \u2013 Ambulance. Most ambulance services recover at least part of their operating expenses by billing the patients to whom they provide treatment and transportation. Medicare has a significant body of policy that drives the types of services reimbursed, levels of payment through a fee schedule, and other details of documenting services provided. Fair Labor Standards Act of 1938, 29 U.S.C. \u00a7 201 et seq. sets forth wage requirements and hour restrictions for employees, including compensation for overtime work and minimum wages. This act frequently affects EMS shift configurations, employee work schedules, overtime payments, and other aspects of labor-management relations.",
        "The future of EMS legislation, regulation, and ordinance": "As EMS systems evolve, the language and content of statutes and rules will constantly need to be updated. Here are two examples of initiatives that may necessitate changes in many states. Involvement in non-emergency out-of-hospital patient management Some EMS systems are becoming involved in community-based programs to assist in managing a variety of chronic health conditions. EMS systems may be well positioned to take on tasks like monitoring patients recently discharged from the hospital in an effort to prevent readmissions. EMS personnel could do relatively simple chores such as assuring that patients have their prescribed medications and are taking them on a regular basis. Taking periodic vital sign measurements and monitoring patient weight could help to head off readmission of patients with congestive heart failure. Some EMS agencies are able to perform dressing changes for postsurgical patients. While the skills and knowledge needed to perform these functions may not exceed an EMT\u2019s or paramedic\u2019s current scope of practice, the application of these services is beyond what most states explicitly authorize today. The development of a model interstate compact for EMS personnel licensure NASEMSO is currently being supported by the Department of Homeland Security in a project to develop a model for the automatic recognition of an EMS personnel license issued in one state in circumstances where the EMS person needs to work in another state. Interstate compacts exist as an instrument of cooperation between states in many settings. The concept is similar to the national driver's license compact where a person holding a driver's license in one state is able to drive in other states so long as that person follows the laws and rules of the road wherever he or she is driving. For a compact to become effective, legislation must be passed by each participating state\u2019s legislature.",
        "Conclusion": "The entire body of federal, state, and local statutes, rules, ordinances, policies, and other documents of governance is important to the orderly management and oversight of EMS systems. Patient safety is at the heart of most EMS laws and rules because EMS patients are vulnerable by the nature of their conditions and the circumstances under which they require EMS. Legislation, regulation, and ordinance define the structure of and relationships within EMS systems. The purpose of laws created by elected officials is to define and enable structures as well as granting authorities to them. Technical aspects of EMS systems such as education, testing, vehicle and equipment specifications, or similar matters are generally better described in rules created as part of an administrative process. Physicians play crucial roles in assuring the medical appropriateness and accountability of EMS systems. EMS legislation, regulation, and ordinance may all serve to define the legal authorities and responsibilities of physicians and others in EMS systems. EMS medical directors need to know what portions of legislation affect their practice in EMS, what roles they are assigned, and how to participate in the processes for updating and improving the applicable bodies of public policy."
    },
    {
        "Introduction": "Firefighting is an inherently dangerous occupation. Although the number of firefighter deaths in the United States has gradually declined in the past several decades, in 2012 the fireground was the most likely place for a firefighter to die, followed closely by deaths resulting from responding or returning from station. Emergency medical services can be expected to fulfill a variety of roles in medical support of fire service or fire department activities. This chapter will focus on supporting firefighting operations, and not the full spectrum of rescue, hazardous materials, or other special operations incidents to which fire departments typically respond. Many of these roles are addressed in other chapters. Depending on the configuration of the local EMS system, these fire service support functions may be provided by EMS personnel who are part of the fire department or by providers working for commercial or third-service agencies. Where EMS is provided by agencies other than fire departments, formal contracts or memoranda of agreement should be executed to ensure consistent availability and quality of these services, as well as clear delineation of responsibilities and authority. Fire suppression can occur in a variety of settings, which dictate different firefighting tactics, call for the use of different personal protective equipment (PPE), and result in different physiological demands on the firefighters. For example, in aircraft rescue and firefighting, proximity suits and foam trucks may be used, while interior structural firefighting relies on thermal protective \u201cturnout gear\u201d and water pumped by engines through hose lines. Wildland firefighting requires lighter, less bulky protective equipment, and containment strategies concentrate more on depriving fires of potential fuel loads than on extinguishment by cooling or oxygen deprivation. This chapter focuses on EMS support for structural firefighting, as its frequency and associated hazards result in the greatest proportion of line-of-duty deaths and injuries to firefighters. Where appropriate, other types of fire suppression will be referenced. There are four principal roles for EMS at structure fires: stand-by for possible illness or injury to firefighters on the scene, treatment and transportation of firefighters with injuries or medical conditions resulting from their duties, management and staffing of a rehabilitation (rehab) area for the working fire personnel, and treatment and transportation of civilian victims of the fire.",
        "Fireground stand-by": "The first two of the EMS responsibilities listed above are required by both federal regulation and industry standards. In hazardous materials (hazmat) incidents, responders don PPE to enter potentially lethal atmospheres that have been designated as immediately dangerous to life and health (IDLH). Similarly, interior structural firefighting takes place in an environment that is considered IDLH by virtue of both ambient temperature and the presence of toxic products of combustion. This means that the hazardous waste operations and emergency response (HAZWOPER, 29 CFR 1910.120) regulations apply to the fire-ground as well as to hazmat incidents. One of the HAZWOPER provisions specifies that transport-capable EMS must be on scene in case of injury or illness of one or more responders. The same requirement with respect to structural firefighting is found in National Fire Protection Association (NFPA) 1500, Standard on Fire Department Safety and Health Programs. The NFPA promulgates consensus standards that fire service organizations adopt voluntarily, except in jurisdictions that mandate compliance with the standards through regulation or statute. Since this transport-capable EMS stand-by is required by both federal regulation and NFPA standard, many local protocols call for automatic dispatch of at least one ambulance and crew to all confirmed structure fires. If that ambulance is diverted to provide treatment and transportation of either a civilian victim or a firefighter, then another should be automatically and immediately dispatched to take its place. This is why it is considered a separate role of the four basic EMS roles on the fireground, despite the common practice of using providers from the stand-by ambulance for rehab activities unless they are needed to perform their primary role. Language in the NFPA 1500 annex indicates that ALS-capable providers are preferred for the stand-by function. Additional considerations for EMS in this stand-by function that require collaborative protocols include positioning of ambulances so that they can rapidly exit the scene with an injured responder, and do not interfere with the positioning of fire apparatus or the functioning of hose lines; ability to communicate between EMS providers and fire command staff (particularly if they come from outside agencies); and safety (including the appropriate use of personnel protective equipment) and accountability of the EMS personnel on the scene. All these issues should be worked out prospectively and in detail. Both fire and EMS personnel must be trained in the protocols and required through departmental discipline to comply with them. During all fireground and other emergency operations, responding EMS personnel must operate within the incident command system (ICS) under the direction of the incident commander or his/her designee.",
        "Physiology of structural firefighting": "The EMS roles on the fireground that do not deal with civilian victims require a substantial understanding of the physiology of firefighting. This topic is briefly discussed here to assist EMS medical directors in the joint development of rehab and treatment/transport protocols with fire department physicians. Fire department physicians are typically occupational medicine providers who use a list of the essential job tasks associated with firefighting to evaluate medical fitness for duty. NFPA 1582, Standard on Comprehensive Occupational Medical Programs for Fire Departments, requires that fire department physicians participate in operational safety matters and that they collaborate with EMS medical directors on procedures for medical support of firefighters at fire incidents. Firefighting involves strenuous physical work, sometimes in extreme heat, for variable periods of time. Fire personnel may be exposed to environmental temperatures in excess of 700\u00b0F during structural firefighting. Firefighters depend on their PPE to allow them to function in such temperatures. This includes bunker pants, boots, coat, gloves, hood, helmet, and self-contained breathing apparatus (SCBA). The full protective ensemble may add 50\u201375lb of weight, increasing firefighters\u2019 workloads significantly. While PPE protects firefighters from heat and burns, it also prevents the physiological cooling that would normally occur through convection and evaporation of sweat. The PPE creates a thermal microenvironment next to the skin that is hot and has 100% relative humidity. The coat and bunker pants comprise multiple layers of composite materials including outer shell, moisture barrier, and thermal barrier. They are rated for total heat loss (THL), which measures evaporative heat transfer or breathability, and thermal protective performance (TPP), which measures thermal insulation as outlined by NFPA 1971, Standard on Protective Ensembles for Structural Fire Fighting and Proximity Fire Fighting. Increasing TPP may result in decreased THL, but any interference with evaporative cooling can contribute to rapid temperature elevations in exercising firefighters. Early studies showed that firefighters\u2019 heart rates increase at the time of initial alarm, before any physical activity occurs. Heart rate monitoring does not directly correlate with energy expenditure or core temperature rise. Part of the increase in heart rate is due to work demand, but much more is due to thermal stress. Increased cardiovascular work and thermal stress are thought to contribute to the substantial cardiovascular morbidity and mortality associated with fire suppression. A study looking at cardiovascular effects of repeated, strenuous live-fire drills found that peripheral vasodilation and sweat loss resulted in significant reduction in stroke volume after as little as 20 minutes of performing such drills. Since heart rate is sustained at or near maximum throughout a fire response, any decrease in stroke volume immediately translates to decreased cardiac output. This physiology is known as uncompensable heat stress and develops rapidly during fire suppression. Firefighters perform many tasks, several of which involve heavy work. A sample list of essential job tasks associated with firefighting appears in NFPA 1582. These tasks represent a combination of aerobic and anaerobic exercise together with requirements for balance, agility, mental acuity, and judgment. Examples of how aerobic, anaerobic, and static physiological demands are combined in firefighting include stair and ladder climbing while carrying 50\u201375lb of tools or hose, and use of pike poles to breach walls or ceilings during overhaul. Live fire exercises induce increased cardiovascular stress when compared to mock fire exercises. Of the typical tasks associated with fire rescue services, interior structural firefighting while wearing SCBA demands the most energy. While wearing SCBA protects firefighters from inhaling carbon monoxide and other toxic products of combustion, it adds weight and restricts movement and peripheral vision. After performing strenuous work such as search and rescue and initial knockdown of a structure fire, firefighters begin \u201coverhaul.\u201d The use of axes and pike poles to search for smoldering fire within walls and ceilings requires further disproportionate upper body exertion, which is associated with greater cardiovascular stress when the firefighter may already be fatigued, hot, and dehydrated. SCBA use is variable during overhaul. Lack of SCBA use while sifting through piles of smoldering material may increase firefighters\u2019 exposure to CO. Non-flaming combustion produces more smoke than flaming combustion; the dominant dangerous gas in smoke is CO. Increased heart rate and exposure to CO during exercise result in changes in ST segments on ECGs. Fire suppression activities (compared to non-emergency duties) may cause much higher chances of death from coronary heart disease in firefighters. Core temperatures of firefighters continue to rise after completion of firefighting tasks in heat. The cumulative evidence underscores the need for rehab areas at fire scenes and incorporation of cooling in rest cycles, as advocated by others, and perhaps to preemptively evaluate firefighters for their ability to tolerate heat stress.",
        "Treatment and transport of ill or injured firefighters": "By far the most common fireground injuries are musculoskeletal, and the most common cause of death is cardiac. Normal protocols for evaluation, treatment, and transport of patients with musculoskeletal injury should be followed when they occur during firefighting operations. In addition, department policy should require medical evaluation of any acute injury sustained by a firefighter before he/she returns to operations in that hazardous environment. Many of the essential job tasks associated with fire suppression may be difficult or impossible if mobility or strength is impeded by pain or swelling. The substantial risk of cardiac events on the fireground primarily drives the recommendation that ALS-level EMS be available at the scene. While the evaluation and treatment of acute cardiac syndrome (ACS) in firefighters is not significantly different from that in other patients, there are a few considerations to bear in mind. First, with the exception of actual chest pain, the signs and symptoms of ACS are generally similar to those accompanying the fatigue, heat, and dehydration experienced to some extent by all firefighters. For this reason, it can be more challenging to distinguish a firefighter with ACS from the others who simply need rehab due to exhaustion. It is therefore important for EMS providers to remain vigilant for this possibility in the rehab area, as will be further discussed below. Second, signs and symptoms of ACS or sudden cardiac death occurring during fireground operations may indicate exposure to toxic products of combustion rather than, or in addition to, structural cardiac disease. Of particular importance in this regard are carbon monoxide, which can be non-invasively measured on the fireground, and cyanide, which may be a more prevalent hazard of fire suppression than previously thought. EMS physicians, in collaboration with fire department medical personnel, may consider specific destination hospitals, such as those with facilities for hyperbaric oxygen therapy, for firefighters when carbon monoxide poisoning is suspected or confirmed by field measurement. In addition, protocols for management of firefighters with refractory altered mental status, hemodynamic instability, or seizures may include empiric use of cyanide antidotes. Finally, protocols for EMS management of firefighters sustaining severe injuries or burns during fire suppression should include threshold criteria for direct transportation to regional trauma and/or burn centers.",
        "Fireground rehabilitation": "In \u201crehab,\u201d EMS personnel provide medical monitoring, cooling (or warming in very cold weather), and basic fluid replacement to fire personnel operating on the fireground. Current standards for rehab are found in NFPA 1584, Standard on the Rehabilitation Process for Members During Emergency Operations and Training Exercises. One of the premises of rehab operations is that through a coordinated system of on-scene mandated rest, medical monitoring, and rehydration, some of the line-of-duty deaths due to stress or overexertion can be prevented. Although intuitively reasonable, objective, conclusive research that validates this premise is scarce. The essential role of EMS medical directors in rehab operations is to ensure that all fire and rescue agencies under their jurisdiction have rehab policies and procedures in place that are not only compliant with applicable standards and laws but are also medically sound. Once in place, medical directors must include rehab operations in their internal quality improvement process. Common rehab functions that require oversight by an EMS medical director include the following. \u2022 Establish vital sign parameters for initial triage and reassessment of firefighters in rehab. These vital sign parameters should define what are considered \u201cabnormal\u201d vital signs that will mandate that a firefighter in rehab undergo additional medical assessment prior to leaving the rehab sector. These parameters usually include the evaluation of objective signs such as heart rate, pulse quality, blood pressure, and body temperature. In addition, some accommodation for more subjective evaluations (such as the firefighter who simply appears too exhausted to return to immediate duty) should be incorporated into medical protocols. \u2022 Establish protocols that will determine which firefighters will require immediate transport from the rehab sector to a medical facility for further evaluation and care. Such protocols are generally based on profoundly abnormal vital signs (e.g. pulse greater than 160), objective physical findings (such as an irregular pulse), and/or subjective complaints (such as acute chest pain). \u2022 Ensure that the medical providers operating in the rehab sector have the delegated authority of the medical director to retain in rehab or order the transport of any firefighter considered unready to return to on-scene duties. This authority is essential to the effectiveness and credibility of medical rehab operations and should be established within the ICS by specific discussions with the fire chief as part of rehab policy development prior to real-time implementation. \u2022 Provide advice regarding optimal rehydration solution for firefighters during company-level and rehab sector operations. Provide advice regarding the roles of passive or active cooling in fireground rehab to decrease heat stress in working firefighters. Passive cooling involves the firefighter removing coat, helmet, and SCBA. Active cooling requires misters, cooling vests, cool wet towels, or immersion in cool water. Passive cooling is effective as long as the environmental temperature is cooler than the firefighter\u2019s core temperature. Misters are easily added and provide significant heat reduction. Studies are beginning to show that hand and forearm immersion in cool water reduces heat strain and may increase work performance. Further research is needed to determine whether firefighters are safely able to resume fire-ground work after use of these simple and readily available interventions.",
        "When to begin rehabilitation": "The two preceding sections outlined the physiological stressors and common causes of illness, injury, and death associated with structural firefighting. If the goal of rehab is to provide rest, rehydration, and medical monitoring in order to prevent or reduce the incidence of heat and stress-related illness in firefighters, then rehab operations should commence whenever emergency operations or training exercises pose the risk of exceeding a safe level of physical or mental endurance. This typically occurs within 20 minutes of starting structural firefighting. All firefighters and fire officers should be trained to recognize the signs and symptoms of fatigue, dehydration, and heat-related emergencies. It is important for firefighters to not only monitor other crew members for the development of such conditions but also to recognize such signs and symptoms in themselves. If a firefighter detects any concerning signs or symptoms either personally or in a fellow firefighter, then standard operating procedures (SOPs) should require that the entire crew withdraw from current activities and begin rehab. Rehab can and should occur not only at the sector/area level in larger incidents, but also at the company/crew level as part of daily operations. Thus, all fire apparatus should carry potable water and/or other basic oral rehydration solutions to facilitate company/crew-level (self) rehab. One strategy to encourage company/crew-level rehab is the placement of rehydration solutions in close proximity to spare SCBA cylinders on the fire apparatus. Exact guidelines and policies as to when to initiate rehab operations will vary from department to department. Commonly used work-to-rest guidelines include the following. At the company/crew level: 5\u201310 minutes of rest and rehydration should occur after the use of one 30-minute SCBA cylinder or after 20 minutes of intensive work without SCBA (including extrication and training situations). At the formal rehab sector/area level: 10\u201320 minutes of rest, rehydration, and a medical assessment should occur after the use of two 30-minute SCBA cylinders, one 45- or 60-minute cylinder, whenever an encapsulating hazmat suit is worn, or after 40 minutes of work without an SCBA.",
        "Setting up a rehabilitation area": "Once the decision is made by the incident commander to establish a formal sector, a rehabilitation manager is assigned within the ICS. The first consideration of the rehab manager is site selection for the rehab area. The rehab area should be large enough, located uphill and upwind of the incident, and in a location well outside the hot zone where it is safe for firefighters to remove their helmets and protective clothing. In addition, the rehab area should be in close proximity to SCBA replenishment and adjacent to an ambulance staging area to facilitate the transport of firefighters who are determined by EMS personnel to require medical evaluation and treatment at the hospital. The rehab area should also be situated to protect firefighters from extremes of environmental conditions, such as providing shade in the summer and warmth in the winter. Some degree of privacy for the personnel in rehab is also a consideration. Various departments around the country use different assets to accommodate the rehab function. Determinants of the types of resources used for rehab include local climate, size of the department, and characteristics of the built environment. For example, some departments deploy specially equipped RVs or trailers for rehab, while others use buses from local school districts or public services. In some climates, retractable awnings on fire apparatus with or without misters for cooling and combined with salvage tarps to delineate the area are adequate. Incident commanders at high-rise fires may establish rehab two or more floors below the fire floor while nearby buildings of opportunity may be the best solution for rehab in other urban operations. Ideally, an ALS provider(s) should staff the rehab area, but at minimum the rehab area should be staffed by an AED-equipped EMT. In order to ensure proper tracking, accountability, and medical evaluation of firefighters in the rehab area, the medical provider(s) assigned to the rehab area should not have on-scene duties outside of rehab. If medical personnel are needed to care for civilian injuries or other on-scene medical needs, EMS personnel other than those in rehab should be assigned to those missions by the incident commander.",
        "Flow through rehabilitation area": "One of the significant logistical challenges in the management of the rehab sector is medical documentation and tracking, or \u201caccountability,\u201d of personnel operating on the fireground. Accountability is the process by which the location of all fire crews and each individual firefighter is known at all times by the incident commander. Such knowledge is essential, and no less than life-saving, in the event of a catastrophic change on the fireground such as a structural collapse in which firefighters may be trapped and unable to communicate their positions. Entry to the rehab area should be through a single portal. This allows the proper logging in of crews and assures accountability. Once the firefighters have been logged in, they should generally doff their helmets, hoods, and coats (and if possible their bunker pants) to allow for cool-down. All firefighters should then receive an entry/triage vital sign determination, including pulse, blood pressure, and temperature. Guidelines that set specific parameters as to what constitutes \u201cabnormal\u201d triage vital signs in rehab should be established by the EMS medical director in consultation with the fire department physician as part of rehab SOPs. Sample triage vital sign parameters are shown in Box 40.1. It should be noted that currently such guidelines are largely anecdotal and intuitively driven because studies that validate such parameters have yet to be published. Because a major goal of rehab operations is to detect and prevent heat-related emergencies, the monitoring of a firefighter\u2019s temperature is a crucial part of the rehab medical evaluation. This is especially important given that most heat-related emergencies can be very effectively treated if detected early. Temperature should be obtained as part of triage into the rehab area. If the temperature exceeds 100\u00b0F, the firefighter should be sent to the medical evaluation section of the rehab area for cooling, rehydration, and subsequent repeat temperature determination. Particularly aggressive temperature-related protocols are found in the Southwest. For example, the Phoenix Fire Department\u2019s rehab SOP states that any firefighter with a temperature higher than 101 \u00b0F (38.3 \u00b0C) must receive intravenous (IV) hydration and be transported to the emergency department. Research on temperature determinations in the rehab setting has demonstrated that oral digital thermometers appear more reliable than tympanic temperature determinations in the outdoor environment of rehab. Because the accuracy of temperature determinations is so crucial to the well-being of firefighters, rapid oral digital thermometers are preferred in the rehab area over tympanic thermometers. In any scenario, interventions to cool firefighters such as misting fans are a critical component of rehab operations in warm weather operations. Vital signs obtained during a rehab evaluation will vary greatly from one firefighter to another. Obtaining \u201cbaseline\u201d vital signs on each department member prior to an incident can be very helpful for the medical personnel trying to evaluate specific vital signs in the rehab area. Ideally all firefighters should have a full set of baseline vital signs obtained and recorded both at rest and after a fixed aerobic activity (such as running in place for 5 minutes). These baseline vital signs can be obtained at drills or as part of an annual physical assessment. The information obtained should then be immediately available to the rehab medical staff. Some departments include this information as part of their accountability systems (e.g. embossed on the firefighters\u2019 accountability tag). During the process of obtaining baseline vital signs, it should also be determined if members are taking any prescribed medications, especially in the general categories of beta-blockers or calcium channel blockers. It is important to note the presence of one of these medications because they may act to slow the heart rate and control hypertension, making pulse rate and blood pressure criteria potentially invalid for those firefighters. The presence of a beta-blocker or calcium channel blocker prescription should be noted alongside baseline vital sign data available to the medical personnel staffing the rehab area. In addition to obtaining vital signs, EMS staff should briefly question entering firefighters about concerning symptoms such as headache, chest pain, shortness of breath, or palpitations that may indicate a potentially life-threatening, stress-related illness. Medical providers performing entry triage and screening should also be alert to more unusual complaints by incoming firefighters such as excessive saliva production or odd tastes in their mouths that could indicate a previously unidentified hazmat danger on the scene. If such a discovery is made, it should be immediately communicated to the incident commander. Based on the triage vital signs, personnel are assigned either to the \u201crest and rehydration\u201d zone (those with acceptable initial triage vital signs) or the \u201cmedical evaluation/monitoring\u201d zones within the rehab area (those with initial vital signs beyond acceptable parameters). In this two-zone rehab system, firefighters receive rest and hydration in both zones, but personnel assigned to the medical evaluation/monitoring zone will receive more careful medical monitoring and reevaluation by EMS. At a minimum, all firefighters assigned to the medical evaluation/monitoring zone will require a repeated full set of vital signs prior to being allowed to return to duty. Personnel who were initially sent to the rest and rehydration zone may not necessarily require repeat vital signs prior to returning to duty, depending on department policy. During rehab and medical monitoring of crews, rehab sector personnel may detect signs and symptoms of potentially life-threatening emergencies. \u2022 Chest pain \u2022 Shortness of breath \u2022 Palpitations or irregular pulse \u2022 Altered mental status (confusion, seizures, dizziness, etc.) \u2022 Skin that is hot and either dry or moist \u2022 Oral temperature greater than 101 \u00b0F (38.3 \u00b0C) \u2022 Pulse greater than 150/min at any time \u2022 Pulse greater than 120/min after cool-down \u2022 Systolic blood pressure greater than 200 mmHg at any time \u2022 Diastolic blood pressure greater than 130 mmHg at any time If any of these conditions is detected, the EMS provider attending the scene should administer high-flow oxygen, initiate appropriate care, and transport the firefighter immediately to a hospital emergency department for further evaluation and treatment. Use of an ALS unit is indicated for all these conditions. However, transport of a firefighter to the designated hospital should not be delayed if ALS is unavailable. Whenever medical personnel assigned to the rehab sector are unsure about the disposition of a firefighter who reports there, it is always better to act on the side of safety. Therefore, if evaluation of a firefighter\u2019s condition indicates that he or she is marginal for return to active duty, that firefighter should be kept off-duty. Similarly, if there is any question about whether a firefighter\u2019s signs or symptoms indicate a potentially dangerous condition, the EMS provider should ensure that the firefighter is transported from rehab to a medical facility for further evaluation and care. Ultimately, vital signs alone should not be the sole criteria for triage to the medical unit or the retention of a firefighter in the rehab area. The \u201clook test\u201d should also be incorporated into the assessment by medical personnel. A firefighter who appears exhausted and fatigued by the subjective observation of his/her gait, skin color, or overall appearance may have vital signs that fall within accepted parameters but may still not be fit to return to duty. That firefighter would fail the \u201clook test\u201d and potentially should receive additional rehab and monitoring prior to returning to full duty. When company officers are observing personnel during periods of company/crew-level rehab (self-rehabilitation), the \u201clook test\u201d is often the only tool available to them to determine fitness for duty. Various tracking systems have been proposed to ensure that each firefighter in the rehab area has vital signs trended and that those data are immediately available to the medical providers in rehab. Although some agencies use a master vital sign document for simultaneously tracking the vital signs of all firefighters in rehab, this system can be easily overwhelmed in large rehab operations. Due to this limitation, experience has demonstrated that individual tags that clearly identify key medical information that is specific to rehab \u2013 and are attached to each firefighter on entry and then collected upon exit from the rehab area \u2013 are very effective. At a minimum, firefighters assigned to rehab should be rested and rehydrated for 10 minutes before returning to duty. Those who had initial triage vital signs outside accepted parameters should remain in the rehab area for 20 minutes, receiving rehydration prior to the reassessment of their vital signs. If after 20 minutes, a firefighter's vital signs remain outside established parameters (examples of such parameters are shown in Box 40.2), then he/she should either be retained in the rehab area for further monitoring or transported to the hospital for further evaluation. The ultimate decision as to whether a firefighter may return to active duty from the rehab area is the responsibility of the ranking medical officer in the rehab area, guided by preestablished department medical guidelines. In situations where company- or crew-level rehab is being used, it is the responsibility of the company officer to determine whether a firefighter appears able to return to duty. After being cleared by EMS, crews should be released from the rehab area in a \u201cfirst in, first out\u201d fashion. Once crew members are released from rehab, they should be logged out, adhering to all department accountability procedures. The crew should exit via the designated point of entry/exit. After leaving the rehab area, crews can be released to return to quarters if no longer needed on the scene, receive a new assignment, or be staged for later deployment. If one or more crew members are not fit to return to duty and have either been retained in the rehab area or transported to the hospital, the remaining crew members can be released from rehab and reassigned to an appropriate task for a small crew or be combined with another crew/company for ongoing operations. In the rare case that a member of a crew was killed or becomes critically ill or injured, then it is appropriate to remove the remaining members of that crew from service and initiate critical incident management measures as dictated by department policy.",
        "Rehydration and nutritional support": "The ingredients of ideal nutritional support for firefighters can be viewed as a balanced triangle. The three sides of the triangle consist of fluid/nutritional needs, the local resources available to provide for these needs, and the ability of emergency personnel to retain and digest the fluids or food provided. By balancing these three factors, the appropriate type of fluid and food replacement can be determined for the personnel at a given incident. The ability of local resources to deliver the necessary fluid and nutritional support will depend not only on the remoteness of the scene but on more practical considerations, such as the availability of refrigeration. In all circumstances, regardless of location, the rehab sector must provide adequate water, electrolytes, and energy-producing carbohydrates to ensure that emergency personnel can continue to function safely at optimal levels, despite adverse environmental and physiological conditions. At most scenes, rehab operations consist of fluid replacement without having to provide nutrition in the form of solid foods. Therefore, from a nutritional standpoint, knowledge of fluids, electrolytes, and the key concept of maintaining water balance remains the cornerstone of most rehab operations. Dehydration is inevitable in situations of increased fluid loss during prolonged exposure to heat or strenuous activity. Firefighters can lose a liter of water in the initial 20 minutes of intense fire suppression activity and a 2-liter fluid loss per hour is a reasonable expectation in hot and humid conditions. When dehydration progresses without adequate rehydration, a person's performance will be affected. If 4% of body weight is lost via sweating (not an unrealistic possibility in extended operations, such as wildland fire suppression), both mental reasoning and physical abilities may be compromised. In addition, dehydration can lead to impairment in thermoregulation and decreased blood volume with resultant increased cardiovascular strain. Another key physiological concern in rehab is that gastric emptying capacity, paradoxically, decreases as the firefighter becomes more dehydrated and heat stressed. This reality has a significant effect on oral rehydration strategies in rehab as overly aggressive rehydration with oral solutions can lead to gastric distension with the potential for resultant nausea and vomiting. It is believed that gastric emptying capacity in dehydrated and exhausted firefighters is limited to about 1 liter per hour. These various physiological challenges demand specific strategies as part of rehab operations to balance fluid loss in as close to a 1:1 ratio with fluid replacement as possible. In practical terms, due to limitations in gastric emptying capacity, a 1:1 repletion ratio is an ideal but potentially unobtainable goal.",
        "Repletion strategies": "The goal of maintaining adequate hydration and nutrition throughout fire suppression is achieved by two basic strategies: prehydration and rehydration.",
        "Prehydration": "With the exception of certain training or prolonged operations, it is difficult to predict exactly when a major response will occur that will place the firefighter in extreme physiological stress. If it is known that a physiologically stressful event is inevitable within the next hour or two, as may be the situation in a task force moving up from staging, then prehydration to a positive water balance should be started. In this situation it is recommended that firefighters ingest an additional 16 oz (500mL) within 2 hours of deployment. If ingested with a meal, water may be used in this situation. Otherwise, a commercial sport drink should be used. Some career fire departments in the Southwest have policies that require firefighters to maintain pre hydration status while on duty during periods of prolonged high temperatures. Such policies often require on-duty personnel to drink 6\u20138 oz of fluid every 6 hours while in addition to routine meals. Obviously, such routine prehydration strategies may be difficult to accomplish for volunteer firefighters. A final concept to consider is that overly aggressive prehydration can lead to overhydration. Overhydration is especially detrimental when plain water is used, since key electrolytes such as sodium chloride and potassium could be diluted out by excessive water being taken in. In a hot environment especially, starting out with initially low electrolytes can cause more rapid onset of electrolyte-mediated heat emergencies such as heat cramps and heat exhaustion. This reality should reinforce the importance of including more than just water alone in hydration fluids. Thus, in prolonged operations (broadly defined as longer than 1 hour), electrolytes and carbohydrates are also considered critical to rehydration in rehab.",
        "Rehydration": "Rehydration is the nutritional key function of the rehab sector. Firefighters who enter rehab should begin rehydration as soon as baseline vital signs are taken and accountability requirements met. Although there may be some local variations, ideal rehydration solutions administered in the rehab sector should contain not only water but electrolytes and simple carbohydrates as well. Commercially available sport drinks contain these three major components. In very brief, low-intensity operations, simple water is an acceptable oral solution for firefighter rehydration. NFPA 1584 recommends that during the initial rotation through rehab, firefighters should drink 8 oz of sports drink. This relatively low volume of rehydration solution is recommended in order to reduce the potential risk of nausea and vomiting due to reduced gastric emptying in physiologically stressed firefighters. During prolonged and high-intensity operations, this document also recommends the intake of 30\u201360 grams per hour of carbohydrates and the consumption of additional carbohydrate sources such as fruit or snack bars (see \u201cMinor nutritional support\u201d section below). Two additional concerns about the exact type of rehydration beverage to be used include that the beverage must possess a taste that is acceptable, and must be easily tolerated by the gastrointestinal system without causing nausea, vomiting, or other adverse consequences. Although taste reflects individual preference, the simple sugars contained in commercially available sports drinks make them palatable to most. Several more factors (in addition to gastric emptying capacity) contribute to how well rehydration solutions are tolerated by the gastrointestinal system. The first factor is temperature. Rehydration fluids should not be served at the extremes of temperature. When rehydrating in hot conditions, fluids should be cool but not ice cold. Rapid ingestion of ice cold fluids can cause painful spasms of the esophagus or even, rarely, precipitous slowing of the heart rate. Similarly, in cold conditions, \u201chot\u201d rehydration beverages should be served warm, rather than \u201cpiping\u201d hot. Another factor that has been cited as contributing greatly to the digestion of fluids is the solution\u2019s osmolarity. The higher the osmolarity, the longer it will take to absorb the fluid, and the harder it will be to digest. In general, it is recommended that rehydration solutions served in the rehab sectors do not exceed 350 mOsm/L. Because most osmolarity in sport drinks is determined by simple sugars, those containing less than 15 grams of simple carbohydrates per 8 oz are recommended for use in rehydration. Once the appropriate rehydration solution is selected, it should be administered to all personnel in the rehab sector with the exception of those with excessive nausea or those who are vomiting (these will likely require IV hydration). Fluid repletion should be provided both during the height of operations as crews are rotating through rehab and also once personnel are released from active on-scene duties and are back in quarters. After operations are completed, firefighters should consume an additional 8\u201332 oz of electrolyte- and carbohydrate-containing fluid over the 2 hours following the operation. Self-monitoring of one\u2019s own urine after the completion of an operation can be helpful in guiding postrehab sector hydration. If personnel continue to note that urine is dark in color or strong in odor after returning home or to the station, or that urinary output is diminished in spite of adequate fluid intake, then addition rehydration will be necessary to return to a proper water balance.",
        "Provision of solid foods in rehab sector": "In prolonged operations it will be necessary to provide not only adequate fluid but more comprehensive nutritional support in the form of solid foods. Indeed, in the case of wildland fire suppression or urban search and rescue operations, formal meals must be provided. The provision of solid foods to firefighters and other rescue personnel is less well understood or studied than fluid rehydration. Often, once replenishment operations move into the realm of solid foods, outside agencies or vendors provide nutritional support. Solid foods being provided to firefighters must meet two basic criteria: they must provide adequate nutrition, and they must be served easily and safely to emergency personnel on scene. Foods served in rehab should contain carbohydrates, proteins, and fats. Because of their crucial energy-producing role in body metabolism, carbohydrates should be the most prevalent nutrient group contained in foods supplied to firefighters and other personnel in the rehab sector during prolonged operations. Ingestion of protein assists in simple carbohydrate uptake, muscle repair, and immune functions. Logistical considerations such as being able to prepare, store, and serve the food in sanitary conditions are essential when selecting foods for the rehab sector. Failure to store, cook, and serve foods at proper temperatures risks spoilage and foodborne illness with resulting incapacitation of the deployed crews. One of the best weapons against food-borne disease in rehab is a food service thermometer. As a general rule, \u201ccold\u201d foods must be served at less than 40\u00b0F and \u201chot\u201d foods must be maintained at temperatures of greater than 140\u00b0F. Preplanning menus of exactly what foods will be served in rehab during prolonged operations should be part of each department\u2019s major incident SOPs. Such plans should take into account both sound nutritional considerations and realistic logistical planning for food preparation, storage, and delivery on the scene. Some agencies make the distinction between \u201cminor\u201d and \u201cmajor\u201d nutritional support.",
        "Minor nutritional support": "At certain medium- and long-duration incidents, it may only be necessary to provide personnel with snack-type foods in the rehab sector. In this setting, complex carbohydrates are perhaps the most important content of any solid foods provided to on-scene personnel. Fruits such as oranges, bananas, and apples are an excellent source of complex carbohydrates, and possess the added benefit of having a high water content to augment oral rehydration with liquids. In addition, fruit is easily stored and served in virtually any rehab setting. Despite these attributes of fruit, care must be taken to prevent potential contamination of the fruit by the products of combustion that often coat the hands of firefighters in rehab.",
        "Major nutritional support": "Preplanning specific logistics with the organization(s) that will provide full meals during protracted operations is an essential component of departmental SOPs for rehab operations. Such preplanning should include notification and dispatch, meal planning, and orientation of the outside agency to the ICS.",
        "Conclusion": "Emergency medical services perform three principal services in support of personnel engaged in structural firefighting: stand-by for possible illness or injury to firefighters on the scene, treatment and transportation of firefighters with injuries or medical conditions resulting from their duties, and management and staffing of a rehab area for the working fire personnel. EMS medical directors should coordinate with fire department physicians and safety officers in the development of medical protocols and procedures that address the specific physiological stresses and environmental hazards associated with fire suppression."
    },
    {
        "Introduction": "The operational effectiveness as well as the safety, or even survival, of all components of the local, regional, and state medical infrastructure confronted with a large-magnitude natural, manmade, or terrorism-related disaster will largely depend on the quality of the overall incident management. Public safety, public health, emergency management, and health care system officials should be familiar with the rudiments of emergency incident management theory and practice. Nowhere is this more important than in EMS, where the system must interface seamlessly with public safety entities that use the incident command system (ICS) for daily operations, and hospitals, where the administration typically alters its organizational management scheme to an ICS during major emergencies.\n\nIt is easy to understand why it is necessary to organize the management of emergency incidents differently than normal business or public administration plans. For example, a bureaucracy is, by definition, the wrong structure through which to manage a low-frequency, high-hazard incident. According to Webster\u2019s Dictionary, a bureaucracy is a \u201cgovernment marked by diffusion of authority among numerous offices and adherence to inflexible rules of operation \u2026 [or] an administrative system in which the need to follow complex procedures impedes effective action.\u201d In organizational theory, the core features of bureaucratic management include formalization (i.e. enforcement of rigid rules and procedures), specialization, and hierarchy. This form of administration is most effective at handling large-volume, variably complex but routine tasks, in stable environments.\n\nManagement of unstable situations with potentially catastrophic outcomes requires establishment of high-reliability organizations. Roberts et al. observed that reliability is directly related to flexibility of the organizational structure. Temporary organizations assembled in response to specific challenges may provide such flexibility, and offer an attractive alternative to conventional structures that have not performed well in high-risk, high-hazard environments. Virtual organization represents an increasingly common temporary administrative architecture for corporate and public safety entities operating in crisis mode.\n\nOne distinguishing characteristic of virtual organizations is the time-limited assembly of diverse agencies, corporations, or other specialized teams into a task-determined architecture for the purpose of accomplishing an immediate goal. Linkage within the virtual organization is through information pathways. When constituent units are not colocated, they are electronically networked. The relationships among the units can be evanescent, as structural changes are dictated by the demands of the mission. Virtual organizations make good high-reliability organizations, as units having diverse expertise or resources can share previously inculcated health and safety priorities as well as the joint vision of the mission at hand. Their innate adaptability to rapidly changing conditions as well as some intrinsic redundancy also favor the use of virtual organizations for management of complex, high-hazard, or high-consequence incidents.\n\nSeveral investigators have studied the ICS employed by local emergency responders as a model high-reliability, virtual organization. As required by presidential directive, state and federal agencies have nominally incorporated ICS into their emergency response plans because of its simple design, and to facilitate integration of their assets into local emergency operations. The National Incident Management System (NIMS) was designed to coordinate multiagency, multijurisdictional responses to large-scale emergencies. For ICS and NIMS to function effectively, the basic premises of ICS must be understood by those implementing it. These principles cannot be compromised without losing the effectiveness and performance for which ICS and NIMS have become so highly regarded.\n\nIncident command systems were first designed for use by civilian emergency responders in the United States in the mid-1970s. An interagency representative group, Firefighting Resources of California Organized for Potential Emergencies (FIRESCOPE), developed the best-known prototype ICS in response to critical management deficiencies associated with the state's wildland firefighting. Foremost among the problems encountered were ineffective communications, unclear jurisdictional and tactical command authority, inability to account for the geographic location or task assignments of personnel, and difficulty responding effectively and expeditiously to challenges of the dynamic, high-hazard environment. Although FIRESCOPE was originally conceived for wildland settings, the Phoenix Fire Department and others recognized similar deficiencies in structural firefighting and formulated the Fireground Command System (FCS), for use in all fire department emergency incidents involving more than a single-company response.\n\nThe US Fire Administration and its National Fire Academy endorsed the FIRESCOPE ICS as the preferred management model for application throughout the fire service, and widely disseminated it through published documents and curricular offerings. Throughout the last two decades, a consortium of fire and emergency services representatives has collaborated on a single incident management system (IMS) incorporating the best features of ICS and the FCS. In the following discussion, the terms ICS and IMS will be used interchangeably, as they are in the emergency response communities.",
        "ICS standardization": "The use of ICS by civilian emergency responders became standardized through its incorporation into a number of consensus standards issued by government and non-government agencies, including the federal Occupational Safety and Health Administration (OSHA) and the National Fire Protection Association (NFPA). Both required incident management through an ICS during emergency operations that are considered dangerous to response personnel, including hazardous materials incidents, confined space rescues, and structural fires. Full implementation of ICS is also a cornerstone of the integrated emergency management system, which is taught to emergency managers by the Federal Emergency Management Agency (FEMA). Health care systems, including EMS and hospitals, have adopted customized versions of ICS for use during mass casualty incidents and other threat- or hazard-associated operations.\n\nIt can be argued that public health emergencies also represent incidents that require multiagency, multijurisdictional responses in that they pose substantial threats to both the population and the response community. The same management deficiencies that launched ICS in the fire service have been cited in after-action analyses of responses to public health emergency incidents. Health and medical emergency incidents are similar to those encountered in the fire service, as they share elements of operating in a hazardous environment and the urgency with which tasks must be accomplished. The need to accomplish a complex mission in the face of proximate threat or hazard distinguishes the ICS management methodology from other business or public administration practice. The tasks integral to mission completion require authority, reporting relationships, and personnel that are not intrinsic to the public health and emergency management structures maintained in local, state, and federal jurisdictions.\n\nThe essential characteristics of ICS must be understood in order to adapt it for use in the all-hazards environment. ICS is a modular management system that can be expanded or contracted to match the size and complexity of an incident and the availability of resources to manage it. The overall priorities of an incident commander (IC) are predetermined, regardless of whether the incident is a structure fire, wildland fire, passenger train derailment, or toxic hazard release. In order of priority, they are life safety, incident stabilization, and property conservation. Strategies and tactics employed by the IC, as well as intermediate goals and objectives, are designed to address those priorities. This facet of the ICS is an important determinant of its success as a high-reliability organization.\n\nThe basic design and staff assignments that typically comprise an ICS also reflect these priorities, and help distinguish ICS from other military command structures, business administration methodologies, and standing bureaucracies. All responsibility for every aspect of response to the incident belongs to the IC until it is specifically delegated. Tasks that are delegated may be assigned to an individual or an individual heading a group. The organization of personnel into assignments and the designation of reporting relationships are guided by certain constraints. One of the most important is referred to as \u201cunity of command.\u201d This ensures that each member of the response team, regardless of assigned position in the organizational chart, is responsible to, or reports to, only one person. Similarly, \u201cspan of control\u201d dictates that no leader anywhere in the organizational structure is directly responsible for more than 3\u20137 (optimally five) personnel or functions. These two features should override the complex reporting relationships characteristic of the mix of elected, appointed, hired, and voluntary personnel that participate in large-scale emergency responses. Those appointed to command role should be trained for that role, and when active, wear easily seen garb (e.g. colored vests) identifying the positions they hold. A job action sheet should be available for each command role to be used as a decision-making reference guide and documentation tool.\n\nIn most circumstances, one individual is designated and recognized as the IC. It is clearly acknowledged, however, that there are instances in which multiple agencies (e.g. fire, EMS, law enforcement, public health) or multiple jurisdictions (e.g. adjacent towns, counties, states, federal government) have legitimate claims on command authority. Under these circumstances, a \u201cunified command\u201d is instituted with senior representatives of each stakeholder agency or government present in the command post who serve as the IC for their jurisdiction or agency. The unified command speaks with one voice as the IC for the situation, and any differences in priorities or tactics are worked out among the individual ICs that make up the unified command. This maintains unity of command, because each responder reports to a single supervisor, but it also maintains a pathway of expertise. For example, a fire department IC in a unified command structure does not tell the police responders how best to accomplish pure law enforcement functions. Instead, the fire IC discusses the best course of action with the police IC, and after agreeing on overall priorities and strategies, the police IC issues orders to the police responders that help fulfill the priorities and objectives set forth by the unified command. In complex, multijurisdictional incidents, the unified command not only generates the incident action plan (IAP), but also must agree on a single operations section chief who will be responsible for executing the IAP. When feasible, the component members of a unified command should be colocated in a single command post in order to facilitate this collaboration and to ensure that the various ICs involved are not duplicating or contradicting each other\u2019s efforts in the response to the incident.\n\nIn its simplest form, the ICS may comprise only an IC directly supervising a handful of personnel assigned to diverse tasks. For example, the IC at a structure fire involving a single-family dwelling would initially need crews for fire attack, search and rescue, water supply, and ventilation. The most expedient way to assign personnel to these tasks is by designating the appropriate fire apparatus crews to those functions. The ICS organizational chart would then be described by where the IC delineates four tasks, and one \u201cresource\u201d representing an identifiable crew is assigned to each task.\n\nIn emergency management practice, there should be an orderly transfer of command when discrete phases of a response are completed. In some cases, this may involve termination of response activities and transition to recovery, and/or law enforcement investigations. Additionally, extended responses occurring over long periods of time, such as a public health response to a pandemic, require orderly change of command at periodic intervals to allow for responder rest and recovery.\n\nMethods for orderly transfer of command are prescribed in ICS, and are routinely used in fire control operations when command is passed from a company-level officer to a staff officer as the incident grows in size or complexity. It is important to point out that purely administrative fire chiefs or commissioners rarely assume command of an incident, as they frequently are not the most experienced operational personnel available. This separation of normal civil authority and incident command is another hallmark of ICS.\n\nReturning to the example of the response to a structure fire, multiple fire attack crews and a water shuttle system may be necessary to extinguish the blaze. In that case, fire attack and water supply officers might be appointed. The officers of Engines 1, 5, 7, and 9 would report to the fire attack officer, while Engine 2 and the two tankers, one from an adjacent town providing mutual aid, would report to the water supply officer.\n\nWithout this new layer, the IC would exceed the prescribed span of control limits by having direct responsibility for the crews of the seven additional services. The IC retains the prerogative of further expanding the incident management team using the following options.\n\nSections are organizational levels with responsibility for a major functional area of the incident (e.g. operations, planning, logistics, finance/administration). The person in charge is called a chief (i.e. logistics section chief, etc.). Branches are used when the number of divisions or groups exceeds the recommended span of control (e.g. EMS branch, rescue branch, etc.). A branch is led by a director. Divisions are used to divide an incident or facility geographically (e.g. first floor). A division is led by a supervisor. Groups are established to divide the incident management structure into functional areas of operation. They are composed of resources that have been assembled to perform a special function, not necessarily within a single geographic division. A group is led by a supervisor. Units are organizational elements that each have functional responsibility for a specific incident planning, operations, logistics, or finance/administration activity (e.g. situation unit, supply unit). Single resources are defined as an individual or piece or equipment with its personnel complement (e.g. engine company or police officer) or a crew or team of individuals with an identified supervisor. A task force is a combination of mixed resources (e.g. four engine companies, four police officers, and a public health epidemiologist) with a common communications capability and headed by a task force leader. A strike team is a set number of similar resources (e.g. four engine companies) with a common communications capability who operate under the command of a strike team leader.\n\nAdoption of a standardized lexicon that distinguishes assignment-specific working groups from task-oriented supervisory groups and personnel locations in horizontal versus vertical planes facilitates effective communication among people who do not work together on a daily basis. Hence, terms such as unit, group, crew, division, branch, or sector may be roughly synonymous in ordinary usage, but are unambiguous in an ICS. For example, while the \u201cmedical branch\u201d and the seem like they would serve similar functions based on terminology, in the regimented vocabulary of ICS, they denote vastly different functions. The medical branch would be subordinate to the operations section, and would manage the operational medical resources responding to and mitigating the situation (e.g. EMS group, treatment group), while the medical unit would have specific responsibility for providing medical support to the responders themselves, and would fall under the logistics section. Likewise, standardized conventions are observed in diagramming organizational charts outlining the supervisory levels between the individual company assigned to a discrete task and the IC. These conventions allow for interoperability and clarity of roles in an incident spanning agencies and jurisdictions. These include conforming to the principles of unity of command and span of control as described above. Intermediate supervisors are not inserted into the scheme unless the working resources exceed an IC's or other supervisor's span of control.\n\nSituational awareness information passed from the working crews though the chain of command and instructions from the IC and supervisors to the crews are tightly circumscribed according to the principles of unity of command and span of control. This eliminates supervisor information overload and ambiguity or reporting relationships for working crews. It is important to understand that these constraints apply only to vertical transmission of information, and not to horizontal communications. Clearly, information sharing among crews and among supervisory staff at the same level within a branch or section may be critical to safe and effective field operations.\n\nThree staff positions generally assigned to individuals at large or complex emergency incidents are considered to be an inherent part of the command function, and are not included in the IC's span of control constraints: safety officer, pubic information officer (PIO), and liaison officer. As the titles imply, the three are responsible, respectively, for scene and overall safety for both responders and civilians threatened by the incident, interacting with media personnel, and providing a conduit for two-way information between the IC and representatives of other responding agencies. These positions make up the IC's command staff.\n\nOne of the key advantages of establishing an incident command center and having individuals designated to these tasks has been better control and better quality of information released to the public. Another has been improved interagency communications, which were previously stymied by incompatible radio frequencies, inconsistent terminology, and turf skirmishes if not overt wars.\n\nThe safety officer is responsible for the overall safety of everyone at the scene of the incident, including responders, civilians and victims already involved with the incident, and bystanders and others at risk of being affected as the incident and response progress. The safety officer works within the chain of command (reporting to the IC) to keep all responders to an incident safe. At the same time, the safety officer maintains an important emergency authority to instantly issue orders to cease any activity that is deemed unsafe. This emergency authority is the only allowable exception to the unity of command concept, in that it allows someone other than a direct supervisor to issue orders to a responder, though it only allows a stop order in cases of a potential hazard.\n\nA joint information center may be created to address the broad range of risk communications and public education issues. The center is usually housed at a suitable location near the incident or the local emergency operations center (LEOC), and is composed of PIOs from all responding partners. The PIOs use the operating procedures defined in a joint information system plan to draft information for IC approval that is given to the media and public in a timely and effective manner.\n\nLiaison officers serve as links between the incident command post and other external partners such as the LEOC. In their role, they share information with various parties and also make requests for various types of assistance as needed.\n\nTo manage large, complex, or protracted emergencies, the working resources under an IC are typically organized into four sections: operations, planning, logistics, and finance/administration. The officers assigned to those sections report directly to the IC. The operations officer is responsible for tactical decisions and for maintaining situational awareness through reports from the work crews. In an incident involving fire in an occupied commercial structure with known chemical hazards on site, the operations chief might need to staff branch positions to supervise multiple EMS crews, fire suppression crews, evacuation crews, and hazardous materials crews. Meanwhile, the fire suppression branch might resemble the full ICS, with multiple crew chiefs reporting to the branch officer. In any public health emergency incident, much of the operations section's responsibility would involve identification of a broad spectrum of medical tasks to be accomplished, and assigning personnel or units to these functions. If the emergency has resulted from a weapon of mass destruction or occurs under a threat situation, the operations section will have both law enforcement and medical components. The staging manager who is responsible for coordinating resources awaiting an assignment also reports to the operations section chief.\n\nThe remaining three ICS sections would operate in a public health emergency in the same general way as in any complex, multiagency, public threat incident. The planning section continually assesses the situational aspects of the incident and provides predictions of likely scenarios. Similarly, this section monitors resources as they are committed to the incident and estimates both immediate and long-term requirements. The planning section has the primary responsibility of drafting an IAP for IC approval. The IAP outlines the control and strategic objectives as well as the anticipated resource requirements for each operational period. It is also used as part of the initial briefing given to each oncoming shift of command personnel. The planning section typically includes all technical specialists who may be needed to advise command personnel. Examples might be structural engineers at a structure collapse or toxicologists at hazardous materials incidents. Responsibility for recording and maintaining documents related to incident operations rests within the planning section, as does planning for logical, sequential demobilization of resources once the incident is under control. The documents used during a response include the appropriate FEMA forms as well as agency- or institution-specific records being completed manually or using computers. The planning section may, at the direction of the IC, play a leading role in drafting the after-action report once the incident response is complete.\n\nThe logistics section frequently comprises separate service and support branches. The service branch provides interoperable communications capabilities as well as food, hydration, and medical support for emergency responders. Equipment, including repair capabilities and fuel, supplies, access to fixed facilities, sanitary requirements, and maintenance of the command post are all under the purview of the logistics section\u2019s support branch. Resources are acquired using existing mutual aid agreements as well as routine or emergency vendor agreements. The LEOC will normally be activated for major incidents and may also assist with resource management and other response-related issues in support of the IC.\n\nThe finance section is staffed when significant procurement capabilities are required to accomplish mission goals. This section also keeps records on personnel involved and periods worked. Such records are essential when responder injuries or death may result in future compensation claims, as well as remuneration of salaried personnel working at an incident. In addition, a cost unit is frequently established for managing budgets and projecting cost estimates. It should be headed by a government official with authority to spend funds and sign contracts.\n\nFor an incident to be managed effectively, those in charge must be familiar with and have ready access to their agency and/or community emergency operations plan and have taken requisite ICS training. In 2004, the NIMS Integration Center (now called the NIMS Integration Division, part of the Department of Homeland Security) outlined a series of required educational programs for local, state, and federal officials. Similar requirements were outlined for health care facilities in 2006. The four primary courses (IS 100 and 200, Incident Command Principles; IS 700, NIMS; and IS 800, National Response Plan, now called National Response Framework) are available online and in classrooms from the Emergency Management Institute; we recommend that all EMS physicians complete this training. Additionally, the NIMS Integration Division has established a process of precredentialing and \u201cresource typing\u201d to set a national standard in order to streamline and standardize the request for and application of resources in an incident in which the NIMS is applied. Precredentialing is a process by which certain assets are screened and their qualifications verified ahead of time in order to avoid the process of issuing emergency credentials upon activation of a resource, delaying their actual response to the incident. This allows much more rapid interoperability of a variety of assets across jurisdictional, geographical, or agency boundaries. Resource typing creates a standardized catalogue of resources from which an IC can choose, and ensures that the responding unit or resource is capable of the task intended for it. All resources, from fixed-wing air ambulances to swiftwater search and rescue teams to emergency floodlights, are broken into four \u201ctypes\u201d based on capability, staffing, and level of support required. This allows an IC to request the unit that will be best suited to the mission at hand.",
        "Conclusion": "Experience has repeatedly shown the importance of an ICS being successfully applied to meet the response challenges posed by any type of emergency incident regardless of type or size. The NIMS is the ICS now in use throughout the United States. The principles it contains were taken from the best management practices from public safety institutions, the military, and business world.\n\nThe NIMS contains principles that recognize emergencies will generate essential tasks that do not exist in the routine job description of any one office, and decisive authority must be given to key personnel, who in some cases may not be the highest-ranking officials within an organization. In ICS, experience and expertise should take precedence over rank.\n\nSpecific positions may be filled by the IC based on situational assessments of the need and availability of qualified people to assume such roles. These positions have standard titles, responsibilities, and reporting relationships.\n\nFor command personnel to be successful, prior training and planning and regular participation in exercises or responses are required. In an effort to promote standardization, improved performance, and readiness, the federal government has outlined a number of NIMS courses for those who will be assigned to command roles at the local, state, and federal level. Some can be completed online, while others are offered only in a classroom setting."
    },
    {
        "Introduction": "Emergency medical services systems consist of the organizations, individuals, facilities, and equipment whose participation is required to ensure timely and medically appropriate responses to requests for prehospital care and medical transportation. The National EMS Management Association defines the EMS system as the full spectrum of response from recognition of the emergency to initial bystander interventions, access to the health care system, dispatch of an appropriate response, prearrival instructions, direct patient care by trained personnel, and appropriate transport or disposition. A provider participating in any component of this response system is practicing EMS. EMS also includes medical response provided in hazardous environments, rescue situations, disasters and mass casualty incidents, and mass gathering events, as well as interfacility transfer of patients and participation in community health activities. The design of the EMS system addresses how the resources are structured \u2013 operationally, financially, legally, and politically. The system design affects virtually every aspect of how requests for services are handled. Changes to the EMS system design can have a profound effect on clinical outcomes, community satisfaction, and cost. Therefore, it is vital for EMS and community leaders, including EMS physicians and medical directors, to have a sound understanding of EMS system design principles and its elements. The principles and elements of EMS system design vary in some respects between environments, organizational settings, health care system differences, community settings, and cultures. Those differences will be addressed in this chapter. At the time of this writing in 2013, the health care system in the United States is rapidly changing. As the general health care system changes, EMS system designs will need to adapt accordingly. This makes it all the more important for EMS and community leaders to understand system design principles so they can competently lead and adapt their EMS systems through the tumultuous times ahead. Agility will become extremely important, as the times ahead are rife with both opportunity and peril.",
        "System design goals": "The design of the EMS system should support the primary goals of providing the best clinical and service quality possible with available resources. Accountabilities embedded in the system design should help align incentives for each provider organization to do its best to help the overall system meet these goals. There are several key areas of the system design that warrant specific attention: clinical quality, service quality, economic efficiency, accountability, improvement, and resilience. Clinical quality addresses the technical performance of clinical processes and the patient outcomes those processes yield. The EMS system design should designate responsibilities, set standards, and create accountabilities for clinical quality. Service quality addresses the experiences and perceptions of patients and other stakeholders. The EMS system design should set realistic and practical standards while establishing accountabilities for service quality just as it does for clinical quality. Economic efficiency can be assessed by how well available resources are utilized to create positive clinical and service quality outcomes. Good system designs provide the best chance of patients receiving quality care within economic reason. This ties into the concept of value \u2013 the combined effect of quality and cost. Communities want value from their EMS systems \u2013 quality and cost both matter. High quality and reasonable cost are not mutually exclusive choices. Accountability is needed to assure that each provider organization and the major components therein fulfill their respective roles and responsibilities in meeting needs, particularly those of patients and the community. The most important needs are expressed as standards. The best system designs require measurement of performance against standards, hold provider organizations accountable for meeting standards, and encourage performance that exceeds standards. Improvement is manifest as a mindset that recognizes that standards often represent minimum acceptable levels of performance. It is both worthwhile and possible to exceed those minimums by changing processes in ways that yield better quality at the same or lower cost. Resilience recognizes that the world around us changes in ways that affect the EMS system. Resilient EMS system designs allow for such changes by creating mechanisms that allow adaptations to be made quickly with minimal disruption. It is sometimes difficult to separate the effect of the system design from the efforts of the individuals who work within it. Some of the key interrelationships are characterized by the following principles. Talented and motivated people can produce good results in a bad system design, but not for extended periods of time. Incompetence can produce poor results in even the best system design. Talented people tend to be attracted to system designs that will potentially nurture and showcase individual talents. Talented people have options because they are talented. In general, the most talented managers choose to avoid employment in EMS systems that hinder their abilities. Good system design makes excellence possible and superior performance probable, but guarantees neither. Bad system design makes excellence impossible and inferior service probable. Sound system design cannot guarantee clinically appropriate and economically efficient performance. Poor system design can make consistent life-saving performance extremely unlikely, if not impossible.",
        "Services": "Most EMS system designs include the services described below. \nPrevention and public education These services typically focus on prevention of problems that may lead to an EMS response, such as injury prevention or prevention of heart attacks and strokes. Public education efforts also include instructions on first aid and when to appropriately call for EMS assistance. \nTriage When someone calls 9-1-1, one of the first services provided is a determination of what the nature of the problem is, its severity and the types of resources that need to be sent to the scene. \nMedical first response Sometimes there are medically trained resources closer to the patient than the closest available ambulance. In cases where the nature of the problem may be time-sensitive, good system designs will attempt to get the closest appropriately trained medical resource to the scene as soon as possible. This is called medical first response. It is typically provided by fire departments but may also be provided by police agencies or volunteer EMS agencies. \nAmbulance response and transport Ambulances typically provide the broadest spectrum of EMS services, including medical transportation. \nPrearrival instructions After the incident has been triaged and resources have been dispatched to the scene, emergency medical dispatchers can guide callers on how to begin treatment and help responding crews safely locate and access the scene. \nAssessment and treatment Emergency medical services crews will evaluate the scene and examine the patient as part of their process to assess the situation and determine what course of action and treatment are called for. They will then initiate treatment as appropriate within the constraints of their protocols. \nMedical transportation At some point during patient care, determinations will be made regarding the need and destination for medical transport. If patient condition and circumstance allow, those determinations will be made in collaboration with the patient. In scheduled non-emergency situations, medical transportation resources may be requested in advance by appointment. \nEvent coverage Emergency medical services systems designs should provide a mechanism for EMS resources to be placed on stand-by for major events. This often requires special logistics and planning so that normal operations are not comprised during the special event. \nDisaster services Emergency medical services system designs provide mechanisms for threat assessment, planning, activation, and delivery of medical resources and services in response to larger-scale incidents. Responding appropriately to requests for services from other communities in need should also be addressed in the EMS system design. \nCritical care transport There is often a clinical need to move patients with unstable or complex conditions between medical facilities. Repatriation to an in-network hospital may also prompt such transfers. These patients will often require care outside the normal scope of a paramedic-staffed ALS ambulance. This need is typically met with critical care transport ambulances which have additional equipment or the ability to accommodate additional equipment. Their staffing is highly variable. Typically, the base level of staffing is with paramedics who have additional training that may qualify them for critical care transport certification. More complex patients may also be accompanied by members of the hospital staff, who may be critical care nurses, respiratory therapists, or physicians. \nAir medical transport Rotor or fixed-wing aircraft may be used as ambulances. Their missions may vary from scene responses to more rural or wilderness incident locations to interfacility transfers. The transfers may be provided at a routine or critical care transport level of care. \nHazardous materials response medical support Many communities will have specialty fire department teams for response to hazardous materials incidents. Given the wide range of unusual cargo and materials that victims or team members may be exposed to, special training, equipment, and protocols are often established for the paramedics assigned to these teams. EMS medical directors may establish relationships with toxicology specialists to assist in training and medical oversight for these paramedics. \nTactical response medical support Some law enforcement agencies have tactical response teams. The team members, perpetrators, and victims may be subjected to significant trauma in unusual situations that preclude normal treatment and transport processes. This may necessitate more extensive on-scene assessment and treatment within the confines of a dangerous tactical scene environment. This calls for special training, equipment, and protocols for the paramedics assigned to these teams. \nCommunity paramedicine Emergency medical services systems are primarily designed to respond to emergencies. A significant portion of EMS requests, however, are for non-emergency situations. This sets up a disparity between what the patients who call 9-1-1 need versus what the EMS system was originally designed to provide. Community paramedicine is a relatively new service that attempts to meet the often underserved need of low-acuity 9-1-1 patients in a more effective and efficient manner than a typical EMS system response provides. Changes in health care system design and payment structures may provide incentives for EMS provider organizations in the near future to leverage their existing infrastructures and resources to provide a broader spectrum of non-emergency out-of-hospital care. EMS provider organizations may be contracted to provide services such as monitoring and support of patients immediately following discharge to reduce length of hospital stays, prevent readmissions, and participate in home care for the chronically ill in ways that traditional home health care services are less suited to provide.",
        "Vehicles, equipment, and supplies": "Facets of EMS system design can also address vehicles, equipment, and supplies. These can have a significant effect on clinical and service quality as well as economic efficiency. Ground ambulance options generally fall into three categories: types I, II and III. These categories were derived from United States ambulance standard KKK-A-1822. A new US standard has been established called NFPA 1917. The US ambulance standards tend to have a strong influence on ambulances manufactured in other countries. Type I ambulances are built on a light- to medium-duty truck chassis. The cab remains and the cargo module is replaced with a patient compartment. The patient compartment typically lasts longer than the cab/chassis module. This permits the patient compartment to periodically be refurbished and then remounted onto a new cab/chassis module. Due to the heavier duty truck construction, type I ambulances can have a longer service life, particularly when the remount strategy is used. Their larger size makes them more difficult to navigate through narrow streets in older, high-density urban areas. Their heavier weight typically makes them less fuel efficient. The balance between longer service life and higher fuel costs must be considered in calculating the total cost per mile and reliability over their entire service life. Type II ambulances are made on a van chassis. They tend to be much smaller than type I or III ambulances, with more agility and better fuel economy. Their service life tends to be shorter than type I ambulances and does not offer the option of remounting to a new cab/chassis module. Type III ambulances are also built on van chassis, but have separate cab and patient compartment modules. They are similar in concept to type I ambulances, but on a van chassis rather than a truck chassis. There is a tremendous variety of non-transport vehicles used for medical first response. When the medical first response agency has a primary mission other than EMS (e.g. fire or law enforcement), the vehicles will often do double duty to meet the need of that agency's primary mission as well as the secondary mission of medical first response. This avoids having to purchase separate vehicles and additional staff to provide medical first response, limiting the cost to accelerated wear and additional fuel. This is why some fire departments will use a fire truck for medical first response. In contrast, some fire departments will choose to use utility-style trucks that have lower operating costs per mile, but with the added cost of another vehicle and additional staffing. EMS leaders should be cognizant of the pros and cons and the complete life-cycle costs for different vehicle options when choosing the type of vehicle to use for fire department medical first response. Law enforcement agencies very consistently use their primary patrol vehicles and regular staff when delivering medical first response. There are situations where specialty vehicles may be used for transport as well as medical first response. Airports and sports arenas may use specially modified golf carts for transport to a location where a standard ambulance is positioned. The cart is also used for first response. Agencies in highly congested urban areas may use motorcycles for medical first response. In parks, fairs, and special events, bicycles and Segways may be used. Off-road vehicles may be used where needed: all-terrain vehicles, boats, and snowmobiles. System leaders and medical directors should have an open mind about vehicle specifications in an effort to find the vehicle best suited to the environments they serve. Equipment and supplies will vary with the clinical service level. Within a particular service level (BLS, ALS), there are many options. For example, agencies have the option of choosing between several brands of automated cardiopulmonary resuscitation (CPR) devices or relying solely on manual CPR. When considering equipment and supply options, the most important factor to consider is the effect on patient outcome. Cost cannot be ignored, however, and can be looked at in more detail from the perspective of cost per use and cost per use over the entire life of the item (if reusable). Size, weight, durability, reliability, and service support also are major factors to consider.",
        "Delivery settings": "The geographic setting of an EMS system can have a significant effect on what constitutes an appropriate system design. What might be entirely appropriate for an EMS system serving a predominantly urban area may not make much sense in a rural or wilderness setting, and vice versa. \n\nUrban/suburban Urban/suburban EMS systems are those that serve communities with high-to-moderate population densities, covering larger areas, and are largely self-contained in terms of receiving emergency departments and key emergency health care resources (e.g. cardiac catheterizations labs, trauma centers). The higher volumes of patients bring higher potential gross revenues. This creates several financially viable options for the type of organization(s) that provide EMS services and the way in which responses are configured. Thus, it is not uncommon for governmental agencies, private companies, and hospitals to all offer EMS services in the same metropolitan area. When there are multiple EMS provider organizations serving the same metropolitan area, planning and coordination are critical. Incidents ranging from a serious multiple vehicle crash to a passenger train or aircraft wreck will often require multiagency, multijurisdictional responses, particularly if the incident takes place near a jurisdictional line. Emergency medical services system designs for urban/suburban areas need to consider how the various agencies in multiple jurisdictions will work together in an operationally and medically efficient manner. Best practices in EMS system design for large urban/suburban areas separate the function of system-level medical oversight from that at a provider agency level. System-level medical oversight, often positioned at a county or regional level, is typically focused on coordination and interoperability issues. It considers issues such as making sure EMS personnel from one jurisdiction have clinical privileges in another when providing mutual aid, and have the same or similar clinical protocols, compatible medical equipment, compatible radio systems, capabilities for data exchange and aggregation, etc. System-level medical oversight might be a county or regional medical director, or it may be provided through a council of the various provider agency medical directors who develop processes to coordinate efforts and come to consensus on multijurisdictional issues. This is something that is also done in some of the better rural and wilderness systems for the same reasons. One of the biggest drivers of EMS system cost is personnel. Consequently, one of the goals in making the system economically efficient is to maximize productivity, with crews running as many calls as possible during their shifts. There may be limits, however, where crews can become overworked with consequent degradations in quality. In some EMS provider organizations, this is mitigated by reducing the duration of shifts. Governmental EMS agencies in particular will commonly work 24-hour shifts. Without adequate rest during longer shifts, the risk of cognitive errors may increase with consequent loss of clinical quality. There are many ways to address these issues while assuring quality and containing costs, but the system design should recognize this potential and have ways to address it. Urban and suburban EMS systems will often have emergency and non-emergency ambulance services offered by separate organizations. The emergency ambulance services will tend to be operated by governmental entities providing ALS service. The non-emergency ambulances will tend to be operated as private companies at a BLS or ALS level. This raises two major issues. Is it better to have all ambulances provide ALS service? Is it better to have a single organization provide both emergency and non-emergency ambulance service? These questions are the subject of ongoing debate. Local politics and incumbency of providers will tend to have more influence on this than the theoretical merits from a pure system design perspective. Changes at this level will be difficult to achieve unless there is sufficient political will to do so, which may manifest in response to a severe financial issue, a high-profile case with a bad outcome, or challenges by one provider organization to take over the ambulance duties of the other. Single versus multiple ambulance service providers There are economic and philosophical issues to consider when debating if a community should have one or multiple ambulance services. From an economic perspective, a single ambulance service provider offers potential cost savings by payers only having to support one infrastructure. More than one provider adds the costs associated with duplications of infrastructure that do not add value. For example, a single ambulance service for a community would have one computer-aided dispatch (CAD) system. A second ambulance service would require its own CAD. The pricing of ambulance services in that community would need to cover the cost of two CAD systems, without a corresponding increase in benefit. Considering the duplication of all the other elements of infrastructure needed to support an ambulance service, the increases in costs quickly add up. The economic virtues of competition must also be considered. A single provider has a monopoly, which does not provide natural cost controls or competitive pressure to provide high-quality service in order to preserve or expand market share. Considering the advantages of single-provider systems and the advantages of competitive pressure to control costs and increase quality, many urban and suburban systems take an approach that can provide a favorable balance. A community can both limit the number of providers and corresponding duplications of infrastructure costs while still providing healthy competitive dynamics. This is achieved by allowing competition for the market rather than within the market. While the details vary from state to state, a city or county generally has the ability to designate who its ambulance service provider(s) is/are. This is called allocation of ambulance service market rights and is one of the most powerful tools in EMS system design. When allocating market rights, the city or county can attach a wide range of requirements and performance standards that must be met to retain those market rights. A competitive procurement process may be used to decide which provider will be awarded the market rights. That competitive process can allow both governmental and non-governmental organizations to submit proposals. If true costs are considered and the evaluation process is conducted properly, the community can reap the benefits of getting a provider that has had to make a more compelling value proposition over competing organizations and made commitments to meet requirements and standards on an ongoing basis. After the market rights are awarded, the competitive pressure can be sustained by building in escalating consequences for minor to major failures in meeting requirements and standards, which can result in loss of market rights in the most severe of circumstances. Absent any severe failures, from time to time, the community may choose to reevaluate the market by having another competitive procurement process for allocation of market rights. This will compel the incumbent provider to step up its level of service and commitment in an effort to fend off competitors. Competitors will make their best offers in an effort to capture a new market. Either way, the community benefits. In communities where this approach is not taken, dislodging a well-established ambulance service provider or providers will require significant political will. Such political will is rare and typically arises in response to severe financial problems, a high-profile case with a bad outcome, or an attempt by one provider to overtake the market rights of another. EMS system leaders should be cognizant of this. If there is interest in having a more formal and deliberate process to allocate ambulance service market rights for the benefits cited above, EMS system leaders should be prepared to introduce these ideas into the political conversation in the event that the political will to make a significant change surfaces. A related issue is the separation of emergency and non-emergency ambulance service. In many communities, the governmental agencies will provide an emergency ambulance service while one or more private corporations will provide a non-emergency ambulance service. This separation tends to be more common with fire department ambulance services. The organizational culture of the fire department tends to focus on provision of emergency services. Non-emergency ambulance service delivery may be shunned by the firefighters. It is not difficult to find private companies more than willing to relieve the local fire department of the \u201cburden\u201d of that portion of the market. This is because the non-emergency ambulance service market can be quite profitable. It has the distinct advantage of being able to determine ability to pay in advance of service delivery. The emergency market can also be profitable, but carries higher financial risk by not having the ability to determine the ability to pay in advance of service delivery. Because many emergency patients do not have the means to pay and all requests for service received through the emergency system are generally honored, the emergency ambulance service is at higher risk for net losses. When the government-operated emergency ambulance service is operating at a net loss, there may be a business case for a community to retain the non-emergency market rights for its own ambulance service. This could allow profits from non-emergency cases to help cover the losses from the emergency service. This assumes that any organizational culture issues can be adequately addressed and that the managers have the needed skills, experience, and support to operate the ambulance service profitably. As the overall US health care system changes and the percentage of the general population not covered by insurance presumably decreases, the economics and assumptions just described may significantly change. \n\nALS and/or BLS levels of care One of the virtues of an all-ALS ambulance service is that each ambulance is capable of delivering both ALS and BLS. The problem of undertriage that arises from sending a BLS unit to a case that turns out to need ALS is eliminated. The response time performance of the system is improved by having every unit qualified to \u201cstop the clock\u201d when measuring how long it took to get the correct type of unit to the scene. The incremental cost between operating a BLS and an ALS unit in an organization that has the training, quality management, etc. in place to provide ALS is small. It amounts to the difference in cost of adding ALS equipment and supplies, higher costs for training and continuing education, and the salary differential between an EMT and a paramedic. For these reasons, the all-ALS ambulance service has been favored in many urban and suburban communities. The counter-arguments, favoring a fleet of BLS ambulances and a smaller cadre of ALS staff, cite the low frequency of the higher-risk ALS procedures, such as endotracheal intubation. Considering the limited number of opportunities to perform such procedures in an EMS system and dividing by a large number of ALS-level staff in an all-ALS ambulance system results in fewer opportunities to perform those high-risk procedures. Therefore, having a smaller cadre of ALS staff allows them each to have more opportunities to perform those skills to achieve and maintain mastery. This same logic is used to support the idea of specialty care centers for major trauma, cardiac catheterization, etc. Another facet of the debate questions if ALS offers a significant benefit over BLS. When ALS-level EMS systems began in the 1970s in most urban and suburban communities, paramedics were the only level of field personnel authorized to provide clearly life-saving procedures like defibrillation. Since then, defibrillator technology has made this life-saving procedure available to BLS providers and the lay public. Defibrillation, nebulized bronchodilator drug administration, a selected set of IV fluids and drugs, and some types of airway devices are now in the scope of practice for AEMTs. Having an EMT or AEMT apply 12 ECG electrodes and transmit the data to the receiving ED would not be unreasonable. Given the scope of services that an AEMT can now perform, it questions the justification for having an ALS level of care. The evidence is insufficient to settle these debates at the time of this writing. It is vital for EMS system leaders to be aware of these controversies, follow the research, and consider these issues carefully when an opportunity presents itself to reconsider the level of service in an EMS system design. \n\nTiered response In some EMS systems, more than one agency may be sent to the same incident. This commonly involves sending a non-transport medical first response unit and an ambulance. This is often done under the premise that ambulances tend to be relatively busy and there may be other qualified and available emergency response units closer to the incident location than the nearest available ambulance \u2013 hence the term medical \u201cfirst response\u201d unit. Some systems will send the ambulance and medical first response unit simultaneously to all calls received via the 9-1-1 system. This is sometimes called a dual or simultaneous response system. The primary advantage is that the worst-case scenario is always covered in terms of getting the closest available unit to the scene as fast as possible. If the medical first response units have a relatively low level of utilization for their primary mission (e.g. fire calls for fire trucks, law enforcement calls for police cars), having them respond at the same time as the ambulance can get someone there sooner. It is acknowledged that most of the medical responses originating from a call to 9-1-1 are not truly time-sensitive emergencies. This points to the major disadvantage of this approach: the medical first response unit will often end up on lower-acuity calls where they may not add significant value by virtue of having responders there a few minutes earlier than ambulance arrival. If there are a lot of these types of calls, it can add considerable expense to the operating costs of the medical first response agency by needing more units to cover all of the first response calls. It can also significantly decrease availability for the medical first response unit\u2019s primary fire or law enforcement mission. A safe, consistent, and clinically appropriate triage process performed by an appropriately trained and quality-controlled dispatch center offers an option for utilizing medical first response units in a more discriminating manner. Emergency medical dispatchers, using appropriate triage protocols, can identify the types of calls that are more likely to be time-sensitive emergencies that would benefit from arrival of personnel a few minutes sooner (e.g. choking with compromised breathing). It may also be possible to identify cases where having the additional manpower from the first response crew on scene sooner than later is of value (e.g. manpower to properly perform the many tasks at a cardiac arrest scene). Beyond \u201cmedical\u201d first response, also consider \u201cfire\u201d and \u201claw enforcement\u201d first response \u2013 where fire and/or law enforcement resources are likely to be needed. \n\nHospital destination policies In contrast to more rural or wilderness settings, urban/suburban EMS systems will often have several hospitals in or near their service areas. This will necessitate protocols and policies that guide the decision-making process on what hospital the patient will be taken to. Patient requests for specific facilities should be honored, but ideally, the patient should go to the closest hospital that is equipped to provide the type of care needed. Guidance to EMS medical directors and policy makers may be provided by certifications obtained by hospitals to verify their capability to care for specific types of patients (major trauma, burns, ST elevation myocardial infarctions, stroke, etc.). Emergency departments in urban and suburban areas are prone to overcrowding. This can have a severe negative effect on the EMS system if the overcrowding significantly delays the physical movement of the patient from the ambulance cot to the emergency department bed. Protocols and policies should be put into place to manage this problem. Unaddressed, ambulance services may find that many of their crews are standing by for extended periods of time in the ED hallway waiting for beds to move their patients onto. Collaboration with hospital administrators is needed to help them avoid legal problems and allow the EMS system to use its resources to respond to requests for service. \n\nRural Rural systems face many challenges quite different from their urban/suburban counterparts. By definition, they cover areas with lower overall population density but usually have some areas of higher density in small towns and villages. Funding for rural systems is highly variable. It may be a county-wide system supported by taxes, a subscription-based program that functions like ambulance insurance, or a volunteer system that works on charitable donations \u2013 or most any creative combination thereof that suits the needs and preferences of those who live in the service area. The smaller tax base in rural communities also makes it more difficult to afford expensive technology. Enhanced 9-1-1 systems that automatically provide the emergency dispatcher with the address associated with the caller's phone number or the real-time location of the calling cell phone may be out of reach. This can lead to further delays in arrival. Creativity is often exercised in designing a response configuration. Local funding may not support having on-duty staff standing by with the ambulance or medical/rescue first response vehicle. Rural systems will commonly alert staff members by phone or pager that a call has been received. Available crew members can then respond from home or work to the ambulance or rescue vehicle to muster a crew and then proceed in the ambulance or rescue unit to the scene of the incident. Response time intervals may be dramatically reduced when some staff respond directly to the scene and have appropriate equipment and supplies with them to help initiate care until the ambulance and additional staff arrive. This type of tiered response necessitates policies and procedures to appropriately control when and how that all happens. Rural systems are often designed with separate BLS and ALS response agencies in mind. The first tier is often a BLS ambulance. If the call requires ALS, the ALS agency often sends a non-transport vehicle staffed by paramedics. The paramedic can either respond to the scene or \u201cintercept\u201d the BLS ambulance along the way to the hospital. A huge challenge for rural services is handling overlapping calls. A large geographic area may only have one ambulance. When that ambulance has a call that requires transport, the hospital may be quite distant. This can result in a single call lasting for hours. If another call occurs during that time, it would have to be covered by a more distant unit or wait until the ambulance gets back into the area. This places added responsibility on medical first response crews, if utilized, to manage the patient for longer periods of time. Emergency medical services education for rural staff is more complicated. Initial training may only be offered in distant cities, which can be particularly challenging for volunteer staff to attend. The lower call volume in rural systems creates barriers to developing and maintaining skills, particularly for high-risk, low-frequency procedures like endotracheal intubation. This makes refresher training all the more important. Evolving and increasingly more affordable technologies for online distance education can be particularly important for rural providers. The combination of long distances for responses and transport, compounded by the problem of even longer time frames in the event of overlapping calls, results in much longer periods of patient contact than in urban/suburban systems. There is more time for patients to get sicker before ambulance arrival and more time to deteriorate before reaching a hospital. This potentially heightens the need for ALS-level care in the rural setting. The low call volume, lower levels of funding, and other factors make it much more difficult to pay for and properly support paramedic services. This is commonly referred to as the rural paramedic paradox. \n\nIndustrial EMS is typically provided on the site of larger and sometimes more isolated industrial facilities. Most commonly, it is provided at sites where there are atypical hazards requiring specialized methods of rescue or care. Large oil refineries and chemical plants are good examples of settings with these characteristics. It may also include large factory complexes in urban areas. Industrial EMS services are usually provided as part of an industrial plant's operations or by a support service contractor. How that company, industrial EMS staff, and their system of care integrate with the general EMS system that provides service outside the industrial site is a significant issue. There must be coordination with the agency with responsibility for regulatory and medical oversight in the jurisdiction where the industrial site is located. The local medical director must understand the unique challenges, issues, and needs of the industrial site. This can pave the way to working out ways to accommodate delivery of high-quality prehospital care by EMRs, EMTs, and paramedics who may work for the company or contractor and not for the local EMS providers that serve the general public. This may require that the industrial EMS system be licensed and regulated just as the other EMS provider organizations, but with special protocols, policies, and procedures as needed. This is similar to the different protocols, policies, and procedures often in place for the specialized needs of tactical and hazmat EMS crews. \n\nInternational Given the diverse historical and cultural influences around the world, along with the broad spectrum of economic conditions that exist, it is no surprise that EMS is so different around the world. Perhaps more surprising, however, is how many elements are shared. Because so many of the challenges and issues facing EMS are universal, it is helpful to learn from international colleagues how they have approached the same needs with different methods. There are two broad \u201cmodels\u201d for EMS staffing in different parts of the world: the Anglo-American and Franco-German models. The Anglo-American model uses non-physicians to staff EMS units. Field care is usually limited to what is necessary to be done sooner than later, with as much as possible deferred until arrival at the hospital. Physician roles are generally limited to direct and indirect medical oversight. This is largely driven by the significantly higher cost of staffing field response units with physicians compared to EMTs and paramedics in the countries where the Anglo-American model is used. In stark contrast, the Franco-German model relies heavily on physician-staffed field response units and emphasizes a high degree of on-scene stabilization prior to transportation to the hospital. This is sometimes referred to as the \u201cstay and play\u201d model in contrast to the \u201cscoop and run\u201d philosophy of the Anglo-American model. The Franco-German model also affords a greater opportunity for treating and releasing some patients without transporting them to the hospital. Elements of this model are used in many countries in Europe. Europe generally has a less aggressive medical malpractice climate than the United States, and the providers are not as focused on defensive medicine. Many permit their dispatchers to screen and prioritize calls, frequently refusing ambulance transport and directing patients to alternative sites for care. The Franco-German model is also utilized in many areas of South America, particularly in Argentina, Chile, Uruguay, and Brazil. In Europe, the costs of the EMS system are generally embedded in the overall costs of the various national health care systems. In South America, the costs of physician salaries are comparatively much lower than in the Untied States or Europe. This allows private ambulance companies to offer physician-staffed ambulances for high-acuity calls as well as physician-staffed sedans for lower-acuity house calls. Theses services are usually prepaid through service subscription programs for individual families, workplaces, shopping malls, or even places of business. There are also public EMS services, but they tend to have lower levels of funding and therefore tend not to offer the same level of response time performance or overall quality as the private subscription-based ambulance companies. The private companies will sometimes offer several different levels of service, based on the price level of the subscription. Many EMS systems built around the Franco-German model are integrating other tiers of response that include EMTs and paramedics. A great example of blending the Anglo-American and Franco-German models occurs in The Netherlands, which has an advanced EMS system that resists characterization as either Franco-German or Anglo-American. At first glance, one might be tempted to label the Dutch as having an Anglo-American system because they employ paramedics. The paramedics are actually critical care nurses who have undergone additional training to become paramedics. In common with the Franco-German model, these paramedics can treat and release autonomously, and dispatch can choose not to send an ambulance. Dispatch, however, is not physician run, and physicians rarely venture into the field. It is a single-tiered response, a separate service in which the fire department assists only with rescue or extrication. Aside from the financing methods and costs of physicians versus non-physicians, international EMS systems are also influenced by the different cultures and traditions of the areas they serve. In many parts of the world, ambulances are rarely used. Personal vehicles are traditionally used to take the ill and injured to clinics or hospitals. Social class and gender may also influence what type of care and the quality of care that is provided.",
        "Provider organization considerations": "Within the United States and other parts of the world that have a similar Anglo-American EMS system staffing design, there are many different organizations that provide EMS. Each type of organization has several theoretically unique advantages and challenges that EMS system designers and medical directors should be aware of. These should be understood as theoretical differences because organizations of the same provider organization type can still be quite different depending on their leadership and specific organizational cultures. \n\nFire department EMS Due to the requirements already in place for fire departments to respond to structure fires within minutes, fire departments across the country, particularly career departments in larger cities, already have the manpower and infrastructure in place to get emergency personnel on the scene of a medical emergency within a few minutes of call receipt. From an economic perspective, the dual-function firefighter/EMT or firefighter/paramedic provides a fire department with \u201ctwo employees for the price of one.\u201d This versatility allows these departments to utilize these cross-trained, dual-function personnel on fire apparatus as both fire suppression and EMS resources (at a BLS or ALS level) for medical first response. Some urban and suburban fire-based EMS systems have all or a very large percentage of their firefighters cross-trained as paramedics. On the face of the issue, it would seem better to have more than fewer paramedics. The counter-argument is that there are a limited number of high-acuity cases where paramedics have an opportunity to exercise their higher levels of clinical knowledge and skills. Without sufficient opportunity to use their knowledge and skills, the quality of paramedic care can suffer. This advocates for having a smaller cadre of paramedics who go to higher-acuity cases over a broader geographic area. This has been the approach used by the highly acclaimed fire-based paramedic program in the Seattle Fire Department for decades. Fire-based medical first response is extremely cost-effective. The cost of adding medical equipment, EMS training, EMS supervision, and fuel and maintenance costs for going on EMS calls to a standing fire response system is minor compared to the investment in the manpower and infrastructure that has already been paid for by the community for fire protection. Unfortunately, these marginal costs usually have to be covered by tax revenues. Under current rules set by the Centers for Medicare and Medicaid Services, with few exceptions, patient transport is the only EMS service that is billable. Another added benefit of fire-based EMS is the ability to more directly integrate medical care into rescue operations. At the scene of a complex rescue, medical care can be initiated while the patients are being disentangled, physically stabilized, or moved. It should be noted that some EMS systems train and equip non-fire EMS crews to provide most of these same types of rescue services. Fire-based EMS personnel are already steeped in the incident command system, which is used to manage major emergency incidents of all types. The physical, mental, and philosophical integration of medical services into the emergency incident environment is one of the most compelling benefits of fire service-based EMS. Fire-based ambulance service requires manpower and vehicles not already in place for fire suppression. This requires a significant additional investment. Manpower costs represent most of the cost for operating an ambulance service. Given the generally higher wage and benefits of firefighters compared to municipal, private, or hospital-based ambulance services, personnel costs for fire-based ambulance service tend to be more expensive. Fire-based ambulance crews tend to have the same 24-hour shift schedules and work out of the same stations as the fire apparatus crews. This can severely limit flexibility in matching the number and placement of ambulances to parallel the generally predictable patterns of demand for ambulance service (commonly referred to as system status management, or SSM). Failure to use SSM in fire-based ambulance services can result in significant added operational costs compared to organizations that do. On the other hand, SSM intentionally limits the number of ambulances in service at different times of the day to match the historical demand level. Unfortunately, the timing of many types of spikes in demand is unpredictable, such as a large multicasualty traffic accident incident or disaster. SSM-based ambulance schedules may not have the same number of ambulances immediately available that a traditional fire-based ambulance staffing model, with its typically larger, and more expensive, reserve capacity, would. One example of this difference was the Northridge, California, earthquake of 1994. This earthquake struck at 04.30 hours on a holiday morning. If fire departments in the area had employed SSM, they would have been woefully unprepared to handle the incredible number of calls for service that flooded the dispatch center immediately after the earthquake struck. During the first 24 hours after the earthquake, LAFD's dispatch center received 3,358 emergency calls for service, compared to its daily average during that time of just over 1,000 calls. Emergency medical services system design requires choices to be made. Some of them are fraught with potential controversy in which cost, service levels, and provider organization selections have to be balanced against each other in choices made by local officials. What may be affordable or politically acceptable in one community may not be in another. If a fire-based ambulance service can find creative solutions to overcome these challenges and effectively utilize its strengths to operate at a net profit, those profits can help offset the costs of its fire-based medical first response program. Because the firefighting and EMS duties are very distinct, prospective personnel may have the desire and aptitude for one occupation but not the other. This can affect recruitment as well as morale and job performance once hired. A concern of incorporating EMS into the larger fire service is that EMS may become the \u201cstep child\u201d to fire. EMS must compete with fire suppression and prevention activities for budget funding. For the provider, working on the busy EMS units is often less desirable than suppression duty. In some services, the EMS role goes to the less experienced and less senior members of the fire service, reinforcing and perpetuating the perception that EMS is a less desirable role. Firefighting activities require great agility, strength, physical stamina, and teamwork. Major fires are relatively rare and the daily routine may include considerable downtime. Yet, the vast majority of fire department responses are for medical calls. The differences between fire and EMS responsibilities, together with long-standing fire department traditions, can lead to major cultural differences among these factions, which inevitably result in performance and management problems. In spite of these challenges, many communities are exceptionally well served by fire-based EMS programs. \n\nLaw enforcement EMS Law enforcement agencies offer many of the same logistical and operations advantages as fire department EMS services. Due to the requirements already in place for police departments to respond to crimes within minutes, police departments already have the manpower and infrastructure in place to get emergency personnel on scene of a medical emergency within a few minutes of receiving a call. A major difference between most police departments and fire departments is excess production capacity. Fire departments have fewer and fewer fires they need to respond to. Despite that trend, the manpower and infrastructure needed to get anywhere in their jurisdictions in a matter of minutes must remain in place to ensure life and property protection. That leaves time available for other missions, such as EMS, to make use of those expensive resources. In contrast, most police agencies have either a rising demand for service or the rate of decline is not enough to warrant a search for other duties to assume. This is why law enforcement EMS is much less common than fire department EMS. Some smaller communities have smaller demand levels for police response, but need a certain number of officers on duty to provide adequate coverage to the entire area of the community. In those cases, communities may be interested in having their police departments provide medical first response services. Police department ambulance service is quite rare. The same type of cultural and prioritization issues that can impede fire department EMS can also affect law enforcement EMS. Some communities have implemented a combined delivery of police, fire, and EMS response services into a single set of personnel, most commonly referred to as public safety officers. Getting a \u201cthree-for-one\u201d employee has attracted strong support in those communities. The cultural and prioritization challenges can be further compounded when trying to meld three rather than just two organizations into one. \n\nMunicipal EMS The municipal EMS provider organization model is most prevalent in urban and suburban settings and where large geographic areas are under a single local government with the resources to fund EMS as a separate agency. The municipal EMS chief or director may report directly to the head of the municipal government, public safety director, or public health director. This variation in reporting structure highlights some of the identity issues that municipal EMS agencies can have. Is EMS a public safety agency that should report to the public safety director? Is it a health care organization that should report to the public health department? In fact, EMS is a hybrid, which can be both a blessing and a curse. Although municipal EMS agencies may be administratively independent entities, they must work closely with the other public safety and health care organizations to assure the provision of optimal prehospital emergency care. A survey of the largest cities in the US showed that fire departments provide first response in 99 of 109 cities, whereas transports are provided by fire departments in 37 of 107 cities (34.6%), private organizations in 36 of 107 (33.7%), and municipal EMS in 15 of 107 (14%). A variety of other providers, including hospitals, public utilities, volunteers, public, private, and police, makes up the remaining ambulance service provider organizations. The primary advantage of the municipal EMS model is its ability to focus. The agency, its managers, and its providers all have the provision of out-of-hospital care as the primary mission and sole focus. From an agency perspective, all resources can be directed to providing efficient and high-quality patient care and transport. Although there may be competing needs, such as replacement of monitor-defibrillators versus rescue equipment, these are all among EMS-related items rather than different lines of service, such as replacement of ambulances versus ladder trucks. Policies, schedules, station and unit distribution, and dispatch protocols can all be developed to facilitate the most effective EMS operation without compromising to concerns for fire or police functions. Managers of municipal EMS agencies are able to direct their attention and administrative efforts to one service line. Further, being separate from fire or police agencies, municipal EMS agencies can select managers who have qualifications, background, and expertise specific to EMS and prehospital care. They are often current or former emergency medical care providers, and so have a medical background that a supervisor or manager trained in another discipline may not possess. Theoretically, this provides them with a better understanding of the needs of the field provider and patient. In addition, their health care backgrounds may help with decisions related to quality improvement, quality of care, and the purchase of medical equipment. Perhaps the most important advantage is that the field provider's only duty is to provide emergency medical care. Each dual-role provider must also be proficient in an additional role, such as firefighting or law enforcement, so training and continuing education must be divided between two very different activities; the firefighter/paramedic must try to maintain proficiency in both firefighting skills and emergency care, for example. There is little overlap in the knowledge base and skill sets of these two distinct professions. Perhaps the greatest perceived disadvantage of the so-called \u201cthird-service\u201d (neither police nor fire) model is based on cost and financial efficiency. Legally, police and fire services must be provided and funded by local government. These agencies are well established in the governmental and public power fabric. The perception is that EMS can be more efficiently provided through incorporation into one of these two existing agencies, thus saving on infrastructure and personnel (both management and providers) costs. Typically, the fire department has a large budget, and government leaders are often pressured to preserve this budget despite the drastic reduction in fire calls over the past 20 years. EMS often does not enjoy this same political protection and may become the vulnerable target of cost reductions. This issue should be carefully evaluated, however, because EMS, in contrast to most fire departments, does generate revenues for its services and thus the net cost is much less than the budgeted expenditures. Another potential disadvantage of the municipal EMS agency model is the need for integration and collaboration with other public safety agencies. In many municipalities, municipal EMS providers perform transport operations. First response is performed by another agency, most often the fire department. Therefore, a good relationship between the fire department and the municipal EMS agency is important. This is sometimes challenging, because the fire and EMS departments may be competing for municipal financing, and providers may have different salary and benefit structures. Although municipal EMS providers tend to run more calls than their fire counterparts, they are often paid less. Municipal fire departments are typically much larger than EMS agencies and as a result their unions and associations generally carry much more political weight. Municipal EMS agencies may still suffer from a bit of an identity crisis with the media, government officials, and public. It is not unusual to see EMS providers described as firefighters, or lumped in with a group of other emergency responders. They are often not identified as distinct EMS personnel. Thus, EMTs and paramedics in municipal EMS agencies often fail to receive proper recognition for their efforts, even when heroic in nature. \n\nPrivate EMS Each community has its own unique history and path for how its ambulance and rescue services started and evolved over time. In many communities, private companies have long-standing traditions of providing high-quality ambulance service. This can offer communities many advantages. If there are a sufficient number of ambulance transports in the community, the ambulance service can be operated profitably without financial subsidy from local government. Lower transport volumes may necessitate some subsidy, but that may be preferable to the cost and financial risk of creating a government-operated ambulance service as a separate agency or within the local fire department. A private ambulance service takes the burden of managing and funding the ambulance service away from the government. In most states, government entities at some level still have the responsibility of assuring that ambulance service is delivered in compliance with applicable rules, regulations, and standards. This can achieved in several ways. Licensure is a mechanism by which an empowered government unit can establish minimum standards under which ambulance service must be provided. Any company that meets the licensure requirements can provide service. This has the advantage of simplicity but the risk of incurring the many downsides of multiple competing ambulance providers. Franchising is similar to licensure but can limit the number of providers. It may also designate exclusive operating areas to prevent \u201ccall jumping\u201d and other forms of inappropriate competition. Many communities choose to award exclusive franchises to a single provider, which completely avoids the issues of inappropriate competition and simplifies oversight and coordination. In the absence of retail competition and natural price and quality controls, the municipality then has to take on a more substantive regulatory role. When a community designates its local fire department or third service municipal agency to be the exclusive ambulance provider, it has essentially granted it an exclusive franchise. In many communities, the fire department or municipal ambulance service will have an exclusive franchise for presumed emergency calls received via the 9-1-1 system, but calls received via seven-digit phone numbers may be given to a private ambulance company. There is an almost endless number of variations for blending governmental emergency services with private non-emergency service. A very common model has private ambulance services respond to 9-1-1 cases when the government service runs short on available ambulances. A common flaw in such arrangements is failure to have the same quality standards and controls in place for both government and private ambulance services. Patients should get equivalent quality of care regardless of which organization provides it. A public utility model designates a single ambulance service provider to provide emergency and non-emergency services. The governmental unit does the billing. The governmental unit owns or is in a three-way lease for ownership of capital equipment. This allows the governmental unit to hire an ambulance service contractor to manage and staff the operation to specifications set in the contract. The contractor is paid a specified amount per call or by some other formula. If there is money left over after paying the contractor, that can be used by the governmental unit as it sees fit. The contractor can be readily replaced if needed for major breach of contract while leaving behind the capital assets. Under the public utility model, it is possible for governmental units to actually bid on the ambulance contract in competition with private services. For example, if a county government is running the public utility EMS system, a city or consortium of cities could bid to provide ambulance service through their local fire departments. The nature of the contractual relationship is important for the EMS medical director to understand. Ideally, the medical director should be somebody who is not beholden to the company, having been appointed by a third party (e.g. local government) and who is not directly compensated by the private company. Further, there is obvious benefit in medical director involvement in the structure of the contract. For example, the medical director ought to be in the best position to offer recommendations for response time standards and clinical capabilities. In any case, the EMS medical director should expect that he or she is going to be working within the confines of the established contract. Nothing more or less can be automatically expected of the private company. At first blush, this seems rather onerous and inflexible. No doubt, at times it might be. Yet the contract should also establish some ground rules that make expectations of all parties more clear. Such clarity in relationships, which is really what is being discussed, can be refreshing and helpful when contentious issues arise. All providers of EMS are undoubtedly, at some level, held to be fiscally responsible. A private provider will have motivation to sustain a profitable business. That is not necessarily a negative factor, for such goals can (and have in many cases) incentivize efficiency, innovation, and quality. These factors can all attract additional business opportunities. For the EMS medical director, an advantage of working with a private provider can be the uniform focus on EMS. As with municipal third services, there is typically no distraction from other competing priorities or missions in the organization, unless the company is also running paratransit or related services. Accountability within the system may be easier to optimize than perhaps in cases involving governmental agencies and municipal employees. Clearly, relationships are key. First, the EMS medical director should seek to gain credibility as an authority with regard to the community\u2019s EMS issues. Second, he or she must have a synergistic relationship with the service\u2019s manager(s) that can only result from understanding each other\u2019s perspectives and priorities. That said, appropriately applied creativity, ingenuity, and expertise can result in a superior EMS system that often relies on collaborative partnerships with other public safety and health care entities to effect the timeliest response to emergencies and outstanding prehospital care. Subsets within the realm of private EMS are hospital-based and volunteer EMS organizations. The key characteristic is not whether the organization is for profit or not for profit; it is more about being a unit of government or a non-governmental (i.e. private) enterprise. Hospital-based EMS services have a significant advantage over their non-hospital-based counterparts in that they are part of a health care organization. This creates opportunities to leverage the clinical and cultural assets of the hospital to enhance training, continuing education, professional development, career ladder options, etc. There are some legal ramifications of having a hospital-based ambulance service on billing and acceptance of patients. One of the downsides is that hospitals often do not have many of the specialized business and logistical competencies needed to manage an ambulance service. There can be an unfortunate tendency to treat the ambulance service like just another department of the hospital, despite its very unique demands and requirements. Volunteer ambulance services and non-transport rescue squads are typically formed as not-for-profit charitable corporations under Chapter 501(c)(3) of the Federal Tax Code. It is important to recognize that many \u201cvolunteer\u201d ambulance services actually pay their members to respond to calls, often a small amount per response. Some volunteer services have some paid staff working from the ambulance station during daytime working hours. The off-site volunteers cover calls at night and on weekends. This is a common transition pattern as communities will often outgrow a volunteer model as call volumes increase and become too burdensome for the volunteers to reliably cover on a 24/7 basis. Regardless of what type of organization provides the ambulance service, EMS medical directors must continually insert themselves at the table with the policy and decision makers, speaking loudly for evidence-based medical care among the echoes of political and financial rhetoric.",
        "Unionized workforce considerations": "Unionized employees tend to be more common in urban and suburban EMS systems. They present some distinct opportunities and challenges for administrators and medical directors. They can often provide a very effective means for communication with the field staff. Collective bargaining agreements with unions can also impose some restrictions in how policies that affect roles, responsibilities, and working condition issues are addressed. When a unionized workforce is present, the system design should recognize its presence and seek to include it as a resource for field staff input and participation, complementary to other mechanisms through the normal chain of command. An important factor is the status of labor/management relations, which can vary tremendously over time. When there is mutual respect and reasonable trust, the dialog can be very constructive and the union can be a strong partner in effecting positive change.",
        "Deployment planning": "Deployment planning refers to the processes used to decide where and when ambulances and medical first response units are to be positioned while waiting for the next call. There are four general types of deployment planning: static, dynamic, real-time, and hybrid. Static deployment is the simplest and most common. Response units are positioned 24/7 in stations. The locations of the stations are chosen strategically based on historical patterns of call locations and call timing. This is most commonly used by fire and municipal EMS services. It has the advantage of offering crews a comfortable location while awaiting their next call. Vehicles can also be kept in garages with shielding from the elements. Dynamic deployment looks for geotemporal patterns of demand and develops a plan to make the most efficient use of resources to meet response time goals. Geographic analysis shows recurring patterns of where calls occur. That information is coupled with temporal or timing analysis to find patterns in when calls occur. The combined geotemporal analysis allows deployment planners to develop detailed contingency plans. At a very detailed level, each of the 168 hours in a week is analyzed separately for how many calls typically are in progress and where those calls tend to be located. Queuing analysis is used to determine how many units are needed to be available for that hour. A table is generated that shows where response units should be located depending on how many units are available during that hour. For example, queuing analysis might show that 17 ambulances are needed between 2pm and 3pm in the afternoon on Wednesdays. At some point, there might be eight units occupied on calls, leaving nine ambulances available. The table will show when nine ambulances are available, where they would be best positioned. Different tables may be generated for different months of the year. Special plans may be used during the timeframe when a special annual festival or sporting event takes place. This approach can be used for both ambulances and medical first response units. The primary advantage of dynamic deployment is that fewer hours of service from response units (called unit hours) are needed to provide the same level of response time performance compared to a static deployment strategy. This has huge potential for reducing the overall cost of the EMS system. There are several pitfalls that must be addressed to use dynamic deployment safely and humanely. Dynamic deployment can save money by keeping crews busy during the entire shift, which increases their productivity for the costs of having them in service; however, keeping crews constantly busy without breaks and over longer periods of time creates a very poor work environment. A reasonable balance has to be achieved for long-term success. Analyses need to use good data and sound methods to yield good results. Bad data and unsound analyses can endanger patients by prolonging response times to time-sensitive medical problems. Competent dynamic deployment requires a much more sophisticated level of managerial expertise and data literacy compared to static deployment. Technology is rapidly evolving to support increasing levels of sophistication in real-time deployment planning. Typically, deployment planners will develop a dynamic deployment plan as described. However, in real time, GPS location data from the ambulance can be combined with historical or real-time traffic data that indicate traffic speeds. This allows the real-time analysis to show the effective range of each response unit on a map for a different response time. This appears on a computerized map as a polygon with gradations showing the area the unit can be expected to reach in 1-minute increments. The shape of the polygon changes as the unit travels (and as road conditions change if real-time traffic data are used). The dispatch center can then deviate as needed and appropriate to make adjustments based on real-time data. This is particularly helpful while units are moving from post to post or from hospitals to posts after calls. Hybrid deployment uses combinations of these approaches. Many systems will have some fixed stations along with some posts at key intersections. Crews can be rotated to station posts for a break to stretch, eat, use the restroom, etc. Systems that cover urban, suburban, and rural areas will often use static deployment in the rural areas and dynamic deployment in the urban/suburban areas.",
        "Performance standards and assurances": "Good EMS system design also sets standards and creates safeguards to help ensure compliance with those standards. System performance standards are primarily derived from patient and community needs, which must be balanced. For example, a small percentage of patients experience sudden cardiac arrest. This is an extremely time-sensitive emergency, with the chances of a neurologically intact survival falling by about 10% with each minute of elapsed time from collapse to initiation of resuscitation. For those patients who are lucky enough to have bystanders witness them collapsing in sudden cardiac arrest, having an EMS unit arrive within 1 minute of getting the call from the bystander would be great \u2013 but unaffordable. In practice, the decision is usually made considering what level of performance can be provided with available resources. If that answer is politically unacceptable for that community, more resources need to be allocated. There are usually very different levels of community acceptance and expectation for urban areas versus rural areas. In short, a community can have whatever level of performance it is willing to pay for. This is where system-level medical oversight is extremely important. The physician medical director needs to advise policy makers on the likely effect of response time performance, specific medical equipment, certification levels, etc. on clinical outcomes. Whenever possible, those recommendations should be based on sound medical evidence. Historically, EMS system performance standards have focused on target response time intervals and the percentage of calls where those targets were met. This was due in large part to the very limited amount of scientific evidence that showed the relationship between clinical outcomes and response time intervals. For decades, the evidence was limited to cardiac arrest. The data show that the sooner EMS crews can initiate resuscitation, the better the outcomes will be. There was also strong political momentum, but not much research, supporting the notion that getting patients to trauma centers sooner than later will improve outcomes. This led to a generalization that getting to EMS patients sooner rather than later was an appropriate surrogate measure of patient outcome and clinical quality. It had the convenient attribute of being relatively straightforward to measure. Emergency medical services research has improved over time and we now have better information and technology. We have a growing body of peer-reviewed EMS research that shows that shortened response times do not have nearly as much effect on clinical outcomes as previously believed. For conditions other than sudden cardiac arrest, a few minutes sooner or later generally does not make a significant difference in outcome. This has huge financial implications for where response time intervals can be set without comprising care \u2013 with the exception of sudden cardiac arrest. This is leading some systems to take a more creative and evidence-based approach to setting response time standards. For example, Kent County, Michigan, is considering relaxations in response time standards while simultaneously increasing efforts to utilize other municipal employees, delivery services, off-duty medical personnel, and citizen bystanders to start hands-only CPR to address the cardiac arrest cases in a more effective manner than primary reliance on EMS to initiate resuscitation. This has the potential to decrease the number of EMS response units needed to meet standards without compromising outcomes. They are also shifting the focus from response time accountability to compliance with processes known to improve clinical outcomes, such as high chest compression fractions, shorter pre- and postdefibrillation pauses, earlier notifications and fewer false positives and false negatives on EMS STEMI alerts, and earlier notification and more reliable documentation of stroke scores. Short response times have also been assumed to correlate with better patient satisfaction. While there probably is a correlation, it may not be a primary factor. Rather than relying on response times as a surrogate for patient satisfaction, there are ways to measure it directly and set standards for it.",
        "Transparency and accountability": "Mechanisms for creating transparency and accountability for performance create powerful incentives for clinical and service excellence. When EMS providers are required by the system design to report their performance using valid and appropriate metrics, they will have a natural tendency to meet standards and improve over time. Emergency medical services provider organizations should be held accountable for meeting fair and meaningful performance standards. Beyond the political capital and reputation loss for failure to meet standards, the system design can impose penalties for chronic failure to meet standards. While this has been common for meeting response time standards, in light of more contemporary research, it might be better applied to clinical process performance metrics such as CPR quality. In extreme cases, the system design should have mechanisms in place to safely and appropriately replace a provider for chronic failure to meet standards. Emergency medical services system design has enormous influence on clinical and service excellence. EMS leaders and policy makers should seek to master its concepts and methods as they seek to improve performance in their communities."
    },
    {
        "Introduction": "In their insightful book Transforming Health Care Leadership, Maccoby et al. state, \u201cLeaders are people others follow. If no one follows you, you are not a leader.\u201d In this chapter, we aim to equip you with tools to become a person others are inspired to follow. Primary leadership activities include: - Setting direction for team members to follow - Monitoring and analyzing system performance - Intervening to make improvements One practical way to build a strong foundation for EMS physician leadership is to develop clear answers to the following five key questions: 1. Why are we here? 2. Where are we going? 3. What guides our day-to-day decisions and actions? 4. How are we doing? 5. What are we doing to make things better?",
        "Why are we here?": "The answer to this question is the system\u2019s purpose or mission. For example, \u201cOur purpose is to reduce suffering.\u201d An effective purpose clearly describes the philosophy of the leader and hopefully the culture of the people in the system. It is tangible and actionable.\n\nThe real purpose of an EMS system is something that people who are served by the system will be able to figure out without reading fancy wall posters or wallet cards. It lives in the actions, the focus, and the conversation of the people working in the system. Avoid platitudes like, \u201cWe are the best EMS system in the world\u201d as they are difficult to lead toward and measure.\n\nFor medical directors it is also important to be clear about the reason you are part of the EMS system. Part of the purpose of an EMS system is to provide clinical care to patients with the same attention, style, and treatment that the system\u2019s medical director would provide.\n\nThe 2001 Institute of Medicine report Crossing the Quality Chasm lists \u201cpatient-centered care\u201d as one of the six domains that define quality health care [2]. If one were to stand back and look objectively at the design and operation of most EMS systems in America, very few actually put patients\u2019 needs and perspective at the center of their design. One EMS system\u2019s purpose is \u201cto reduce suffering,\u201d which aligns with a patient-centered system design.",
        "Where Are We Going?": "The answer to this question lies in the system\u2019s vision \u2014 a crystal-clear description of a future state you're striving to create. The clearer and more vivid the vision, the easier it is to align everyone\u2019s work toward realizing it. For example: - \u201cA world in which no one dies suddenly as a result of an acute, treatable medical event\u201d \u2014 from Physio-Control \u2014 is bold, clear, and measurable. - Contrast this with, \u201cTo be the best provider of out-of-hospital patient care services,\u201d which is vague and difficult to lead toward.",
        "What Guides Our Day-to-Day Decisions?": "The answer: Values. A well-defined set of values helps team members align their actions with the organization's purpose and vision. As Maccoby et al. point out: \u201cTo gain trust and support from the people you lead, they need to know what they can expect from you.\u201d One of the most widely adopted EMS value systems is STAR CARE, developed by Thom Dick in 1990 for BayStar Medical Services. These values are: - Safe: Were my actions safe for everyone \u2014 patients, colleagues, the public? - Team-based: Did I consider my co-workers\u2019 perspectives and collaborate effectively? - Attentive to human needs: Did I treat the patient with compassion, comfort, and clear communication? - Respectful: Did I act respectfully toward all \u2014 patients, colleagues, responders, and the public? - Customer-accountable: Could I face each customer and honestly say, \u201cI did my very best for you\u201d? - Appropriate: Were my actions appropriate legally, medically, and practically? - Reasonable: Would a reasonable colleague agree with my actions? - Ethical: Were my actions fair, honest, and morally sound? A helpful ethical test: If your planned action were tomorrow\u2019s newspaper headline, would you and your team be proud of it? If not, reconsider. The STAR CARE guidelines are used by EMS systems throughout the world today.\nSafe: Were my actions safe \u2013 for my patient, for me, for my colleagues, and for the public?\nTeam-based: Were my actions taken with due regard for the opinions and feelings of my co-workers, including those from other agencies?\nAttentive to human needs: Did I treat my patient as a person? Did I keep him/her warm and comfortable? Was I gentle? Did I use his/her name throughout the call? Did I tell him/her what to expect in advance? Did I treat his/her family and friends with similar compassion?\nRespectful: Did I act toward my patient, my colleagues, my first responders, the hospital staff and the public with the kind of respect that I would have wanted to receive myself?\nCustomer-accountable: If I were face to face with the customers I interacted with, could I look them in the eye and say, \u201cI did my very best for you\u201d?\nAppropriate: Was my care appropriate \u2013 medically, professionally, legally, and practically considering the circumstances I faced? Alignment with medical protocols is the easiest way to display this value.\nReasonable: Did my actions make sense? Would a reasonable colleague of my experience, credentials, and position have acted similarly, under similar circumstances?\nEthical: Were my actions fair and honest in every way?\n\nA shortcut for deciding whether a planned action is ethical or not is to imagine how you would feel if what you are about to do were featured as the headline story in tomorrow\u2019s newspaper. If you and the people in your system would be proud of the article, it is probably an ethical decision. If not, then it is probably not something you should do.\n\nThis STAR CARE checklist is copyright free and can be printed on wallet-sized cards for everyone in any system. (You are welcome to put your own logo on STAR CARE cards; all we ask is that you please give credit to Thom Dick and BayStar.) It provides a very simple yet powerful framework for decisions, education, coaching, and investigation of unusual occurrences.",
        "How Are you Doing?": "When health care providers take care of patients, they constantly monitor vital signs. This ongoing monitoring allows them to give a good answer to the question, \u201cHow\u2019s she doing?\u201d A patient\u2019s pulse, blood pressure, respiratory rate, oxygen saturation, Glasgow Coma Scale, end-tidal carbon dioxide, pain level, temperature, etc. highlight the performance of various organ systems in the body.\n\nWhen viewed as a system, these vital signs provide a reasonably reliable picture of how a person is doing. If one of these vital signs is off, it inspires the clinician to investigate the cause and possibly intervene to improve the patient\u2019s health. A good clinician knows that an intervention designed to address one area of the body is likely to have an effect on other aspects of the patient\u2019s health. For example, epinephrine administered to open the airways, improve oxygenation, and decrease the work of breathing for someone having an asthma attack can cause unintended cardiac arrhythmias.\n\nEffective leaders view their organization as a system of interconnected processes. Like clinicians monitoring vital signs, leaders should monitor key performance indicators (KPIs) across areas such as clinical quality, operations, safety, and more. Start by identifying macro categories: - Clinical - Employee experience - Fleet management - Safety - Materials management Then, define one meaningful KPI for each. For example, for fleet maintenance: - KPI: Number of vehicle failures per month - A low failure rate likely reflects good preventive maintenance practices In the clinical category, the 7 Things That Matter (TtM), developed by Ed Racht, Scott Bourn, Lynn White, and AMR Medicine\u2019s leadership team, offer a strong framework: 1. Assuring Safe Patient Care and Transport 2. Cardiac Arrest Resuscitation 3. Reduction in Pain and Discomfort 4. Safe and Effective Maintenance of Airway and Ventilation 5. Relief of Respiratory Distress 6. Recognition and Care of Ischemic Syndromes 7. Effective and Timely Trauma Care Understanding the difference between outcome measures and process measures is key: - Outcome measure example: % of shockable witnessed cardiac arrests discharged with CPC 1 or 2 - Process measure examples: - % receiving bystander CPR - % identified early by 9-1-1 dispatch with CPR instructions - CPR fraction (time compressions were ongoing) Use run charts or Shewhart control charts to track these KPIs over time. Avoid reacting to single data points or relying on static dashboards like pie charts or traffic lights. The advantage of displaying the performance of these dynamic processes in their naturally occurring time order is that it allows the viewer to draw statistically valid meaning from the charts better than reacting inappropriately to something that does not really exist. For dynamic processes, it is best to avoid static displays such as bar charts, pie charts, or traffic light color-coded dashboard indicators. These displays often lead viewers to attribute something unusual to performance data that do not have anything special going on. Leaders who take action based on these inappropriate displays run the real risk of decreasing performance, or doing what Deming called \u201ctampering.\u201d All processes monitored through KPIs have variation, whether it is the percentage of false-positive STEMI activations or the average lactate levels of patients with sepsis. Effective leadership requires the ability to distinguish between common cause variation (the variation inherent in the process) and special cause variation (the variation caused by something outside the normal process). For example, when an EMS system added 12-lead ECGs for non-traumatic chest pain, its average scene time increased nearly 6 minutes, a special cause due to a change in process. As the medical director, your questions carry a lot of weight and have the potential to inspire a lot of action by your team. Therefore you have the responsibility to ask statistically valid (good) questions. For a process with common cause variation, the valid question is, \u201cIs this good enough?\u201d For one with special cause variation, the valid question is, \u201cWhat happened here?\u201d Deming said, \u201cPrediction is the problem, whether we are talking about applied science, research and development, engineering, or management in industry, education, or government.\u201d He adds, \u201cThe question is, \u2018What do the data tell us? How do they help us to predict?\u2019\u201d Knowing how to accurately read the data so that you can make predictions is a key leadership skill. There are several signs of special cause variation. Health care statistician Davis Balestracci focuses on three rules that are easy to remember and cover the majority of the special cause variation seen on run charts and Shewhart control charts. It is special cause variation if there is: \u2022 a trend, defined as six or more consecutive data points ascending or descending \u2022 a run, which is eight or more consecutive points above or below the median \u2022 a point outside the upper or lower control limits on a Shewhart control chart. If you make the run chart into a Shewhart control chart, upper and lower control limits will be added. Points above the upper control limit or below the lower control limit are considered to be special cause. The proper selection of Shewhart chart type (I, U, P I, Xbar and S, T, G) is based on the type of data, subgroups, size of subgroups, frequency of the data, area of data opportunity, etc. An easy-to-use and affordable way to build these is available from www.qimacros.com. If you would like to learn more about assessing for and understanding variation, these books are good places to start: Data Sanity by Davis Balestracci, The Improvement Guide by Gerald J. Langley et al., and Understanding Variation by Donald Wheeler. The system\u2019s leadership team should review overall system performance using their suite of KPIs at least once a month. The two primary things leaders should be looking for as they review the run or control charts showing the KPIs in their system are to make sure that unanticipated changes in performance have not occurred, and to decide what areas of the system need improvement. One key is to focus on a vital few KPIs, as it is very difficult for busy people to pay real attention to hundreds of graphs. Ten to 12 crystal clear graphs displaying vital information is much better than thick multipage reports that no one has time to really read. Resist the urge to purchase expensive software systems that will use a color-coded traffic light static display of dynamic data. These displays often mislead leaders into making inaccurate assessments of performance and therefore recommending ineffective or potentially damaging recommendations for change.",
        "What are you doing to make things better?": "Dr W. Edwards Deming, the father of quality management, said, \u201cMost troubles and most possibilities for improvement add up to proportions something like this: 94% belong to the system (the responsibility of management), and 6% are attributable to special causes (the responsibility of employees).\u201d The biggest improvements in EMS come from system, process, and management practice changes, not from tuning up individual EMTs or paramedics. In the late 1980s, Dr Don Berwick and some colleagues founded the Institute for Healthcare Improvement (www.ihi.org). They engaged a group of statisticians from Austin, Texas, called the Associates for Performance Improvement (www.apiweb.org) and adopted their Model for Improvement as the vehicle for making health care better across the US and the rest of the world. This simple yet powerful model holds the key to making effective improvements. The first step in this model is to write an AIM statement. Thousands of crazy, costly EMS ideas would be derailed if leaders just stopped and asked their team \u201cWhat are we trying to accomplish?\u201d For example, it is very common for paramedics to ask their medical directors to allow them to perform rapid sequence intubation. What usually follows is a spirited conversation about the need to save more lives, the safety of sedation and paralytic medications, the competency of paramedics to place a tube in the trachea quickly and reliably, and transport times to local trauma centers. Helping people focus on answering the question \u201cWhat are we trying to accomplish?\u201d before engaging in any other part of the conversation tends to cut through the emotions and bring the focus back to what is best for patients. Asking this first question is an effective way to steer conversations from \u201cWe need \u2026\u201d rapid sequence intubation, vacuum splints, tissue oxygen monitors, etc. to \u201cWhat do our patients need?\u201d Airways open and clear of gunk, a way to decrease their nausea, the fastest possible time to the cath lab, etc. The second question in the model is \u201cHow will we know that a change is an improvement?\u201d This pairs perfectly with the first question in the model. In practice, they can almost be asked at the same time. This question relates to data. Quality guru W. Edwards Deming used to say, \u201cIn God we trust, all others must bring data.\u201d When it comes to the request to add rapid sequence intubation, the data would probably include the number of prehospital non-cardiac arrest patients who needed intubation who were not intubated because their airway reflexes were intact. An outcome indicator might be the percentage of these patients who suffered death, aspiration of stomach contents, or hypoxic brain injury as a result of not being intubated. If it is not possible to produce data to support the AIM, then it is difficult if not impossible to move forward with an improvement project. Also, if you are not able to measure (qualitatively or quantitatively) what you are trying to improve, it is impossible to know if performance has improved. Leaders who take the time to help their team craft clear answers to the first two questions will improve their results and reduce wasted time, energy, and money. The third question is where creativity is key: \u201cWhat changes can we make that will result in improvement?\u201d The answers to this question come best from a team brainstorm about ideas for improvement based on the AIM and measurement criteria. You will make better progress if you push yourself and your team to come up with at least three (and hopefully more) ideas. Too often we stop after grabbing one, or we craft an improvement project around the idea we are most attached to. There is a tendency in EMS to start with this third step. EMTs, paramedics, and medical directors fall prey to the seduction of EMS conference exhibit halls. iPhone-driven portable ultrasound, tissue hemoglobin oxygenation saturation monitors, and adjustable headrest cervical immobilization devices may be useful or they might be really cool solutions looking for problems. Leaders who ask \u201cWhat are we trying to accomplish?\u201d and \u201cHow will we know that change is an improvement?\u201d in response to pleas for new devices or medications are much less likely to head down a path to waste or potential patient harm. It is important to involve the folks who will be doing the actual work in the brainstorming process. It is common to hear EMS leaders say \u201cWe need to get buy-in from the front line before we implement this.\u201d Dr Peter Senge, the author of The Fifth Discipline, was facilitating a small-group dialogue this author attended when someone asked a question about getting buy-in from employees. Dr Senge shared his employee engagement ratings system, to the effect that: ... the lowest level of employee involvement is terrorist, someone who will actively sabotage change efforts to make sure that they are not successful. The next level is buy-in. All you get from people who are bought in is non-terrorism. The next level up is enrollment, which means putting your name on the roll. It involves a level of volunteerism and energy toward making the change successful. The highest level of engagement is commitment: \u201cGet the heck out of our way, we are going to make this happen.\u201d If you\u2019re trying to make a big, important change you need people who are committed not just bought in on your team. Most leaders find that it is very difficult to inspire commitment to their ideas. Commitment usually comes from people having real involvement in creating the details of the change they are expected to execute.",
        "Leadership for performance improvement: project example from American Medical Response\u2019s Ventura County operation": "What are we trying to accomplish? Measurably decrease suffering for the patients we serve. How will we know that change is an improvement? A higher percentage of our patient care reports (PCRs) will show a decrease in suffering. We measure this by taking a random sample of 100 (PCRs) each month and evaluating them for documentation of the nature and severity of suffering (pain, nausea, shortness of breath, anxiety, etc.), an intervention of some kind designed to decrease the suffering (CPAP, morphine, ondansetron, etc.), and a postintervention reassessment of the suffering. The numerator will be the number of patients in the monthly sample where the PCR demonstrates a reduction or elimination of suffering. What changes can we make that will result in improvement? In the case of suffering reduction, improvement ideas might include the following. \u2022 Adding ondansetron to the medications carried by crews to address nausea. \u2022 Encouraging non-pharmacological interventions for orthopedic pain, like cold compresses, elevation, and splinting. \u2022 Changing the morphine dosing protocol from 2\u20134 mg to a weight-based 0.01 mg/kg. - Expanding the use of CPAP beyond pulmonary edema to asthma, pulmonary infections, CO poisoning, etc. - Provide myth-busting pain management education that deals with perceived drug seekers, abdominal pain, and the limited ability of health care providers to assess pain severity using anything other than the patient's own pain rating. The last part of the Model for Improvement involves a series of Plan-Do-Study-Act (PDSA) tests to learn about the effectiveness of your improvement ideas. For clinical improvements it is important that only changes supported by the scientific literature be on the brainstorm list. Improvement ideas that are not supported by science need to be properly researched with full IRB patient protection before they can be considered for use in an EMS system. The objective of PDSA testing is to learn what really produces beneficial results in your system before anything is implemented. One secret is to start with the smallest, quickest test you can imagine. Then do several small rapid PDSA cycles to quickly learn what works and what does not. Lots of people have written about PDSA cycles over the years and the descriptions can sound a little intimidating. Here is a what-you-need-to-know version. Plan: Describe briefly what you are going to try and how you are going to measure the results. Then make a prediction about what will happen. For example, \u201cOn ambulance 421 B shift we are going to have them give weight-based morphine to the next patient they have with pain and they will measure the premedication and post-medication pain scale. We predict that their 1\u201310 pain scale will drop at least two points.\u201d Do: Carry out the plan. Collect data related to the prediction and record notes about any observations on things that went well, did not go well, were unanticipated, etc. Study: Compare the result with your prediction and capture any ancillary learning. For example: \u201cWe had a 27-year-old male with a fractured ankle from a mountain bike crash. His pain scale was 7 premedication and 2 postmedication. The morphine made him nauseated and the medic thought that it was easy to calculate the dose.\u201d Act: Here you will do one of three things. \u2022 Adopt the change concept as successful. \u2022 Adapt the change concept and try another PDSA cycle. \u2022 Abandon the change concept as unsuccessful. In our example we might decide to adapt the weight-based morphine dosing protocol to include the administration of ondansetron to manage the nausea. The concept is to continue doing PDSA cycles until your \u201cdegree of belief\u201d as shown by the results you are able to produce indicates that it is time to implement one or more of the changes system-wide. Too often, EMS systems implement interesting ideas without these testing cycles, which is how we got military antishock trousers, esophageal gastric tube airways, and high-dose epinephrine. Often EMS improvement ideas include some form of education. Communication and education about the new information are best accomplished with an eye toward developing new competencies in clinicians. The most effective systems use multiple mechanisms (classes, newsletter, audio education, computer-based training) to ensure that everyone practicing in the system understands and can activate the new information. Psychologists call it \u201cmagical thinking\u201d to believe that issuing a new protocol via memo means that all patients in the system will instantly be cared for in alignment with the new protocol. The effectiveness of training can be assessed using the four-level effectiveness assessment first described by Donald Kirkpatrick in 1959. Level 1: Posttraining participant satisfaction assessment. This is designed to fine-tune the delivery mechanism for training to best meet the needs of the learner. Level 2: Knowledge retention assessment (posttraining test). This is designed to see how well students remember the information that is presented in the training program. Level 3: Behavior change assessment. This is designed to see if the new knowledge translates into a change in action by crews when taking care of patients. Level 4: Clinical outcomes assessment. This is the most difficult level of training effectiveness assessment and can only be accomplished in certain clinical conditions.",
        "Interventions with individuals": "Occasionally situations will arise where the medical director will need to intervene to help an individual EMT or paramedic improve, or to help that provider find another way to make a living. It is always good to follow Steven Covey\u2019s second habit, \u201cBegin with the end in mind.\u201d As a medical director, chances are good that part of the end in mind you hope to accomplish is better or safer patient care. It is easy for leaders to be so distracted by how employees react to feedback that they forget the results they are trying to produce for patients.",
        "Feedback": "Management author Ken Blanchard says, \u201cFeedback is the breakfast of champions.\u201d In the world of EMS, feedback from the medical director and her or his physician colleagues is the breakfast, lunch, dinner, and midnight snack of champion clinicians. Medical directors who are skilled at interpersonal communications can have a powerful effect on the retention and satisfaction of clinicians in their system. No matter how scientific and academic the conversation, the vast majority of a message that is received by a team member in conversation with the physician leader is emotional. Albert Mehrabian researched interpersonal communications in the early 1970s and found that of the messages people receive, 7% are made up of the words used, 38% from tone of voice, and 55% from body language. How one communicates has a greater effect than what is actually said. The phrase \u201cI love you\u201d leaves one impression when it is delivered by a sarcastic angry person and another when it is shared in a loving fashion. The same can be true for the phrase, \u201cI\u2019m the doctor and you practice according to my protocols.\u201d When kindness and caring are communicated, the receiver can perceive even negative feedback positively. Replace \u201cconstructive criticism\u201d with \u201cfeedback for improvement.\u201d The term constructive criticism is an oxymoron. Construct means to build; criticize means to tear down. When constructive criticism is provided, receivers are torn down. When that happens, they are not likely to improve their performance. It is very difficult to improve effectiveness when one is feeling down. Also, people react to criticism by becoming defensive and are likely to become more firmly entrenched in their beliefs. On the other hand, useful feedback is like a gift that can be used to improve the future. Useful feedback can be a powerful relationship-building tool. A couple of linguistic constructs can improve the chance that a listener will be able to integrate feedback without becoming defensive or torn down. The first is to construct feedback in the form of an \u201cI statement.\u201d An I statement comes across as a request for assistance. Almost everyone in EMS likes helping people, so the I statement is a useful way to engage their energy. Effective I statements have four parts: your emotional state, the other person\u2019s action, your interpretation of his or her action, and a request. For example, \u201cI get frustrated when you bring in patients with only their head taped down to the back board, because my interpretation is that you don\u2019t understand the damage that can occur if you have to roll the patient to clear their airway when the rest of their body is not immobilized. My request is that whenever you immobilize a patient\u2019s spine you secure the head, shoulders, chest, and hips to the board.\u201d Another trick for providing feedback that is well received is to replace the word \u201cbut\u201d with the word \u201cand.\u201d \u201cYou are a really good EMT but\u2026\u201d has a very different impact from \u201cYou are a really good EMT and\u2026\u201d When most people hear the word \u201cbut\u201d used like this, it sends the message that everything said before the word is a lie and it signals that an attack will immediately follow. Instantly a psychological defensive wall flies up, blocking the very message that you are trying to deliver. When people hear a compliment followed by \u201cand\u201d their ears tend to perk up expecting more good news. \u201cYou are a really good paramedic and if you had checked this patient\u2019s temperature it would have increased the chance that you\u2019d have recognized their difficulty breathing was caused by pneumonia rather than CHF.\u201d Most customer service literature suggests that people will treat others similar to the way that they have been treated. Medical directors who are kind and caring in their interactions with paramedics are likely to have paramedics who are kind and caring towards their patients. Conversely, paramedics who feel harshly judged and abused are more likely to be judgmental and abusive with patients. How paramedics feel when they leave an interaction with their physician leader \u2013 happy and supported or angry and frustrated \u2013 is likely to influence their next patient interaction. Similarly, meaningful feedback should be provided in private. Even if the feedback is not likely to embarrass or stress the receiver, it should be given in private. That approach increases respect for the leader. It is also more effective, as demonstrated in the following case. A medical director dressed down a paramedic in front of the emergency department staff and a patient; the paramedic had made a potentially dangerous mistake. Following the interaction, the physician felt that he had been effective in his communication. He also felt that it was an added benefit for the rest of the staff to hear the feedback, so they would not make the same mistake. However, all the paramedic and the staff who witnessed the event could focus on was what a jerk the medical director was. They felt that he acted had inappropriately, and they totally missed the valuable feedback that he provided. The general consensus was that in the future, they needed to be more careful not to get caught. A similar situation occurred in another city. However, this medical director chose to wait until the patient was cared for and her anger had lessened. She then asked the paramedic to step into a private room to discuss what had happened. After the physician communicated her concern in the form of an \u201cI statement,\u201d she asked the paramedic what he thought about the situation, and he was encouraged to explain his thought process and decision making. Only then did the medical director point out the cognitive flaws and provide remedial education. After the interaction, the medical director felt that she had been effective in communicating the message; more importantly, the paramedic felt the medical director really cared about the treatment that patients received. Feeling supported and committed to patients, the paramedic shared the details of the situation and what he had learned with as many peers as he could. Now, the paramedics in this system bring their mistakes and concerns to the medical director before she hears about them from another source. In addition, she is regularly sought out as a consultant for advice about challenging calls."
    },
    {
        "Defining mass gatherings and special events": "Mass gatherings present unique challenges to EMS as they put pressure on the surrounding emergency response systems. History demonstrates that they can produce, or are vulnerable to, escalating events such as crowd disturbance, fire, structural collapse, natural disaster, disease outbreak, or terrorist attack. Mass gatherings are not isolated events. Despite best efforts to manage and contain events within normal operations, they often strain peripheral resources, including EMS, hospitals, transportation, and law enforcement. As a result, when a mass casualty incident (MCI) occurs during a mass gathering, emergency services are often already saturated and the response is compromised. Traditional mass gathering planning has concentrated on normal operations using historic patient presentation rates from comparable events. As a result, when an escalating event does occur, conventional planning tools and available resources are generally not prepared to manage the catastrophe. However, with proper planning and tools, a mass gathering can not only be better prepared for an escalating incident during the operational period, but can also be used as a disaster response training exercise between collaborating response services. This chapter reviews the definitions and types of mass gatherings, provides a historic perspective of MCIs that have occurred at mass gatherings, covers planning and management methodology, highlights unique EMS capabilities that are useful for response within mass gatherings, and presents MCI tools and lessons learned from case studies of prior experiences. The goal of this chapter is to go beyond the traditional role of preparing for normal operations at mass gatherings by integrating MCI planning and tools to address historical vulnerabilities and emerging threats. The vulnerabilities that mass gatherings expose can be converted into an opportunity by using these events as repeatable training exercises for MCI response. These exercises incorporate many of the actors required to respond, which forges interagency relationships and facilitates application of the procedures and protocols. Mass gathering planning that includes preassignment of MCI leadership roles, predesignation of disaster communications channels, coordination with regional hospitals, integration of unique EMS tools and capabilities, staging of disaster supplies, recognition and mitigation of historic vulnerabilities, and preservation rather than saturation of regional resources with physician-based treatment centers will better prepare for normal operations as well as for a MCI.",
        "Types of mass gatherings and definitions": "There is a broad variety of mass gatherings that vary in scale, location, and nature of event. Large athletic events, rock concerts, religious celebrations, and street fairs will each present a different set of challenges to planners. A mobile and open event, such as a marathon, that is spread across a city will differ significantly from an enclosed, ticketed event at a stadium. The nature of the attendee will also influence the challenges faced. For example, a rock concert may have a higher potential for substance abuse and violence while a religious celebration might have a higher number of elderly or infirm participants. The scale of planning will differ greatly for a local parade, when compared to a large-scale event such as the Olympic Games, which requires planning and coordination at the federal and international level. Mass gatherings have varied definitions as well as terms to describe them. Some authors define mass gatherings as over 1,000 persons, but most published data are for events with greater than 25,000 persons in attendance. The United States Federal Emergency Management Administration (FEMA) uses the term \u201cspecial events.\u201d The operational definition that FEMA uses for the Special Events Contingency Planning Job Aids Manual is: ...a non-routine activity within a community that brings together a large number of people. Emphasis is not placed on the total number of people attending but rather the impact on the community\u2019s ability to respond to a large-scale emergency or disaster or the exceptional demands that the activity places on response services. A community\u2019s special event requires additional planning, preparedness, and mitigation efforts of local emergency response and public safety agencies. The World Health Organization similarly defines a mass gathering as \u201c\u2026any occasion, either organized or spontaneous, that attracts sufficient numbers of people to strain the planning and response resources of the community, city or nation hosting the event.\u201d The definitions do not focus on the number of attendees; rather, they recognize that mass gatherings will strain surrounding resources. Therefore, mass gathering planning must recognize that these events are not isolated and must account for the surrounding system pressures that are generated by the event.",
        "History of disasters and mass casualty incidents at mass gatherings": "From a theater fire in Canton, China in 1845, that claimed over 1,600 lives, to a riot at a soccer game in 1964 in Lima, Peru, that had approximately 300 fatalities, to a crowd surge in Mecca, Saudi Arabia, in 1990 with over 1,600 deaths, history demonstrates that disasters and MCIs occur at, or are caused by, mass gatherings. Every year at mass gatherings held across the globe, attendees fall victim to the consequences of poor planning, inadequate preparation, or violence. Soomaroo and Murray found that there are several common causes of these disasters as well as areas of mitigation in planning that can help prevent loss of life. The five general areas of risk management and planning mitigation that were identified were overcrowding and crowd control, event access points, fire safety measures, medical preparedness, and emergency response. Overcrowding and inadequate crowd management and control are a recurrent cause of MCIs at mass gatherings. Crowd densities and pedestrian traffic flow patterns create predictable patterns of behavior and bottlenecks. In dense crowds, people are often unable to see what is happening only a few feet ahead and this can exacerbate a crowd crush with pushing behaviors. Stairways, tunnels, turns, equipment, and stages can all create obstacles that will impede traffic flows. In addition, stimuli such as weather changes, event cancellation, crowd violence, rumor of danger, intoxicated individuals, or structural collapse can create a sudden surge in the crowd that may cause individuals to fall and be crushed regardless of strength or size. Some of these risks can be avoided with a properly designed venue that is appropriate for the event. Ticketed and controlled event access points can help control the number of attendees and provide additional security screening. Access points that are used for both entrance and exit will have greatly reduced traffic flows. An adequate number of clearly marked emergency exits that are not blocked in an emergency can help prevent loss of life in the event of a catastrophe. Robust fire safety, prevention, and response measures can prevent loss of life. Examples include using approved site construction materials and strict enforcement of fire safety codes, such as set numbers of extinguishers in each temporary structure present. Medical preparedness and emergency response planning can help manage an event during normal operations and also prepare for an escalating event. Traditional planning has focused on suggesting the number and type of medical personnel based on historic patient presentation rates at similar events under normal circumstances. However, there often is a disconnect and lack of recognition that events commonly saturate emergency services on one hand, yet the expectation remains that these stretched services will be able to effectively respond to an escalating event. Practical budget constraints coupled with the improbability of a major disaster will generally not allow for the number of medical personnel on scene that would be required to manage a MCI. However, planning, staging, and education can help prepare event providers with the necessary tools to better manage the early, critical stages of an MCI. Mass gathering medical operations share many characteristics of MCI management and as a result can be used as an opportunity for repeatable training exercises for all levels of community response. Emergency response must be preplanned. Emergency access corridors must be protected and maintained for responders. Proper communications are necessary for both crowd management and emergency response.",
        "Role of the medical director": "The medical director should be knowledgeable in EMS, emergency medical conditions and treatment, and the logistical and personnel limitations inherent in mass gatherings. The goals of medical service are to establish rapid access to the injured or ill patients; provide triage, stabilization, and transport for seriously injured or acutely ill patients; and provide on-site care for minor injuries and illnesses, thereby preserving the EMS function in the surrounding community. The medical director responsible for the planning and provision of medical care at a mass gathering must understand the interrelated consequences of all the planning variables. While the medical director is primarily responsible for the provision of medical care, he or she must be an active participant in many aspects of the planning phase to identify risks and operational concerns. Major system failures are often caused by an interrelated cascade of decisions and smaller failures that converge to create chaos. Although not all vulnerabilities can be foreseen, each area must be reviewed for weakness and potential failure.",
        "Mass gatherings event planning and management": "The key to mitigation of MCIs at mass gatherings is proper planning. The following outline can be used in the planning stages of mass gatherings to anticipate challenges and prepare for an escalating event. Preparation before a mass gathering event allows for the triage and rapid stabilization of patients as well as on-scene medical care for minor complaints. Although most medical calls during mass gatherings are minor, the ability to respond to and treat life-threatening problems should be rapid and organized.",
        "Timeline": "Adequate preparation time is crucial to the success of the mass gathering. An appropriate timeline can be divided into preplanning, planning, operations, and postevent review. The preplanning phase is dependent on the scale of the event and can begin up to 2 years in advance for larger events, down to a few months or weeks for smaller events. The event is defined in terms of type of event, expected attendance, dates and duration of event, agencies involved, attended demographic and transport mode, alcohol and drug policy, event history, and local site map. The planning phase involves preparation of the site, personnel, and resources. The operations phase is the duration of the event, which can range from a few hours to a few days. All mass gatherings should conclude with postevent reviews that may occur immediately following the event or a short time after. The Provision of Emergency Medical Care for Crowds by Calabro and colleagues delineates an event planning schedule.",
        "Resources": "Accurate resource planning depends on the number of spectators and scale of the event. The actual crowd size estimate may be difficult and can be inaccurate in the event of a street festival, but is more accurate in a stadium concert event with a ticket count. There are certain factors that indicate a higher level of resources might be needed, the most important of which is the size of the crowd. In addition, age (increased medical calls with young adult and elderly people), event type (rock concerts have been described as having more medical calls), and environment (outdoor events generally have more calls than climate-controlled events) are all important factors to consider. Factors such as drugs or alcohol, crowd density, venue layout, and length of event all contribute to medical usage. Medical usage rate (MUR) is defined as the percentage of visits or patients per 10,000 (PPTT) persons in attendance. Hartman and colleagues describe a stratification scoring model to predict resource use at mass gatherings using weather, number in attendance, presence of alcohol, crowd demographic, and crowd intentions. Recurring events benefit from the knowledge of prior experiences in building the medical resources list. Some venues may have facilities or medical equipment available while others may need importation of resources and staff. Currently there is no widely accepted standard list of minimum medical equipment and medications needed according to provider level, but an example is provided at http://tinyurl.com/specialeventresourcelist. Basic food, water, sanitation facilities, and shelter are included in the resources preparation.",
        "Stakeholders": "Mass gathering plans should be coordinated with stakeholders who have the authority and funding to implement the plan. Groups that may have an interest include politicians (local, state, or federal, depending on the scale), hospital administrators, EMS agencies, 9-1-1 dispatchers, law enforcement, transportation operators, event sponsors, and event planners. The financial support for the medical response can be through the event sponsor, a hospital group, the local EMS agency, or volunteer organizations.",
        "Regulations": "Knowledge of local regulations is an important component in the legal aspects of mass gatherings management. Does the city or county require any special permits? Are there local minimum staffing regulations? The event managers should cover primary medicolegal liability but each health care provider should have active certification or licensure at the level and the region they are performing. The medical director must ensure that malpractice insurance is covered through either his or her employer or through the event sponsor.",
        "Medical plans": "The purpose of advanced planning for mass gatherings is to identify a medical response plan that does not place additional stress on the existing EMS system. Daily EMS operations must be able to meet dispatch requirements and not be expected to additionally cover a preplanned event. While some situations may necessitate transport by the local EMS agency, efforts should be made to keep the event medical care separate. Event medical staff should be identified prior to the date and operate within the scope of their licenses for the event. Medical plans should include staffing requirements, treatment areas, identified BLS and ALS transport options, and planning for a potential mass casualty incident. The guidelines presented apply only to normal event operations and need to be adjusted for escalating events. Most events average 0.5\u20132 medical calls per 1,000 spectators. Smaller events may only need first aid level response while larger events may need a physician on site. Although there are many different recommendations without an evidence base, one of the most widely used references is one physician for 5,000\u201350,000 spectators, one nurse for 2,600\u201315,000 spectators, and one EMT for every 2,600\u201365,000 spectators. Another recommendation is to place medical teams based on response interval. Saunders and colleagues suggest a BLS/first aid trained responder within 4 minutes, an ALS provider within 8 minutes, and transport to a medical facility within 30 minutes. Although the predicted cardiac arrest prevalence at mass gatherings is very low, early access and defibrillation through BLS intervention is one of the main reasons to have medical plans for large events. Medical plans should be reviewed with event management and operations staff and approved at least 30 days prior to the date.",
        "Public health surveillance": "Disease surveillance at large-scale events can detect outbreaks or the possible deliberate use of chemical or biological agents or radioactive material and may speed response and intervention. In addition, the risk of transmission of infectious disease is potentially increased. Respiratory or droplet infectious agents, food-borne gastrointestinal illness, and skin contaminants can all be pathogenic. Coordination of knowledge between patient treatment areas to identify symptom trends can initiate an epidemiological analysis.",
        "Documentation": "Each patient encounter should be documented on a standardized patient care record (PCR) in paper or electronic format. Any PCR is a medical and legal record of care rendered so careful completion and review are important even though the complaint might be minor. Contracting with a local EMS agency may allow use of their company PCRs, but the medical director must create a document if none exists. Recording each patient contact is important in terms of liability, equipment restocking, future event staffing, and reimbursement.",
        "Environmental factors": "Even the best planned events can be influenced by \u201cmother nature.\u201d Extreme cold and hot temperatures in combination with wind, rain, and other weather factors can affect both the participants and event staff. Preevent monitoring of weather predictions can indicate conditions for the event time period. Warm summer weather is a popular time to schedule outdoor events and minimal preplanning by patrons can subject them to heat illness. Maintaining plenty of water, shade, fans, and cooling centers can minimize casualties. Cold temperature events are typically held inside or patrons come dressed for the event but may need access to rewarming capability. If the venue does not already have adequate restroom facilities and water fountains, the event management should coordinate additional portable toilets and drinking water. Proper public health regulations should be followed for food preparation, storage, and waste removal. Traffic routes and parking options should be laid out prior to the event with special access routes for emergency medical vehicles. Event type can also influence the crowd disposition and atmosphere. Outdoor music events may have alcohol or drug use, sports games may have opposing team fan brawls, and rock concerts may have mosh pit-related injuries.",
        "Venue review": "A complete site review is an important component of the planning stage. Venue walk-through should identify the number and accessibility of exits, hazard recognition, site mapping, and evacuation routes. Security personnel should be available to control spectator and patient flow as well as maintaining potential evacuation routes. In the event of an MCI, venue-specific plans should be in place to convert normal operations into disaster operations.",
        "Communications": "Constant and accurate communication during a mass gathering is needed to relay information and prepare for any complication or escalating situation during the event. The command center should be centrally located and share the post with medical oversight or have close contact by phone and radio. There should be direct communication from medical oversight to the field providers for both status reports and online medical direction. Medical oversight should also have external contact with the local EMS agency, fire department, 9-1-1 dispatch center, and emergency departments. A communications plan with designated channels should be pre-established and distributed to the surrounding EMS systems for MCI operations with a minimum of two separate communication modalities such as cell phones and public safety radios. Some challenges include loud ambient noise, overloaded cell tower systems, and a limited number of radio channels. Recently, social media have been incorporated into communications. For example, larger events in some systems have a blacked-out site or web page that is ready to be used in case of an emergency. There may be a benefit in following Facebook or Twitter feeds during an event to monitor crowd sentiment or to get early information regarding a situation. After-action reports frequently cite that communications can be a vulnerability if not tested in advance of the event.",
        "Disaster preparedness": "Even in the most prepared events, situations can expand beyond planned response configurations. Knowledge of incident command system (ICS) structure and predesignation of roles allows the transition from normal operations to disaster response to occur in a smooth manner. Mutual aid may be needed in the event of patient numbers that exceed the resources of the planned response, and discussions or contracts should be finalized ahead of the event.",
        "Postevent review": "After the mass gathering, a debrief session is important to address the successes and failures during the event. For recurring events, a quality improvement program is important. In addition, an after-action report or \u201clessons learned\u201d session can identify areas of improvement for future events.",
        "Event resources": "The following specific tools can be used to manage mass gathering medical care, depending on the needs of the event and benefits of each.",
        "Types of response capabilities": "Medical care delivery sites can be grouped by capability, capacity, and mobility. Some mass gatherings take place in well-established venues, which enables planners to provide emergency department-like capability in specifically designed medical spaces, often labeled as first aid stations. Examples include stadiums, arenas, and exhibit halls. The capability of these fixed facilities varies according to the professional level of staffing. In many cases, large numbers of patients can be treated in these facilities at an emergency department level of care and returned to the event that they are attending. Other first aid station capability is housed in more mobile spaces such as tents and mobile intensive care vans and for larger events, field hospitals. These facilities can provide basic to advanced level care depending on staffing, space, and equipment but need provisions for security, triage, staff work space, patient treatment and staging for transport, water, electricity, restrooms, family or patient companion waiting area, signage, and climate control. Mobile teams, whether on foot, bicycle, or small motorized transports, become valuable to access patients within desired response intervals. The type of mobile platform is best determined by event footprint, congestion, and vertical as well as horizontal distance as appropriate to provide cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) access for patients in cardiac arrest within 3 minutes. These include foot teams, bicycle teams, stair chairs, gurneys, and motorized vehicles similar in size to golf carts. Mobile teams should consist of at least two personnel, with at least one of them being certified as an EMT or higher level field provider. For events with a significant presence on bodies of water, motorized boat access for medical teams is essential. Guidelines suggest having a minimum of one mobile team per 20,000 spectators. A useful adjunct of fixed or semi-fixed treatment facilities is the ability to provide sobering services for participants at mass gatherings who become intoxicated. These facilities can be staffed with health care providers familiar with alteration in mental status caused by various chemical substances and can provide safe, observational care according to strict protocols and with rapid availability of additional medical services at the ALS level. Transportation resources will be needed for patients with complex medical problems, or issues for which the period of treatment will exceed the hours for the on-site medical facility. Taken as a whole, the rate of ambulance transports from mass gatherings does not exceed the community baseline rate; however, other factors such as the use of alcohol, the physical stress of the event, the age and type of participants/spectators assembled, and the past rate of medical facility and EMS transport use must be taken into account. ALS or BLS unit selection will likely be dictated by local EMS system policy, and may be dependent on the level of care staffing of the first aid facility on site. Integration of air medical assets will be crucial if distances to hospital treatment facilities are great or if significant delay is anticipated due to crowd interference with ground transport routes. Multiple transport units are likely to be of value if the event venue is geographically large or has inaccessible areas such as water elements or off-road activities. Staffing of both first aid facilities and mobile units is important to the success of the event medical presence. Physicians on site have been able to affect ambulance transport rates and preserve EMS and emergency department resources for surrounding communities. Other capabilities that physician staffing brings to the medical mission are the expansion of on-site definitive treatment, such as advanced wound care, the ability to expand the scope of practice on site for other staff, such as enabling the use of chemical sedation for patient restraint or antidote use for certain intoxications, more efficient patient disposition in higher-risk cases, such as patients wishing to sign out against medical advice not having to call in to base hospital facilities, and potentially improved relationships with the hospitals and other medical facilities surrounding the event venue due to the physician's day-to-day role in those environments. Finally, MCI preparations of the medical presence must be considered. Recent events such as the Boston Marathon bombing have shown that MCIs with significant patient physical and psychological effects can happen rapidly. The well-prepared medical team will have alternative communication modalities available for their use, have an MCI plan and on-site, event-based training in the use of the plan, triage capability and equipment, and a cache of supplies to support their efforts in responding to such incidents.",
        "Converting into mass casualty incident operations": "Even with comprehensive, robust event planning, there is always the potential for a MCI at a mass gathering. The following section describes how the tools, preparations, and planning above can transition to MCI operations and the implementation of the ICS. If an escalating event occurs during a mass gathering that creates a MCI, the first phase is to activate the event emergency plan. On-site communications will notify the command center of the incident. First responders on scene will need to communicate the following information: the nature of the incident (fire, crowd disturbance, structural collapse, terrorist attack), identified hazards (debris, smoke, violence), estimated potential number of patients and injury patterns (crush injury, gunshot wound, burns, chemical attack), resources needed (heavy rescue, CRBNE response, fire suppression, law enforcement), and the best route of ingress and egress for resources, taking any hazards into account. The command center will communicate with the local 9-1-1 center to activate the local or regional MCI plan, depending on the scale of the incident. Regional mutual aid agreements may be enacted. The predesignated communications channels will be activated so incoming responders can communicate with the scene of the incident. Area hospitals that have already been notified of the mass gathering as part of the planning phase will be notified of the MCI and will be able to implement surge capacity and recall procedures. Each medical provider will transition to the predesignated mass casualty officer role as trained in the ICS, don the appropriate vest, and deploy the appropriate equipment and management aids (protective gear, ICS documentation aids and job action sheets, triage tags, etc.). For example, the medical director may become the medical group supervisor or treatment officer. Roles may change as incoming resources arrive. Because roles have been predesignated, each officer should be familiar with his or her roles and responsibilities as well as the specific job aids for each position. Because MCIs create chaos and confusion, and because of the infrequency of large-scale MCI drills, it is challenging for responders to implement the infrequently used skill set and officer roles required for successful MCI management. Predesignation of roles of personnel on scene allows for immediate implementation of the command structure, opportunity to review roles and materials before the chaos, and perhaps even as ongoing training even if an escalating incident does not occur. Mobile teams will likely perform the initial triage of patients and organize potential transport of non-ambulatory patients to the treatment center. Meanwhile, the treatment center will also transition to prepare for patients. The staged MCI supplies (cots, blankets, bandaging) will be deployed to receive patients and organized to receive the different classifications of patients (red/immediate, yellow/delayed, green/minor, and potentially black/deceased). The initial planning and organization of the treatment centers should mimic the classification of patients. For example, a sobering center can become the treatment area for the green patients, a rehydration center can handle the yellow patients as it has IV supplies and is staffed with advanced personnel, and the most acute patients, red, can be sent to the advanced clinic prepared for immediate transport. The clinic intake area will become a secondary triage area and documentation point that will direct incoming patients to the appropriate level of care. The different levels of care should be clearly separate yet adjacent to one another, so that patients may be moved from one to another if their conditions change. In addition to protected ground unit access, a helicopter landing zone with preidentified longitude and latitude coordinates may be useful in a large-scale incident. In the case of potential terrorism, site security is imperative to maintain the safety of responders by preventing a secondary attack that targets the treatment centers and medical personnel. In these types of events, deceased patients may need to be left in place to preserve the crime scene. Otherwise, an area should be reserved to serve as a temporary morgue. Larger events should dictate the mobilization of system-wide coordination and management teams, such as city emergency operations centers.",
        "After a mass casualty incident": "In the aftermath of a mass casualty incident, responders and attendees will likely suffer the effects of stress. Every effort should be made to provide psychological support to all who were involved in management of the incident as well as the victims. Medical directors can be instrumental in putting a critical incident stress management process in motion. A postevent operational debriefing can be helpful to identify areas for improvement and to assist in planning for future events and disaster management. The medical director can set the tone for a non-judgmental, objective, and constructive environment to review successes and challenges faced. A candid after-action report can be a helpful document for future planning and training for all levels of responders. Even with the best training and preparation, mistakes and errors will occur in MCIs. Some individuals and agencies may resist, but the need to apply lessons learned to future events is paramount.",
        "Potential complications and considerations": "Each event will present unique challenges. The axiom \u201cwe prepare for the last disaster, not the next one\u201d is a potential weakness for emergency planners. Nonetheless, implementing the planning principles, plan flexibility, and preparing for the worst will benefit the management of a potential escalating incident. Planners may encounter resistance due to budgetary restrictions or organizational inertia; however, it is the ethical responsibility of municipalities, event organizers, and service providers to mitigate the risks inherent in mass gatherings.",
        "Conclusion": "Mass gatherings can present challenges to planners and emergency response services at every level. These challenges can be addressed with proper planning that includes EMS response capabilities geared to meet event-specific predicted needs plus preassignment of MCI leadership roles, predesignation of disaster communications channels, coordination with regional hospitals, integration of unique EMS tools and capabilities, staging on-site disaster supplies, recognition and mitigation of historic vulnerabilities, and preservation rather than saturation of regional resources with physician-based treatment centers. A mass gathering can be converted from an event that creates potential risk for a community to a superior, ongoing training tool for MCI preparedness while preserving system standards of care. The error is not in the inability to foresee a specific calamity; rather, it is in the lack of coordination, preparation, and planning of actors on all levels to be trained to work together to prevent the foreseeable, train for the exceptional, and prepare for the unthinkable."
    },
    {
        "Altered standards of care": "The prevailing standard of care under usual operating conditions assumes a baseline level of resource availability. In a disaster zone, resources become scarce or insufficient, leading to altered standards of care. In this context, the term standard of care has two overlapping but distinct aspects: one legal and one ethical. The legal standard of care is defined by federal statutes, such as the Health Insurance Portability and Accountability Act (HIPAA) and the Emergency Medical Treatment and Active Labor Act (EMTALA), and state law, a breach of which is one required element to prove malpractice. The ethical standard of care is derived from professional codes of conduct, based on core principles of patient autonomy, justice, beneficence, and non-maleficence. The unique circumstances of disaster zones may lead to changes in one or both of these standards.\n\nIn April 2005, the Agency for Healthcare Research and Quality published a report containing five principles, covering both of these aspects, to guide planners in prospectively developing and defining altered standards of care. More recently, the National Research Council published a letter report offering guidance and a national framework for key elements which should be included in standards of care protocols for disaster situations. It also acknowledges both the legal and ethical aspects to such protocols and further specify that a \u201ccrisis standard of care\u201d should include five key elements.\n\nLegal standards of care may only be altered by an executive governmental official. A report from the Institute of Medicine in August 2009 details the process by which that may occur: \u201cThis change in the level of care delivered [in a disaster zone] is justified by specific circumstances and is formally declared by a state government, in recognition that crisis operations will be in effect for a sustained period. The formal declaration that crisis standards of care are in operation enables specific legal/regulatory powers and protections for healthcare providers in the necessary tasks of allocating and using scarce medical resources and implementing alternate care facility operations.\u201d In addition to state governors, as alluded to in the IOM report, the president and directors of federal agencies, such as the Secretary of Health and Human Services, may also make declarations of emergency which waive certain specific regulatory provisions. Note that none of these declarations is a blanket authorization to disregard all laws, rules, and regulations.\n\nResource limitations in a disaster setting may also force changes in ethical standards of care. This occurs in two major ways: ethical standards become more utilitarian and less individualistic, and resource scarcity changes the relative risks of standard treatment options. Utilitarianism defines an ethical action as one that creates \u201cthe greatest amount of good for the greatest number.\u201d Prioritizing the health of the larger population over the needs of a single patient often requires a different course of action than heeding traditional professional ethics. As an example, some disaster triage algorithms require withholding treatment from critically injured (black tag) patients in the earliest phases of disaster response. Any disaster triage algorithm may require the provider performing the initial assessment to leave the side of a patient who has just been labeled critically injured, rather than immediately providing medical interventions. The discomfort that providers (and patients) experience when faced with these decisions is, in part, a reflection of the deviation from usual standards of care. However, these decisions are justified under utilitarian reasoning because the outcome for the larger group is best advanced by devoting time and resources to patients with the greatest chance for improvement. To reflect this ethical justification and to clarify the relevant standard of care, the World Medical Association released a statement in 2006 which comments on disaster triage.\n\nIt is ethical for a physician not to persist, at all costs, in treating individuals \u201cbeyond emergency care,\u201d thereby wasting scarce resources needed elsewhere. The decision not to treat an injured person on account of priorities dictated by the disaster situation cannot be considered a failure to come to the assistance of a person in mortal danger. It is justified when it is intended to save the maximum number of individuals.\n\nEven in situations that do not change the absolute amount of care provided to individual patients, the relative risks of different treatment options may suggest different actions in a disaster setting. For instance, many health care facilities have policies which require the disposal of unused medication from containers not designated as. This policy assumes there is no drug shortage and that the risk of contamination of the medication exceeds the risk of delayed treatment imposed by the need to restock supplies more frequently. If there is an acute shortage of critical medications or there are significant delays to restock supplies during a disaster, reusing medication vials may become the most ethical course of action.\n\nBoth of the examples given above reflect how options which may be less ethical under standard conditions may become the preferred treatment decision in a disaster zone with limited resources of time, personnel, and supplies.\n\nMedical directors should be aware of the underlying legal requirements and ethical principles when making treatment guidelines for disaster zones which reflect altered standards of care. The legal standard of care may be altered for a specific period of time defined by the declaration of emergency from the respective government official. The ethical standards of care may change on a minute-to-minute basis depending on local resource constraints. Advance planning, through disaster drills or tabletop exercises, is vital to anticipating the various ways in which altered standards of care may affect the delivery of emergency medical care.",
        "Allocation of scarce resources": "While the specific definition of the term disaster varies depending on the source and context, the common defining characteristic is an event that exceeds local capacity or resources. Thus all disaster responses will require the allocation of limited or scarce resources, by definition. This scarcity, in combination with the demand for acute medical care, can be so severe as to alter prevailing standards of care. As was discussed previously, altering standards of care has significant ethical implications; so too does the series of decisions by medical directors and EMS physicians regarding allocation of existing resources.\n\nAllocation of resources occurs at several levels within a disaster response and the health care system overall. Macroallocation, defined as broad policies to distribute resources across populations, determines disaster response elements such as the distribution of trauma centers and the number of available intensive care unit (ICU) beds. Though these allocation choices greatly affect patient outcomes in a disaster, and though an EMS medical director may choose to influence the public policies that lead to these decisions, this section will focus on scene management. Microallocation is the process by which the needs of an individual patient are prioritized above or below those of another patient. In these decisions, the Hippocratic duty of a medical director or EMS physician to an individual patient may conflict with the utilitarian ethical goal discussed earlier \u2013 prioritizing the collective health of the community.\n\nThe primary principle for the rationing or distribution of scarce resources among individuals is an intervention\u2019s likelihood of medical benefit to the patient. This derives from the ethical principle of beneficence and underpins the utilitarian philosophy, \u201cthe greatest good for the greatest number.\u201d Triage algorithms sort patients into categories based on the severity of injury so that priority can be given to those with the most immediate needs and the greatest likelihood of medical benefit. Within those broad categories, however, medical directors and EMS physicians may be called upon to prioritize individual patients\u2019 needs (either via direct on-scene management or through guidelines to field triage providers).\n\nImagine a disaster scenario with multiple burn patients with similar body surface area involvement, all of whom are alert, breathing normally, with intact peripheral pulses. All of these patients would be classified as Delayed/T2 priority under the SALT triage system. Decisions regarding an individual patient\u2019s order of transport and destination facility are not specified by any mass casualty triage algorithm but may have a significant effect on his or her outcome. The primary principle to make this determination should be maximizing medical benefit and lives saved. As one medical director described his experience treating patients of the 2010 earthquake in Haiti, \u201cWe use a process by which we make a decision and allocation of health care resources as to how those resources are going to best help not just one individual, but the populace as a whole \u2026 So we\u2019re more likely to give resources to someone who is likely to live.\u201d\n\nWhen the number of patients with similar predicted medical benefit still exceeds the available resources, another deciding principle must be used. Two options for this secondary principle exist. The first option is a rule which gives all similar patients an equal possibility of accessing the available resources. Examples of this type of rule would be selecting patients alphabetically, by their month of birth, or first come/first served. This option can be justified by the ethical principle of distributive justice and egalitarian philosophy. A similar approach was advocated by some bioethicists in response to public discontent and perceived bias in the allocation of dialysis treatment before it became more widely available. The second option for a secondary principle to decide the allocation of scarce resources (after likelihood of medical benefit is determined) is an assessment of a patient\u2019s quality of life or societal value. This type of rule can be ethically justified through the same utilitarian value system discussed earlier: maximizing the benefit to the community as a whole. In practice, these decisions could be compromised by bias or prejudice on the part of individual providers and the subjective nature of these assessments could lead to variability across providers. Since both types of secondary principle have ethical justifications, different providers may value different criteria in a pluralistic society.\n\nSimilar ethical factors have been considered in other settings which required the allocation of scarce health care resources. In 1962, the Seattle Artificial Kidney Center used two sets of criteria to determine eligibility for dialysis, which was at that time a scarce resource. The first was \u201clikelihood of medical benefit\u201d and the second was \u201csocial worth.\u201d For this second set of criteria, an attempt was made to weigh the anticipated contributions patients would make to society were their lives saved. The \u201csocial worth\u201d evaluations proved very difficult and troubling, since they led to highly discriminatory judgments. Organ transplantation committees also often weigh a mix of objective factors (e.g. immunological compatibility) and subjective ones (e.g. severity of patient need) when selecting recipients. More directly relevant to a disaster setting, the Ethics Subcommittee of the CDC put forth recommendations on the allocation of mechanical ventilators during a potential influenza pandemic. These recommendations discuss multiple allocation criteria, including those based on maximizing net benefits and social worth.\n\nUltimately the group \u201csuggest[s] that a multi-principle allocation system may best reflect the diverse moral considerations relevant to these difficult decisions. Most importantly, triage models for allocation of scarce life-saving resources should be evaluated based on the extent to which they result in fair processes and should take into account the values and priorities of the community members who will be impacted.\u201d\n\nIn summary, medical directors and EMS physicians play a key role in the allocation of scarce resources among various organizations in a health care system and between individual patients in a disaster response. These choices have both operational and ethical implications. At its most basic level, the goal of disaster triage is to prioritize patients for medical treatment with the utilitarian goal of maximizing outcomes for the population as a whole. There is widespread agreement that priority should be given first to those patients who are most likely to recover. Several other secondary decision rules can also be used for resource allocation, each with its own ethical justification ranging from utilitarian to egalitarian. Since subjective value-based assessments may differ between and among providers, patients, and community leaders, it is important to combine them with more objective disaster triage tools and to prospectively identify stakeholders and develop consensus guidelines before resources become scarce.",
        "Provider credentialing issues": "Due to limited local resources, disaster response assets may be deployed from across regional, state, or even international boundaries. Since nearly all EMS and public safety providers are credentialed by states or local jurisdictions, issues may arise related to scope of practice or legal liability.\n\nNearly 70% of providers stated that exposure to legal liability was an important factor in their decision to participate in a disaster response. Providers may feel they are at legal risk if an adverse patient outcome occurs in a situation that would fall outside the baseline (non-disaster) standard of care. Some states have adopted statutory language which specifically addresses this issue. For example, South Carolina\u2019s Emergency Health Powers Act states, \u201cAny health care provider appointed by [the South Carolina Department of Health & Environmental Control] \u2026 must not be held liable for civil damages as a result of medical care \u2026 unless the damages result from \u2026 circumstances demonstrating a reckless disregard for the consequences.\u201d Medical directors and disaster planners should collaborate with policymakers and emergency response officials to understand the local legal provisions.\n\nWorkforce shortages may arise in either the initial or ongoing stages of a disaster response. Disaster managers may then be presented with the option of allowing other health care workers, trainees, or volunteers to serve functions outside their usual scopes of practice. Examples of potential disaster response strategies which would require providers to operate beyond their typical scopes of practice include:\n\n\u2022 allowing community pharmacists to give vaccinations against a pandemic influenza strain\n\n\u2022 permitting surgical residents or physician assistants to perform procedures independently at a field triage station\n\n\u2022 allowing paramedics to administer medications in a hospital-based emergency department\n\n\u2022 asking a nurse to temporarily return to clinical practice after ten years of retirement.\n\nThe utility of each of these strategies will depend on multiple factors specific to the individual disaster scenario, and may evolve over time as resource availability changes.\n\nDuring the active response phases of a disaster, the supervision of provider credentialing is one key role of the planning section within the incident command structure, if one is operational. However, each of these credentialing issues is best addressed prospectively. In their disaster preparedness role, medical directors should encourage each local resource (health care facilities, alternative care sites, emergency response agencies, state health and public safety departments) to develop or review its policy addressing the accommodation of non-credentialed providers during a disaster."
    },
    {
        "Introduction": "Emergency medical services, along with health care in general, has progressed in the last decade from a paper-based documentation system to an electronic health record. The short-term goals for this evolution were to improve operational efficiencies, with a strong focus on billing and risk management. The long-term goal should be integrated health information systems that support the 'Iron Triangle' of health policy: improving access, improving quality, and controlling cost. In the next 10 years, health information systems will continue to evolve. Current medical devices and software that function as tools in service delivery and patient care of an EMS system will become true members of the health care team. Devices and software will become real-time assistants assuring patient safety, providing recommendations based on evidence-based guidelines, and ultimately improving operational effectiveness and efficiency. By embracing this new health care doctrine and infrastructure, EMS will no longer be isolated as an expensive source of transportation. It will be held accountable for response times, service quality, medical care, and cost or value to the customer (citizen). EMS will be held to standards based on an overall 'system of care' approach, integrated with other health care specialties. EMS must prove its effect on patient outcome as a justification for its existence. Finally, EMS will be truly integrated with the rest of the health care system at the local, regional, state, and federal levels through the exchange of health information.",
        "Historical foundations": "The US Department of Health, Education, and Welfare defined 15 components of an EMS system within the 1973 EMS Act. Although an information system was not listed as one of the 15 components, each component was shaped or defined as a piece in a puzzle. The puzzle, when completed, requires a significant amount of data to interact and monitor each of the pieces or components through a coordinated patient record. It was not until 20 years later that the National Highway Traffic Safety Administration (NHTSA) developed a consensus document defining 81 data elements important to an EMS information system. The purpose of the Uniform Prehospital Dataset (version 1.0) was to allow EMS systems to benchmark their service, patient care, personnel performance, patient outcome, and data linkage with other organizations or larger datasets. Perhaps even more important than the data elements themselves was the creation of a standard definition for each element, critical for any information system. In 1996, NHTSA published the EMS Agenda for the Future, which addressed EMS as a community-based health management system, fully integrated with the overall health care system. The goal of the agenda was to improve the quality of community health, resulting in more appropriate use of acute health care resources. To meet this goal, the agenda recommended development of 14 distinct attributes of EMS, one of which was information systems. Formal recommendations within the information systems attribute were as follows. \u2022 EMS must adopt a uniform set of data elements and definitions to facilitate multisystem evaluations and collaborative research. \u2022 EMS must develop mechanisms to generate and transmit data that are valid, reliable, and accurate. \u2022 EMS must develop and refine information systems that describe the entire EMS event so that patient outcomes and cost-effective issues can be determined. \u2022 EMS should collaborate with other health care providers and community resources to develop integrated information systems. \u2022 Information system users must provide feedback to those who generate data in the form of research results, quality improvement programs, and evaluations. The EMS Agenda for the Future Implementation Guide was published by NHTSA in 1998 and reinforced the concept that an EMS information system is the backbone connecting every component of the EMS system.\n\nIn 1991, an international consensus group published the Recommended guidelines for uniform reporting of data from out-of-hospital cardiac arrest: the Utstein style. As the first major document to specifically address EMS systems and their performance with respect to patient outcome, the Utstein criteria were a standard dataset with standard definitions for measuring and reporting cardiac arrest survival across systems. The Utstein criteria required the exchange of information between the dispatch center, the EMS system, and the hospital. A revised version was published in 2004 unifying the hospital, prehospital, and pediatric templates, providing a more usable standard for outcomes measurement. A second revision of the Utstein dataset is under way.\nThe first formal funding for an EMS information system came in 2001. Based on a 1999 Health Resources Services Administration Emergency Medical Services for Children program feasibility study demonstrating it was possible to create an organized EMS data system, NHTSA formally funded the National EMS Information System Project (NEMSIS). The NEMSIS project has four primary goals and objectives:\nEstablish a state EMS database in every state where a portion of the data collected by each local EMS system can be aggregated to support the EMS regulatory and disaster management functions.\nEstablish an electronic EMS documentation system in every local EMS system to support service delivery and clinical care operations.\nEstablish a state EMS database in every state where a portion of the data maintained by each state's EMS database can be aggregated to support federal EMS program, educational, fiscal, and advocacy needs.\nEstablish a national EMS database where a portion of the data maintained by each state\u2019s EMS database can be aggregated to support federal EMS program, educational, fiscal, and advocacy needs.\n\nNHTSA Uniform Prehospital Dataset (Version 2.2.1) is currently in use with more than 400 data elements defined. This national standard has been adopted in principle by all 56 US states and territories. In 2012, 19,831,189 records were added to the national EMS database, submitted to state repositories by 8,448 local EMS agencies. This represents 54% of the 36,968,670 EMS responses and 42% of the 19,971 EMS agencies identified by the National EMS Assessment in 2011. Every state and US territory has a goal, pending resources and funding, to establish a NEMSIS-compliant state EMS data system.\n\nata are used differently at each level of EMS (local, state, and national). A national dataset was identified consisting of data elements especially relevant to describing EMS at the national industry level which can be used to better target EMS needs, national policy, advocacy, educational curricula, and reimbursement. Each state EMS office works with its local EMS agencies to define a state EMS dataset that can be implemented locally. At the state level, EMS data determine how state and federal resources are applied, target legislative initiatives and funding, assure EMS coverage and service delivery, develop and maintain educational programs, and promote performance improvement initiatives that ultimately assure quality patient care. Locally, EMS data are used to determine resource allocation, service delivery, personnel performance, and patient care.\n\nBeginning in 2005, NHTSA funded the NEMSIS Technical Assistance Center (TAC), which houses the national EMS database and provides technical assistance to states implementing NHTSA dataset. The TAC ensures that software programs used to document EMS care at the local level are compliant with the current NEMSIS standard. In 2006, four states (North Carolina, Minnesota, Mississippi, and New Hampshire) began providing data into the national EMS database. Today, more records are received each month than were received in that complete initial year of data collection. Information on NEMSIS and access to the web-based reports associated with the National EMS Database can be found online at www.nemsis.org. In addition, an aggregate NEMSIS research dataset is released each year and can be accessed at www.nemsis.org/reportingTools/request NEMSISdata.html.\n\nIn 2012, NHTSA Uniform Prehospital Dataset was revised to Version 3.0. As the dataset was revised through EMS industry consensus, it was also processed through the Standards Developing Organization (SDO), HL7, and included the federally required migration to ICD-10. The NEMSIS HL7 CDA is now ready to be approved by the American National Standards Institute (ANSI) as a US health care standard. ANSI approval is a requirement to be included in the National Healthcare Information Infrastructure (NHII) initiative that has a presidential mandate for all health care entities to be using integrated electronic health records by 2014. The implementation of integrated electronic health records empowers health information exchange, a key component of the Affordable Care Act and US health care reform.\n\nIn 2006, the Institute of Medicine released Emergency Medical Services at the Crossroads reflecting a very detailed evaluation of EMS, including the current organizational structure, EMS service delivery, and financing of EMS services and systems from a national perspective. Recommendations from the report specifically addressed the need for standardized EMS data and information systems, including:\nthe development of evidence-based categorization systems for EMS, emergency departments, and trauma centers based on adult and pediatric service capabilities\nthe development of evidence-based model prehospital care protocols for the treatment, triage, and transport of patients\nthe development of evidence-based indicators for emergency and trauma system performance\nthe development of demonstration programs to promote regionalization, coordination, and accountability of EMS and trauma care systems\nthe development of integrated and interoperable hospital, EMS, public safety, emergency management, and public health communications and data systems\nthe National Coordinator for Health Information Technology should fully involve prehospital EMS leadership in the discussions about design, deployment, and financing of the NHII\nfederal agencies that fund emergency and trauma care research should target an increased share of research funding for prehospital EMS research, with an emphasis on systems and outcomes research.",
        "Health care databases": "Trauma registries serve as valuable descriptive and quality management tools for trauma centers and trauma systems. Containing detailed information regarding the course and management of patients within the trauma system, trauma registries capture some EMS data. A link with EMS data is extremely important to complete the description of trauma care from event through hospital discharge or rehabilitation. The American College of Surgeons Committee on Trauma maintains the National Trauma Data Bank (NTDB), a standardized dataset based on the National Trauma Data Standard. Developed in cooperation with NEMSIS and incorporating the same data element definitions as NHTSA Uniform Prehospital Dataset, the NTDB currently contains more than 5 million records from trauma centers in the United States and Puerto Rico. Access to the NTDB can be obtained through the American College of Surgeons website. Currently the Centers for Disease Control and Prevention's Paul Coverdale National Acute Stroke Registry is active in 11 states documenting the incidence, treatment, and outcome of stroke. Data associated with EMS care are critical to stroke registries to understand and optimize stroke systems of care. Outcome data from stroke registries are also critical for EMS to evaluate their service delivery and care. ST-elevation myocardial infarction (STEMI) registries are being implemented to document incidence, treatment, and outcome including clinical performance parameters such as time from onset of symptoms until definitive care or reperfusion. Integration with EMS data provides a complete picture of STEMI care from first medical contact to patient outcome. The Cardiac Arrest Registry to Enhance Survival (CARES) focuses on improving the survival associated with out-of-hospital cardiac arrest (OHCA). CARES is housed at Emory University and while it was initially funded through the Centers for Disease Control and Prevention (CDC), it is currently funded through combination of for-profit and non-profit organizations. Data collection through CARES began in 2005 and is currently implemented within 40 communities within 26 states, including eight state-wide implementations. More than 40 EMS agencies and 900 hospitals currently participate in CARES.\n\nThe Cardiac Arrest Registry to Enhance Survival helps local EMS administrators and community leaders establish and improve a cardiac arrest system of care. One unique attribute of CARES is its interface with hospitals to obtain OHCA outcomes. Hospitals are given access to the web-based application. When an OHCA victim is brought to a specific hospital, email notification prompts the hospital to log in to the system and securely enter the patient\u2019s outcome. This method has allowed EMS agencies using CARES to obtain outcome information on well over 95% of their OHCA events.\n\nSeveral other health care-related databases and information systems exist at local, state, and national levels. Most states have some form of hospital insurance or admission/discharge database. These databases may or may not capture information on patients who are not admitted to the hospital, such as those seen in the emergency department and released. Each state maintains vital statistics and medical examiner\u2019s databases that record information on all births and deaths. Most states also have some form of public health and/or injury surveillance database. The amount of information and usefulness of these databases vary greatly from state to state.",
        "Law enforcement database": "At the state and national level, motor vehicle crash data are collected and maintained through either the US Department of Transportation or law enforcement. The various state motor vehicle departments also maintain databases of information with respect to drivers and vehicles. Both of these data sources have potential interaction with EMS information systems. NHTSA has a program, known as the Crash Outcomes Data Evaluation System (CODES), which uses probabilistic linkage to match state data from law enforcement, EMS, and the emergency department or hospital. CODES uses a collaborative approach to generate medical and financial outcome information relating to motor vehicle crashes, and uses this outcome-based data as the basis for decisions related to highway traffic safety. CODES has been in existence since 1992, and it is currently working with 16 states.",
        "Disaster and preparedness data systems": "The National Hospital Available Beds for Emergencies and Disasters (HAVBED) Project consists of a standardized dataset to monitor hospital bed availability. The system provides a national hospital bed tracking system that can be used to address any surge of patients during a mass casualty event. The system is maintained by the Office of the Assistant Secretary for Preparedness and Response within the Department of Health and Human Services. Information on the HAVBED project can be found online. Several events, beginning with the terrorist attacks of 11 September 2001, increased the national attention given to public health emergency preparedness. These events underscored the need for an emergency 'surge' or supplemental health care workforce that can be mobilized to respond immediately to a mass casualty event that overwhelms existing health care resources. The Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP), administered on the state level, verifies health professionals' identification and credentials so that they can respond more quickly when disaster strikes. Information on ESAR-VHP can be found online.",
        "Public health surveillance data systems": "Events over the past decade, including the potential for terrorist acts using chemical or biological weapons, and concerns of an influenza pandemic, have increased the national attention given to public health surveillance systems. The CDC provided initial funding for these systems and still serves a role in their coordination. Most states maintain some type of public health surveillance data system which monitors public health and other health care-related data in an effort to provide early event detection and a timelier public health response. Data being used for surveillance vary from state to state but include data sources such as poison center call data, EMS event data, emergency department data, pharmacy sales data, and school attendance data. Additional information on public health surveillance data systems can be found at the CDC website.",
        "EMS information system design": "The raw material for information is data. Information systems collect and arrange data to serve particular purposes. Following the recommendations of the EMS Agenda for the Future, uniform data elements with uniform definitions which can describe an entire EMS event are the goal of an EMS information system. An EMS event begins with layperson or patient recognition of a problem, which leads to activation of the system through the 9-1-1 or communications center. The end of an EMS event is the transfer of care of a patient to another health care provider outside the EMS system, EMS release of the patient from care, patient refusal of EMS care, or death. To measure and draw conclusions through research, patient outcomes, quality management, or evaluation, the end of an EMS event must include information regarding emergency department care, hospital care, and final disposition. Information systems must also provide a mechanism for storage and retrieval of EMS events in the form of historic medical records. The knowledge of previous medical care or EMS usage can be crucial in true acute care situations when little patient information can otherwise be obtained. A movement within health care reform is the development of regional health care information organizations and accountable care organizations which unite health care providers through policy and information technology to allow individual health care information to flow and be visible across organizations. Information should be available to each health care provider in a format that can be accessed prior to or during patient care. An EMS information system must be able to include data from several sources. The communication center can provide time-related data, such as dispatch and arrival times, dispatch complaint information, vehicle response information, and other emergency medical dispatch (EMD) data. EMD protocols identify general demographics of the patient, the chief complaint, the protocol used for the response, and prearrival instructions. A patient or event identifier should be established to link these data with the EMS patient care record. The Utstein criteria and NHTSA Uniform Prehospital Dataset, when combined, give an important definition standard to prehospital data points. It is important to work within these recommendations to create an environment where information can be linked with other databases, systems, and registries. Through this uniform data, standardized evaluation, research, and outcome measures can be obtained. These two datasets fundamentally recommend only a subset of their data, known as a 'minimum dataset.' For complete documentation of an EMS event, other data elements must be created to include standards of medical care documentation, such as current medications taken by the patient, drug allergies, medical and injury-related risk factors, examination results, narrative interactions or treatment exceptions, and disposition details or instructions. As EMS moves outside its traditional treatment and transport modalities, the need to create a medical document with the consideration of treatment and referral or treatment and non-transport must be addressed. This requires increased documentation of disposition instructions and patient education. Information collected during an EMS event can be improved through the use of medical devices. Information collected by a medical device, stored, and later downloaded into the information system is essential to the future of EMS information systems. Direct data collection from medical devices removes many of the inherent data entry errors, improves the completeness of the medical record, and frees personnel to provide patient care. Currently, prehospital medical devices do not have a universal capability to transfer all their numeric and waveform data to information systems outside their proprietary software, but a standardized solution is incorporated into NEMSIS Version 3. Often a single EMS system will have multiple devices from multiple manufacturers performing the same function. This duplication forces a system to have the proprietary software from each manufacturer to download and archive data, limiting the ability to combine and functionally use the data, especially if waveforms from monitors/defibrillators are included. This same problem makes it impossible to create an electronic medical record in a timely manner for use immediately after patient care, and makes the retrieval of previous EMS events for comparison extremely difficult. Manufacturers must work to implement NEMSIS Version 3 as an open architecture where device data, both alphanumeric and waveform, can be moved from database to database within an information system in a time frame to allow electronic record retrieval or generation. Information systems must be designed to interface with the other health care providers participating in a patient\u2019s care. Communication with emergency departments and hospitals is critical to the linkage between the EMS and other health care databases, while assuring patient confidentiality and health information security. It is only through these linkages that systems of care and patient outcomes can be measured and improved. States should work toward improving EMS law and regulations so that information can flow in both directions. The future of EMS is dependent on the ability to obtain outcome information in a timely manner. Emergency medical services systems are now, more than ever, in a position of financial accountability; they are held accountable for their service quality, patient care, and finances. All EMS information systems should incorporate information required for billing and reimbursement in a format that will allow interaction with billing software and fulfill government regulations for Medicare reimbursement. Finally, EMS data collection and use must be based on system design and workflow. It is impossible to separate EMS operations from patient care. Failure to consider these two issues together will result in incomplete data, useless information, and failure of the information system. Many EMS data collection systems have failed for the lack of understanding and consideration of the end user and workflow.",
        "EMS system types": "Stout was the first to describe models of EMS delivery and management through the analysis of several urban-based EMS systems. Using methods at the time known as system status management, he postulated that the ideal size for EMS efficiency was a population base of just more than 1 million people. High-performance EMS implementations now commonly use both predictive and real-time data analysis within their dispatch and administrative software to manage resources on a case-by-case basis. To be successful, EMS information systems must be based on standards and yet mirror the diversity of the EMS systems they serve. When implementing an EMS information system, it is critical to consider each and every attribute of the EMS system. The amount, method, and mechanism for data collection and data analysis are very different for each system. Information system design is critical to measurement and analysis when patient outcomes and system design are compared between urban and rural EMS implementations. Emergency medical services data must also be considered from a time perspective. Documentation of an EMS event should include information regarding the entire EMS event, from dispatch through disposition (with or without transport). This involves preevent information, the actual patient encounter, and the postevent disposition and documentation. Data should be defined and analyzed based on sound business principles including documentation with the ability to analyze performance at three levels: the EMS agency, the EMS health care professional, and the patient. EMS data must take into account the system workflow. Definitions of data must be clear and understandable, collection must be as automated as possible, and should have a positive effect on the system\u2019s performance by improving the provider\u2019s time with each patient, improving the treatment and care for individuals, and providing real-time (or near real-time) feedback to the system and personnel.",
        "EMS operations from a data perspective": "An EMS event begins with the recognition, by a victim or bystander, of a medical or traumatic event that requires medical care. There is an established workflow from 9-1-1 call activation through hospital discharge, each of which has a unique time-stamp. These time-stamps, describing the 'action' times of an EMS response, document when the call arrived in the dispatch center; when the responders were alerted to the call, and when the responding unit(s) rolled out of the station, arrived at the scene, arrived at the patient, departed the scene, arrived at the receiving facility, and was or were again ready for service. Computer-aided dispatch (CAD) entry is critical to the documentation and analysis of EMS system response. Dispatch centers still using radio-acknowledged time-stamps are less accurate than those with automated GIS-based systems. EMS agencies should be electronically importing data from the dispatch center into their EMS patient care reports (PCRs) so these data are available for EMS service delivery and patient care documentation, peer review, and performance improvement initiatives.",
        "Public safety answering point": "Early in the chain of events, a public call into the public safety answering point (PSAP) is processed through a series of computerized data management systems. Dispatch priority can be assigned to the EMS call based on the response to a few key questions asked by the dispatcher. A high-priority call can involve a multiple agency and multiple vehicle response. Data sharing among responders may involve voice, alpha-pagers, mobile data printers, and mobile data terminals. Voice communication to responders provides a traditional medium for communicating information (scene safety, patient condition, and other hazards). Although communications interoperability has improved with the lessons learned from 11 September 2001, most communities are still working to fully integrate emergency communication systems across all public safety agencies. An important measure of system effectiveness is a reasonable and consistent response time. To achieve the optimum response time for any EMS event, the EMS agency must navigate the shortest distance and/or most efficient route to the event, and if necessary, to the destination health care facility. Technology in the dispatch center and the response unit should assist in call assignment to the closest unit, suggest the best route from the EMS unit's current location, and record key time-stamps for event documentation. A modern CAD system with supplemental automated vehicle locators and in-vehicle navigation can determine the closest unit and direct the responders via an electronic map with the shortest distance of travel. In some emergency situations, such as motor vehicle crashes, commercial services implemented within motor vehicles can automatically notify the closest PSAP when a vehicle crash occurs. Systems such as On-Star provide automated collision notification services as well as the GPS location of the vehicle and a voice operator interaction to its subscribers. Data collected through these vehicle telemetry systems can also predict the possibility of serious injury based on the force of impact associated with the motor vehicle crash. This information can be used by the dispatch center to determine the level of EMS response that is appropriate for the event. One other important data component of an EMS dispatch center is EMD, a structured question-and-answer approach by the dispatcher to obtain key information and assure the appropriate EMS service level and response urgency to the event. EMD also provides guidance to dispatch centers on how to prioritize events when requests are made at the same time or are stacked awaiting EMS responses. Finally, using EMD prearrival instructions, medical care such as CPR can be relayed over the phone to the scene while EMS is en route. There are key EMD data elements associated with each EMS event that should be collected and incorporated into the EMS data system and its performance improvement process.",
        "EMS systems for 2020: a look at the future": "Personnel 2020 In the year 2020, EMS personnel are now equipped with handheld multifunctional devices capable of assessing and monitoring vital signs (non-invasive blood pressure, pulse oximetry, pulse, respiratory rate, cardiac rhythm, 12-lead ECG, carbon dioxide and/or carbon monoxide levels, tissue perfusion, hemoglobin, and blood glucose) to evaluate patients. The device is quickly attached to the patient and automatically performs these functions while EMS personnel spend time interviewing the patient and performing the needed physical exam and treatment. As they perform their assessment and provide treatment, personnel enter data into a second portable device that allows data to be entered in a combination of ways. Verbal information is entered by voice recognition. Treatment and procedures are entered by a combination of touch screen and radiofrequency-identified medications and supplies. Scanning the barcode of the patient's driver license or personal ID enters the patient's demographic data and assigns the patient a tracking identifier for follow-up and tracing activity. While the patient assessment and care are under way, the data collected are continuously monitored to guide the EMS professional based on the patient's medical problem and the treatment protocols in use. Patient errors are minimized with the assistance of software decision support, avoiding the administration of contraindicated medications, medications to which the patient is allergic, etc. During the response and transport associated with the EMS event, software within the vehicle is also monitoring the vehicle and occupants for safety. Using 'black box' type technology, similar to what has been used on aircraft for decades, the EMS vehicle is monitored based on the driving behavior of the EMS professional. As acceleration, speed, stopping force, and other parameters are monitored during the event, the driver is provided with signals and alerts to assure the safety of the occupants within the EMS vehicle and the other vehicles in its path. The hand-held device then communicates back to a central database through a wireless interface to determine if this patient has received EMS services in the past and, if so, provides the most recent past medical history, medication, and allergy list. It imports all other pertinent information in the system into the PCR to minimize data entry by personnel. The advanced monitoring device communicates with the hand-held data unit through a wireless or Bluetooth connection to complete the PCR. Dispatch, 9-1-1, and EMD data are electronically retrieved and imported in to the PCR over the wireless network. EMS personnel choose from a list of destinations, and the event and patient care information are automatically relayed to the receiving hospital where it is visible during the transport to the receiving facility prior to the arrival of the EMS unit. If a life-threatening, time-dependent illness or injury is associated with the event, the appropriate trauma, STEMI, or stroke team is activated. On arrival to the emergency department, the EMS PCR is electronically reviewed based on the type of event, the patient's primary medical condition, and the treatment protocols used to assure that all of the required documentation is complete, prompting or querying for any missing data. The completed PCR is then finalized using a combination of electronic and touch screen signatures. Once the report is finalized, it is electronically transmitted into the hospital electronic medical records system (using the NEMSIS HL7 CDA). The PCR is also relayed to any other EMS administrative areas, assuring the EMS unit is restocked, performance improvement processes are reviewed, and the EMS event is electronically billed within the same workday. The PCR data are stored centrally on a database with a web browser/internet interface. Concerned about another call that has just been paged out, the EMS personnel quickly restock the ambulance based on the list of used supplies provided on the hand-held data unit's tabulations, and a crew member activates the button on the hand-held unit, signifying they are back in service. At the end of the day, the EMS provider generates a quality management report from this specific call, which indicates all care was provided appropriately based on the complaint and protocol and the patient was admitted for definitive care.",
        "EMS information system components": "\n\nDataset An EMS information system must begin with a well-structured and defined dataset. Patient care data can be divided into four broad categories. - Patient information: demographics, billing information, medical history - Surveillance data: injury risk/mechanism, cardiac arrest, review of systems - Current diagnostic/physiological monitoring: vital signs, physical exam - Interventional: procedures and treatment (pharmacology), disposition \n\nHardware Modern computer technology has done much to remove barriers to collecting and using data across devices and various types of hardware. Most databases can either exist in, or move data back and forth through, desktop computers, cloud-based servers, hand-held personal digital assistants, and other medical devices. The design of any information system should include specifications that provide for this data exchange. \n\nSoftware Software associated with EMS information systems often is grouped into three components. There is the 'front-end' user interface where users interact with the information system to view or enter information. There is a database that serves as the nerve center for the storage and retrieval of information. Finally, there is a 'back-end' which provides a user interface for report generations and data analysis. The front-end user interface for an EMS information system can vary in its implementation. It may consist of a simple form that will allow the user to view or enter information, but quality EMS software will do much more. Good user interfaces will assist the users in their task of data entry or retrieval. Based on the patient\u2019s medical problem, the EMS service provided, and the treatment protocol, the user interface should guide the user through the documentation workflow. Using business logic and decision support, the software can improve documentation quality, completeness, and speed. The database component of the software often does much more than store and retrieve data based on the user interface. It is often at the database level that external data from dispatch, medical devices, external medical records, and other data sources are imported or exchanged, and that linkage of records is accomplished. Examples of linkage could be the linkage between an EMS PCR and an emergency department database so that the outcome of the EMS patient can be connected with the EMS care and event. Finally, some of the analysis and calculations of the EMS data are done at the database level so that notifications and messaging can occur to EMS units, professionals, and administrators. The back-end user interface is typically associated with the generation of reports or data analysis. Report generators can be very open, allowing the user to move information and explore the data very loosely, or very specific, allowing minimal interaction other than the generation of a preconfigured report. Some EMS PCR solutions allow access to their data from third-party reporting and analysis tools such as Crystal Reports or Microsoft Excel. Complex statistical analysis, business modeling, GIS mapping, and other detailed trending often require specialized software. Almost all information systems (in or out of EMS and health care) are moving toward internet-based solutions via hosted or cloud-based software. The advantage of a cloud-based solution is that the hardware, software, security, and availability of the application are combined into a single solution. Since the system is centrally hosted, it is maintained by experts in the specific software and information technology. This frees the EMS agency from having to maintain complex and costly information technology staff in house. Cloud-based solutions are often more economical initially as there is no hardware to purchase and can be more easily budgeted as the maintenance cost is often based on an ongoing monthly fee. As each EMS information system is implemented locally and matures, there is a shift in focus from data entry to data use. As EMS systems begin using data, performance improvement programs are implemented. These programs evaluate the service delivery, personnel performance, and patient care provided. Although a formal discussion of performance improvement is provided elsewhere in this textbook, EMS data systems are key to the success of these programs.\n\nMaintenance: All computers and computer software require ongoing maintenance and support. EMS information systems are no exception. The nature of EMS, being unpredictable with disparate locations and conditions, provides many opportunities for equipment and software failure, malfunction, or system overload. Cloud-based EMS implementations have extensive back-up and security components and are recommended if the information technology resources for the EMS agency are limited. With any EMS information system, a formal educational program, support, and maintenance structure must be planned, developed, and maintained. The quality and service provided in this one area will determine the success and failure of an EMS information system.\n\nSecurity:The security of an EMS information system is critical and can be split into two areas: security and confidentiality of the patient\u2019s information, and that of the EMS system\u2019s information. EMS system security is important for many reasons. EMS is a political entity and is subject to public and private scrutiny. EMS is also a component of the health care system that comes with a significant amount of medicolegal risk. EMS is also often in a competitive market where details of operational and system issues, if made available outside the agency, could be detrimental. Finally, EMS, as part of the health care system, is responsible for peer review, performance improvement, and benchmarking. This process provides a continuing analysis of patient care and system operations to optimize service delivery and care. An EMS information system should be designed from the ground up to provide top-level security to the EMS system and its personnel. Policies and procedures should be developed that define access and use of the system, complete with appropriate disciplinary actions to assure their compliance. Any information system that aggregates data from multiple EMS systems should have adequate policies and procedures in place to prevent the identity of EMS systems from being disclosed to any outside agencies, or the public, without the consent of that EMS agency. Patient security is also critically important to an EMS information system. Policies and procedures should be developed and implemented to provide appropriate access by EMS personnel in need of patient data but also to protect the patient from undue or unnecessary exposure. In 2000, the US Department of Health and Human Services released regulations protecting patients and health care data that are transmitted electronically. This regulation (the Health Insurance Portability and Accountability Act, or HIPAA) has significant implications for all of health care, including EMS. This Act provides detailed requirements relating to health care information that is collected by any health care entity. Much of the document addresses electronic transactions with respect to reimbursement, but there are significant sections on patient confidentiality and security. From an EMS information system perspective, HIPAA basically divides security and confidentiality into four major components. \u2022 Patient privacy and confidentiality \u2022 User policy and procedure \u2022 Physical security \u2022 Software security Clear definitions are provided stating when a patient's record can be released from the health care provider. Within the HIPAA regulation, the data elements that can be used to identify a patient are defined, as well as the process and procedures heath information systems must follow to protect patient-identifiable information. Any health care data or information system must have a detailed policy and procedure describing who, when, where, how, and why any personnel can access the system. Any such must meet the physical security requirements of HIPAA, including issues such as locked files, controlled access, and entry logs. Finally, any health care information that is transmitted electronically must meet the HIPAA requirements, including issues such as user authentication and data encryption.",
        "Elements of successful information systems": "There are several qualities that can be identified in successful information systems. The design must start by defining what information is needed and can actually be collected. Each of these data points must be identified and defined through a consensus of the front-end data entry personnel as well as the back-end data maintenance and processing personnel. The methods of data entry must be considered based on the equipment, training, experience, and education of the EMS provider. As data points are defined, classifications or schemes must be derived to allow information to be sorted into useful groups. This is a difficult process, in that no standard diagnostic or reimbursement coding system was designed with EMS as a primary user. EMS documents are based on chief complaint, rather than diagnosis; providers at all levels have difficulty in translating EMS records into usable ICD-9 or ICD-10 code parameters. The depth of these coding systems is much too complex for day-to-day operations. It is critical for the success of an EMS information system to have a standardized problem-based classification scheme, which can objectively and reliably cross over to other EMS and data systems. This will also be the foundation for true EMS billing and reimbursement based on services provided, rather than transportation of a patient from one location to another. The introduction of any new data system requires planning and patience. There is no 'off the shelf' solution for EMS that does not require significant configuration and testing to assure it is functional and meets the needs of the EMS agency. Once the software is configured and tested, every staff member must be trained both initially and in an ongoing fashion as updates and changes to the software occur. A successful implementation requires designated technical and operational staff who represent both the front-end and back-end users. Whether the system is installed locally or via a cloud-based solution, 24/7/365 support from the software provider is mandatory. Locally created systems will need similar support mechanisms. If ambulance-based hardware is part of the project, care for safety (airbag clearance and locked mounts), security, lighting (visible in night and day), and power must be addressed. New wireless technologies are expanding connected devices in areas where traditional 'wire-based' connections were costly or impossible."
    },
    {
        "Introduction": "Ambulance crashes and the resulting injuries, fatalities, and liability have elevated the discussion of ambulance safety to an urgent level. This chapter includes an introduction to the issue and an exploration of the factors related to crashes, and concludes with recommendations for ways in which EMS professionals, medical directors, and agency administrators can help mitigate this serious problem.",
        "Risks to others": "Crashes involving ambulances on public roads in the US produce twice as many casualties as the national average. Evidence also suggests that civilians make up a large portion of the victims. Kahn et al. found that \u201cthe greatest burden of serious injury and death fell upon persons not in the ambulance,\u201d with 89 fatalities among ambulance occupants but 316 among non-ambulance occupants. Sanddal et al. found that \u201cpersons in other vehicles involved in collisions with ambulances were the most likely to die as a result of crashes.\u201d Maguire et al. described 25 ambulance occupant fatalities in the US between 1994 and 1997; eight were described as EMS personnel, and 68% of the fatalities were non-EMS personnel including patients, family members, and friends.",
        "Legal risks": "The risks associated with ambulance crashes extend beyond injuries and fatalities. For example, the proportion of EMS agency lawsuits that relate to ambulance crashes has been reported to be between 45% and 100%.",
        "Other considerations": "While grieving for lost colleagues and civilians or coping with catastrophic medical bills, companies are simultaneously attempting to cover lost workdays and train replacement workers. It is conceivable that these stresses cause further distractions, which may lead to more deaths, crashes, injuries, costs, and lost workdays. In a state-wide study, Weiss et al. found that there were more ambulance injuries in the urban environment, but the severity of injury was greater in rural environments. For all vehicle crashes, the injury fatality rate is \u201calmost three times higher in rural areas.\u201d Elling examined New York State data between 1984 and 1987 and found that 1,894 ambulance occupants were injured in 1,412 ambulance collisions. Becker et al. found a significant difference in risk of fatality or serious injury between restrained and unrestrained ambulance passengers. Ray and Kupas found that the highest-risk locations for ambulance crashes are at intersections and traffic signals. The same authors found that \u201coperator error was the most common cause of crashes.\u201d Maguire found an average of over 70 injuries and fatalities per year in ambulance crashes that involved at least one fatality on major roads in the United States. Clawson et al. found that ambulance \u201cwake-effect\u201d collisions may occur with greater frequency than collisions involving ambulances. Therefore, there may be over 140 people killed or injured in ambulance-related collisions every year. With a reported 31 million EMS calls in the US during 2004 and 37 million calls in 2010, the risks to personnel, patients, and the public are growing.",
        "Contributing factors": "Although insufficient data exist to quantify factors contributing to ambulance crashes, Haddon\u2019s Matrix provides a logical approach to categorizing and describing factors that seem likely to contribute to the risks. Human factors include fatigue, poor driver training, distractions, stress, poor driving skills, and diesel fume exposure. Vehicle factors include poor maintenance before the event, and protruding objects, sharp corners, and unsecured equipment during the event. Examples of environmental issues include both the ambulance\u2019s environment at the time of the event and the environment (culture) of the agency. For example, poor visibility and hazardous road conditions relate to the crash environment while inadequate agency policies and/or enforcement of policies (e.g. related to speed or seat belts) are examples of inadequacies in the agency culture, as is insufficient support for research and prevention.",
        "Fatigue": "Joseph Neal Sherman was a 25-year-old paramedic. He was killed in an ambulance crash on March 16, 2001. The night before the crash, his partner had worked the overnight shift at a volunteer fire department. At the time of the crash, Neal was caring for a patient in the back of the ambulance. His partner fell asleep, veered off the road, and struck a guardrail. The vehicle rolled 300 feet, flipping over several times before landing upside down in a ditch. The other three ambulance occupants were injured. Neal was killed; he left behind a wife and an unborn child. A growing body of literature links fatigue to a host of occupational risks, including crashes. Dawson and Reid found that \u201cmoderate levels of fatigue produce higher levels of impairment than the proscribed level of alcohol.\u201d Arndt et al. found that 21 hours of wakefulness produces impairment of the same magnitude as a 0.08% blood alcohol concentration (BAC); the legal limit for commercial drivers in the United States is 0.04% BAC. A 2007 report by the International Association of Fire Chiefs noted that sleep deprivation is an important factor contributing to injuries within the fire service; several studies were cited noting that alertness and postural stability decline during extended shifts, leading to increased worker stress and more crashes. The National Highway Traffic Safety Administration (NHTSA) National EMS Advisory Council, Safety Committee, noted that \u201cpoor sleep and fatigue among EMS workers represent potential threats to patient care, provider wellbeing, and the public\u2019s health.\u201d NHTSA notes that \u201cfatigued drivers were twice as likely to make performance errors as compared to drivers who were not fatigued.\u201d Patterson et al. found a \u201c3.6 greater odds of safety compromising behavior among fatigued respondents versus non-fatigued respondents.\u201d Studnek and Fernandez found that the odds of involvement in an ambulance crash within the past year were significantly higher for those reporting sleep problems. In one survey, \u201calmost half (48%, n=29) of paramedics answered yes to having nodded off or fallen asleep whilst driving.\u201d The JEMS 2012 survey of 200 cities found \u201c85.9% of respondents (are) working 24-hour shifts.\u201d Although long shifts may be less problematic for workers in slower areas who may be able to have extended sleep periods, it is likely a significant problem for busier units and systems.",
        "Poor driver training": "Anecdotal evidence suggests that many ambulance driver training programs (perhaps thousands) exist in the United States. These programs range from a short orientation to courses of over 40 hours, incorporating classroom presentations and discussion, driving practice on a dedicated track, and field internship with a driver-training mentor. However, no research was found that demonstrates efficacy or any difference in outcomes between these various programs.",
        "Passenger restraint": "Larmon et al. found that seat belt usage is low among EMS providers working in the patient compartment. They noted that the following issues may account for the low usage: the providers perceive that seat belts in the patient compartment are ineffective (that the seat belts were designed for forward-facing passengers and, as such, provide minimal protection for and may even cause additional harm to side-facing passengers); they perceive that the use of seat belts will decrease their ability to care for their patients; some believe there is minimal risk of injury or death associated with the provision of emergency medical care. Johnson found that two-thirds of EMS respondents \u201creported not wearing their seatbelt on the squad bench while treating patients.\u201d Maguire and Porco found that at least four of 13 EMS workers injured in collisions were not wearing restraints. Proudfoot reviewed 25 fatal ambulance collisions resulting in 27 fatalities and found that 22% of EMS workers killed while riding in the patient compartment were not wearing restraints, and 26% who died while driving the ambulance were unrestrained. Becker et al. found that \u201crestrained ambulance occupants involved in a crash were significantly less likely to be killed or seriously injured than unrestrained occupants.\u201d So it is shocking to find that \u201cmost states do not require patients of any age to be restrained in ambulances.\u201d",
        "Distractions": "Emergency medical services personnel are confronted with many distractions while driving ambulances. These include \u201cmultiple radios, a computer, and warning system controls, in addition to all the usual controls found in a typical vehicle. The driver of the ambulance may be expected to operate several devices while driving on busy streets with a vehicle full of distraught patients and family members.\u201d NHTSA estimates that distractions account for 20\u201330% of passenger car crashes. Saunders and Heye found that a major cause of ambulance crashes in an urban environment was \u201cinattention.\u201d",
        "Ambulance structural design": "In 2003, Maguire reported that \u201cthe crashworthiness of ambulances is largely unknown. The integrity of vehicle structures, the vehicle's ability to protect occupants from fatal and serious injuries, the vehicle's ability to prevent occupant compartment intrusion or ejection of passengers, and the vehicle's ability to prevent or reduce injuries from occupant impact with interior surfaces (especially sharp cabinet corners, IV holders, and oxygen ports) probably varies significantly from manufacturer to manufacturer. The compatibility of structural crash performance with occupant restraint systems is also largely unknown.\u201d Levick and Yannaccone evaluated ambulance patient compartments under crash conditions and demonstrated the need for special testing to be done for the ambulance patient compartment.",
        "Diesel fumes": "Although the US nationwide ambulance fleet has been largely converted to diesel, nothing is known about the effects this may be having on the EMS workforce. Mills et al. describe an increased coronary risk associated with diesel fume exposure. The Environmental Protection Agency reports that short-term exposure can cause neurophysiological symptoms (e.g. lightheadedness, nausea). Kilburn found that workers exposed to diesel fumes had \u201csignificantly impaired reaction time.\u201d",
        "Recommendations": "Any intervention designed to improve the health of the population should be subject to the same rigorous scientific evaluation as an intervention designed to improve the health of an individual. We would never consider administering a drug that had not gone through rigorous scientific evaluation. Sadly, we are not much further along than \u201cgrandma\u2019s home remedies\u201d when it comes to interventions designed to save the lives of paramedics. Years of well-intentioned interventions have resulted in a variety of unproven solutions, including possibly thousands of driver training programs. Many of these courses could, for all we know, be increasing the risks of collisions, injuries, and fatalities. In all the literature, only two papers were found that describe interventions to reduce ambulance collisions, with one focusing on outcomes and the other on process. The first is a 1997 paper by Maguire and Porco that describes a bimodal intervention. The authors concurrently introduced a standardized driver training program and a change in department policy. The pre- and posttest evaluation found that the ambulance collision rate changed from one collision per 1,146 calls during the 12 months before the interventions to one collision per 2,940 calls during the 12 months after the interventions. Levick and Swanson described an 18-month evaluation of 36 vehicles in a metropolitan EMS group using an \u201conboard computer-monitoring device.\u201d \u201cIn >1.9 million recorded miles, performance improved from a baseline low of 0.018 miles between penalty counts to a high of 15.8 miles between counts. Seatbelt violations dropped from 13,500 to 4.\u201d Before we begin any efforts to improve ambulance safety we must first and foremost accept that ambulance crashes are largely preventable. We have both the responsibility and the ability to drastically reduce the number and severity of ambulance crashes. We can no longer delude ourselves by thinking \u201caccidents\u201d are unavoidable. Instead we must use the tools and abilities we have to make the changes necessary to reduce the risks for ourselves, our employees, our patients, and our communities. Using the four Es of injury prevention: Education, Engineering, and the Enactment and Enforcement of risk reduction policies A turning point in EMS history came about in 1994 when a group of paramedics noticed that the pediatric drowning rate was increasing in their county. It is a turning point in history because, instead of asking how can we get there faster or what new drugs or tools can we use, someone asked: \u201chow can we prevent them?\u201d They did a retrospective analysis of the circumstances surrounding the cases. Then they used the four Es. They educated the community about the problem and the ways to prevent drowning. They called for engineering interventions in the form of fences around swimming pools. They worked with elected officials and enacted and enforced policies related to fences around swimming pools. A postintervention analysis showed that the pediatric drowning rate decreased by 50%! As related to improving ambulance safety, the four Es mean: \u2022 educating the workforce \u2022 evaluating engineering interventions such as electronic monitoring \u2022 enactment and enforcement of policies on topics such as speeding, safe driving, and safety measures such as requiring slow ambulance speed when occupants are unbelted. The World Health Organization has laid out a logical approach to reducing crashes and injuries. \u2022 Conduct surveillance to determine as much as possible about all aspects of the crashes and injuries \u2022 Research causes of crashes and injuries \u2022 Explore ways to prevent crashes and reduce the severity of injuries by designing, implementing, monitoring, and evaluating appropriate interventions \u2022 Implement interventions that appear promising \u2022 Conduct cost-benefit analyses \u2022 Disseminate (i.e. publish in peer-reviewed journals) the results \u2022 Translate effective science-based information into policies and practices that protect pedestrians, cyclists, and vehicle occupants \u2022 Promote capacity building in all these areas, particularly in the gathering of information and in research What follows are suggestions for interventions that seem to be effective, but should still be evaluated before large-scale deployment. It should be noted that single-construct approaches to any given problem often fail to account for the breadth, complexity, and nuances of that problem. Brice et al., for example, recommended that \u201cthe unique challenges of ambulance safety may be met by analyzing systems and incorporating process improvements.\u201d This section focuses on multimodal risk reduction strategies projected to have maximal effect for improving ambulance safety.",
        "Fatigue (Recommendations)": "There is now no doubt that extended shifts place EMS workers, EMS agencies, patients, and the community at increased risk for injury and death. Therefore, shifts of no more than 12 hours must become the standard in the industry. Training to educate the workforce about the risks associated with fatigue must be implemented and continued. Policies that address the issues of adequate sleep time between multiple employers, and how to address unplanned sleep loss (such as caring for a sick child all night), should also be developed. In 1997, Heather Brewster was 23 years old, a former college volleyball star and a graduate student with a promising life ahead of her. All the promises vanished abruptly as her car was rear-ended in a tragic collision. Heather received massive brain injuries that have left her permanently disabled. Although the incident had nothing to do with EMS, it raised issues that may have a profound effect on the future of EMS operations. The crash was caused by a medical resident who had just come off a 36-hour shift. The family sued the hospital on the grounds that the hospital had at least as much responsibility as a bartender and should not have allowed an impaired person to drive. Although an appellate court found for the hospital, at least two states (Oregon and West Virginia) have ruled that \u201can employer\u2019s responsibility for fatigue-related crashes can continue even after they have left work.\u201d Research on medical residents found a 2.3-times greater risk of collision on the way home from extended (>24-hour) shifts than after non-extended shifts. An indisputable body of research now proves that fatigue increases the risk of self-harm and harm to others, including patients, occupants of the ambulance, and other vehicles and pedestrians. However, changing to 8-hour shifts alone, for example, would not necessarily eliminate the problems. Neal Sherman was killed when the driver of the ambulance fell asleep; the driver had worked just an 8-hour shift the day before but then worked all night at a volunteer firehouse before returning to work the day of the crash. Nor is the risk limited to those with multiple jobs; for example, being up all night with a sick child could have the same effect. Clearly there must be an agreement for shared responsibility between employee and employer, for clearly there are shared risks. Both EMS employers and EMS employees are at risk of legal liability for fatigue-related crashes both during and after shifts. Only through research, education, and a change in culture toward a shared responsibility for safety can this problem be mitigated.",
        "Driver training": "Without research to determine the effectiveness of the many ambulance driver training programs currently used, no logical recommendations can be made. Therefore, research must be supported that will allow EMS professionals, medical directors, and agency administrators to implement driver training programs proven to reduce the risk of ambulance collisions as well as crash-related injuries among EMS personnel, ambulance occupants, occupants of other involved vehicles, and pedestrians.",
        "Use of red lights and sirens": "In 1994, the National Association of EMS Physicians and the National Association of State EMS Directors (now the National Association of State EMS Officials) released a joint position statement and noted the risks associated with the use of warning lights and sirens (WLS). Custalow and Gravitz found a disproportionate percentage of crashes occurred during WLS operations. Despite the published concerns, no subsequent reports have been found to indicate that the rate of WLS has changed. There are many factors that may contribute to this apparent disregard for safety. EMS field personnel may consider WLS necessary in congested areas to help facilitate response and transport. Dispatchers and medical directors have concerns about delays in providing medical care to critically ill patients. The public often has an expectation that emergency vehicles will arrive with active warning devices and may voice dissatisfaction that their call for help was not \u201ctaken seriously\u201d if vehicles arrive in non-emergency mode. A blanket policy is unlikely to change the use of WLS. Instead, all stakeholder groups require education and training that will give them the ability to make appropriate risk decisions related to vehicle operations. Improved education, as well as improved communication and coordination among various stakeholders, may finally allow for a reduction in the use of WLS.",
        "Passenger restraints (Recommendations)": "There is no question that the use of safety belts, in addition to being good practice and required by law, is a proven method for reducing fatalities and serious injuries in a collision. From an evidentiary standpoint, there is no reason for EMS personnel to be unrestrained while in ambulances, yet many EMS personnel choose not to wear safety belts in ambulances, despite laws and agency regulations to the contrary. Further rule making, by itself, is likely to prove futile. Instead, personnel must be educated about the risks so that they can make appropriate risk/benefit decisions. Part of this education should include considerations of alternative risk reduction strategies. For example, adopting a practice of notifying the driver whenever a medic is unrestrained would allow the driver to immediately reduce speed and take added precautions.",
        "Driving history": "Custalow and Gravitz found that 71% of the emergency vehicle drivers involved in collisions had histories of prior emergency vehicle collisions. Kahn et al. found that a significant portion of ambulance operators had prior records of traffic violations and crashes. Although this number was not significantly different from that in the general population, it may be that providing additional, targeted education to these drivers (or perhaps not giving driving privileges to personnel with particularly worrisome driving records) could result in a reduced rate of crashes. Further, many agencies, even those that do conduct initial driving background checks, do not do background driving checks on a regular basis. As a result, it is possible that a significant change in an EMS worker's driving record (such as a suspension, serious crash, or driving under the influence conviction) could occur without the agency's knowledge. EMS agencies are encouraged to implement regular programs of assessing driving records and driving ability.",
        "Sex and age": "A 2011 study of EMS transportation-related injuries and fatalities found that females were the victims in 53% of the cases, yet females only accounted for 27% of the study population. The disparity echoed earlier findings that female EMS personnel have a higher rate of injuries than male EMS personnel. These findings warrant specific research on sex differences in EMS. In addition to determining any differences in injury rates, future research should investigate differences in ambulance crash causative factors by sex. As an example, Baker et al. found that \u201cthere are large gender differences in the types of pilot error involved in general aviation crashes.\u201d If there are significant sex differences in ambulance crash causative factors, then sex-specific ambulance driving training programs may be needed. Clearly, more research is needed in this area. Reasons for crashes also vary by the age group of the driver. As a result, we should also investigate the utility of age group-specific ambulance driver training.",
        "Vehicular design": "Although the chassis and front compartment of an ambulance are regulated by the Federal Motor Vehicle Safety Standards, exemptions apply to the rear compartment. The Ambulance Manufacturers Division of the National Truck Equipment Association (AMD) has issued a set of standards to help define when an ambulance is considered safe. Controversy exists as to whether these standards are sufficient. In addition to being the most dangerous area of the ambulance, the rear compartment is also the least regulated. One of the factors involved with the death of Neal Sherman was that he was struck by an oxygen bottle at some point during the crash or subsequent rollover of the ambulance. Any equipment in the ambulance must be secured in such a way as to not come loose during a crash or rollover. Sharp corners and hard surfaces should be padded. The inside of the vehicle should be free of protruding objects. A metal IV pole hanging from the ceiling could result in a punctured skull; an oxygen nipple protruding from the wall could be as deadly as a knife if someone is thrown against it during a crash. Back-up alarms are essential for any large vehicle; adding rear-vision cameras and the safety sensor systems now available on some automobiles may help reduce injuries associated with driving the ambulance in reverse. Having a live person behind the ambulance to direct the driver during reverse driving should always be the rule. Improving the visibility of the vehicle for use during day and night, and emergency and non-emergency operations, in both normal and harsh conditions should continue to be a priority. Changes to the interior design of the ambulance must consider safety during crashes as well as ergonomic factors affecting EMS personnel on a daily basis. It is unlikely that significant improvements to ambulance design can be made without partnerships between national organizations, government agencies, ambulance manufacturers, engineers, researchers, EMS agencies, and EMS professionals. Many manufacturers have attempted to improve the safety of ambulances through design changes such as better equipment tie-downs, increased padding on corners, rounding of corners, and more ergonomic considerations of seat placement and restraints. The National Institute for Occupational Safety and Health (NIOSH) has been working to develop designs for safer ambulances. There are insufficient data, however, to help drive these changes in an evidence-based fashion. Further, there are significant questions regarding the design of restraints for the rear compartment that will likely not be satisfactorily resolved without rigorous research. The partnership should also consider design changes from the international community. For example, other nations have adopted significantly different ambulance designs. Although data are currently lacking to promote one design over another, further research on these alternative designs may lead to improvements in vehicle structure and operational safety.",
        "Diesel fumes (Recommendations)": "As with all potential exposures, we should monitor our providers to assure they are not suffering from short- or long-term complications from these fumes. In the meantime, ambulance garages should be kept well ventilated and ambulances should be kept idling for as little time as possible.",
        "Vehicle safety": "One recent innovation in ambulance safety is a device similar to the \u201cblack box\u201d used in airplanes. It is a real-time monitor of speed, acceleration, seat belt use, and other safe driving parameters. Unsafe use is noted by warning tones from the monitor, with a change in tone indicating a highly unsafe condition. These data are logged and individually identified. The device combines real-time feedback, allowing self-correction of potentially hazardous conditions. Such a device may help 'modify the risk-taking behavior' of EMS drivers and 'improve driver safety.' With appropriate oversight, EMS agency administrators can determine if particular drivers require further education or revocation of driving privileges. One report using the technology with ambulances showed a remarkable drop in the number of dangerous conditions; as an additional benefit, maintenance costs were sharply decreased due to less mechanically stressful driving conditions. In 1997 and 1998, a new ambulance occupant restraint device was described, called the Kicker Vest. Although the initial reviews were promising, an engineer noted that the device might result in a fatal injury if the paramedic was, for example, turned to face the squad bench at the time of the collision. The Kicker Vest is one example of a new piece of equipment, designed to protect ambulance personnel and patients, which is well meant but may not function as intended and may even be dangerous. The example also reemphasizes the need for reliable, rigorous research before new devices, policies, or interventions are adopted. The Centers for Disease Control and Prevention recommended that 'Ambulance manufacturers should evaluate and develop occupant protection systems designed to increase the crash survivability of EMS workers and patients in ambulance patient compartments and ensure that such systems allow EMS workers mobility to access patients and equipment.' This is not, by itself, a reasonable solution. Individual ambulance manufacturers do not have the resources to undertake a project of this magnitude. Instead, a partnership of manufacturers, industry, and government must work together to develop realistic solutions. ",
        "Research": "Judging by the publication dates of the references used for this chapter, it appears that the rate of research on ambulance crashes is increasing; however, many questions remain. Over a decade ago, NHTSA noted the importance of dedicated funding in order to conduct EMS research and develop EMS researchers. Today, there remains a paucity of EMS research funding and little incentive or support for EMS professionals to become researchers. Reliable solutions for EMS problems can only be achieved following rigorous research. We in the EMS community must take it upon ourselves to create the support needed for these efforts. Coalitions of individuals, agencies, researchers, associations, manufacturers, and government must be formed to help mitigate this serious national problem through effective research, testing, sharing findings, and implementing best practices. In order to conduct that research, funding will be required and research teams will need access to comprehensive data. An agency-based systems approach to the problem must include considerations for human factors, vehicle factors, and environmental factors. For example, each agency should have a team dedicated to ambulance safety. Members of the team must be well-trained collision investigators. The ambulance safety team should: \u2022 ensure that the agency has a reliable, comprehensive data collection system \u2022 determine the agency's historical risks, e.g. crashes per year (or per thousand calls or million miles driven) for the past few years \u2022 set goals for improvement \u2022 develop and test interventions \u2022 celebrate accomplishments \u2022 work with state, national, and international groups to develop, evaluate, and share best practices.",
        "Conclusion": "An average of ten EMS professionals die every year and hundreds more are injured in transportation-related events in the US alone. Many of those injuries may result in the end of a career that was dedicated to helping the community. These are not 'accidents,' they are predictable, preventable events. Emergency medical services professionals are not the only victims in these events. Based on the cited ambulance safety research, we can estimate that ambulance-related incidents result in 20 civilian fatalities and hundreds of non-fatal injuries among our patients, passengers, and community members every year in the US alone. Working together, we can pursue a vision of improved ambulance safety and zero fatalities from ambulance crashes. This means EMS professionals working with engineers, epidemiologists, researchers, physicians, manufacturers, government officials, and others to analyze the problems and to develop, test, and implement solutions. Development of effective strategies to improve ambulance safety and the means to conduct effective research to monitor the implementation of these strategies requires the efforts of a broad coalition of individuals, manufacturers, industry, and government."
    },
    {
        "Introduction": "In order to adequately understand the process of risk management, the best approach would be to start with a definition of risk. Although there are varied definitions, there are some common threads: uncertainty, potential for harm, and potential for loss are a few examples. The US Fire Administration defines risk as the objective or subjective probability that something negative will occur. In the prehospital environment, risk management is tightly integrated into all aspects of patient care, training, and supervision. One must consider both the probability that an event that is undesirable will occur and that there is potential for harmful consequences. Managing those events proactively is the ideal, but the problem that we often have is how to best create an ideal environment. In addition, we need to know how to classify risks in terms of frequency and severity. Two components to be considered are the internal and external aspects of risk management. Internal components are safety, training, health and wellness, personnel management, and equipment readiness. External components are prevention programs, public education programs, and one of the most important, the perception of the public. In 1989, Valenzuela reported that fewer than 65% of emergency medicine residency training programs provided formal instruction in EMS risk management. Both present and future EMS medical directors must become active, knowledgeable participants in prehospital risk management. Risk assessment and root cause analysis are critical factors in risk management. They will be addressed in this chapter, along with training, supervision, and incident investigation.",
        "Risk assessment": "Assessing risk in health care involves identifying those things that place us at risk and then attempting to predict the frequency and severity of occurrences. It is important to know what to monitor. Activities classified as \u201chigh frequency, high risk\u201d obviously should be monitored closely. Low-frequency, low-risk activities or even high-frequency, low-risk activities do not require as much of our attention. In fact, the costs of monitoring these types of activities may outweigh the benefits. The two high-risk activities that require most of our attention are intubations (low-frequency) and no-transports (high-frequency). We look at historical data to determine those activities that require frequent monitoring and typically the two mentioned above are the ones that every service wants to closely monitor. Obviously we want to make as few errors in risk assessment as possible. The development of pre-loss and post-loss strategies is one way to achieve that goal. Pre-loss strategies include the use of effective protocols or guidelines, education (both initial and continuing) that is thorough and provides feedback to the field practitioners, good documentation, and an effective quality improvement program. Post-loss strategies include a good investigation, matching behavior to protocols or guidelines, and remediation/education as indicated.",
        "Initial training": "Training of prehospital personnel has great effect on patient care. A solid foundation of knowledge, skills, and attitudes is necessary for EMS personnel to function effectively and provide consistent quality patient care. An awareness of the quality of primary training institutions used to educate EMS personnel is important. Factors such as curriculum, teaching techniques, methods of evaluation, and clinical training have important roles in the student\u2019s preparation for a role providing prehospital care. This knowledge is the responsibility of the EMS medical director, but EMS administrators should also be aware of this background. If the course medical director and the EMS medical director are different people, then communication between them is essential. EMS systems primary training is often provided as part of the individual\u2019s employment, and this facilitates involvement of the system\u2019s medical director in the training process.",
        "Preemployment screening and orientation": "If a potential EMS field employee received primary training outside the EMS system, it is important for this individual to be assessed in terms of medical knowledge and patient care skills before being released to function independently in the field. As a prehiring assessment, many systems use a written examination that may include tests of basic knowledge such as reading and math. Other assessments that are used include EMS knowledge-based written and skills testing, physical ability testing, interviews, and psychological screening. Most systems have standard administrative procedures, such as background checks. New employees should receive field orientation and evaluation before functioning as patient care providers. Orientation is provided in administration, operations, and medical areas, including protocols, equipment, and field performance standards.",
        "Medical supervision": "Assurance of quality prehospital health care is provided through the process of medical accountability. The medical supervision of prehospital care is discussed extensively throughout this book. The vital role of the medical director in defining patient care standards, establishing protocols, approving the level of prehospital medical care that may be rendered by all individuals in the system, and positively affecting all the operational aspects that affect patient care cannot be overemphasized. In addition, the medical director should be directly involved in the risk management program.",
        "Continuing medical education": "Continuing medical education (CME) serves multiple purposes in an EMS system, including updating personnel on protocol changes, providing reviews, presenting medical information and technology, and evaluating knowledge and skills of field personnel. A number of studies have demonstrated deterioration of knowledge and skills in EMS providers. In 1980, Latman and Wooley demonstrated that personnel certified at the now-defunct Emergency Medical Technician-Ambulance (EMT-A) level lost 50% of their basic skills proficiency, and paramedics lost 61% of their basic skills proficiency within 2 years of training. In 1987, Skelton and McSwain reported a correlation between the amount of technical skill deterioration and increasing length of time from completion of the training program. One role of continuing medical education is to evaluate and enhance knowledge and skills of field personnel. Other roles of CME include updates on protocol changes, patient care reviews, and new medical information and technology. CME also serves as a forum for EMS personnel to both provide and receive feedback regarding patient care. In 1990, Goldberg published a review of litigation in a large metropolitan EMS system and suggested that medicolegal continuing education could protect EMS systems and paramedics from future litigation.",
        "Documentation": "The Joint Commission (TJC, formerly JCAHO) requires that a medical record is established and maintained on every patient seeking emergency department care [8]. TJC mandates certain elements be included in the record; other elements may be added to conform with state regulations and hospital requirements. In comparing this with the prehospital arena, it is apparent that documentation requirements for EMS patient records vary widely. Patient records are required for all transported patients, yet specific elements of the record are far from universal. A number of states have standardized EMS patient records, but use of such a patient care report (PCR) may not be required.\n\nMany systems maintain limited or no patient documentation if a patient is not transported. In 1992, Zachariah reported serious, even fatal, outcomes in patients not transported by EMS. Situations in which EMS personnel either denied transport or mutually agreed with the patient not to transport by ambulance were twice as likely to result in hospitalization than cases in which the patients declined transportation against the advice of the EMS personnel [7]. In 1990, Selden studied medicolegal documentation of prehospital triage and suggested that, rather than an abbreviated form or small section of the usual PCR, the release form (when a patient is not transported) must be at least as detailed as the usual incident report [9]. In 1985, Solar reported on the 10-year malpractice experience of a large urban EMS system and stated that a properly completed PCR is the best defense against a malpractice allegation [10]. Documentation remains one of our most critical areas for risk exposure.\n\nOther important areas of documentation include the new employee\u2019s application, pre-employment screening, and field orientation. Some systems document the new employee\u2019s knowledge of written protocols, thus holding him or her accountable for the information and providing written evidence of that accountability. All aspects of patient care incident management should also be documented.",
        "Quality management and risk management": "Quality management (QM) of the patient care rendered in an EMS system may identify actual or potential risks to patients and the system. This identification allows for the proactive management of such risks, and takes the EMS system out of the reactive mode of dealing with problems in patient care. The QM loop forms a continuous action loop, starting and ending with protocols and education. Documentation of variance from or compliance with protocols forms the basis for analysis of the quality of care delivered. Quality management and risk management are closely linked. The goals and objectives of a risk management program must be clearly understood, measurable, and attainable. There must be buy-in from all of the personnel within the organization. There are five principal steps in the development of an effective risk management program: (1) identifying risk exposure, (2) evaluating risk potential, (3) ranking and prioritizing risks, (4) determining and implementing control actions, and (5) evaluating and revising actions and techniques as needed. These steps include identifying and addressing those internal and external factors that create risk within the organization. ",
        "Other factors": "Other incidents may occur in an EMS system that have potential effects on patients. If an ambulance is involved in an accident, the patient may receive injuries directly or have increased morbidity from a delay in transport. In 1992, Bowers reported on 182 incidents of alleged negligence involving prehospital care providers; 40% of the cases involved ambulance accidents (although some of these cases involved several identified categories of negligence). This is compared with 42% of the cases that were related to negligence involving treatment or care. A provider who is injured while extricating a patient may no longer be able to provide patient care at the scene, potentially affecting patient care. Equipment malfunctions such as defibrillator failure may have direct bearing on morbidity and mortality for a patient. Steps should be taken to identify and address potentially preventable occurrences, such as driver training programs and regular equipment checks. ",
        "Patient expectations": "The concept of patient expectations concludes the components of prehospital risk management. Locales, socioeconomic status, cultural influences, and many other factors play a role in a patient's expectations of the EMS system. It is important that patient expectations are taken into consideration. As a group, patients come to the health care system with fairly realistic expectations. They expect that the healing professionals will treat them with dignity and regard their welfare as a principal concern. When the expectation of the patient is different from that of the EMS crew, conflict may arise. Discussions with EMS personnel regarding potential patient expectations and responses to possible conflicts may have significant positive consequences for an EMS system. In a study of 17,271 emergency department (ED) patients, the first and third factors that patients perceived as reflecting quality care were physician courtesy and nurse courtesy. The other factors cited follow in order of importance: comfort of waiting area, satisfactory answers to patient questions, protection of privacy, acceptable waiting time for treatment, cleanliness of treatment area, and satisfaction with pain control. Extrapolation of these findings to the prehospital area is logical, though poorly studied. In health care, patient satisfaction remains the major product. When expectations are not met, patients feel they are not getting their \u201cmoney\u2019s worth.\u201d Anger can be expressed in many ways in this culture, and filing a lawsuit is one of them.",
        "Patient care incident management": "As a clearly recognized component of the health care system, EMS personnel are affected by the trend of increasing litigation. Over the 12-year period of Goldberg\u2019s review (1976 to 1987), claims made against Chicago Fire Department EMS increased threefold. Of the 60 lawsuits presented, 47% named a paramedic as a defendant and 3% named the medical director. As the direct medical oversight physician is increasingly recognized as a fundamental component of quality prehospital care, correlative potential liability will necessarily follow. It is likely that oversight physicians will be named more often in lawsuits as time progresses. In the 1992 study by Bowers, the category of \u201ctreatment and care\u201d represented about 43% of the cases. Goldberg reported 77% of the cases in his study involved alleged improper medical treatment. It is important that the physician responsible for medical oversight grasps the full import of this information and responds by using an effective risk management system. ",
        "Patient care incident": "A patient care incident is any situation where there is a concern or complaint regarding patient care. This concern or complaint may be related to the commission or omission of actions on the part of EMS personnel, bystanders, other prehospital personnel, physicians providing direct medical oversight, or others that affect or potentially affect patient care and outcome of the situation. At times, extenuating circumstances such as prolonged scene time may affect patient care, but could not have been prevented. Equipment failures, scene injuries to crew members, or accidents involving ambulances may affect patient care. The documentation and consideration of such problems are part of patient care incident management.",
        "Establishing a comprehensive mechanism": "Establishing a comprehensive mechanism for managing patient care incidents is an important aspect of a risk management program. This mechanism includes incident identification, incident investigation, investigation findings, indicated actions, documentation, and system impact. It is important that all are oriented to this mechanism, including field employees, supervisors, and senior level management.",
        "Incident identification": "Incident identification occurs when a patient or other source expresses a verbal or written concern regarding EMS patient care. It also may result from an identified equipment failure or a crew's assessment of a difficult patient encounter such as a prolonged extrication. Quality management studies and reviews may show areas that need improvement, such as success rate for initiation of IVs. The risk management program itself may identify trends in patient care incidents that indicate necessary systemwide intervention. It is important that a mechanism be in place to identify, document, receive information, and initiate the process for handling a patient care incident. ",
        "Serious or critical patient care incidents": "Serious or critical patient care incidents are occurrences that involve significant injury to a patient or negatively affect patient care, morbidity, or mortality. These incidents should be reported immediately. Usually the system has a chain of command for reporting incidents, and it is vital that this chain includes contacting the medical director.",
        "Incident investigation": "Incident investigation is a uniformly applied, prearranged mechanism for investigating a patient care incident. It includes a chain of command that identifies roles for all of the players in the system and provides a routing mechanism for information and documentation obtained in the investigation. Certainly, all interactions related to the investigation should be documented; an investigation worksheet is a useful tool for the personnel investigating a patient care incident. This worksheet contributes consistency to investigations and also serves as a reminder for necessary actions to be taken and items to be obtained. The personnel responsible for carrying out the investigation should be educated in this aspect of their work. These investigators should respond in a timely manner to patients or other sources expressing negative comments or concerns about patient care. Many complaints may be resolved quickly with the education of the person who calls or writes about some aspect of prehospital medical care. For example, a physician may be concerned because his patient was not brought to the desired hospital. When the EMS supervisor explains that the patient was critically ill, and that it is the policy of the system to transport critical patients to the closest hospital, the physician gains a better understanding of the process, and the problem may be resolved. Some EMS systems require receipt of a formal written complaint before initiating an investigation. This is short-sighted, and it profoundly limits the scope of risk management. Some systems have less formal requirements for when an investigation may be initiated; prompt notation, however, of all complaints and discussions is important. Emergency medical services crew members involved in an incident should have the opportunity to respond verbally and in writing to a concern that is being investigated. These written incident reports serve as information sources and are a routine part of the investigation. Other individuals may be asked to make oral or written statements regarding the events surrounding an incident. For example, the ED physician who finds an endotracheal tube placed in the esophagus and notifies the EMS system should be interviewed by the investigator. Any other information, tape transcripts, PCRs, and equipment pertinent to the investigation should be collected. These materials are then collated with the incident reports and other relevant information to formulate the summary of the investigation. EMS administration and the medical director should evaluate this information through a formal process and make a disposition of the incident. Further discussions, interviews, or investigations may be necessary. Patient privacy must be respected, and the PCR should be treated with the same concern for privacy as a physician record. This is a logical extension of the premise that providers function under the delegated authority of the physician medical director. States such as Texas protect PCRs in the same fashion as hospital medical records. Any unnecessary written or verbal reference to an incident report or its contents lessens the confidentiality of the report, contributes to potential negative repercussions, and minimizes the resultant value of its completion. In most states the limits on discoverability of hospital incident reports are much better defined than for EMS incident reports. In general, only necessary copies of the report should be made and those who receive them should be in the appropriate reporting pathway. It may help to clearly label the recipient of each incident report that it is being prepared for possible use by legal counsel. Because there may be multiple regulations and statutes involved, such as those protecting peer-review material, it helps to design the incident report and the risk management program with consultation from all appropriate medical, administrative, and legal entities. All aspects of the investigation should be fair and involve due process for the employee, including the employee\u2019s prospective understanding of how the risk management program functions and how investigations are conducted. Some systems have review panels that include field personnel. EMS medical directors are the key individuals in the resolution of a patient care incident; therefore, they should be made aware of the initiation of an investigation for minor incidents and be actively involved for more serious or critical incidents. Medical directors must have final authority on the evaluation of the clinical aspects of the incident.",
        "Investigation findings": "Investigation findings are the conclusions from the investigation of a patient care incident. The medical director must play an active role in evaluating investigation findings to determine appropriateness and accuracy. Results of the investigation may show that the incident was related to: - environmental influences - safety factors - training - employee clinical performance - employee behavior - judgment error - equipment deficiency or failure - incomplete documentation - patient expectations - protocol or policy problems - actions of other personnel - direct medical oversight.",
        "Incident investigation using root cause analysis": "The goal of a root cause analysis is to determine what happened, what the scope of the problem is, and what the best actions are to keep the problem from happening again. In prehospital care, when we see an EMS practitioner make a mistake, it often looks on the surface as though he or she made a mistake and the problem is a simple one of human error. Although that may very well be the case, we would be remiss if we did not look at the root cause of each incident as it occurs. In essence, we need to develop strategies for preventing problems in the future. To be effective, the analysis must include a determination of all of the factors involved, a review of the systems and processes involved, the factors that potentially contributed to the error, and the best method for remedy. The initial evaluation looks at what happened, and the root cause analysis determines the scope of the problem and the appropriate action to take.",
        "Indicated actions": "Indicated actions depend on a number of factors, including seriousness of the incident from an administrative, medical, or media standpoint; system response to previous similar incidents or similar types of incidents; and the employee's long-term performance and disciplinary history. Indicated actions are administrative or medical. There is overlap at times, and communication between the administration and the medical director is essential. Administrative actions usually fall into the generic classification of employee personnel actions. Medical actions generally fall into the categories of no action, policy or protocol revisions, product changes, remedial education, and corrective measures such as decertification. Remedial education actions include classroom education, clinical hospital education, testing, and supervised field preceptorship. Actions of an educational nature may also include systemwide training or retraining through continuing medical education. Potential corrective measures include counseling, probation, and decertification. The physician charged with medical oversight by contract has final authority on medical actions in response to patient care incidents. Generally, for an initial performance problem, the employee receives some type of counseling and retraining that is specific to his or her needs. This process should be viewed as education based rather than discipline based, unless there are circumstances for which disciplinary measures are truly indicated. Even in the latter case the educational aspects must still play a vital role and represent a positive system response to a problem.",
        "Future directions \u2013 prehospital medical error": "Medical error is a topic of an increasing body of literature and of increasing public awareness. In 1999, the National Institute of Medicine reported that medical errors kill from 44,000 to 98,000 Americans each year. For example, medication prescribing/dispensing errors kill an estimated 7,000 patients per year. Yet little literature exists on medical error in the prehospital setting. Medical error is what risk management programs seek to manage, and more importantly, to prevent. Risk management is more than responding to errors or potential errors, and includes a response to studies that objectively evaluate or refine techniques used to treat patients, and to studies that seek to reduce error in patient care. In a study of CPR techniques using mannequins, a high rate of error was noted for emergency health-care providers (EMTs, firefighters, first responders, and CPR instructors). Though the application of this to the patient care setting has limitations, CPR is a standardized technique that was monitored for adherence and found to have significant error rates. Recommendations were made to modify training programs. In a landmark study of pediatric intubation, Gausche et al. found that the addition of out-of-hospital endotracheal intubation to a paramedic scope of practice that already includes bag-valve-mask use did not improve survival or neurological outcome of pediatric patients treated in an urban EMS system. This study was done because of the difficulty associated with intubation of small children and because of intubation error, including unrecognized esophageal intubation. An EMS system risk management program should include a review of these types of studies. Changes to a particular EMS system may or may not be needed as a result, but the system should be aware of the studies. One effective tool used by multiple industries to reduce error is already in place in EMS systems: standardization. Examples of standardization in EMS systems include protocols that guide patient care, consistency in the type and location of equipment used by EMS personnel, operational protocols that guide scene management, and dispatch protocols. And because of the \u201csystem\u201d nature of EMS, prehospital care providers are in a unique position of being able to implement systemwide changes. Leape stated that total quality management requires a culture in which errors and deviations are regarded not as human failures, but as opportunities to improve the system. The psychology and culture of hospital and prehospital providers will need to change if progress is to be made in reducing errors.",
        "Conclusion": "One major goal for the risk management program is to provide effective patient care incident management so the incident becomes part of the overall quality management program, and does not simply become an isolated circumstance with no system impact. Trends and patterns must be observed and interventions taken as necessary. The goals for an EMS risk management program extend far beyond reactive management of patient care incidents. A good program allows for the prospective management and evaluation of all the medical care provided in an EMS system; it considers factors and influences that may negatively affect patient care even before an incident occurs. The program affects protocols, continuing education, training, pre-employment screening, medical oversight, and administration. Change is facilitated through the identification of problems reactively and proactively; all personnel involved in the EMS system become part of the solution. The ultimate benefactors are the patients in the EMS system; their medical care improves through the changes and growth that result from the program."
    },
    {
        "Introduction": "Thousands of patients are treated by EMS providers each day. For most of these patients, their exposure to the health care system will improve their well-being. However, some will experience unintentional harm or be put at risk of being harmed. The sentinel Institute of Medicine paper To Err is Human: Building a Safer Health System brought to light the effects these risks and harms can have on patients and systems throughout the health care industry. Since the release of this paper, health care systems and practitioners from a broad spectrum of fields have worked towards understanding the threats to patient safety, researching factors that contribute to unintentional harm and developing methods to reduce, eliminate or mitigate accidental harm. The term adverse event describes an occurrence that resulted in unintended and detrimental morbidity or mortality (patient harm). Adverse events are thought to stem from systemic weaknesses, individual behaviors, or a combination of the two. It has been estimated that one-third of patients admitted to acute care hospitals experienced at least one adverse event. The uncontrolled and time-sensitive prehospital setting offers unique challenges that make adverse events all the more likely to occur. The concept of EMS as high-reliability organizations (operating relatively error-free operations over a long period of time) is new. Long ago embraced by the nuclear power, aviation, and military industries, high-reliability organizations avoid catastrophes, consistently make safe decisions, and have high-quality, reliable operations. This chapter summarizes the challenges and risks of emergency medical care delivered in the field, presents mechanisms that can address these challenges and reduce these risks, and provides a framework for becoming highly reliable. There is considerable research and theory focused on the predictors of error and adverse events in high-risk settings. Health care has borrowed from this work and adopted many of the concepts and practices that improve safety. Programs widely used in health care, such as the Agency for Healthcare Research and Quality's TeamSTEPPS, are based on this prior research and theory. Many of these programs or interventions may be active in the hospitals where medical directors practice. Below is an overview of the most common and widely accepted concepts in safety, which may aid medical directors in their efforts to adopt, adapt, or develop programs specifically for their EMS organizations and systems.",
        "How accidents happen - The Swiss cheese model": "Several factors can affect patient safety in EMS, and rarely does any one factor act alone to create an adverse event. These factors may be human, relying on people to either commit or omit certain functions, or systemic, depending on procedures, administrative controls, or engineering and design. When people and systems function properly, these aspects work to protect patients from hazards. However, weaknesses can occur. The Swiss cheese model likens these weaknesses to holes in slices of Swiss cheese; many layers of Swiss cheese slices rarely line up to have a hole that one could peer through, but when the slices align in just the right way, a trajectory through the cheese opens up, and an adverse event can occur. The model attributes these holes to two conditions: active failures, where unsafe acts are committed by people, and latent conditions referred to as systemic flaws in design or processes that allow hazards to be present. When active failures and latent conditions align in the right manner, an adverse event can occur.",
        "How accidents happen - System factors": "While human error often contributes to adverse events, humans are considered the last piece of cheese in the Swiss cheese model. As humans are, by nature, not highly reliable, additional slices of cheese are installed in organizations to make processes safer. These system factors can include the workplace culture itself, written policy and procedure, training in process and best practice, and technological solutions or engineering modifications that account for human fallibility. Examples of system factors that may lead to ambulance collisions include policies that require lights and sirens use, poor training in emergency vehicle operation, a culture that glorifies speedy driving, and vehicles with poor reflective markings. Examples of system-level safety improvements to these problems include evidence-based algorithms that recommend judicious lights and sirens use, provision of special vehicle operator training, a culture that emphasizes safety over speed, and ambulances with science-guided reflective markings. Many different organizations work together to ensure EMS services are provided to the community. This includes all the partner organizations that contribute to a tiered response, including municipal fire and police agencies, ambulance dispatch centers, base hospitals providing medical oversight, and receiving hospitals. With these multiple groups come inherent opportunities for miscommunication and adverse events to occur. Fragmented oversight of the system could lead to a situation where the same adverse event goes unrealized and occurs repeatedly. Interagency collaboration and training can improve team performance.",
        "How accidents happen - Human factors and ergonomics": "Human traits that contribute to adverse events are known as human factors. Examples of human factors that can have negative effects on patient safety include complacency, fatigue, eyesight, and inattention. However, it is important to remember that human factors also contribute to safety, as human action or inaction is often the last \u201cslice of cheese\u201d protecting patients. Examples include seeking clarification from a partner or developing strong habit patterns for checking medication concentrations. Task fixation is a common human factor that can contribute to error in EMS. Commonly termed \u201ctunnel vision,\u201d it can occur during endotracheal intubation or 12-lead ECG acquisition. Here, providers are so focused on a task perceived to be important that changes in the patient condition, such as desaturation, or competing priorities, such as chest compressions, can be excluded from thought. Many EMS procedures involve many actions and decisions. When the critical step is completed, it is common for downstream sequential actions to be forgotten. An example would be failure to release a tourniquet after placing an intravenous cannula. Another term used alongside human factors is ergonomics. This refers to physical human limitations, and is most commonly employed in developing work environments that complement the human body. Applying ergonomic science has brought about color- and font-coded medications, advanced \u201ctrack system\u201d stairchairs, and cardiopulmonary resuscitation (CPR) metronomes. A classic example of a common adverse event that was addressed using human factors and ergonomic science is that of the tourniquet; previously made of latex that was a similar tone to Caucasian skin, phlebotomists and other health care workers were known to leave tourniquets applied after collecting blood. By changing the color of tourniquets to bright blue, the incidence of forgetting to remove tourniquets dropped dramatically. The visual cue of the bright blue was all that was required to help providers remember the step of tourniquet release. Communication is also a key component to safety. Not being heard, or being heard incorrectly, can lead to a task not being performed, the wrong task being performed, or a task being performed in the wrong way. Examples include medication errors and procedures being performed on the wrong limb. Callouts are used to ensure clear communication among all members of a team. Yelling \u201cClear!\u201d prior to discharging a defibrillator is an example of a callout. A readback occurs when the receiver repeats the message from the sender. For example: Paramedic A: \u201cPlease give 5 milligrams of morphine\u201d Paramedic B: \u201cOk, giving 5 milligrams of morphine\u201d Paramedic A: \u201cYep, thank you\u201d When a readback does not happen, the sender should challenge the receiver to make sure he or she interpreted the message correctly. For example: Paramedic A: \u201cDid you hear me ask you to give 5 milligrams of morphine?\u201d",
        "Judgment and clinical thinking": "There is limited research describing the actions, inactions, and clinical decision making of EMS personnel in relation to safety. Prehospital care providers exercise clinical decision-making skills on each and every call. Two key outcomes of these decisions are working diagnoses and treatment plans. Often protocols and guidelines are used to help field clinicians arrive at an accurate working diagnosis, which increases the likelihood that a correct treatment plan will be initiated. However, error exists in this area. Physicians are estimated to make a misdiagnosis in 10\u201315% of cases, and this is likely higher in emergency medicine. Over 100 biases contribute to error in emergency medicine and can be related to cognitive pathways used by emergency workers to arrive at decisions. The first is the intuitive pathway, developed through repeated experience. In this pathway, patterns are recognized quickly, and interventions are applied without much thought. While this serves paramedics well, there will be times when intuition is wrong. Following an analytical pathway can improve reliability in decision making by applying conscious, deliberate thought processes to a clinical situation. While this may take longer, the process of careful examination and testing can improve upon the intuitive pathway. Analytical reasoning is resource intensive, and requires a certain state of mind that can be clouded by stress, workload, and human factors such as personal stress, sleep patterns, and diet. By understanding how emergency physicians and prehospital care providers think in the clinical setting, we can start to appreciate how patient safety is safeguarded by making sound clinical decisions, and how poor decisions can lead to disaster. Remembering that nearly all clinical staff want to perform well and improve patients\u2019 lives, it is important to examine poor clinical decisions from a system perspective and not place blame on individuals. Addressing clinical decision making is best done with educational strategies that train clinicians how to think critically. Described as the \u201cability to engage in purposeful, self-regulatory judgment,\u201d this construct permits clinicians to make treatment decisions based on the analytical pathway when needed, specifically to \u201cdouble check\u201d and override the intuitive pathway. An example of this metacognition would be when a paramedic walks into a residence and sees a patient who is diaphoretic, clutching his chest. Intuitively the paramedic may think \u201cOh, this guy is having a STEMI!\u201d but the analytical process of obtaining a 12-lead ECG and inquiring about risk factors and incident history may elucidate a scenario more suggestive of aortic dissection, pulmonary embolism, or cocaine toxicity. Croskerry describes the development of critical thinking which, while not innate, can be \u201ctaught and cultivated, but even accomplished critical thinkers remain vulnerable to occasional undisciplined and irrational thought.\u201d In contrast to hospital settings, there is a stunning lack of epidemiological data pertaining to adverse events in the prehospital setting, despite a recognized need to better understand patient safety in EMS systems. While there is some evidence documenting medical error by prehospital care providers, research from time-sensitive areas in the hospital, such as the critical care unit or emergency department, can also shine a light on adverse events that likely occur in the field as well. In one retrospective chart review of 15,000 cases, the emergency department was the most prevalent location in the hospital for negligent adverse events to occur and others have made efforts to establish definitions and measurements for error in emergency medicine.",
        "Patient safety in EMS - the unique environment": "Emergency medical services personnel often work in small, poorly lit spaces in an environment that is chaotic, unfriendly, and challenging for time-sensitive health care interventions; indeed, it is often the dangerous nature of the environment that has led to the call for help. Unlike a hospital, emergency scenes can be filled with distracters that can increase the odds that an adverse event will occur. Physical characteristics of these scenes include loud noises, poor lighting, uncontrolled movement of people and vehicles, and small spaces. Language barriers, noise, stress, and medical conditions may limit effective communication between providers and their patients. Providers often work from compact bags rather than large, well-labeled cabinets and drawers. This limitation reduces the opportunity to place visual cues or organize equipment for optimal performance. In addition to these challenging environmental factors, emotional stressors are often heightened by the presence of panicked family members and curious bystanders, and a lack of human and medical resources. The time-sensitive nature of EMS care further compounds these physical and emotional stressors. Further, EMS work can be complicated by multiple handoffs from BLS providers to ALS providers to air ambulance crews and finally to hospital staff. Lastly, EMS work is round the clock, and often EMS workers endure 12-, 14-, or 24-hour shifts with few opportunities for meals or rest. This can lead to fatigue, which is known to play a role in adverse event incident rates. The arena in which EMS providers work is rich with opportunities for adverse events attributed to provider or system errors. Importantly, unintentional error can have profoundly negative effects on EMS providers. Increased stress, time away from work, family disruptions, job burnout, divorce, depression, and suicide in health care workers have all been correlated to adverse events.",
        "Patient safety in EMS - Defining patient safety in EMS": "There is no common language used to define adverse events in the EMS setting, making general discussion and comparisons challenging. The World Health Organization defines patient safety as the \u201creduction of risk of unnecessary harm associated with health care to an acceptable minimum.\u201d The term \u201cacceptable minimum\u201d refers to the collective notions given current knowledge, resources available, and the context within which care was delivered weighed against the risk of non-treatment or other treatment. In other words, the acceptable minimum risk fluctuates based on the context of the health care delivery system. What may be considered an unacceptable risk in an operating theatre may be an acceptable risk in the prehospital setting, and vice versa. Harm need not occur for patient safety principles to apply; potential risks of unintended harm, termed near misses, are of core interest as they represent opportunities to implement safer practices before harm has been inflicted. Examples of near misses include drawing up, but not administering, the wrong medication, or charging a defibrillator when a patient has a palpable pulse. Sometimes, the distinction between patient safety and clinical efficacy can be difficult. The efficacy of specific treatments for specific diseases, such as albuterol for asthma or needle thoracostomy for tension pneumothorax, is excluded from the realm of patient safety, while drug dosing errors and diagnostic errors surrounding these treatments are included. Adverse events are commonly categorized as active failures, involving humans at the point of care, or latent conditions, where contributing factors facilitated the human-driven error to occur. An example of an active failure would be a paramedic calculating a drug dose incorrectly. Examples of latent conditions could be the lack of preloaded medications, long work hours, and poor training.",
        "Patient safety in EMS - Measuring adverse events in EMS": "The very nature of EMS creates complex challenges to measuring adverse event rates. Currently, recognition of adverse events is achieved in one of three ways. First, an EMS provider recognizes that an error has occurred. Second, another health care provider, such as a receiving hospital physician, recognizes an adverse event. Lastly, retrospective quality assurance measures rely on documentation review (chart review) to identify adverse events. Often, adverse events go unrecognized. Once providers transport a patient to an emergency department or an inpatient bed, they return to service in their community. Often, providers will transport patients to several different hospitals during a shift. These aspects of EMS work make patient follow-up difficult, and adverse events that do not present immediately are difficult if not impossible to realize. In addition, privacy legislation often prohibits EMS services from accessing outcomes on patients transported to hospital as some interpret the legislation in such a way that it excludes the paramedic and the EMS service from the \u201ccircle of care.\u201d Emergency department staff caring for individuals may not realize the role EMS played in a patient safety incident and may not be familiar with a process to report such events even if they suspected it was attributed to EMS care. Efforts to calculate adverse event rates in EMS may require extension into the emergency department and include hospital outcomes to truly understand the scope of adverse events associated with prehospital care. If recognized, adverse events must then be reported. Until recently, formal adverse event reporting processes were lacking in most EMS systems. Today, reporting systems remain heterogeneous and underutilized. Providers often admit they do not report adverse events for fear of punitive action by employers or medical directors. Others report feeling ashamed, and fear humiliation in the face of their colleagues. To combat this human tendency, many EMS systems use anonymous adverse event reporting systems. EMS providers also express a willingness to report but often complain about the complexity or inconvenience involved in certain electronic or paper-based reporting tools. To benefit from recognized adverse events, organizations must foster a culture where adverse event and near-miss reporting is encouraged and develop convenient platforms that facilitate reporting. The term just culture is applied to describe an environment where unintentional human error is supported rather than penalized. Currently there is no uniform method for measurement or a national dataset to quantify the rate of adverse event rates in EMS systems. The lack of a common language to define adverse events in EMS makes comparing literature difficult. Few EMS systems have attempted to measure the incidence of adverse events, and those that have done so have relied on self-reported adverse event rates provided in retrospective surveys. Without a framework for defining, classifying, and reporting adverse events, there is no way of knowing the true incidence of adverse events in the prehospital setting. Recent research focused on measurement validity provides a foundation from which to fill this gap in structure and standardization. This problem is not unique to EMS, and has been described in the hospital and mental health settings as well.",
        "The major problems -  Scientific literature": "\n\nA systematic review published in 2012 compiled 88 peer-reviewed articles that investigated patient safety in EMS. The articles identified seven key themes related to patient harm in the EMS setting and mostly studied low-hanging fruit \u2013 topics that are easy to define and retrospectively measure. The methods and quality of the articles were highly variable, and only one was a randomized controlled trial. Populations studied included patients of all ages, from neonatal to geriatric, as well as the providers themselves. Conditions studied ranged from \u201call-callers\u201d to specific patient subgroups. Both 9-1-1 and interfacility encounters were studied, and providers ranged from EMTs to physicians. In the only randomized controlled trial, safety outcomes for patients >59 years of age who received treatment from standard paramedics versus extended scope paramedics who had received additional training in the management of low acuity conditions were studied. Patient safety outcomes studied in the literature ranged from physiological variables (heart rate, blood pressure, oxygen saturation, etc.) and equipment malfunction (defibrillators, stretchers, aircraft, etc.), to perceived barriers in self-reporting adverse events (culture, fatigue, policies, etc.). Other outcomes examined patient discourse (readmission, death, etc.), information exchange (in dispatch, at transfer of care, etc.), and technical skill accuracy (medication dose calculation, endotracheal intubation success rates, etc.). \n\nThe literature and the experts: a disconnect As part of a large, multiphase study into patient safety in EMS, the Canadian Patient Safety Institute and EMS Chiefs of Canada conducted qualitative research with EMS experts following completion of the 2012 systematic review. The objective was to triangulate the findings of the systematic review with knowledge users working in clinical and administrative positions in the EMS industry. However, the experts interviewed were surprised by the systematic review findings. Generally, they considered that the literature studied matters that were not priority issues in safety. For examples, ground vehicle collisions and endotracheal intubation featured prominently in the literature, but experts felt these were studied because of the dichotomous nature and \u201csexiness\u201d of the topics. Core problems were felt to be more complex and difficult to measure. Clinical judgment was felt to be the greatest threat to patient safety. Citing \u201cscope creep,\u201d where additional skills and responsibilities are added to EMS provider practice without the requisite foundational education, experts felt that good clinical judgment was the best attribute of a provider. Strong foundational training and years of experience were thought to contribute to strong clinical decision making. The second topic felt to be affecting safety is an \u201cidentity crisis\u201d in EMS where it is torn between the health care industry and the public safety industry. Fundamental cultural differences between these two industries were thought to be exploitable to improve safety. For example, the emphasis on speed in public safety may not benefit patients clinically and may in fact cause harm. Similarly, the hierarchy that can be present in public safety chains of command may lead to a lack of communication between providers that can allow recognized harms to happen. The emphasis placed on judgment and culture by the experts has been poorly studied, yet some evidence supports their convictions. Providers with more experience or education tend to make fewer errors than their inexperienced or lesser trained counterparts, and organizational culture has been found to be closely associated to adverse event rates, reporting rates, and the ability of systems to improve safety metrics.",
        "Just culture and adverse event reporting": "In recognition of human factors and previously discussed systemic deficits that contribute to adverse events, safety experts advocate for a \u201cjust culture\u201d in health care organizations. The most important step in creating a safe culture is the establishment of justice. In a \u201cjust\u201d culture, a term coined by David Marx, a system of shared accountability exists where an organization is responsible for safe system and process design, and employees are responsible for safe choices and behaviors. Rather than operating in a \u201cblame and shame\u201d environment, where employees feel frightened of reporting safety concerns and human error, in a just culture employees trust the leaders to respond fairly to employee concerns and behaviors. In turn, leaders act when human error is anticipated by establishing system-level solutions to support employee operations and prevent adverse events. Employees are expected to make safe choices and utilize the tools and processes implemented by leaders. In this collaborative environment, maximum safety can be achieved. Employee reporting is critical to achieving maximum safety. Using an iceberg to illustrate this importance, EMS leaders are aware of only the tip of the iceberg when it comes to safety challenges in EMS systems, while field providers are aware of the ice beneath the surface. To encourage adverse event and near-miss reporting, several steps can be taken as an EMS agency develops a safety culture. The use of anonymous adverse event report systems has been successful in demonstrating the commitment of leaders to developing trust with employees. By not identifying those who report, the perceived threat of punitive action is removed. Reporting must be made easy to do. The use of complex, password-protected reporting tools using mandatory data fields often results in non-compliance due to perceived hassle or time required to report. Each report of an adverse event or near miss should feature a \u201cclosed loop\u201d where the person who reported the concern receives a synopsis of investigations and actions taken to establish system-level improvements. This will reinforce reporting behavior and lead to grassroots support of the reporting system. Praise those who come forward. It takes remarkable courage to admit error, especially in the EMS environment. Highlight staff who come forward as being exceptional, professional, brave, and caring. Fostering a just culture will encourage reporting, but processes must be in place to make sure that reports do not get ignored. A safety management system, described later in this chapter, features processes that facilitate reporting, trigger key actions that mitigate harm, mandate the systems-level search for root causes that could be addressed, assign responsibility to follow up with stakeholders and implement safety solutions and feedback pathways to reinforce reporting and analyze the actions of individuals and the organization itself. Several successful adverse event tools have been implemented by various groups. For example, an online publicly accessible form is run by the State of Pennsylvania and the Center for Leadership, Innovation and Research in EMS operates the EMS Voluntary Event Notification Tool (EVENT) used by several agencies in both the US and Canada. A just system does not necessitate a blame-free system. Three levels of behavior can be considered in hierarchical fashion. 1 Human error: an inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake. 2 At-risk behavior: a behavioral choice that increases risk where risk is not recognized, or is mistakenly believed to be justified. 3 Reckless behavior: a behavioral choice to consciously disregard a substantial and unjustifiable risk. By carefully analyzing an adverse event, leadership can then select appropriate responses to the unsafe behavior. Such responses may be only to console, to provide additional training or reminders, or, in the case of reckless behavior, to respond punitively. In a just culture, employee and leader responsibilities can reach a balance and striving for safety excellence becomes a shared vision of everyone in the organization.",
        "Evaluating organizational safety culture": "Given the difficulty with detecting and quantifying adverse events, there is great interest and wide-scale acceptance for the measurement of workplace safety culture as a barometer of safety conditions in the health care workplace. Organizational (workplace) safety culture refers to the shared meaning, language and metaphors, rituals and convictions, beliefs, attitudes, behaviors, and norms adopted and displayed by workers regarding safety. Attention to and research of workplace safety culture originated in high-risk industries such as nuclear power, manufacturing, and aviation. Since 1980, more than 140 studies have been completed on workplace safety culture in health care settings. The most commonly used tool for measuring safety culture is a survey of front-line workers. Multiple survey tools are available, including the Safety Attitudes Questionnaire (SAQ), the Agency for Healthcare Research and Quality safety culture survey, and others. Most tools assess multiple components of safety culture and provide a score to indicate positive or non-positive perceptions of safety. These scores are commonly used for benchmarking purposes and to evaluate the effect of a safety focused intervention. The SAQ is a frequently used tool that has been adapted for diverse settings, including the prehospital setting. Few studies have examined the safety culture of EMS organizations. The first known study showed that an adaptation to the SAQ, in the form of the EMS-SAQ, would provide reliable and valid data. A follow-up study deployed the EMS-SAQ to 61 diverse EMS agencies, exposed wide variation in safety culture scores across EMS agencies, and provided base-rate data for comparison/benchmarking purposes. A third study demonstrated a linkage between EMS-SAQ scores and safety outcomes, including injury, errors, adverse events, and safety-compromising behaviors. Related efforts demonstrate the utility of adapting other safety culture tools for application in the EMS setting. Higher, more positive safety culture scores have been linked to air medical EMS agencies, private free-standing EMS systems, smaller organizations with fewer employees (e.g. \u226450), and EMS organizations with fewer total patient contacts. Lower, or non-positive scores, have been linked to urban ground-based models, hospital-based systems, larger organizations with >101 employees, and agencies that amass >10,000 annual patient contacts. Administrators of EMS agencies may examine their safety culture and gather base-rate data for benchmarking by deploying the EMS-SAQ survey tool, available free to all.",
        "Changing organizational culture": "Change in workplace safety culture begins with and is sustained by upper management. The renowned father of patient safety, Dr Lucian Leape, emphasized the importance of the role of leadership in the following statement: \u201cOver and over again, we have observed process and quality improvement efforts implemented but ultimately fail because the CEO did not lend support to the initiatives.\u201d Whether recognized or not, our leaders set the example for employees to follow. Their visibility or lack thereof, tone of message, communication or lack thereof, and commitment to safety infiltrate the workforce and affect behavior. Some key attributes of a positive safety culture and supportive leadership structure include: safety as a core value and philosophy of the organization and leadership safety principles/assumptions known and adhered to by the workforce and proclaimed by leadership presence, operation, and support for an internal safety management system integrity to safety reporting and management and commitment from the leadership for safety improvement amnesty for reporting and a blame-free culture empowerment of safety leaders within the front-line workforce constant monitoring and improvement in safety. Change does not and cannot begin with front-line employees. Unfortunately, disconnects can exist between what leadership perceives as the workplace safety culture and what the front-line workers perceive. Often times, leaders perceive a much higher (more positive) safety culture while workers perceive the culture to be much lower. This disconnect must be addressed and not ignored. High-level management must also decide that safety is a priority and that the time, resources, and commitment required to improve safety will be provided, or change will not occur.",
        "Safety management systems in EMS": "Safety management systems are formal, organized programs within or across high-reliability organizations. They must have written policies and procedures in place, prescribe responsibility, authority, accountability and expectations, ensure strong record keeping, encourage deliberate and early recognition of potential problems, and support quick intervention to address hazards and manage risk. The collection and analysis of data are used to support and advance safety goals and assure progress is being made. Audit/investigations are a component of assurance. While medical directors may not have control over all aspects of the safety of EMS operations, they can play a role in continual improvement and change management. Lastly, safety must be promoted throughout the organization through training, communication, and cultural integration. This starts by seeking out safety-focused qualities in job candidates, training staff in just culture, and socializing them into an organization that supports and in fact demands safe behavior. In some systems, medical directors will have a great deal of control over the design and day-to-day operations of a safety management system. Others will have only a small role. Regardless of the degree of control, medical directors can ensure that there is a data collection process so that all members of an organization can and do report adverse events and near misses. Further, medical directors can play a role in using these data to seek continuous improvements. The International Helicopter Safety Team\u2019s safety management system (SMS) toolkit lists the following methods of promoting safety. Publish a statement of the commitment of the leadership to the SMS. Leaders should demonstrate their commitment to SMS by example. Communicate the output of the SMS to all employees. Provide training for personnel commensurate with their level of responsibility. Define competency requirements for individuals in key positions. Document, review, and update training requirements. Share \u201clessons learned\u201d that promote improvement of the SMS. Have a safety feedback system with appropriate levels of confidentiality that promotes participation by all personnel in the identification of hazards. Implement a \u201cjust culture\u201d process that ensures fairness and open reporting in dealing with human error.",
        "The future of patient safety in EMS": "The past decade has seen patient safety become a focus of the EMS industry. Numerous national initiatives to improve patient safety in the EMS industry are under way. Several researchers from both paramedic and physician backgrounds have begun to build a solid body of knowledge and meaningful frameworks from which to drive further academic study. The EVENT anonymous reporting system has spread to include several jurisdictions in both Canada and the US. In addition to a plethora of literature about patient safety in other health care settings, a white paper entitled Patient Safety in EMS: Advancing and Aligning the Culture of Patient Safety in EMS was a large initiative published by the Canadian Patient Safety Institute in 2009. Following this, the National Highway Traffic Safety Administration launched a \u201cCulture of Safety\u201d initiative that describes the issue of patient safety in EMS as \u201can urgent problem of unknown scope\u201d and expands the issue of patient safety into that of public safety and provider safety. Indeed, the triad of patient, provider and the public are all at risk when ambulances crash en route to hospital. Commonly, both the Canadian and American strategy documents identify a lack of data-driven decision making as a major obstacle to improving safety in EMS, and addressing this will be a focus of the next decade. In addition to sound safety data systems, just culture, adverse event reporting, provider and leader education, safety standards and resources, and collaboration between organizations and regulators are priorities as EMS agencies seek to become highly reliable.",
        "Conclusion": "The EMS industry is fraught with challenges by the very nature of responding to emergencies in the field. Physical and emotional stressors can challenge providers in their technical skills, cognitive thinking, and communication tasks. Several latent environmental and system factors exist that make EMS scenes ripe with opportunity for adverse events to occur, and the system of care involves several organizations that do not share common leadership or culture. This fragmented characteristic of EMS delivery requires extensive collaboration amongst many agencies to identify potential system attributes that can lead to adverse events, recognize adverse events through front-line staff engagement, create a just culture, and employ safety management systems to engineer and implement solutions that can prevent adverse events from occurring. Through collaboration and the fostering of a just culture, data-driven decisions will allow EMS agencies to achieve higher reliability and offer the safest care to the patients they serve."
    },
    {
        "Introduction": "Hazardous materials can be classified as chemical, radiological, or biological agents that can cause human illness when contacted. The basic physical and chemical properties of a hazardous material determine the manner in which victims/patients are exposed, the degree of morbidity and mortality associated with a given \u201chazmat\u201d event, the type of decontamination necessary, and the type of personal protective equipment (PPE) required in the response. Each hazardous material has a unique set of chemical properties. Here we will discuss the chemical properties of a hazardous material that can be used to place it into a group allowing assessment of the potential for contamination, the extent of exposure, the decontamination process, and type of PPE required. One of the best examples of how the chemical properties of a substance can affect a hazmat response can be seen in the \u201csarin gas\u201d attacks which occurred in Japan. On June 27, 1994 in Matsumoto, a Japanese terrorist released sarin gas, producing symptoms consistent with a cholinergic syndrome in approximately 600 individuals over a few hours. Over that time period, eight of the 53 prehospital responders developed symptoms of sarin exposure and one of those responders required hospitalization for treatment. Similarly, 11 of the 18 physicians caring for these patients in one emergency department developed symptoms, six of whom required treatment after exposure to contaminated patients alone. In Tokyo, Japan, on March 20, 1995, a terrorist released sarin into five subway cars on three separate rail lines. As a result, 11 commuters were killed and over 5,000 patients required emergency medical evaluation. Again, victims quickly developed symptoms of cholinergic agent exposure and 640 victims arrived at the closest hospital (St Luke's International Hospital) over just a few hours. Although unable to fully decontaminate all who arrived, simple measures taken (removal of clothing, optimization of ventilation in patient waiting areas, and frequent rotation of staff through waiting areas) resulted in limited exposure of medical staff. No staff required treatment for toxic exposures. Of note, several other hospitals reported staff members who required treatment for exposure to sarin (25 of 39 prehospital providers required treatment at one facility).",
        "Types of contamination": "In order to understand the effect of chemical properties on hazardous materials response, we must first differentiate between exposure and contamination and discuss the types of contamination that can occur. When an object or individual is exposed to or comes into contact with a hazardous material, that object or individual may or may not become contaminated with the substance. Contamination occurs when the hazardous substance is physically transferred from the source to an object or individual. Primary contamination occurs when an object or individual comes into direct contact with a hazardous material in such a manner that the material is transferred from the source and is physically on the object or individual. This type of contamination is most common in victims at the hazmat site, as well as first responders including police, fire, and EMS personnel. Secondary contamination occurs when an object or individual comes into contact with a contaminated object. The hazardous material on the object may then be transferred to the clean object or individual, resulting in secondary contamination. Secondary contamination is the most common manner in which health care workers, such as emergency department staff receiving patients from the field, become contaminated after the release of a hazardous material. Contamination may be best understood through the example of a child with dirty hands. A child gets out of the bath and is clean (non-contaminated). The child goes out to play in the yard, finding a mud puddle (the contaminant). After playing in the mud, the child has mud all over his hands (primary contamination). The child then goes inside and pets the dog, leaving dirty handprints on the dog (secondary contamination). The child washes his hands (decontamination) and no longer has any evidence of playing in the dirt. The child\u2019s father later arrives home and gives his perfect child a hug. He pets the dog and notes dirt on his hands (secondary contamination). The father looks at his dog and asks, \u201cHave you been rolling in the mud again?\u201d Both primary and secondary contamination may occur in an overt or covert manner.\n\nOvert exposure occurs when something is obviously contaminated or exposure is known. Overt exposures may become obvious when a material causes rapid onset of symptoms, or the material is a large liquid or solid that can easily be identified. Both of the examples above (the release of sarin and the child with muddy hands) illustrate overt exposures. The release of sarin gas (actually a liquid vapor) may be too small to detect visually but the rapid onset of symptoms allows for early identification of contamination. The dirt on the child\u2019s hands illustrates a material that can be visually identified despite the distance in both time and space from the scene.\n\nCovert exposure occurs when an object or individual does not have obvious contamination or does not immediately know that he or she has been contaminated. Covert exposure may occur when the hazardous material is associated with delayed onset of symptoms or a hazardous material is too small to see. Biological agents are commonly associated with covert exposure. As illustrated in the example below, biological agents not only are too small to see but also have an incubation period in which exposed individuals are not aware that they have been exposed.\n\nIn the fall of 2001, envelopes filled with spores of Bacillus anthracis were mailed via the United States postal services to multiple locations. Individuals inhaled these microscopic spores when they were released from the envelopes during the mail sorting processing, delivery of the envelopes, or opening of the envelopes. Initially, ten patients became ill with symptoms of inhalational anthrax and four died. None of these individuals were aware that they had been exposed. As awareness of the anthrax attacks spread, early recognizing aggressive medical management, and prophylactic treatment resulted in only six deaths in the 22 individuals known to have become ill.\n\nAn understanding of the types of contamination allows first responders to be aware of the potential for contamination and protect themselves and others. Only with vigilance can we control or mitigate secondary contamination. Mitigation is critical and can prevent a small incident from becoming a mass casualty incident or true disaster.",
        "Biological": "Biological agents include bacteria, viruses, and biological toxins. Biological events are unique in that the release of biological hazards is almost always covert. Because of this, contaminated patients will likely have already performed decontamination at home without knowledge that contamination has occurred, having returned home, changed clothes, and showered as part of their normal daily routine. For most exposures this will be sufficient, and no further decontamination is necessary. There have been instances in which exposure to a suspected biological agent has occurred in an overt fashion, such as the anthrax scare events that occurred in the wake of the 2001 anthrax attack. When exposure to a biological agent is suspected, exposed and/or contaminated individuals may be instructed to wash their hands and face in a bathroom, return home, change and wash clothes, shower, and then wash surfaces they have contacted since the time of the exposure. Biological hazmat incidents are unique in that responders must consider prophylactic treatment of the biological exposure based on the agent involved. Consultation with the local or state health department should occur when considering such measures.",
        "Radiation/nuclear": "Ionizing radiation is an energized particle (alpha particle, beta particle) or wave (x-ray, gamma ray) released from a nuclear or radioactive material, capable of breaking covalent bonds. Ionizing radiation can cause illness when the covalent bonds of DNA and other molecules vital to cellular function are damaged. Through this mechanism, ionizing radiation can cause an acute radiation syndrome or local tissue damage at the site of exposure. Each type of radioactive material will produce a specific particle or wave. These particles or waves have unique physical properties that affect the ability of the particles to travel through material and cause tissue injury. The type of ionizing radiation encountered will not only determine the injury and illness encountered but also affect the type of PPE required to protect responders. Nuclear and radiation incidents are frequently separated as the distinction helps to highlight the difference between management of the two types of events. Exposure to radiation alone does not result in contamination but can cause significant tissue damage. Nuclear events, however, can result in the release of radiation as well as the release of radioactive and nuclear particles with the potential to cause contamination and radiation-related injury. Therefore, decontamination and PPE are not necessary when caring for patients who have simply been exposed to radiation. On the other hand, radioactive or nuclear material can cause contamination and will require decontamination. Finally, contamination with radioactive material does not represent an acute medical emergency. Exposure to radiation can cause both acute radiation sickness as well as local tissue damage but the onset to symptoms is delayed. Therefore, although it is important to remove the nuclear material as soon as possible, stabilizing medical care, including surgical procedures for repair of traumatic injury, should not be delayed for complete decontamination.",
        "General categories of hazardous materials": "One common method used to group hazardous material incidents is by the category of material involved: chemical, biological, radiological, and nuclear (CBRN \u2013 note that E for Explosives is sometimes added to this acronym in the context of weapons of mass destruction). Each category has unique characteristics and requires a different approach to decontamination. Knowledge of the categories will aid in understanding the expected patient presentation and type of decontamination required.",
        "Chemical": "Exposure to a chemical hazard is generally overt; patients are immediately aware of their contamination. Most who are contaminated by chemicals will require formal decontamination. The morbidity associated with the event will depend on the physical properties of the chemical encountered.",
        "Basic properties of hazardous materials": "The physical properties of a hazardous material will affect the type of contamination (primary/secondary), exposure (overt/covert), degree of morbidity associated with an incident, and decontamination procedures/PPE necessary in the response to an incident. The most important chemical property of any substance is its state of matter (solid, liquid, or gas) at ambient temperature. Solids in general will be the least likely to cause widespread contamination and require less complicated decontamination procedures and a lower level of PPE, while vapors and gases will have the greatest potential to cause increased morbidity and require the higher levels of PPE. Solids occupy a fixed volume and shape. Large solids are less likely to cause contamination as they are easy to detect and more difficult to move. However, small solids such as dust particles may be easily transferred from a single source to another object or individual and result in both primary and secondary contamination in an overt or covert manner. The explosion of a \u201cdirty bomb\u201d illustrates contamination with a solid hazardous material. Detonation of a device constructed with TNT and a small amount of radioactive U234, a radioactive solid, could result in blast injuries from the explosion and contamination with U234. Small particles can cause primary contamination of anyone in the immediate vicinity of the explosion, and could be transferred to first responders, resulting in secondary contamination. Decontamination should therefore be aimed at removing the solid particles (picking or wiping them off). When responders encounter a solid hazardous material, they may make several assumptions based on this physical state. In general, Level D PPE with a simple particulate face mask is sufficient to protect responders from secondary contamination. Decontamination requires only removal of the solid. Washing with soap and water may be required to remove very small particles of a solid contaminant. It should be noted that solid aerosols (such as the anthrax spores that aerosolized when the contaminated envelopes were opened in the 2001 anthrax attacks), although solids, will not follow these general rules. The most important physical property of a solid is its melting point or the temperature at which the solid becomes a liquid. Liquids occupy a fixed volume but not a fixed shape. Because of this, liquids can flow, are more likely to cause contamination, and may be more difficult to detect and contain. The volume of liquid will affect the ease with which it can cause primary and secondary contamination. Large volumes of liquids are easier to detect but harder to avoid, while small volumes of liquids will be harder to detect and more likely to be aerosolized (as in the sarin example above). When responders encounter a liquid hazardous material, they may make several assumptions based on this physical state. In general, Level C PPE is sufficient to protect responders from secondary contamination with liquid hazardous materials. Level C PPE includes a splash-resistant suit that will protect against most liquids. Decontamination of victims/patients exposed to a liquid will likely require washing with soap and water. The amount of washing will depend in large part on the water solubility of the material as well as the corrosive properties of the material. Liquid hazardous materials can be absorbed through the skin or mucous membranes, making decontamination critical. It should be noted that liquid aerosols, although liquids, will not follow these general rules. The most important physical property of a liquid is its boiling point, or the temperature at which the liquid becomes a gas. Gases do not occupy a fixed volume or a fixed shape. Because of this, they are difficult to both detect and contain. However, in general, a gas will not cause contamination but rather only result in symptoms of exposure to the gas. The exception to this general rule is the absorption of a gas by a liquid or porous material (clothing). That material may then become contaminated and result in secondary exposure when that material \u201coff-gases\u201d or releases the gas. Off-gassing will occur when the contaminated material moves to an area in which the concentration of the gas is lower than the initial environment. Because gases do not occupy a fixed volume or space and can be easily compressed, what may appear to be a small release may quickly become a widespread event, impossible to contain. Carbon monoxide (CO) is one of the most commonly encountered hazardous gasses. When decontaminating a patient exposed to CO, responders must only remove the patient from the area of contamination. No further decontamination is necessary. Clothing may absorb CO and off-gassing will occur; however, the amount of CO released will be quickly reduced to a non-toxic concentration in open air. When responders encounter a gaseous hazardous material, they may make several assumptions based on this physical state. In general, Level A or B PPE is required to protect responders from exposure to the hazardous material. Decontamination of victims/patients exposed to a gas generally requires only removal of the victim from the source followed by removal of any material that may result in off-gassing (taking their clothes off). Further decontamination using soap and water or other decontamination material is generally not necessary. Gaseous hazardous materials are inhaled and may be absorbed through the skin or mucous membranes. As such, even after appropriate decontamination, the victim/patient may continue to be exposed to the hazardous material and experience adverse effects of the material in a delayed manner. The most important physical property of a gas is its density relative to ambient air. This will determine its tendency to either disperse or settle in low-lying areas. Aerosols are very small solid or liquid particles which when released into the air remain suspended for a period of time, and thus behave like a gas. The amount of time these particles remain in the air is dependent on the mass of the material. Larger particles such as droplets may only stay suspended for seconds, while smaller particles can stay suspended for hours. Aerosols are extremely common and the ability of a solid or liquid to aerosolize makes that material much more dangerous. When aerosolized, toxicants are harder to contain, more difficult to detect, and have an increased potential to reach a human mucosal surface (eyes, mouth, lungs, etc.) that would not otherwise contact the material. Several examples of aerosolized solids and liquids are illustrated below. Smoke is a classic example of an aerosolized solid. One might assume that smoke is a cloud of gas. However, the majority of the material visible is a solid aerosol of particles (soot). This soot or partially combusted solid is black in color and due to its small mass, easily becomes aerosolized and may stay suspended for days. Water is the most commonly encountered aerosolized liquid. Everyone has encountered mist, fog, or clouds which are common names given to aerosolized water. Any liquid can become aerosolized, resulting in a \u201ccloud\u201d of toxic material, which is impossible to contain, with increased potential to contaminate and cause illness. One of the most devastating examples of aerosolization of a liquid used in a terrorist attack was illustrated in the Japan sarin incident. When responders encounter an aerosol, they may make several assumptions based on this physical state. In general, these types of hazmat events are the most dangerous and have the greatest potential to result in morbidity. As such, responders should assume that Level A PPE is required to protect them from exposure. If the solid or liquid is not absorbed through the skin, Level B or C PPE with a \u201cclean\u201d air supply may be sufficient. Decontamination of aerosolized liquids or solids will likely require removal of the victim from the source and full decontamination using soap and water or other decontamination materials.",
        "General chemical properties of hazardous materials": "The solubility and the acid/base characteristics of a hazardous material are chemical properties that will determine, to a large extent, the degree of morbidity associated with an incident, as well as the type of decontamination necessary and the type of personal protective equipment (PPE) required in the response.",
        "Solubility": "The solubility of a hazardous material is the ability of that substance (the solute) to dissolve in another (the solvent). The solubility of any material is determined by the molecular polarity of the solute relative to the polarity of the solvent. A polar molecule is one that has a negatively charged end and a positively charged end. A non-polar molecule is one that has no relative charge associated with the molecule. A particular material is soluble in another substance when both substances are either polar or non-polar. Simply stated, Like dissolves like. In most cases we are concerned with the ability of the hazardous material to dissolve in water (water soluble) or lipid (non-water soluble).\n\nThe solubility of hazardous materials will determine both the ability of material to be absorbed through the skin and the type of decontamination procedures necessary for an individual material. Because skin is made of cell walls with a lipid bilayer, water-soluble molecules are less likely to be absorbed through the skin. Indeed, skin breakdown is required for polar hazardous materials to cause systemic illness when absorbed through the skin. As a result, polar hazardous materials are associated with a decreased risk of significant exposure when skin contamination occurs. It should be noted that the opposite is true of the mucous membranes. Due to the high water content in these regions, water-soluble materials will be easily absorbed through mucous membranes and appropriate precautions must be taken. Alternatively, absorption of a lipid-soluble material across the skin may occur quickly without any evidence of skin breakdown and result in significant systemic illness despite a seemingly mild exposure.\n\nBecause water is the most common solvent used in the decontamination process, the water solubility of a substance is critical to determine the type of decontamination required for an individual hazardous material. Water, a polar molecule, will dissolve any other polar molecule or water-soluble molecule. Because of this, when performing decontamination of those contaminated with an isolated polar molecule, use of water alone may be sufficient. Water alone, however, will be unable to dissolve a non-polar or non-water-soluble hazardous material. These molecules will require an emulsifiant to be used in the decontamination process. The most commonly used emulsifiant is soap. Soap has a polar head and non-polar or uncharged tail. The non-polar tails of soap surround the non-polar (non-water-soluble) molecule such that the only exposed part of the solute is the charged heads of the soap molecule. Water can then bind to the polar end of the soap molecules, making the non-water-soluble molecules water soluble. These complexes are referred to as micelles.",
        "Acids and bases": "Caustic substances (acids or bases) are commonly encountered hazardous materials. These chemicals are discussed in detail in Volume 1, Chapter 46. However, it should be noted that the pH of an individual material might help in its early identification. Acids and bases also cause rapid onset of symptoms and therefore exposure is more likely to be detected early. Finally, if a hazardous material acts as an acid or base, that characteristic will determine the end point of decontamination as victims should be washed with copious amounts of water until their skin pH is again neutral.",
        "Identifying basic properties of hazardous materials": "Several resources are available to assist responders in the identification of the chemical properties of hazardous materials. Toxicologists, clinical pharmacists, and poison information specialists are available for consultation through the US poison control center system. Poison Control can be accessed 24 hours a day, 7 days a week by calling 1-800-222-1222. Additional resources are available in hard copy, electronic copy, and as mobile applications for multiple operations systems. These resources can be found at the web addresses listed below. ",
        "Conclusion": "Hazardous materials may be solids, liquids, or gases. The state of the hazardous material will affect both the ease with which the material can be spread and the measures necessary to remove it. Both solids and liquids can be aerosolized. Aerosolized materials are more difficult to contain than their non-aerosolized counterparts and may result in widespread contamination. When performing decontamination, responders must consider not only the state of the hazardous material but also its water solubility. Water may be used to decontaminate water-soluble toxins, while soap and water may be necessary to decontaminate those exposed to non-water-soluble materials. Providers should maintain a high level of situational awareness and consider the potential for hazardous materials exposure when responding to any incident. Through a basic knowledge of the chemical properties of a hazardous material, and their effect on contamination and exposure, providers will be better able to make an initial assessment of the risk of secondary contamination, the minimum level of PPE necessary, and the decontamination procedures required. However, responders should also remember that each hazardous material will behave in a unique manner based on its individual chemical characteristics. Because of the wide variety of substances encountered and the potential for injury or loss of life, responders should consider consultation with a qualified clinical toxicologist, hazmat response expert, or others with advanced training to ensure a safe and successful response."
    },
    {
        "Introduction": "Public Law 93-154, the EMS Act of 1973, facilitated a sea change in the organization and delivery of EMS, including its communications system. Communications were identified as one of 15 critical components of a modern EMS system. Prior to that, in the era of EMS as horizontal taxicab, telephone access to the local ambulance base was the most sophisticated part of the communications system. Ambulance attendants in the field had little need to talk to a doctor in the hospital and an approaching siren was the only clue for emergency room staff that a patient was on the way in. The EMS Act not only caused the role of radio communications in EMS operations to be defined for access, dispatch, and medical oversight and coordination, but brought significant grant funding to, among other developments, putting VHF and UHF radios in ambulances. The former enabled communications between dispatchers and ambulance crews and between EMTs and hospital staff for arrival notification and medical direction. The latter were the core of systems to send biotelemetry (ECGs) from the field to the hospital in ALS systems.\n\nThe development of the EMS communications system has not significantly progressed since that time. The communications capabilities and practices of the 1970s are, for the most part, reflected in most EMS operations today. While cell phones have found their way into most ambulances, 12-lead ECG transmission has taken the place of earlier three-lead systems, and trunked communications systems have improved public safety systems in general, narrowband voice communications still rule the roost. While the average teenager's smartphone has more broadband data communications capability than the average EMS provider's communication system, that is beginning to change.\n\nThe National EMS Information System (NEMSIS), electronic patient care report (PCR) systems, and the concept of the longitudinal electronic health record available to the EMS provider in the field have begun our transition to data communications. Integrated computer-aided dispatch (CAD) and emergency medical dispatch (EMD) systems enable data communications to match resources to needs and to manage resources with increasing situational awareness.\n\nIn 2012, President Obama signed Public Law 112-96, the Middle Class Tax Relief and Job Creation Act. The law created the First Responder Network Authority, or FirstNet, and funded it to create a nationwide public safety broadband network. It will, in essence, be a wireless carrier like Verizon or AT&T but reserved for the use of public safety providers, including all types of EMS providers and acute care hospitals. It promises to have as much impact on EMS communications as did the EMS Act of 1973.\n\nThe topic of communications, taken broadly, encompasses all the ways EMS providers communicate among themselves, with the public they serve, and with other health professionals. It includes public education, data and information technology systems, protocols, and standard operating procedures. Recognizing that, and that most of these topics are covered in depth elsewhere in this text, this chapter focuses on information communications technology (ICT), the nuts and bolts underlying how we communicate now and how we will communicate in the future.",
        "The context of EMS information communications technology": "The 2006 Institute of Medicine report Emergency Medical Services at the Crossroads summarizes the issues facing emergency system leaders, and their patients. A notable recommendation suggested a regionalized, coordinated, and accountable emergency care system and the development of an EMS workforce that can improve the quality of care in the long term. A regional accountable emergency system would provide health service in a more integrated and broad delivery model in the vein of current efforts in community paramedicine and mobile integrated health care. The role is more one of unscheduled health service, of which true emergency responses are a subset.\n\nThe function of the regional accountable emergency system would be to deliver the right care to the right patient at the right time in the right setting, and then move that patient to the correct site for the next level of care needed.\n\nNow and into the future, the EMS system is an integrator of public safety and health care functions. Emergency providers interact with numerous organizations in the provision of unscheduled health services. Ideally, the communications system integrates the various delivery components into the smooth, seamless operation desired and expected by the public. The communication system for EMS must be designed to support these elements:\n- system readiness/access/demand management\n- dispatch\n- patient interaction and collaboration with medical oversight.",
        "System readiness/access/demand management": "The mission of the EMS system is to prevent injury and emergency illness and, where prevention fails, to reduce their consequences to the patient, family, and society. It does this by bringing the patient together with the appropriate type and level of care, generally following an unscheduled demand for service. The mission of the EMS communications system is to provide timely information to EMS system providers in the field and in the hospital to bring the patient and this care together.\n\nThe EMS communications system integrates the hardware and software components, service providers, and administrators to provide emergency medical care. An effective communication system uses hardware and software elements for routine daily operations, with flexibility and redundancy necessary for disasters and other special needs. The efficiency of the system for facilitating medical care must be measured locally, as each EMS provider has unique geography, medical service providers, and public expectations to consider in system design. Medical and administrative leadership is required from EMS system medical directors to prioritize those aspects of the communications system that promote optimal care.\n\nThe communication system sets the stage for high-quality patient care. A needs assessment should be performed on a regular basis, with objectives outlined for the various communication components. As new configurations of system access, dispatch, and medical communications become available, local EMS leaders can design smart radio systems to integrate medical and administrative roles. System status management and vehicle locator systems are other efficiency tools to facilitate medical care and allow administrative oversight.\n\nService providers must develop appropriate administrative information systems that maintain the service available for patient care. Administrative information on nuts-and-bolts issues of vehicle maintenance, equipment and supplies, personnel licensure and education, and facility upkeep are necessary. Human resource issues of due process, health surveillance, and employee recognition are other components of the management information system supporting direct medical care. Billing systems must be developed to address the compliance needs of the payers, especially the federal government which is the largest payer for health services.\n\nSome communities have developed models for broad inclusion of communication needs in the health system. A communication system with medical oversight can navigate patients to a broad range of services other than an ambulance ride to an emergency department. Community paramedicine and mobile integrated health care resources are increasingly integrated into the access/demand management system to help the health care system better match patient need to resources provided.\n\nCommunication leaders have been successful in providing universal access in America through the 9-1-1 system. Other countries have comparable access numbers. The enhanced 9-1-1 (or E9-1-1) system, activated from a landline, permits automatic caller location and phone number identification to be displayed at the dispatching site. This feature eliminates telephone queries about emergency location in many situations and offers assistance to those callers unable to communicate due to age or nature of injury. This identification can be automatically tied to a system status computer, which will then immediately display the closest available emergency responders.\n\nThe 9-1-1 system has created challenges in many communities. It has come to be used for almost any request for service from the public (anecdotal stories abound). Concurrently, demand for timely access to EMS has increased. Other three-digit numbers (e.g. 3-1-1 for government service questions and 5-1-1 for travel information) have evolved to aid this. Many systems now have over half of 9-1-1 calls originating from mobile phones. The use of mobile phones has defeated the automatic call location function, and new triangulation and global positioning system (GPS) technology for locating the cell phone position has been implemented over the past several years.\n\nPlanning recognizes that emergency dispatch centers must be able to receive demands for service from automatic notification systems from vehicles (OnStar\u00ae and others), homes (\u201cI\u2019ve fallen and I can\u2019t get up\u201d), medical monitoring devices, and smartphones (texted messages, video, and pictures) among a wide variety of communications devices.",
        "Dispatch": "The emergency medical dispatcher now has the role of call receiving, interrogation, determining response configuration and mode, and delivering any appropriate prearrival instructions to the caller. EMD protocols are now in place and verified to reduce use of \u201clights and siren\u201d response, decreasing the likelihood of vehicle accidents. Navigating patients to non-emergency resources, through a call center or other resource, is also an increasing role. Following the initial response, the dispatcher supports field operations with additional information regarding scene location, a complete description of the medical complaints, road conditions, potential hazards, special approaches, and simultaneous fire and police response. The dispatcher may designate which channel and hospital to use for direct medical oversight, and may also assist in linking field and hospital personnel.\n\nDispatchers must be knowledgeable about the entire emergency response system, and be able to access all necessary support resources. Any medical protocols used should be reviewed by medical oversight. Properly administered, EMD in metropolitan areas will shorten average response times for urgent patients, decrease unnecessary use of back-up resources, improve public perception of emergency services, and help minimize the inappropriate use of emergency resources.\n\nIdeally, one dispatch center should operate in an EMS system with trained emergency medical dispatchers. Central dispatch will usually save money, manpower, and equipment when compared to individual dispatch centers for each community. It will also minimize time delays in coordinating scene responses, particularly near jurisdictional borders. The dispatch center will coordinate activities among responding vehicles, including special rescue units, support services, police, fire, utilities, and tow vehicles. Without timely coordination and communication, the full life-saving potential of the system may not be realized.",
        "Patient interaction and collaboration with medical direction": "One of the hallmarks of early EMS development was the initiation of medical communications between trained field providers and direct medical oversight. This development allowed the delegation of complex medical tasks and equipment from a physician to the out-of-hospital scene. Direct medical oversight is best provided by experienced physicians who are immediately available for medical guidance of field personnel.\n\nIt is the responsibility of the state or regional EMS authority to determine system configuration to provide the communication pathway from EMT to medical oversight. The system will be configured with consideration of the number of receiving hospitals and field units requiring communication channels. Direct medical oversight may be provided by a single resource hospital \u201cbase station.\u201d When the EMS system uses a non-receiving base station for direct medical oversight, it may become the responsibility of the base station to notify the receiving facility of the emergency situation, the patient\u2019s condition and estimated time of arrival, the treatment, and other pertinent medical data that will make the receiving facility better able to respond.\n\nDirect medical oversight communications between physician and provider may be by telephone (landline or mobile), radio, or combinations of the two. Selection of equipment for hospital-to-ambulance communications must take into consideration transmission interference and distances. The next generation of direct medical oversight communications will allow multimedia exchange between field personnel and physicians, with immediate and simultaneous audio, video, and biodata exchange.\n\nSystem leaders now have opportunities to implement video-recording technologies to link information from the emergency scene to later care. ED personnel found great value in this photographic addition to the PCR. The availability of the FirstNet broadband system will enable enhanced real-time video applications. Telemedicine communications between field providers and the medical director are most likely to benefit community paramedicine and rural emergency medical providers.\n\nWith data communications in our near future, the information exchange between field providers and the medical director may be very different and more effective. Today, this exchange is voice based, with perhaps some biotelemetry data integrated on a separate device. This requires two parties to be present and focused on either end of a radio or phone system at the same time to exchange that information. In the sometimes chaotic environments of an emergency scene and the emergency department, this does not always work well. In the future, the value of \u201cpushing,\u201d \u201cparking,\u201d and \u201cpulling\u201d information on an as-needed basis will become more recognized. For example, a medic could activate a miniature head camera, speak her basic patient findings and requested treatment plan into a speech recognition application through a throat microphone, while attaching a small multi-vital signs monitor on the patient\u2019s chest and inserting the patient\u2019s health record chip into her smartphone. Simultaneously, four data sets are populated and available to the medical oversight physician, incoming helicopter crew, and others. When the medical oversight physician is available, he can pull in these four sets of data, make a determination, and push out orders to be parked until the medic is ready for them.\n\nFuture EMS systems will continue to rely on voice communications but field personnel will access real-time information by connecting with information that is parked, and continually updated, in a database. Systems will allow acute \u201csituational awareness\u201d of events that can affect decisions about care and transport of patients, and of the resources available to us to best make those decisions. A \u201ccommon operating picture\u201d of an event, and the resources available to manage that event and the patient involved, will be shared by all personnel contributing to a patient\u2019s care regardless of their locations.\n\nCommunications with other medical personnel and legal documentation of the patient interaction are provided by the PCR. A variety of hardware devices, from hand-held devices to laptop computers, have been designed with software for prehospital use. The software can be designed for instantaneous transmission to the receiving hospital, integrated quality assurance, data collection, and linkage to digital cameras. ED providers value typed PCRs because they are legible and formatted consistently. There are software and hardware designs that package standing protocols, dosage calculators, medical references, and guides to other hazards. They can also be married to global positioning devices and mobile phones for further utility.",
        "Current system infrastructure and components": "The radio systems developed for EMS in the 1970s had communication \u201cpipes\u201d that would accommodate only voice traffic and minor data traffic such as biotelemetry. These \u201cpipes\u201d were called \u201cnarrowband\u201d because of this limitation. Until we became initiated in the need for data speed and bigger \u201cpipes\u201d to accommodate it, we didn\u2019t know that these small pipes were limitations. In the present age of high-speed wireless access by almost everyone, the ways in which EMS providers are dispatched, communicate with resources they require for response and patient care, and communicate with hospital staff are the same as they were in the early 1970s.\n\nAs a baseline for a later discussion on how we plan for improved communications with bigger, broadband, pipes, let\u2019s look at the common infrastructure components of current systems.",
        "Land mobile radio systems": "Land mobile radio systems (LMRS) in the EMS context include the traditional VHF and UHF dispatch-to-vehicle (mobile and portable radios), vehicle-to-vehicle, vehicle-to-hospital, and hospital-to-hospital (and other facility) communications. They also include evolving 700MHz and 800MHz trunked radio systems in which EMS agencies have increasingly participated. System hardware requirements will be specific to the area's geography, budget, and communication goals. In all systems, redundancy and flexibility should be engineered and available.\n\nThe standard for public safety communications has, as we have experienced with cell phone technology, evolved from analog to digital technology. This means that voice \u201csounds\u201d are encoded in the sending radio into packets of data, sent as data packets, and then decoded back into \u201csounds\u201d at the receiving radio. In essence, then, all communications in the future will be data communications, whether voice, video (which is also encoded and decoded), or data files and messages as we more typically think of them. As with cellular technology, the practical effect is cleaner transmission with less distortion; calls suddenly \u201cdrop\u201d rather than fade away as they used to.",
        "VHF radio systems": "VHF communications formed one of two LMRS foundations for EMS communications in the 1970s and today. Frequencies 155.340, 155.400, and 155.175MHz were traditionally used for ambulance-to-hospital or administrative/dispatch use. Frequency 155.280MHz was initially intended for hospital-to-hospital use but has generally fallen to other uses as that functionality was never well evolved in most locations. Ironically, some post-9/11 efforts to establish facility-to-facility communications links have ignored this capability, or have found it to now be otherwise employed. With the longest range of the frequencies typically used for EMS, VHF is still the predominant choice in frontier, rural, and suburban EMS systems. Range also depends on power output of individual radios, antenna height, and any fixed or mobile repeaters used to bounce signals forward. Some public safety licensed frequencies do not allow repeaters in the VHF band. This regulation results in some range limitations in rural areas.\n\nServices opting into newer 700 and 800MHz systems, or which use EMS UHF systems, are wise to maintain VHF capabilities for redundancy. VHF radio systems are \u201csimplex\u201d which means messages can be sent only one way at a time (\u201cyou talk, then I talk\u201d).",
        "UHF radio systems": "The other 1970s communications foundation for EMS was UHF, primarily the ten \u201cMED\u201d channels used for ambulance-to-hospital voice and biotelemetry (ECG only), and for regional frequency coordination. These paired frequencies in the 463 and 468MHz ranges allow two-way or duplex conversations. Licensees are authorized to use all ten channels and, although these frequencies usually do not have the range of VHF frequencies, they can penetrate buildings better. Mobile and fixed repeaters and microwave systems may be used to extend range and/or to create redundant regional communications loops (e.g. if one tower fails, signals can travel \u201cbackwards\u201d around the loop and still be received on the other side).\n\nIn both VHF and UHF radio systems, many EMS agencies have installed some type of tone-coded squelch system to minimize monitoring of medical communications by unrelated agencies. Tone-coded squelch or \u201cprivate line\u201d (PL) systems can prevent other agencies from hearing radio transmissions, but they do not prevent other transmissions on the same frequencies from interfering with or blocking messages.",
        "700 MHz and 800 MHz public safety trunked systems": "The Federal Communications Commission (FCC) has redesigned 800 MHz public safety radio frequencies (originally 821\u2013824 MHz and 866\u2013869 MHz) as 806\u2013809 MHz and 851\u2013854 MHz for use in public safety trunked radio systems. This was done to reduce interference with commercial wireless communications systems. The FCC has also allowed such systems in a narrow slice of spectrum in the 700MHz range, though this is less used for regional and state-wide systems than is 800 MHz. Trunked systems, which usually are computerized, allow more efficient use of frequencies because the computer automatically searches for an open frequency when a call is made. Thus the caller is not required to select a frequency manually each time, helping to prevent radio frequency congestion and interference. Trunking is currently allowed in the 700 and 800 MHz frequencies used by public safety and EMS.\n\nA major drawback to 800 MHz radio systems for rural areas is the limited range of these frequencies. Many more tower-based antennas are usually needed to cover a given geographic area than would be required with lower band frequencies, which can significantly increase the cost of providing 800 MHz radio systems in rural areas. Another challenge is posed by 800 MHz systems in that vehicle repeaters are not allowed, so EMS responders who need communications while caring for patients inside homes or other settings away from the ambulance may not be able to access the closest tower.",
        "Telephone and cellular telephone systems": "Emergency medical services providers often use standard telephone service from patient homes and other sites. While limited in obvious ways, such communications offer superior protection of information being transmitted.\n\nCellular telephone use in EMS has become commonplace, largely because of the greater latitude it provides in conversations involving patient identification and other confidential information. In addition, the ability of smartphones to not only provide voice communication but to take and send photographs and other data files and to access the internet makes them more powerful tools. Other advantages of cell phones for EMS communications include the provision of an alternative means of communicating in some radio dead spot areas, ease of use, easy access to conventional telephone systems, and duplex voice capabilities. Disadvantages of cellular systems include that they often become overloaded or otherwise unreliable during disaster situations and, in multiunit or multiagency responses, one-to-many transmissions cannot happen as they can with radios. Taking into account these limitations, cellular telephones can provide a good supplement to EMS radio systems, but they should not be relied upon exclusively.\n\nAssuring priority phone use for emergency response agencies for both landline and cellular telephone systems is the job of the National Communications System (NCS), an agency of the US Department of Homeland Security (DHS). \u201cThe NCS offers a wide range of National Security and Emergency Preparedness (NS/EP) communications services that support qualifying Federal, State, local and tribal government, industry, and non-profit organization personnel in performing their NS/EP missions.\u201d Specifically, the NCS offers priority designations for governmental and other qualifying emergency response entities to enable them to access landline and wireless phone services ahead of other users during emergencies which limit access to such communications.\n\nAnother cell phone targeted technology is the Commercial Mobile Alerting System (CMAS), developed by the FCC and DHS in the past decade but only emerging in use after 2011. It enables public safety agencies at any level to broadcast Amber (child abduction) alerts, major emergency notifications, and presidential emergency declarations to display-capable cell phones. It can be targeted to all wireless cellular clients in a county level or larger geographic area (finer targeting is being developed). It has been rebranded by the Federal Emergency Management Agency, which operates it as the Wireless Emergency Alerts system.",
        "2.4 to 5.9 GHz systems and fiber-based connections": "Wireless \u201chotspot\u201d-based (\u201cmesh\u201d) systems are evolving rapidly in urban areas and along major highways. These offer the advantage of very robust broadband voice and data communications and the disadvantage of requiring virtually \u201cline of sight\u201d connection between the communications device (e.g. PDA, laptop) and the \u201chotspot\u201d connection to the communications system. This renders these systems prohibitively expensive outside urban areas or beyond devices at a single emergency scene. Municipalities are turning to unlicensed 2.4 GHz mesh systems to provide city-wide access to the internet on a free or \u201cpay-to-play\u201d basis. To support the cost of building out the necessary infrastructure, leaders propose using these systems for EMS and public safety communications applications. However, because it is an unlicensed system, it has open access to any user, which suggests potential interference, periodic and perhaps increasing frequency of data transfer speed slowdown, and security issues. Such systems may start up well but become impeded as general system use by the public increases.\n\nThe 4.9GHz band (4,940\u20134,990 MHz), on the other hand, is licensed strictly for public safety uses, including EMS. As such, applications for licenses are coordinated by a regional planning committee, and use is controlled. Users of this 50 MHz resource would enjoy all the advantages of the 2.4GHz system without the security and interference concerns.\n\nFiber-based infrastructure is increasingly finding its way into rural schools, libraries, health centers, and other such facilities, supported by FCC Universal Service Program funding. Fiber connections for telemedicine between large and small health care facilities are commonplace, and plugging hotspot connections along the length of that fiber can allow access by rural EMS providers.",
        "Land mobile satellite communications": "In sparsely populated, remote rural areas, providing EMS radio system coverage can be very expensive. Though generally expensive, land mobile satellite communications may provide a cost-effective alternative to terrestrial radio systems in rural areas. Several companies are now developing this technology. Some plan to use satellites in \u201cfixed\u201d geostationary orbits, while others plan to use multiple low-orbit satellites. These systems will use omnidirectional antennae, more compact than the traditional satellite dishes that must be pointed at a satellite in a fixed point in the sky.",
        "Future system infrastructure and components - Multiband radio and software-defined radio (SDR)": "Multiband radio and software-defined radio (SDR)\n\nThe contemporary ambulance, particularly post-9/11, often features multiple communications devices to provide redundancy and security in urban areas where radio frequencies may be saturated and in rural areas where \u201cdead spots\u201d make contact with dispatch, medical oversight, and other resources impossible. An urban/suburban ambulance equipped with UHF, 800 MHz, 4.9GHz and cell phone devices, and a rural ambulance similarly equipped though trading a satellite radio for the 700/800 MHz or 4.9 GHz device, could easily be imagined.\n\nMultiband radios have evolved in the past few years, allowing the user access to all public safety/EMS VHF, UHF, and 700/800 frequencies in one device. This requires that the user know and switch among the frequencies desired.\n\nIn the future, cognitive and/or software-defined radio will change this picture. First, radios will be equipped with the ability to \u201csniff\u201d radio channels to detect whether or not they are in use at the time that transmission is desired (cognitive radios). Second, they will be able to change the channel across multiple bands based on the use and strength of frequencies in the area where transmission is being attempted. The device of the future, then, will feature multiple channels of communications in one box and the EMT, in selecting to call \u201chospital A\u201d on that device, may have no idea at any moment which frequency the radio has selected to call that hospital (nor would the physician on the other end necessarily know how he or she was being called).\n\nTelemetry (e.g. capnography, ECG, pulse, blood pressure, oxygen saturation), video, and perhaps portable diagnostic studies that prove useful in the field and in community para-medicine applications. EMS applications to take advantage of this bandwidth are being studied by the EMS committee of the National Public Safety Telecommunications Council (NPSTC). As can be seen, 20 MHz of spectrum for broadband (10 MHz allocated to the Public Safety Spectrum Trust in 2007 and the 10 MHz \u201cD Block\u201d) have been turned over to FirstNet. There is also adjacent narrowband bandwidth for public safety use.",
        "FirstNet \u2013 the nationwide public safety broadband network": "The FCC created a major new communications resource for public safety in the 700MHz range when it allocated mixed narrowband and broadband spectrum for use by public safety. This spectrum became available for this purpose in 2009 when analog television broadcasters abandoned television channels in that spectrum to transition to digital broadcasting. However, the FCC\u2019s original plan to establish a public/private partnership for use of the broadband spectrum failed, creating national debate over use of the spectrum. Following a successful effort by national public safety associations to convince Congress and the White House that the spectrum should be given in total to public safety, Public Law 112-96 was signed into law in February 2012. An omnibus bill, it contained a section to:\n- dedicate the spectrum in question to public safety\n- fund $7 billion to build the network, and\n- create a governing body called the First Responder Network Authority (or \u201cFirstNet\u201d) Board with a public safety advisory committee to advise it. The current board has an EMS representative. This is important for EMS users who want to develop robust data communications capabilities to transmit multi-vital sign.\n\nThis is expected to create a nationwide broadband network, not unlike Verizon and AT&T, but dedicated to some 2\u20133 million users instead of tens of millions of users. The technology selected for FirstNet is LTE, which is the technology increasingly being selected by Verizon and other commercial wireless carriers for smart device use. While robust in its ability to speedily transport large amounts of data, it lacks some features common to current-day land mobile radio systems. It has no voice transmission inherent in it, so a \u201cvoice over LTE\u201d feature is evolving. It has no push to talk, one-to-many transmission capability, or ability to transmit directly from one device to another without hitting a tower and using the network. For all these reasons, the FirstNet network will emphasize its role in data transmission, and land mobile radio will continue to be the mission-critical voice carrier of choice for many years. FirstNet expects to have three approaches to cover the population.\n\n- A terrestrial network to cover the vast majority of public safety day-to-day needs. It will first attempt to use existing infrastructure of towers, fiber, microwave and other capabilities belonging to public safety, and other public and systems that provide effective, redundant, mission-critical voice private parties. Then it will build connections as necessary (and then) data communications. A system should assure three or four layers or types of voice redundancy (e.g. VHF, 700MHz, cellular, satellite) before it explores the development of video or advanced biotelemetry capabilities.\n\n- A satellite network to serve rural and frontier populations where terrestrial systems cannot be entirely relied upon.\n\n- Deployable systems, both land and air, to serve areas with occasional needs to serve temporary populations (e.g. festivals attracting thousands of people to an area that is in the woods, desert, or otherwise empty of people most of the year) or disasters.\n\nFirstNet will work with states, federal agencies, tribes, and local responders to develop radio access networks to link responders, hospitals, and others to \u201ccores\u201d or hubs in the nationwide network that supports data communications. In this way, a disaster medical assistance team setting up in an area many states away from home will simply turn on the devices they bring with them and begin communicating seamlessly with others at the event.",
        "Planning to transform current systems to future systems": "The US Department of Homeland Security\u2019s Office of Emergency Communications and its SafeCom program have developed useful conceptual diagrams to guide this planning. The first describes the transition from land mobile only systems, like those EMS has used for the past 40 years, to a system in which voice and data communications can be effectively and reliably assured.\n\nAssuring interoperability between EMS and others is a complex planning and coordination process that goes well beyond technology. In fact, the DHS diagram describing the evolutionary steps from a system with little interoperability to full interoperability focuses on five functions or processes, only one of which is technology. An immature system, represented by the left side of the chart, must develop capabilities moving toward the right side of the chart in each of those five areas if it is to take advantage of modern voice and data communications networks.",
        "Resources for communications planning": "State level\n\nAs technologies and frequency regulating requirements change, state EMS communications plans should be periodically updated. To help address this need, the National Association of State EMS Officials (NASEMSO) has developed a planning guide, Planning Emergency Medical Communications. One guide deals with planning at the state level and the other deals with planning at the local level. A NASEMSO Guide to EMS Information Communication Technology (ICT) Systems for EMS Officials has a comprehensive set of planning discussions and resources.\n\nEvery state should have a state-wide communications interoperability plan, generally coordinated by an official known as a state-wide interoperability coordinator. In addition, FirstNet requires that there be a single point of contact for public safety broadband network development. Contact your governor\u2019s office, chief information officer, or the DHS Office of Emergency Communications to track down these officials to learn more about planning in your state.\n\nNational level\n\nThe DHS Office of Emergency Communications and Office of Interoperability and Compatibility both have planning and development roles that affect your system. SafeCom is a group of national public safety and EMS associations who provide guidance to these offices. All three of these have a web presence and have valuable planning guidance available.\n\nNPSTC is an association of public safety associations with an interest in communications. It has been extremely valuable in representing public safety in matters before the FCC, as well as in developing standards and guidance for land mobile radio and the FirstNet network. It has an EMS committee that is active in conceptualizing applications for the FirstNet network. It has a web presence and sponsors the National Interoperability Information eXchange (NIIX) where a variety of planning tools may be found."
    },
    {
        "Introduction": "The phrase \u201cweapons of mass destruction\u201d was originally a military/political term for chemical, biological, or nuclear weapons intended for use in society-wide terrorization or destruction; the original term may have been used for chemical weapons delivered by aircraft. A weapon of mass destruction (WMD) itself can harm or kill large numbers of people, and potentially damage the environment or make it hazardous for humans or animals. While the definition is somewhat flexible, in general the assumption is that referring to something as a \u201cWMD event\u201d means that it was a deliberate and planned use of a powerful and dangerous material or device intended to cause large numbers of casualties and significant damage. Weapons of mass destruction were originally developed by governments and nations, in large part due to the expense and technical expertise required to research, create, and employ them. In recent decades, though, so-called \u201cnon-state actors\u201d have acquired, created, and employed WMDs in attacks on both humans and nature. The term non-state actor is generally understood to mean a political, social, religious, or other group not declared to be acting on behalf of a national government but to further a particular cause. The methods used by such groups may range from peaceful discussion and publicity, to non-violent civil disobedience, to targeted violence, to indiscriminate terrorist attacks. Since such groups are often not publicly organized or accessible, it is difficult to affect or dissuade them from courses of action in the ways that nation-states may be influenced, such as trade actions, diplomacy, blockade or other acts of war. This, along with some organizations\u2019 secrecy, may contribute to the apparent unpredictability of their actions. In effect, what they do may not fit with the rational worldview of many disaster planners. One of the early uses of WMDs by such a group was the Aum Shinrikyo attacks with sarin nerve agent in Matsumoto, Japan, in 1994, and on the Tokyo mass transit system in 1995. These two events resulted in thousands of casualties, including 11 deaths. Especially concerning, EMS responders were among the injured, potentially compromising the response. In large part, the rescuer casualties were due to lack of training or understanding of the scene threats posed by a WMD attack. In the years since then, several major attacks have been popularly accepted as WMD terrorist events. The anthrax letters mailed in the United States in 2001\u20132002 fit the classic definition of a WMD event in that they involved a biological weapon which caused some casualties and deaths and also compromised the environment and functioning of the US postal service. Other events such as the 9/11 New York attacks loom in the public mind as WMD terror, even though the weapons themselves were essentially explosives and incendiaries. Mass shooting events, such as the Columbine, Colorado, and Newtown, Connecticut, school shootings, and the 2011 Norway mass shooting tragedy, also share some of these characteristics. From the planning and response view, it is fair to approach all such major terror attacks as \u201cWMD events,\u201d in that they share certain characteristics which directly affect the EMS planning and response to them. While the remainder of this chapter will briefly address specific agents and the response to them, the approach will be more of a description of a general planning and response mindset. Other chapters in this book, and numerous other references, provide detailed information on treatment of specific entities such as chemical weapons (improvised hazardous materials, nerve agents, blister agents, choking agents, blood agents), biological weapons (anthrax, smallpox, tularemia, hemorrhagic fevers, toxins), radiological agents (powder, gas, or other forms of radioactive contamination), blast agents (explosives, whether commercial, military, or improvised), nuclear weapons (combining blast and radiological issues), and intentional trauma (typically by gunfire in these cases).",
        "Unique aspects of WMD": "There are several characteristics peculiar to WMD attacks (whether terroristic or military) that must be considered in preparing for an EMS response. Three particularly salient ones are intent, magnitude, and forensics. Training, planning, and drilling for a WMD response must incorporate means of facing all of these issues. Intent is used to mean that the perpetrators of a WMD attack want to cause casualties. This is not an accidental event or a complication of another emergency (such as a hazmat spill occurring due to a vehicle crash). The planners and executors of a WMD attack at minimum want to inflict some casualties, usually to draw attention to their cause. Often they may intend to inflict very large numbers of casualties, or do so in a particularly noteworthy way. EMS providers and hospitals are seen by society as help and succor; as a result, targeting them may be a very effective way of demoralizing a society. In addition, if the attackers wish to aggravate the effect of their attack, eliminating or crippling the medical response can multiply the number of casualties significantly. This puts EMS providers at high risk of attack in a WMD event, whether as part of the initial event or as targets of a \u201csecondary device.\u201d Picture, for example, the effect at the Boston Marathon of a delayed bomb going off as rescuers moved in to render aid. EMS physicians and providers must be trained and equipped to detect and survive initial attacks and avoid secondary attacks even as they do their jobs. As alluded to earlier, the sheer magnitude of a WMD event may be overwhelming. Casualty figures can easily rise into the hundreds or thousands, and there may be a significant penumbra of psychological casualties in addition to those physically injured by the event. The medical care systems may be quickly overloaded, and EMS providers may need to serve as the primary care personnel for long periods of time. In addition, hospital use and destination may be changed, especially in a longer-term biological event, and supplies may be strained due to the number of casualties, the duration of the event, or the unusual antidotes needed. To face these issues, an EMS system must have robust communications between its units, dispatchers, and destinations (typically hospitals). In addition, it is critical that EMS systems be aware of local, regional, state, and national plans for response that may affect their actions. If, for example, a locality has decided that all patients from a smallpox outbreak must be treated at Hospital A, EMS must know how to determine which patients are to be transported there. There may also be significant secondary loads on an EMS system due to the need to move hospital inpatients to other levels of care, such as skilled nursing facilities. In some biological WMD events, EMS may have an expanded role, such as providing community-level health screening, treatment, or vaccination. In preparation for all these eventualities, an EMS system\u2019s medical director and administrators must be part of local and regional planning, and either pre-train their personnel or be ready to implement just-in-time training when an event occurs. Communication networks must be established, tested, and robust, to allow for a complex and potentially lengthy response to be controlled. The forensic aspect of WMD events is less salient in the immediate response but since by definition this type of event is deliberate, there will be a criminal investigation. It is imperative that EMS providers (and other rescuers) take all care possible to not compromise such an investigation by inadvertent damage to evidence. In a WMD event, bodies themselves may be relevant evidence, and victims may include the perpetrators themselves. Investigative teams may be operating in unsecured scenes, and may need specific medical expertise or support to do their jobs. While the primary focus of an EMS system response to a WMD event is still patient care, it is useful to have preevent discussions and training with law enforcement on scene security, tactical EMS response, and interagency cooperation.",
        "Special requirements for WMD response": "Emergency medical services preparation for WMD response begins with the general training needed to respond to any mass casualty event, including principles of communication, triage, scene control, and destination choice. In addition, all EMS physicians and providers should be familiar with basic aspects of response to hazardous materials, and with basic principles of health maintenance and infection control (self-care, vaccination, universal or air-borne precautions). These skills form the bedrock for training to respond to a WMD attack. The next layer of training most likely should encompass how to operate in a complicated interagency environment, since that is what will be faced in a WMD response. Training should be required in local, regional, and state mass disaster response plans. Individuals\u2019 roles must be specified, even if the role is as simple as \u201cYou must come to work and will be assigned to an ambulance.\u201d Higher level administrators and system medical personnel (supervisors, medical directors, field physicians) may need further specialized training to be ready to serve as a resource in a WMD environment (e.g. how to dose specific antidotes or safely perform field amputations). Logistics and supply are critical to an effective and sustained response. In many cases a WMD event may require large quantities of otherwise rarely used materials, such as hundreds of tourniquets, thousands of doses of antidotes, or tens of thousands of doses of antibiotics. Part of an EMS system\u2019s preparation for a WMD event is to ensure access to supplies. Some resources may include local distributors, stockpiles at hospitals, or state or federal agency resources (such as the National Pharmaceutical Stockpile managed by the US Department of Health and Human Services). Much of the planning for this aspect of an event is similar to planning for natural or accidental mass casualty events, but the medical director must be aware of specialized resources such as large quantities of atropine for nerve agents, radiological antidotes, or mass trauma supplies. In some jurisdictions there may be issues with physician authority for controlled substance dispensing, storage, and use; it is imperative to sort out such issues ahead of time so that medications such as opiates and benzodiazepines are available to EMS units if needed. In addition to patient care supplies, EMS crews must be able to obtain personal protective equipment in adequate quantities to protect themselves when operating in a WMD environment. This aspect of planning requires that an agency know how its personnel are supposed to be deployed in such an event, and therefore must be discussed prior to an attack. Other logistics that must be planned for include staff needs, such as food, replacement clothing, and communications with family. In some circumstances an agency may need to provide for the physical needs of family members to allow the staff to function at full effectiveness. Coordination of response to a WMD event does not stop with the paper plan, of course. Full field drills, tabletop exercises, and skills maintenance are critical in maintaining an EMS system's readiness to respond to a WMD event. Personnel must, for example, know how to use autoinjectors if that is part of a response plan, but also know where they are stored and who to ask to get them. Since time may be critical in an actual response, \u201cmuscle memory\u201d is vital to quick and effective action. This means that training and drills should be as realistic as possible, so as to inculcate the proper \u201cautomatic\u201d responses in personnel. Local, regional, and state government agencies hold periodic exercises, and the federal government does so as well. It behooves an EMS medical director to be aware of such exercises in his or her area, and get local agencies involved. Due especially to the number of casualties that may result from a WMD attack (or a pandemic such as influenza), there has been national planning for using so-called \u201caltered standards of care\u201d in such situations. In addition, there is the possibility that jurisdictions or regional health systems may need to specifically direct patients to particular facilities in some WMD events, such as bringing victims to sites that have extensive decontamination capability or stockpiles of antidotes. While altered standards of care and alternative destinations may not be relevant for all WMD responses, agencies must be part of the planning so they can do what is expected in the response. Safe and effective response to a WMD event is the ultimate test of an EMS system. Personnel must be properly trained, directed, equipped, and led to save the most lives possible in a complex environment where they themselves may be targets, may be the only medical care available, or may notice peculiarities that lead to identification of perpetrators. Preparing for a WMD response requires more than just knowing how to treat specific clinical entities. It requires cooperation, communication, and coordination with all aspects of the emergency and governmental response to the attack. Medical directors and EMS physicians must play an active part in preparing for such a scenario."
    },
    {
        "Introduction": "Regionalization of emergency medical care has become the rule over the last few years. A complex process from a clinical and a political perspective, the desired result of these efforts is improved patient care in those areas addressed by these efforts. The Institute of Medicine in 2006 promoted regionalization as a means of improving patient outcomes and reducing costs. Indeed, regionalizing specialty referral centers improves patient outcomes. For example, solid evidence exists that regionalized systems of care for trauma patients significantly improve patient outcomes. Similarly, studies also demonstrate outcome improvements for victims of ST-elevation myocardial infarction (STEMI) patients in many systems. The design of the system is vital to its success, and that success is highly dependent upon the ability of the designers to examine the entire system of emergency patient care. The design of a regionalized system of care \u2013 across the spectrum of clinical presentations \u2013 must focus on every aspect of the patient\u2019s complex journey through the emergency medical care system, identify any \u201cweak links,\u201d and target these areas for improvement. The need for regionalization may not be fully understood by individuals who do not understand the intricacies of the entire emergency medical care system, even though many of them work within the system. Many tend to operate within organizational silos, and thus integrating their work with other providers must begin by breaking down system barriers",
        "The emergency medical care system": "The emergency medical care system in a nation is a broad network that encompasses the component EMS systems that make it up. The system encompasses the entire care pathway that the patient must traverse in the journey resulting from an out-of-hospital care activity, and all components of care of the EMS System Circle. The individual components of the emergency medical care system vary widely in their capabilities and responsibilities. For example, both ground and air response may be quite variable in clinical care abilities. Hospitals may vary significantly in their abilities to care for severely ill or injured patients. Patients often require a high level of care that is unavailable at a local level to optimize outcomes. The early identification and \u201ccare mapping\u201d for such patients form the basis of the need for an integrated, prospectively designed emergency medical care system through regionalization of medical care. EMS medical directors must be the leaders in bridging the many disciplines necessary for the creation and maintenance of a broad system, addressing actively the need to educate others on the entire spectrum necessary for system design and improvement. The importance of the EMS medical director in accepting this responsibility with a broad perspective cannot be overstated. Success in efforts to regionalize facilities through categorization and designation has varied historically, first noted some 30 years ago as a pressing public imperative. Only when all participants are committed to focus on the goal of improved patient care, across the spectrum of the variety of human clinical presentations, can the necessary system improvements begin to occur. It is useful to consider an example of a case that might occur in an emergency medical care system on any given day.",
        "A patient episode": "The emergency medical care system in a nation is a broad network that encompasses the component EMS systems that make it up. The system encompasses the entire care pathway that the patient must traverse in the journey resulting from an emergency. The dispatcher in a seven-digit public safety answering point (PSAP), with no 9-1-1 number available, receives a call for emergency medical help. The caller tells the dispatcher that a child is choking and turning blue. The dispatcher in this rural setting, not trained in giving prearrival instructions, replies, \u201cI'm sending someone right now!\u201d A first responder unit and a transport ambulance are quickly dispatched. A total of 12 minutes is required from the initiation of the call to the initiation of care. Upon arrival of the EMS providers, the child is pulseless and apneic. The initial resuscitative efforts return a weak pulse. The transport ambulance arrives, and after a 20-minute scene time, their protocol is to transport to the nearest facility. The transport interval is 15 minutes. The closest hospital facility is a low-volume ED that rarely cares for critically ill pediatric patients. Though the ED staff quickly gears up to provide the best care that they can, a lack of pediatric-specific equipment at the hospital delays definitive airway care and IV placement for the hypotensive, unresponsive child. A decision is made to transfer the child to a pediatric regional referral center. Elapsed time from arrival at this facility to the call for transfer is 40 minutes. The pediatric tertiary center insists on sending its own transport team for the child and a 1-hour response time ensues. This interval is followed by a 45-minute scene time at the local hospital and a 50-minute transport time back to the tertiary center. The child is admitted to the tertiary care center\u2019s pediatric intensive care unit, exhibits evidence of severe anoxic encephalopathy, and dies 3 weeks later. The EMS medical director for the local emergency medical care system (EMCS) reviews this case and initiates the formation of an oversight body to improve the system. Quality improvement processes occur and each entity, from the dispatch agency to the transport team, concludes that it did the best it could have done at the time in this setting. The initial conclusion was that the outcome in this case was unavoidable and most unfortunate. This assessment is of little solace to the child\u2019s family. They realized that it was 12 minutes from the time of their call for help before their child was ventilated. They saw that it took 4 hours to get their loved one to a tertiary care facility. And they felt that if the original ambulance had turned right toward the pediatric hospital 30 minutes away instead of left toward the local hospital \u2013 at one crucial intersection \u2013 maybe the outcome would have been different. How could regionalization have helped this child? The EMS medical director, looking at the entire spectrum of care provided to this patient, saw many areas for potential improvement that were then set before the oversight committee for consideration. The group saw that each component reflected individual \u201csilos\u201d that barely communicated. A process was initiated that examined every section and opportunity for care within the context of the whole system. Deficiencies were identified and proactive plans were made for maximizing that care on a regional basis, across the spectrum. The committee, led by the EMS medical director, set out to form a truly integrated emergency medical care system for the region.",
        "Definitions": "Regionalization is the formation of a coordinated system of care across a geographical area that combines all necessary components to optimize patient outcomes. This includes out-of-hospital components, in-hospital components, and public health components. The goal of the effort is both to facilitate the provision of quality patient care and to assure the overall economy of the system through utilizing appropriate resources within the region, coordinating overall care to focus on patient outcomes. Categorization is the classification of facility capabilities against accepted standards. Categorization should be initiated before formal facility designation occurs. Designation is the formal selection for patient referral and transfer by an organized body that has the authority to do so, typically both governmental as well as specialty designation bodies. A minimum set of standards exists for the various specialty designation areas that a facility must meet to become designated as a specialty receiving center. The time-critical diagnosis system is the concept that a coordinated, integrated emergency medical care system can use to treat those diagnoses that are truly time critical. Clear evidence demonstrates that severe trauma, acute ischemic stroke, and STEMI outcomes can be improved by specialty care at regional referral centers designated by an accrediting body. The time-critical diagnosis concept seeks to avoid the creation of three separate systems (stroke, trauma, and STEMI) within a state or region, since the individual components of the system (EMS, local and regional hospitals, and various bureaucratic and oversight entities) play essential roles for all of these clinical cases. It is far more appropriate and cost-effective to coordinate all the critical cases within the emergency medical care system under a common banner of time-critical diagnosis. This allows resource sharing and coordination at many different levels and decreases duplication. Once formed, the combined time-critical diagnosis body has a significantly more powerful position in the political arena than do individual efforts. Bypass is the decision to avoid transport of an out-of-hospital patient to a particular hospital facility when transport to a more distant facility will provide more optimal care. The decision to bypass the closer facility is made in the setting of clinical time-critical diagnosis cases in which care at the more distant facility \u2013 such as a stroke center, a STEMI center, a trauma center, a pediatric center \u2013 will most likely improve the patient\u2019s outcome. Diversion is an act taken by a hospital facility that informs field providers that transport to that facility should not occur. Diversion most commonly occurs when the patient traffic in the emergency department of that facility is of such a magnitude that additional EMS traffic could endanger either the current patients in the facility or the patient being transported. Diversion is commonly defined as an action that is allowed as a courtesy from the EMS medical director of that EMS system.",
        "Historical background": "Care of the severely injured in the military sector progressively improved through World War II and both the Korean and Vietnam conflicts, mainly through the prompt, judicious transport of the critically injured to centers specializing in trauma care. The lessons learned in the military sector, however, were slow to translate into the civilian sector. In 1961, a \u201cshock-trauma\u201d unit was established at the University of Maryland to study shock in humans, followed by the first civilian trauma unit at Cook County Hospital in Chicago in 1966. This first trauma unit began promoting the concept of regionalization of trauma care in the civilian sector. The publication in 1966 of the far-sighted study from the National Academy of Sciences, Accidental Death and Disability: The Neglected Disease of Modern Society, was the seminal event that fostered the regionalization concept and modern civilian trauma care. The report detailed the problems within the medical care system of the day that contributed to the high morbidity and mortality due to trauma in the US. A few selected quotes from this 48-year-old report are useful to review today. It is useful to look at the progress made in the emergency medical care system era today, and to examine the steps that were required to produce many of the positive results that have been seen. Congress paid attention to the report and began to address some of these shortcomings by directing funding into the Department of Transportation. Late in the 1960s and early into the 1970s, the conceptual design of a \u201csystems approach\u201d to trauma and emergency medical care began to emerge in some areas of the country. Programs emerged that targeted specific types of patients such as cardiac, trauma, burns, and spinal cord injuries. Illinois founded the first regionalized system in 1971. The Emergency Medical Services Act of 1973, signed into law by President Nixon, funded a nationwide shift from funeral home-based ambulances to a professional system of response and transport. A major goal of that federal grant program was regional EMS systems development on a national scale.",
        "Categorization and designation": "As the EMS Systems Act became implemented, it quickly became apparent that a system of categorization of hospital capabilities was needed so that other health care providers \u2013 both out-of-hospital and transferring emergency departments \u2013 would be better informed about optimal referral of patients. The need for standards for specialty referral centers was quickly seen to be necessary. Trauma centers needed specialty teams ready to perform key interventions up to and including major surgery at all hours. Stroke center and STEMI center accreditation emerged, providing the requirements that these centers must be able to administer appropriate therapy to promote restoration of blood flow promptly. Indeed, as trauma became recognized as an emergency of critical injury, the care of stroke and heart attacks became recognized as \u201cacute vascular emergencies\u201d requiring prompt specialty care. Formal designation of facilities by authorized bodies has followed. This designation process ensured that the categorization of facilities was accurate and that minimum standards were being met. In states that did not mandate those minimum standards, care was often found to be mediocre when compared to a formal process, though it was also found that any attempt at organization was better than no system at all. Regionalization has followed the process of designation, requiring growth and change on the part of EMS providers. Enactment of state and/or municipal laws and regulations provides authorization for lead agencies to oversee processes within the emergency medical care system. For example, in New York State in 1998, facilities in half of the EMS regions were categorized based on guidelines established by the State EMS Council without formal state authority. Since there was no legal authority to designate facilities, the process relied on voluntary participation that was uneven in some regions and non-existent in others. Absent an authorized lead agency to carry out the process of oversight, it is important for the EMS physician to know that the risk of legal challenges against an emergency medical care system might increase. Designation often creates de facto monopolies by restricting the number of facilities allowed to participate within a given system, by requiring that certain standards of care be met prior to participation. For example, the state of Texas (Administrative Code 157.133) requires that acute stroke patients be transported to the nearest comprehensive stroke center (CPC), primary stroke center (PSC), or secondary stroke center (SSC). If a PSC or CSC is within 10 minutes of the nearest SSC, the stroke patient will be directed to the PSC or CSC since more comprehensive care will be available at that center. In the absence of explicit authority, the designation process may be impeded by physicians, hospitals, or other special interest groups. Initially, system planners did not adequately address the need for explicit authority to designate trauma centers. Compounding this shortfall was the lack of federal funding for upgrading hospital facilities. Individual hospitals were expected to make costly improvements on a voluntary basis. Since it was assumed that designation of trauma centers would promote the development of the regionalized emergency medical care system, attempts were made in the 1970s to organize such systems around trauma center development. When federal EMS systems funding effectively ended in 1982, program initiatives and necessary legislative changes became the responsibility of individual states. Those responsible for developing or managing EMS systems found that in the absence of both federal money and legal authority, plans for regionalization through facility designation commonly failed. Many of the specialty referral center problems were caused by a relaxing somewhat of the originally strict criteria recommended by the American College of Surgeons and the development of Level II trauma center designations. The competition for designation as Level II centers among smaller community hospitals, and the litigation from this action, effectively halted development of the designations process altogether in many areas. Concern regarding adverse economic effects (mainly the loss of patients) by those institutions not designated occasionally resulted in resistance by hospital administrators and physicians to both categorization and designation. It was noted that fewer than 10% of all trauma patients actually required trauma center care, and thus the actual loss of patients from non-designated hospitals was modest. These same concerns are evident more than two decades later in the discussions about categorization and designation for acute ischemic stroke and STEMI. However, increased competition among facilities that have geared up for multispecialty critical care has increased the desire among these facilities to have EMS patients with these conditions transported to their facilities. At this writing, in the county of Dallas, Texas, there are 15 facilities that receive emergency 9-1-1 EMS patient transports from within the county. All 15 have percutaneous coronary intervention capability and are certified chest pain centers. Also, at this writing, 13 of these facilities either are certified stroke centers or are in the process of application to become certified. Thus, the competition for EMS emergency patients with these two conditions in this geographical area is very high. Lead agencies with appropriate empowerment are important to a stable emergency medical care system process, as they oversee the planning, implementation, and operation of these systems, generally in the absence of serious legal challenge. System development is much more difficult absent statutory and regulatory authority facility designation, establishing of regionalization processes, and overall system design. A branch of government with legislative authority to designate is best suited to serve as the lead agency. This authority may assume many different forms besides an actual government unit. For example, Colorado and Pennsylvania utilize independent foundations for trauma center designation. The county of Dallas, Texas, worked with a non-profit organization and local foundation funding to create a county-wide network for the management of patients with acute coronary syndrome. Together with the American Heart Association local chapter, the University of Texas Southwestern, and local EMS agencies and hospitals, a grant was obtained from the W.W. Caruth Foundation to support the funding of a county-wide program \u2013 the \u201cSystem Onset to Arterial Reperfusion\u201d project \u2013 for the management of patients with acute coronary syndrome. All hospitals and EMS agencies participated in the project, together with the Regional Area Council. Of note, this was not a \u201cdesignation process\u201d but a voluntary process with funding to support common patient care protocols, training, and data tracking and analysis. The effectiveness of such an approach has not yet been fully determined, however, and should be observed carefully by system medical directors in other states. Whatever format is chosen, there must be a clearly defined body that has responsibility and authority to ensure an effective system. Unauthorized designations expose agencies to antitrust liability. Explicit statutory authority affords the greatest protection against exposure to risk of liability for violation of the Sherman Act when limitations are made on the number of medical facilities used by a system. In Huron Valley Hospital Inc. v. City of Pontiac, the court held that, \u201c[State] regulatory actions within the gambit of valid legislation \u2026 are exempted from the antitrust laws under the \u2018state action\u2019 defense.\u201d Proper authorization to designate granted to an agency that enforces state policies through activities closely supervised by state officials would not violate antitrust laws. However, anything short of properly constituted authority may fall foul of federal law. To avoid such antitrust problems, the proper authority must perform hospital designation. Although the law is unsettled nationally, it would appear that, in the absence of definitive court decisions or express legislative authority, governmental agencies with \u201cimplied\u201d powers may be considered to be outside the scope of the antitrust laws. The more recent development of effective stroke and STEMI acute therapy has again raised these same issues but within different groups. A few states have already developed classification standards for these categories of care on a legislative level, typically referring to national standards established by organizations such as the Joint Commission. Early on, some hospitals \u201cself-designated\u201d themselves as \u201cstroke centers\u201d or \u201ccardiac centers\u201d without objective review against established criteria, very similar to the formative days of the trauma system where hospitals rushed to self-designate as \u201ctrauma centers.\u201d However, self-designation did not produce the expected clinical outcome improvements for trauma patients. Absent the development of specific criteria from the Joint Commission for the designation of stroke and STEMI centers, it is more than likely the same process might have repeated itself.",
        "Public Law 101-590": "The concept of regionalization and its ability to improve patient care is not new. The enactment in November 1990 of the Trauma Care Systems Planning and Development Act (PL 101-590) provided for the establishment of a federal trauma systems program. This Act was intended to assist the local and regional planning efforts for trauma system development by breaking down some of the barriers to effective organization that were noted during the 1980s. However, the 1990 Act, which was supposed to provide grants to states for planning, implementing, and developing comprehensive trauma systems, was not funded when enacted. In November 1991, funding that finally was authorized to implement a new federal trauma systems program for 1992 totaled only $5 million. This amount was well below earlier projections, which were as high as $75 million. Public Law 101-590 had two primary goals. First, it was designed to remove the barriers and rectify the problems that in many parts of the country prevented timely and efficient development of a comprehensive emergency medical care system. Second, it provided incentives, including grants, to states and localities to establish coordinated regionalized trauma care systems that would enable severely injured individuals to receive timely and highly specialized care at designated trauma centers. Passage of PL 101-590 ratified the widely held belief that regionalized trauma systems reduced death and disability from trauma. Regionalized trauma care systems were models of health care delivery that could coordinate and integrate prehospital services and hospital resources to assure that optimal care was provided to traumatically injured patients. The 1990 legislation specified that such systems must identify and designate trauma centers with specialized physicians and equipment immediately available on a 24-hour basis. Also required were methods to identify severe trauma victims in the prehospital phase and to ensure that all major trauma victims were transported to trauma centers. Public Law 101-590 addressed the issue of authority, effectively diminishing the threat of legal challenges to development and implementation of designation schemes. However, while the threshold issue of legal authority to designate was resolved, the financial burden caused by the large numbers of uninsured or indigent patients brought to designated facilities, compounded by inadequate reimbursement rates, still presented a great barrier to regionalization. Progressive elements of PL 101-590 are found in the authorization of the Secretary of Health and Human Services to: establish an information clearinghouse to disseminate information on the experience of state and local agencies with respect to trauma care system development and operation; establish an Advisory Council on Trauma Care Systems to conduct needs assessments on a country-wide basis; establish funding for research and programs that seek to improve rural EMS. By early 1993, progress was being made in each of those areas. Unfortunately, enthusiasm has been greatly tempered by an economically constrained environment in which this legislative action has been able to attract only token funding. Ultimately, funding for this trauma program was lost in the mid-1990s. Funding authorization returned in 2001 and again in 2007 with passage of the HR 727-Trauma Care Systems Planning and Development Act amendments, but the level of funding to be provided was unclear at that time. Unfortunately, the need for this type of system development remained poorly understood at all levels, the appropriations process failed to support the bill's intentions, and funding remained elusive. Once again, the support for regionalization of care slipped from fiscal federal support back to the state and local level.",
        "Simultaneous processing": "Contrasted with the typical means of provision of emergency medical care (\u201csequential processing\u201d), a key concept in the design of any regionalized system is \u201csimultaneous processing.\u201d A typical emergency call occurs in this manner. A call is made to 9-1-1. An ambulance responds. An assessment is made and treatment started. The patient is transported to the ED, admission information is gathered, and the assessment is repeated. After the ED examination, diagnostic tests are done. A provisional diagnosis is made, and a treatment plan is developed. Specialty consultants are called to the ED, if needed. Admission or discharge occurs. Thus, in the usual world of EMS, evaluation and management are performed in a sequential fashion of \u201cFirst A, then B, then C.\u201d If a transfer from one hospital ED to another must occur \u2013 as is often the case with seriously ill and/or injured time-critical patients \u2013 this sequential process has even more steps added. Early in the development of trauma systems and trauma care, it was noted that this sequential process often resulted in excessive delays for severely injured patients whose care was of a time-critical nature. In the earliest days, the trauma team was activated only after the patient had been examined in the ED. Out-of-hospital assessment and classification of injury severity (through the field trauma classification process) made it possible to move care forward and have the trauma team respond at the same time as the patient was being brought to the ED \u2013 an early example of simultaneous processing. \u201cMoving care forward\u201d means that providers are performing tasks earlier during the sequence of care that typically were only performed by a higher-level health care provider later in the sequence. As in the above example, paramedics became authorized to give \u201ctrauma alerts,\u201d an activity that was previously only in the purview of physicians. Significant time savings resulted between symptom onset and definitive care. It is a key component of simultaneous processing. Today that concept expands into field activation of stroke teams and cardiac catheterization labs. This authorization for activation by field personnel allows the simultaneous activities of catheterization lab (or stroke team) response while the patient is being transported to the hospital. Through this simultaneous activation of processes, vastly improved treatment of these conditions has occurred. Indeed, in 2013, the American Stroke Association stated, \u201cStroke care quality improvement should be an ongoing process for every hospital. One example of this process improvement is to shorten the door-to-needle time to <60 minutes. For every 15-minute reduction of door-to-needle time, there is a 5% lower odds of in-hospital mortality.\u201d The design of any regionalization system must account for this important concept to decrease the time elapsed from symptom onset to definitive care. In the future, with the assistance of programs such as advanced automatic crash notification and helicopter early launch programs, simultaneous processing should come under the purview of the modern 9-1-1 telecommunications center to continue to enhance patient outcome.",
        "Outcomes": "At present, three major diagnoses are considered \u201ctime-critical\u201d emergencies: severe trauma, acute ischemic stroke, and STEMI. In these clinical scenarios, early identification through field evaluation to an appropriate (though not necessarily closest) facility, combined with appropriate treatment, can dramatically affect morbidity and mortality. Thus, outcomes can be directly affected by planning for \u201cthe right care, at the right place, in the right time.\u201d Other clinical diagnoses, such as patients with post-cardiac arrest return of spontaneous circulation, sepsis, and asthma, may join these time-critical conditions as efforts to maximize outcomes within integrated systems become increasingly standardized. Achieving such a level of integration is a formidable task. Despite the common goal of helping the patient obtain the best available care, each of these levels may possess potential issues that may not produce a highly coordinated response. PSAP call takers may not be part of a 9-1-1 system, or may be primarily engaged in other public safety work and not trained, certified, or allowed to perform formal emergency medical dispatch. Initial responders such as law enforcement and fire service agencies may be more attuned to rapid, limited intervention. Local EMS policies may only provide for the transport of the patient to the nearest available community hospital, and a return to local readiness as soon as possible. Air ambulance providers may be engaged elsewhere, potentially depriving other time-critical patients of air transport to appropriate facilities. Community hospitals may have unclear guidance as to what patient work-up is required at that facility before transfer to a higher level of care to avoid a potential violation of the Emergency Medical Treatment and Active Labor Act. Regional referral centers may express concern that the case-load of patients referred to that facility by outlying facilities is too high.",
        "Trauma": "Research measuring the outcomes of a patient population that was treated within a trauma system compared to those treated outside a trauma system began early in trauma system development. Absent electronic patient registries, a tool was developed to measure these cases within the limitations of the data of the time. A panel of surgeons, blinded to the hospital and system, reviewed cases and determined if deaths were preventable, probably preventable, or not preventable. These panels routinely found that care within trauma systems with a rigid specialty referral center designation process was best. Such a system design, using outside site review teams, was compared with both \u201cno system\u201d and a \u201cself-designation\u201d system, where a hospital performed the review process and designated itself according to various published standards. Patient outcomes were found to be best with external review and designation. These differences were sometimes quite dramatic. For example, the classic study by West, Trunkey, and Lim compared the San Francisco area, which had a formal designated trauma system, with Orange County, CA, which had no formal designated trauma system. West et al. found that only one of 92 deaths was deemed potentially preventable in the San Francisco system. In distinct contrast, 11 of 30 Orange County deaths were deemed clearly preventable and another 11 of 30 were deemed potentially preventable. They estimated that a formal system in Orange County could result in as much as a 73% decrease in non-central nervous system (CNS)-related deaths and a 28% decrease in CNS-related deaths. In a follow-up, Cales studied the same Orange County area several years later, comparing outcomes from before and after a regionalized trauma system was implemented. He found that potentially preventable deaths fell from 34% to 15%, a 56% relative decrease. Thus, formal, rigorous, external site review processes can improve the performance of hospitals already designated as trauma centers. Even rural Level III facilities have improved outcomes, even after transferring the patient. At all levels of care it has become widely accepted that a regionalized system of care for the trauma victim is desirable. The overall reduction in preventable mortality is probably in the 50% range and the reduction in time to disposition falls from 54% to 7%. The question then arises: Does the same logic apply to other time-critical diseases, and can we realize the same improvements in care?",
        "Stroke": "\u201cStroke networks\u201d are relatively new, and data are now accumulating of abundant improvements in overall quality of care. Improved outcomes for patients with acute ischemic stroke and for hemorrhagic stroke have been shown when patients are treated within a designated stroke center system. Organized stroke systems decrease mortality. As mentioned above, emphasis on the management of acute ischemic stroke has become fully stressed within facilities that have been certified as either primary or comprehensive stroke centers. The rapid identification of victims of acute ischemic stroke who are appropriate candidates for fibrinolytic therapy is now an area of intense focus. Given the widely accepted statistic that some 2 million brain cells are dying each minute in these victims, there is now strong impetus to treat at least 50% of eligible patients with fibrinolysis within 1 hour of arrival to a stroke center. It is now fairly clear that the benefit in improved morbidity and mortality for these patients outweighs the risks of fibrinolysis, especially when these selected patients are treated within 90 minutes of symptom onset. There are more data that suggest that adherence to rigorous fibrinolysis administration criteria can minimize complications and gain the mortality benefits delineated in the original study. A critical area of focus in stroke management today is the identification of these patients by prehospital providers. Standardized patient examinations such as the Cincinnati, Los Angeles, Miami, and Melbourne stroke scales allow EMS personnel to provide a level of assessment that is reasonable to permit activation of stroke teams in the destination facilities. Indeed, \u201cprenotification\u201d of the stroke teams in the stroke centers is central to achieving the \u201c50% of eligible patients treated within an hour of arrival\u201d goal to which stroke centers are now being held. Thus, within the regional system of care for stroke, EMS providers must have initial and ongoing training and appropriately tailored quality management systems that feed back onto their assessments.",
        "Diversion and bypass": "Diversion is a scenario in which an emergency receiving facility may decline to allow transport to that facility by EMS providers. This fact has been shown to be a \u201csurrogate\u201d for ED crowding. Regardless of the cause, the effect of diversion is to potentially threaten patient care through prolonging the pre-hospital phase of the encounter. Diversion, in effect, is the pushing of emergency patients in ambulances away from a facility due to systemic problems within that hospital as regards patient flow. It is extremely important for a hospital to have prospectively designed diversion criteria. Such a decision cannot be made by a tired emergency provider in the department, seeing a glut of emergency patients within that department, calling a medical control area to say that ambulances are diverted. For a hospital to close its doors to inbound ambulance traffic is for the hospital to declare that it can no longer participate in the emergency medical care system at that moment. Such a decision must be made according to strict criteria, approved by the medical director, and activated only in the setting of appropriate administrative oversight, together with the emergency medicine team in the ED. Justifications can be made for diversion of certain types of inbound ambulance patients on occasion. If the trauma team at a Level I trauma center has received a number of critical patients, is in the operating room, and has hours more of potential surgeries waiting for care, then an incoming trauma victim may be better served if there is another appropriate trauma facility in the area that is not so overloaded. Similar considerations apply to stroke and STEMI victims in the settings of receiving hospital teams being already occupied \u2013 and vascular intervention laboratories already full \u2013 and patients may benefit from being transported to another appropriate facility. Progressive EMS systems have abandoned the ambulance diversion process. Massachusetts implemented a moratorium on ambulance diversion in 2009. Their study showed, according to pre-determined criteria, no clinically significant changes were found in any ED group in mean monthly volume, admissions, elopement, or length-of-stay for any patient disposition group. They concluded, \u201cno diversion was not associated with significant changes in throughput measures in \u2018all\u2019, \u2018high\u2019 diversion, and \u2018low\u2019 diversion emergency departments.\u201d Examples abound of similar processes, including Dallas and Fort Worth, Texas. Finally, EMS physicians should consider carefully whether ambulance diversion should be allowed at all within the emergency medical care systems in which those physicians have influence. The patients in the backs of those ambulances are ultimately under the care of the indirect medical oversight physician: the EMS medical director. Diversion, then, must be a courtesy extended by the EMS medical director to the receiving hospital and should be considered in that context. While proactive medical liaison efforts by the medical director can help pave the way for emergency medical care system progress in this area, the ultimate disposition of the patient nonetheless falls to the medical director. As to the matter of \u201cbypass,\u201d the emergency medical care system structure must allow for transporting agencies that have identified patients falling into certain clinical categories to be mobilized to the appropriate facility for the condition. This ensures the most appropriate care for the acutely ill or injured patient. Streamlining care also avoids additional unnecessary testing \u2013 perhaps duplicative testing \u2013 and better oversight of overall system finance within the emergency medical care system. Cooperative agreements must be in place, and system guidelines must be developed prospectively.",
        "ST-segment elevation myocardial infarction": "Systems that deal with STEMI have shown significant improvements in patient care. Efforts abound to establish systems such as these. The entire state of North Carolina (flowing into bordering states) has been organized into the Reperfusion of Acute MI in North Carolina Emergency Departments (RACE) effort. While a 2007 report in JAMA failed to demonstrate any overall mortality improvement, ongoing maintenance and monitoring of this system demonstrate a state-wide effort allowing for a high level of coordination of care for these patients. Similar effort occurred in the Dallas, Texas, area, which is now being actively extended into the Dallas-Fort Worth metroplex of four counties. The Dallas data indicate an improvement in overall survival for STEMI patients during the study period from 4.6% to 1.9%. An interesting public health dilemma continues to be noted across these systems of care, both for STEMI and for acute stroke. Some 50% of patients continue to \u201cself-transport\u201d to receiving facilities, a saddening point resulting in an increase in morbidity and mortality for these patients. The Dallas AHA Caruth effort found that, in spite of public education, the relative percentage of patients self-transporting to area hospitals did not change.",
        "Payer/funding issues": "Funding is a key factor in the overall operation of an emergency medical care system. Critical trauma, for example, has a poor history of reimbursement, while cardiac care may be relatively well reimbursed. This may foster competition for various hospital designations. A local private hospital may be a \u201cchest pain center\u201d and \u201cstroke center\u201d but its medical staff may decline to be involved with the trauma system on critical patients. Transporting agencies must be reasonably reimbursed for their work within systems, especially in the setting of longer transport costs. Indeed, the capabilities of each and every component within the emergency medical care system must be adequately funded to allow for the high efficiency necessary for such a complicated system to function properly. In the new paradigm of time-critical diagnoses, \u201cstabilization\u201d at facilities without the capacity for definitive care may result in the delay of treatment and the worsening of outcomes. Gross et al. found that when a STEMI patient was stopped at an outside facility for \u201cstabilization,\u201d an average of 79 minutes was added to the patient\u2019s eventual definitive care. Notably, this was in a system that sought to decrease the time required to transfer by several means, including a \u201cone-call system.\u201d Furthermore, when they studied the subgroups, those patients who were delayed for \u201cstabilization\u201d had a 4.3% overall mortality, versus 0% for those who either walked into or were field triaged directly to a percutaneous coronary intervention center. These data argue forcefully against any delays in definitive care, and payers must apportion their reimbursement standards to accommodate the advances and concepts of regionalization.",
        "The optimal emergency medical care system": "Regionalization of emergency medical care is a \u201cwork in progress\u201d within the overall spectrum of medical care. It is critical that ongoing assessment of the condition of the system and continuous improvement be made consistently. Several key concepts and tenets are useful in the management of such systems. A designated overarching agency must be identified that possesses the necessary legal authority to oversee the political and administrative processes needed for a regional system to succeed. An oversight committee must be established to allow for the input of expert stakeholders and to encourage their participation in the design and refinement of system processes. Common subcommittees include medical oversight, funding, public education, prevention, quality improvement, individual clinical committees (9-1-1, EMS, stroke, STEMI, trauma), and legislative. Organizational silos need to be acknowledged and resolved. Leadership focused on improving patient outcomes through decreasing the time from symptom onset to definitive care is the key to bridging the gaps between provider groups. Care must be \u201cmoved forward\u201d, and providers must be able to perform at the appropriate level for the system. The most correct diagnosis should be made quickly in time-critical cases, with a proper triage and destination decision being made. Prehospital personnel must be able to activate the appropriate receiving facilities and personnel. Prehospital personnel must be trained to recognize and make appropriate destination decisions and must be given consistent feedback regarding their field decisions. EMS medical directors have to ensure that their personnel appropriately identify stroke and STEMI candidates while avoiding \u201covertriage\u201d when possible. For example, a prehospital provider should find that an altered patient with stroke-like symptoms was, in fact, a hypoglycemic diabetic who, when treated, regained stable clinical status. To have given prehospital stroke notification for such a patient would have been an \u201covertriage.\u201d It is important for EMS medical directors to monitor their systems for overtriage decisions and to minimize those instances where possible through initial and continued education based upon quality improvement benchmarks. A functional quality management system is vital to the success of a modern emergency medical care system, providing an integration of all members of the network into a coordinated quality management process. An aggressive data collection process that encompasses all components of the system is critical. This data collection process allows analysis and effective quality improvement of the entire system so that \u201cweak links\u201d in the chain may be identified and improved. Benchmarking standards within the system facilitate facility performance within the overall quality management process. Clear protocols are needed at every level within the emergency medical care system to allow for early identification, moving care forward, simultaneous processing, and field triage of patients to the correct destinations. Incorporation of the traditional public health roles of public education and prevention as integral parts of the overall system is essential. This necessitates a working relationship with non-traditional partners and brings an enlarging audience to our daily work. Designation of specialty receiving centers should be done in a structured, formal fashion using outside review teams.",
        "Conclusion": "The formation of emergency medical care systems will continue to grow as regions identify methods of improving the quality of patient care while searching for ways to make the system function in a fair and economical manner. Data are compelling now that for time-critical clinical conditions, patients benefit from such organized systems of care, which are also helping keep down the rising cost of medicine. It is clear that pressure to demonstrate quality of care will drive the destination of medical development. Referral facilities will continue to promote their programs, yet field providers must triage patients appropriately to protect all members of the EMCS team. EMS medical directors are therefore uniquely positioned to coordinate activities within the EMCS, gaining understanding of the many viewpoints of all participants."
    },
    {
        "Introduction": "Emergency medical services personnel work in a unique environment and under exceptional circumstances. Work is spontaneous, unpredictable, and often dangerous. There is great diversity in patient age, size, sex, and presenting condition. Care occurs on the side of the road, in patient homes, and in environments that require creative solutions combined with care that is timely and appropriate. An EMS worker may provide routine, non-emergency care for one patient, and then respond urgently to a scene to provide care that is critical, timely, and life-saving. The occupation is rewarding and attracts many who are altruistic or seeking sensation and excitement. Concurrently, the setting and manner of care delivery can be dangerous with numerous hazards and threats to worker wellness and safety. Common hazards and threats include operation of a motor vehicle (often by inexperienced and excitable providers), violent patients, poor general health status, stress, burnout, chronic health effects from shift work, and sleep-related performance impairment. Exposure to blood-borne pathogens is a particular risk in this uncontrolled setting. Many EMS providers are in poor physical condition and suffer from obesity and physical inactivity. Leadership and medical oversight that are strong, objective, and visible may minimize threats and enhance EMS provider wellness.",
        "Wellness of EMS workers": "Wellness refers to the physical and mental well-being of the individual. Good sleep hygiene, regular physical exercise, and proper diets are required to maintain individual wellness. A well individual will suffer fewer chronic medical conditions and generally enjoys a higher quality of life and longevity. EMS providers should be physically fit and in good mental health to optimally perform their duties.",
        "General health": "Self-rated, global assessments of health status are commonly used to assess general wellness and well-being and predict risk of morbidity and mortality. The rate of death among men and women who rate their health as \u201cpoor\u201d is significantly greater than that of men and women who rate their health as \u201cfair\u201d or \u201cgood\u201d. After adjusting for age, the relative risk of death for men and women reporting poor health versus good health was 2.9, and for those reporting fair health versus those reporting good health was 1.6. Many EMS workers rate their health as poor and are thus at an elevated risk of early mortality. In a sample of 19,960 EMS workers, 1.8% rated their health as \u201cfair/poor,\u201d 75.5% as \u201cvery good/good,\u201d and 22.7% as \u201cexcellent\u201d. In a separate study of >500 EMS workers, fewer than 10% rated their health status as \u201cfair to poor,\u201d 64% as \u201cgood,\u201d and 27% as \u201cexcellent\u201d. These data are comparable to data from the National Health and Nutrition Examination Survey (NHANES 2005\u20132008). National estimates show that 17% of adults rate their health as excellent, 66% as very good or good, and <17% as fair or poor.",
        "Body weight, tobacco use, and physical inactivity": "Overweight and obesity, tobacco use, and physical activity are leading indicators of health and wellness. There is no database of health indicators for all EMS workers but data from small studies provide a window onto the current status of EMS worker wellness. Data from the National Registry of EMTs show that nearly three-quarters (71.2%) of nationally registered EMS workers are overweight or obese, 17% currently smoke tobacco, and 75.3% fail to meet recommendations for physical activity. In a convenience sample of 119 EMS workers in Pennsylvania, greater than 80% were classified as overweight or obese, and approximately 15% reported smoking tobacco. A separate study involving 511 EMS workers affiliated with 30 diverse US-based EMS organizations revealed that 77.5% are overweight or obese and 15.5% smoke tobacco. Data from the Behavioral Risk Factor Surveillance System (BRFSS) shows that the percentage of US adults who are obese (BMI >30 kg/m\u00b2) varies across states, with a mean prevalence of 24.6%. The mean percentage of US adults classified as physically inactive was 51.4%. Data from the National Health Interview Survey (NHIS) show that one in five US adults were considered current cigarette smokers during 2008 and 2010. The reversible conditions of obesity and smoking are significant risk factors for cardiovascular disease and place EMS workers at risk of future chronic disease conditions such as hypertension. Furthermore, the nature of EMS operations facilitates physical inactivity, which contributes to poor health and reduced longevity.",
        "Work-related stress": "Emergency medical services workers regularly care for patients who are at their moment of greatest need. These moments may involve critical illness or injury and result in stressful reactions by the patient, family members, other bystanders, or the care providers. Repeated exposure to critically ill or injured patients may lead to high levels of work-related stress and stress-related outcomes. Work-related stress can be defined as \u201ca process by which workplace psychological experiences and demands (stressors) produce both short-term (strains) and long-term changes in mental and physical health\u201d. There are numerous theories of stress and the effect/response in humans. A common underpinning of these theories is the belief that psychological stressors have mental and physical effects through a common set of physiological processes. Data show that work-related stressors differ by occupation (e.g. white-collar versus blue-collar), and are affected by work characteristics such as hours worked, role ambiguity, interpersonal conflict, and other factors. High levels of work-related stress can contribute to depressive disorders and poor mental health, physical disorders such as pain, job dissatisfaction, burnout, greater absenteeism, and poor work-family fit. Stress among EMS workers has been a topic of research and discussion since the evolution of modern EMS in the 1970s. Our understanding of stress and stressors in EMS remains imperfect, however, due to wide variations across studies that attempt to quantify the magnitude of EMS work-related stress. For example, one study of 658 EMS workers examined work-related stress using the Medical Personnel Stress Survey and determined that the mean survey score exceeded the cut-point for high work-related stress by 19 points. More recent research of 34,340 nationally registered EMS workers showed that ~6% report work-related stress, 6% anxiety, and approximately 7% depression. Studies of severe stress reactions show wide variation in the proportion reporting signs and symptoms of posttraumatic stress disorder (PTSD); however, the trend across studies suggests EMS workers report symptoms of PTSD with greater frequency than the general population. Commonly reported stressors include high patient demand, shift work and job scheduling, medically unnecessary use of EMS resources by the public, poor relationships with administration and leadership, lack of public recognition, and perceived low pay/income. The outcomes of chronic or acute stress among EMS workers include alcohol use, depression, burnout, and turnover. While there are limited data on substance abuse among EMS workers, there is growing concern that many in the profession may be at risk. Data from the Emergency Medical Services Agency Research Network (EMSARN) at the University of Pittsburgh School of Medicine\u2019s Department of Emergency Medicine show that a large proportion of EMS workers are incapable of recognizing when stress is present. We have administered the EMS-Safety Attitudes Questionnaire to a group of EMS providers each year since 2010. A small percentage of EMS workers report the ability to recognize when stress has a negative effect on their performance across all years and across a diverse sample of EMS agencies. Medical directors and supervisors may wish to invest in worker health and wellness programs that address recognition and treatment of worker stress.",
        "Sleep and fatigue": "The National Sleep Foundation describes normal sleep for adults as 7\u20139 hours per sleep period. Inadequate sleep is defined as total sleep that is less than 7 hours. Data from the National Health Interview Survey show that the mean amount sleep per night for the average employed US adult is 7 hours yet one-third of US adults reports inadequate sleep. Data from the Behavioral Risk Factor Surveillance System show that 31% of adults report inadequate sleep in the previous 24-hour period and approximately 11% in the previous 30 days. Pirrallo and colleagues found that 70% of actively employed EMS workers report at least one sleep problem. Shift workers such as nurses, physicians, and EMS workers are vulnerable to inadequate sleep due in part to work schedules that are non-traditional (e.g. 24-hour shifts, night shifts, rotating shifts). A recent study of hospital nurses showed that the mean amount sleep between scheduled shifts for both night and day workers was less than 6 hours per night. A study of emergency physicians working in an academic medical center showed that short-term memory declined after day and overnight shifts and confirmed the high incidence of disturbed sleep among physicians. Data from hundreds of EMS workers submitting data to the EMSARN consistently show that about half of these workers achieve less than 6 hours of sleep per sleep episode. Total sleep hours is only one component of an individual\u2019s overall quality of sleep. Sleep quality is a multidimensional concept that is most commonly referenced using seven domains of the Pittsburgh Sleep Quality Index (PSQI): subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medication, and daytime dysfunction. Scores on the PSQI range from 0 to 21 with scores \u22656 considered indicative of poor sleep quality. Benchmarking data show that sleep quality scores among \u201chealthy\u201d controls are <3 and scores for persons diagnosed with depression are >11. Data from a convenience sample of EMS workers in Pennsylvania show a mean PSQI score of 9.2. Recent data from a nationwide sample of 511 EMS workers identified a mean PSQI of 6.9, with 60% of workers scoring \u22656. Sleep quality data have been collected annually since 2010 by the EMSARN. There is growing evidence linking characteristics of EMS worker sleep to negative outcomes, including a higher odds of sustaining a workplace injury (unadjusted odds ratio (OR) 2.3) or ambulance crash. Daytime sleepiness is another common measure in sleep medicine, and the Epworth Sleepiness Scale (ESS) is used frequently to assess daytime sleepiness or sleep propensity. The ESS scores range from 0 to 24 and scores \u226510 are often used to indicate excessive daytime sleepiness. The proportion of US adults that report daytime sleepiness varies by demographic and work-related factors. Data from 5,173 older adults (mean age 66) show that ~16% of whites, 12.5% of Chinese, ~22% of African Americans, and 15% of Hispanics report excessive daytime sleepiness (ESS >10). Recent research involving 458 firefighters in the Midwestern US show that 25% scored \u22658 on the ESS. Data from a sample of 1,854 nationally registered EMS workers show that 36% suffer from excessive daytime sleepiness (ESS >10). High ESS scores were associated with difficulty remembering protocols and tiredness-related difficulty in operating motor vehicles. Sleepiness has also been linked to job satisfaction and intent to leave the profession in EMS workers. Severe mental and/or physical fatigue may result from EMS workers not receiving the sleep and rest that they need. Fatigue refers to an \u201cunpleasant symptom incorporating feelings of tiredness to exhaustion creating mental and physical conditions that interfere with the ability to function in a normal capacity\u201d. Fatigue is most often measured using self-report surveys but there is no recognized standard for fatigue assessment and the debate on how best to measure fatigue is ongoing [40]. Population-level data suggest that fatigue affects approximately one-third of US adult workers [41]. Self-reported fatigue varies by occupation and study sample. One-third (36%) of hospital-based nurses [31], 40% of truck drivers [42], and 75% of small-airline commercial pilots have reported acute or chronic fatigue [43].\n\nFew studies have examined fatigue among EMS workers. A study of 221 EMS workers in the Netherlands showed that 10% of those answering the Checklist Individual Strength survey were classified as severely fatigued and at risk of sick leave or work disability [12]. A study involving a convenience sample of 119 EMS workers in western Pennsylvania showed that 44.5% reported severe mental and physical fatigue while at work using a modified version of the Chalder Fatigue Questionnaire [8]. A separate study involving 511 workers affiliated with 30 diverse EMS agencies showed that 55% reported severe mental and physical fatigue while at work [5]. Figure 20.4 includes multiple years of data from the EMSARN network and suggests that greater than half of EMS workers feel severely fatigued. Fatigue has been associated with an increased risk of injury (unadjusted OR 2.9), medical error or adverse event (unadjusted OR 2.3), and safety-compromising behaviors (unadjusted OR 4.9)",
        "Shift work": "The term shift work refers to \u201cany arrangement of work hours other than the standard daylight hours\u201d. It is well established that shift work extending into the overnight and early morning hours disrupts the homeostatic and circadian mechanisms that regulate the human sleep/wake cycle. Shift work has also been linked to degradation in performance, safety, and health. There is no standard shift work schedule for EMS workers, and research on EMS shift work characteristics and patterns is limited. However, available data show that a large proportion of EMS personnel work long hours and multiple shifts. More than half work greater than 45 hours per week, most work 12- or 24-hour shifts, and 40% work more than 16 shifts per month. A large proportion of EMS workers \u2013 as much as 80% \u2013 have additional employment and/or work a high number of overtime hours. The long-term effects of shift work in the EMS setting have not been delineated, but recent research shows that retired shift workers have worse sleep quality in retirement than workers with no prior exposure to shift work.",
        "Conclusion": "The EMS worker, employer, and medical director share responsibility for achieving and maintaining wellness. The unpredictable nature of EMS work poses a unique challenge for work site wellness program implementation and maintenance. Wellness programs for EMS organizations will need to fit the unique needs and operations of each EMS organization. Employers will need to invest and devote resources \u2013 which are often limited \u2013 to work site health and wellness. Investment can lead to positive returns with improvement in worker health behaviors and a healthier workforce. Despite the evidence in favor of work site health promotion, there are numerous challenges and barriers to program adoption, implementation, and maintenance in the EMS setting. Many EMS workers live and work with one or more chronic diseases. A high proportion of EMS workers are at risk of an acute injury or developing work-related chronic health problems through repeated exposure to stress, violence, blood-borne pathogens, physical exertion, etc. Employers, medical directors, and supervisors may not know what conditions to focus on and what to \u201clet go.\u201d The EMS worker may find it difficult to engage in a work site program given the unpredictable nature of EMS work and lack of protected time during work to participate. Despite these challenges, there is widespread support and rapid growth in resources that EMS leaders can and should use to promote and protect the health and wellness of our EMS workforce."
    },
    {
        "Before 1966: historical perspectives": "Before 1966: historical perspectives Early hunters and warriors provided care for the injured. Although the methods used to staunch bleeding, stabilize fractures, and provide nourishment were primitive, the need for treatment was undoubtedly recognized. The basic elements of prehistoric response to injury still guide contemporary EMS programs. Recognition of the need for action led to the development of medical and surgical emergency treatment techniques. These techniques in turn made way for systems of communication, treatment, and transport, all geared toward reducing morbidity and mortality. The Edwin Smith Papyrus, written in 1500 BC, vividly describes triage and treatment protocols. Reference to emergency care is also found in the Babylonian Code of Hammurabi, where a detailed protocol for treatment of the injured is described. In the Old Testament, Elisha breathed into the mouth of a dead child and brought the child back to life. The Good Samaritan not only treated the injured traveler but also instructed others to do likewise. Greeks and Romans had surgeons present during battle to treat the wounded. The most direct root of modern prehospital systems is found in the efforts of Jean Dominique Larrey, Napoleon's chief military physician. Larrey developed a prehospital system in which the injured were treated on the battlefield and horse-drawn wagons were used to carry them away. In 1797 Larrey built \u201cambulance volantes\u201d of two or four wheels to rescue the wounded. Larrey had introduced a new concept in military surgery: early transport from the battlefield to the aid stations and then to the frontline hospital. This method is comparable to the way that modern physicians modified the military use of helicopters in Korea and Vietnam. Larrey also initiated detailed treatment protocols, such as the early amputation of shattered limbs to prevent gangrene. The Civil War is the starting point for EMS systems in the United States. Learning from the lessons of the Napoleonic and Crimean Wars, military physicians led by Joseph Barnes and Jonathan Letterman established an extensive system of prehospital care. The Union Army trained medical corpsmen to provide treatment in the field; a transportation system, which included railroads, was developed to bring the wounded to medical facilities. However, the wounded received suboptimal treatment in these facilities, stirring Clara Barton\u2019s crusade for better care. The medical experiences of the Civil War stimulated the beginning of civilian urban ambulance services. The first were established in cities such as Cincinnati, New York, London, and Paris. Edward Dalton, Sanitary Superintendent of the Board of Health in New York City, established a city ambulance program in 1869. Dalton, a former surgeon in the Union Army, spearheaded the development of urban civilian ambulances to permit greater speed, enhance comfort, and increase maneuverability on city streets. His ambulances carried medical equipment such as splints, bandages, straitjackets, and a stomach pump, as well as a medicine chest of antidotes, anesthetics, brandy, and morphine. By the turn of the century, interns accompanied the ambulances. Care was rendered and the patient left at home. Ambulance drivers had virtually no medical training. Our knowledge of turn-of-the-century urban ambulance service comes from the writings of Emily Barringer, the first woman ambulance surgeon in New York City. Further development of urban ambulance services continued in the years before World War I. Electric, steam, and gasoline-powered carriages were used as ambulances. Calls for service were generally processed and dispatched by individual hospitals, although improved telegraph and telephone systems with signal boxes throughout New York City were developed to connect the police department and the hospitals. During World War I, the introduction of the Thomas traction splint for the stabilization of patients with leg fractures led to a decrease in morbidity and mortality. Between the two world wars, ambulances began to be dispatched by mobile radios. In the 1920s, in Roanoke, Virginia, the first volunteer rescue squad was started. In many areas, volunteer rescue or ambulance squads gradually developed and provided an alternative to the local fire department or undertaker. After the entry of America into World War II, the military demand for physicians pulled the interns from ambulances, never to return, resulting in poorly staffed units and non-standardized prehospital care. Postwar ambulances were underequipped hearses and similar vehicles staffed by untrained personnel. Half of the ambulances were operated by mortuary attendants, most of whom had never taken even a first aid course. Throughout the 1950s and 1960s, two geographic patterns of ambulance service evolved. In cities, hospital-based ambulances gradually coalesced into more centrally coordinated city wide programs, usually administered and staffed by the municipal hospital or fire department. In rural areas, funeral home hearses were sporadically replaced by a variety of units operated by the local fire department or a newly formed rescue squad. Additionally, in both urban and rural areas, a few profit-making providers delivered transport services and occasionally contracted with local government to provide emergency prehospital services and transport. Before 1966, very little legislation and regulation applicable to ambulance services existed. Providers had relatively little formal training, and physician involvement at all levels was minimal. A number of factors combined in the mid-1960s to stimulate a revolution in prehospital care. Advances in medical treatments led to a perception that decreases in mortality and morbidity were possible. Closed-chest cardiopulmonary resuscitation (CPR), reported as successful in 1960 by W.B. Kouwenhoven and Peter Safar, was eventually adopted as the medical standard for cardiac arrest in the prehospital setting. New evidence that CPR, pharmaceuticals, and defibrillation could save lives immediately created a demand for physician providers of those interventions in both the hospital and prehospital environments. Throughout the 1960s, fundamental understanding of the pathophysiology of potentially fatal dysrhythmias expanded significantly. The use of rescue breathing and defibrillation was refined by Peter Safar, Leonard Cobb, Herbert Loon, and Eugene Nagel. Safar persuaded many others that defibrillation and resuscitation were viable areas of medical research and clinical intervention. In 1966 Pantridge and Geddes pioneered and documented the use of a mobile coronary care unit ambulance for prehospital resuscitation of patients in Belfast, Ireland. Their treatment protocols, originally developed for the treatment of myocardial infarction in intensive care units, were moved into the field. Because the medical team was often with the patient at the time of cardiac arrest, the resuscitation rate was a remarkable 20%. Their \u201cflying squads\u201d added a dimension of heroic excitement to the job of being an ambulance attendant, and their performance data helped convince American city health officials and physicians that a more medically sophisticated prehospital advanced life support (ALS) system was possible.",
        "1966: the NAS-NRC report": "The modern era of prehospital care in the United States began in 1966. In that year, the recognition of an urgent need, the crucial element necessary for development of prehospital systems nationwide, was heralded by a report generated by the National Academy of Sciences National Research Council (NAS-NRC), a non-profit organization chartered by Congress to provide scientific advice to the nation. Accidental Death and Disability: The Neglected Disease of Modern Society documented the enormous failure of the United States health care system to provide even minimal care for the emergency patient. The NAS-NRC report identified key issues and problems facing the United States in providing emergency care. Its summary report listed recommendations that would serve as a blueprint for EMS development, including such things as first aid training for the lay public, state-level regulation of ambulance services, emergency department improvements, development of trauma registries, single nationwide phone number access for emergencies, and disaster planning. This document established a benchmark against which to measure subsequent progress and change. The 1966 NAS-NRC document described both prehospital services and hospital emergency departments as being woefully inadequate. In the prehospital arena, treatment protocols, trained medical personnel, rapid transportation, and modern communications concepts, such as two-way radios and emergency call numbers, were all identified as necessities that were simply not available to civilians. Although there were more than 7,000 accredited hospitals in the country at the time, very few were prepared to meet the increased demand that developed between 1945 and 1965. From 1958 to 1970, the annual number of emergency department visits increased from 18 million to more than 49 million. In addition, emergency departments were staffed by the least experienced personnel, who had little education in the treatment of multiple injuries or critical medical emergencies. Early efforts of the American College of Surgery (ACS) and the American Academy of Orthopedic Surgery (AAOS) to improve emergency care were largely unsuccessful because medical interest was essentially non-existent. The 1966 NAS-NRC document was the first to recommend that emergency facilities be categorized. It also emphasized aggressive clinical management of trauma, suggesting that local trauma systems develop databases, and that studies be instituted to designate select injuries to be incorporated in the epidemiological reports of the US Public Health Service. Changes were also recommended concerning legal problems, autopsies, and disaster response reviews. Trauma research was especially emphasized, with the ultimate goal of establishing a National Institute of Trauma. Another problem identified in the report was the broad gap between existing knowledge and operational activity. The NAS-NRC was not the first report in which many of these issues were raised. The President\u2019s Commission on Highway Safety had previously published a report entitled Health, Medical Care, and Transportation of Injured, which recommended a national program to reduce deaths and injuries caused by highway accidents. Its findings were complemented by and consistent with the NAS-NRC report. The recommendations in both documents were used when the Highway Safety Act of 1966 was drafted. This law established the cabinet-level Department of Transportation (DOT) and gave it legislative and financial authority to improve EMS. Specific emphasis was placed on developing a highway safety program, including standards and activities for improving both ambulance service and provider training. The Highway Safety Act of 1966 also authorized funds to develop EMS standards and implement programs that would improve ambulance services. Matching funds were provided for EMS demonstration projects and studies. All states were required to have highway safety programs in accordance with the regulatory standards promulgated by DOT. The standard on EMS required each state to develop regional EMS systems that could handle prehospital emergency medical needs. Ambulances, equipment, personnel, and administration costs were funded by the highway safety program. Regional financing, as opposed to county or state funding, was a new concept that would be echoed in federal health legislation throughout the remainder of the decade. With the Highway Safety Act as a catalyst, DOT contributed more than $142 million to regional EMS systems between 1968 and 1979. A total of roughly $10 million was spent on research alone, including $4.9 million for EMS demonstration projects. A number of other federal EMS initiatives in the late 1960s and early 1970s poured additional funds into EMS, including $16 million in funding from the Health Services and Mental Health Administration, which had been designated as the lead EMS agency of the Department of Health, Education, and Welfare (DHEW), to areas of Arkansas, California, Florida, Illinois, and Ohio for the development of model regional EMS systems. In 1969 the Airlie House Conference proposed a hospital categorization scheme. The AMA Commission on EMS urged facility categorization and published its own scheme, which identified staffing, equipment, services, and personnel types. This became known as \u201chorizontal categorization.\u201d Although it was supported by professional and hospital associations, many hospitals and physicians feared hospitals in lower categories would suffer a loss of prestige, patients, or reimbursement. DHEW EMS program developed a categorization scheme based on hospital-wide care of specific disease processes. Known as \u201cvertical categorization,\u201d this concept was ultimately embraced by many regional programs as a major theme in the development of EMS systems. By the late 1960s, drugs, defibrillation, and personnel were available to improve prehospital care. As early as 1967, the first physician responder mobile programs morphed into \u201cparamedic\u201d programs using physician-monitored telemetry as a modification of the approach by Pantridge in Belfast. The \u201cHeartmobile\u201d program, begun in 1969 in Columbus, Ohio, initially involved a physician and three EMTs. Within 2 years, 22 highly trained (2,000 hours) paramedics provided the field care, and the physician role became supervisory. Similarly, in Seattle, physicians supervised highly trained paramedics, increasing the survival rate from 10% to 30% for prehospital cardiac arrest patients whose presenting rhythm was ventricular fibrillation. The Seattle story was also one in which fire department first responders played a crucial role in building what is now called a chain of survival. In Dade County, Florida, rapid response of mobile paramedic units was combined with hospital physician direction via radio and telemetry for the first time. In Brighton, England, non-physician personnel provided field care without direct medical oversight. Electrocardiographic data were recorded continuously to permit retrospective review by a physician. National professional organizations such as the ACS, the AAOS, the American Heart Association (AHA), and the American Society of Anesthesiologists (ASA), in concert with other groups, provided extensive medical input into the early development of EMS. New organizations were formed to focus on EMS, including the AMA's Commission on EMS, the AHA's Committee on Community Emergency Health Services, the American Trauma Society, the Emergency Nurses Association, the Society of Critical Care Medicine, the National Registry of Emergency Medical Technicians (NREMT), and the American College of Emergency Physicians (ACEP). In the years prior to 1973, such groups made significant but uncoordinated efforts toward the reorganization, restructure, improvement, expansion, and politicization of EMS. In 1972, the NAS-NRC published Roles and Resources of Federal Agencies in Support of Comprehensive Emergency Medical Services, which asserted that the federal government had not kept pace with efforts by professional and lay health organizations to upgrade EMS. The document endorsed a vigorous federal government role in the provision and upgrading of EMS. It recommended that President Nixon acknowledge the magnitude of the accidental death and disability problem by proposing action by the legislative and executive branches to ensure optimum universal emergency care. It urged the integration of all federal resources for delivery of emergency services under the direction of a single division of DHEW, which would have primary responsibility for the entire emergency medical program. It also recommended that the focal point for local emergency medical care be at the state level, and that all federal efforts be coordinated through regional EMS programs. By early 1973 many national organizations supported further federal involvement, both in establishing EMS program goals and in providing direct financial support. The first efforts at passing federal EMS legislation were defeated, but a later modified EMS bill passed with support from numerous public and professional groups. President Nixon vetoed this bill in August 1973. The standard conservative philosophy was that EMS was a service that should be provided by local government, and the federal government should neither underwrite operations nor purchase equipment. Additional congressional hearings led to the reintroduction of a bill proposing an extensive federal EMS program, based on the rationale that individual communities would not be able to develop regional systems without federal encouragement, guidelines, and funding. Finally, in November 1973, the Emergency Medical Services Systems Act was passed and signed. It was added as Title XII to the Public Health Service Act, wherein it addressed EMS systems, research grants, and contracts. It also added a new section to the existing Title VII concerning EMS training grants.",
        "1973\u20131978: rapid growth of EMS systems": "In 1974 the Robert Wood Johnson Foundation allocated $15 million for EMS-related activities, the largest single contribution for the development of health systems ever made in the United States by a non-profit foundation. Forty-four areas received grants of up to $400,000 to develop EMS systems. This money was intended to encourage communities to build regional EMS systems, emphasizing the overall goal of improving access to general medical care. The money was provided over a 2-year period to establish new demonstration projects and develop regional emergency medical communications systems. In early 1974 a newly reorganized DHEW-DEMS began implementing the legislative mandate. Adopted from earlier experiences, the basic principles were that an effective and comprehensive system must have resources sufficient in quality and quantity to meet a wide variety of demands, and the discrete geographic regions established must have sufficient populations and resources to enable them to eventually become self-sufficient. Each state was to designate a coordinating agency for statewide EMS efforts. Ultimately, 304 EMS regions were established nationwide. By 1979, 17 regions were fully functional and independent of federal money. However, of the 304 geographic areas, there were 22 that had no activity and 96 that were still in the planning phase. Testimony was given before the congressional committee considering extension of funding, and an additional year of funding was authorized as the 1202b program for planning. In the regulations, David Boyd strictly interpreted the congressional legislative intent of the EMS Systems Act to mandate that all communities adopt the 15 essential components. Regions were limited to five grants, and with each year of funding, progress toward more sophisticated operational levels was expected. By the end of the third year of funding, regions were expected to have basic life support (BLS) capabilities, which required no physician involvement. ALS capability, which was expected to perform traditional physician activities, was expected at the end of the fifth year. The use of BLS and ALS terminology in the regulations spread widely. However, the original definitions that corresponded directly to the funded emergency medical technician-ambulance (EMT-A) and paramedic levels of training quickly became elusive as variations in the EMT-A and paramedic levels emerged. The EMT-A level required no medical input, but some states such as Kentucky did extend medical oversight to BLS because of insurance laws \u2013 laws making medical care and transportation across a county line virtually impossible without a physician's approval over the radio. Developing the geographic regions required to secure federal funding through the EMS Systems Act usually necessitated new EMS legislation at the state level. The state laws that developed throughout the 1970s varied markedly in regard to the issues of medical oversight, overall operational authority, and financing. In some states, physician involvement was required. In others, medical oversight was not even mentioned. Often, the responsibility for coordinating activities was assigned to a regional EMS council of physicians, prehospital providers, insurance companies, and consumers who often had interests to protect. Commonly, physician input was somewhat removed from the medical mainstream.",
        "Personnel": "A lack of appropriately trained emergency personnel at every level of care had been identified in the NAS-NRC document. After 1973, extensive effort and money were directed at correcting this educational deficiency, and serendipity played a role. A large number of medical corpsmen, physicians, and nurses, who understood that trained non-physicians could perform life-saving tasks in the field, were returning from Vietnam. Many argued that rapid transport and early surgery could improve civilian trauma practice.",
        "Physicians": "In 1966 the NAS-NRC document stated, \u201cNo longer can responsibility be assigned to the least experienced member of the medical staff, or solely to specialists, who, by the nature of their training and experience, cannot render adequate care without the support of other staff members.\u201d Thus the importance of physician leadership and training in EMS was identified early. During the 25 years following World War II, increasing demands for care were placed on hospital emergency departments. Not surprisingly, a branch of medicine evolved with its focus on the critically ill. The academic discipline and scientific rigor necessary to define a separate medical specialty began to develop. In 1968 ACEP was founded by physicians interested in the organization and delivery of emergency medical care. In 1970 the first emergency medicine residency was established at the University of Cincinnati, and the first academic department of emergency medicine in a medical school was formed at the University of Southern California. Soon the directors of medical school hospital emergency departments founded the University Association for Emergency Medical Services. Between 1972 and 1980 more than 740 residents completed training at 51 emergency medicine residencies throughout the country. The first major step toward certification as a specialty occurred in 1973 when the AMA authorized a provisional Section of Emergency Medicine. In 1974 a Committee on Board Establishment was appointed, and a liaison Residency Endorsement Committee was formed. Further impetus toward expansion of residency programs in emergency medicine occurred with the formation of the American Board of Emergency Medicine (ABEM) in 1976. Before that time there was some hesitancy to create residency programs that might not lead to board certification. In September 1979, emergency medicine was formally recognized as a specialty by the AMA Committee on Medical Education and the American Board of Medical Specialties. One of the strongest arguments in favor of the new specialty was that emergency physicians had a unique role in the oversight of prehospital medicine. The ABEM gave its first certifying examination in 1980, which incidentally did not touch on any areas of prehospital care. Although emergency medicine, emergency nursing, and prehospital care were all nourished by the funds distributed between 1973 and 1982, the interest of ACEP in EMS activities lagged, perhaps because individual physician interest lagged. The first full-time EMS medical director was not appointed until April 1981. Previously, all had been part-time, and some had simply been functionaries. Shortly thereafter, cities like Salt Lake City and Houston followed New York's lead, and appointed full-time EMS medical directors. Even then, EMS as a physician career choice was perceived by many as too limited and perhaps a risky career undertaking.",
        "Prehospital providers": "The Highway Safety Act of 1966 funded EMT-A training and curriculum development. By 1982, there were approximately 100,000 providers trained at the EMT-A level. They were trained to provide basic, non-invasive emergency care at the scene and during transport, including such skills as CPR, control of bleeding, ventilation, oxygen administration, fracture management, extrication, obstetrical delivery, and patient transport. The educational requirements, which began as a 70-hour curriculum published by the AAOS in 1969, soon grew to 81 hours of lectures, skills training, and hospital observation, with most of the increase in hours being due to the addition of training in the use of pneumatic anti-shock garments. After working for 6 months, graduates were allowed to take a national certifying examination administered by the NREMT. Founded in 1970, the NREMT developed a standardized examination for EMT-A personnel as one requirement for maintaining registration. Many states began to recognize NREMT registration for the purposes of reciprocity or state certification or licensure. While the EMT-A quickly became a nationally recognized standard, the development of national consensus at the paramedic level lagged behind, with marked differences in training from locality to locality. Paramedic practices became somewhat formalized with the adoption of DOT emergency medical technician \u2013 paramedic (EMT-P) curriculum. By 1982, EMT-P training ranged from a few hundred to 2,000 hours of educational and clinical experience. Typical clinical skills included cardiac defibrillation, endotracheal intubation, venepuncture, and the administration of a variety of drugs. The use of these skills was based on interpretation of history, clinical signs, and rhythm strips. Telemetric and voice communications with physicians were usually required. In the early days of paramedics, extensive \u201conline\u201d medical oversight was mandatory for all calls in most systems. With time, this requirement was modified by the introduction of protocols allowing for greater use of standing orders. However, a great deal of variation in the use of direct medical oversight remained. As early as 1980, paramedics in decentralized systems such as New York\u2019s used many clinical protocols, most of which had few indications for mandatory direct medical oversight. On the other hand, as late as 1992, many centralized systems, such as the Houston Fire Department, had only a few standing orders (mainly for cardiac arrest) that did not require contemporaneous instruction from direct medical oversight. The concept of the EMT-Intermediate (EMT-I) evolved as a provider level located somewhere between EMT-A and EMT-P. Airway management, IV therapy, fluid replacement, rhythm recognition, and defibrillation were the most common \u201cadvanced\u201d skills included in the EMT-I curriculum, though significant variation existed (and still does) from state to state. Many states developed several levels of EMT-I, often in a modular progression with formal bridge courses. By 1979, formally recognized prehospital providers existed at dozens of levels, with highly variable requirements for medical oversight.",
        "Public education": "Cardiopulmonary resuscitation training gradually became more widely accepted, as evidenced by participation in training programs throughout the country. As early as 1977, a Gallup Poll reported that 12 million Americans had taken CPR courses and another 80 million were familiar with the technique and wanted formal training. The success of public training was documented by many studies. The issues of whom to train and how to improve skill retention continue to be explored, as reflected in the AHA/International Liaison Committee on Resuscitation\u2019s Guidelines 2010 document, which contains significant changes in how the techniques of CPR and emergency cardiac care are taught to laypersons.",
        "Communications": "Before 1973, there were few communication systems available for emergency medical care. Only one in 20 ambulances had voice communications with a hospital, a universal emergency telephone number was not operational, and telephones were not available on highways and rural roads. Centralized dispatch was uncommon and there were problems in communications because of community resistance, cost, and insufficient technology. With DOT funding, major steps were taken toward overcoming these communication problems. National conferences, seminars, and public awareness programs advocated diverse methodologies for EMS communication systems. A communications manual published in 1972 provided technical systems information. In 1973, the 9-1-1 universal emergency number was advocated as a national standard by DOT and the White House Office of Telecommunications. The Federal Communications Commission (FCC) established rules and regulations for EMS communication and dedicated a limited number of radio frequencies for emergency systems. In 1977 DHEW issued guidelines for a model EMS communications plan. Emergency medical services medical directors gradually began to appreciate the importance of more structured call receiving, patient prioritizing, and vehicle dispatching. Physicians were forced to look seriously at EMS operational issues that had previously been seen as neither critical nor medical. On the other hand, telemetry as it had been pioneered by Gene Nagel in Florida was generally seen to be impractical, expensive, and unnecessary, and essentially disappeared over time.",
        "Transportation": "Transportation of the critically ill or injured patient rapidly improved after 1973. Although national standards for ambulance equipment were developed in the early 1960s, a 1965 survey of 900 cities reported that fewer than 23% had ordinances regulating ambulance services. An even smaller percentage required an attendant other than the driver, and only 72 cities reported training at the level of an American Red Cross advanced first aid course, the nearest thing to a standard ambulance attendant course before the advent of EMT-A in 1969. The hearses and station wagons used in the 1960s did not allow personnel room to provide CPR or other treatments to critically ill patients. The vehicles were designed to carry coffins and horizontal loads, not a medical team and a sick patient. In the 1960s, two reports focused national attention on the hazardous conditions of the nation\u2019s ambulances. In addition to inadequate policies, staff training, and communications, ambulance design was faulty and equipment absent or inadequate. Morticians ran 50% of the ambulance services because they owned the only vehicles capable of carrying patients horizontally. No US manufacturer built a vehicle that could be termed an ambulance. As early as 1970, DOT and the ACS had developed ambulance design and equipment recommendations. In 1973, DHEW released the comprehensive guide, Medical Requirements for Ambulance Design and Equipment, and a year later the General Services Administration issued federal specifications KKK-A 1822 for ambulances. Although the KKK specifications were originally developed for government procurement contracts, local EMS agencies were often politically obligated to meet or exceed the specifications when ordering new ambulances. A 1978 study of 183 EMS regions described the status of ambulance services within 151 of the regions. Only 65% of the 13,790 ambulances in those regions met the federal KKK standards. Eighty-one regions used paramedics and 72 had some type of air ambulance capability. Response time was often longer than 10 minutes in urban areas and as much as 30 minutes in rural areas.",
        "Hospitals": "When awarding grants for EMS under the EMS Systems Act, DHEW required regions to develop standards and guidelines for categorization of emergency departments in the following eight critical clinical groups: trauma, burns, spinal cord injuries, poisoning, cardiac, high-risk infants, alcohol and drug abuse, and behavioral emergencies. Regions were required to identify the most appropriate hospitals for each of these clinical problems. In reality, only a small portion of emergency facilities was functionally categorized and in many cases the system did not work as described on paper. Hospital administrators resisted losing control, physicians feared surrendering clinical judgment, and both feared losing patient revenues. Despite this resistance, DHEW used EMS hospital categorization fairly effectively to restructure acute patient distribution along the lines of clinical capability rather than market share.",
        "1978\u20131981: EMS at midpassage": "By 1978 many of the original problems and questions concerning EMS had come into focus. Most of the deficiencies identified in the 1966 NAS-NRC report had been addressed, and progress was being made in many areas. Economic resources and political support were being contributed by local and state governments, private foundations, non-profit organizations, and professional groups. However, there was still tremendous geographic variability regarding distribution of services, access, accessibility, quality, and quantity of EMS resources. Basic questions concerning the effectiveness of the various components, system designs, and relationships still existed, and future funding was uncertain. In 1978, the NAS-NRC released Emergency Medical Services at Midpassage, which stated, \u201cEMS in the United States in midpassage [is] urgently in need of midcourse corrections but uncertain as to the best direction and degree.\u201d The report was sharply critical of how the EMS Systems Act had been implemented by DHEW, and recommended \u201cresearch and evaluation directed both to questions of immediate importance to EMS system development and to long-range questions. Without adequate investment in both types of research, EMS in the United States will be in the same position of uncertainty a generation hence as it is today.\u201d The report documented coordination problems among various governmental agencies, focusing particular concern on the multiple standards promulgated as a condition of funding. Some of the standards were conflicting; often they had never been evaluated. Between 1974 and 1981, there were various sources of federal and private funds, and each grant often came with a new set of requirements. DOT established standards for ambulance design, provider training, and other transportation elements, and DHEW announced seven critical care areas as the basis for a systems approach and 15 components as modular elements for EMS design. A variety of private organizations also produced standards. With regard to the technique of CPR, the American Red Cross and the AHA established slightly different standards, criteria, and training requirements. By 1978 some states still had not enacted EMS legislation, whereas others had legislated exactly what prehospital providers could do, potentially hampering the flexibility needed for successful local development. Lack of national conformity or agreement precluded the development of universally accepted national standards in most areas of EMS. On 26 October 1978, a memorandum of understanding was signed by DOT and DHEW describing each organization\u2019s responsibilities relating to development of EMS systems. The agreement was an attempt to coordinate government activities and assign national level responsibility for EMS development and direction. DOT, in coordination with DHEW, was to \u201cdevelop uniform standards and procedures for the transportation phases of emergency care and response.\u201d DHEW was responsible, in coordination with DOT, for developing \u201cmedical standards and procedures for initial, supportive, and definitive care phases of EMS systems.\u201d Research and technical assistance were to be performed cooperatively, and both agencies agreed to exchange information and \u201cestablish joint working arrangements from time to time.\u201d Because the roots, constituencies, and operating philosophies of the agencies were markedly different, the 1978 agreement quickly failed. Over the four subsequent years the lack of coordination continued. In 1980 the EMS directors from each state banded together to form the National Association of State EMS Directors (NASEMSD). With membership from all 50 states and the territories, it attempted to take a leadership role with regard to national EMS policy, and to collaborate on the development of effective, integrated, community-based, and consistent EMS systems. Its strategy was to \u201cachieve our mission by the participation of all the states and territories, by being a strong national voice for EMS, an acknowledged key resource for EMS information and policy, and a leader in developing and disseminating evidence-based decisions and policy.\u201d ",
        "Financing": "By 1978, termination of federal funding in most regions was imminent, and the potential effect on operations and future development began to raise concerns. The 1976 and 1979 amendments to the EMS Systems Act reflected concerns about future funding and had consequently demanded evidence of financial self-sufficiency as one basis for further support. Significant disagreement in describing financial self-sufficiency was apparent in the testimony and documents provided by the various agencies. DOT estimates of non-federal monies spent annually between 1968 and 1980 ranged up to $800 million. In 1979, DHEW officials estimated in testimony that 90% of regions with paramedic service had achieved financial self-sufficiency by 1978. However, the Comptroller General, in a 1976 report entitled Progress in Developing Emergency Medical Services Systems, cited considerable inconsistency in the degree and duration of support provided by community resources. A few years later, in 1979, the Comptroller General testified on the financial status of the EMS regions after analyzing grant applications under the 1976 amendments. Regions were required to document commitment by local governments to continue financial support after federal funds were terminated under Title XII. By the 1980s, the discrepancy between DHEW\u2019s and the Comptroller General\u2019s estimates of financial self-sufficiency of EMS systems suggested serious unrecognized difficulties in the continued underwriting of EMS systems. The financial demands on an EMS system were considerable, related to four major elements: prehospital care, hospital care, communications, and management. The specific costs varied by community. The original 1966 NAS-NRC report estimated that ambulance services accounted for about one-fourth of total EMS system costs, with 75% of that amount for personnel. Communications costs varied from 7% of total cost when there was integration with existing public services, to 35% when completely new systems needed to be established. Although management costs were high during the development phases, they were originally expected to account for less than 2% of the total cost during the operational phase. Health insurance reimbursement did not keep pace with EMS costs, which presented a real problem for EMS providers. Health care benefits were often limited to hospital care and had maximum fixed reimbursements. For example, 20% of Blue Cross patients were not covered for emergency transport, and, of those covered, one-third were only covered after an accident. By 1982, the NAS-NRC wrote, \u201cAvailability of advanced emergency care throughout the nation is a worthy objective, but the cost of such services may prohibit communities from obtaining them.\u201d ",
        "Research": "A total of $22 million was appropriated between 1974 and 1979 for EMS research. The National Center for Health Services Research, in coordination with DHEW, funded various clinical and systems research projects. During the 1979 legislative hearings, testimony from DHEW and the leadership of academic research centers stressed the need for continued EMS research. Annual reports from DHEW detailed the type of research under way, questions being studied, and the scope of long-term and short-term research projects funded under Section 1205 of Title XII. These projects included \u201cmethods to measure the performance of EMS personnel, evaluate the benefits and the costs of advanced life support systems, examine the impact of categorization efforts, determine the clinical significance of response time, and explore the consequences of alternative system configurations and procedures.\u201d Other projects focused on \u201cdeveloping systems of quality assurance, designing and testing clinical algorithms, and examining the relationships between Emergency Departments and their parent hospitals (including rural-urban differences).\u201d In early 1979, the Center for the Study of Emergency Health Services at the University of Pennsylvania urged continued support of EMS research, claiming \u201cDollars spent in EMS research have great potential to help control rising health care costs, [and can] have a significant and visible effect in preventing death and enhancing the quality of patient life following emergency events.\u201d The center suggested research identifying EMS cost control potentials because the phasing out of federal funds, coupled with the effects of local tax revolts, would certainly reduce financing. As the 1980s progressed, the demand for more efficient, effective systems would become universal. Managers of EMS systems, just like their counterparts elsewhere, needed to know which components of the system were crucial and which could be deleted if funding was limited. The answers to those questions were anything but clear.",
        "1981: the Omnibus Budget Reconciliation Act": "Late in the summer of 1981, President Reagan signed comprehensive cost containment legislation that converted 25 Department of Health and Human Services (DHHS) funding programs into seven consolidated block grants. EMS was included in the Preventive Health Block Grant, along with seven other programs such as rodent control and water fluoridation. In effect, individual states were left to determine how much money from the block grants would be distributed locally. Although existing EMS programs were temporarily guaranteed minimal support, a state could later decide to withdraw all block grant money from one or more regional EMS programs. This concept, simply a fundamental premise of conservative federal government, evolved quite differently in each of the states. As with decisions regarding how to implement provider levels and assure competence, the funding process was generally quite political, with little direct input from the public or the medical community. The 1976 Forward Plan for the Health Services Administration made it clear that by 1982, all federal EMS system financial support would end, and regional EMS programs would be the responsibility of the regional agencies. The federal role was to be \u201cone of technical assistance and coordination.\u201d",
        "1982\u20131996: changing federal roles": "The public health initiative for developing a national EMS system came to a gradual, quiet, and unceremonious demise after 1981. In most regions the remnants of the old DHEW program were left to die off slowly under the cloud of confusion occasioned by the Preventive Health Block Grants formula. In most, but not all, states EMS regional programs were lost in the shuffle of competing health programs while the Reagan administration was systematically eliminating federal support for all such programs. In fact, in most jurisdictions the regional EMS momentum present throughout the 1970s simply evaporated. Paradoxically, some individuals involved in EMS saw the end of DHEW era as an opportunity to develop and implement alternative approaches that would not previously have been permitted. Organizations such as the NREMT, National Association of EMTs (NAEMT), and NASEMSD stepped into the vacuum and endeavored to provide some degree of national infrastructure and EMS identity. At the state level, state EMS agencies managed to keep the momentum by sponsoring well-attended state-wide provider conferences. In 1984 the Emergency Services Bureau of the National Highway Traffic Safety Administration (NHTSA) was instrumental in creating the American Society for Testing and Materials (ASTM) Committee F-30. Through the ASTM, NHTSA sought to legitimize the promulgation of standards in many areas of EMS. Through a complex consensus process, thousands of ASTM technical standards were arrived at in many different industries, including construction and building. Although these standards have no federal mandate, they were often enforced at the local level, for example, in building codes. Since a confusing but enthusiastic beginning in 1984, more than 30 EMS-related standards have been developed, including those for the EMT-A curriculum, rotary and fixed-wing medical aircraft, and EMS system organization. This last document outlines the roles and responsibilities of state, regional, and local EMS agencies. The resultant standards, although mandated by no authority, were considered by several state legislatures when state EMS laws or guidelines, written to obtain federal funding in the mid-1970s, required updating. The F-30 Committee prospered as long as physician involvement was evident and decisive, but it was clearly NHTSA\u2019s decision what standard to expedite and when. the NREMT, NAEMT, and other interest groups joined the physicians, each to protect themselves. Although many physicians and physician groups eventually tired of the F-30 exercise, NHTSA preserved some semblance of a central authority. As early as 1983, NHTSA began assuming some roles previously associated with the old DHEW program. Many of the original evaluation staff were hired on a part-time basis to promote use of EMS management information systems. Management conferences were arranged for regional EMS system grantees. Saddled with growing financial problems under block grants, few could attend. In 1988, NHTSA attempted to organize the electronic exchange of information among surviving EMS clearing houses, but those efforts eventually failed after 3 years. Because NHTSA had no specific legislative mandate to assume many of the roles previously performed by DHEW, some states tried to assume those roles but were often unsuccessful. One area that received less attention at the federal level was trauma research and systems development. That would remain so until the passage of the Trauma Care Systems Planning and Development Act in 1990 (Public Law 101-590). It would be incorrect to view the period since 1982\u20131996 as simply stagnant. It might be better characterized as a time when centrifugal forces played havoc with attempts by the federal government and national organizations to define and standardize EMS. During this time, neither an operational consensus nor a discrete EMS development philosophy emerged. Across the country, local activists battled others in pursuit of diminishing funds. By 1992, patients had clearly emerged as customers, and, by the beginning of the Clinton administration, EMS was just as conceptually unified, standardized, efficient, expensive, and confused as the rest of American health care. The Clinton health care plan of 1993 barely mentioned ambulance services, and it did not address EMS systems at all. The Emergency Medical Services for Children (EMSC) program was first authorized and funded by the US Congress in 1984 as a demonstration program under Public Law 98-555. Administration of the EMSC program is jointly shared by the Health Resources and Services Administration\u2019s Maternal and Child Health Bureau (MCHB) and NHTSA. This program is a national initiative designed to reduce child and youth disability and death caused by severe illness or injury, and serves as an example of a successful collaboration between government and academic forces. In the late 1970s, the Hawaii Medical Association laid the groundwork for the EMSC program. It urged members of the American Academy of Pediatrics (AAP) to develop multifaceted EMS programs that would decrease morbidity and mortality in children. It worked with Senator Daniel Inouye (D-HI) and his staff to write legislation for a pediatric EMS initiative. In 1983, a particular incident demonstrated the need for these services. One of Senator Inouye\u2019s senior staff members had an infant daughter who became critically ill. Her treatment showed the serious shortcomings of an average emergency department when caring for a child in crisis. A year later, Senators Orrin Hatch (R-UT) and Lowell Weicker (R-CT), backed by staff members with disturbing experiences of their own, joined Senator Inouye in sponsoring the first EMSC legislation. Initial funding from the EMSC program supported four state demonstration projects. These state projects developed some of the first strategies for addressing important pediatric emergency care issues, such as disseminating educational programs for prehospital and hospital-based providers, establishing data collection processes to identify significant pediatric issues in the EMS system, and developing tools for assessing critically ill and injured children. In later years, additional states were funded to develop other strategies and to implement programs developed by their predecessors. This work progressed through the 1990s when all 50 states and the territories received funding to improve EMSC and integrate it into their existing EMS systems. In response to the available money, in many areas prehospital care of children became the focus of all EMS innovation. After several years, with projects developing many useful and innovative approaches to taking care of children in the prehospital setting, a mechanism was needed to make these ideas and products more easily accessible to interested states. In 1991, two national resource centers were funded to provide technical assistance to states and to manage the dissemination of information and EMSC products. In 1995, the EMSC National Resource Center in Washington, DC was designated the single such center for the nation. Additionally, with the recognition of the dire need for research and the lack of qualified individuals in each state to perform it, a new center was funded, the National EMSC Data Analysis Resource Center (NEDARC) located at the University of Utah School of Medicine. Created through a cooperative agreement with the Maternal and Child Health Bureau, the NEDARC was established to \u201chelp states accelerate adoption of common EMS data definitions, and to enhance data collection and analysis throughout the country.\u201d As the 1980s ended, members of Congress requested information that justified continued funding of the EMSC program. The Institute of Medicine (IOM) of the National Academy of Sciences was commissioned in 1991 to conduct a study of the status of pediatric emergency medicine in the nation. A panel of experts was convened to review existing data and model systems of care, and to make recommendations as appropriate. The findings from this national study revealed continuing deficiencies in pediatric emergency care for many areas of the country and listed 22 recommendations for the improvement of pediatric emergency care nationwide. These recommendations fell into the following categories: education and training, equipment and supplies, categorization and regionalization of hospital resources, communication and 9-1-1 systems, data collection, research, federal and state agencies and advisory groups, and federal funding. These findings convinced Congress to raise funding for the EMSC program. In response to the IOM report, the EMSC program developed a strategic plan. With the assistance of multiple professionals, including physicians, nurses, and prehospital providers, major goals and objectives were identified. The EMSC 5-year plan for 1995\u20132000 served as a guideline for further development of the program. The plan had 13 goals and 48 objectives. Each objective had a specific plan that identified national needs, suggested activities and mechanisms to achieve the objective, and listed potential partners. In 1998, the plan was updated with baseline data, refined objectives, and progress in completing activities.",
        "1996\u20132008: the role of the federal government matures, the United States faces terrorism, and EMS is at breaking point - EMS Agenda for the Future": "In 1996, NHTSA and the Health Resources and Services Administration (HRSA) published the EMS Agenda for the Future. This document was the culmination of a year-long process to develop a common vision for the future of EMS. The federally funded project was coordinated by NAEMSP and NASEMSD, but involved hundreds of other organizations and EMS-interested individuals who provided input to the spirit and content of the agenda. In addition to describing a vision for the future of EMS, the document discusses 14 attributes of the EMS system and outlines steps that will enable progress toward realizing that vision. Shortly after its initial publication, thousands of copies of the EMS Agenda for the Future had been distributed to guide EMS system-related planning, policy creation, and decision making.",
        "1996\u20132008: the role of the federal government matures, the United States faces terrorism, and EMS is at breaking point - EMS Education for the Future: A Systems Approach": "In December 1996, NHTSA held a conference to address EMS education recommendations of the EMS Agenda for the Future report published earlier in the year. Over the next 2 years an EMS Education Task Force was established and the goals were expanded to include defining the essential elements of a national EMS education system as well as the interrelationships necessary to achieve the recommendations in the agenda. The outcome of the Task Force was the document entitled the EMS Education for the Future: A Systems Approach, which called for the development of five components of an overall EMS education system: a national EMS core content, a national EMS scope of practice blueprint, national EMS education standards, national EMS education program accreditation, and national EMS certification.",
        "1996\u20132008: the role of the federal government matures, the United States faces terrorism, and EMS is at breaking point - National ambulance fee schedule": "Complaints about Medicare reimbursement for ambulance services increasingly became an issue during the 1990s. Specifically, there were concerns about the lack of uniformity in reimbursement from region to region. The Balanced Budget Act of 1997 required the Health Care Financing Administration (HCFA) to commence a negotiated rule-making process with industry groups and develop a national fee schedule for ambulance services. That process began in 1999 when the HCFA established a rules committee that included the HCFA, the American Ambulance Association, the International Association of Fire Chiefs, the International Association of Firefighters, the National Volunteer Fire Council, the AHA, the National Association of Counties, the NASEMSD, the Association of Air Medical Services, and a single physician representing both ACEP and NAEMSP. The regulations and national fee schedule that resulted from the negotiated rule-making process became effective on 1 April 2002. The fee schedule established seven national categories of reimbursement for ground ambulances: BLS (emergency and non-emergency), ALS (emergency and non-emergency), a second level of ALS for complex cases, paramedic ALS intercept, and specialty care transport. In addition, there were two categories for air medical transport: fixed winged and rotary winged. The final rule also included adjustments for regional wage differences as well as for services provided in rural areas where the cost per transport is generally higher due to the lower overall numbers of transports. A medical committee was established during the negotiated rule-making process to develop a coding system for ambulance billing that would better convey to the HCFA the medical necessity for transport and the need for ALS. This document was not an official component of the rule-making process. However, the coding system was eventually adopted in 2005 by the Centers for Medicare and Medicaid Services as an 'educational tool.' It was never made a requirement for reimbursement as was originally proposed.",
        "1996\u20132008: the role of the federal government matures, the United States faces terrorism, and EMS is at breaking point - National EMS Information System": "In 2001 the NASEMSD, in conjunction with its federal partners at NHTSA and the Trauma/EMS Systems program at the HRSA, began developing a national EMS database, the National EMS Information System (NEMSIS). By 2003, a detailed data dictionary was completed. Information about each of the data elements, the variables, and the definitions associated with the data elements as well as how to deploy the elements in a database were described. With funding from NHTSA, EMSC, and CDC, the NEMSIS Technical Assistance Center (TAC) was established at the University of Utah School of Medicine in 2005. The mission of the TAC is to partner with the University of North Carolina at Chapel Hill to provide support to the NEMSIS project.",
        "1996\u20132008: the role of the federal government matures, the United States faces terrorism, and EMS is at breaking point - 11 September 2001": "The attacks on the World Trade Center and the Pentagon on 11 September 2001 changed the way that Americans think about the world as well as the way they live. Efforts to enhance the capability to prevent and respond to terrorist attacks have become routine. Shortly after 9/11, the Department of Homeland Security (DHS) was established, which represented the largest and most expensive reorganization of the federal government in history. Congress began funding preparedness efforts with billions of dollars going to federal agencies, state and local governments, and private entities such as hospitals. Despite the massive funding for public safety and medical preparedness, reports have indicated that only a small percentage (less than 4%) of this funding has gone to EMS. Advocacy efforts to increase federal funding for EMS, for both day-to-day services and preparedness, were largely unsuccessful.",
        "1996\u20132008: the role of the federal government matures, the United States faces terrorism, and EMS is at breaking point - Advocates for EMS": "Recognizing the need for greater national advocacy for EMS, the NASEMSD and NAEMSP formed a non-profit organization, Advocates for EMS (AEMS), on 22 October 2002, for promoting, educating, and increasing awareness among decision makers in Washington on issues affecting EMS. Although there had been previous efforts to establish national EMS advocacy coalitions, none were able to sustain their efforts for more than a few years.",
        "1996\u20132008: the role of the federal government matures, the United States faces terrorism, and EMS is at breaking point - Federal Interagency Committee on EMS": "The Federal Interagency Committee on EMS (FICEMS) has coordinated efforts between federal agencies on related EMS issues for several decades. Although this forum provided an opportunity for collaboration between federal agencies on EMS issues, the FICEMS lacked statutory authority and its representatives were not senior officials, which often led to policy and implementation challenges. In 2005, Congress created a new FICEMS with senior representatives from DOT, DHS, DHHS, the Department of Defense, the Federal Communications Commission, and a single state EMS director. The role of the FICEMS is to identify state and local EMS needs, to recommend new or expanded programs for improving EMS at all levels, and to streamline the process through which federal agencies support EMS. The first meeting of the new FICEMS was held in December 2006. In 2007, the National EMS Advisory Council was established to provide advice and consult with the FICEMS and the Secretary of Transportation relating to EMS issues affecting DOT.",
        "1996\u20132008: the role of the federal government matures, the United States faces terrorism, and EMS is at breaking point - Trends in air medical services": "Air medical services in the United States struggled financially for a number of decades and the industry as a whole experienced only modest growth until 2000. However, by 2005, an estimated 700 air ambulances were in operation, more than double the number from a decade before. Unfortunately, that same growth was associated with a more than 200% increase in helicopter crashes. From 2000 to 2005, 60 people died in 84 crashes, and an estimated 10% of air ambulances in the United States had experienced crashes. At the same time, the number of flights paid for by Medicare was up 58% from 2001, and during the same period Medicare payments for air ambulance transports doubled to $103 million. This has led to a belief that the improved reimbursement for air medical services that came with the implementation of the national fee schedule in 2002 was a factor that contributed to this increase in helicopter utilization. Efforts by states to regulate air ambulance services have been hampered by legal challenges from the industry related to the Airline Deregulation Act of 1978. The act preempts states from regulating FAA-licensed air transport services in ways that affect their rates, routes, or services. Although the FAA recognizes the role of states in regulating the medical aspects of air ambulance services, questions frequently arise as to what is medical and what is related to rates, routes, or services.",
        "1996\u20132008: the role of the federal government matures, the United States faces terrorism, and EMS is at breaking point - Institute of Medicine report on the future of emergency care": "In the decade from 1993 to 2002, the number of emergency departments and hospital inpatient beds in the United States declined at the same time that the number of patients coming to emergency departments (EDs) increased by 26%. As emergency medicine has matured as a specialty, patients have increasingly come to EDs as a place to get what is perceived as good care at a convenient time. Additionally, they are frequently referred to EDs by private physicians for unscheduled care. There is also evidence that patients without insurance use EDs as a safety net for obtaining care that they cannot get elsewhere. The result of these intersecting issues, combined with an aging population, is hospital and ED overcrowding. When hospitals are full, admitted patients are frequently \u201cboarded\u201d in the ED until an inpatient bed becomes available. ED boarding, as well as elective admissions, are felt to be the major factors contributing to ambulance diversion. In 2003 there were more than 500,000 ambulance diversions in the United States. The IOM began a study of hospital-based emergency care in 2003 that rapidly expanded to address long-standing and significant issues related to EMS and emergency care for children. In particular, EMS systems were viewed as increasingly overburdened and underfunded. The result was a three-volume IOM report titled The Future of Emergency Care, which was released in 2006. Key findings of the report included the following: many EDs and trauma centers are overcrowded; emergency care is highly fragmented; critical specialists are often unavailable to provide emergency and trauma care; EMS and EDs are not well equipped to handle pediatric care. Key recommendations of the report included the following: create coordinated, regionalized, and accountable emergency care systems; create a lead (federal) agency for emergency care; end ED boarding and diversion; increase funding for emergency care; enhance emergency care research; promote EMS workforce standards; enhance pediatric presence throughout emergency care. The IOM report was the first major report on emergency care since the 1966 NAS-NRC report and included a number of recommendations for EMS that, if adopted, would have a major impact. One recommendation of particular relevance to EMS physicians is the recommendation to create a subspecialty for EMS physicians. Other recommendations of specific interest to EMS include developing national standards for the categorization of emergency care facilities; developing evidence-based national model EMS protocols; increased funding for EMS preparedness; states should require national accreditation of paramedic education programs and national certification for state licensure; EMS agencies should have pediatric coordinators to ensure appropriate equipment, training, and services for children.",
        "2009\u20132013: a period of incremental progress - Subspecialty in EMS medicine": "Following decades of efforts and bolstered by a recommendation in the 2006 IOM report The Future of Emergency Care, ABEM successfully petitioned and the American Board of Medical Specialties approved a physician subspecialty in EMS on 23 September 2010. The ABEM website has the following description of the subspecialty. Emergency Medical Services (EMS) is a medical subspecialty that involves prehospital emergency patient care, including initial patient stabilization, treatment, and transport in specially equipped ambulances or helicopters to hospitals. The purpose of EMS subspecialty certification is to standardize physician training and qualifications for EMS practice, improve patient safety and enhance the quality of emergency medical care provided to patients in the prehospital environment, and facilitate further integration of prehospital patient treatment into the continuum of patient care. A task force developed and published an article entitled \u201cThe core content of EMS medicine\u201d on 10 January 2012. The first certification examination was administered in October 2013.",
        "2009\u20132013: a period of incremental progress - EMS provider education": "In 2009, NHTSA published the National EMS Education Standards. These are consistent with the principles of the 1996 EMS Education Agenda for the Future: A Systems Approach and establish the entry-level educational competencies for the levels of EMS providers outlined in the National EMS Scope of Practice Model. The current model has four levels of providers: emergency medical responder, emergency medical technician, advanced emergency medical technician, and paramedic. The emergency medical technician-intermediate that was established in 1999 was eliminated. The National EMS Education Standards are replacing the National Standard Curricula and will enable more diverse implementation methods and more frequent updates.",
        "2009\u20132013: a period of incremental progress - Community paramedicine": "There has been growing interest in the United States in expanding the role of paramedics to include the management of urgent low-acuity illnesses, monitoring patients with chronic illnesses at home, and performing other functions that do not involve the traditional EMS role of treating and transporting patients to emergency departments. While scientific evidence of the safety and effectiveness of such expanded roles is limited, the success of programs in Canada, England, and Australia has drawn the attention of governments and others interested in innovative models of health care delivery and incorporating non-physician providers, who are sometimes viewed as underutilized, into these models. Legislation passed in Minnesota in 2011 (2011 Minn. Laws, Chap. #12) defines community paramedics and establishes a process for educating and certifying them. In 2012 a law was passed to enable reimbursement for community paramedic services under the medical assistance program and to study the cost and quality of the program (2012 Minn. Laws, Chap. #169). Also in 2012, the Maine legislature passed a law to establish pilot community paramedic projects (Chapter 562, Sec. 1 \u00a784). Community paramedic programs also function in Western Eagle County, Colorado, and Fort Worth, Texas.",
        "2009\u20132013: a period of incremental progress - National EMS Culture of Safety Project": "Emergency medical services is known to be a high-risk profession; EMS providers are 2.5 times more likely than the average worker to be killed on the job, and their transportation-related injury rate is five times higher than average. Additionally, there are patient safety concerns as outlined in the 1999 IOM report To Err is Human as well as concerns about risks to EMS personnel, patients, and the community from ambulance crashes. In 2009 the National EMS Advisory Council recommended that NHTSA create a strategy for building a culture of safety in EMS. With support from the EMS for Children Program at the HRSA, NHTSA contracted with ACEP to develop a National EMS Culture of Safety Strategy that was published in October 2013.",
        "2009\u20132013: a period of incremental progress - EMS research": "In response to the recommendations to improve research in emergency care that were included in the 2006 IOM report The Future of Emergency Care, the National Institutes of Health (NIH) established an Emergency Care Research Working Group in 2007. The purpose of the working group is to coordinate research in emergency care across the NIH in an effort to improve efficiency, realize scientific opportunities, and enable the rigorous training of new investigators. In November 2010, the NIH published four papers in the Annals of Emergency Medicine summarizing the progress, promise, and process of emergency care research and reporting on the outcomes of three roundtables. An Office of Emergency Care Research has been established and Jeremy Brown MD was appointed the first permanent director in July 2013."
    },
    {
        "Tactical EMS": "Tactical medicine comprises out-of-hospital medical services and supports for civilian law enforcement operations, typically SWAT operations.",
        "What Does a SWAT Team Do?": "SWAT (Special Weapons and Tactics) teams are law enforcement units with specialized training suitable for high-risk assignments. They can be local, state, or federal. Occasionally, these teams may be called something other than SWAT, like Special Response Teams (SRT). Assignments frequently include: \u2219High-risk warrant service \u2219Active shooter response \u2219Barricaded suspects \u2219Hostage situations \u2219Clandestine drug lab interdiction \u2219Domestic terrorism \u2219Riots or civil unrest",
        "Common Terms in the Tactical Environment": "Cold zone:  Outer-most perimeter of a tactical scene where risk is lowest. Warm zone: Moderate risk area of the tactical scene where medical decision-making is most influenced by the dynamics of the tactical scene. Hot zone:  Inner perimeter of the tactical scene where risk is highest (ie, area of active fire). Breach:  To open or port a structure by force, usually with a tool. Entry:  The act of entering a structure with the intent to neutralize a known threat and/or clear the structure of additional or unknown threats. Cover:  Any structure on the tactical scene suitable to protect one from danger; not to be confused with \u201cconcealment.\u201d Concealment:  The state of being out of the visual field of the threat; not to be confused with \u201ccover.\u201d Operator:  A law enforcement officer (LEO) who is a SWAT team member. Stack:  The term used for the entry team, based on its formation.",
        "What is the role of the Tactical Medical Provider (TMP)?": "TMPs can be paramedicine professionals, nurses, physician assistants, or physicians. Sometimes, a TMP is a sworn law enforcement officer with a medical background. The role of the TMP includes, but is not limited to: \u2219Providing team health and preventive care. \u2219Performing medical pre-planning for tactical operation. \u2219Attending to injury or illness during training and operations. \u2219Self-aid/buddy aid education for LEOs. \u2219Medical evaluation of a suspect prior to incarceration. \u2219Acting as liaison between the tactical team and medical community.",
        "Challenges of the Tactical Environment": "The tactical scene differs from the conventional pre-hospital environment because of the challenges presented. Frequent and focused training optimizes the ability of TMPs to work in this environment. Challenges include: \u2219Presence of an active, unpredictable threat to safety. \u2219Low light conditions. \u2219Sound impediments. \u2219Restrictive, bulky nature of protective gear. \u2219Chemical munitions. \u2219Limited field resources. \u2219Extraction and evacuation. \u2219Logistics of sustained operations. \u2219Preservation of evidence.",
        "Medical Threat Assessment": "The medical threat assessment (MTA) is the cornerstone of tactical medical support. It is the method by which the TMPs collect and document information for the medical pre-planning of an operation. This information is to be shared with the tactical commander for consideration when planning an operation. At a minimum, the MTA document should attempt to include the following information: \u2219Type of operation. \u2219Number of operators. \u2219Number of civilians and suspects on scene, and any pre-existing conditions they may have. \u2219Nearest ED, trauma center, and burn center. \u2219Any public works or other obstacle that would impede transport to definitive care. \u2219Nearest landing zone for air medical transport. \u2219Canine threats on scene. \u2219Emergency veterinary care. \u2219Fresh water source on scene. \u2219Weather and environmental conditions.",
        "On-Scene": "For tactical operations, the positioning and movement of TMPs are at the discretion of the tactical commander and can vary widely from team to team. Some TMPs will line up in the \u201cstack\u201d and make entry with operators. Others may remain in the \u201cwarm zone\u201d behind hard cover or in the \u201ccold zone.\u201d Safety is paramount.",
        "PPE for the TMP": "\u2219Body armor and ballistic helmet \u2219Eye protection \u2219Ear protection (unless it interferes with communication) \u2219Knee pads \u2219Medical PPE \u2219Air-purifying respirator (APR) \u2219Hydration system",
        "Medical Care in the Tactical Environment": "The medical treatment paradigms for civilian tactical operations are extrapolated from military medicine models. Based on military data, the 3 most common causes of preventable battlefield death are: 1. Extremity hemorrhage. 2. Tension pneumothorax. 3. Airway obstruction. Tactical Combat Casualty Care (TCCC) is the military model for battlefield trauma care and is the most commonly used model for the civilian tactical environment. The 3 phases of care under TCCC are: 1. Care Under Fire: The phase of care rendered under hostile fire or while the threat is still active. Depending on the structure of the tactical team or the dynamics of the scene, the first responder may be an operator, and medical equipment may be limited to the contents of the operator\u2019s individual first aid kit (IFAK). a. Contrary to conventional civilian trauma treatment models, emphasis is placed on hemorrhage control before airway management. The MARCH acronym is frequently used: M \u2014 Massive hemorrhage A \u2014 Airway R \u2014 Respiration C \u2014 Circulation H \u2014 Head injury/hypothermia 2. Tactical Field Care: Care rendered when the first responder is no longer under hostile fire. It may also refer to care for the injured on a scene in the absence of antecedent hostile fire. Care may be more detailed and comprehensive, but is still limited by conditions and equipment. Multiple casualties should be triaged accordingly. Delay to definitive care should be minimized. 3. Tactical Evacuation Care:  Care rendered once the casualty is en route to definitive care. Additional medical equipment and personnel may be present, but conditions are still a limitation.",
        "Medical Equipment": "Tactical medical kits vary based on the level of the provider, medical protocols, and practice environment. Many teams employ a \u201cmodular\u201d system, where the medical kit is organized based on convenience, type of operation, length of operation, and other considerations. Though an exhaustive list of kit contents and formulary medications are beyond the scope of this reference, all kits should include the basic equipment necessary to address the 3 most common causes of preventable battlefield death. This includes: \u2219Tourniquets \u2219Compression bandages \u2219Nitrile gloves \u2219Gauze \u2219Nasopharyngeal airway \u2219Chest seals \u2219Large bore needles \u2219Shears",
        "Resources": "Campbell JE, et al. Tactical Medicine Essentials.  Sudbury, MA: Jones & Bartlett Learning, 2012. Schwartz, Richard B., John G. McManus, and Raymond E. Swienton. Tactical Emergency Medicine.  Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins, 2008."
    },
    {
        "Introduction": "Water rescue is any incident that involves the removal of victims from any body of water other than a swimming pool. Floods are the most common of all natural disasters and generally cause greater mortality than any other natural hazard.",
        "Hazards Associated with Water Rescue": "\u2219Human nature: The \u201cneed to do something now\u201d can prompt people to make rescue attempts without proper training or equipment. \u2219Environmental: Hazards can involve extreme temperatures; cold affects ability to think clearly and hampers fine motor skills; heat exhaustion and dehydration are a concern as well. \u2219Weather: Accelerates hypothermia. In still water body heat is lost 25 times faster than in air at the same temperature. \u2219Aquatic environment: Be aware of animal life, fish, insects, plant life, seaweed, biohazards, bacterial, and viral risks. \u2219Dive option hazards: These include barotrauma, decompression sickness, nitrogen narcosis, oxygen toxicity, embolism, fatigue, loss of air, anxiety reactions. \u2219Ice operation hazards: Cold injuries such as frostbite or hypothermia; thin ice with sudden immersion reflex or entrapment under ice. \u2219Swift water operation hazards: Strainers and debris, holes, obstructions above or below the water surface.",
        "Safety of a Rescuer \u2013 \u201cThrow, Don\u2019t Go\u201d": "Jumping in the water to rescue a victim is the last resort. Avoid getting into a dangerous situation. Your safety is priority.",
        "Water Rescue PPE": "Wet suits/dry suits/exposure suits Thermal protectionPFDs include a whistle, knife, strobe light, or light stick worn by all personnel in or near water or on a boat Lifelines, helmet, gloves",
        "Rescue Plan of Action & Methods": "First unit on scene sizes up the situation and determines the number and condition of patients. If rescue is deemed necessary, consider the need for additional personnel and equipment. Secure the immediate area to prevent an increase of victims. Assess hazards, location, and number of victims. Before commencing extraction, yell clear and simple instructions to the victim. Ensure firm footing and remember the victim is in duress and may pull rescuers into the water.",
        "REACH": "Step 1: Reach with an outstretched arm, leg, or other tool (long stick/scarf/clothes) from a crouched or lying position. - DO NOT enter water any deeper than knee deep, unless tethered.",
        "WADE": "Step 2: Test the depth with a long stick before wading in and then use the stick to reach out. Hold on to someone else or the bank.",
        "THROW": "Step 3: Throw rope bags, life rings, and floats - anything that will float (this is only effective when the subject is cooperative)",
        "ROW": "Step 4: Use a boat if you can use it safely. Do not try to pull the person on board in case they panic and capsize the boat.",
        "Post-Rescue Care": "Once the victim has been removed to a safe area, medical personnel should be on scene to evaluate and transport to the hospital if necessary.",
        "Safe Swimming Position": "If you get swept away, assume the safe swimming position and navigate with ferry angle.",
        "Awareness Level Personnel (Resident)": "\u2219Establish scene controls. \u2219Establish Incident Command. \u2219Initiate accountability and safety. \u2219Evaluate patient condition. \u2219Activate needed resources. \u2219Secure and interview witnesses. \u2219Establish last seen point. \u2219Identify number of victims, age, and sex of victims.",
        "Sectorization of Rescue Operation": "Upstream group: Responsible to watch for and advise of any obstacles and hazards that may hinder the rescue operation. Downstream group: Prepare to rescue victims and rescuers that may be swept downstream. All members in this group should have a throw rope bag in hand and deploy on both sides to the bank. River right/left group: Responsible for rigging the opposite end of a rope rescue system. Rescue group: Responsible for developing an action with command. Once action plan has been developed, rescue group will execute plan in the safest possible manner. Medical group: Responsible for providing first aid treatment to victims removed from the water.",
        "Rescue Communications": "Whistle Commands 1 Blast = Stop and look at me 2 Blasts = Begin the action that we agreed upon or is indicated 3 Blasts (repetitive) = I need help Hand Signals One arm in air = I need help One hand on top of head = I am OK Rope Signals 1 Tug = OK 2 Tugs = Advance 3 Tugs = Take up slack 4 Tugs = Help",
        "Technique for Mechanical Advantage": "Vector pull: By attaching one end of the rope to an anchor and the other to the pinned object, the rope can then be pulled near the mid-point in a sideways direction to exert a much greater force on the pinned object. Z drag/pulley system: Theoretical mechanical advantage of 3, giving a 3:1 haul ratio. Requires excess gear, time, and only pulls the pinned object 1 foot for every 3 feet pulled by the user. Prusik 1 provides the mechanical advantage. Prusik 2 can be used to hold the position of the rope. Prusik knot slides easily along a tight rope but jams solidly upon loading.",
        "Drowning": "Drowning is a process resulting in primary respiratory impairment from submersion or immersion in a liquid medium. The distinction between salt water and fresh water drowning is no longer important in non-fatal drowning. Both result in hypoxia and pulmonary edema. Panic causes loss of normal breathing pattern and reflex inspiratory efforts, followed by aspiration and reflex laryngospasm, hypoxemia, end organ damage, and death.",
        "Management": "Ventilation is priority, unlike in cardiac arrest. If the patient does not respond to 2 rescue breaths that make the chest rise, the rescuer should immediately begin performing high-quality chest compressions. CPR, including the application of an automated external defibrillator, is then performed according to standard guidelines. Cervical spine immobilization is not recommended unless there are clinical signs of injury or concerning mechanism, as it can interfere with essential airway management.",
        "Hypothermia": "Hypothermia is a core temperature less than 35 Celsius. Water does not have to be ice-cold for hypothermia or other cold-related injuries. Most water is well below human core body temperature. Prolonged exposure to water may result in hypothermia. Generally, a hypothermic patient is never considered dead until the core temperature is increased to 32\u00ba Celsius.",
        "Stages of Hypothermia": "Mild hypothermia: Core temperature 32-35\u00ba C (90-95\u00ba F); result is tachypnea, tachycardia, initial hyperventilation, ataxia, dysarthria, impaired judgment, shivering, and cold diuresis. Moderate hypothermia: Core temperature 28-32\u00ba C (82-90\u00ba F); proportionate reductions in pulse rate and cardiac output, hypoventilation, central nervous system depression, hyporeflexia, decreased renal blood flow, and loss of shivering. Paradoxical undressing may be observed. Atrial fibrillation, junctional bradycardia, and other arrhythmias can occur. Severe hypothermia: Core temperature < 28\u00ba C (82\u00ba F); pulmonary edema, oliguria, areflexia, coma, hypotension, bradycardia, ventricular arrhythmias including ventricular fibrillation, or asystole occur.",
        "Treatment of Hypothermia": "Passive external rewarming (PER) is the treatment of choice for mild hypothermia. Remove wet clothes and apply blankets or different types of insulation. Active external rewarming (AER) is used for moderate to severe hypothermia or failure to respond to passive rewarming. Use a combination of warm blankets, heating pads, radiant heat, warm baths, or forced warm air applied directly to the patient\u2019s skin. Rewarming of the trunk should be undertaken before the extremities to minimize hypotension and acidemia due to arterial vasodilation and core temperature afterdrop.",
        "References": "1. Giesbrecht GG, Hayward JS. Problems and complications with cold-water rescue Giesbert. Wilderness Environ Med. 2006;17(1):26-30. 2. Orlowski JP, Szpilman D. Drowning. Rescue, resuscitation, and reanimation. Pediatr Clin North Am. 2001;48(3):627-646. 3. Poole J, Hogan DE. Disaster Medicine \u2013 Floods. Wolters Kluwer Health. 2007 4. Water Rescue Awareness \u2013 Pasco Fire Department 5. Pendley T. The Essential Technical Rescue Field Operations Guide. 4th ed. 2003 Pendley."
    },
    {
        "Types of Radiation Exposure": "Radiation is the release of energy from atoms. It can be categorized as non-ionizing or ionizing. \u2219Non-Ionizing: Low intensity and low frequency waveforms, such as microwaves and heat. \u2219Ionizing radiation is composed of particles and high frequency waveforms with sufficient energy to remove electrons from atoms. \u2219Alpha particle: 2 protons and 2 neutrons. High energy with low penetration. Travels only a few centimeters in air. Primary sources include uranium and plutonium. Main risk is inhalation injury or ingestion. \u2219Beta particle: Travels several meters. Penetrates several centimeters into tissue. Potential sources include Carbon-14, Iodine-131, Radium-226, Cobalt-60, Selenium-75. Hazardous as an external or internal contaminant. \u2219Neutron particle: Variable energy and penetration. Major source from fission reactions, such as nuclear weapons and power plants. \u2219May be absorbed by metal devices. \u2219Waveforms: Electromagnetic energy, such as x-ray and gamma rays, emitted from the cell nucleus. High energy and high penetration of tissue. Gamma emitters include Cobalt-60, Cesium-137, and Iridium-192. Large doses of whole body exposure can cause acute radiation sickness.",
        "Detection": "EMS detection of radiation can be accomplished by: \u2219Portable instruments: \u201cGeiger counter\u201d is the most commonly used. \u2219Personnel dosimeters: Worn on the anterior thorax. These instruments should be provided to all staff working in a potentially contaminated field. First responders must consider that, in the post-9/11 era, any bombing could potentially be a \u201cdirty bomb.\u201d In addition, responders should suspect potential radioactivity on any scene they see the trefoil, which is the international radiation symbol.",
        "En-Route Considerations": "Responders should attempt to gather as much information as possible while traveling to an incident that could involve a radioactive substance. A checklist to help determine initial actions should be developed and made available to all EMS personnel. This checklist should include: \u2219Type and nature of the incident \u2219Radioactive substance name if known \u2219Name and age of victims \u2219Signs and symptoms experienced by patients \u2219Injuries sustained by patients \u2219Routes of exposure \u2219Length of exposure In addition, communication should be established with local authorities, particularly police and fire.",
        "On Scene": "In general, the ambulance should park upwind, uphill, and at a safe distance from a potential radioactive site. Helicopters should not be used as the transport vehicle, because the draft wind can stir up radioactive particles. Scene safety takes priority in the emergency response to a radiologic event. The primary goal of first responders is to isolate the scene. NIOSH, OSHA, USCG, and EPA recommend dividing the incident area into 3 zones, establishing access control points, and delineating a contamination reduction corridor based on the military model.",
        "Exclusion (Hot) Zone": "Encompasses all suspected hazardous material. The Gross Decontamination Phase and basic lifesaving measures such as airway and hemorrhage control occur in this zone.",
        "Contamination Reduction (Warm) Zone": "A safe distance from hot zone; may still have some contamination and PPE is still worn. Definitive decontamination occurs in this zone.",
        "Support (Cold) Zone": "Free of all hazardous contamination materials and includes the command and staging areas. A quick scene assessment by trained personnel should determine the nature of personal protective equipment (PPE) required in the Hot Zone.",
        "Decontamination": "In general, decontamination requires: \u2219A safe area. \u2219A method for washing off contaminants; typically large volumes of tepid water. \u2219A means of containing the rinsed and contaminated material, such as marked double plastic bags. \u2219PPE for providers. \u2219Disposable or cleanable equipment. \u2219This includes gross patient contamination and secondary/definitive patient. The Gross Decontamination phase includes the medical provider\u2019s primary assessment of ABCs, as well as the cutting away of clothing and jewelry once immediately life-threatening emergencies such as respiratory failure and hemorrhage are addressed. Open wounds should be cleaned and then covered with a water repellant dressing. The patient should then be rinsed with tepid water from head to toe. Definitive Decontamination occurs in the \u201cwarm\u201d zone and involves making the patient as clean as possible before transferring to the support zone and receiving facilities. Guidelines on duration of decontamination vary, but generally fall between 3-5 minutes, if not longer. If resources or time constraints do not allow for thorough cleansing, the patient should be cocooned in a blanket or sheet prior to transfer. The removal of clothing and shoes will reduce external contamination by 70-90%. Thorough washing with soap and water will provide over 95% decontamination.",
        "Treatment": "EMS treatment of the victim of radiation contamination or exposure is no different from standard patients, with the exception of the provider protecting oneself from contamination. The primary survey should be concurrent with the gross decontamination process. Secondary survey occurs when time allows. Treatment of airway emergencies follows standard protocols. Consider inhalation injury in anyone near blast sites. The majority of injuries resulting from a \u201cdirty bomb\u201d will be blast and thermal injuries. Extensive burns require cleansing with saline or tepid water as part of decontamination. The patient should then be covered with sterile dressings and preferably transported to a burn center. If able, provide comfort with analgesics.",
        "Transport": "No patient should be transported who, at a minimum, has not undergone gross decontamination. Make sure to contact the receiving institution and ask for instructions for entering the hospital with a contaminated patient. The ambulance should park in a designated decontamination area. Upon release of the patient to the hospital, inquiries can be made as to where the ambulance can safely decontaminate and whether the institution has protocols and resources for this. The ambulance should not go back into service until deemed safely decontaminated by an adequately trained staff, such as a haz-mat team coordinator.",
        "Resources": "1. Agency for Toxic Substances and Disease Registry. Managing Hazardous Material Incidents (MHMI). Volumes 1, 2, and 3. Agency for Toxic Substances and Disease Registry (ATSDR). 2001. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service 2. Brennan R, Waeckerle J, Sharp T, et al. Chemical warfare agents: emergency medical and emergency public health issues. Ann Emerg Med. 1999;34(2):191-204. 3. Broad W, Engelberg S, Glanz J. A Nation Challenged: The Threats; Assessing Risks, Chemical, Biological Even Nuclear. The New York Times; November 1, 2001. 4. Burgess JL, Kirk M, Borron SW, et al. Emergency department hazardous materials protocol for contaminated patients. Ann Emerg Med. 1999;34(2):205-212. 5. The Emergency Response Guidebook. A Guidebook for First Responders During the Initial Phase of a Dangerous Goods/Hazardous Materials Transportation Incident. 2012. 6. Houston M, Hendrickson RG. Decontamination. Crit Care Clin. 2005;21(4):653-672. 7. Radiation Emergency Assistance Center/Training Site (REAC/TS). http://www.orau.gov/reacts/default.htm 8. Skorga P, Persell DJ, Arangie P, et al. Caring for Victims of Nuclear and Radiological Terrorism. The Nurse Practitioner. 2003;28(2):25-41."
    },
    {
        "content": "Prehospital emergency care in the modern age is often described as a \u201chierarchy\u201d of human and physical resources utilized in the acute setting to provide the best possible patient care until definitive care can be established. Like most hierarchies, the system in place today was forged one link at time, dating as far back as the Civil War. With widespread trauma, a systematic and organized method of field care and transport of the injured was born out of necessity. In 1865, the first civilian ambulance was put into service in Cincinnati, Ohio, followed by a civilian ambulance surgeon in New York 4 years later. The New York service differed slightly from the modern approach, as they arrived equipped with a quart of emergency brandy for each patient. Military conflicts and necessity provided much of the impetus to develop innovations in the transportation and treatment of the injured. In the wake of World War I, the Roaring \u201820s saw the first volunteer rescue squads forming in locations such as Virginia and New Jersey. Control began to shift toward municipal hospitals or fire departments as funeral home hearses were slowly joined by fire departments, rescue squads, and private ambulances in the transportation of the ill and injured. Landmark articles in the late 1950s and early 1960s began to detail the science and methods for initial cardiopulmonary resuscitation (CPR), forging yet another vital link in the chain as EMS began its first steps to transition from transport-only into the treatment of prehospital cardiac patients. Departments trained in cardiac resuscitation began to record successes in major urban areas such as Columbus, Los Angeles, Seattle, and Miami. The 1960s provided another challenge to public health as traffic accidents began to lead to considerable trauma and death. This \u201cneglected disease of modern society\u201d was detailed in the 1966 white paper, Accidental Death and Disability: The Neglected Disease of Modern Society. The paper, prepared by the National Academy of Sciences and the President\u2019s Commission on Highway Safety, detailed the injury epidemic and the lack of appropriate prehospital care and an organized system to treat patients suffering from critical traumatic injuries. Reforms were indicated in education and training, systems design, staffing, and response in the nation\u2019s ambulance services. The white paper gave way to the National Highway Safety Act of 1966, which established the Department of Transportation (DOT). The DOT and its daughter organization, the National Highway Traffic Safety Administration (NHTSA), were critical in pushing for the development of EMS systems while standardizing education and curriculum standards, encouraging involvement at the state level, and providing oversight into the creation of regional prehospital emergency systems and regional trauma center systems, forming the birth of trauma center accreditation by the American College of Surgeons Committee on Trauma. For the first time in U.S. history, a curriculum standard was being set in skills and qualifications required to become an emergency medical technician. Paramedic education arrived shortly afterward, but it still has a ways to go in terms of scope and depth. The EMS Systems Act of 1973 provided funding for the creation of more than 300 EMS systems across the nation and set aside funding for key future planning and growth. During this time, EMS grew alongside the development of emergency medicine as a distinct specialty, with the first residency training program approved in 1970, at the University of Cincinnati. By 1975, more than 30 EM residencies developed across the nation, preparing physicians who would interface with EMS at all levels: from responders and educators, all the way to medical directors. Advances in care standards and education continued throughout the 1980s with changes in the principles of EMS funding through the Omnibus Budget Reconciliation Act. The act established EMS funding from state preventative health block grants rather than funding from the EMS Systems Act. The role of EMS also began to change towards the front line of healthcare to include chronic diseases, pediatric patients and the underserved. EMS practice was no longer just for adult trauma and cardiac emergencies. Recognizing the need to advance its own practice while creating a cohesive integration with the health care landscape, the 1996 EMS Agenda for the Future was drafted. The EMS Education Agenda for the Future was published shortly thereafter and described more modern recommendations for core curriculum content, scope of practice, and certification of EMS professionals. Within the past 20 years, EMS has become a focus of intense research of prehospital interventions into many commonly encountered acute care issues seen in emergency medicine, such as acute respiratory distress, cardiac arrest, chest pain, and trauma. With increasingly integrated technology between prehospital care and the emergency department, patient data is beginning to be transmitted real-time, allowing for earlier determination of patient severity and care management needs prior to arrival. Quality improvement with integrated electronic charting, including patient outcomes, is beginning to provide much-needed feedback as EMS endeavors to become a dedicated subspecialty of emergency medicine. Within regional stroke centers, cardiac catheterization centers, and trauma systems, EMS has become the forefront of emergency medical care and can only serve to advance how emergency medicine is conducted in the future. EMS has come a long way from the horse and buggy. Growing alongside emergency medicine, there are opportunities for physicians to become involved in many different aspects of the system. While EMTs are not independent practitioners and generally operate under a medical director\u2019s authorization, the situations they face require considerable problem-solving, judgment, and clinical decision-making skills. Physicians are needed at every step to help develop treatment protocols, provide quality improvement, hold regular training sessions, and ensure all personnel have the tools they need to perform high-quality prehospital care. In addition, EMS physicians may be called upon for situations that require their presence on scene in the field including mass casualty incidents, high acuity and high-risk scenarios, tactical situations, or patients that require advanced skills such as surgical airways, pericardiocentesis, thoracostomy tubes, and others. Large-scale operations including concerts, conventions, and city events also benefit from physician input. EMS will continue to be the front line of emergency medicine as the field expands in the coming future. Physicians involved with pre-hospital care will be paramount to providing the support and knowledge required to help EMS systems grow, as evidenced by the recent recognition of EMS as an official clinical subspecialty. Involvement in the EMRA EMS Division will be a great opportunity for EMRA members with a career interest in EMS as well as those seeking exposure to working with prehospital systems in the future. If you are interested, please feel free to contact us at emsctte@emra.org."
    },
    {
        "Introduction to Safety": "Safety is a process requiring awareness, experience, and con - tinuous reassessment. It is the primary concern for medical stu - dents and residents on EMS rotations. This section will explore common scenes encountered by first responders and will offer guiding principles to ensure provider safety; however, this is by no means conclusive or all-encompassing. The most import - ant principle is to not enter a situation where your safety may be compromised. Your No. 1 priority at all times is looking after your own safety!",
        "Emergency Vehicle Operations": "Operating an emergency vehicle is the highest-risk task EMS providers undertake. Should you find yourself operating these vehicles (only after formal training and authorization; very few EM residency programs allow this), follow these general guide - lines: \u2219Emergency response vehicles are requesting the right of way; expect other drivers to deny that request or not understand it. \u2219More noise is better noise! Utilize the many sound settings on your vehicle to broadcast your intentions. \u2219For all opposing signals (red lights, stop signs, yield zones), make a full stop and eye contact with other drivers to ensure they see you and understand your intentions. Do not proceed if you are not confident other drivers understand you are responding to an emergency and are requesting the right of way. \u2219When you arrive on scene, reduce your noise level, but keep lights on even after you leave your vehicle. Do not operate an emergency response vehicle without appropriate formal training and orientation.",
        "Sizing up the Scene": "Make it a habit, no matter the call, to take a few seconds for critical scene assessment. This will also help determine what equipment to take when you do leave the safety of your vehicle. \u2219Scene Approach: Look for obvious hazards first; any mention of hazards on dispatch call? \u2219Potential Assault or Harm: Is law enforcement on scene? If there is any doubt about safety, call for law enforcement to secure the scene prior to your entry! Do not enter the scene without an all-clear from law enforcement personnel. \u2219Required Equipment: Flashlight, traffic or safety vest, helmet or head protection, safety glasses, and personal protective equipment for infection control. \u2219Requesting Additional Resources: Use radio to describe the scene (eg, number of potential patients, entrapment, mechanisms of injury, location, and other potential hazards). \u2219Questionable Safety: Retreat immediately to a predetermined staging area while awaiting law enforcement. Open public areas like parking lots one or two blocks away on a main road allow for quick entrance and exit to main roads, with good scene visualization.",
        "The Motor Vehicle Collision (MVC)": "This is one of the most frequent calls EMS responds to, and it entails significant risks to providers. These scenes should not be entered without appropriate traffic control and support from other units. \u2219Evaluate the scene and determine required resources; do not enter traffic without other units providing traffic control. Watch especially for downed wires, which may be energized. \u2219Always wear a bright, reflective traffic vest. \u2219Unstable vehicles: If there a vehicle is unstable, especially in cases of required extrication or any question of fire/combustion safety, wait for fire and rescue assistance. \u2219Vehicles can be hot: any exposed body area can be burned. Wear appropriate fire safe materials before working with any potential for exposed engine components. \u2219Ongoing /prolonged extrication or rescue work: establish ABCs, reassure patient, communicate rescue progress, consider pain management options, and begin initial medical care when possible. Scrubs are not appropriate apparel for out-of-hospital medicine.",
        "Fire, Water Emergencies, and Other Rescue Operations": "The type of scene may vary significantly, but the ultimate ob - jective is the same: making sure that providers (and patients!) go home safely at the end of the day. \u2219Do Not Enter a Fire Scene: The fire professionals will handle fire. Wait for patients at designated medical treatment areas. These areas may require your supervision as a physician. Review National Incident Management System (NIMS) mass casualty protocols. \u2219Water Emergencies: DO NOT attempt a water rescue without specific training. Wait for patients at designated areas. \u2219Ensure Safety of Medical Treatment Area: Winds may change, and your location will require periodic reassessment. Consider smoke and hazardous materials flow, and continuously reassess. \u2219Scene-specific Provider Health Hazards: Smoke inhalation, CO poisoning, burns, and hypo/hyperthermia are all risks. Evaluate providers with full exam, and watch for those who need further ED evaluation. Solicit assistance from other fire personnel as needed. Providing simple scene support such as water and cool-down areas can have a significant effect for other responders.",
        "Team Dynamic": "Coordinate with incident commanders to find where your talents will be best utilized. ALWAYS check in with a scene commander when you arrive and before you enter any potentially hazardous areas.",
        "Residential/Domestic Scenes": "In a metropolitan or suburban area, a common scene for EMS is in the domestic residence. Whatever the location, the basic principles of safety must be considered. \u2219Reduce Risk Before Entering Scene: Hazardous scenes warrant law enforcement involvement. These include assault, use of deadly force (guns, knives, blunt trauma, etc.), domestic violence, psychiatric emergency, drug overdoses, or any high-risk scenarios. \u2219Approaching Domestic Residence: Knock and announce your presence. Stand to the side of doors when waiting for response. \u2219Entering Enclosed Areas (apartment, living room, etc.): Scan for safety, keep eyes on exits, know where you are at all times. Avoid going anywhere alone or without support. \u2219Altered Mental Status: Consider safety aspects involving altered/combative patients/citizens, nature of illness (stimulant overdose, hallucinogen, etc.). Be prepared to use an exit strategy or law enforcement support. \u2219Dangerous Situations: Use an appropriate amount of force to protect yourself/others; metal clipboards, flashlights, and even O2 cylinders can be used to deter assaults. Exit immediately and call for assistance. Inquire about radio emergency code words prior to your shift. Do not retrieve equipment! No amount of equipment is worth a provider\u2019s safety."
    },
    {
        "EMS Delivery Models, Provider Levels, and Scope of Practice": "EMS has evolved into a multifaceted medical care delivery machine with multiple delivery models catering to geographic and demographic needs - each part integral to the whole and serving a specific role. For example, the 911 service may take a call, transfer it to an EMS dispatcher who then triages the call for response by a firefighter, ambulance company, or law enforcement official, each of whom may be a BLS, ALS, or even flight responder. As one can imagine, this takes great effort and organization with clearly defined medical care delivery and provider roles.",
        "Additional Definitions": "Alternate Transport Vehicle \u2013 A vehicle used by an EMS agency to move patients from difficult terrain or unusual situations; can include stretcher-equipped golf carts, specially retrofitted fire engines, and armored personnel vehicles. Community Paramedic \u2013 A service delivery model where paramedics provide home-visit type services, including targeting high-frequency 911 utilizers and patients who are at high risk for hospital re-admission (eg, CHF exacerbation). Exclusive Operating Area \u2013 A jurisdiction, zone, or geographic area that maintains a sole EMS provider that, through a competitive bidding process, has exclusive contractual rights to all emergency transports for a given area. Fixed Wing Aircraft \u2013 An airplane used for EMS transports or specialized medical services such as organ donation transport. Interfacility Transport \u2013  Transfer of a patient between two health care facilities, without the activation of the 911 system. Examples include transferring a patient from a community hospital to a trauma center, or from a skilled nursing facility to a dialysis center. Multiple Role EMS Agency \u2013  Emergency service agency that provides public safety services in addition to its role in the EMS system, such as firefighting, hazardous materials mitigation, or law enforcement. Fire and public safety departments commonly fit this model. Quick Response Vehicle (QRV) \u2013  A non-transporting EMS vehicle (eg, an SUV-type automobile) that is part of the initial 911 system response. Usually staffed by a paramedic. Priority Dispatching \u2013 A system used by emergency medical dispatch agencies to triage the severity of 911 calls in order to allocate appropriate resources. In some areas the dispatching protocol may also dictate if emergency signaling devices (eg, red lights and sirens) are to be used. Rotor-Wing Aircraft \u2013 A helicopter used for EMS transport, and sometimes also for search and rescue. System Status Management \u2013 A dynamic deployment model for EMS resources, which uses historical data to deploy (\u201cpost\u201d) ambulances where they are most likely to be utilized. (This is in contrast to a fixed deployment model, such as the use of fire stations.) Tiered Response \u2013  Service delivery model in which multiple levels of providers can be dispatched to an emergency. For example, a basic life support fire department is dispatched alongside a paramedic-staffed ambulance when a 911 medical call is received.",
        "References": "1. US Fire Administration. Handbook for EMS Medical Directors. FEMA. March 2012. 2. NHTSA. National EMS scope of Practice Model. Publication DOT HS 810 657. February 2007.",
        "EMS Provider Definitions & Scope of Practice": "Emergency Medical Responder (Previously known as First Responder) \u2014 Minimum training standard for many fire, law enforcement, ski patrol, and volunteer EMS squads Scope of Practice \u2219Basic life support (eg, bag-valve-mask ventilation, CPR, AEDs) \u2219Airway adjuncts (eg, oral and nasal airways) \u2219Oxygen therapy \u2219Treatment of hemorrhage and splinting fractures  \u2219Manual cervical spine immobilization  \u2219Vital signs assessment, including manual blood pressure Advanced Emergency Medical Technician (Previously known as EMT-Intermediate) Scope of Practice Includes skills of Emergency Medical Technician and: \u2219Supraglottic airways \u2219Suctioning of an endotracheal tube  \u2219Intravenous and pediatric intraosseous access \u2219Provision of the following medications: IV fluid therapy, IV dextrose, glucagon, epinephrine (for anaphylaxis), inhaled beta agonists, naloxone, nitrous oxide, and sublingual nitroglycerin  \u2219Blood glucose monitoring Paramedic (Previously known as EMT-Paramedic) Scope of Practice Includes skills of Advanced Emergency Medical Technician and: \u2219Endotracheal intubation \u2219Cricothyrotomy \u2219Pleural space needle decompression \u2219Gastric decompression (eg, nasogastric or orogastric tube) \u2219Adult intraosseous access \u2219Cardioversion and defibrillation \u2219Vagal maneuvers \u2219Transcutaneous pacing  \u221912-lead EKG interpretation \u2219Continuous positive airway pressure \u2219Capnography \u2219Provision of additional prescription enteral and parental medications (eg, lidocaine, amiodarone)  \u2219Maintaining infusion of blood/blood products Critical Care Transport Paramedic and Flight Paramedics. * Note: This level of training is not part of the National EMS Scope of Practice Model; requirements are not standardized and will vary depending on agency or jurisdiction. Paramedics who have received this level of training are typically responsible for high-acuity interfacility transports (eg, transfer of ICU, trauma, stroke, or STEMI patients). \u2219Additional training in flight physiology, hemodynamic monitoring, lab data, and radiographic interpretation  \u2219Provision of infusions and other medications not commonly used in the prehospital setting  \u2219Mechanical ventilator operation"
    },
    {
        "Introduction": "Urban search and rescue (USAR) is the process of locating, extricating, and providing for the immediate medical treatment of casualties trapped in confined spaces due to natural disasters, structural collapse, transportation accidents, mines, and collapsed trenches.",
        "Goals": "The objective of USAR is to recover casualties in a manner that maximizes the chance of recovery to their previous state of health and to rescue the highest number of people in the shortest amount of time while minimizing the risk to the rescuers.",
        "Challenges": "In confined spaces, special techniques are required to evaluate and treat the entrapped victim before extrication. Scoop and run philosophy is not possible with the trapped or pinned individual. The most important medical intervention in this setting is the prevention of cardiac complications and renal failure due to crush injury or crush syndrome. Stabilize patients prior to extrication if the scene is safe.",
        "Characteristics of Confined Space Medicine": "Confined spaces offer limited access and egress, along with unfavorable environmental conditions. Temperature extremes make hypothermia and hypoglycemia common; IV fluids and oxygen should be warmed. Confined spaces also contribute to heat-related illness, particularly for rescuers (protective clothing, strenuous activity, confined space, limited fluid intake). Encourage breaks with liberal hydration.",
        "Crush Injury/Crush Syndrome": "The most dangerous time during a casualty is during the extrication phase when compressive forces are suddenly released. Prolonged, continuous pressure involving skeletal muscle mass results in muscle breakdown, and the subsequent release of muscle contents into the circulation results in renal failure and eventual cardiac arrest. Death can occur a few minutes after the casualty is freed. The deceptive feature of crush syndrome is that it does not develop until the limb is free from entrapment. Adverse effects do not occur until circulation is restored to muscles when the crushing object is lifted. Rehydration, rewarming, and bicarbonate must be started prior to the complete extrication. Anticipate large amounts of IV fluid (6-10L) in the immediate post-release period.",
        "Pulmonary Concerns": "Airway obstruction, particulate contamination, restriction of ventilation, inhalation injury, and blast lung are the main concerns. Crush injury to the chest can be fatal and is not a common cause of death in collapse casualties. Particles from building collapse may induce acute and chronic pulmonary toxicity, primarily with the inflammatory and fibrogenic effects, and by injury to the cellular defense mechanism of the lung.",
        "Volume Concerns and Vascular Access": "Trapped victims are subject to dehydration, hemorrhage, and third spacing. Early fluid administration is important to prevent delayed complications as the victim is freed from the rubble. Vascular access must be initiated as soon as possible.",
        "Timing Is Everything": "Urban search and rescue uses the concept of \u201cthe golden day.\u201d The chance of extricating a casualty alive drops dramatically after 24 hours. However, there are reports of casualties surviving after being entrapped for 6 days and longer. Efforts should not be delayed or abandoned after 24 hours. \u221930 minutes \u2014 91.0% survive \u22191 day \u2014 81.0% survive \u22192 days  \u2014 36.7% survive \u22193 days \u2014 33.7% survive \u22194 days \u2014 19.0% survive \u22195 days \u2014 7.4% survive",
        "FEMA (Federal Emergency Management Agency)": "FEMA, an agency of the U.S. Department of Homeland Security, promotes an emergency response based on small, decentralized teams trained in areas of the National Disaster Medical System (NDMS), Urban Search and Rescue (USAR), Disaster Mortuary Operations Response Team (DMORT), Disaster Medical Assistance Team (DMAT), and Mobile Emergency Resource Support (MERS). If there is a disaster warranting USAR support, local emergency manager may request assistance from state or the state may request federal assistance. FEMA will deploy the three closest task forces within 6 hours of notification.",
        "Task Forces": "The team should be self-sufficient for a minimum of 72 hours before needing to resupply and should have a capability to operate for at least 10 days before personnel replacement is needed. The team is also responsible for bringing its own rescue equipment, support materials, and medical equipment.",
        "Treatment Priorities": "After the care of the task force is ensured, attention can be turned to entrapped casualties, search team canines, and the surrounding community. The USAR medical team will hand casualties over to local EMS agencies or DMAT at a designated location just outside the perimeter of the working rescue zone.",
        "United States FEMA Markings": "The structure triage, assessment, and marking system is designed to help identify, select, and prioritize the buildings with the highest probability of success with respect to finding and rescuing live victims. It is important that information related to building identification, conditions and hazards, and victim status be posted in a standardized fashion.",
        "International Search and Rescue Advisory Group (INSARAG)": "INSARAG is a global network of disaster-prone and disaster-responding countries and organizations dedicated to USAR and operational field coordination. It aims to establish standards and classification for international USAR teams as well as methodology for international response coordination in the aftermath of earthquakes and collapsed structure disasters. The INSARAG Secretariat is located in the United Nations Office for the Coordination of Humanitarian Affairs (OCHA).",
        "References": "1. Goodman C, Hogan, D. Urban Search and Rescue. In: Hogan D, Burstein, J, eds. Disaster Medicine. Philadelphia: Lippincott Williams and Wilkins; 2002:112-122. 2. National Urban Search & Rescue Response System\u2019s Rescue Field Operations Guide. https://www.fema.gov/pdf/emergency/usr/usr_23_20080205_rog.pdf."
    },
    {
        "Fire Operations": "The fire service follows the FEMA ICS structure when on calls. This system is adaptable for large and small incidents. The Incident Commander (IC) typically is the most senior officer on scene.",
        "Chain of Command": "\u2219Chief:  The overall commander of the fire department. \u2219Assistant or Deputy Chief: Helps the chief with administrative duties. \u2219Battalion Chief:  Tactical commander of several stations. \u2219Captain:  Commander of a station and apparatus. \u2219Lieutenant:  Not present in many departments; often in command of a specific apparatus within a company if multiple apparatus are at one station. \u2219Firefighter:  The \u201crank and file.\u201d Specific operations roles may be subdivided. \u2219Personnel Accountability System (PAS):  A means of tracking who is on scene and where they are. This is achieved by each responder placing a nameplate or tag on a larger tag for their apparatus, which is given to the IC when checking in at a scene. Some departments use an electronic version of PAS.",
        "Fire Apparatus": "The engineer or driver of the apparatus is responsible for that vehicle and everything it carries. Nobody takes equipment from the fire apparatus without being told to do so and without informing the engineer. \u2219Engine (aka pumper): Pumps the water and carries hose \u2219Truck (aka ladder): Carries ladders and rescue gear \u2219Combination: Apparatus that combine engine and truck functions \u2219Brush: Wildland apparatus \u2219Tanker: Large water tank apparatus used for scenes with limited water supply \u2219Utility: Contains equipment for support operations, such as generators, lighting, and extra SCBA bottles \u2219Heavy Rescue: Carries equipment for heavy technical rescue like trench, high-angle, vehicle extrication, and confined space \u2219Haz-mat: Carries equipment for containment and decontamination of hazardous material scenes",
        "Helmet Color Coding": "Helmet color coding aids in rapid identification of roles on a scene. Many departments use specific helmets for certain personnel. \u2219White: Chief \u2219Red: Captain \u2219Others: Departments may decide to code the engineers, firefighters, paramedics, and support personnel with different colors, including yellow, black, blue, and green",
        "Structure Fire": "\u2219Sides of building: The street side (front) of a building is referred to as the A or alpha side. Subsequent sides are named in clockwise order around the building; B (bravo), C (charlie), D (delta). \u2219Hose safety: Use caution when standing near hoselines. As water is flowing into a hose, or being charged, they can move rapidly and cause injury. \u2219Teams: Depending on the nature of the call, various tactical teams may be formed. \u2219Suppression: Primarily hose teams; can be interior or exterior. \u2219Ventilation: Remove heat and smoke by using fans or cutting holes in the roof. \u2219RIC/RIT: Rapid Intervention Crew/Team is charged with being ready to rescue downed firefighters at all times. \u2219Collapse zones: Standard \u201csafe distance\u201d from a building prone to collapse; 1\u00bd times building height.",
        "Wildland Fire": "\u2219Air Support \u2219Planes are used to drop retardant in front of an advancing fire line. Some firefighters parachute into remote locations. \u2219Helicopters are used to drop water on hotspots and crews in strategic locations. \u2219Line Crew: Firefighters use hand tools and machinery to cut fire lines or breaks in fuel to slow or stop fire spread. They may also light smaller, controlled fires called back burns to remove fuel prior to the main fire reaching critical structures. \u2219Operational zone: Sectors are named using letters to track where resources are deployed and fire progresses.",
        "Medical Considerations": "\u2219Heat exposure: Temperatures inside homes can reach above 1000 degrees Fahrenheit. Limiting exposure to this heat, as well as effective means of cooling firefighters, is essential. \u2219Dehydration: Hard work in heavy gear leads rapidly to dehydration and worsens risk of heat illness. \u2219Hypothermia: Fires that occur in the winter create risk of hypothermia as firefighters leave a building wet and warm, and subsequently cool rapidly. \u2219Cardiovascular disease: This is still the leading cause of death among firefighters. Some are relatively sedentary until placed on the fireground, where they strenuously exert themselves.",
        "Other Fireground Terms": "\u2219Company: A crew under a Captain\u2019s command \u2219Platoon: Comprised of multiple companies under a Battalion Chief\u2019s command \u2219LDH: Large Diameter Hose; Hose greater than 3 inches in diameter typically used to supply fire engines \u2219SCBA: Self Contained Breathing Apparatus; a firefighter\u2019s air supply. Typically contains 30 to 45 minutes of air. \u2219PASS: Personal Alert Safety System; a device that alerts when a firefighter is motionless for a period of time or when air is low in the SCBA to aid the RIC/RIT in locating the downed firefighter quickly. \u2219Turnout or Bunker gear: A firefighter\u2019s personal protective equipment. Protects from both thermal injury during firefighting operations and contact injury from debris during extrication or other rescue operations. \u2219Shift: Most departments are staffed by three rotating shifts of firefighters\u2014A, B, and C. Each shift is often referred to as a Platoon. \u2219Bay: A garage at the station where fire apparatus are kept \u2219Fire Classes \u2219Class A\u2014Ordinary Combustibles (wood, paper, cloth, etc.) \u2219Class B\u2014Liquids and Gases \u2219Class C\u2014Energized electrical equipment \u2219Class D\u2014Combustible metals \u2219Foam: Mixture of water and soap-like chemicals to cool fuel more effectively by decreasing water surface tension to improve penetration into fuel. Can be used in most firefighting applications. \u2219Aqueous Film Forming Foam (AFFF)\u2014Most common type of foam. Forms films over Class B fuels to aid in smothering fire. Also dilutes Class B fuels. \u2219Compressed Air Foam System (CAFS)\u2014Combines foam mixture and air to make a shaving cream-like substance that is used in similar applications as AFFF. \u2219ARFF: Aircraft Rescue and Fire Fighting; specialized form of firefighting for airports. \u2219NFPA: National Fire Protection Association; governing body for fire service operations and training."
    },
    {
        "Mass Gathering": "Mass gatherings, recognized as events with relatively large numbers of people, are becoming more frequent. These scenarios present unique problems for health care provision and safety. These differences arise from a high concentration of people, often within venues that have limited or defined space.",
        "Challenges": "\u2219Access to traditional EMS can be difficult. \u2219The resources present can be quickly overwhelmed. \u2219At a mass gathering, there is a higher incidence of people requiring medical care than the same population in the general public.",
        "Planning": "Large gatherings require deliberate planning, with careful attention to detail. Take into consideration: \u2219Venue size, layout, number of attendees/density, location, and expected weather. \u2219Venue entrance(s)/exit(s) and access. \u2219Social environment: Alcohol sales or consumption, drug use, access to water. \u2219Population: Elderly, young adults, children, and type of crowd (eg, dignitaries with security teams, etc.). \u2219Best models are previous events - ideally at the same venue and same previous event. This is often not available, so events similar in scope and population must be used as a comparison.",
        "Providing Care": "The role of a resident in a mass gathering event can vary. Keys to understanding your role: \u2219Know who is charge of medical care (local EMS, Red Cross, hospital, volunteer organization, etc.). \u2219Be aware of local legislative regulation for the particular region. \u2219Know the method of communication (dedicated radio systems, phones, etc.). \u2219Familiarize yourself with patient tracking and medical records system. This is important for patient care and planning future events. \u2219Understand the scope of patient care, drugs, and resources available. \u2219Consider methods of patient transport (gurney, carrying, golf carts, ambulances, etc.). \u2219Insurance coverage: Most events are planned well ahead of time. In these situations, the Good Samaritan law is often void. Determine the level of insurance coverage needed and adjust accordingly.",
        "Unique Events": "Airline travel \u2219Most common complaints: Gastrointestinal, abdominal pain, and nausea/vomiting. \u2219Most serious complaints (aircraft can divert): Cardiac (MI), respiratory (PE), and neurological (stroke) complaints. \u2219Every airline has 24/7 physician consultation availability via satellite phone or radio. \u2219A medical provider can request to increase cabin pressure or descend to a lower altitude. \u2219Unique environment: Dry air, lower partial pressure of oxygen, potential virulent airborne particles, potential chemical irritants, and venous stasis. Wilderness Events \u2219Considerations: Extreme temperatures, possible severe weather, risk of providers becoming patients, remote access creates problems with extrication. Cruise Ships \u2219Considerations: Isolated and dense population, often high-morbidity patients. \u2219Most common complaints: Dyspnea and injuries. Ultradistance Events \u2219Considerations: Location (city, wilderness, etc.), hydration status, and electrolyte abnormalities. \u2219Develop a plan for rehydration and electrolyte replacement, including use of PO vs. IV and possible use of hypertonic saline.",
        "Mass Casualty Incidents": "Mass casualties are chaotic situations in which multiple casualties are present. They can occur at mass gatherings, workplaces, highways, or any other location in which multiple people are present. The needs of the patients usually outweigh the resources available. Consequently, the goal of care becomes the greatest good for the greatest number. These challenges necessitate the use of a triage method to determine the order in which patients are addressed. Multiple triage methods can be used for mass casualties. A federally funded committee was appointed to evaluate the evidence pertaining to mass casualty triage and develop the Model Uniform Core Criteria, a set of requirements to ensure interoperability regardless of the triage system used. The resulting algorithm is called SALT: Sort, Assess, Lifesaving intervention, Transport. It is a non-proprietary triage scheme that meets Model Uniform Core Criteria and is used in some communities. It is important to understand what triage algorithm is used in your community.",
        "Global Sorting": "1. Instruct those who can walk to move to a designated area. Assess last. They exhibit cerebral perfusion and essentially intact motor function. 2. Instruct those who can hear but cannot walk to wave. These patients exhibit cerebral perfusion but have some other injury or situation. Assess second. 3. Those who do not walk or wave need to be assessed first. They most likely have the most serious, time-sensitive injuries.",
        "Assess": "Patients are given a color corresponding to their need for treatment. A system will be in place to designate the color and record any intervention. This could range from commercially available cards to a marker on patient\u2019s head or skin.",
        "Provide Lifesaving Interventions": "\u2219Performed simultaneously with assessment. \u2219Controlling hemorrhage (tourniquet, direct pressure, etc.). \u2219Needle thoracostomy for tension pneumothorax. \u2219Autoinjector medications. \u2219Two rescue breaths may be given to children due to higher incidence of respiratory-related arrest. \u2219Not recommended: Chest compressions, intubation, bag-valve-mask ventilation. \u2219If patient is not breathing in the field, s/he is effectively considered dead.",
        "Transport": "\u2219Largely incident command dependent. \u2219Those transported first are those who have the highest likelihood of survival given more interventions.",
        "Mistakes to Avoid": "\u2219Considering triage complete: Patients require reassessment. \u2219Providing inappropriately complex care: Keep decisions and interventions within the scope of time and resources. \u2219Forgetting about the expectant patients: Enact palliative measures (eg, pain control) as more resources become available.",
        "Incident Command System": "Incidents where resources are overwhelmed require many responders from many agencies. The management and integration of all resources is critical for a good outcome. In the United States the incident command system (ICS) provides this framework.",
        "ICS Structure": "\u2219Flexible virtual organization to meet the needs of time-limited situations \u2219Task-determined architecture linked by information pathways \u2219Modular design allows expansion or contraction to integrate needs and assets \u2219Goals (in order of priority): life safety, incident stabilization, and property conservation \u2219Directed by an incident commander to whom all responsibilities belong until delegated.",
        "Main principles of ICS": "1. Unity of Command: Each person only answers to one superior. 2. Span of Control: Each person has only 3-7 constituents immediately answering to him or her.",
        "Residents": "\u2219Function under the operations section within the medical branch. \u2219Avoid freelancing; do not change roles unless instructed by superior."
    },
    {
        "Rural EMS": "Providing emergency medical care outside of urban settings presents unique challenges. Agencies charged with this responsibility have developed means to meet this goal with limited resources. Two broad categories of non-urban EMS will be reviewed: rural EMS and wilderness EMS.",
        "Rural EMS:": "While no specific definition exists for rural EMS, such agencies are faced with challenges regarding personnel staffing, limited medical training, and logistical issues.",
        "Staffing models": "Although the names vary, most rural EMS agencies use one of three staffing models. 1. Volunteer:  All personnel within an agency are perpetually \u201con-call.\u201d Anyone available to respond does, often in personal vehicles. They are unpaid. 2. Home call:  A subset of personnel is on call for a given shift. They must remain within a certain distance of the station in the event a call comes in. When a call is paged out, they drive to the station and take the ambulance to the scene. 3. In-vehicle call:  On-call providers remain with the ambulance for their shift and respond to calls as needed. This is essentially akin to urban EMS models.",
        "Medical Training": "\u2219Time: Personnel for rural EMS agencies are almost universally providing this service as a second job or, more frequently, as volunteers. As such they cannot dedicate sufficient time to become trained to advanced levels, such as paramedic. Even meeting CME requirements for basic levels can be challenging. \u2219Number of providers: Rural communities are, by definition, sparsely populated and, as such, do not provide a large pool of potential providers. Many of these agencies are woefully understaffed and cannot respond to multiple calls simultaneously without aid. \u2219Retention: With time constraints, there typically is high turnover in these agencies. This increases burden on those leading the agency to recruit and train new staff. \u2219Clinical skills: Rural EMS providers have significantly lower call volumes and therefore have less exposure to critically ill patients. Therefore, their clinical skill proficiency for advanced procedures, such as ACLS and intubations, is in jeopardy unless the agency recognizes this gap and provides sufficient training.",
        "Logistical Considerations": "\u2219Prolonged transport time: Some agencies have transport times in excess of 6 hours to reach definitive care. The \u201cgolden hour\u201d is generally unachievable in rural EMS. This long patient contact time creates a need for ongoing assessments in addition to the usual \u201cstabilize and transport\u201d mantra. \u2219Aeromedical intercepts: For critical patients, rendezvousing with a helicopter or airplane to complete timely transport is routine. Typically the ground unit will proceed toward the hospital until intercepted by the air ambulance at a predetermined landing zone. \u2219Reciprocal aid: With limited personnel and ambulances, mutual aid agreements are often employed in an attempt to provide resources in the event of multiple, simultaneous calls or a disaster. \u2219Fire department: Because rural agencies are typically volunteer, fire department personnel may not be medically cross-trained like urban firefighters are. This can leave rural EMS providers without medical assistance on scene. \u2219Medical direction: Rural EMS medical directors may be available on occasion for online medical direction. In some circumstances, the receiving hospital may serve to provide online medical control, but this may not be feasible if the call occurs outside of hospital radio or cellphone reception. The off-line protocols, or clinical guidelines, address the most commonly encountered scenarios.",
        "Wilderness Medicine": "This section of medicine is so broad it includes academic societies, numerous large textbooks, and post-residency fellowships. Commonly defined as an environment where definitive care is farther than 1 hour away, many rural response areas could technically be considered wilderness. In this context, we will only consider formal response agencies that an emergency medicine resident may encounter, a brief description of provider levels unique to this field, and the unusual considerations this practice environment creates.",
        "Types of Wilderness EMS Agencies": "\u2219Search and Rescue (SAR): These are generally law enforcement affiliated, with varying levels of medical competence, from first aid to paramedic. Frequently takes ambulance personnel into the field on medical calls to provide patient care while the SAR team coordinates the technical aspects of rescue. \u2219Ski Patrol:  Skilled at winter rescues. Generally trained to the EMT-B level. \u2219Park Service: Varying levels of sophistication, with some services having large teams while others have a single ranger. Medical training also varies. \u2219Police:  Often participate in the role of SAR. Most officers have first responder training but varying levels of comfort with treating patients.",
        "Wilderness Provider Levels": "\u2219Wilderness First Aid: 1- to 2-day course on the basics of first aid. Unlike urban first aid, emphasis is not solely on \u201ccalling 911.\u201d \u2219Wilderness First Responder:  Approximately 80-hour course covering a broad range of medical topics. Such responders can be very skilled if they use their training frequently. Otherwise, training fades quickly. \u2219Wilderness EMT:  Weeklong course offered to EMTs to teach improvisation and how to function outside of an ambulance filled with medical tools. \u2219Advanced Wilderness Life Support:  3- to 5-day course designed for medical professionals who want to learn how to provide care with limited diagnostic and treatment options. Typically, course consists of doctors, mid-levels, and some nurses.",
        "Special Considerations": "\u2219Limited resources: Medical tools limited to what can be carried on one\u2019s back. Extra personnel may take a long time to get to the scene. \u2219Extended scope of practice:  Medical directors will frequently create protocols for providers to act beyond their formal level of training if certain conditions exist. This is helpful when communication and resources are limited. \u2219Extreme environments:  Shelter from elements is often not readily available. Working in these conditions will place rescuers at risk for becoming patients themselves and must be considered prior to exposing personnel. \u2219Air support:  If available, air support can aid in extracting patients and avoiding long carrying of an injured patient. If the patient is not critical, the air ambulance can rendezvous with a ground unit for the remaining portion of the transport, which saves both money and resources. \u2219Legal:  In the absence of well-defined provider roles, the legal implications of wilderness EMS are unclear, and standards of care in wilderness settings have not been well-established. It is safest to assume most EMS laws will apply in wilderness situations, but do not place rescuers or the patient at risk merely to meet a law."
    },
    {
        "Introduction": "EMS training experiences vary between programs. In fact, many programs don\u2019t even require ambulance ride-alongs, let alone flight time. With the advent of ACGME accreditation of EMS fellowship programs, a more generalized educational experience across residencies is likely to develop in order to meet standardized expectations of fellowship directors. For the time being, residents should become familiar with their individual program requirements. However, a model curriculum created in 1996 offers some expectation of resident EMS education. The \u2018Experiential Components\u2019 section the curriculum offers a reasonable focus.",
        "On-scene Experience": "Your level of involvement may vary \u2013 you might just help here and there with any of the following tasks, or you may wish to become a resident/assistant medical director, working with an attending physician to provide medical oversight for a particular 8 Chapter 2: Resident Roles EMS agency in your area. Regardless of the particular opportunities of individual residency programs, it is critical for EM residents to understand the nuances of EMS medicine and how they differ from emergency medicine. On-scene Experience:  Direct observation allows evaluation of subtleties not captured in written EMS run reports. You will also gain a greater appreciation for what the EMS providers deal with on scene, and their protocols prior to ED arrival. You will also have the opportunity to experience prehospital specific procedures, like backboarding/spinal immobilization, vehicle extrication, and various airway rescue devices. Depending on your residency program you may be in an observer-only role or, as a junior resident, you might operate only under EMS protocols. As a senior resident, you may be allowed to assume on-scene medical oversight, allowing the use of your own clinical judgment, procedures, and skills to perform interventions outside the EMS scope of practice.",
        "Training": "Opportunities abound to give a lecture at your local EMS agency, facilitate hands-on training, or lead an interactive review of some recent runs. This can be provided on a set schedule, or in response to specific concerns. For example, if the department has been having trouble with pediatric airway management, you may choose to review those run reports and discuss appropriate intubation and non-invasive airway management options and techniques specific to the pediatric airway. You may also consider other lecturing opportunities to develop public speaking skills. Check with your local EMS coordinator, training program instructor, or EMS official at your organization to find out about local classes, EMS conferences, and provider courses for potential opportunities.",
        "Medical Oversight": "This aspect of training involves online medical direction via phone or radio or offline via protocol development and case review. Each residency program and EMS group will have its own protocols or guidelines for medical direction, so be sure to become familiar with them prior to participating in this capacity. Another means of gaining experience with medical direction lies in quality assurance and improvement activities. The Medical Director, along with the Quality Improvement team, regularly review EMS runs. A robust QA/QI program can recognize systematic as well as individual trends, which may allow for focused training, individual action plans, or a system-wide change. Many regions have a set schedule for this (eg, review of chest pain runs in January, shortness of breath in February, etc.). Others use random chart sampling for a fixed interval, review of sentinel events, or trend analysis. Another opportunity in medical direction experience is the review, creation of, or implementation of protocols. Most EMS providers operate under protocols, which may be designed and revised by groups (a regional physician advisory board or a standing orders committee) or by an individual, like the system or state medical director. Protocols specify prehospital provider scope of practice: what medications/doses they may use, whether they may perform rapid sequence intubation, or if they may call ahead to activate the cardiac cath lab. Involvement in developing and drafting protocols is a great way to learn more about EMS systems at the local, state, or national level, and also is an opportunity to ensure that best medical practices, new and emerging technology, and up-to-date evidence-based medicine is reflected in these protocols.",
        "Disaster Planning": "Most hospitals run disaster drills that include patient evacuation, haz-mat, and limited-resource training, and participating at this level is often required. However, as an emergency medicine resident you will need a working knowledge of prehospital disaster management. Mass gatherings like concerts, sporting events, and political rallies often require EMS presence. This is a valuable exposure to disaster planning and to the many aspects of mass casualty medicine. Involvement may include preplanning, evacuation plans, and providing direct patient care at on-scene aid stations. If you are interested in disaster medicine, join your local DMAT (Disaster Medical Assistance Team), or US&R (Urban Search & Rescue) Task Force. Their medical directors help provide training, but their main purpose is to ensure the health and well-being of their crews preparing for and during a deployment. Some states have their own disaster response teams that provide services similar to the DMAT or US&R Task Force, which can be deployed at the state level without federal approval. Depending on where you live, there also may be opportunities to work with more specialized teams like wilderness or air and sea search and rescue.",
        "Beyond the typical EMS and fire department model": "NREMT test item writing:  Several times a year, physicians and EMS providers and educators gather at the National Registry of Emergency Medical Technicians headquarters in Columbus, OH, to write test questions for the national certifying exams for EMTs and paramedics. This is another good way to become more familiar with the EMS curriculum, develop your test-writing skills, and contribute at the national level to education and certification of EMS providers. Advocacy on behalf of EMS, and liaison between EMS and other groups:  This is a role that every medical director must fill to some extent. For some, it may be the simple day-to-day communication on behalf of EMS \u2013 explaining to hospital-based physicians/nurses why EMS did things a certain way, how they operate, or what their protocols do or do not allow them to do. Others may take this role much further \u2013 working with leaders in the community to build a strong local EMS system, or speaking to government officials up to the national (or even international) levels to advocate on behalf of EMS.",
        "Additional Opportunities": "SWAT/Tactical law enforcement:  These teams are increasingly looking for active EM physician involvement. This includes providing training for their own medics and working alongside the tactical team as a primary medical asset. Opportunities abound in this exciting and expanding area of emergency medicine. EM residents across the country are actively supporting tactical teams at the city, county, regional, state, and even federal levels, including FBI SWAT. Medical director for EMD (emergency medical dispatch) centers:  EMS are the first people to physically see and touch the patient, but dispatchers are the earliest link in the emergency response system, as they answer the phone call and provide verbal instruction for things like CPR and bleeding control, or even walk the caller through delivering a baby. Flight medicine:  There is likely a helicopter transport service of some type in your area. In many ways, flight medicine is similar to ground EMS in that they have specific protocols and require regular training. There are, of course, many nuances specific to the flight service that make this another good opportunity to be involved. Metropolitan Medical Response System: The MMRS is a federal grant program designed to promote and improve disaster response involving multiple agencies, jurisdictions, and roles. An MMRS may have several smaller committees, focusing on anything from preparation for a mass casualty, to preparing for EMS\u2019s response to an active shooter, to planning resources and response for an epidemic disease outbreak. Even if there is not an MMRS active in your region, there is probably some person or agency working on these types of domestic preparedness activities."
    },
    {
        "Before My First Ambulance Ride I Wish I\u2019d Known\u2026": "J. Reed Caldwell, MD Brent Myers, MD, FACEP Paradigm change:  A new patient-care experience, new ways of doing things. In the prehospital setting, the disease processes and patho- physiology of the patients we care for are the same \u2013 but the priorities, practices, and procedures are often different. Given the austere environment encountered in the provision of pre- hospital patient care, procedures should be considered entirely new activities as compared to performing them in the emergen- cy department. This is true even for familiar procedures such as peripheral IV starts, endotracheal intubation, and checking vital signs.",
        "1. Look and listen. Both for safety and learning, it is important to observe the style and teamwork of the crew you are working with. In-depth questions are often best asked/answered after the call has been completed at the hospital. EMS work occurs in a dynamic, sometimes volatile, environment \u2013 looking and listening more than you are speaking helps keep you safe.": "",
        "2. Have fun. EMS workers are interesting and fun people with amazing senses of humor and unbelievable stories.": "",
        "3. Help carry equipment.  If you help with the work, the crew will have immediate respect for you as a teammate. Also, if you carry \u201cthe kit\u201d (bag with the most equipment and medications) you can be sure you won\u2019t be left behind on scene.": "",
        "4. Be ready for anything. Chest pain, complete boredom, CPR, childbirth \u2013 you might see all of these in one shift. Be sure to bring a snack in case there is no time to stop for food, and bring reading materials in case you have a slow day with a lot of downtime.": "",
        "5. Absorb the surroundings.  You often deliver care in a 70 degree, well-lit environment with lots of resources. But EMS delivers care in extreme temperatures, on train tracks, and in shopping malls. Be sure to look around to appreciate EMS crews and where YOUR patients are coming from when they reach the ED. Also, internalize appreciation for what it takes to get patients \u201cpackaged,\u201d extricated, and transported to the ED bed.": "",
        "6. Participate!  Be ready to evaluate patients, help with spinal immobilization, formulate a differential, listen to breath sounds, and take manual vital signs. Need to practice with a blood pressure cuff beforehand? Don\u2019t forget your stethoscope.": "",
        "7.  Answer questions.  You are a physician and the crew you are working with will be interested in some of the knowledge you have. Interaction with EMS is great practice at simultaneously being a teacher and a student. Never lose sight of the fact that the crew is ultimately in charge of all decisions during your time on their ambulance \u2013 they have final say and are responsible for the safety of you and the patients.": "",
        "8. Dress appropriately.  Often third riders on an ambulance are asked to wear a white button-down shirt and black or navy blue pants. Regardless, be sure you are dressed modestly and neatly. Footwear is very important \u2013 a work boot is best. Dress shoes, slip-ons, and sandals are not appropriate from an appearance, functional, and OSHA perspective. Be prepared for changing weather \u2013 rain, wind, snow.": "",
        "Consider reading People Care: Career-Friendly Practices for Pro- fessional Caregivers  (Thom, Dick, et al) prior to your EMS rotation.": ""
    },
    {
        "Physiology and Problems to Consider Along the Way": "Transporting patients via air has become a way of doing business, especially to tertiary referral centers from rural medical centers. This resource has great utility in critical times. Yet it also presents numerous challenges, thanks to basic laws of physics. In alleviating the dangers associated with air transport, it is imperative that all EMS providers associated with transport as well as physicians at the receiving center have a basic understanding of this physiology.",
        "Boyle\u2019s Law": "Gases expand with increasing altitude as barometric pressure decreases. The inverse applies on the descent. Transport considerations:  Altitude becomes an important consideration in an unpressurized aircraft, such as a helicopter. At altitudes where most helicopters fly, gas expansion is roughly 10-15%. In mountainous regions where helicopters may fly up to 8000 feet above sea level, gas expansion may be 30%. This may affect IV flow rates, ET cuff expansion, and body cavities such as the intestines, middle ear, sinuses, and fascial compartments.",
        "Dalton\u2019s Law": "As altitude increases, gases expand and the available oxygen decreases. \u2219At 10,000 feet, atmospheric pressure is 525 mmHg compared to 760 mmHg at sea level, while FiO2 remains 21%. However, the partial pressure of oxygen has decreased to 110 mmHg. This becomes important as a pressure differential is required to cross from the alveoli into the bloodstream. Medical consideration:  This affects oxygen delivery to the body. Newborns and neonates are more likely to develop hypoxia, as a newborn\u2019s alveolar-arterial difference is roughly 25 mmHg compared to 10 mmHg in adults. As altitude increases, oxygen delivery decreases. Transport considerations:  As altitude increases and pressure decreases, gas expansion causes available oxygen to decrease. Therefore, someone with an SpO2 of 92% at sea level may desaturate to 80% at altitude, even in a cabin pressurized to 12,000 feet.",
        "Henry\u2019s Law": "This pertains to solubility of gases within a liquid. The partial pressure of gases and the solubility of the gas determine the amount of gas that will dissolve into liquid. Decreasing pressures at higher altitudes allows for gases to come out of solution, such as blood, into tissues. Medical considerations:  Decompression sickness or the bends and decreasing oxygenation at altitude. Trapped gas in tissue being released or evolved gas in blood being released. The most common joints affected are the shoulders and elbows in recreational divers. In technical divers and aviators, the hips and knees are most affected. The chokes  are caused by gas embolization, mimic a PE, and can lead to cardiovascular collapse. Subcutaneous emphysema is another decompression sickness. Transport considerations:  Unless a patient has been exposed to compressed gas within 24 hours, such as SCUBA diving, transport is rarely a problem under 25,000 feet. If a diver requires transport, stay below 8,000 feet, as this is equivalent to a non-diver flying above 40,000 feet in an unpressurized aircraft. Treatment for all patients is 100% oxygen and rapid descent.",
        "Charles\u2019 Law": "At constant pressure, the volume of gases is proportional. As temperature rises, molecules move faster and volume increases. Medical considerations:  Hypoxia and compartment syndrome Transport considerations:  Flight during the winter or middle of summer affects expanding and contracting structures, which rely on the rigidity of the structure containing the gas.",
        "Real Stresses of Flight and Transport": "The most common and worrisome problem in air medical transport is hypoxia, which can go undetected. There are four physiologic classifications of hypoxia. Hypoxic Hypoxia (Altitude):  Stages include indifferent (90-98% SpO2), compensatory (80-89%), disturbance (70-79%), and critical (60-69%). This results in inadequate gas exchange at the alveolar-capillary membrane. Without compensatory mechanisms, this is usually encountered above 10,000 feet. Oxygen Adjustment Equation:  (FiO2 x BP1) / BP2 = FiO2 required BP1 = current barometric pressure BP2 = altitude or destination barometric pressure",
        "Barometric Stress": "Trapped gas (Boyle\u2019s Law) and evolved gas (Henry\u2019s Law) disorders. Free gas in body cavities expands, and if it cannot escape, positive pressure develops barotrauma. Organ systems affected \u2219GI tract:  At constant temperature and altitude, the volume of wet gas is greater than dry gas due to water vapor. 1L of wet gas in the stomach and intestines may rapidly expand and cause severe pain, tachycardia, hypotension, syncope, and interfere with breathing. Expel gas by whatever means necessary via NG/OG.",
        "Thermal Stress": "Thermal stress is the body\u2019s physiologic response to its environment, as the body is either dissipating heat to its environment to cool itself or creating heat by using energy. In all cases, the body is exchanging energy. The major concern of thermal stress is causing hypothermia and coagulopathy in patients moving toward the, \u201cLethal Triad,\u201d defined as hypothermia, acidosis, and coagulopathy. Factors contributing are ambient temperature, exposure time, cabin air circulation, litter position, and hot loading/unloading. Cold physiologic effects include shivering, vasoconstriction, increased metabolic rate, myoclonic tensing, hypothermia, and coagulopathy.",
        "G-Forces": "Gravitational forces are acted on the patient during ascent, descent, and banking which may affect blood pooling and cause stagnant hypoxia. Positive \u201cGs\u201d will move blood from the head toward the feet causing increased intravascular pressures, hypoxia, G-LOC (G force induced loss of consciousness), and blackouts. Negative \u201cGs\u201d will cause blood pressure to rise in the head causing \u201credout,\u201d headaches, and increasing ICP.",
        "Noise": "Provide your patient and yourself with hearing protection as even non-hazardous noise may become hazardous with prolonged exposure. Hazardous noise may cause fatigue and headache. Noise also inhibits your ability as a care provider to properly monitor the patient.",
        "Vibration": "Little can be done to decrease vibration in transport, but precaution should be taken. Vibrations may interfere with patient assessment, invasive and noninvasive monitoring, and pacemakers. Effects include motion sickness, blurred vision, increasing heart and respiratory rates, metabolic rates, pain, irritability, fatigue, and thermal regulation. In a hypothermic patient, vibration may worsen the patient\u2019s condition. In a hyperthermic patient, vibration may cause vasoconstriction, delaying the body\u2019s ability to cool itself. Ensure the patient and crew is properly restrained and place padding on any part of the frame that may contact the patient to combat effects of vibration.",
        "Third-spacing": "This is primarily an effect seen during long distance transports where decreasing barometric pressure may cause leakage of fluid from intravascular spaces. This is further aggravated by temperature changes, vibration, and G-forces.",
        "Humidity deficit": "Water vapor in the air decreases as altitude increases. After 2 hours of flight, less than 5% of relative humidity remains in air circulation. Physiologic effects include respiratory membrane inflammation, decreased efficiency of gas exchange, desiccation, hypoxia, increasing BMR, and oxygen demand. Monitor high-risk patients such as burn, ventilator, and pre-existing dehydration patients closely. Maintain fluid replacement and humidified oxygen as needed.",
        "References": "1. Blumen IJ, et al. Principles and Direction of Air Medical Transport. Air Medical Physician Association. 2006. 2. Aeromedical Training For Flight Personnel: Altitude Physiology. Training Circular. Department of the Army. 2000. 3. Critical Care in the Air. U.S. Air Force Critical Care Air Transport Team. 4. Aeromedical Training. FM 3-04-301. U.S. Air Force Critical Care Air Transport Team Training Document. 5. Capt John Michael Fowler. Flight Physiology. CCAT instructor."
    },
    {
        "Introduction": "The hazardous materials (haz-mat) category includes materials that are radioactive, flammable, explosive, corrosive, oxidizing, asphyxiating, bio-hazardous, toxic, pathogenic, or allergenic. The aim of emergency personnel should be to make a chemical-specific identification while exercising caution to prevent exposure to any chemicals. Identifying the hazardous material and obtaining information on its physical characteristics and toxicity are vital steps to the responder\u2019s safety and effective management of the haz-mat incident.",
        "If release is suspected": "1. Remain calm. 2. Put on personal protective equipment (PPE). 3. Reassure victims that assistance is on the way. 4. Wait for properly equipped help at a safe location (upwind, upstream).",
        "Chapter 7: Haz-Mat Incident Objectives": "\u2219Secure perimeter and designate zones of operation. \u2219Identify and control agent. \u2219Rescue, decontaminate, triage/treat/transport affected individuals. \u2219Move uninvolved crowd/persons to safe zones. \u2219Stabilize the incident. \u2219Avoid secondary contamination. \u2219Secure evidence and crime scene. \u2219Protect against secondary attack.",
        "Six primary clues to hazardous materials": "Occupancy and Location \u2013 Obvious locations in the community that use and/or store hazardous materials include laboratories, factories, farms, paint supply outlets, construction sites, etc. Container Shape \u2013 Haz-mat transport container specifications are regulated by the Department of Transport (DOT). Markings/Colors  - Marking scheme designed by National Fire Protection Association (NFPA 704M system) identifies hazard characteristics of materials at terminals and industrial sites (but does not provide product-specific information). Placards/Labels  - Hazard class wording or four-digit identification numbers, placards used when hazardous materials are stored in bulk (>1001 lbs), and labels identify smaller packages. Shipping Papers - These are required to have a 24-hour emergency information phone number. Provides shipping name, hazard class, ID number, quantity, and may indicate if the material is waste or poison. Senses  \u2013 Odor, vapor clouds, dead animals/fish, fire, skin/eye irritation can signal the presence of hazardous materials. People can be biological detectors (coughing, choking, vomiting). Some chemicals can impair an individual\u2019s sense of smell (eg, hydrogen sulfide) and others have no odor/color/taste (eg, CO).",
        "NFPA 704 Marking scheme (Fire Diamond)": "This is the standard system for the identification of the hazards of materials for emergency response.",
        "Recognition of Common Toxidromes": "\u2219constellation of clinical clues to identify the poison. Begin with vital signs and mental status, then add other autonomic indicators.",
        "Treatment for Common Toxidromes": "SYMPATHOMIMETIC Benzodiazepines ANTICHOLINERGIC Physostigmine (not recommended in prehospital setting) CHOLINERGIC(Muscarinic)Atropine, pralidoxime (not for carbamates) CHOLINERGIC(Nicotinic)Atropine, mainly supportive NARCOTIC Naloxone",
        "Personal Protection Equipment (PPE)": "Personal protection equipment (PPE) is used to isolate or shield individuals from chemical, physical, and biological hazards. The use of PPE itself creates significant worker hazards, such as heat stress, physical and psychological stress, and impaired vision, mobility, and communication. In general, the greater the level of PPE protection, the greater the associated risks. Personnel should not use PPE without adequate training (specific training is mandatory).",
        "Respiratory Protection": "There are 2 basic types of respirators: air-purifying and atmosphere-supplying. Atmosphere-supplying respirators include self-contained breathing apparatus (SCBA) and supplied-air respirators (SAR).",
        "Air-Purifying Respirators (APRs)": "Purifies ambient air by passing it through a filtering element before inhalation. The advantage is mobility; however, it requires sufficient oxygen (19.5%) since it depends on ambient air to function. APRs should not be used when substances with poor warning properties are involved or if the agent is unknown, or when the environmental levels of a substance exceed the capacity of the canisters. Powered air-purifying respirators (PAPRs) have the advantage of creating an improved seal, thus reducing the risk of inhalation injury. PAPRs come in masks or pullover hoods; men with beards can wear the hooded system but not the full facemask.",
        "Atmosphere-Supplying Respirators": "A self-contained breathing apparatus (SCBA) contains its own air supply, with a face piece connected by a hose to a compressed air source. \u2219A Supplied Air Respirator (SAR) depends on an air supply provided through a line linked to a distant air source. It allows personnel to work longer than SCBA, and it\u2019s less bulky than SCBA. The air source has to be within 300 ft.",
        "Site Control": "Hazardous materials incidents often attract large numbers of people and equipment. This complicates the task of minimizing risks to humans, property and environment.",
        "Exclusion (Hot) Zone": "This \u201cground zero\u201d perimeter should encompass all known or suspected hazardous materials contamination.",
        "Contamination Reduction (Warm) Zone": "A secondary zone of protection is determined by the length of the decontamination corridor, which contains all of the needed decontamination stations.",
        "Support (Cold) Zone": "The outermost zone is free of all hazardous materials contamination, including discarded protective clothing and respiratory equipment. *Command post and staging areas for necessary support equipment should be located in the support (cold) area, upwind and uphill of the exclusion (red) zone.",
        "Personnel decontamination method": "Be aware of telephone and computer-based information sources concerning hazardous materials. The regional Poison Control Center, Soldier and Biological Chemical Command (SBCCOM), and Centers for Disease Control and Prevention (CDC) can be contacted 24 hours a day to provide vital information on the medical management of hazardous material exposures.",
        "References": "1. NIOSH Pocket Guide to Chemical Hazards. Centers for Disease Control and Prevention. http://www.cdc.gov/niosh/npg/. 2. Alibek K, Dashiell T, Dwyer A, et al. Jane\u2019s Chem-Bio Handbook. 3rd ed. Surrey, UK: Jane\u2019s Information Group; 2005. 3. USAMRIID\u2019s Medical Management of Biological Casualties Handbook. 4th ed. Fort Detrick, MD: U.S. Army Medical Research Institute of Infectious Diseases; 2001. 4. Medical Management of Chemical Casualties Handbook. 4th ed. Aberdeen Proving Ground, MD: USAMRICD Chemical Casualty Care Division; 2007."
    },
    {
        "Key Terms": "Abandonment: Ending the care of an injured or ill person without obtaining that patient\u2019s consent or without ensuring that someone with equal or greater training will continue care., Advance directive: A written instruction, signed by the patient and a physician, that documents a patient\u2019s wishes if the patient is unable to communicate their wishes., Applied ethics: The use of ethics in decision making; applying ethical values., Assault: A crime that occurs when a person tries to physically harm another in a way that makes the person under attack feel immediately threatened., Battery: A crime that occurs when there is unlawful touching of a person without the person\u2019s consent., Competence: The patient\u2019s ability to understand the emergency medical responder\u2019s (EMR\u2019s) questions and the implications of decisions made., Confidentiality: Protection of a patient\u2019s privacy and personal information., Consent: Permission to provide care; given by an injured or ill person to a responder., Do no harm: The principle that people who intervene to help others must do their best to ensure their actions will do no harm to the patient., Do not resuscitate (DNR) order: A type of advance directive that protects a patient\u2019s right to refuse efforts for resuscitation; also known as a \u201cdo not attempt resuscitation (DNAR) order.\u201d, Durable power of attorney for healthcare: A legal document that expresses a patient\u2019s specific wishes regarding their healthcare; also empowers an individual, usually a relative or friend, to speak on behalf of the patient should they become seriously injured or ill and unable to speak for themselves., Duty to act: A legal responsibility of some individuals to provide a reasonable standard of emergency care., Ethics: A branch of philosophy concerned with the set of moral principles a person holds about what is right and wrong., Expressed consent: Permission to receive emergency care granted by a competent adult verbally, nonverbally or through gestures., Good Samaritan laws: Laws that protect people against claims of negligence when they give emergency care in good faith without accepting anything in return., Healthcare proxy: A person named in a healthcare directive, or durable power of attorney for healthcare, who can make medical decisions on someone else\u2019s behalf., Implied consent: Legal concept that assumes a patient would consent to receive emergency care if they were physically able or old enough to do so., In good faith: Acting in such a way that the goal is only to help the patient and that all actions are for that purpose., Legal obligation: Obligation to act in a particular way in accordance with the law., Living will: A type of advance directive that outlines the patient\u2019s wishes about certain kinds of medical treatments and procedures that prolong life., Malpractice: A situation in which a professional fails to provide a reasonable quality of care, resulting in harm to a patient., Medical futility: A situation in which a patient has a medical or traumatic condition that is scientifically accepted to be futile should resuscitation be attempted and, therefore, the patient should be considered dead on arrival., Moral obligation: Obligation to act in a particular way in accordance with what is considered morally right., Morals: Principles relating to issues of right and wrong and how individual people should behave., Negligence: The failure to provide the level of care a person of similar training would provide, thereby causing injury or damage to another., Next of kin: The closest relatives, as defined by state law, of a deceased person; usually the spouse and nearest blood relatives., Patient\u2019s best interest: A fundamental ethical principle that refers to the provision of competent care, with compassion and respect for human dignity., Physician Orders for Life-Sustaining Treatment (POLST) form: Medical orders concerning end-of-life care to be honored by healthcare workers during a medical crisis., Refusal of care: The declining of care by a competent patient; a patient has the right to refuse the care of anyone who responds to an emergency scene, either before or after care is initiated., Standard of care: The criteria established for the extent and quality of an EMR\u2019s care., Surrogate decision maker: A third party with the legal right to make decisions for another person regarding medical and health issues through a durable power of attorney for healthcare.",
        "INTRODUCTION": "This chapter addresses, in general terms, some of the medical, legal and ethical principles that relate to emergency care. As an emergency medical responder, it is your responsibility to keep yourself up-to-date on laws and regulations that affect your duties. If you are unclear about any aspect of these laws and regulations, speak with your employer, regulatory agency or a legal professional. You should also follow any rules and guidelines established by your employer or organization with which you are affiliated when you are acting as an emergency medical responder.",
        "LEGAL DUTIES - Scope of Practice": "The emergency medical responder\u2019s (EMR\u2019s) scope of practice is defined as the range of duties and skills an EMR is allowed and expected to perform as appropriate. The scope of practice also defines boundaries and distinctions within the healthcare system, ensuring that each level of provider operates within a legally accepted range of duties and skills. Scope of practice also draws a distinction between these professionals and the layperson. The EMR, like other out-of-hospital care providers, is governed by legal, ethical and medical guidelines. Since practice may differ from state to state or in regions of the same state, you must be aware of variations existing for your level of training in your state or area. The term \u201cscope of practice\u201d also refers to the authority to practice, given by the state to individuals licensed or certified to practice in that state.",
        "LEGAL DUTIES - Standard of Care": "The public expects a certain standard of care from personnel summoned to provide emergency care. The standard of care is the criteria established for the extent and quality of EMR care. When providing emergency care, EMRs are expected to perform to at least the minimum standard set forth by their training and protocols. State laws and other authorities, such as national organizations, may govern the actions of EMRs. If your actions do not meet the set standards, and harm another person, you may be liable for negligence or malpractice.",
        "LEGAL DUTIES - Duty to Act": "While on duty, an EMR has an obligation to respond to an emergency and provide care at the scene. This obligation is called a duty to act. It applies to public safety officers, certain government employees, licensed and certified professionals, and medical paraprofessionals while on duty. For instance, members of a volunteer fire department have a duty to act based on participation in the fire department. An athletic trainer has a duty to provide care to an injured athlete. Failure to fulfill these duties could result in legal action. As an EMR, if you see a motor-vehicle crash while you are off duty, in most states you do not have a legal obligation to stop (although you may have a moral obligation). However, if you stop and begin to provide care, you are legally obligated to continue until the patient is turned over to someone with an equal or a higher level of training.",
        "LEGAL DUTIES - Competence": "Competence refers to the patient\u2019s ability to understand the EMR\u2019s questions and the implications of decisions made. EMRs must obtain permission from competent patients before beginning any care. To receive consent or refusal of care, the EMR should determine competence. In certain cases, such as those involving intoxication, drug abuse or cognitive impairment such as dementia or Alzheimer\u2019s disease, the patient is not considered competent. Some individuals, such as minors, are not competent to make decisions about their care as a matter of law.",
        "LEGAL DUTIES - Good Samaritan Laws": "The vast majority of states and the District of Columbia have Good Samaritan laws that protect people against claims of negligence when they provide emergency care in good faith without accepting anything in return. These laws, which differ from state to state, may apply when an EMR volunteers to assist in an emergency when not on duty. Although professional responders such as EMRs are not usually considered Good Samaritans when on the job, many states have other laws that protect EMRs from negligence claims arising out of job activities in some situations. When a responder\u2019s actions are willful or reckless, however, these liability protections most likely will not apply. Along with the lay public, Good Samaritan laws may protect off-duty EMRs who are providing emergency care in good faith. The laws do not protect an individual from a claim that an act was grossly negligent. Good Samaritan laws vary from state to state. For more information, check your local and state laws or consult with a legal professional to see if, and when, Good Samaritan laws protect you.",
        "LEGAL DUTIES - Ethical Responsibilities": "As an EMR, you have an ethical obligation to carry out your duties and responsibilities in a professional manner. This includes showing compassion when dealing with a patient\u2019s physical and emotional needs, and communicating sensitively and willingly at all times. Try to avoid becoming satisfied with meeting minimum training requirements and instead strive to develop your professional skills and knowledge. Doing so includes not only practicing and mastering the skills taught in this course, but seeking out further training and information, such as through workshops, conferences, and supplemental or continuing advanced medical educational programs. Your instructor may be able to provide ideas and information about opportunities in your area for further education and professional development. In addition to being the best you can be in providing care, be honest in reporting your actions and the events that occurred when you respond to an emergency. Make it a personal goal to be a person whom others trust and can depend on to give accurate reports and provide effective care. Address your responsibilities to the patient at every emergency. Periodically, carry out a self-review of your performance (e.g., patient care, communication, documentation) to help improve any areas of potential weakness or opportunities for professional growth. Ethical responsibilities include the following concepts: Morals: Morals are a set of principles relating to issues of right and wrong and how individual people should behave. To understand the morals of a society, you have to know what that society believes. Ethics: Ethics is a branch of philosophy that deals with the set of moral principles a person holds about what is right and wrong. Applied ethics: The term \u201capplied ethics\u201d refers to the application of ethical values in decision making.",
        "Decision-Making Models": "A decision-making model is a tool or technique to assist you in making decisions. The term can also refer to a set of principles which, when applied, lead to the desired decision. Some of those principles include the following: Do no harm: The phrase \u201cdo no harm\u201d is attributed to Hippocrates and first appeared in his treatise, Of the Epidemics. The treatise states, \u201cPractice two things in your dealings with disease: either help or do not harm the patient.\u201d \u201cDo no harm\u201d has been brought into several trained and professional healthcare practices. In essence, it means that people who intervene to help others must do their best to ensure their actions will do no harm to the patient or patients. (For more information on the National Association of Emergency Medical Technicians\u2019 Code of Ethics and EMT Oath, see naemt.org/about_ems/emtoath.aspx.) Act in good faith: To act in good faith means to act in such a way that the goal is only to help the patient and that all actions are for that purpose. Patient\u2019s best interest: To act in the patient\u2019s best interest is a fundamental ethical principle that refers to providing competent care with compassion and respect for human dignity. This implies that the care one provides serves the integrity of the patient\u2019s physical well-being while at the same time respecting the patient\u2019s choices and self-determination.",
        "PATIENT CONSENT AND REFUSAL OF CARE": "Individuals have a basic right to decide what can and cannot be done to their bodies; they have the legal right to accept or refuse care. Therefore, to provide care to an injured or ill person, you must first obtain the patient\u2019s consent. Usually, the patient needs to tell you clearly that you have permission to provide care. To obtain consent, you must: Identify yourself to the patient. Give your level of training. Ask the patient whether you may help. Explain what you observe. Explain what you plan to do.",
        "Forms of Consent": "Consent may be either directly expressed or implied. There are also some special situations in which exceptions or alternate means of providing consent may apply.",
        "Expressed Consent": "After you have provided the required information, the patient can give expressed consent either verbally or through a gesture. If the patient is a minor, the law requires that an EMR obtain consent from a parent or legal guardian, if one is available. The patient has the right to withdraw consent for care at any time. If this should occur, step back and call for more advanced medical personnel. In some circumstances, you may be asked to explain why the person needs your care. To give expressed consent, a patient must be competent. This means the patient must be able to understand the EMR\u2019s questions as well as the implications of accepting or refusing any care that the EMR has proposed. The EMR should ensure that the patient understands the condition and both the risks and benefits of the proposed treatment.",
        "Implied Consent": "Certain patients may not be able to give expressed consent. This includes patients who are unconscious, have an altered level of consciousness, such as confusion, or who are mentally impaired. In these cases, the law assumes that the patient would give informed consent for emergency care if they were able to do so. This legal concept is called implied consent.",
        "Implied Consent and Minors": "Remember, when the patient is a minor, an EMR is required by law to obtain permission to provide care from a parent or legal guardian, if one is available. However, if the condition is life threatening and a parent or legal guardian is not present, consent is implied. A minor is usually considered anyone under the age of 18, unless the person is an emancipated minor, but this varies by state. If you encounter a parent or legal guardian who refuses to allow you to provide care, try to explain the consequences of not caring for the patient. Use terms the parent or legal guardian will understand. If a law enforcement officer or more advanced medical personnel are not present, have someone call. If necessary, call them yourself. Do not argue with the parent or legal guardian. Doing so can create a potentially unsafe situation. Emancipated minors are minors who have been granted the legal rights to make their own decisions, such as consent for emergency or medical care. Examples include a minor who is married, pregnant, a parent, a member of the armed forces or financially independent and living away from home.",
        "Special Situations": "In certain cases, such as those involving intoxication and drug abuse, patients may not be considered competent and therefore are unable to make rational decisions or give expressed consent. In such cases, call more advanced medical personnel and law enforcement personnel or have someone call them. If possible, attempt to provide care, but do not endanger your personal safety. Always maintain a safe distance from potentially violent or hostile patients. If a patient appears to be mentally incompetent, the EMR should verify if there is a guardian present with the legal right to consent to treatment. A mentally incompetent patient who is seriously injured or ill falls under implied consent when a parent or legal guardian is not present. If an adult is legally incompetent\u2014that is, determined by a court to be unable to handle personal or financial affairs, and under a legal guardian\u2019s care\u2014you must also get that legal guardian\u2019s consent to provide care. Summon a law enforcement officer if necessary.",
        "Refusal of Care": "Some injured or ill people may refuse care, even those who may desperately need it. Even though patients may be seriously injured or ill, you should honor their refusal of care. Patients with decision-making capacity who are of legal age have a right to refuse care. If this occurs, you must ensure that the person is competent and is able to make rational, informed decisions. Refusal of care does not have to be all or nothing. Patients can agree to receive part of the care that an EMR has suggested, but refuse another part. For example, a patient could choose to be assessed at the scene but refuse transport to the hospital, or agree to be transported to the hospital but not to be treated at the scene. They can also decline care after it has been initiated. If a patient refuses care, be sure to: \uf0a7 Follow local policies related to refusal of care. \uf0a7 Tell the patient what treatment is needed and why. Explain the benefits of receiving treatment as well as the risks of refusing treatment, and mention any reasonable alternative treatments that fall within the parameters of care. \uf0a7\tTry again to convince the patient that the care is needed or that the patient should consider going to the hospital instead, but do not argue. If possible, have a witness listen to and document the refusal, to make it clear that you did not abandon the patient.\n\uf0a7\tRemind injured or ill persons that they can call 9-1-1 or the designated emergency number to summon emergency medical services (EMS) personnel again if the situation changes or if they change their mind and decide to accept care before you leave the scene.\n\uf0a7\tNotify more advanced EMS personnel about the situation.\n\uf0a7\tNotify medical direction, if required by your local protocols.\n\uf0a7\tDocument the patient\u2019s refusal, according to local policy. If the patient continues to refuse care, document any assessment you performed and have the patient sign the refusal documentation. If the patient refuses to sign the form, have a family member, police officer or bystander sign the form, verifying that the patient refused to sign. Also, have a family member, police officer or bystander sign the form as a witness. A law enforcement officer is preferable, if available.\n\uf0a7\tTry one more time to persuade the patient to go to a hospital before leaving the scene.",
        "Advance Directives": "An advance directive is a set of written instructions that describes a person\u2019s wishes about medical care. These instructions, signed by the patient and a physician, make a person\u2019s intentions known while they are still capable of doing so and are used when the patient can no longer make their own healthcare decisions. The most common types of advance directives are do not resuscitate (DNR) orders, living wills and Physician Orders for Life-Sustaining Treatment (POLST) forms.\nMany states have strict requirements for advance directives and the circumstances in which they should be followed. You must be aware of your state and local laws governing advance directives. Your state EMS office is a good source of this information. If you are providing emergency medical responder services as part of your employment or affiliation with an organization, you should also seek guidance from them.",
        "Do Not Resuscitate Orders and Medical Futility": "One type of advance directive, a do not resuscitate (DNR) order, also called a \u201cdo not attempt resuscitation (DNAR) order,\u201d protects a patient\u2019s right to refuse efforts for resuscitation. These orders, which differ from state to state, are usually written for people who have a terminal illness.\nThere must be written proof of a DNR order unless your state is one of the few that accepts verbal verification. If there is no proof of a DNR order, or if you are not certain that it is valid or applicable in the current situation, you must act and provide care as you would in any similar situation where a DNR order does not exist. The exception to this is in cases of medical futility or obvious death.\nThe term medical futility is used to describe situations where emergency medical interventions, such as CPR, would not provide any likely benefit to the patient. Be familiar with and follow local protocols and medical control for these situations. If there is any doubt as to whether medical futility exists, treatment should be provided.",
        "Living Wills": "A living will, another kind of advance directive, is a legal document that outlines a patient\u2019s wishes about certain kinds of medical treatments and procedures that prolong life. In the event that the patient cannot communicate healthcare decisions, this document may take effect.\nAs an EMR, you should follow a living will only if you are sure that it is valid and applicable to the current emergency. If in doubt, or if the situation is urgent and you do not have the time to assess the living will, you must provide care until the matter has been clarified. More general than a DNR order, which refers only to the act of resuscitation, living wills can go further into dictating what may and may not be done to a patient.",
        "Physician Orders for Life-Sustaining Treatment Forms": "A Physician Orders for Life-Sustaining Treatment (POLST) form, while not currently available in all states, is a tool that complements an advance directive. Its primary purpose is to document the types of treatments a patient wants or does not want in the case of a medical emergency. POLST forms are signed by the patient\u2019s physician or other approved healthcare provider such as a physician\u2019s assistant or nurse practitioner, based on state rules or protocols. As an EMR, it is important to understand how POLST forms are used in your area and which sections apply to prehospital care. When assessing an advance directive, check for written physician\u2019s instructions that most often accompany the directive. The phrasing must be clear and understandable, with no room for interpretation. It is vital that you review your particular state\u2019s laws to see if advance directives, DNRs, POLST forms and/or living wills are permitted in your area of practice. Also, clarify whether they require more than one healthcare provider to verify the patient\u2019s condition, which is the case in some states.",
        "What Is a Do Not Resuscitate Order?": "DNR orders are intended to direct the care of a patient in the specific setting of either respiratory or cardiac arrest. DNR orders are very specific orders that express a patient\u2019s denial of consent for specific interventions limited to CPR for either respiratory or cardiac arrest. As such, they only apply to the following specific interventions in the setting of respiratory or cardiac arrest: \u2022 Airway\u2014positioning, adjuncts and intubations \u2022 Breathing\u2014assisted ventilations \u2022 Circulation\u2014cardiac compressions, defibrillation and cardiac arrest medications Up to the point of either respiratory or cardiac arrest, the DNR order would not apply and responders should provide the normal care for any conditions that they identify. In most states, a DNR order is a physician\u2019s order not to resuscitate if a patient goes into cardiac or pulmonary (respiratory) arrest. It is part of the prescribed medical treatment plan and must have a physician\u2019s signature. Issues surrounding DNR orders are complex, and the laws and regulations regarding them vary from state to state. For these reasons, the American Red Cross advises all professional and certified trained lay responders to receive specific training from their employer, agency or medical director. In addition, responders are encouraged to check local laws and regulations. However, there are some general principles that all responders should be aware of and can use to guide their practice. End-of-life care legislation is in place across the country and serves as a mechanism to address two equally valid, competing interests. Specifically, it allows patients to be involved in their own healthcare decision making and it protects healthcare personnel from liability for honoring patients\u2019 wishes. Ethical principles require that responders respect a person\u2019s right to make decisions regarding their own healthcare. This usually involves obtaining the patient\u2019s consent. However, sometimes a patient is either (Continued  )Always honor a patient\u2019s refusal of care. In cases of refusal, follow local policies; tell the patient what treatment is needed and why; try to convince them, but do not argue; remind the person that they can call EMS if the situation changes or they change their mind; and notify more advanced EMS personnel as well as medical direction, based on local protocols. An advance directive is a set of written instructions that describes a person\u2019s wishes about medical care. A DNR order protects a patient\u2019s right to refuse efforts for resuscitation. It is usually written for those who have a terminal illness. You must be aware of state and local legislation and protocol in regard to DNR orders.CRITICAL FACTS unconscious or otherwise incapacitated. In these cases, advance directives, such as healthcare proxies, living wills, DNR orders and POLST forms, provide mechanisms by which individuals can make their wishes known when they are unable to speak for themselves. In addition, advance directives allow those responsible for the care of others\u2014such as a minor or an adult lacking the capacity for decisions\u2014to make end-of-life decisions prior to the time when the decision is necessary. Of course, in the absence of an applicable advance directive, consent for emergency treatment is implied.",
        "How Do You Know If There Is a DNR Order?": "In most cases, the family, a caretaker or healthcare provider will inform you that a DNR order is in place. A DNR order is written on a form developed, in most states, by the individual state\u2019s Department of Health or state EMS office to identify patients who do not wish to be resuscitated in the event of respiratory or cardiac arrest. In the case of inpatient admissions at hospitals and long-term care facilities, the DNR order may be on a form that complies with state laws and regulations but has been designed by the facility. In some states there are both hospital and inpatient forms. The properly completed form is signed by the competent patient or by the patient\u2019s representative, and then signed by a licensed physician on a specific form developed and approved by the respective state. Unless provided with clear written documentation that meets legal requirements or unless your state laws and regulations allow acceptance of oral verification (which most states\u2019 laws do not), you must perform all procedures as you would in the absence of a DNR order. In some states, there is a patient ID device in the form of a bracelet or a smaller version of the form that can be worn on a chain around the neck or clipped to a key chain or to clothing/bed so it can travel with the patient. It is equally as valid as a traditional DNR form and can be presented to EMS personnel when they arrive on scene; it is designed to allow the patient to move between settings with one document.",
        "Can a DNR Order Be Revoked?": "Review of individual state laws for specific criteria is necessary. Generally, the DNR order can be revoked at any time orally or in writing, by physical destruction, by failure to present it, or by the oral expression of a contrary intent by the patient or the patient\u2019s healthcare proxy. In the out-of-hospital setting, it may be difficult to determine who the actual surrogate is and, likely, the question has arisen because the patient is in cardiac or respiratory arrest and cannot express their own wishes. If there is any doubt regarding revocation of the DNR order or someone verbally requests revocation, begin normal care procedures.",
        "In What Healthcare Settings Is the DNR Order Honored?": "The DNR order is honored in most healthcare settings, including hospices, adult family care homes, assisted living facilities, emergency departments, nursing homes, home health agencies and hospitals. State laws further provide that healthcare providers employed in these healthcare settings may withhold or withdraw CPR if presented with a valid DNR order and be immune from criminal prosecution or civil liability. In addition, most state laws and regulations allow DNR orders to be honored by prehospital providers. In those instances where the DNR order is presented to a prehospital emergency medical provider in a setting other than a healthcare facility, the form may be honored. Review of individual state and local laws as well as local protocols is essential for compliance. Direct questions regarding DNR orders to the state regulating agency or state EMS office. In the out-of-hospital setting, if there is any doubt as to whether a DNR order is valid or may have been revoked, care should proceed as it would  in the absence of a DNR order; this includes activation of the EMS system and transport to a hospital. Usually, the hospital is better equipped and has additional resources to determine the validity and applicability of a DNR order than the resources that are available in the out-of-hospital setting. Professional and workplace providers should receive specific training from their employer, agency or medical director regarding DNR orders.",
        "Surrogate Decision Making": "A surrogate decision maker is a third party who has been given the legal right to make decisions regarding medical and health issues on another person\u2019s behalf through a durable power of attorney for healthcare. A person may be given this role for an older parent, an incapacitated spouse or an ill child, for example. You must be able to see the legal document, and the writing should be understandable, leaving no room for interpretation. A healthcare proxy is the person named in a durable power of attorney for healthcare to make medical decisions on the patient\u2019s behalf. This person may also be known as an attorney-in-fact, an agent or a patient advocate. The healthcare proxy may be a friend, family member or other person designated at an earlier time by the patient or by the courts to be responsible for making health and medical decisions for the patient. Next of kin refers to the closest relatives, as defined by state law, of a patient or deceased person. Most states recognize the spouse and the nearest blood relatives as next of kin, and these individuals may have certain legal authority regarding medical decisions for an incapacitated patient or the affairs of a deceased person.",
        "OTHER LEGAL ISSUES - Assault": "Assault is a threat or an attempt to inflict harm on someone. Assault can be physical, sexual or both. It may result in injury, and often results in emotional distress to the patient. If the patient feels threatened with bodily harm and the other person has the capability of inflicting harm, the act may be considered assault.",
        "OTHER LEGAL ISSUES - Battery": "Battery is the legal term used to describe the unlawful touching of a person without that person\u2019s consent. The EMR must obtain consent before providing care to a patient. Every patient has a legal right to determine what happens to and who touches that patient\u2019s body.",
        "OTHER LEGAL ISSUES - Abandonment": "Just as you must obtain the patient\u2019s consent before beginning care, you must also continue to provide care once you have begun. Once you have started emergency care, you are legally obligated to continue that care until a person with equal or higher training relieves you, you are physically unable to continue or the patient refuses care. Usually, your obligation for care ends when more advanced medical professionals take over. If you stop your care before that point without a valid reason, such as leaving momentarily to get the proper equipment, you could be legally responsible for the abandonment of a patient in need.",
        "Do EMRs Fail to Provide the Standard of Care If They Follow a DNR Order?": "A professional responder who follows a valid DNR order is actually complying with the standard of care by respecting the patient\u2019s wishes, respecting the patient\u2019s denial of consent for CPR in the setting of either respiratory or cardiac arrest, and complying with the physician\u2019s order for DNR. Follow local protocols and medical direction when presented with a DNR order.",
        "OTHER LEGAL ISSUES - Negligence": "Negligence refers to a failure to follow a reasonable standard of care, thereby causing or contributing to injury or damage to another. A person could be considered negligent by either acting wrongly or failing to act at all. There are four elements of a negligence claim: 1. The EMR had a duty to act. When an EMR is on duty, the duty to act is the obligation to respond to emergency calls and provide emergency care according to the expected level of knowledge and skills. Once care has begun, the duty is to continue providing care until the patient can be handed over to someone of equal or higher training. 2. The EMR breached that duty. Breach of duty refers to deviation from the standards of care expected for the responder\u2019s level of knowledge and skill. 3. The patient was injured because the EMR breached their duty. In legal terms, this is known as proximate cause. If injuries occurred to a patient due to breach of duty or negligence by the EMR, the patient must prove that these injuries were the direct result of the EMR\u2019s action or non-action. 4. Harm or injury occurred.",
        "CONFIDENTIALITY AND PRIVACY": "While providing care to a patient, you may learn details about the patient that are private and confidential. Information such as medical issues, physical and mental conditions, and any medications the patient is taking are personal to the patient and considered confidential. Respect the patient\u2019s privacy and obey the law by maintaining confidentiality. Exceptions to this rule include providing this information to the medical personnel who will take over care of the patient from you and any mandatory reporting requirements, public health issues or legal requirements.",
        "CRITICAl FACTS": "Personal information, such as the patient\u2019s medical issues, physical and mental conditions, and medications they take, is considered confidential. You should treat patient information with respect and not share it with unauthorized individuals.",
        "Health Insurance Portability and Accountability Act": "The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule was the first comprehensive federal protection for the privacy of protected health information (PHI). It makes provisions for aspects such as patient control over health information, the use and release of health records, appropriate disclosure of health information, and civil and criminal penalties for violation of patients\u2019 privacy rights. Some states have their own medical privacy laws.",
        "Protected Health Information": "Depending on the nature of your role as an EMR (including whether you are providing EMR services as part of your employment or affiliation with an organization), you may have obligations under HIPAA or state medical privacy laws. Regardless of whether a privacy law applies, however, you should treat patient information as confidential. You must not share the patient\u2019s health information with others, such as the media, employers, colleagues or friends, unless the patient consents. You must continue to maintain confidentiality even after your role with the patient has finished. However, you may release information if you have written consent from the patient, or a parent or legal guardian if the patient is a minor.",
        "Permitted Disclosures of Health Information Without Written Patient Consent": "In some circumstances, disclosure of health information is appropriate without patient consent. It is important to note that in most situations you may share information with other healthcare providers who are involved in caring for the patient, and you may share a child\u2019s information with their parent or legal guardian. In addition, in some situations, such as when a patient is transported to a hospital or medical center, information must be disclosed to facilitate payment for services. Your employer or other organization with which you are affiliated to provide emergency medical services should give you guidance on documentation for payment purposes. Other situations where disclosure without consent is permissible include cases of mandatory reporting of abuse or neglect, situations involving public health issues and some law enforcement situations. For example, you must provide requested information if you have received a subpoena.",
        "Medical Identification": "Medical Identification Medical identification tags are designed to provide healthcare providers and EMS personnel with pertinent health information about a patient who may be unable to communicate in an emergency. The tag may be included on a bracelet, necklace or sports band. Others may carry this information on a wallet card. More and more people are carrying their medical identification information on mobile phone apps that responders can access even when the phone is locked by a password. These identifiers indicate special medical situations. pertinent to a medical emergency. It is imperative that you look for them whenever you examine a patient. Examples of conditions you may be alerted to include allergies, diabetes and epilepsy. Some medical identification information lists a phone number to call to obtain further information. Some people also list their emergency contact(s) in their mobile phone under the heading ICE, which stands for in case of an emergency.",
        "Obvious Death": "Although it is ultimately a physician\u2019s job to declare a patient dead, you will often be faced with situations in which death is obvious. In these situations, resuscitative efforts may not be required. These situations include: \uf0a7 Decapitation. \uf0a7 Rigor mortis. \uf0a7 Decomposition of the body. \uf0a7 Dependent lividity (discoloration in the skin caused by the pooling of blood). \uf0a7 Transection of the body. \uf0a7 Incineration of the body.",
        "Organ Donors": "Organs may only be donated when there is a signed, legal document that gives permission for the patient\u2019s organs to be harvested in the case of death. Often this documentation is an organ donor card or a sticker on the patient\u2019s driver\u2019s license. Treat these patients as you would any other patient and provide the same lifesaving emergency care.",
        "Evidence Preservation": "Emergency medical care of the patient is the EMR\u2019s top priority. However, when faced with a crime scene, there are some precautions you must take to ensure the integrity of the scene is not disturbed. Do not disturb any item at the scene unless emergency medical care requires it. Observe and document anything unusual at the scene. Do not cut through bullet or knife holes in clothing, as they are part of the evidence collected during the investigation. Work closely with appropriate law enforcement authorities and obtain permission to do anything that may interfere with the investigation.",
        "CRITICAL FACTS 3": "Most state laws require that EMRs report suspected child abuse, and some states also require that they report other types of abuse and violence. In some circumstances, an EMR may be mandated to report infectious diseases such as hepatitis B or HIV/AIDS. Know your state\u2019s requirements to ensure that you make the necessary reports and do not make unauthorized disclosures.",
        "CRITICAL FACTS": "Medical identification tags alert you to the patient\u2019s pertinent health information, such as allergies, diabetes and epilepsy, when the patient cannot communicate. Look for medical identification bracelets, necklaces, sports bands, wallet cards or mobile phone apps whenever you examine a patient. Although it is a physician\u2019s job to declare a patient dead, death is obvious in situations such as decapitation, rigor mortis, decomposition of the body, dependent lividity, and transection or incineration of the body.",
        "Special Reporting Requirements": "Mandated reporting usually refers to the practice of reporting situations in which a patient\u2019s injuries may have been caused through battery, abuse or other forms of violence. The requirements for reporting vary from state to state, and it is the EMR\u2019s responsibility to learn and follow specific state requirements for reporting incidents in which abuse is suspected. In most states, EMRs are required to report suspected child abuse. Some states also require the reporting of abuse of older adults, patients in domestic violence situations, injuries that may be the result of a crime and suspected sexual assaults. Mandatory reporting can also apply to some infectious diseases such as tuberculosis, hepatitis B, HIV and AIDS. You should check your state\u2019s laws on mandatory reporting to learn what is covered, or check with your employer or the organization with which you are affiliated when you provide emergency medical services. You should fully document your observations when you deem it necessary to report a situation. You should act in good faith, report only what you know to be factual, and avoid any speculation as to what you believe may have occurred or reporting how you feel.",
        "PUTTING IT ALL TOGETHER": "In your role as an EMR, you are guided by certain legal parameters, such as the duty to act and professional standards of care. Injured or ill persons have a right to expect competent initial care by an EMR. They also have a right to expect that you have a thorough understanding of the ethical and legal issues involved. As a trained EMR, you have minimum standards for your performance, but it is important that you do not let your training stay at that minimum level. Practice your skills and increase your knowledge, taking the opportunity to learn as much as you can within your scope of practice. Most areas require that EMRs participate in a minimum number of continuing education or refresher courses to remain certified. As an EMR, you can provide the best service to your patients and adhere to the standard of care if you continually examine your role and skill level. You should explain all of your actions, as appropriate, receive consent before performing any procedure and carry out those procedures to the best of your ability within your scope of practice. You must also be aware of the types of exceptional circumstances you may encounter, such as refusal of care and providing care for patients who may not be competent. Stay current on your state\u2019s laws that relate to EMR services to ensure that you are providing care in a high-quality and legally compliant manner."
    },
    {
        "Key Terms": "Deceased/non-salvageable/expectant (Black): A triage category of those involved in a multiple- (or mass-) casualty incident (MCI) who are obviously dead or who have suffered non-life-sustaining injuries., Delayed care (Yellow): A triage category of those involved in an MCI with an injury, but whose chances of survival will not be reduced by a delay., Immediate care (Red): A triage category of those involved in an MCI whose needs require urgent lifesaving care., Incident command system (ICS): A standardized, on-scene, all-hazards incident management approach that allows for the integration of facilities, equipment, personnel, procedures and communications operating within a common organizational structure; enables a coordinated response among various jurisdictions and functional agencies, both public and private; and establishes common processes for planning and managing resources., Incident commander: Through delegated authority of a local government, the incident commander (IC) is responsible for establishing the incident objectives and managing resources, including assessing the situation, deciding what calls to make and what tasks need to be done, and assigning those tasks to appropriate personnel., Multiple- (or mass-) casualty incident (MCI): An incident that generates more patients than available resources can manage using routine procedures., National Response Framework (NRF): The guiding principles that enable all response partners to prepare for and provide a unified national response to disasters and emergencies\u2014from the smallest incident to the largest catastrophe. The Framework establishes a comprehensive, national, all-hazards approach to domestic incident response., Simple Triage and Rapid Transport (START): A method of triage that allows quick assessment and prioritization of injured people., Triage: A method of sorting patients into categories based on the urgency of their need for care., Triage tags: A system of identifying patients during an MCI; different colored tags signify different levels of urgency for care., Walking wounded (Green): A triage category of those involved in an MCI who are able to walk by themselves to a designated area to await care.",
        "INTRODUCTION": "As an emergency medical responder (EMR), you are likely to be required to assist with an emergency with multiple victims, and to do so you need a plan of action to enable you to rapidly determine what additional resources are needed and how best to manage them. During a serious incident, you may be on the scene for 15 minutes or longer before adequate resources are available to care for a large number of injured people. Management of an appropriate initial response can eliminate potential problems for arriving personnel and possibly save the lives of several injured people. To accomplish this, you must be able to make the scene safe for you and others to work, delegate responsibilities to others, manage available resources, identify and care for the patients most in need of care, and relinquish command as more highly trained and qualified personnel arrive.",
        "NATIONAL INCIDENT MANAGEMENT SYSTEM": "According to the Federal Emergency Management Agency (FEMA), \u201cThe National Incident Management System (NIMS) provides a systematic, proactive approach to guide departments and agencies at all levels of government, nongovernmental organizations and the private sector to work seamlessly to prevent, protect against, respond to, recover from and mitigate the effects of incidents, regardless of cause, size, location or complexity, in order to reduce the loss of life and property and harm to the environment.\u201d \u201cNIMS works hand in hand with the National Response Framework (NRF). NIMS provides the template for the management of incidents, while the NRF provides the structure and mechanisms for national-level policy for incident management.\u201d",
        "The National Response Framework": "The NRF (or Framework) is a guide to how the nation conducts all-hazards response. It is built upon scalable, flexible and adaptable coordinating structures to align key roles and responsibilities across the nation. It describes specific authorities and best practices for managing incidents that range from the serious but purely local, to large-scale terrorist attacks or catastrophic natural disasters.",
        "Incident Command System": "To effectively manage an emergency situation and to provide appropriate care, an incident command system (ICS) must be established, organizing who is responsible for overall direction, the roles of other participants and the resources required. Although the ICS is capable of providing a management structure for incidents both large and small, it is scalable based on incident requirements. Establishing the ICS is particularly important in a multiple- (or mass-) casualty incident (MCI) to effectively manage many resources. The EMR is highly encouraged, and in some cases, mandated by local and state regulations to take the following independent-study, interactive web-based ICS courses: \uf0a7 ICS-100: Introduction to the Incident Command System \uf0a7 ICS-700: National Incident Management System: An Introduction \uf0a7 IS-800: National Response Framework: An Introduction The ICS is a management system, originally developed in the early 1970s in California to help manage the process of fighting forest fires, that has since evolved into an all-hazards incident management system. It has proven especially effective as a strategy in emergencies involving multiple patients because of its ability to manage many functions and resources. To understand the ICS, think of it as an organization composed of responders working together to achieve a common goal. The incident commander (IC), through delegated authority of a local government, is tasked with the responsibility of establishing the incident objectives and managing resources. The IC supervises these resources utilizing the ICS. Also, depending on the size of the incident, the IC may need to establish branches for logistics, finance/administration, operations and planning as part of the IC structure.",
        "EMS Roles in the ICS": "In any emergency, the incident commander is responsible for assessing the situation, deciding what calls to make and what tasks need to be done, and assigning those tasks to appropriate personnel. The responder who assumes the role as incident commander remains in that role until a more senior or experienced person arrives on the scene and assumes command, or until the incident is over. When transitioning command to a more senior person, the outgoing incident commander must ensure that everything necessary has been done before leaving the scene or accepting another assignment. If the incident is small and contained, it is likely that one person in the incident commander role may handle all aspects of directing care. However, in situations with multiple casualties and/or events, the incident commander must delegate a variety of roles to other responders. While not all of these functional positions may be necessary, these are the ones most often required\u2014the larger the incident, the more functional positions are required: \uf0a7 The triage officer supervises the initial triage, tagging and moving of patients to designated treatment areas. \uf0a7 The treatment officer sets up a treatment area and supervises medical care, ensuring triage order is maintained and changes the order if patients deteriorate and become eligible for a higher triage category. \uf0a7 The transportation officer arranges for ambulances or other transport vehicles while tracking priority, identity and destination of all injured or ill people leaving the scene. \uf0a7 The staging officer releases and distributes resources as needed to the incident and works to avoid transportation gridlock. \uf0a7 The safety officer maintains scene safety by identifying potential dangers and taking action to prevent them from causing injury to all involved. Other roles that may need to be filled include: \uf0a7 Supply. \uf0a7 Mobile command/communications. \uf0a7 Extrication. \uf0a7 Rehabilitation. \uf0a7 Morgue. \uf0a7 Logistics.",
        "CRITICAL FACTS 2": "As an EMR, you are likely to be required to assist with an emergency with multiple victims, and to do so you need a plan of action to enable you to rapidly determine what additional resources are needed and how best to manage them. The ICS is a management system, originally developed in the early 1970s in California to help manage the process of fighting forest fires, that has since evolved into an all-hazards incident management system. In any emergency, the incident commander is responsible for assessing the situation, deciding what calls to make and what tasks need to be done, and assigning the tasks to appropriate personnel. If you are the first and most senior EMR on the scene, you are the incident commander until someone more experienced arrives. As incident commander, it is your responsibility to identify a scene as an MCI, assess the scene safety and determine if any action is required to secure the scene.",
        "The Role of the Emergency Medical Responder": "Your role as an EMR is to fit into the team wherever you are assigned by the IC or their designee. You may find yourself acting as incident commander until someone more experienced arrives. If you are with a partner or co-worker, the most senior person takes on the role of incident commander. Your responsibility is to identify if this is an MCI and assess the scene\u2019s safety to determine if any action must be taken to secure the scene to prevent further injury. After assessing safety, as incident commander, you must account for the number of patients, including those who may not appear to be injured, determine whether anyone needs rescuing (extrication), determine the number of ambulances required, and indicate the number of functional positions and extra personnel required. You must also ensure access to areas to stage resources and make note of any situations that may affect the scene, including weather, difficulty accessing the site and the terrain. You must be easily identifiable as the incident commander to prevent confusion. Determine local protocols in effect for identifying yourself as the officer-in-charge and your vehicle as the initial command post (vests or a green light on the command vehicle are common procedures). Be sure to report all issues and necessary information\u2014do not go into detail during radio transmission. This is the time for short, concise, accurate and pertinent bits of information. When someone with more experience or seniority relieves you, be sure to relay all important and pertinent information verbally, including what has been recorded. The person taking over will need to know information such as when the incident began, when you arrived on the scene, how many people are injured, how many people are acting as responders, any potential dangers, what has been done since the beginning of the rescue and objectives that need to be accomplished. If you arrive on the scene after someone has already taken command, identify yourself to the incident commander and report to the staging officer. You will then be tasked to a detail where you are most needed, based on your experience and capability. This could be assisting medical personnel, aiding in crowd or traffic control, helping to maintain scene security or helping to establish temporary shelter. By using the ICS in numerous emergencies, the tasks of reaching, caring for and transporting injured or ill people are performed more effectively, thereby saving more lives. Since there are variations in the plan for managing MCIs with ICS throughout the country, you should become familiar with the MCI plan for your location.",
        "MULTIPLE-CASUALTY INCIDENTS": "An MCI is an incident that generates more patients than available resources can manage using routine procedures. As the term implies, an MCI refers to a situation involving two or more people. You are most likely to encounter MCIs involving injury to small numbers of people, such as a motor-vehicle crash involving the driver and a passenger. But MCIs can also be large-scale events, such as those caused by natural disasters or those from materials/structures made by humans. Examples include: \uf0a7 Transportation incident. \uf0a7 Flood. \uf0a7 Fire. \uf0a7 Explosion. \uf0a7 Structure collapse. \uf0a7 Train derailment. \uf0a7 Airliner crash. \uf0a7 Hazardous material (HAZMAT) incident. \uf0a7 Earthquake. \uf0a7 Tornado. \uf0a7 Hurricane. Some incidents can result in hundreds or even thousands of injured or ill people. Whether small or large scale, MCIs can strain the resources of a local community. Coping effectively with an MCI requires a plan that enables you to acquire and manage additional personnel, equipment and supplies.",
        "CRITICAL FACTS 3": "An MCI is an incident that generates more patients than available resources can manage using routine procedures.",
        "TRIAGE": "In an MCI, you must modify your assessment skills and technique for checking injured or ill people. This requires you to understand the priorities of treatment and transportation. It also requires you to accept death and dying because some patients, such as those in cardiac arrest who would normally receive CPR and be a high priority, will be beyond your ability to help in this situation. To identify which patients require urgent care in an MCI, you use a process known as triage. Triage is a French term derived from \u201ctrier,\u201d meaning \u201cto sort,\u201d and was first used to refer to the sorting and treatment of those injured in battle.",
        "The Triage Officer": "The first step is to identify and assign a triage officer. This is a responsibility of the incident commander. The triage officer is an integral position of the ICS in MCI management. If you are the only person on the scene, the role falls on you until you receive help. The triage officer remains in that role until all patients are triaged and until relieved or reassigned by the IC. The triage officer determines the requirements for additional resources (to perform triage), performs triage of all patients, and assigns personnel and equipment to the highest-priority patients in the triage area.",
        "Primary and Secondary Triage": "Primary triage is used on the scene to rapidly categorize the condition of patients. When performing your first assessment, note the approximate number and location of patients and what the transportation needs are going to be, such as stretchers, litters or special extrication equipment. Keep in mind that these are just primary assessments and patients may be re-triaged later; their status may change accordingly. Using the methods outlined by your locality, ensure that all patients have the appropriate color tape or card attached in a visible fashion. According to Simple Triage and Rapid Transport (START) principles, it should take no longer than 30 seconds per patient to do your assessment and tagging. Patient status can change quickly. If it is necessary and there is time and space, a secondary triage may be performed after the primary triage. This is often performed after patients are moved to the treatment area or at a funnel point just before they enter the treatment area. If the status of a patient changes, leave the first tag in place and draw a bold line through it. Then, add the second, most up-to-date assessment tag. Note that slots on tags do not necessarily need to be completely filled out at once. As new information becomes available, add that information to the triage tag.",
        "Triage Tagging Systems": "There are a variety of triage tags you may use or encounter in a triage area. Because large disasters can bring responders in from a wide area, internationally understood methods of communication are essential. Thus, the colors green, red, yellow and black are commonly used for the triage tagging system. The METTAG\u2122 patient identification system uses symbols, rather than words, to allow responders to quickly identify patient status. The rabbit means urgent, the turtle means can be delayed, the ambulance with a bold line through it means that no urgent transport is needed, and a shovel and cross symbol is used for the dead. Another option is the Smart Tag\u2122, adopted by certain U.S. cities and states. This tag features a folding design for ease of use. Additionally many states have adopted the START tag or adaptations of it. Some states choose to customize their tag designs, while some response systems simply use colored flagging tape",
        "The START System": "The Simple Triage and Rapid Transport (START) system is one of several triage methods and is a simple way to quickly assess and prioritize injured or ill people. It requires you to check only three items: breathing, circulation and level of consciousness (LOC). As you check these items, classify injured or ill people into one of four levels that reflect the severity of their injury or illness and the need for care. These levels are \u201cminor/walking wounded,\u201d \u201cdelayed,\u201d \u201cimmediate\u201d and \u201cdeceased/non-salvageable.\u201d Some advanced triage systems also include a fifth category, \u201chold,\u201d to indicate patients with minor injuries who do not require a physician\u2019s care.",
        "Ambulatory (Walking Wounded)": "The first step is to sort those who can walk on their own, the ambulatory or walking wounded (Green). To do this, use a public address (PA) method if possible. Get their attention and direct these patients to move on their own to a designated area. This allows you to find out quickly who is not in grave danger and clears the emergency area of those who do not need to be there. Ambulatory patients are tagged as Green.",
        "Immediate": "The first of the other categories is immediate care (Red). This categorization means that the patient needs immediate care and transport to a medical facility. Patients are considered immediate if they are unconscious or cannot follow simple commands, require active airway management, have a respiratory rate of greater than 30, have a delayed (more than 2 seconds) capillary refill absent radial pulse, or require bleeding control for severe hemorrhage from major blood vessels. Immediate patients are tagged Red.",
        "Delayed": "The second category is delayed care (Yellow), meaning patients who may be suffering severe injuries but a delay in their treatment will not reduce their chance of survival. Those tagged delayed are non-ambulatory and are breathing, have a pulse and their LOC is within normal limits. While they do not have life-threatening injuries, they may have back injuries with or without spinal cord damage, major or multiple bone or joint injuries, or burns without airway problems. However, the following types of burns need immediate, advanced care: flame burns that occurred in a confined space; burns covering more than one body part; burns to the head, neck, hands, feet or genitals; any partial-thickness or full-thickness burns to a child or an older adult; or burns resulting from chemicals, explosions or electricity. Delayed patients are tagged Yellow.",
        "Deceased": "The third category, deceased/non-salvageable/expectant (Black), is assigned to those individuals who are obviously dead or who have mortal injuries. Patients who are not breathing and who fail to breathe after attempts to open and clear the airway (even if they have a pulse) are classified as deceased/non-salvageable/expectant. This classification also applies to obvious mortal injuries such as decapitation. Deceased patients are tagged Black.",
        "Hold": "Some advanced triage systems also include a hold category, to indicate patients with minor injuries who do not require a physician\u2019s care, such as minor painful, swollen, deformed extremities or minor soft tissue injuries. These patients may be tagged White and dismissed, with a recommendation to obtain basic first aid care at home or elsewhere.",
        "Assessment in Triage": "The START system is a popular method that is simple and depends on condition-based classification. You determine the different levels by assessing four aspects that can be recalled with the acronym ARPM. ARPM stands for: \uf0a7 Ability to get up and walk (ambulatory). \uf0a7 Respiratory status. \uf0a7 Perfusion status. \uf0a7 Mental status.Once ambulatory patients are out of the area, you will need to check respiratory status of the remaining patients. If there are no respirations, clear the mouth of any foreign objects and make sure the airway is open. If there are still no respirations and the patient does not begin breathing independently, even with the airway open, the patient is classified as \u201cdeceased/non-salvageable.\u201d There is no need to check the pulse. Place the appropriate tag on the patient and move on. If the patient begins to breathe independently when you open the airway, classify the patient as needing immediate care and tag appropriately. Any individual who needs help maintaining an open airway is a high priority. Position the patient in a way that will maintain an open airway, place the appropriate tag on the person and move on to the next patient. Once triage of all injured or ill people is complete, you may be able to come back and assist with care. If the patient is breathing when you arrive, check the rate of the patient\u2019s breathing. Someone breathing more than 30 times a minute should be classified as immediate care. The third step is to determine the perfusion status. This is done by checking capillary refill and radial pulse, with the pulse being the more reliable measure, as capillary refill is dependent on multiple factors. If you cannot find the radial pulse in either arm, then the patient\u2019s blood pressure is substantially low. Control any severe bleeding by using direct pressure and applying a bandage, tourniquet or hemostatic dressing, based on your available resources and local protocols. A large-scale incident with limited resources may require the use of a tourniquet as the first option to control severe, life-threatening bleeding, as maintaining direct pressure may not allow the responder to continue to triage and care for other patients. If this is the case, classify the patient as requiring immediate care and move on to the next patient. The fourth step is to determine the patient\u2019s LOC, by using the AVPU (Alert, Voice, Pain, Unresponsive) scale. A patient who is alert and responds appropriately to verbal stimuli is classified as delayed care. This patient has some injury that prevents them from moving to safety, but the condition is not life threatening. Someone who remains unconscious and responds only to painful stimuli or responds inappropriately to verbal stimuli is classified as immediate care.",
        "Other Methods of Triage": "Besides the START triage system, there are others, such as the Sort-Assess-Lifesaving Interventions-Treatment and/or Transport (SALT) Mass Casualty Triage. The SALT Mass Casualty Triage was developed using all existing triage systems, and is meant for all patients involved, even special populations and children. It sorts patients into three priorities: Priority 1: Still/obvious life threat; Priority 2: Waving/purposeful movement; and Priority 3: Walking. It then goes on to include individual assessments, beginning with limited, rapid lifesaving interventions (LSIs), such as controlling severe bleeding; opening and clearing the airway; or giving 2 ventilations if the patient is a child, chest compressions or auto-injector antidotes. At this point, you would prioritize patients for treatment and/or transport by assigning them to one of five categories: Immediate, Expectant, Delayed, Minimal or Dead.",
        "CRITICAL FACTS 4": "Besides the START triage system, there are others, such as the SALT Mass Casualty Triage. The JumpSTART triage method should be used on anyone who appears to be a child, regardless of actual chronological age, but is not used on infants younger than 12 months old. Always remember that a multiple-casualty incident involving children is handled differently than one involving adults.",
        "Treatment": "Following triage, patients must be processed through the treatment area. The treatment officer is appointed by the IC and is responsible for identifying a treatment area of sufficient space and with adequate ingress and egress for ambulances. The treatment officer ensures the appropriate medical care of all patients, directs re-triage if indicated, and communicates with the transportation officer regarding the transportation of the patients and appropriate destination hospital requirements (trauma center consideration) in the correct order, according to triage. Patients tagged as immediate have priority and should be treated to correct any life-threatening conditions. They should be transported by the most appropriate means to the various hospitals according to the local MCI plan. While patients are waiting for transport, they should be continually monitored for changes in status. For example, it is always possible that a patient tagged as delayed may experience deterioration in condition and need to be tagged as immediate.",
        "Treatment - Pediatric Considerations": "JumpSTART Pediatric Triage  An emergency that involves children must be handled differently from the way you would an emergency with adults. The psychological differences between adults and children could cause errors in tagging children. The JumpSTART triage method should be used on anyone who appears to be a child, regardless of actual chronological age, but is not used on infants younger than 12 months old (Fig. 30-12). Using the same START steps outlined previously, you would assess whether the child is ambulatory, the respiratory status, whether there is any major bleeding and the mental status. Children who are ambulatory should be tagged accordingly and escorted to the proper area; do not send them alone. Children who are breathing must be monitored for the rate. It should be between 15 and 45 breaths per minute. If it is any lower or higher, or if they begin breathing spontaneously after you open the airway, they should be tagged as immediate care. A child who does not breathe after the airway has been cleared and does not have a peripheral pulse should be tagged as deceased/non-salvageable. However, if a pulse is present, even if there is no breathing after the airway is cleared, you should give 5 ventilations before determining the child\u2019s status. For circulation, or perfusion, check the child\u2019s peripheral pulse. If there is none present, the child should be tagged for immediate care. Finally, for mental status, see if the child responds to your voice. Code the child as delayed care if there is no response to all stimuli. If the child does respond to pain but only with sounds, the tag should be for immediate care. While patients are waiting for transport, they should be continually monitored for changes in status. For example, it is always possible that a patient tagged as delayed may experience deterioration in condition and need to be tagged as immediate.",
        "Staging": "The staging officer should be one of the first officers assigned by the IC. It is important that the staging officer establish an area suitable to park multiple units in an organized fashion. This officer must maintain accountability of all units assigned for immediate release to the transportation officer.",
        "Transportation": "The transportation officer is assigned by the IC. The major responsibility of the transportation officer is patient accountability. This is a documentation-rich position, and aide(s) are often required based on the scope and complexity of the incident. The transportation officer communicates with receiving hospitals, units assigned by the staging officer, the staging officer and the treatment officer. The transportation officer is responsible for assigning patients to ambulances, helicopters and buses, assigning destination hospitals and maintaining patient tracking records. The ambulances, helicopters and buses will be instructed which hospital is accepting their patient.or patients. They then radio ahead to the hospital, notifying hospital personnel of their impending arrival. This is the time when appropriate advance information is given, such as the injuries involved and estimated time of arrival. Once all the immediate and delayed patients have been transported, the ambulatory patients also may be transported. Essential emergency equipment and EMRs should be on the transport, in case a patient deteriorates from ambulatory to delayed, or even immediate, care.",
        "STRESS AT AN MCI - Patient Stress": "The impact of an MCI can reach far beyond visible injuries. The stress of living through such an event can result in cognitive, emotional, physical and behavioral responses. Some may occur right away, others may only appear days after the event. Patient stress can be the result of individual injuries, but also concern over loved ones who may have been involved in the MCI. Not knowing what is happening is very stressful and frightening, and can interfere with the physical care of the patient.Some people are at greater risk of severe stress reactions. Children may react strongly, experiencing extreme fears of further harm. Older adult patients and those who already suffer from health problems, either physical or emotional, may also be at increased risk.",
        "STRESS AT AN MCI - Responder Stress": "After each call, there should be opportunity to discuss how the call went, as well as any feelings or issues that may have resulted. This is particularly important following an MCI, which can often seem overwhelming and difficult to handle. Trained counselors may help lead the discussion and reduce the risk of post-traumatic stress. Reducing stress during the MCI is also important. This can be done by ensuring that responders know exactly what is expected of them. If they do not understand their roles or duties, frustration and stress may result. If responders are in roles that match their specific strengths, this helps in reducing stress. Ensure that responders get adequate rest, according to the protocols for your organization. Rest and downtime are essential, regardless of the situation. This time can be used for the responders to eat and drink (no alcohol), close their eyes or talk. If possible, counselors on the scene can help at this point. Keep an eye on the responders. Even though they may feel they are coping well, if you are on the lookout for exhaustion or stress, you may be able to intervene and provide rest and support. Encourage responders to talk among themselves, though their conversation must be kept professional to avoid misunderstandings from other workers or the patients.",
        "STRESS AT AN MCI - Managing and Reducing Stress": "Whenever possible, reunite family members. The goal is to reduce their stress and fear, but this can also be helpful for responders, since family members can provide missing information and can support each other. Limit the information that may be getting out of the scene. Only designated authorities should be speaking to members of the media, and those responders who are working on the scene should not discuss individual patients with anyone other than immediate family members who are on hand. Be honest. Tell patients what is happening in terms they can understand. Limit the use of official or medical language, as it can seem confusing and frightening if misunderstood. If possible, for those who are able, assign tasks to help others. This can help reduce stress and make them feel useful. If patients are reluctant to receive help, encourage them to accept it, so that perhaps they may return the favor at some point by helping someone else. Encourage questions and discussion. Fear of the unknown is often worse than reality. Be careful not to offer false hope; if you cannot answer a question, say so and see if you can determine the answer from the right sources.",
        "COMMUNICATION": "Communication is a vital link in the smooth running of an MCI. However, it is important that responders understand that communication is not always as smooth and effective as would be desired. If you find yourself in a situation where communication is not ideal, remember that your first priority is your patients and the care you are there to provide. Do not let the frustration of difficulties with communication affect your work. To help communication run smoothly, remember to always speak as clearly as possible\u2014do not rush your speech\u2014because being asked to repeat or being misunderstood can cause a delay in care or transport. Use simple, clear language. Use communication tools such as radio communications only when necessary, so as not to clutter the airwaves. For obvious reasons, face-to-face communication is usually the easiest means of communication.",
        "PUTTING IT ALL TOGETHER": "As an EMR, you may need to assist with an emergency involving multiple people. To do so effectively requires a plan of action so that you can rapidly determine what additional resources are needed and how best to use them. An appropriate initial response can eliminate potential problems for arriving personnel and possibly save the lives of several injured people. You will need to be able to make the scene safe for you and others to work, delegate responsibilities to others, manage available resources, identify and care for the patients most in need of care, and relinquish command as more highly trained personnel arrive. MCIs can be stressful and challenging for EMRs. By following set protocols for establishing priority care, confusion can be minimized for both responders and patients. The two most important issues to remember are assessment and communication. For patients in an MCI, your assessments differ from those of one-on-one situations. In an MCI, you must be able to provide care to as many patients as possible, so you must focus on those who can be saved or helped. Communication between you and your colleagues is vital in maintaining control of the situation, minimizing stress and providing quality care. Communication with the patients and their loved ones will help keep them from panicking and help them listen to instructions. Finally, equally important to caring for your patients is caring for yourself. Be sure that you and your colleagues get enough rest and support during and after the MCI.",
        "CRITICAL FACTS 7": "Communication is a vital link to manage an MCI smoothly. However, if you find yourself in a situation where communication is not ideal, remember that your first priority is your patients and the care you are there to provide. Do not let the frustration of difficulties with communication affect your work."
    },
    {
        "Key Terms": "Acute: Having a rapid and severe onset, then quickly subsiding., Adaptive immunity: The type of protection from disease that the body develops throughout a lifetime as a person is exposed to diseases or immunized against them., AIDS: A disease of the immune system caused by infection with HIV., Antibodies: A type of protein found in blood or other bodily fluids; used by the immune system to identify and neutralize pathogens, such as bacteria and viruses., Bacteria: One-celled organisms that can cause infection; a common type of pathogen., Biohazard: A biological agent that presents a hazard to the health or well-being of those exposed., Bloodborne: Used to describe a substance carried in the blood (e.g., bloodborne pathogens are pathogens carried through the blood)., Bloodborne pathogens: Infectious microorganisms that are present in human blood or other potentially infectious materials (OPIM) and can cause disease in humans., Body substance isolation (BSI) precautions: Protective measures to prevent exposure to communicable diseases; these precautions define all body fluids and substances as infectious., Chronic: Persistent over a long period of time., Critical incident stress: Stress triggered by involvement in a serious or traumatic incident., Direct contact: Mode of transmission of pathogens that occurs through directly touching infected blood or OPIM, or other agents such as chemicals, drugs or toxins., Disease-causing agent: A pathogen or germ that can cause disease or illness (e.g., a bacterium or virus)., Droplet transmission: Mode of transmission of pathogens that occurs when a person inhales droplets from an infected person\u2019s cough or sneeze; also known as respiratory droplet transmission., Engineering controls: Control measures that eliminate, isolate or remove a hazard from the workplace; things used in the workplace to help reduce the risk of an exposure., Exposure: An instance in which someone is exposed to a pathogen or has contact with blood or OPIM or objects in the environment that contain disease-causing agents., Exposure control plan: Plan in the workplace that outlines the employer\u2019s protective measures to eliminate or minimize employee exposure incidents., Hepatitis: An inflammation of the liver most commonly caused by viral infection; there are several types including hepatitis A, B, C, D and E., HIV: A virus that weakens the body\u2019s immune system, leading to life-threatening infections; causes AIDS., Homeostasis: A constant state of balance or well-being of the body\u2019s internal systems that is continually and automatically adjusted., Immune system: The body\u2019s complex group of body systems that is responsible for fighting disease., Indirect contact: Mode of transmission of a disease caused by touching a contaminated object., Infection: A condition caused by disease-producing microorganisms, called pathogens or germs, in the body., Infectious disease: Disease caused by the invasion of the body by a pathogen, such as a bacterium, virus, fungus or parasite., Innate immunity: The type of protection from disease with which humans are born., Lividity: Purplish color in the lowest-lying parts of a recently dead body, caused by pooling of blood., Meningitis: An inflammation of the meninges, the thin, protective coverings over the brain and spinal cord; caused by virus or bacteria., Methicillin-resistant Staphylococcus aureus (MRSA): A staph bacterium that can cause infection; difficult to treat because of its resistance to many antibiotics., Multidrug-resistant tuberculosis (MDR TB): A type of tuberculosis (TB) that is resistant to some of the most effective anti-TB drugs., Needlestick: A penetrating wound from a needle or other sharp object; may result in exposure to pathogens through contact with blood or OPIM., Occupational Safety and Health Administration (OSHA): Federal agency whose role is to promote the safety and health of American workers by setting and enforcing standards; providing training, outreach and education; establishing partnerships; and encouraging continual process improvement in workplace safety and health., Opportunistic infections: Infections that strike people whose immune systems are weakened., Other potentially infectious materials (OPIM): Materials, other than blood, that can cause illness; these materials include body fluids such as semen and vaginal secretions., Pandemic influenza: A respiratory illness caused by virulent human influenza A virus; spreads easily and sustainably, and can cause global outbreaks of serious illness in humans., Passive immunity: The type of immunity gained from external sources such as from a mother\u2019s breast milk to an infant., Pathogen: A term used to describe a germ; a disease-causing agent (e.g., bacterium or virus)., Personal protective equipment (PPE): All specialized clothing, equipment and supplies that keep the user from directly contacting infected materials; includes gloves, gowns, masks, shields and protective eyewear., Standard precautions: Safety measures, including BSI and universal precautions, taken to prevent occupational-risk exposure to blood and OPIM; these precautions assume that all body fluids, secretions and excretions (except sweat) are potentially infective., Stress: The body\u2019s normal response to any situation that changes a person\u2019s existing mental, physical or emotional balance., Sudden death: An unexpected, natural death; usually used to describe a death from a sudden cardiac event., Tuberculosis (TB): A bacterial infection that usually attacks the lungs., Universal precautions: A set of precautions designed to prevent transmission of HIV, hepatitis B virus (HBV) and other bloodborne pathogens when providing care; these precautions consider blood and OPIM of all patients potentially infectious., Vector-borne transmission: Transmission of a pathogen that occurs when an infectious source, such as an animal or insect bite or sting, penetrates the body\u2019s skin., Virus: A common type of pathogen that depends on other organisms to live and reproduce; can be difficult to kill., Work practice controls: Control measures that reduce the likelihood of exposure by changing the way a task is carried out., content: After reading this chapter, and completing the class activities, you will have the information needed to: \u2022 Describe how the immune system works. \u2022 Identify ways in which diseases are transmitted and give an example of how each transmission can occur. \u2022 Describe diseases that cause concern and how they are transmitted. \u2022 Describe conditions that must be present for disease transmission. \u2022 Explain the importance of standard precautions. \u2022 Identify standard precautions to protect yourself against disease transmission. \u2022 Describe the steps an emergency medical responder (EMR) should take for personal protection from bloodborne pathogens. \u2022 Describe the procedure an EMR would use to disinfect equipment, work surfaces, clothing and leather items. \u2022 Explain the importance of documenting an exposure incident and post-exposure follow-up care. \u2022 Explain how the OSHA standard for bloodborne pathogens influences your actions as an EMR. \u2022 Acknowledge the importance of knowing how various diseases are transmitted.",
        "INTRODUCTION": "The demands on an emergency medical responder (EMR) can be significant and are physical, emotional and mental in nature. To meet these demands, it is essential to take good care of yourself, by making healthy choices that promote your own physical, emotional and mental well-being. These choices will benefit not only you but also the patients and families you assist as you carry out your work each day. Bloodborne pathogens, such as bacteria and viruses, are present in blood and other potentially infectious materials (OPIM) and can cause disease when certain conditions are present. Being aware of disease-causing agents, how they are spread, and their signs and symptoms will help you prevent exposure to these illnesses and recognize them. It is also important for you to keep immunizations up-to-date to protect against vaccine-preventable diseases and wear proper personal protective equipment (PPE) while providing care. EMRs must also look after their mental and emotional health. A serious injury, sudden illness or death can have an emotional impact on everyone involved: patients, family, friends, bystanders, EMRs and others. The degree of impact varies from person to person. The way one person responds to a stressful situation can differ substantially from the response of another person in a similar situation. At times, you may encounter a patient who is experiencing an emotional crisis. Besides providing care for a specific injury or illness, you may also need to provide emotional support. Being able to understand some of what a patient feels when coping with an injury or illness is an important part of what you do as a responder.",
        "PREVENTING DISEASE TRANSMISSION": "To help prevent disease transmission, you need to understand how infections occur, how diseases spread from one person to another and what you as an EMR can do to protect yourself and others. Infectious diseases can be spread from infected people and from animals, insects or objects that have been in contact with them. EMRs must protect themselves and others from infectious diseases.",
        "How Infection Occurs - Disease-Causing Agents": "The disease process begins when a pathogen (germ) gets into the body. When pathogens enter the body, they sometimes can overpower the body\u2019s natural defense systems and cause illness. Bacteria and viruses cause most infectious diseases. Other disease-causing pathogens include fungi, protozoa, rickettsia, parasitic worms, prions and yeasts. Bacteria are everywhere. They do not depend on other organisms for life and can live outside the human body. Most bacteria do not infect humans. Those that do may cause serious illness, such as bacterial meningitis and tetanus. The body may have difficulty fighting infection caused by bacteria. The body\u2019s ability to fight infection depends on its immune system. In people with healthy immune systems, a bacterial infection is often avoided. When an infection is present, healthcare providers may prescribe antibiotic medications that either kill the bacteria or weaken them enough for the body to get rid of them. Commonly used antibiotics include penicillin, erythromycin and tetracycline. Unlike bacteria, viruses depend on other organisms to live and reproduce. Viruses cause many diseases, including the common cold (caused by the rhinovirus). Once in the body, viruses may be difficult to eliminate because very few medications are effective against viral infections. While there are some medications that kill or weaken viruses, the body\u2019s immune system is the main defense against them. Some infections, such as measles, malaria, HIV and yellow fever, affect the entire body. Others affect only one organ or system of the body\u2014for example, the virus that causes the common cold, which occurs in the upper respiratory tract.",
        "Pathogens and the Diseases and Conditions They Cause": "Viruses can cause a wide range of illnesses including hepatitis, measles, mumps, chicken pox, meningitis, rubella, influenza, warts, colds, herpes, HIV (which causes AIDS), genital warts, smallpox, avian flu, Ebola, and Zika. Bacteria are responsible for diseases such as tetanus, meningitis, scarlet fever, strep throat, tuberculosis, gonorrhea, syphilis, chlamydia, toxic shock syndrome, Legionnaires\u2019 disease, diphtheria, food poisoning, Lyme disease, and anthrax. Fungal infections include athlete\u2019s foot, ringworm, and histoplasmosis. Protozoa can cause malaria, dysentery, cyclospora, and giardiasis. Rickettsia are linked to typhus and Rocky Mountain spotted fever. Parasitic worms may lead to abdominal pain, anemia, lymphatic vessel blockage, lowered antibody response, and respiratory and circulatory complications. Prions are known to cause Creutzfeldt-Jakob disease (CJD) and bovine spongiform encephalopathy (mad cow disease). Yeasts, such as Candida, can lead to candidiasis, also known as \u201cthrush.\u201d",
        "The Body\u2019s Natural Defenses": "The body has a series of natural defenses that prevent infectious microorganisms from entering. The body depends on intact skin and mucous membranes in the mouth, nose and eyes to keep infectious microorganisms out. When the skin is damaged, infectious microorganisms can enter through openings, such as cuts or sores. Mucous membranes in the mouth, nose and eyes also work to protect the body from intruding infectious microorganisms, often by trapping them and forcing them out through a cough or sneeze. However, mucous membranes are less effective than skin at keeping bloodborne pathogens out of the body. If these barriers fail and a germ enters the body, the body\u2019s immune system begins working to fight the disease. The immune system\u2019s basic tools are antibodies and white blood cells. Special white blood cells travel around the body and identify invading pathogens. Once they detect a pathogen, white blood cells gather around it and release antibodies that fight infection. These antibodies attack the pathogens and weaken or destroy them. Antibodies usually can rid the body of pathogens. However, once inside the body, some pathogens can thrive and, under ideal conditions, multiply and overwhelm the immune system. This combination of preventing pathogens from entering the body and destroying them once they enter is necessary for good health (homeostasis). Sometimes, however, the body cannot fight off infection. When this occurs, an invading pathogen can become established in the body, causing infection, which may range from mild to serious and brief (acute) to long-lasting (chronic). Fever and exhaustion are often a sign and symptom that the body is fighting off an infection. Other common signs and symptoms include headache, nausea and vomiting. There are three different types of human immunity: innate, adaptive and passive.",
        "Innate immunity": "Innate immunity is the type of protection with which we are born. The term \u201cinnate immunity\u201d also refers to the natural barriers our bodies have, such as the skin and mucous membranes in the nose, throat and gastrointestinal tract that prevent most diseases from entering our bodies.",
        "Adaptive immunity": "Adaptive immunity develops throughout our lives as we are exposed to diseases or are immunized against them.",
        "Passive immunity": "Passive immunity is immunity we gain from external sources such as from a mother\u2019s breast milk to an infant.",
        "CRITICAL FACTS": "Intact skin, as well as mucous membranes in the mouth, nose and eyes, are part of the body\u2019s natural defenses to help keep infectious microorganisms out. For any disease to spread, pathogens must be present in sufficient quantity and pass through the broken skin or mucous membrane of a susceptible person.",
        "How Diseases Spread": "Exposure to blood and OPIM occurs across a wide variety of occupations. Healthcare workers, emergency response personnel, public safety personnel and other workers can be exposed to blood and OPIM through injuries from needles and other sharps devices, as well as by direct and indirect contact with skin and mucous membranes. For any disease to spread, including bloodborne diseases, all four of the following conditions must be met: 1. A pathogen must be present. 2. A sufficient quantity of the pathogen to cause disease must be present. 3. A person must be susceptible to the pathogen. 4. The pathogen must pass through the correct entry site (e.g., eyes, mouth and other mucous membranes or skin pierced or broken by needlesticks, bites, cuts, abrasions and other means). To understand how infections occur, think of these four conditions as pieces of a puzzle. All of the pieces must be in place for the picture to be complete. If any one of the conditions is missing, an infection cannot occur. Bloodborne pathogens, such as hepatitis B, hepatitis C and HIV, spread primarily through direct or indirect contact with infected blood or OPIM. While these diseases can be spread by sexual contact through infected body fluids, such as vaginal secretions and semen, these body fluids are not usually involved in occupational transmission. Hepatitis B, hepatitis C and HIV are not spread by food or water or by casual contact. such as hugging or shaking hands. The highest risk of occupational transmission is unprotected direct or indirect contact with infected blood. Disease-causing germs can also cause infection through contaminated food or water. In this way, germs can spread to many people through a single source, such as sometimes occurs with Escherichia coli (E. coli); this type of infection is referred to as food poisoning.",
        "Direct Contact": "Direct contact transmission occurs when infected blood or OPIM from one person enters another person\u2019s body at a correct entry site. For example, direct contact transmission can occur through infected blood splashing in the eye or from directly touching the OPIM of an infected person. The infected blood or OPIM then enters the body through a correct entry site.",
        "How Bloodborne Pathogens Are Transmitted": "Hepatitis B is transmitted through both direct and indirect contact, primarily via blood and semen. Signs and symptoms may include jaundice, fever, dark urine, clay-colored bowel movements, fatigue, abdominal pain, loss of appetite, nausea, vomiting, and joint pain. Hepatitis C is also spread through direct and indirect contact with infective materials like blood and semen. Symptoms may include jaundice, fever, fatigue, dark urine, clay-colored stool, abdominal pain, loss of appetite, nausea, vomiting, and joint pain. HIV (Human Immunodeficiency Virus) is transmitted through direct and possibly indirect contact, with blood, semen, and vaginal fluid as the infective materials. Symptoms in the early stages may be absent or mild, but in later stages, individuals may experience fever, headache, fatigue, diarrhea, skin rashes, night sweats, loss of appetite, swollen lymph glands, significant weight loss, white spots in the mouth, vaginal discharge (indicative of yeast infection), and memory or movement difficulties.",
        "Indirect Contact": "Some bloodborne pathogens are also transmitted by indirect contact. Indirect contact transmission can occur when a person touches an object that contains the blood or OPIM of an infected person, and that infected blood or OPIM enters the body through a correct entry site. These objects include soiled dressings or equipment and work surfaces contaminated with an infected person\u2019s blood or OPIM. For example, indirect contact can occur when a person picks up blood-soaked bandages with a bare hand and the pathogens enter through a break in the skin on the hand.",
        "Respiratory Droplet and Vector-Borne Transmission": "Other pathogens, such as the flu virus, can enter the body through droplet transmission. This occurs when a person inhales droplets propelled from an infected person\u2019s cough or sneeze from within a few feet. A person can also become infected by touching a surface recently contaminated by infected droplets and then touching the eyes, mouth or nose with contaminated hands. Vector-borne transmission of diseases, such as malaria, rabies and West Nile virus, occurs when an infectious source, such as an animal or insect bite or a sting, penetrates the body\u2019s skin.",
        "Risk of Transmission": "Infectious diseases have widely varying levels of risk of transmission. Hepatitis B, hepatitis C and HIV share a common mode of transmission\u2014direct or indirect contact with infected blood or OPIM\u2014but they differ in the risk of transmission. Workers who have received the hepatitis B vaccine and have developed immunity to the virus are at virtually no risk for infection by the hepatitis B virus (HBV). For an unvaccinated person, the risk for infection from a needlestick or cut exposure to hepatitis B-infected blood can be as high as 30 percent, depending on several factors. In contrast, the risk for infection after a needlestick or cut exposure to hepatitis C-infected blood is about 2 percent, and the risk of infection after a needlestick or cut exposure to HIV-infected blood is less than 1 percent.",
        "Diseases That Cause Concern - Hepatitis A, B, C, D and E": "Hepatitis is a type of liver disease. Hepatitis A is caused by the hepatitis A virus (HAV). This disease is spread primarily through food or water that has been contaminated by stool from an infected person. HAV is transmissible by: \uf0a7 Eating food prepared by someone with HAV who did not wash hands after using the bathroom. \uf0a7 Engaging in certain sexual activities, such as oral-anal contact with someone who has HAV. \uf0a7 Changing a diaper and then not washing hands. \uf0a7 Drinking water that has been contaminated. HAV causes inflammation and swelling of the liver. The patient may feel ill, with flu-like symptoms, or may experience no symptoms at all. Symptoms of HAV usually disappear after several weeks. This disease rarely causes permanent damage or chronic illness. HAV can be prevented with the hepatitis A vaccine, which is a series of two injections administered at least 6 months apart. The most effective prevention, though, is healthy habits. Always wash your hands thoroughly before preparing food, after using the toilet and after changing a diaper. International travelers should be careful about drinking tap water. Hepatitis B is a liver infection caused by HBV. Hepatitis B may be severe or even fatal and it can be in the body for up to 6 months before symptoms appear. These may include flu-like symptoms such as fever, fatigue, abdominal pain, loss of appetite, nausea, vomiting and joint pain, as well as dark urine and clay-colored bowel movements. Later-stage symptoms include jaundice, which causes a yellowing of the skin and eyes. Medications are available to treat chronic hepatitis B infection, but they do not work for everyone. The most effective means of prevention is the hepatitis B vaccine. This vaccine, given in a series of three doses, provides immunity to the disease. Scientific data show that hepatitis B vaccines are safe for adults, children and infants. There is no confirmed evidence indicating that the hepatitis B vaccine causes chronic illnesses. The hepatitis B vaccination series must be made available to all employees who have occupational exposure, usually within 10 working days of initial assignment, after completing appropriate training. However, employees may decide not to have the vaccination. If an employee decides not to be vaccinated, the person must sign a form affirming this decision. However, if an employee who initially declines hepatitis B vaccination decides to accept the vaccination at a later date, the employer must make the hepatitis B vaccination available at that time, so long as the standard still covers the employee. Hepatitis C is a liver disease caused by the hepatitis C virus (HCV). It is the most common chronic bloodborne infection in the United States. Its symptoms are similar to those of hepatitis B infection, including fever, fatigue, abdominal pain, loss of appetite, nausea, vomiting, dark urine, clay-colored stool, joint pain and jaundice. There is no vaccine against hepatitis C and no treatment available to prevent infection after exposure. For these reasons, hepatitis C is more serious than hepatitis B. Hepatitis C is the leading cause of liver transplants. Hepatitis D is a serious liver disease caused by the hepatitis D virus (HDV) and relies on HBV to replicate. It is uncommon in the United States. It is transmitted through contact with infectious blood, similar to how HBV is spread. There is no vaccine for hepatitis D. Hepatitis E is caused by the hepatitis E virus (HEV). It is commonly transmitted via the fecal-oral route and is associated with ingestion of drinking water contaminated with fecal material in countries with poor sanitation. It occurs primarily in adults. The potential for HEV transmission from contaminated food is still under investigation, and there is no evidence of transmission by percutaneous (through the skin) or sexual exposures. There is currently no FDA-approved vaccine for hepatitis E.",
        "HIV/AIDS": "HIV is the virus that causes AIDS. HIV attacks white blood cells and destroys the body\u2019s ability to fight infection. This weakens the body\u2019s immune system. Infections that strike people with weakened immune systems are called opportunistic infections. Some opportunistic infections that occur in patients with AIDS include severe pneumonia, tuberculosis, Kaposi\u2019s sarcoma and other unusual cancers. People infected with HIV may not feel or appear sick. A blood test, however, can detect the HIV antibody. When an infected person has a significant drop in a certain type of white blood cell or shows signs of having certain infections or cancers, the patient may be diagnosed as having AIDS. These infections can cause fever, fatigue, diarrhea, skin rashes, night sweats, loss of appetite, swollen lymph glands and significant weight loss. In the advanced stages, AIDS is a very serious condition. Patients with AIDS eventually develop life-threatening infections from which they can die. Currently, there is no vaccine against HIV.",
        "Tuberculosis": "Tuberculosis (TB) is an infection caused by a bacterium called Mycobacterium tuberculosis. The bacteria usually attack the lungs, but they may also damage other parts of the body such as the brain, kidneys or spine. TB is spread through the air when an infected person coughs, sneezes or talks. Anyone exposed to TB should be tested. People with a weakened immune system are more likely to get TB. Symptoms of TB in the lungs may include: \uf0a7 A bad cough lasting 3 weeks or longer. \uf0a7 A pain in the chest. \uf0a7 Weight loss. \uf0a7 Loss of appetite. \uf0a7 Coughing up blood or bloody sputum (phlegm from inside the lungs). \uf0a7 Weakness and/or fatigue. \uf0a7 Fever and chills. \uf0a7 Night sweats. TB must be treated properly or it can lead to death. It can usually be cured with several medications over a long period of time. Patients with latent (asymptomatic) TB can take medicine to prevent development of active TB.",
        "Multidrug-Resistant Tuberculosis": "Multidrug-resistant tuberculosis (MDR TB) is TB that is resistant to at least two of the most effective anti-TB drugs, isoniazid and rifampicin. These drugs are the ones most widely used to treat TB. MDR TB is more likely to occur in patients who: \uf0a7 Do not take their TB medicine regularly or who do not take all of the prescribed medication. \uf0a7 Get active TB, after having taken medication to treat it in the past. \uf0a7 Come from areas of the world where MDR TB is prevalent. \uf0a7 Spend time with someone known to have MDR TB.",
        "Meningitis": "Meningitis is a contagious meningococcal infection that attacks the meninges, the protective coverings that surround the brain and spinal cord. Several different bacteria can cause meningitis, but a virus can also cause it. The bacteria are transmitted from person to person through droplets. Close and prolonged contact (e.g., kissing, sneezing or coughing on someone) and living in close quarters or dormitories (e.g., military or student housing) facilitates the spread of the disease. Meningitis can infect anyone but is more commonly found in those who have compromised immune systems and have trouble fighting infections. The most common symptoms are stiff neck, high fever, light sensitivity, confusion, headache, nausea, sleepiness and vomiting. Bacterial meningitis is a serious infection; even when diagnosed early and properly treated, 5 to 10 percent of patients die, typically within 24 to 48 hours of the onset of symptoms. Bacterial meningitis may result in brain damage, hearing loss or learning disability in 10 to 20 percent of patients and sometimes death. Viral meningitis is less severe and usually resolves without specific treatment. Bacterial meningitis is potentially fatal and is a medical emergency. Admission to a hospital or health center is necessary. There are vaccines available to prevent meningitis and antibiotics with which to treat it.",
        "Community-Associated MRSA": "Methicillin-resistant Staphylococcus aureus (MRSA) is a type of bacterium. As one of the staph bacteria, like other kinds of bacteria, it frequently lives on the skin and in the nose without causing any health problems. It only becomes a problem when it is a source of infection. These bacteria can be spread from one person to another through casual contact or contaminated objects. Infections with MRSA are more difficult to treat than ordinary staph infections because they are resistant to many types of antibiotics, the medications used to treat bacterial infections. Infections can occur in wounds, burns and sites where tubes have been inserted into the body. When MRSA occurs in groups of people who have not been recently hospitalized or have not had a medical procedure, this type of MRSA is referred to as community-associated MRSA (CA-MRSA). For example, it can occur among young people who have cuts or wounds and who are in close contact with one another, such as members of a sports team.",
        "Influenza": "Seasonal influenza is a respiratory illness caused by both human influenza A and human influenza B viruses, which can be transmitted from person to person. Most people have some immunity to influenza and there is a vaccine available. Seasonal influenza usually has a sudden onset, with symptoms of fever (usually high), headache, extreme tiredness, dry cough, sore throat, runny or stuffy nose and muscle aches. Abdominal symptoms such as nausea, vomiting and diarrhea may also be present, but these symptoms occur more often in children than in adults. Influenza is transmitted from person to person via large virus-laden droplets from coughing or sneezing. These large droplets settle on the mucosal surfaces of the upper respiratory tracts of susceptible persons who are within 3 feet of infected people. Transmission can also occur through direct contact or indirect contact with respiratory secretions\u2014for example, when touching surfaces contaminated with influenza virus and then touching the mouth, nose or eyes. Pandemic influenza (or pandemic flu) is a virulent human influenza A virus. The term \u201cpandemic\u201d refers to a worldwide epidemic occurring over a wide geographic area that affects a large number of people. Pandemic flu causes a global outbreak, or pandemic, of serious illness in humans. Because there is little natural immunity, the disease spreads easily from person to person. Although we do not know for sure when the next pandemic influenza will strike or that it would present in the same way as seasonal influenza, it is helpful to be aware of the symptoms of seasonal influenza in order to plan for a pandemic flu. The best defense is to take steps to prevent disease transmission, such as frequent hand washing.",
        "Protecting Yourself from Disease Transmission": "An EMR may be exposed to many other illnesses, viruses and infections. Keep immunizations current, have regular physical checkups and be knowledgeable about other pathogens. For more information on infectious diseases and illnesses of concern, contact the Centers for Disease Control and Prevention (CDC) at (800) 232-4636 (800-CDC-INFO) or visit the website at cdc.gov. You may also refer to your organization\u2019s exposure control officer.",
        "Exposure Control Plan": "Federal Occupational Safety and Health Administration (OSHA) regulations require employers to have an exposure control plan. The exposure control plan is a written plan outlining the protective measures the employer will take to eliminate or minimize employee exposure incidents. The exposure control plan should include exposure determination, methods for implementing other parts of the OSHA standard (e.g., ways of meeting the requirements and recordkeeping) and procedures for evaluating details of an exposure incident. The exposure control plan guidelines should be available to employees and should specifically explain what they need to do to prevent the spread of infectious diseases.",
        "CRITICAL FACTS 1": "Exposure control plans, as required by OSHA, contain policies and procedures that help employers eliminate, minimize and properly report employee exposure incidents.",
        "Immunizations": "Before working as an EMR, you should have a physical examination to determine your baseline health status. Your immunizations should be current while practicing in healthcare and should include protection against:\n\uf0a7\tTetanus, diphtheria, pertussis.\n\uf0a7\tHepatitis B.\n\uf0a7\tMeasles/mumps/rubella (German measles).\n\uf0a7\tChicken pox (varicella).\n\uf0a7\tInfluenza.\n\uf0a7\tMeningococcal (meningitis).\nIn addition to immunizations, it is recommended that you be screened for TB and have an annual tuberculin test.",
        "Standard Precautions": "Standard precautions are safety measures taken to prevent occupational-risk exposure to blood and OPIM such as body fluids containing visible blood. Standard precautions combine body substance isolation (BSI) precautions and universal precautions and assume that all body fluids may be infective.\nUniversal precautions are OSHA-required practices of control to protect employees from exposure to blood and OPIM. These precautions require that all human blood and OPIM be treated as if known to be infectious for hepatitis B, hepatitis C, HIV or other bloodborne pathogens.\nBody substance isolation (BSI) precautions are a group of measures to prevent exposure to pathogens. This approach to infection control can be applied through the use of:\n\uf0a7\tPPE.\n\uf0a7\tProper hand hygiene.\uf0a7\tEngineering controls.\n\uf0a7\tWork practice controls.\n\uf0a7\tProper equipment cleaning.\n\uf0a7\tSpill cleanup procedures.",
        "Personal Protective Equipment": "Personal protective equipment (PPE) is equipment that is appropriate for your job duties and should be available in your workplace and identified in the exposure control plan. PPE includes all specialized clothing, equipment and supplies that keep you from directly contacting infected materials. These include, but are not limited to, CPR breathing barriers, disposable (single-use) latex-free gloves, gowns, masks, shields and protective eyewear.",
        "Disposable Latex-Free Gloves": "Wear disposable, latex-free nitrile gloves for all patient contact when providing care to injured or ill people. There are powder-free gloves available as well as disposable latex-free gloves made of vinyl. However, nitrile gloves are preferred and offer the greatest protection from bloodborne pathogens. For information on glove removal, refer to Skill Sheet 2-1.",
        "Eye Protection": "Safety glasses with side shields may be worn for eye protection. Use goggles or a full-face shield if there is a risk of splash or spray of body fluids. These reduce the risk of contamination of the mouth, nose or eyes. Examples of when these are necessary are when a patient is bleeding profusely, when delivering a baby, when suctioning and when providing ventilatory support (e.g., bag-valve-mask [BVM] resuscitator or resuscitation mask).",
        "CPR Breathing Barriers": "CPR breathing barriers include resuscitation masks (pocket masks), shields and BVMs. CPR breathing barriers help protect you against disease transmission when performing CPR or giving ventilations to a patient.",
        "CRITICAL FACTS 2": "Standard precautions are safety measures to prevent occupational-risk exposure to blood and OPIM. These assume that all body fluids may be infective.",
        "The History of Isolation Precautions": "Isolation precautions have evolved over the last few decades, in response to the expansion of healthcare delivery from a mostly primary care hospital setting to a wide range of settings, as well as our understanding of new pathogens and how they spread.\nWhile isolation precautions were already in place in the early 1980s, new guidelines, called universal precautions, were developed in the mid-1980s in response to the HIV/AIDS epidemic. These precautions dictated the application of blood and OPIM precautions to all patients, whether or not they were known to be infected. These precautions included such measures as hand washing immediately following glove removal, handling of needles and other sharps devices, and PPE to protect healthcare personnel from mucous membrane exposures.\nIn 1987, new precautions were developed, called BSI precautions, which shared some features with universal precautions but emphasized the need to avoid contact with all moist and potentially infectious body substances, even if blood was not present. Another difference from universal precautions was that BSI precautions did not specify hand washing after glove removal unless there was visible soiling.\nIn 1996, the Healthcare Infection Control Practices Advisory Committee (HICPAC) blended the major features of universal and BSI precautions in a broader guideline referred to as standard precautions, directing healthcare workers to apply these precautions to all patients at all times. Standard precautions address some gaps in the earlier guidelines, by including three transmission-based categories of precautions: airborne, droplet and contact.\nToday, standard precautions constitute the primary strategy to prevent healthcare-associated infection among patients and healthcare personnel.",
        "Masks": "A mask is a personal protective device worn on the face that covers at least the nose and mouth, and reduces the wearer\u2019s risk of inhaling hazardous airborne particles (including dust particles and infectious agents such as TB), gases or vapors. A high-efficiency particulate air (HEPA) or N95 mask filters out at least 95 percent of airborne particles, and is therefore given a \u201c95\u201d rating. Respirators that filter out at least 99 percent receive a \u201c99\u201d rating. Those that filter at least 99.97 percent (essentially 100 percent) receive a \u201c100\u201d rating. Remember that masks must be fit-tested to be effective. Place a surgical mask on the patient if you suspect an airborne disease.",
        "Gowns": "Wear a disposable gown in situations with large amounts of blood or OPIM. If your clothing becomes contaminated, remove it and shower as soon as possible. Wash the clothes in a separate load, preferably at work.",
        "Hand Hygiene": "Hand washing is the most effective measure to prevent the spread of infection. By washing your hands often, you physically remove disease-causing germs you may have picked up from other people, animals or contaminated surfaces. In addition, jewelry, including rings, should not be worn where the potential for risk of exposure exists. Wash your hands frequently. When practical, wash your hands before providing care and always after providing care\u2014whether or not gloves are worn. Local protocols may vary and should be followed. Wash your hands with soap and running water, and dry your hands thoroughly. Wash your hands and other exposed skin immediately if exposed to contaminants, such as blood and OPIM. Always wash hands after using the restroom and before and after handling food. Use alcohol-based hand sanitizers when soap and running water are not available, but wash your hands with soap and water as soon as it is practical.",
        "Hand-Washing Tips": "To ensure you wash your hands correctly, follow these steps: \uf0a7 Wet hands with warm water. \uf0a7 Apply soap to hands. \uf0a7 Rub hands vigorously for at least 20 seconds, covering all surfaces of the hands and fingers. Use soap and warm running water. Scrub nails by rubbing them against the palms. \uf0a7 Rinse hands with water. \uf0a7 Dry hands thoroughly with a paper towel. \uf0a7 Turn off the faucet using the paper towel. In addition to washing your hands frequently, keep your fingernails less than one-quarter of an inch long and avoid wearing artificial nails.",
        "Hand Sanitizer and Hand-Washing Stations": "At some outdoor events or workplaces, for example on a farm or at a fair, the only source of clean water may be a portable hand-wash station. These stations consist of a supply of soap and potable water, and a bucket, cooler or other container with a turn-spout that allows the water to run over your hands to rinse soap away. The stations also include a catch bucket to catch the wastewater, and an ample supply of paper towels. Alcohol-based hand sanitizers allow you to cleanse your hands when soap and water are not readily available and your hands are not visibly soiled. If your hands contain visible matter, you should use soap and water instead. When using an alcohol-based hand sanitizer: \uf0a7 Apply the product to the palm of one hand. \uf0a7 Rub hands together. \uf0a7 Rub the product over all surfaces of the hands and fingers until hands are dry. \uf0a7 Wash your hands with soap and water as soon as they are available.",
        "Engineering and Work Practice Controls": "Engineering controls are control measures that isolate or remove a hazard from the workplace. In other words, engineering controls are objects used in the workplace to help reduce the risk of an exposure incident. Examples of engineering controls include: \uf0a7 Sharps disposal containers (Fig. 2-10). \uf0a7 Self-sheathing needles. \uf0a7 Safer medical devices, such as sharps with engineered sharps injury protections or needleless systems. \uf0a7 Use of biohazard containers and labels, and posting of signs at entrances to areas where infectious materials may be present. \uf0a7 PPE. Biohazard containers are marked with a biohazard symbol\u2014typically, a three-sided design in bright, fluorescent orange or orange-red, with lettering or symbols in a contrasting color. This symbol warns of potential infection hazards. The origin of the biohazard symbol dates back to the 1960s. It was created out of a need for a standardized, unique symbol to use as a warning symbol in response to accidental infections that occurred as a result of biomedical research. These unfortunate incidents were viewed as preventable. The symbol\u2019s development was spearheaded by Charles Baldwin, an environmental health engineer at Dow Chemical Corporation. The symbol that was eventually chosen best met the criteria that were tested in development of the symbol. It is easy to recognize, has three sides so it can be identified from any angle, and can be easily stenciled for labeling purposes. The symbol was soon adopted by the National Institutes of Health, the CDC and OSHA. Work practice controls reduce the likelihood of exposure by changing the way a task is carried out. These are the methods of working that help reduce the risk of an exposure incident. Examples of work practice controls include: \uf0a7 Placing sharps items (e.g., needles, scalpel blades) in puncture-resistant, leak-proof and labeled containers, and having the containers at the point of use. \uf0a7 Avoiding splashing, spraying and splattering droplets of blood or OPIM when performing all procedures. \uf0a7 Removing and disposing of soiled protective clothing as soon as possible. \uf0a7 Cleaning and disinfecting all equipment and work surfaces possibly soiled by blood or OPIM. \uf0a7 Washing your hands thoroughly with soap and water immediately after providing care, using a utility or restroom sink (not one in a food preparation area). \uf0a7 Not eating, drinking, smoking, applying cosmetics or lip balm, handling contact lenses, or touching your mouth, nose or eyes when you are in an area where you may be exposed to infectious materials. \uf0a7 Using alcohol-based sanitizers where hand-washing facilities are not available.",
        "CRITICAL FACTS 3": "Engineering controls, such as biohazard containers and PPE, are control measures that isolate or remove a hazard from the workplace. Work practice controls reduce the likelihood of exposure by changing the way tasks, such as disposal of sharps items or soiled clothing, are carried out.",
        "Vehicle and Equipment Cleaning and Disinfecting": "After providing care, the equipment and surfaces you used should always be cleaned and disinfected or properly disposed of (Fig. 2-11). Handle all soiled equipment, supplies and other materials with care until it is properly cleaned and disinfected. Place all used disposable or single-use items in labeled biohazard containers. Place all soiled clothing in marked plastic bags for disposal or washing. Take the following steps to clean up spills: \uf0a7 Wear disposable latex-free gloves and other PPE when cleaning spills. \uf0a7 Clean up spills immediately or as soon as possible after the spill occurs. \uf0a7 If the spill is mixed with sharp objects, such as broken glass and needles, do not pick these up with your hands. Use tongs, a broom and dustpan or other similar items. \uf0a7 Dispose of the absorbent material used to collect the spill in a labeled biohazard container. \uf0a7 Flood the area with a fresh disinfectant solution. Use a commonly accepted disinfectant of approximately 1\u00bd cups of liquid chlorine bleach to 1 gallon of water (1 part bleach per 9 parts water, or about a 10 percent solution), and allow it to stand for at least 10 minutes. Other commercial disinfectant/antimicrobial solutions are available and may have different set times. Follow local protocols and manufacturer\u2019s instructions. \uf0a7 Use appropriate material to absorb the solution, and dispose of it in a labeled biohazard container. \uf0a7 Scrub soiled boots, leather shoes and other leather goods such as belts with soap, a brush and hot water. If you wear a uniform to work, wash and dry it according to the manufacturer\u2019s instructions. Clean and disinfect the vehicle according to standard procedures. Wear appropriate PPE (disposable gown and gloves) during the cleaning process and discard after use. Thoroughly clean and disinfect all surfaces that may have come in contact with the patient or materials that may have become contaminated while providing care for the patient (e.g., stretcher, rails, control panels, floors, walls, work surfaces). Use an Environmental Protection Agency (EPA)-registered hospital disinfectant and follow manufacturer\u2019s recommendations.",
        "If an Exposure Occurs": "Exposure incidents involve contact with blood or OPIM\u2014for example, a patient\u2019s blood gets into a cut on your hand, you are stuck with a needle used on a patient, or bloody saliva splashes into your mouth or eyes. You may also be exposed when in unprotected, close contact with someone who has an airborne disease involving exposure to aerosolized, respiratory droplets (e.g., coughing, sneezing), such as with a patient infected with influenza (including pandemic flu), TB or MDR TB.",
        "CRITICAL FACTS 4": "If you are exposed to blood or OPIM, immediately take the appropriate steps, such as cleaning contaminated areas, as part of a proper exposure control plan.",
        "What to Do If You Are Exposed": "If you are exposed, take the following steps immediately: \uf0a7 Clean the contaminated area thoroughly with soap and water. Wash needlestick injuries, cuts and exposed skin with soap and water. \uf0a7 Flush splashes of blood and OPIM to the mouth and nose with water. If the eyes are involved, irrigate with clean water, saline or sterile irrigants for 20 minutes. \t Seek immediate follow-up care as identified in your department exposure control plan.",
        "Reporting Exposures": "Following any exposure incident:\n\uf0a7 Report the exposure incident to the appropriate person identified in your employer\u2019s exposure control plan (often the infection control officer) immediately and to the emergency medical services (EMS) providers who take over care of the patient. This step can be critical to the success of post-exposure treatment.\n\uf0a7 Write down what happened. Include the time and date of the exposure as well as the circumstances of the exposure, any actions taken after the exposure and any other information required by your employer.",
        "OSHA Regulations": "OSHA has issued regulations about on-the-job exposure to bloodborne pathogens. OSHA determined that employees are at risk when exposed to blood or OPIM. OSHA therefore requires employers to reduce or remove hazards from the workplace that may place employees in contact with infectious materials.\nOSHA regulations and guidelines apply to employees who may come into contact with blood and OPIM that could cause an infection. These regulations apply to you as an EMR because you are expected to provide emergency care as part of your job. In 2001, in response to passage of the federal Needlestick Safety and Prevention Act, OSHA revised the Bloodborne Pathogens Standard 29 CFR 1910.1030. These guidelines may help you and your employer meet the OSHA bloodborne pathogens standard to prevent transmission of serious diseases. (For additional information on the Bloodborne Pathogens Standard 29 CFR 1910.1030, visit OSHA\u2019s website at www.osha.gov/SLTC/bloodbornepathogens/standards.html.) OSHA regulations regarding bloodborne pathogens have placed specific responsibilities on employers for protection of employees, including:\n\uf0a7 Identifying positions or tasks covered by the standard.\n\uf0a7 Creating an exposure control plan to minimize the possibility of exposure and making the plan easily accessible to employees.\n\uf0a7 Developing and putting into action a written schedule for cleaning and decontaminating at the workplace.\n\uf0a7 Creating a system for easy identification of soiled material and its proper disposal.\n\uf0a7 Developing a system of annual training for all covered employees.\n\uf0a7 Offering the opportunity for employees to get the hepatitis B vaccination at no cost.\n\uf0a7 Establishing clear procedures to follow for reporting an exposure.\n\uf0a7 Creating a system of recordkeeping.\n\uf0a7 In workplaces where there is potential exposure to injuries from contaminated sharps, soliciting input from non-managerial employees with potential exposure regarding the identification, evaluation and selection of effective engineering and work practice controls.\n\uf0a7 If a needlestick injury occurs, recording the appropriate information in the sharps injury log, including:\n\tyThe type and brand of device involved in the incident.\n\tyThe location of the incident.\n\tyA description of the incident.\n\uf0a7 Maintaining a sharps injury log in such a way that protects the privacy of employees.\n\uf0a7 Ensuring confidentiality of employees\u2019 medical records and exposure incidents.",
        "CRITICAL FACTS 5": "Per OSHA regulations, employers are required to remove items that might put employees in contact with infectious materials. OSHA regulations regarding bloodborne pathogens have placed specific responsibilities on employers for protection of employees. These include creating exposure control plans, scheduling decontamination and cleaning of the workplace, training on OSHA regulations and free hepatitis B vaccinations.",
        "Needlestick Safety and Prevention Act": "Blood and OPIM have long been recognized as potential threats to the health of employees who are exposed to these materials through penetration of the skin. Injuries from contaminated needles and other sharps have been associated with an increased risk of disease from more than 20 infectious agents. The most serious pathogens are hepatitis B, hepatitis C and HIV. Needlestick and other sharps injuries resulting in exposure to blood or OPIM are a concern because they happen frequently and can have serious health effects. In 2001, OSHA revised the Bloodborne Pathogens Standard 29 CFR 1910.1030. The revised standard clarifies the need for employers to select safer needle devices and to involve employees in identifying and choosing these devices. Needleless systems are one option to reduce the possibility of accidental needlestick injuries and possible infection. The updated standard also requires employers to maintain a log of injuries from contaminated sharps. (For additional information on the Needlestick Safety and Prevention Act, visit OSHA\u2019s website at www.osha.gov/SLTC/bloodbornepathogens/standards.html.) Also, be aware of any areas, equipment or containers that may be contaminated. Biohazard warning labels are required on any container holding contaminated materials, such as used gloves, bandages or trauma dressings. Post signs at entrances to work areas where infectious materials may be present.",
        "EMOTIONAL ASPECTS OF EMERGENCY CARE - Stressful Situations": "Stressful Situations EMRs experience an extraordinary number of stressful situations beyond what others may encounter. Some of the more powerful situations include: \uf0a7 Dangerous situations. Fires, scenes of violent crime, agricultural accidents and other emergency scenes all involve a certain measure of danger. \uf0a7 Physical and psychological demands. Some rescues, such as extrications, may place substantial physical burdens on the EMR; others, such as rescuing an abused child, may involve extraordinary psychological demands. \uf0a7 Critically injured or ill people. Responding to a call to help someone who is critically injured or ill can be highly stressful because of the possibility of not being able to save the patient. \uf0a7 Death and dying patients. Death is disturbing to most people, but the feelings of powerlessness at not being able to save someone\u2019s life may also bring about tremendous guilt and grief. \uf0a7 Overpowering sights, smells and sounds. Disturbing sights, strong smells and sounds that are upsetting to the EMR may accompany scenes of illness and accidents, especially those that are severe. \uf0a7 Multiple-patient situations. All of the above situations can occur when a single person is injured or ill, but the effects are magnified in a multiple-casualty incident, which can be truly overwhelming. \uf0a7 Angry or upset patients, family and bystanders. In an emotionally charged situation, tempers may flare, adding to the intensity of the situation. During stressful situations, cooperate with other personnel responding to the situation. It is important that you handle the situation in a professional manner when dealing with public safety responders, other EMS providers, the patient and the family.",
        "EMOTIONAL ASPECTS OF EMERGENCY CARE - Death and Dying": "Experiencing the dying process is difficult for most people. The following measures may help the patient and family deal with the dying process: \uf0a7 Recognize that the patient\u2019s and the family\u2019s needs include dignity, respect, sharing, communication, privacy and control. \uf0a7 Allow the patient and the family to express rage, anger and despair. \uf0a7 Listen empathetically and remain calm and nonjudgmental. \uf0a7 Do not falsely reassure. \uf0a7 Use a gentle tone of voice. \uf0a7 Let the patient and the family know that everything that can be done to help will be done. \uf0a7 Use a reassuring touch, if it is appropriate. \uf0a7 Comfort the patient and the family.",
        "CRITICAL FACTS 6": "Measures such as listening empathetically, speaking gently, and allowing anger or despair to be expressed may help the patient and family cope with the dying process.",
        "Resuscitation": "You may be summoned to an emergency in which one or more people have died or are dying. The cause could be natural, accidental or intentional. Though your responses will vary according to the situation, you must recognize that death will have an emotional impact on you, as well as on others involved. You may be in a situation in which you think a person has been dead for a while and you are unsure whether you should attempt to resuscitate that person. The general rule is to always attempt to resuscitate a patient without a pulse or normal breathing except in the following situations: \uf0a7 A valid do not resuscitate (DNR) order or a Physician Orders for Life-Sustaining Treatment (POLST) form that meets local guidelines is present at the scene and directs not to attempt resuscitation. \uf0a7 Obvious signs of death are present in the patient. These signs include tissue decay (putrefaction); rigor mortis (stiffening of joints that occurs after death; assess two or more joints, such as the fingers and jaw, to verify); obvious mortal wounds (injuries clearly not compatible with life, such as decapitation); or dependent lividity (purplish color in the lowest-lying parts of a recently dead body, due to pooling of blood). \uf0a7 The situation is so dangerous (such as a gunman on the scene) that attempting to resuscitate the patient would endanger your life. To determine that a person is dead, the patient is often placed on a heart monitor and vital signs are assessed by more advanced EMS personnel. When it is determined that the patient has no electrical activity of the heart and no respirations and blood pressure, the person may be declared dead. This may occur after prolonged resuscitation attempts, or it may occur immediately if one of the above conditions is present. Some patients may have advance directives, POLST forms or DNR orders, which are written legal documents saying that they do not wish to be resuscitated or kept alive by mechanical means. In most instances, you should honor the wishes of the patient if they are expressed in writing. However, since state and local laws about these situations vary, you should summon more advanced medical personnel immediately to provide care. If you are in doubt about the validity of the advance directives, attempt to resuscitate the patient. (For more information on advance directives, POLST forms and DNR orders, refer to Chapter 3.)",
        "Individual Responses to Death": "Dying is part of the living process. Death affects everyone, and the way we respond varies widely. Be prepared to handle your feelings and the feelings of others. Remember that reactions to death and dying range from anxiety to acceptance. How well you and others handle the situation will depend on both personal feelings about death and the nature of the incident. One of the most disturbing emergency situations is sudden death. Sudden death generally refers to an unexpected, natural death. It is commonly used to describe death resulting from an abrupt cardiac event, but it also describes a death that occurs within a few hours after an abrupt onset of symptoms in an otherwise healthy person. Sudden death of an infant can be especially disturbing to new parents, though it is difficult for anyone involved. EMRs can never fully prepare themselves for an emergency involving sudden death.",
        "Stages of Grief": "There will be times you are called to assist grieving patients or family members. There are some predictable responses to grief, though people do not always experience them in any particular order. Keep in mind that everyone\u2019s reaction to death and dying is unique and not everyone will experience every stage of grief, nor will everyone experience grief in the same order. Remain nonjudgmental throughout the grieving process. The stages of grieving include: \uf0a7 Denial. The patient or family member denies the seriousness of the situation in order to buffer the pain of the event. \uf0a7 Anger. The patient or family member projects feelings of anger toward other people, especially those closest to the individual. Do not take anger personally, even though it may seem to be directed toward you. Be alert to anger that may become physical and endanger you or others. \uf0a7 Bargaining. The patient or family member may attempt to negotiate with a spiritual higher being or even with EMS providers in an effort to extend life. \uf0a7 Depression. The patient or family member exhibits sadness and grief, is usually withdrawn and may cry continually. Allow the affected person to express these feelings, and help the patient or family member to understand that these are normal feelings associated with death.\uf0a7 Acceptance. The patient or family member ultimately accepts the situation and incorporates the experience into the activities of daily living, in an effort to survive or to support a loved one. Use good listening skills in this phase.",
        "Helping the Patient and the Family": "The care EMRs provide to patients often focuses on the patient\u2019s physical needs, but care must also include supporting patients and their families through the emotions they may experience when someone is injured or ill. In these situations, be calm, supportive and nonjudgmental. Allow the patient or family member to safely vent feelings.",
        "STRESS MANAGEMENT - What Is Stress?": "Stress is the body\u2019s normal response to any situation that changes a person\u2019s existing mental, physical or emotional balance. Stress can result from positive experiences, such as a wedding, or more difficult situations, such as responding to a life-threatening emergency. Stress can arise from any situation or thought that brings about feelings of frustration, anger or anxiety. Stress is unique to the individual; what is stressful to one person may not be so to another. Stress is a normal part of life. In small quantities, it can be positive, motivating people and helping them to be more productive. Too much stress or a strong response to stress, however, can be harmful, contributing to illnesses such as heart disease or depression. An event like a serious injury, illness or death may produce great stress in patients, family members and EMRs. By learning how stress builds up, how to identify its signs and symptoms, and how to manage stress, you can help yourself and others cope with the stressful impact of an emergency situation. While providing care, you may encounter angry, scared or violent patients and family members, especially when the patient is seriously injured or ill. Personal feelings triggered by these situations can affect you. Learn what to expect and how to assist patients, their families, yourself and others in dealing with this stress. Those involved in a serious injury, sudden illness or death may face an emotional crisis. Their reactions to the crisis will depend on a number of factors and will differ from person to person. Often, reactions will come during or immediately following the event, but in some cases they may be delayed for hours, days or even longer.",
        "STRESS MANAGEMENT - Warning Signs and Symptoms of Personal Stress": "As an EMR, be sure to note if you or those around you are exhibiting any signs or symptoms of personal stress during or following a response. When interacting with patients and their families during an emergency, you may hear them talk about or exhibit certain signs or symptoms of stress. Warning signs and symptoms of stress include: \uf0a7 Difficulty sleeping and nightmares. \uf0a7 Irritability with co-workers, family and friends. \uf0a7 Feelings of sadness, anxiety or guilt. \uf0a7 Indecisiveness. \uf0a7 Loss of appetite. \uf0a7 Loss of interest in sexual activity. \uf0a7 Isolation. \uf0a7 Loss of interest in work. \uf0a7 Feelings of hopelessness. \uf0a7 Alcohol or drug misuse or abuse. \uf0a7 Inability to concentrate.",
        "CRITICAL FACTS 7": "When interacting with patients and their families, watch carefully for signs of stress, which can include sleep disorders, loss of appetite, emotional and behavioral changes, and drug abuse.",
        "INCIDENT STRESS MANAGEMENT": "An EMR\u2019s job can be highly stressful, often involving \u201ccritical incidents.\u201d These emergencies involve a serious injury or death. Critical incidents are especially stressful if you feel you did something wrong or failed to do something even after responding exactly as you were trained. A particular type of stress, called critical incident stress, can result from such a situation. It is important to understand the powerful impact this stress can have on you. The stress of the emergency can cause distress or disruption in a person\u2019s mental or emotional balance. It can cause sleeplessness, anxiety, depression, exhaustion, restlessness, nausea, nightmares and other problems. Some effects may appear right away and others only after days, weeks or even months have passed. People suffering from critical incident stress might not be able to do their job well. Closely monitor your performance and watch for the following signs and symptoms of critical incident stress reactions: \uf0a7 Confusion \uf0a7 Shortened attention span \uf0a7 Poor concentration \uf0a7 Denial \uf0a7 Guilt \uf0a7 Depression \uf0a7 Anger \uf0a7 Change in interactions with others \uf0a7 Increased or decreased eating \uf0a7 Uncharacteristic, excessive humor or silence \uf0a7 Any other unusual behavior",
        "EMS Incidents Likely to Produce Stress": "Events that trigger critical incident stress are often powerful and traumatic, and are usually outside of the range of what we consider normal human experiences on the job. This might include the death or serious injury of a co-worker, the death of a child or a multiple-casualty event.",
        "Pre-Incident Education": "To help EMRs cope with job-related stress before it occurs, employers sometimes offer stress-management classes and crisis-mitigation training. This preparation helps responders set expectations and improve their ability to cope with stress. It is also a good idea to create a self-care plan that lays out how you will take care of your own well-being while involved in emergency work. This should include mental health considerations. For example, your employer may offer prearranged professional counseling to help you cope with work-related stress. Finally, an EMR\u2019s job often requires long hours, including weekends and evenings. To lower your stress level, it is a good idea to arrange in advance for personal responsibilities such as care for children and older parents.",
        "Stress Management During an Emergency": "Pay attention to your own stress responses during an emergency, through continual self-monitoring. In monitoring your stress, consider factors such as stamina, expectations, prior traumatic experiences and eating habits. Partner with a colleague so that you can help monitor each other\u2019s stress levels to determine when relief is necessary. If you feel your stress level rising to a concerning level, you may need a second to step back from a situation, recollect your thoughts and then continue with care.",
        "Post-Incident Stress Management": "To relieve stress, the following steps can help: \uf0a7 Use quick relaxation techniques, such as deep, slow breathing. \uf0a7 Eat a good meal and avoid beverages with caffeine. \uf0a7 Avoid alcohol or drugs. \uf0a7 Review the event and clear up any uncertainties. \uf0a7 Get enough rest. \uf0a7 Get involved in some type of physical exercise or activity, either alone or in a group.",
        "CRITICAL FACTS 8": "The stress of critical incidents can be powerful for EMRs, and the effects may be latent or immediate. Watch for signs, including guilt, poor concentration, depression, or any uncharacteristic or unusual behavior.",
        "Emergency Medical Response Follow-Up": "EMRs sometimes do not recognize how much the stress of what they do can affect their family and friends. They sometimes complain that their loved ones show a lack of understanding for what they do. Family members can experience frustration because of an EMR\u2019s unwillingness to share information and feelings about an incident. EMRs do not always realize that family members and friends suffer fear of separation and are afraid of being ignored for something \u201cmore exciting.\u201d An EMS career can be cut short by the invisible dangers of unmanaged stress. By taking a serious look at your life and making necessary adjustments, you can ensure a healthy balance in all the things you choose to do. If you begin to exhibit signs and symptoms of critical incident stress that do not seem to be going away after an emergency, work with your supervisor to arrange for professional counseling by a licensed mental health professional.",
        "When to Access Professional Help": "If you or a colleague show signs of critical incident stress, work with your employer as soon as possible to arrange for professional counseling by a licensed mental health professional. Do not wait until after an emergency to figure out where you should go if you begin to exhibit signs and symptoms of critical incident stress. Incidents that could lead to a necessity to access professional counseling by a licensed mental health professional include: \uf0a7 Line-of-duty death or serious injury. \uf0a7 Multiple-casualty incidents. \uf0a7 Suicide of an emergency worker. \uf0a7 Serious injury or death of children. \uf0a7 Events with excessive media attention. \uf0a7 Victims known to EMS personnel. \uf0a7 Events that have unusual impact on EMS personnel. \uf0a7 Any disaster. Activation protocols vary from area to area. Your employer should be able to supply you with information on how to access this service in your community. Some people think that participating in counseling is an admission of weakness. Quite the contrary is true. Counseling should be\u2014and in many areas is\u2014a routine part of any overwhelming incident, such as an airline disaster. Counseling can help in any situation, regardless of how minor you may think the event was. The most important thing you can do to minimize the effects of any emergency is to express your feelings and thoughts after the incident.",
        "PUTTING IT ALL TOGETHER": "In order to provide emergency care to others, it is important first to look after yourself. This includes physical, emotional and mental health concerns. One of the ways EMRs must look after themselves is by preventing illness. Bloodborne pathogens\u2014most commonly bacteria and viruses\u2014are present in blood and OPIM and can cause disease in humans. The bloodborne pathogens of primary concern to EMRs are hepatitis B, hepatitis C and HIV. These pathogens spread primarily through direct or indirect contact with infected blood or OPIM. To prevent the spread of bloodborne pathogens and other diseases, EMRs should follow standard precautions. These precautions require that all blood and OPIM be treated as if known to be infectious. Apply these precautions by using PPE, frequently washing your hands, using engineering controls, following work practice controls, properly cleaning and disinfecting equipment, cleaning up after spills, and properly disposing of used disposable or single-use equipment. If exposed to blood or OPIM, you should immediately wash, flush or irrigate the exposed area of your body and report the incident to your supervisor. It is equally important that you attend to mental and emotional health concerns in yourself and the patients and families you are helping. An emotional crisis often results from an unexpected, shocking and undesired event, such as the sudden loss of a loved one. Although people react differently in different situations, everyone experiences some or all of the stages of grief. By considering the nature of the incident, you can begin to prepare yourself to deal with its emotional aspects.",
        "Removing Disposable Latex-Free Gloves": "NOTE: To remove gloves without spreading germs, never touch your bare skin with the outside of either glove.\nSTEP 1: Pinch the palm side of one glove on the outside near your wrist.\nSTEP 2: Pull the glove toward your fingertips, turning it inside out as you pull it off your hand.\nSTEP 3: Hold the glove in the palm of your other (still-gloved) hand.\nSTEP 4: Carefully slip two fingers under the wrist of the other glove. Avoid touching the outside of the glove.\nSTEP 5: Pull the glove toward your fingertips, turning it inside out as you pull it off your hand. The other glove is now contained inside.\nSTEP 6: Dispose of the gloves (and any other PPE) properly in a biohazard container.\nAfter removal: Wash your hands thoroughly with soap and running water, if available. Otherwise, use alcohol-based hand sanitizer if hands are not visibly soiled, then wash hands as soon as practical.",
        "Health of the Emergency Medical Responder": "Being an EMR is a rewarding experience, but it also can be physically, emotionally and mentally challenging. Making healthy lifestyle choices benefits not only yourself, but also the patients who will rely on you in their moments of need.",
        "Physical Well-Being": "Taking care of your body is a must for an EMR. There are situations you may face where physical strength and stamina will be key components in successfully caring for patients or assisting other responders. There are many factors to obtaining good physical well-being, and you should consider it your responsibility to address all of them as part of a healthy lifestyle. Physical activity not only helps you keep fit but also is an effective way to reduce stress.",
        "Physical Fitness": "Your physical well-being is one of the most important assets you hold to ensure that you are able to effectively perform your job as an EMR. Maintaining your own physical fitness is necessary for having the stamina and strength to respond at the level required. One of the key aspects of physical fitness is cardiovascular endurance. Be sure to get regular cardiovascular training. According to the American College of Sports Medicine, approximately 30 minutes of physical activity per day can help lower blood pressure and cholesterol and help you maintain a healthy weight. The more you exercise, the better your endurance\u2014resulting in better health, strength and stamina. Muscle strength and flexibility are also important assets for EMRs to assist in day-to-day tasks. Strength training develops strong bones, increases bone density and controls body fat. Strength training will also reduce your risk of injury, as muscle protects your joints and helps you maintain flexibility and balance.",
        "Stretching": "Stretching on a regular basis is the best way to maintain flexibility. Therefore, in tandem with your aerobic and strength training, make sure to incorporate stretching as part of your daily workout routine.",
        "Nutrition": "Following basic nutrition strategies will help keep you fit, reduce stress and assist in maintaining your stamina throughout the day. Choose an eating style that is low in saturated fat, sodium and added sugars and follow the USDA MyPlate recommendations for a healthy diet (at choosemyplate.gov).",
        "Sleep": "Sleep deprivation is one of the most potentially dangerous challenges EMRs may face, as it affects your ability to think clearly and can decrease your hand-eye coordination. This means you are less productive and may make mistakes that can lead to injury or negatively affect the patients you treat. If you find yourself consistently feeling drowsy, adjust your sleep schedule to ensure you are getting enough rest. Speak to your healthcare provider if you are experiencing sleeplessness.",
        "Disease Prevention": "Emergency care personnel must take precautions against disease transmission by potentially infectious substances. Make sure to protect yourself against disease transmission by following standard precautions and using recommended PPE. Remember, hand washing is the most important way to prevent the spread of infection, even if you were wearing gloves when possibly exposed. Controlling risk factors for heart disease is the best way to minimize your chance of cardiovascular disease. Taking steps to maintain a healthy lifestyle by not smoking, becoming more active, lowering stress in your life and eating a healthy diet will dramatically reduce your risks.",
        "Injury Prevention": "As mentioned, strength training is a good start to helping prevent injury on the job. As an EMR, it is challenging to keep your own safety in mind, especially when your patient is in a life-threatening situation. Trying to remain aware of your surroundings, using proper lifting techniques, and following proper procedures and protocols will help ensure your safety and that of your patient.",
        "Sun Safety": "According to the American Academy of Dermatology, 1 in 5 Americans will develop some form of skin cancer during their lifetime. Remember when exposed to the sun to drink plenty of fluids and dress appropriately, such as in long-sleeved shirts, pants, hats and sunglasses. Apply a broad-spectrum sunscreen that has a sun protection factor (SPF) of 15 or higher and that is water resistant for at least 40 minutes. Broad-spectrum sunscreens protect the skin from ultraviolet A (UVA) and ultraviolet B (UVB) rays, both of which cause cancer. Reapply sunscreen every 2 hours, even on cloudy days, and especially when sweating or swimming. One ounce of sunscreen is considered the amount needed to cover exposed areas of the body.",
        "Mental Well-Being": "There is no doubt that being an EMR is stressful. The sense of responsibility for other people\u2019s lives can be overwhelming. Mental well-being, like physical well-being, is important to allow you to stay focused and be prepared to deal with the day-to-day stress of your job.",
        "Reducing Stress": "If you find yourself feeling overwhelmed or indifferent toward your job, irritable, angry, sarcastic or quick to argue, chances are you are not coping well with the stress in your life. It is important to find ways to help relieve your feelings of stress before they begin to affect your job performance. Three types of stress reactions are common to EMRs: acute, delayed and cumulative. Recognizing the warning signs of stress is imperative, as the earlier they are identified, the easier they are to address. The warning signs and symptoms include: \uf0a7 Irritability. \uf0a7 Lack of concentration. \uf0a7 Difficulty sleeping and nightmares. \uf0a7 Anxiety. \uf0a7 Indecisiveness. \uf0a7 Guilt or shame. \uf0a7 Loss of appetite and sexual desire. \uf0a7 Isolation. \uf0a7 Loss of interest in work. If you feel stress affecting your life, it is important to get it under control. These stress management techniques may be helpful: \uf0a7 Reprioritize work goals and tasks. \uf0a7 Perform physical activity every day. \uf0a7 Make sure you eat at every meal and avoid fast food. \uf0a7 Share household chores with family members. \uf0a7 Practice relaxed breathing or muscle relaxation. \uf0a7 Put a positive spin on negative thoughts.",
        "Personal Relationships": "Finding work-life balance is always challenging and must be managed properly so you can enjoy a rewarding personal life. Too much focus on work can place stress on your relationships. Often, when faced with difficulties in your personal life, concentrating on your job can be difficult. This can lead to mistakes or injuries. Some people throw themselves into work as a way to avoid dealing with relationship problems at home, which can lead to burnout. Discovering you are having difficulty coping with problems at home can be overwhelming. Counseling can help you cope with conflict in your personal relationships and be better prepared to focus while on the job. Family therapy and marriage counseling can help mend strained relationships, teach new coping skills, and improve how you interact with family and partners. Counseling gives families the tools to communicate better, negotiate differences, problem solve and even argue in a healthier way.",
        "Alcohol and Drug Problems": "High levels of stress, anxiety or emotional pain can lead some people to drink alcohol to excess or use drugs. In actuality, this increases stress. Addiction is a complex problem, including both psychological and physical aspects. If you are addicted to a drug, you will experience intense cravings for it, sometimes many times throughout the day. Your cravings for the substance will persist in spite of the physical, psychological and social consequences it brings. You may find yourself repeatedly trying to stop taking the drug, but being unable to do so because of the unpleasant reactions to stopping, such as insomnia, anxiety and tremors. You may also find yourself rationalizing the need to do things you would not normally do, such as stealing or lying, to continue drug use. Or, you may try to convince yourself that you need the drug in order to cope with your problems. If you show any of the signs of addiction, seek help immediately through addiction services in your community. If you are a smoker, deciding to quit smoking will be one of the best and most responsible decisions you make in your life. It will also be one of the most challenging. Speak to your healthcare provider for advice on quitting, and remember the health benefits as a way to stay focused on your goal.",
        "Health Risks and Assessments": "Your employer may offer wellness tools, such as online health profiles, to help you identify health risks and develop wellness goals through personalized health assessments. Take advantage of these and other tools that may be offered to you in an effort to lead a healthier lifestyle."
    },
    {
        "Key Terms": "Access: Reaching a patient who is trapped in a motor vehicle or a dangerous situation, for the purpose of extrication and providing medical care., Complex access: In an extrication, the process of using specialized tools or equipment to gain access to the patient., Cribbing: A system using wood or supports, arranged diagonally to a vehicle\u2019s frame, to safely prop it up, creating a stable environment., Extrication: The safe and appropriate removal of a patient trapped in a motor vehicle or a dangerous situation., Rule of thumb: A guideline for positioning oneself far enough away from a scene involving hazardous material  (HAZMAT): one\u2019s thumb, pointing up at arm\u2019s length, should cover the hazardous area from one\u2019s view., Simple access: In an extrication, the process of getting to the patient without the use of equipment., Vehicle stabilization: Steps taken to stabilize a motor vehicle in place so that it cannot move and cause further harm to patients or responders.",
        "INTRODUCTION": "One of your primary responsibilities as an emergency medical responder  (EMR) is to provide care for an injured or ill patient. Sometimes, however, providing care is not possible because you cannot reach the patient. One example is a situation in which someone is able to call 9-1-1 or the designated emergency number for help but is unable to unlock the door of a home or office to let responders inside. This situation also occurs in a large number of motor-vehicle collisions, with locked or crushed vehicle doors, tightly rolled up windows or unstable vehicles. In other instances, fire, water, fuel leaks or other elements may prevent you from reaching the patient.In these cases, you must immediately think of how you can safely gain access to the patient. If you cannot reach the patient, you cannot provide medical care. Always remember, when attempting to reach someone, your safety is the most important consideration. Protect yourself and the patient by doing only what you are trained to do, using equipment you are trained to use and wearing clothing appropriate for the situation. Items such as helmets, face shields, protective eyewear and heavy-duty gloves will help keep you safe as you attempt to gain access to a trapped patient. Simple tools can also be helpful.",
        "FUNDAMENTALS OF EXTRICATION AND RESCUE OPERATIONS - Role of the EMR": "Extrication is the safe and appropriate removal of a patient trapped in a motor vehicle or a dangerous situation. At times, an EMR may be called upon to help care for someone in this type of situation. It will be your role to administer the necessary care to the patient before extrication and ensure that the patient is removed in a way that minimizes further injury. Providing care for the patient may come before the extrication process; however, in many instances, patient care will occur simultaneously with the extrication process. During any extrication, it is critical that those providing medical care and those who are performing extrication are in constant communication with each other to maintain safety and avoid aggravating the patient\u2019s injuries or causing further pain. Although fire rescue workers, emergency medical technicians (EMTs) and other specially trained personnel will perform most extrication procedures, when EMRs are involved in this type of rescue, they should work closely with other responders to protect the patient. A chain of command through the incident command system should also be established to ensure that the scene is well managed and the patient\u2019s care remains a priority.",
        "FUNDAMENTALS OF EXTRICATION AND RESCUE OPERATIONS - Additional Resources": "Basic extrication equipment includes crowbars, screwdrivers, chisels, hammers, pliers, work gloves and goggles, wrenches, shovels, car jacks, tire irons, knives, and ropes or chains. Many emergency scenes draw crowds of onlookers and individuals wishing to help. Law enforcement personnel will play a major role in helping to secure the scene and control the crowd while the extrication is in progress. Also, consider the need for specialists to handle or help control any hazards present. This could include representatives from utility providers, such as the natural gas company or the power company, or could include hazardous material (HAZMAT) responders. HAZMAT responders provide medical care and extrication of patients from a hot zone (area with the highest degree of danger in a HAZMAT emergency scene), where potentially hazardous chemical spills are involved. In the case of fuel spills or other potential hazards associated with extrication, the fire department may deploy a charged hose line to protect the scene, the patient and rescue personnel. Depending on the severity of the injuries and location of the scene, patient transportation by an air medical service may be required. Other activities, such as patient decontamination, may be required prior to transport by ground ambulance or other ground transport vehicle, or by air medical services.",
        "Scene Safety - Personal Safety": "The first priority for all EMRs is their own safety. All personnel involved at the scene should wear protective clothing and follow guidelines set up by state and local protocols. The National Fire Protection Association (NFPA) and the Occupational Safety and Health Administration (OSHA) have guidelines to follow when considering the purchase of safety clothing. At a minimum, when responding to a motor-vehicle collision or other extrication situation, EMRs should have the following equipment:\n\uf0a7 Protective helmet with chin strap\n\uf0a7 Protective eyewear\n\uf0a7 Puncture- and flame-resistant outerwear (turnout gear)\n\uf0a7 Heavy, protective gloves\n\uf0a7 Boots with steel toes and insoles As with any emergency, begin by sizing up the scene to see if it is safe. If it is not safe, determine whether you can make it safe so you can attempt to gain access to the patient. Well-intentioned EMRs and others are injured or killed each year while attempting to help patients involved in motor-vehicle collisions. Such unfortunate instances are preventable by taking adequate measures to make the scene safe before trying to gain access and provide care.",
        "Scene Safety - Patient Safety": "Once you have obtained safe access to a trapped patient, provide the same care you would to any trauma patient. Ensure you maintain spinal motion restriction, complete the primary assessment and provide critical interventions as necessary. Patients will require protection from the debris created by the extrication process. Cover patients with tarps or blankets to protect them from broken glass, sharp metal and other hazards, including the environment. Lessen their fears by explaining what you will do and any noise that may occur in the process. Establishing a rapport with patients will help them focus on your support and listen to your instructions and guidance throughout the extrication. Asking patients if they are prepared as each step takes place will also help them feel more in control of the situation and less panicked or frightened. It is also important to continue to monitor patients throughout the process and, if their condition changes, immediately inform the rescue crew of any growing danger. Caution bystanders in the area to stay away from the scene. Their presence can cause additional confusion and increase the risk of injury. Ensure spinal motion restriction, if possible, before removing the patient from the vehicle. The only time you should consider an emergency move without spinal motion restriction is in an emergency when there is an immediate threat to life, such as from cardiac arrest, fire or other critical situation.",
        "CRITICAL FACTS": " Extrication is the safe and appropriate removal of a patient trapped in a motor vehicle or a dangerous situation. Basic extrication equipment includes crowbars, screwdrivers, chisels, hammers, pliers, work gloves and goggles, wrenches, shovels, car jacks, tire irons, knives, and ropes or chains",
        "CRITICAL FACTS 2": "Protective clothing is essential on the scene. Follow state and local protocols and familiarize yourself with guidelines put forth by NFPA and OSHA. Minimum equipment when dealing with collisions and extrications includes protective helmets and eyewear, turnout gear, protective gloves, and boots with steel toes and insoles. Once you have obtained safe access to a trapped patient, provide the same care you would to any trauma patient. Ensure you maintain spinal motion restriction, complete the primary assessment and provide critical interventions as necessary.",
        "Scene and Traffic Control": "There are several important reasons to control traffic at the scene: to protect the scene from further potential collisions, prevent injury to the rescue team, ensure minimal disruption and allow emergency vehicles to reach the scene. On arrival, request the assistance of additional law enforcement and fire services personnel to help control the scene and assign a scene safety officer. Emergency vehicles should be placed in optimal positions for safety and for easy patient loading. Blocking is a technique of positioning emergency vehicles at an angle to traffic lanes. This creates a physical barrier between the work area and traffic flowing toward the emergency scene. The scene should be protected with the first-arriving apparatus; block off at least one additional lane. Ambulances should park within the \u201cshadow\u201d created by the larger apparatus. The apparatus should also \u201cblock to the right\u201d or \u201cblock to the left,\u201d so as not to obstruct the loading doors of ambulances. The ambulance patient loading area should be facing away from the closest lane of moving traffic. All patient loading into ambulances is carried out from within the protected work zone that is created by the positioning of the other rescue apparatus. Establish advance warning for vehicles by using traffic cones or flares. Place these at 10- to 15-foot intervals, to create a safe zone in a radius of at least 50 feet around the scene. If using flares, be sure there are no fluid leaks.",
        "Unique Hazards": "Alternative-Fueled Vehicles It is important to understand the differences between gasoline- and alternative-fueled vehicles, especially hybrid and electric vehicles. Many people are concerned about the risk of electrocution. Following safety precautions and the manufacturer\u2019s recommendations reduces the risk of injury to responders and vehicle occupants. As with any conventional vehicle, removing the ignition key and disconnecting the battery will disable a hybrid\u2019s high-voltage controller. Keep in mind that some hybrid vehicles do not have an ignition key, but do have an on/off switch that must be pressed before disconnecting the battery. However, some models may remain \u201clive\u201d for up to 10 minutes after the vehicle is shut off or disabled. Responders must always follow the manufacturer\u2019s emergency response guidelines for the specific make and model of the vehicle. One important difference is that a hybrid vehicle can remain silent and still be operational if the collision is minor and/or did not activate any of the collision sensors. Therefore, it is essential that responders chock or block the wheels to prevent the vehicle from moving under power or by gravity. Be careful not to place cribbing under any high-voltage (usually orange in color) cabling. Hybrid and electric automobile manufacturers publish emergency response guides for each model of vehicle they produce. Responders should be familiar with the safety procedures provided in these resources.",
        "Undeployed Vehicle Safety Devices": "In some collisions, air bags may not have deployed and may present a hazard during extrication. The force of a deploying air bag can turn access and extrication tools into destructive missiles that can cause serious injury to responders and patients. Air bags can be found in several locations throughout a vehicle and can number as many as a dozen separate units depending on the vehicle make and model. If a patient is pinned directly behind an undeployed air bag, both battery cables should be disconnected, following established safety protocols. Ideally, wait for deactivation of the system before attempting to extricate the patient. Do not mechanically cut through or displace the steering column until after deactivation of the system. Do not cut or drill into the air bag module. Also, do not apply heat to the area of the steering wheel hub, as an undeployed air bag inflates in a normal manner if the chemicals sealed inside the air bag module reach a temperature above 350\u00b0 F (177\u00b0 C).",
        "HAZMAT": "As an EMR, you may find yourself involved in a situation in which there are chemical or other harmful or toxic substances. EMRs must be trained to quickly identify such situations and access specially trained personnel to deal with the situation. A hazardous material is any chemical substance or material that can pose a threat to the health, safety and property of an individual. A HAZMAT incident is any situation that deals with the release of hazardous material. When dealing with a HAZMAT situation, work within a structured system that provides guidance in managing this type of scene. Unless you have received special training in HAZMAT handling and have the necessary equipment to do so without danger, stay well away from the area or in the designated cold zone (support area in the outer perimeter of a HAZMAT emergency scene). While en route to a potential HAZMAT scene, obtain as much prearrival information as possible from dispatch. Stay out of low areas where vapors and liquids may collect, and stay upwind and uphill of the scene. Be alert for wind changes that could cause vapors to blow toward you. Do not attempt to be a hero. It is common for responding ambulance crews approaching the scene to recognize a HAZMAT placard and immediately move to a safe area and summon more advanced help. When approaching the scene, use binoculars from a safe distance to look for potential hazards and to obtain the placard number. Refer to the Department of Transportation\u2019s Emergency Response Guidebook for detailed information. Many fire departments have specially trained HAZMAT teams to handle incidents involving these materials. While awaiting help, keep people away from the danger zone. One easy method to determine the danger zone area is called \u201c rule of thumb .\u201d The \u201crule of thumb\u201d states that, to be safe, position yourself far enough away from the scene that your thumb, pointing up at arm\u2019s length, covers the hazardous area from your view. When approaching any scene, be aware of dangers involving chemicals. Whether a motor-vehicle collision or an industrial emergency is involved, you should be able to recognize clues that indicate the presence of hazardous materials. These include signs (placards) on vehicles or storage facilities identifying the presence of these materials, evidence of spilled liquids or solids, unusual odors, clouds of vapor and leaking containers.",
        "VEHICLE STABILIZATION": "Any movement of the vehicle during patient care or extrication can prove dangerous or even deadly to patients with severe spinal injuries, or could result in injury to the rescue team. Local fire department and rescue squad personnel specially trained in vehicle stabilization and extrication will respond to the scene when requested. To make the scene as safe as possible, it is important to ensure that the motor vehicle is stable. You can assume a vehicle is unstable if: \uf0a7 It is positioned on a tilted surface. \uf0a7 It is stacked on top of another vehicle, even partly.\uf0a7 It is on a slippery surface. \uf0a7 It is overturned or on its side. Stabilizing an upright vehicle is a relatively simple task. Placing blocks or wedges against the wheels of the vehicle will greatly reduce the chance of the vehicle moving. This process is called chocking. You can use items such as rocks, logs, wooden blocks and spare tires. If a strong rope or chain is available, attach it to the frame of the car and then secure it to strong anchor points, such as large trees, guardrails or another vehicle. Letting the air out of the car\u2019s tires also reduces the possibility of movement. To stabilize a vehicle, take the following steps: \uf0a7 Put the vehicle in \u201cpark,\u201d or in gear (if a manual transmission). \uf0a7 Set the parking brake. \uf0a7 Turn off the vehicle ignition and remove the key. \uf0a7 If there are no patients in the seats, move the seats back and roll down the windows. \uf0a7 Disconnect the battery or power source. \uf0a7 Identify and avoid hazardous vehicle safety components such as seat-belt pretensioners, undeployed air bags, integrated child booster seats, and a lower anchors and tethers for children (LATCH) system. Depending on the condition and positioning of the vehicle, further steps must be taken to ensure the vehicle cannot fall or roll. Cribbing is a system that creates a stable environment for the vehicle. It uses wood or supports, arranged diagonally to the vehicle\u2019s frame, to safely prop up a vehicle. Cribbing should not be used under tires because it tends to cause rolling. There should never be more than 1 to 2 inches between the cribbing and vehicle. For vehicles remaining upright, use blocks or wedges to prevent rolling. When possible, position the wheels against the curb. The tire valve stem may also be cut so the car rests safely on its rims. The rims should also be chocked as a precaution. Overturned vehicles must have a solid object such as a wheel chock, timber, spare tire or cribbing between the roof and roadway. A jack can be used to angle the vehicle against the object. Hook a chain to the axle, and loop the chain to a tree or post.",
        "GAINING ACCESS - Simple Access": "The term simple access describes the process of getting to a patient without the use of equipment. Although simple access does not require the use of equipment, the EMR should remember to wear protective equipment and use standard precautions as appropriate. Methods of simple access include: \uf0a7 Trying to open each door. \uf0a7 Trying to open the windows. \uf0a7 Having the patient(s) unlock the doors or open and roll down the windows. When you arrive on the scene, if specialized equipment and personnel are necessary to access patients, call to have these units dispatched. If after accessing the patients you realize that the additional personnel and equipment are not necessary, you can easily cancel them.",
        "GAINING ACCESS - Complex Access": "Complex access describes the process of using specialized tools or equipment to gain access to a patient. Several types of rescue training courses are available that deal with vehicle and rope rescue. Other types of programs provide training in trench, high-angle and water rescue. As an EMR, you may encounter situations in which you will use basic equipment and techniques to gain access to a patient.",
        "CRITICAL FACTS 3": "A vehicle should be considered unstable if it is on a tilted or slippery surface, completely or partly on top of another vehicle, or overturned or on its side. To stabilize a vehicle, take the following steps: \u2022 Put the vehicle in \u201cpark,\u201d or in gear (if a manual transmission). \u2022 Set the parking brake. \u2022 Turn off the vehicle ignition and remove the key. \u2022 If there are no patients in the seats, move the seats back and roll down the windows. \u2022 Disconnect the battery or power source. \u2022 Identify and avoid hazardous vehicle safety components.",
        "GAINING ACCESS - Tools": "There are different types of extrication tools used to access patients. Hand tools might include a \u201ccome-along,\u201d a ratcheting cable device. used for pulling. Pneumatic tools might include air bags, which can be used to aid with lifting.\nThe most commonly used extrication tool is the power hydraulic tool, such as the Hurst Jaws of Life\u00ae. This tool uses anywhere from 20,000 to 40,000 pounds per square inch (psi) to spread apart metal, and is most commonly used to remove the doors from a vehicle. However, it can also be beneficial for crushing and pulling or pushing the dash area forward. Hydraulic tools, such as a jack, may also be used to lift the vehicle.\nOther frequently used tools are cutters, which can employ 30,000 to 60,000 psi. Cutters do as their name suggests\u2014cut. Most often, they are used to cut the posts that hold up the roof of a motor vehicle. There are also hydraulic tools that combine cutters and jaws into one tool. A third type of extrication tool is the ram, which uses its force to spread. This is in similar fashion to the action of a jaws tool but with a much straighter and wider spread. Often the ram is used to push the dash area away from the front passenger compartment of a vehicle.",
        "EXTRICATION - Role of the EMR": "During extrication, ensure your own safety. Contact the communications center immediately and request that fire and law enforcement personnel respond to the scene. Information regarding number of vehicles, number of patients and the presence of any hazardous substances is very important. Wearing the proper equipment is essential to ensure your safety; however, this is not enough in the case of some incident scenes. Ensure the scene is safe before approaching a patient. Once the scene is secure and the vehicle stable, attempt to reach the patient and complete the primary assessment. Together with other rescue personnel, establish a chain of command to ensure the utmost safety and care for patients and rescue team members.",
        "EXTRICATION - Extrication Tools": "It is important to be prepared in case the local rescue squad cannot make it to the scene as quickly as necessary. In these situations, the following tools and equipment are key to assisting in the safe extrication of a patient as quickly as possible: \uf0a7 Hammer \uf0a7 Screwdriver \uf0a7 Chisel \uf0a7 Crowbar \uf0a7 Pliers \uf0a7 Work gloves and goggles \uf0a7 Shovel \uf0a7 Tire irons \uf0a7 Wrenches \uf0a7 Knives, including linoleum knives \uf0a7 Car jacks \uf0a7 Ropes or chains",
        "EXTRICATION - Extricating the Patient": "Extricating the patient is a task carried out by specially trained personnel. Of primary concern is preventing further harm to the patient. The most important factor in achieving this is proper training of personnel, so that everyone is familiar with extrication procedures and team members communicate effectively. Every extrication is different, and some can be quite complex. In some situations, the patient may be trapped in the car seat or partially trapped under the seat. When this happens, it may be possible to alleviate the situation by using the car\u2019s seat adjustment lever. If this is insufficient, the seat can be taken out by removing the nuts securing the seat or by forcing the seat using portable rams, spreaders or come-alongs. This latter option may involve rough movement, which may not be a viable option, depending on the patient\u2019s condition.",
        "EXTRICATION - Providing Care": "It is important to have a sufficiently large number of skilled personnel available during extrication, as there are multiple tasks to look after at the same time. Always try to move the device, not the patient, during extrication. At all times, maintain spinal motion restriction. Use the path of least resistance when making decisions regarding equipment and moving the patient. Once you have gained access to the patient, follow procedures for suspected head, neck and spinal injuries. Complete the primary assessment and provide the appropriate care. Stay with the patient at all times and continually monitor their condition. If it worsens, communicate this to the rest of the team members, as they may wish to change the method to a more rapid type of extrication.",
        "CRITICAL FACTS 5": "The term simple access describes the process of getting to a patient without the use of equipment. Complex access describes the process of using specialized tools or equipment to gain access to a patient.",
        "PUTTING IT ALL TOGETHER": "There are times when an EMR may not be able to provide immediate care for an injured or ill person because the EMR cannot reach the person. This can happen as a result of motor-vehicle collisions, fire, water or other elements. While fire rescue personnel and others have special training and equipment, an EMR may be called upon to assist in vehicle extrication. Vehicle extrication involves multiple steps\u2014stabilizing the vehicle, attempting to gain access to patients inside the vehicle and, if unable to do so, carrying out the steps involved in extricating the patients from the vehicle in the safest manner possible. All steps in the vehicle extrication process require specialized training and must be carried out by a team of rescue personnel. During the procedure, it is critical that EMRs take steps to ensure their own safety. Sadly, some EMRs and others are injured or killed each year when struck by an oncoming vehicle while attempting to help patients involved in motor-vehicle collisions. Be sure to take adequate measures to make the scene safe before trying to gain access and provide care. When providing care, responders should take steps to protect the patient\u2019s head, neck and spine.",
        "CRITICAL FACTS 6": "Extricating the patient is a task reserved for specially trained personnel. Preventing further harm to the patient is a primary concern in extrication. Be sure to stay with the extricated patient at all times. Continually monitor their condition."
    },
    {
        "Key Terms": "Closed-loop communication: A communication technique in which the listener repeats orders word for word to ensure the message was heard and understood accurately., Communications center (dispatch): The point of contact between the public and responders (also known as a public safety answering point, or PSAP); responsible for taking basic information from callers and dispatching the appropriate personnel; in some communities may also provide prearrival instructions to the 9-1-1 caller., Medical control: Direction given to emergency medical responders (EMRs) by a physician when EMRs are providing care at the scene of an emergency or are en route to the receiving facility; may be provided either directly via radio or indirectly by pre-established local medical treatment protocols; also called standing orders., Minimum data set: A standardized set of data points about the response and care for patients; this information is included in the prehospital care report (PCR)., Patient narrative: A section on the prehospital care report where the assessment and care provided to the patient are described., Prehospital care report (PCR): A document filled out for all emergency calls; used to keep medical personnel informed so they can provide appropriate continuity of care; also serves as a record for legal and billing purposes; may be written or electronic; if electronic, it is then an E-PCR., Run data: A section on the PCR where information about the incident is documented.",
        "INTRODUCTION": "When you arrive on the scene to assist injured or ill persons, what you think you see and what has actually happened may not be the same thing. It is easy to make judgments that may turn out to be incorrect. Communication may be difficult in times of stress, particularly if there are other factors involved, such as language barriers or fear. For this reason, the emergency medical responder (EMR) must be able to assess the situation and work out the best methods of obtaining the needed information. Other factors such as background noise may also inhibit communication between the EMR and other members of the team or patient. Effective communication with the patient and bystanders is of utmost importance to understand what took place. By using various techniques to gain the trust and confidence of the public, an EMR can discover details of the injury or illness that may otherwise go undiscovered. Communication among response team members is also a major part of responding to a medical or trauma emergency. Communication is important for EMRs, as they may need to call for additional resources to transfer patient care to other responders or to the receiving facility. Communication is also important as it facilitates interaction within the team structure. By using the appropriate communication techniques, and understanding the equipment used and the type of information that needs to be relayed, the EMR improves the quality of care provided to the patient. The final element of emergency care is documentation. Records of all that has occurred, from the beginning of the call for help to the point at which the patient has been transported to the receiving facility or to a higher level of care, are extremely important. Proper and thorough documentation will assist more advanced medical personnel in continuing care and can help in any associated legal proceedings.",
        "COMMUNICATING WITHIN THE EMERGENCY COMMUNICATIONS SYSTEM": "For an emergency medical services (EMS) system to run properly, constant communication must be a priority among its key components, which include: \uf0a7 The communications center (dispatch), which is responsible for taking basic information from callers and dispatching the appropriate personnel. In some communities, the communications center may also provide prearrival instructions to the 9-1-1 caller. \uf0a7 The medical director and receiving facility, often a hospital. \uf0a7 The EMS personnel in the field. To work efficiently, the EMS system must have a communications system geared toward its particular needs. Often, this involves a radio communication system and/or a mobile phone system for communication among members of its network.",
        "Radio Communication System Components": "Radio communication for an EMS system is composed of four key components, including the base station, mobile radios, portable radios and repeaters. All radios in the United States, including those used by EMS personnel, are regulated and licensed by the Federal Communications Commission (FCC). The base station is the hub of communications and should be situated in the best possible location for sending and receiving signals. It must have access to power and an antenna for maximum quality reception. Mobile radios are mounted in emergency vehicles. Their ability to send and receive messages varies and is affected by terrain and objects, such as tall buildings, which may be in the vicinity. Portable radios are handheld radios that are particularly useful when you must be out of your vehicle. Their range is limited but can be boosted by use of a repeater, a device that receives a low-powered radio signal and rebroadcasts it at a higher power. Repeaters increase the amount of territory you can access through radio communication. Digital equipment uses an encoder and a decoder, which allow emergency personnel to communicate more easily, without overutilizing bandwidth. A mobile data terminal uses data rather than voice instructions. The terminal is situated in the emergency vehicle, and information is relayed from the base to the terminal. The information is then displayed in text, to be read off the screen. To respond, emergency personnel can transmit in the same manner or push a button to switch to voice mode.",
        "Rules for Radio Communication": "The FCC regulates the use of radio communication systems. Therefore, those who use these systems must follow FCC rules. Ground rules for use of an EMS radio communication system help ensure that information is communicated as completely and accurately as possible. (The FCC website can be found at fcc.gov.) Here are some important FCC rules to follow when using an EMS radio communication system: \uf0a7 Use assigned or licensed EMS frequencies only for EMS-related communication. \uf0a7 Before speaking, listen to make sure the channel you are using is clear. \uf0a7 Close your vehicle windows to avoid distortions.\n\uf0a7 To communicate, press the push-to-talk (PTT) button and wait 1 second before speaking.\n\uf0a7 Speak slowly, with your lips about 2\u20133 inches from the microphone.\n\uf0a7 Address the unit you are calling by its name and number, and then identify yourself by your unit name and number.\n\uf0a7 Wait for the unit to let you know they are ready to receive your communication.\n\uf0a7 Use concise, clear and plain language in your communications. Because of a lack of uniformity across jurisdictions and the need for rapid and clear communications from different responding agencies in a major crisis, the 10 code system (operational/brevity codes) is being phased out in favor of plain language as required by the Department of Homeland Security (DHS) and in support of the National Incident Management System (NIMS).\n\uf0a7 Keep transmissions brief, organized and to the point. Omit courtesy terms like \u201cplease\u201d and \u201cthank you.\u201d\n\uf0a7 When saying numbers that might be confused with other numbers, say the number, then the individual digits (e.g., to avoid confusing 15 with 50, say \u201cfifteen,\u201d then \u201cone-five\u201d).\n\uf0a7 Give only objective, verifiable information and remember that others can listen in on radio communications. Do not use patients\u2019 names or other identifying information in your communications.\n\uf0a7 Use \u201caffirmative\u201d and \u201cnegative\u201d rather than \u201cyes\u201d and \u201cno.\u201d",
        "Communicating with Dispatch": "The communications center (dispatch) is also known as a public safety answering point (PSAP). The role of dispatch is to receive emergency calls and send the appropriate team to respond. Dispatch is the point of contact between the public and responders. In the 9-1-1 system, emergency medical dispatchers (EMDs) must decide which emergency service resources are required. Most EMS dispatch centers use a validated system to determine the appropriate response based on information received from the caller. These systems can be computer based but they are often a physical flip card-type system. EMDs (and the call takers who assist them) must gather as much information as possible regarding the emergency. They also may advise callers about what the callers may be able to do while awaiting your arrival. Dispatchers note the time the call was received and the time they dispatched emergency services. Also, they usually record all conversations and radio dispatches, in order to have an indisputable record of the events. (For more information on EMDs, refer to Chapter 27.) As an EMR and depending on the work setting, you are responsible for: \uf0a7 Receiving instructions from dispatch and acknowledging receipt. \uf0a7 Providing an estimated time of arrival (ETA) to dispatch, if requested, and reporting any delays along the route that may change the ETA. \uf0a7 Announcing your arrival at the scene to dispatch, and providing your assessment of whether additional resources should be sent or if assigned resources can be released. \uf0a7 Informing dispatch when you leave for transport to the hospital or when your role is finished, if you have been relieved by more advanced medical personnel. When relaying information about transport, you must inform dispatch of how many patients you have, the name of the receiving facility and your ETA. \uf0a7 On arrival, notifying dispatch that you have arrived at the hospital or other designated location such as a helicopter landing zone. \uf0a7 When the patient transfer is complete and you are able to leave the hospital, letting dispatch know you are once again available for service. You may have to contact dispatch again once you return to your station or home base. Communicating with Medical Control Depending on your EMS system, medical control may or may not be located at the receiving facility. There may be times when you must speak to medical control while you are on scene. This would most likely be in a situation in which standing orders or protocols would not be sufficient and you have questions about the care provided to the patient. Communications with medical control must be thorough but brief. CRITICAL FACTS When communicating with medical control, always identify yourself and give all relevant information on the patient and the care provided. Successful interpersonal communication with patients and their families means being empathetic, having awareness of cultural differences, showing sensitivity to an individual\u2019s emotions and listening effectively.",
        "CRITICAL FACTS": "Ground rules for use of a radio communication system, as set forth by the FCC, help ensure that information is communicated completely and accurately throughout the EMS system.",
        "Communicating with Medical Control": "When communicating with medical control, provide the following information:\n\uf0a7 Who you are (unit, level of service and your role)\n\uf0a7 Patient characteristics (age, gender, chief complaint)\n\uf0a7 The patient\u2019s mental status\n\uf0a7 SAMPLE ( signs and symptoms, allergies, medications, pertinent medical history, last oral intake, events leading up to the incident) history\n\uf0a7 Relevant information about past illnesses\n\uf0a7 Vital signs and results of your physical assessment\n\uf0a7 Any care you provided and the patient\u2019s response to the care\n\uf0a7 Your questions\nAsk whether you should perform any further actions, and estimate when you will arrive at the receiving facility. Whenever you receive medical direction, repeat the order word for word. This is called closed-loop communication. Write down important or lengthy medical instructions.",
        "Communicating with Medical Personnel": "When other EMS personnel arrive on the scene, identify yourself and give a verbal report. Interact within the team structure, communicating any information concerning the patient and the scene to law enforcement and other responders.",
        "Communicating with the Receiving Facility": "As soon as possible, the transport crew should notify the receiving facility about the patient, any special alerts concerning the patient\u2019s condition and the ETA. The receiving facility (medical control) or operator is informed if there are any changes in the patient and the ETA, and communicates any changes in the patient\u2019s condition.\nWhen communicating with the receiving facility, give the following information:\n\uf0a7 Who you are (unit and role)\n\uf0a7 How many patients will be arriving\n\uf0a7 Patient characteristics (age, gender, chief complaint)\n\uf0a7 Immediate history (events leading to the injury or illness)\n\uf0a7 Any care you provided and the patient\u2019s response to the care\n\uf0a7 Any vital information, such as the need for isolation or specialized services (e.g., a trauma team)\n\uf0a7 ETA\nAt the receiving facility, crew members will provide additional information about the scene and the patient(s). They will also complete whatever documentation is necessary to meet local or state standards and their organization\u2019s protocols.",
        "Mobile Phone Communication": "Mobile phones are becoming more popular in some EMS districts. They can be useful for covering longer distances than radio communication, and their sound clarity in communication is usually superior. Since mobile phones are fairly maintenance-free and provide the ability for direct communication between parties, they are also often used as backup sources of communication should the radio system fail. However, there are drawbacks to mobile phones. For example, in cases of emergencies that involve multiple people, mobile phone service can be compromised due to system overload and it often cannot be recorded to assist in creating a record of events and orders received. Mobile phones are also impractical for multiunit coordination.",
        "INTERPERSONAL COMMUNICATION": "Every person deserves equal care, dignity and respect for their differences including age, language, ethnicity, culture or socioeconomic status. To be empathetic means to understand, to be sensitive to cultural differences and to the thoughts, feelings and experiences of another person. In order to listen effectively to what is being said to you, it is important that you have empathy for the people involved.Communicate with patients in a way that achieves a positive relationship. Before doing anything, unless it is a life-threatening situation, introduce yourself to the patient and family members, if present. Tell the patient what your role is and what you will do. Introducing the other members of your team is also important. Medical and trauma emergencies can be frightening to those involved. When speaking to an injured or ill person and family members, be sure to speak slowly and clearly. Avoid using medical terms and abbreviations, and speak in words that are easily understandable. If possible, try to adapt the physical environment to facilitate communication by making sure there is adequate lighting and that you have minimized distractions such as noises, interference from others and noisy equipment nearby. Get down to the patient\u2019s eye level to avoid appearing threatening. Make eye contact and use body language that shows you are open and interested in what people have to say, for example, standing with arms at your sides instead of crossed, and with hands open rather than in closed fists. One way to put people at ease is to address them by name, whenever possible. Note, however, that if the patients are older adults, as a matter of showing respect, you should not call them by Emergency Medical Responsetheir first names unless invited to do so. A general rule of thumb is to address individuals in the way that they introduce themselves to you. For example, if the patient and family member introduce themselves as Mr. and Mrs. Smith, you should address them as such. If possible, have the patient tell you their name and what problems they are having. It may be instinctive for family members or friends to do so, but it is best if you can have the patient speak, so you can observe the patient\u2019s ability to communicate, level of consciousness (LOC) and mental status. You can also learn a lot about physical problems just by observing people while they are talking. If someone can only speak a few words before needing to take a breath, for example, that may mean there is a respiratory emergency. Someone clutching the stomach or chest may be doing so without being aware of it, and this can give you information. Someone who winces with pain should be asked about the pain. If the patient cannot speak or is unable to give you information, then ask bystanders for the information. Listen carefully to what the injured or ill person is telling or trying to tell you. Observe the patient as you listen. Provide reassurance if there seems to be some reluctance to speak about a topic. Mention that any information you are told about the problem may be important and will remain confidential, even if it is upsetting to talk about. Attempt to gather patient information in a private setting that is away from bystanders. Individuals may feel uncomfortable giving information about the situation in front of others. Because of the stressful nature of the situation, it is always best to ask one question at a time so the person answering can concentrate while giving the answers. Also, the answer to one question may lead you to another related one. Asking more than one question at a time may provide confused responses. Avoid interruptions as much as possible. Allow the patient to finish a thought. If you need clarification, ask questions at the end of the patient\u2019s statement. Depending on the type of information you are trying to find out, you may want to ask closed or direct questions, to which patients should be able to give you a \u201cYes\u201d or \u201cNo\u201d answer or a short answer. For example, you might ask, \u201cDid you have something to eat?\u201d or \u201cWhat time was it when you last ate?\u201d For more detailed information, you may need to ask more open-ended questions, which allow for more detailed answers. This type of question may be a little more difficult for patients to answer but can provide answers with greater depth. A typical open-ended question might be, \u201cHow are you feeling right now?\u201d From the patient\u2019s perspective, not being listened to can be frustrating. Consider the last time you had to repeat information to someone several times; it is not a pleasant experience. Listening lets people know you believe they are important. If you ask a question, listen for the answer. Make notes, if necessary, so you do not forget what was said. If you forget too often, the patient may stop answering your questions. As you interview the patient or bystanders, be careful to avoid the pitfalls of interviewing. For example, be sure to word questions so that you do not provide false assurance or reassurance. Avoid giving advice or asking leading or biased questions. Try to let the person you are interviewing do most of the talking, and do not interrupt. Avoid asking \u201cWhy\u201d questions, which can be perceived as judgmental; in most circumstances you do not need to know why something happened, only what happened. Listen to what bystanders tell you; they may have seen or heard something that will help you determine how to care for the patient. But, after they have provided the information you require, you must consider the patient\u2019s privacy while you continue to assess the situation and provide care. Often, bystanders want to stay and watch. Be firm but reasonable with bystanders. Ask them to move away for the safety and comfort of everyone. If a crowd appears that could become hostile, explaining your role may set the crowd at ease. If, however, the crowd appears to be threatening, call for backup from the appropriate service. It is important not to make judgments about a patient on the basis of cultural or other differences, such as the patient\u2019s physical appearance. Instead, be more mindful of your own physical appearance. By being neat and well groomed, you help give both patients and their family members a sense of confidence in you. If you are providing care for someone who speaks a language you do not understand, call for someone who can translate. A family member or neighbor, for example, may be able to speak both your language and that of the patient. Some dispatch centers and hospitals also offer language line services, which may be useful. Watch the patient\u2019s body language, whether your language is spoken or not. Nonverbal clues can help determine what is wrong. Be sensitive to cultural differences; in some cultures, it may be inappropriate to make eye contact or for someone of the opposite gender to help the patient. There are also cultural differences that relate to the appropriate distance to stand apart from another person. Respect these differences and do what you can to help.",
        "THE IMPORTANCE OF DOCUMENTATION": "Documentation procedures are established by state regulations or local policy and may vary from state to state and one EMS system to another. Documenting your care is as important as the care provided. Your record will help more advanced medical personnel to assess the patient and continue care. It is important to write the record as soon as possible after the emergency, while the information is fresh. Because a patient\u2019s condition may change before arriving at the receiving facility, a record of the condition immediately after the emergency will provide useful information for responders and emergency department staff. They can compare the current condition with what you recorded earlier. Your record is a legal document and is important if legal action occurs. Should you be called to court for any reason, your record will support what you saw, heard and did at the emergency scene. Documentation of injuries and illnesses is also useful when analyzing current response practices and protocols and planning preventative action for the future. Records are also used for quality assurance (QA) and quality improvement (QI) practices within a department.",
        "Description and Uses of the Prehospital Care Report": "A prehospital care report (PCR), also called a run report or trip sheet, is the essential documentation for each emergency call. The primary function of this report is to ensure high-quality patient care. Hospital and other more advanced medical personnel need to know what transpired during a call in order to provide the patient with appropriate continuity of care. This information allows medical personnel to determine what treatment the patient needs and which complaints must be addressed first. The PCR can also be used to evaluate care provided and identify areas where quality of care requires improvement in future scenarios. Keeping good records allows EMRs to learn from both successes and failures. The PCR has multiple functions. As mentioned before, the PCR also serves as a legal document, particularly if the responder was present at the scene of a crime or if the incident leads to legal proceedings. It is not uncommon to be called to testify in court years after the response. In addition, the PCR is a valuable educational and research tool. The information may be used in research projects on a variety of issues, including studies on the safety and efficacy of certain interventions, the cost-effective implementation of patient care or the typical presentation of certain injuries or illnesses. The PCR also has an administrative function\u2014serving as an important part of the patient\u2019s medical record. It may be used for billing, insurance reimbursement or maintaining statistics on hospital emergency services. Given the importance and multiple functions of the PCR, it is crucial that the PCR is filled out accurately, completely and correctly.",
        "CRITICAL FACTS 2": "A PCR is the essential document of every emergency call. Not only does it serve as a patient\u2019s medical record, it also fulfills important legal, educational and administrative functions. Documentation procedures and regulations are set forth locally or through the state.",
        "Sections of the PCR": "Typically, the four sections of a PCR include: 1. Run data. The run data section contains administrative information, including the time the incident was reported, when the unit was notified, when the unit arrived and left the scene, when the unit arrived at its destination and when the transfer of care was made. It also includes such information as the EMS unit number, names of the EMS crew members, and their levels of certification and the address to which the unit was dispatched. 2. Patient data. The patient data section contains all the background information on the patient, including legal name, age, gender, birth date, home address, Social Security Number (where required), and billing and insurance information. It also contains the time the incident occurred, address where the patient was picked up and any care the patient received before EMS personnel arrived. 3. Check boxes. The check boxes section, as the name implies, contains a series of boxes that are checked in accordance with the patient\u2019s condition. The check boxes refer to information about the patient, including vital signs (often more than one set must be taken), chief complaint, level of consciousness, appearance and respiration rate. In an E-PCR, these often appear as drop-down menus. 4. Patient narrative. The patient narrative section is an open-ended portion of the PCR in which a description of the assessment and care is provided. The goal is to provide a complete and thorough picture of what went on and what the patient\u2019s condition is. This section must include the SAMPLE history, the patient\u2019s chief complaint (in the patient\u2019s own words, if possible), how the chief complaint began and how it progressed, and the mechanism of the injury or nature of illness. It should also include relevant details of the patient\u2019s medical history. It is important to remain objective in this section: that is, describe what happened but do not draw any conclusions about the situation.",
        "Minimum Data Set": "The minimum data set refers to all the information that must be included in the PCR. It consists of the following: \uf0a7 Patient information gathered by the EMR yTime of events yAssessment findings, including the following: \uf0a7 Chief complaint \uf0a7 LOC \uf0a7 Systolic and diastolic blood pressure \uf0a7 Skin perfusion (capillary refill) \uf0a7 Skin color and temperature \uf0a7 Pulse rate \uf0a7 Respiratory rate and effort \tEmergency Medical Response\tyEmergency medical care provided\tyPatient demographics, such as age and gender\tyChanges in the patient after care and who the patient was turned over to\tyObservations at the scene\tyDisposition (e.g., whether the patient refused care or was transported to a hospital)\n\uf0a7\tAdministrative information\tyTime the incident was reported\tyTime the unit was notified\tyTime unit en route to the call\tyTime the unit arrived at the scene\tyTime the unit left the scene\tyTime of arrival at the receiving facility\tyTime of transfer of care\tyTime unit available for next call\nNote that it is important to use accurate and synchronous clocks to allow all involved to gather accurate medical information. For example, it is important to know details such as how long the patient was in cardiac arrest. The National EMS Information System (NEMSIS), which is a system to gather data on the local and state level of EMS systems and prehospital care, can be a helpful tool for tracking data in the local area and benchmarking services, regions and states for system and patient care improvement opportunities.",
        "Confidentiality": "Control of the contents of a PCR falls within the Health Insurance Portability and Accountability Act (HIPAA). HIPAA has strict rules about how patient information is used and distributed. Violation of HIPAA rules can have severe penalties. The contents of the PCR must be kept confidential, as it contains personal and potentially sensitive information about the patient. While in your care, it is your responsibility to ensure that the PCR is in appropriate hands. (For more information on HIPAA and confidentiality, refer to Chapter 3.)\nRefusal of Treatment\nWhile any competent adult has the right to refuse treatment, questions may come up later as to whether the patient was truly competent at the time of refusing treatment. Therefore, it is important to perform as complete an assessment of the patient as is possible, given the situation. For a patient who refuses treatment, record on the PCR exactly what care you recommended providing to the patient, and make one last effort to convince the patient to accept this care before leaving the scene. Be sure to include in the PCR that the patient received a complete explanation of the possible consequences of refusing care, including the risk of death if this is appropriate. Offer the patient alternative methods of obtaining care, such as visiting the patient\u2019s family healthcare provider. Tell patients that you or another EMS team is willing to return to the scene should they change their decision. Make sure this is all documented in the PCR and is signed by the patient and a witness, if available. Always follow local protocols for refusal of care as they may differ from state to state. (For more information on refusal of treatment, see Chapter 3.)",
        "Falsification": "The PCR must be a thorough and accurate record of what occurred during a call. Any error of omission or commission in care must be highlighted in the PCR, along with any steps that were made to correct the situation. Only document the facts on the PCR. Do not leave anything out and do not add anything that was not done.\nBe aware that falsification of a PCR is a serious offense. It can lead to revocation of your certification or license and even to criminal charges. More seriously, it can significantly compromise patient care.\nParts of the PCR that are most frequently falsified are vital signs and treatment. EMRs who forget to measure vital signs have been known to make them up, or those who forget certain crucial treatments, such as administering supplemental oxygen to a patient with chest pain, may fail to mention this error. Be honest; it is far better for you and the patient if you own up to your mistakes up front.",
        "TRANSFER OF CARE": "When more advanced medical personnel arrive on the scene, you will need to give a verbal report on the number of patients involved, their conditions and the emergency situation. If a multipart PCR is available, the copy should be transferred with the patient. This relieves the transferring provider from having to collect redundant information, thus saving time.\nCRITICAL FACTSControl of the contents of a PCR falls within HIPAA. Specifically, you will need to provide the following information about the patient(s): \uf0a7 Current condition \uf0a7 Age and gender \uf0a7 Chief complaint \uf0a7 Brief, pertinent history of what happened \uf0a7 How you found the patient(s) \uf0a7 Major past injuries or illnesses \uf0a7 Vital signs \uf0a7 Pertinent findings of the physical exam(s) \uf0a7 Emergency care provided and the response to care",
        "SPECIAL SITUATIONS": "Documentation of the emergency situation and the care you provided is not only important for the patient, but also may prove essential for local authorities when legal matters are involved. It is particularly important to report any abuse, exposure to dangerous situations or injuries. Once your report is complete, it should be submitted to the proper authorities in the proper time frame and should include the names of all agencies, people and facilities involved in the emergency response. As always when writing these legal documents, be objective. Write only the facts and your observations; do not write your own subjective comments or opinions and do not draw any of your own conclusions. The only subjective comments or opinions should be those of the patient. Be sure to sign and date the document. Always keep a copy for your own records while making copies to distribute to the proper authorities based on local protocols. Your region or location will have its own standards and procedures, which will indicate which authorities are authorized to receive this documentation.",
        "PUTTING IT ALL TOGETHER": "Communication and documentation are a major part of providing emergency care. It is important for everyone on the team to understand what is going on and what happened before they arrived on the scene. This is only possible through good communication with patients, bystanders and colleagues. Although emergency situations may make it difficult for some patients to effectively communicate, the EMS team, by showing confidence and encouragement, can successfully elicit the required information. Effective communication within the response team is based on understanding the modes of communication (radios, phones), factors for effective communication (speaking clearly, using correct terminology) and speed of communication. By following the rules and protocols of your region, miscommunication should be kept to a minimum. Documentation is the final step in providing emergency care. State laws and regulations require that documentation be done as accurately and as soon as possible following the emergency situation. In the midst of the emergency, it is possible to forget instructions or answers to questions, so it is best to take notes when asking questions of patients and bystanders, and also when receiving instructions from medical control. Always remember to be objective in your reports as these documents may be used for legal purposes or for evaluating procedures. Finally, keep a copy of all records for yourself based on local protocols; this will allow you to have access to the information should it be needed."
    },
    {
        "KEY TERMS": "Confined space: Any space with limited access that is not intended for continuous human occupancy; has limited or restricted means of entry or exit., Distressed swimmer: A swimmer showing anxiety or panic; often identified as a swimmer who has gone beyond their swimming abilities., Drowning: An event in which a victim experiences respiratory impairment due to submersion in water. Drowning may or may not result in death., Drowning victim\u2014active: Someone who is vertical in the water but has no supporting kick, is unable to move forward and cannot call out for help., Drowning victim\u2014passive: Someone who is not moving and is floating either face-up or face-down, on or near the surface of the water, or is submerged., Litter: A portable stretcher used to carry a patient over rough terrain., Non-swimming rescues and assists: Rescues and assists that can be performed from a pool deck, pier or shoreline by reaching, by using an extremity or object, by throwing a floating object or by standing in the water to provide either of these assists; performed instead of swimming out to the person in distress., Rappelling: The act of descending (as from a cliff) by sliding down a rope passed under one thigh, across the body and over the opposite shoulder or through a special friction device., Reaching assist: A method of rescuing someone in the water by using an object to extend the responder\u2019s reach or by reaching with an arm or leg., Throwing assist: A method of rescuing someone in the water by throwing the person a floating object, with or without a line attached., Wading assist: A method of rescuing someone in the water by wading out to the person in distress.",
        "INTRODUCTION": "As an emergency medical responder (EMR), you may be involved in rescues that find you in some precarious and dangerous situations. These situations will require special operations units to assist in the rescue efforts. These units may include: \uf0a7 The Tactical Emergency Medical Services (EMS) Unit: for situations such as hostage barricades, active shooters, high-risk warrants and other situations requiring a tactical response team. \uf0a7 The Hazardous Materials (HAZMAT) EMS Response Unit: for situations involving weapons of mass destruction (WMD) and HAZMAT incidents, to provide EMS care to patients in the warm zone, the area immediately outside the hot zone (the area in which the most danger exists). \uf0a7 The Fire Rehabilitation Unit: to provide \u201crest, rehydration, nourishment and medical evaluation to members (firefighters) who are involved in extended or extreme incident scene operations\u201d (Source: NFPA 1584). \uf0a7 The Disaster/Multiple-Casualty Incident (MCI) Response Unit: to support responders at MCIs, major incidents and those responding to other disasters with basic MCI equipment such as caches of backboards, splinting equipment, wound care supplies and IV administration supplies. Equipment also may include multi-patient oxygen delivery systems. This unit also provides services for managing large-scale or special rescue situations. \uf0a7 The Search and Rescue (SAR) Unit: to support search and rescue operations. The Specialized Vehicle Response Unit: to support operations involving all-terrain response vehicles required for difficult-to-reach or hazardous terrains.",
        "CRITICAL FACTS": "Drowning is the fifth most common cause of death from unintentional injury in the United States among all ages, and it rises to the second leading cause of death among those 1 to 14 years of age. Males are more than three times more likely to drown than females. A victim may have never intended on even being in the water. Younger children can drown at any moment, even in as little as an inch of water. Young children commonly drown in home pools. Children with seizure disorders are 13 times more likely to drown than those without such disorders. Most people who are drowning spend their energy trying to keep their mouth and nose above the water. Recognizing someone who seems to be having trouble in the water, but is not calling out for help, may help save their life.",
        "CRITICAL FACTS 2": "There are three types of water-related victims: a distressed swimmer who is too tired to continue but afloat; a drowning victim who is active, vertical but not moving forward; and a drowning victim who is passive, floating or submerged and not moving. Only those trained in swimming rescues should enter the water to assist with drowning emergencies. For your safety, look for a lifeguard before attempting a rescue, have the appropriate safety equipment, call for additional resources immediately if you do not have that equipment, and only swim out if you have the proper training, skills and equipment.",
        "Water Rescue": "Some people who drown never intended to be in the water. They may have simply slipped in and did not know what to do. Drowning is the fifth most common cause of death from unintentional injury in the United States among all ages, and it rises to the second leading cause of death among those 1 to 14 years of age. More than 3500 Americans die annually from drowning. Children with seizure disorders are 13 times more likely to drown than those without such disorders. Males are more than three times more likely to drown than females. Younger children can drown at any moment, even in as little as an inch of water. Young children commonly drown in home pools. But, children can also drown in many other types of water settings, including drainage canals, irrigation ditches, and even bathtubs, large buckets and toilets. Alcohol and water do not mix. Drinking alcohol in, on or around water is dangerous. The U.S. Coast Guard reports that more than half of boating-related drowning deaths involve alcohol. Being able to recognize that an individual is having trouble in the water may help save that person\u2019s life. Most people who are drowning cannot or do not call for help. They spend their energy trying to keep their mouth and nose above the water to breathe. They might slip underwater quickly and never resurface. There are two kinds of water emergency situations\u2014a swimmer in distress and a drowning person. A distressed swimmer may be too tired to get to shore or to the side of the pool, but is able to stay afloat and breathe and may be calling for help. The person may be floating, treading water or clinging to an object or a line for support. Someone who is trying to swim but making little or no forward progress may be in distress. Without assistance, a person in distress may lose the ability to float and begin to drown. A drowning victim\u2014active could be at the surface or sinking. They could also be positioned vertically in the water and leaning back slightly. This victim is unlikely to have a supporting kick or the ability to move forward. The person\u2019s arms are at the sides, pressing down in an attempt to keep the mouth and nose above water to breathe. All energy is going into the struggle to breathe, and the person cannot call out for help. A drowning victim\u2014passive may have a limp body or convulsive-like movements. They could be floating face-up or face-down on or near the surface, or may be submerged. Table 32-1 shows characteristics of drowning persons. You should not attempt a swimming rescue unless you are trained to do so. Following these steps will help to reduce your risk of drowning:\n\uf0a7 Look for a lifeguard to help before attempting a rescue.\n\uf0a7 Make sure you have appropriate equipment for your own safety and that of the drowning person.\n\uf0a7 Call for additional resources immediately if proper equipment is not available.\n\uf0a7 Never swim out to a person unless you have the proper training, skills and equipment.\nTo be prepared for an aquatic emergency, it is important to understand the environment. Pay attention to the potential hazards that exist and the conditions of the water. Familiarize yourself with the common recreational activities in your area and the potential hazards. Consider the age, ability and physical challenges of participants in those activities, and learn what kinds of local water incidents and injuries are common in your area. As in any emergency situation, proceed safely. Make sure the scene is safe. If the person is in the water, decide first whether help is needed in order for the person to get out, and then act based on your training. Look for anyone else who may be in trouble. Look for bystanders who can call for help or help you provide first aid. During the emergency situation, your preparation will allow you to respond quickly; you may only have seconds to act. Your first goal is to stay safe. Rushing into the water to help someone may put you at risk of drowning, too. Once you ensure your own safety, your goal is to help get the person out of the water. If the person is unconscious, send someone to call for more advanced medical personnel while you start the rescue. If the person is conscious, first get the person out of the water and then determine whether more advanced medical personnel are needed. You can help a person in trouble in the water by using reaching assists, throwing assists or wading assists. Whenever possible, start the rescue by talking to the person. Let the person know help is coming. If noise is a problem or if the person is too far away to hear you, use nonverbal communication strategies. Tell the person what to do to help with the rescue, such as grasping a line, ring buoy or other object that floats. Ask the individual to move toward you, such as by using the back float with slight leg movements or small strokes. Some people reach safety by themselves with the calm and encouraging assistance of someone calling to them. Non-swimming rescues and assists include:",
        "Reaching Assists": "Firmly brace yourself on solid ground, such as a pool deck, pier or shoreline, and reach out to the person with any object that will extend your reach, such as a pole, oar or paddle, tree branch, shirt, belt or towel. If no equipment is available, you can still perform a reaching assist by lying down and extending your arm or leg for the person to grab.",
        "Throwing Assists": "An effective way to rescue someone beyond your reach is to throw a floating object with a line attached out to the person. Once the person grasps the object, pull the individual to safety. Throwing equipment includes heaving lines, ring buoys, CRITICAL FACTSNon-swimming rescues and assists include reaching, throwing and wading assists. The distance of the victim and the conditions of the water will dictate which method is best.",
        "Wading Assists": "If the water is safe and shallow enough (not over your chest), you can wade in to reach the person. If a current or soft or unknown bottom makes wading dangerous, do not go in the water. If possible, wear a life jacket and take something with you to extend your reach such as a ring buoy, buoyant cushion, kickboard, life jacket, tree branch, pole, air mattress, plastic cooler, picnic jug, paddle or water exercise belt. When the emergency is over, you may need to assist with follow-up procedures that may include: Confirming and documenting witness interviews. Reporting the incident to the appropriate individuals. Filling out proper report forms to document injuries for use in court or for insurance purposes. Contacting the patient\u2019s family or legal guardian. Dealing with the media. Assessing what happened and evaluating the actions taken. Critical incident stress may follow an incident in which a serious injury or death occurs. The stress of the experience may overcome your ability to cope, and some effects of critical incident stress may appear right away while others may follow days, weeks or even months after the incident. Consider seeking professional help in these cases to prevent posttraumatic stress disorder.",
        "Ice Rescue": "In icy water, a person\u2019s body temperature begins to drop almost as soon as the body hits the water. The body loses heat in water 32 times faster than it does in the air. Swallowing water accelerates this cooling. As the body\u2019s core temperature drops, the metabolic rate drops. Activity in the cells comes to almost a standstill, and the person requires very little oxygen. Any oxygen left in the blood is diverted from other parts of the body to the brain and heart. If a person falls through the ice, do not go onto the ice to attempt a rescue, as it may be too thin to support you. It is your responsibility as a responder to call for an ice rescue team immediately. In the case of a drowning person, always attempt to rescue the person using reaching and throwing assists. Continue talking to the person until the ice rescue team arrives. If you are able to pull the person from the water, provide care for hypothermia.",
        "HAZARDOUS TERRAIN": "Nature can offer many challenges to the EMR when faced with a rescue in hazardous terrain. Whether it is challenging weather conditions or dangerous, rough terrain, special procedures must be in place to help provide safety for both the responder and patient. One of the challenges you may face is evacuating a patient from a dangerous area where the terrain is rough and difficult to maneuver over. The most common equipment used for this type of rescue is the litter, or portable stretcher. Part of the challenge offered by rough terrain evacuation is that it takes 18 to 20 people to carry a patient over 1 mile of rough terrain. This is why teams must be selected in groups of four, and to ensure equal balance of the litter, team members should be as close in height as possible. The reason 18 to 20 people are required is to ensure no one on the team overtires. After a short distance, teams should rotate positions, changing sides and positions after each progression. It is then advised that teams alternate, giving each team a chance to rest. This will ensure a safe rescue, without anyone becoming exhausted and unable to complete the evacuation. Another factor during a hazardous terrain rescue is the position of the patient in relation to the terrain: the more drastic the angle of the terrain, the more risky the rescue. To avoid dropping the patient or falling during the rescue, a rope system can be used to lift or lower the patient on the litter. A high-angle rescue, such as from a cliff, gorge or side of a building, would entail lifting or lowering a patient with these ropes. In severe cases, a high-angle rescue team may be required. These scenarios may include: \uf0a7 A slope of more than 40 degrees. \uf0a7 Terrain below and around the slope that poses serious danger for slips and falls. \uf0a7 Terrain that requires rescue teams to approach and evacuate using a secured rope (rappelling) .In the case of a low-angle rescue, a rope may not be required. These scenarios would include situations where: \uf0a7 The slope is less than 40 degrees. \uf0a7 Approaching or evacuating the patient, hands are not required to provide balance. \uf0a7 Slips or falls would not prove life threatening or result in serious injury. As with any emergency scene, it is your responsibility as a responder to assess the situation and call for the proper rescue team. While waiting for the team to arrive, follow proper procedures, including assessment of the patient as appropriate.",
        "CONFINED SPACE": "Any space with limited access that is not intended for continuous human occupancy is considered a confined space. Rescues in confined spaces are usually for falls, explosions, asphyxia, medical problems or machinery entrapment. Confined spaces may be at ground level, above ground or below ground. Silos used to store agricultural materials are often designed to limit oxygen and, therefore, present the hazard of poisonous gases caused by fermentation.",
        "CRITICAL FACTS 4": "Any space with limited access that is not intended for continuous human occupancy is considered a confined space. Rescues in confined spaces are usually for falls, explosions, asphyxia, medical problems or machinery entrapment. Confined spaces may be at ground level, above ground or below ground.",
        "Confined Spaces": "as well as the danger of engulfment by the contained product in the silo. Grain bins and grain elevators pose the same dangers as silos. Low oxygen levels in these spaces pose a significant risk, as do poisonous gases such as carbon monoxide, hydrogen sulfide and carbon dioxide. Atmospheres containing other gases also may be explosive. Below-ground confined spaces, such as underground vaults or utility vaults for water, sewers or electrical power, also can pose situations in which poisonous gases may be present. Electrical vaults pose the added danger of possible electrocution. Wells, culverts and cisterns containing water may also present a high risk of drowning. Upon arrival at the scene, determine the nature of the emergency and find out if there are any permits for the site so that you can determine the type of work being done. Without entering the site, try to determine how many workers are involved and whether there are any hazards present. Next, call for a specialized rescue team and establish a safe perimeter around the area, preventing anyone from entering. Do not enter the scene unless you are sure it is safe. When able, assist in the rescue and offer medical assistance if appropriate. There are specific safety precautions dictated by the Occupational Safety and Health Administration (OSHA). These guidelines are intended to protect workers who must access confined spaces to perform specific jobs. These safety precautions include requirements for proper ventilation and monitoring for poisonous gases, safely locked electrical systems, dissipated stored energy and disconnected pipes. They also address the use of appropriate respiratory protection for responders, including self-contained breathing apparatus (SCBA) or supplied air breathing apparatus (SABA).",
        "Cave-Ins": "Cave-ins from a trench are associated with particular risk. To prevent cave-ins, OSHA has rules about shoring or making a \u201ctrench box\u201d in any trench deeper than 5 feet, to prevent walls from giving way. If a worker is involved in a cave-in, the person may be buried either completely or partially. If a second worker jumps in to save that person, the worker may cause a secondary collapse and become buried as well. It is easy to underestimate the danger of being covered in soil, but it weighs about 100 pounds per cubic yard. Buried under only 2 feet of soil may mean a worker is under about 1000 pounds of weight, which can cause respiratory problems if the soil is covering the person\u2019s chest. It is imperative to call a specialized trench team for rescue at a cave-in. Do not let anyone enter the trench or the area immediately around it; once there has been a cave-in, the likelihood of a secondary one is increased.",
        "CRIME SCENE": "Law enforcement officers are in charge of a crime scene. It is your responsibility to keep in mind the importance of maintaining the integrity of evidence that can be compromised or destroyed when you enter a crime scene. Always consult with police officers before disturbing items that may be evidence of a crime. You must take precautions to avoid disturbing crime scene evidence (e.g., weapons, bloodstains, vehicles, skid marks) or other evidence that can be vital to investigators to reconstruct the crime or incident scene. It is also important not to introduce evidence into a crime scene. In all such cases, direction will be provided from the officer in charge and EMRs should not take action without permission from law enforcement that it is clear for you to enter, usually with an appropriate escort. You may be called to one of four types of crime scene situations: \uf0a7 A closed access to an unsecured crime scene means that a hazard still exists, such as in a hostage situation, when the suspect(s) is still on the scene or environmental hazards are still present \uf0a7\tA limited-access crime scene means that critical evidence could be destroyed or compromised on the scene and that hazards may still be present, including environmental hazards.\n\uf0a7\tAn open-access crime scene still has evidence to be collected. However, personnel have access to the entire area. It is still necessary to consult with police before disturbing anything, as critical evidence could still be destroyed or compromised.\n\uf0a7\tA cold crime scene no longer has evidential concerns or hazards present.\nAs a responder, when you arrive at a scene where criminal activity is suspected, take the following steps:\n\uf0a7\tNotify law enforcement personnel if they are not already at the scene.\n\uf0a7\tTake precautions not to remove or disturb anything at the scene unless it is absolutely necessary to perform critical patient care.\n\uf0a7\tDocument any situations in which you need to disturb the scene in the interest of patient care.\n\uf0a7\tIn situations where sexual assault is suspected or alleged by the patient, notify law enforcement personnel and do not allow the patient to wash, shower or change clothing.\n\uf0a7\tWhen removing clothing following gunshot wounds, stabbing or other assaults, if at all possible, do not cut clothing through or near the bullet or stab wound holes.\n\uf0a7\tAllow bloody clothing to dry.\n\uf0a7\tAvoid allowing blood or debris to contaminate another area or clothing.\n\uf0a7\tDo not roll clothes up in a ball.\n\uf0a7\tNever put wet or bloody clothes in plastic bags.\n\uf0a7\tHandle clothing as little and as carefully as possible, as powder flakes from gunshot wounds may be present and this may decrease the value of powder-deposit examination.\n\uf0a7\tConsider bagging the patient\u2019s hands if the situation permits, and if required by local protocols.\n\uf0a7\tMinimize the introduction of evidence into a crime scene. Communicate with law enforcement concerning any items you left behind (such as medical supplies) and if you disturbed anything (such as moving furniture to access a patient).\n\uf0a7\tYield to the primary investigative agency on the scene.",
        "FIREGROUND OPERATIONS": "Any fire can be dangerous. Make sure that the local fire department has been summoned. Only firefighters, who are highly trained and use equipment that protects them against fire and smoke, should approach a fire. Do not let others approach. Gather information to help the responding fire and EMS units. Find out the possible number of people trapped, their location, the fire\u2019s cause and whether any explosives or chemicals are present. Give this information to emergency personnel when they arrive. If you are not trained to fight fires or lack the necessary equipment, follow these basic guidelines:\n\uf0a7\tDo not approach a burning vehicle.\n\uf0a7\tNever enter a burning or smoke-filled building.\n\uf0a7\tIf you are in a building that is on fire, always check doors before opening them. If a door is hot to the touch, do not open it.\n\uf0a7\tSince smoke and fumes rise, stay close to the floor.\n\uf0a7\tNever use an elevator in a building that may be burning. As with a crime scene situation and law enforcement personnel, fireground operations always yield to the fire services department to lead and coordinate operations. Fire departments are uniquely equipped to simultaneously address patients\u2019 needs at a fire, including: \uf0a7 Physical rescue of patients. \uf0a7 Protection from the dangers posed by a fire. \uf0a7 Creation of a safe physical environment. As always, scene safety is the primary objective at every fire rescue. The rapid response times of the fire department offer a crucial advantage to fire-related emergency situations. Most fire departments are equipped with automated defibrillators. They are also equipped to perform rapid multi-faceted response, rapid identification and triage to the appropriate facility.",
        "Special Events and Standby": "You may be assigned to a special event or be on standby in case there is a need for emergency medical attention. Such events could include major sporting events like the Super Bowl or concerts, large-scale conventions or other national security events. The following general guidelines are for awareness purposes and may vary by state or EMS jurisdiction. An individual, agency or organization may submit a request for an EMS team to be present at a special event by providing a plan outlining the following information to the appropriate agency: \uf0a7 The nature of the event and its location, length and anticipated attendance \uf0a7 The sponsor of the event \uf0a7 The qualifications of the special event supervisory physician and the special event EMS incident commander, as well as their names \uf0a7 The number of emergency medical personnel involved and their qualifications \uf0a7 The type and quantity of emergency medical vehicles, equipment and supplies required, in accordance with the anticipated number of participants or spectators \uf0a7 A description of the on-site treatment facilities, including maps of the special event site \uf0a7 The level of care to be provided: basic life support (BLS), advanced life support (ALS) or both \uf0a7 Patient transfer protocols and agreements \uf0a7 A description of the special event emergency medical communications capabilities \uf0a7 Plans for educating event attendees regarding EMS system access, specific hazards or severe weather \uf0a7 Measures that will be taken to coordinate EMS care for the special event with local emergency services and public safety agencies, A special event EMS incident commander must be assigned at a special event to supervise the EMS team during the event. The director\u2019s responsibilities include:\n\uf0a7 Preparation of the plan.\n\uf0a7 Management of the delivery of special event EMS care.\n\uf0a7 Ensuring implementation and coordination of details contained in the special event EMS plan.\nThe special event EMS incident commander must be experienced in the administration and management of prehospital care at the BLS or ALS level. This person must possess experience in the medical supervision of prehospital care at the BLS or ALS level.\nThe required staff, qualifications and equipment for a special event are as follows:\n\uf0a7 Special event emergency medical staff shall be certified at BLS or ALS levels.\n\uf0a7 The number of staffed, licensed ambulances or other transport vehicles required to be stationed on-site are as follows:\n\tyOne ambulance for known or expected populations of 5000 to 25,000 participants\n\tyTwo ambulances for more than 25,000 but less than 55,000 participants\n\tyThree ambulances for more than 55,000 participants\n\tyPersonnel must be available to care for special event spectators or participants within 10 minutes of notification of the need for emergency care.\n\tyEMS personnel must be currently certified at the ambulance attendant, emergency medical responder, emergency medical technician (EMT), advanced EMT, paramedic or healthcare provider level.\nA special event where more than 25,000 participants or spectators are expected requires an on-site treatment facility, providing protection from weather or other elements to ensure patient safety and comfort. Beds and equipment for at least four simultaneous patients must be provided for evaluation and treatment, with adequate lighting and ventilation. A special event EMS system must also have on-site communication capabilities, to ensure uniform access to care for patients in need of EMS care; on-site coordination of the activities of EMS personnel; communication with existing community public safety answering points (PSAPs); and interface with other involved public safety agencies. Receiving facilities and ambulances providing emergency transportation must also be ensured.\nThe sponsoring agency is responsible for the implementation of the plan and must ensure participants and spectators are aware of the following:\n\uf0a7 The location of EMS providers at the special event\n\uf0a7 How to obtain emergency medical care at the special event\n\uf0a7 The procedure in the case of specific hazards or serious changing conditions, such as severe weather",
        "PUTTING IT ALL TOGETHER": "As with all calls, the main focus of a special operations situation is to remember your safety and the safety of the patient. Calling the proper service to assist in the rescue will contribute to the success of the rescue efforts.\nUse reaching and throwing assists when attempting to retrieve a patient from water. Remember never to enter fast-moving water, and to tether yourself or any rescue craft you may be using in the rescue attempts. Watch for signs of a distressed swimmer and an actively or a passively drowning victim when sizing up the scene. When attempting ice rescues, remember the dangers thin ice can pose and the added consideration of how hypothermia can affect a person\u2019s ability to grasp rescue equipment.\nConfined space situations pose different dangers during a rescue. The presence of gases, engulfment and possible drowning or electrocution can all be factors, depending on the nature of the space.\nThe physical demands of litter rescue from hazardous terrain can require as many as 20 responders to ensure the safe evacuation of a patient. The slope of the area can also pose challenges and, in high-angle situations, a special team is required to evacuate patients.\nWhen approaching a crime scene, remember that law enforcement personnel on the scene are in charge. Always obtain permission to enter the scene and, when attending to victims of a crime, ensure that the scene is left as undisturbed as possible.Management of fireground operations must be passed on to the fire rescue team. Never enter a burning structure or vehicle. Always call for the fire department when danger of fire exists, or whenever a team has not already been called. Finally, when attending a special event, remember to receive direction from the special event EMS director and keep in mind that a special event emergency supervisory physician will be present to assist in case of a serious medical emergency. The number of staffed, licensed ambulance requirements stationed on-site is dictated by the number of spectators or participants at the event."
    },
    {
        "Key Terms": "Blast injury: An injury caused by an explosion; may occur because of the energy released, the debris, or the impact of the person falling against an object or the ground., Blunt trauma: An injury in which a person is struck by or falls against a blunt object such as a steering wheel or dashboard, resulting in an injury that does not penetrate the body, may not be evident, and may be more widespread and serious than suspected., Chocking: The use of items such as wooden blocks placed against the wheels of a vehicle to help stabilize it., Dispatcher: Personnel trained in taking critical information from emergency callers and call takers and relaying it to the appropriate rescue personnel., Hazardous materials (HAZMATs): Chemical substances or materials that can pose a threat or risk to health, safety and property if not properly handled or contained., Hematoma: A mass of usually clotted or partially clotted blood that forms internally in soft tissue space or an organ as a result of ruptured blood vessels., Kinematics of trauma: The science of the forces involved in traumatic events and how they damage the body., Mechanism of injury (MOI): The force or energy that causes a traumatic injury (e.g., a fall, explosion, crash or attack)., Nature of illness: The medical condition or complaint for which the person needs care (e.g., shock, difficulty breathing), based on what the patient or others report as well as clues in the environment., Penetrating injury: An injury in which a person is struck by or falls onto an object that penetrates or cuts through the skin, resulting in an open wound or wounds, the severity of which is determined by the path of the object (e.g., a bullet wound)., Tripod position: A position of comfort that a person may assume automatically when breathing becomes difficult; in a sitting position, the person leans slightly forward with outstretched arms, and hands resting on knees or an adjacent surface for support to aid breathing.",
        "INTRODUCTION": "It is natural when you arrive at the scene of an emergency to want to rush in and start helping people who may be in obvious pain or distress. But, no matter what the situation, it is essential to take the time to carefully and systematically prepare for and size up the scene. By doing this, you may save time later, prevent further harm to yourself and the patient, and reduce the risk of overlooked injuries. In this chapter, you will learn about the priority of preparation, ensuring your personal safety, determining the number of patients, identifying the mechanism of injury or nature of illness, and assessing the possible need for additional resources.",
        "DISPATCH INFORMATION": "As an emergency medical responder (EMR), it is important that you come prepared with the best available information before arriving at any emergency scene. Therefore, paying close attention to the information the dispatcher has provided to you is essential. This information gives you the first clues as to what you may encounter, including hazards you may need to take into consideration. It will also affect the personal protective equipment (PPE) and other equipment you may need. Keep in mind that the information provided by dispatch is likely to be incomplete and may not be entirely accurate. The caller may have only given a location and some indication that medical assistance was needed. Hazards may be present that were not relayed by the person who reported the emergency, or the person may deliberately lie or exaggerate the severity of the condition in order to get medical attention. However, never undervalue the information dispatch can provide you as a foundation for your preparations.",
        "SAFETY - Scene Safety": "Almost every emergency response carries a certain risk to the safety of the EMR. Upon arrival at an emergency scene, safety should be your first priority. Safety includes both personal safety and the safety of others, including patients and bystanders. Begin with assessment of the scene and the surroundings, both of which provide valuable information about the emergency situation and will help ensure your own well-being. Use each of your senses to size up the scene. In addition to seeing and feeling for hazards, listen for unusual sounds, for example loud explosions or crackling sounds. Use your sense of smell to detect any unusual or unexpected odors, such as gasoline or other chemicals. Always observe the scene thoroughly for dangers such as traffic, unstable structures, downed electrical lines, leaking fuels or fluids, smoke or fire, broken glass, swift-moving water, violence, explosions or toxic gas exposure. Some emergency scenes are immediately dangerous; others may become dangerous while you are providing care. Sometimes the dangers are obvious, such as at a fire or with the presence of hostile patients or bystanders. Other dangers may be less obvious, such as the presence of hazardous materials (HAZMATs) or unstable structures. Take safety measures that are appropriate to the situation. In some cases, this might mean leaving or moving away from the scene if it is too dangerous, and may require a call for specialized personnel or other additional resources.",
        "SAFETY - Controlling the Scene": "Once you have eliminated or removed the current dangers, you need to prevent new hazards from affecting the scene as you provide care for the patient(s). This is frequently a concern when dealing with emergencies on or near a road, and traffic control may be needed. Always pay attention to the road. Keep your eyes and ears open to avoid becoming a victim yourself. Usually, the police will take responsibility for directing traffic at a scene. However, if the police have not yet arrived, you may need to manage this task. Always follow local protocols or guidelines, but, in general, one person should be designated to be in charge of traffic control. If possible, traffic should be directed onto an entirely different road. If another route is not possible, the blocked-off area should be arranged so that any moving traffic is at least 50 feet from the scene. Safety includes both personal safety and the safety of others, including patients and bystanders. The redirection of the vehicles needs to start well back from the scene. Traffic may be moving quickly, and you need to provide plenty of time for vehicles to slow down and move over. Flares, reflective cones, signs and other warning devices should be put in position, about 10 to 15 feet apart in a slanting line. Avoid placing a flare near puddles of fluid that may have spilled or leaked out of the involved vehicles, as the fluid may be flammable. On a curve, start the line of flares at the beginning of the curve; on a hill, start at the top of the hill. If the crash happened on a two-way road, put up flares or warning devices in both directions. Any responders setting out the flares or waving traffic away should be wearing reflective clothing based on local, state and national guidelines and always be walking toward traffic. Do not turn your eyes away from oncoming traffic. Ambulances or other transport and emergency vehicles should be positioned to help control the scene. If there are other emergency vehicles present, ambulances should be parked in front of the scene with the tires angled away from where care is being provided and with the loading doors facing away from traffic. Ambulances and fire apparatus should be blocking the road as much as possible but allow other emergency vehicles to access the scene. If other emergency vehicles are present, they should park down from the scene with their tires angled away from where care is being provided. If there is a fire, park at least 100 feet away; in a HAZMAT situation, aim for a distance of 2000 feet or park where directed by on-scene personnel or the dispatcher. Also look for a location that is uphill and upwind if there are HAZMATs or fire. Leave emergency lights on to provide another warning to drivers approaching the scene, and turn headlights to a lower setting.",
        "SAFETY - Crowd Control": "You can help keep the situation calm at the scene by staying calm yourself. For example, walk quickly to patients rather than run. Walking is not only safer but also sends a message to the crowd that you are in control and confident. In very chaotic situations, it may help to set up a barrier around the scene and designate one person to ensure people stay behind the barrier.",
        "SAFETY - Re-Evaluating the Scene": "Continually reassess the situation for new dangers that may arise. For example, a building or structure that seemed stable when you arrived may begin to crumble or become unstable. True scene safety and control is a continuous, not an initial, process. Ensure a responder has been assigned to serve as a safety officer to focus on overall scene safety. If resources allow, this responder should have no other task than ensuring scene safety.",
        "SAFETY - Personal Safety": "Of your primary responsibilities, safety should always be foremost. You should always ensure your own safety. When you arrive on the scene, your first priority is to determine your own personal safety needs. The only safe scene is one that does not represent a threat to you or to the response team. A cornerstone of personal safety is the use of appropriate PPE. Approach all emergency scenes cautiously until you can size up the situation. If you arrive at the scene by vehicle, park a safe distance away. If the scene appears safe, continue to evaluate the situation as you approach. Pay particular attention to the:\n\uf0a7 Location of the emergency.\n\uf0a7 Extent of the emergency.\n\uf0a7 Apparent scene dangers.\n\uf0a7 Apparent number of injured or ill people.\n\uf0a7 Behavior of the patient(s) and any bystanders.\nIf at any time the scene appears unsafe, move to a safe distance. Notify additional personnel and wait for their arrival. Never enter a dangerous scene unless you have the training and equipment to do so safely. Well-meaning responders have been injured or killed because they forgot to watch for hazards. If your training has not prepared you for a specific emergency, such as a fire or an incident involving HAZMAT, notify appropriate personnel. When arriving at an emergency scene, always follow these four guidelines to ensure your personal safety and that of bystanders:\n1. Take time to evaluate the scene. Doing so will enable you to recognize existing and potential dangers.\n2. Wear appropriate PPE for the situation. Be a constant advocate for the use of appropriate protective equipment.\n3. Do not attempt to do anything you are not trained to do. Know what resources are available to help.\n4. Get the help you need by notifying additional personnel. Be prepared to describe the scene and the type of additional help you require. Another important aspect of personal safety is protecting yourself from exposure to infectious diseases. This is especially important if you are providing care for a patient when blood and other potentially infectious materials (OPIM) may be present. Since it is impossible to know if a patient may be infected or not, you should always take protective measures. These protective measures are discussed in detail in Chapter 2.",
        "CRITICAL FACTS": "Once you determine the scene is safe, approach and continue to evaluate the scene. Evaluation should include location and extent of the emergency, scene dangers, number of patients, and behavior of patients and bystanders. To ensure the safety of all involved, always evaluate the scene, wear PPE, call for additional personnel if needed and only treat within the scope of your training.",
        "Personal Protective Equipment-Standard Precautions Overview": "Standard Precautions Overview\nPPE is an important component of standard precautions, which are based on the principle that all blood and OPIM such as body fluids, secretions, excretions (except sweat), nonintact skin and mucous membranes may contain transmissible infectious agents. Standard precautions include a group of infection prevention practices that apply to all patients, regardless of suspected or confirmed infection status, in any healthcare delivery setting. They are based on universal precautions, which were developed for protection of healthcare personnel. Standard precautions focus on protection of responders and patients.",
        "Implementation of Standard Precautions": "The extent of standard precautions used is determined by the anticipated blood and OPIM exposure, and includes the use of:\n\uf0a7 Hand washing. Keeping hands clean is one of the best ways to keep from getting sick and spreading illnesses.\n\uf0a7 Gloves. Disposable latex-free gloves should be worn whenever you touch or are in contact with a patient. Gloves are essential for any rescue situation.\n\uf0a7 Gowns. A gown may provide further protection from blood and OPIM that could otherwise be splashed onto your clothing or skin.\n\uf0a7 Masks. Masks block blood and OPIM, including airborne droplets, from reaching your face; most germs and viruses can enter the body easily through the mouth or nose.\n\uf0a7 Protective eyewear. In hazardous situations, these protect your eyes from debris and heat as well as blood and OPIM.\n\uf0a7 CPR breathing barriers (e.g., resuscitation masks and bag-valve-mask [BVM] resuscitators). Use when providing ventilations to the patient is necessary.",
        "Personal Protective Equipment": "PPE includes clothing or specialized equipment that provide some protection to the wearer from substances that may pose a health or safety risk. Use the appropriate PPE, such as steel-toe boots, helmets, heat-resistant outerwear, self-contained breathing apparatus and leather gloves, that is specific to the potential hazard. Specialized protective equipment and gear are designed to protect appropriately trained responders, and include items such as: \uf0a7 Chemical and biological suits. \uf0a7 Specialized rescue equipment for difficult or complicated extrications. \uf0a7 Ascent or descent gear for specialized rescue situations. In addition to using appropriate PPE, do not forget the role that frequent hand washing or use of hand sanitizers play to keep you\u2014and those around you\u2014safe, by reducing the spread of germs.",
        "Safety of Others": "You have a responsibility for the safety of others at the scene, as well as for your own personal safety. Discourage bystanders, family members or other responders from entering an area that appears unsafe. You can ask well-intentioned individuals to help you keep unauthorized people away from unsafe areas and summon more appropriate help. Some dangers may require you to take special measures, such as placing physical barriers to prevent onlookers from getting too close. Other situations may require you to act quickly to free someone who is trapped or to move a patient in immediate danger.",
        "Patient Safety": "Once you are confident of your own safety and the safety of the general scene, turn to the safety of the patient. As you approach the patient, continue to scan the area for possible dangers. Do not move a patient unless there is an immediate danger. Ideally, you should move patients only after you have assessed and properly cared for them. If the patient does not seem to be seriously injured, and the area is dangerous, you can ask the patient to move to safety where you can provide care. If, however, immediate dangers threaten a patient\u2019s life, you must decide whether to move the person. If the area is dangerous and the patient is not able to move, move the patient as quickly and safely as possible without making the injuries or illness worse. If the situation is so dangerous that you cannot reach or move the patient, move to safety yourself and call for additional assistance. If there is no immediate danger, tell the patient not to move. Situations that may require an emergency move include: \uf0a7 The presence of explosives or other HAZMATs that present an immediate danger (such as a natural gas or gasoline/fuel leak or fire). \uf0a7 The inability to make the scene safe (such as a structure about to collapse). \uf0a7 The need to get to other patients who have a more serious problem to provide the appropriate care. \uf0a7 When it is necessary to provide appropriate care (such as moving a patient to the top or bottom of a flight of stairs to perform CPR). Chapter 5 provides more detailed information on how to safely move injured or ill patients.",
        "Bystander Safety": "Look for bystanders who are in potential danger at the scene. You may be able to take steps to reduce the danger, but if not, tell them to move to safety. If the scene is safe and you need help, look for bystanders who may be able to assist you. They may be able to tell you what happened or how many people were involved, or they may help in other ways. A bystander who knows a patient may know whether there are any medical conditions or allergies you should be aware of. Bystanders can meet and direct an ambulance to your location, help keep the area free of unnecessary traffic and even help you provide care if it is appropriate.",
        "Number of Patients": "Another important aspect when you are sizing up the scene is the number of patients at the scene. Often this is quick and easy to determine. But in some cases\u2014for example, a multiple-vehicle crash or a significant explosion\u2014it can be quite challenging. Patients may be trapped inside motor vehicles or may have been forcefully ejected from their vehicles and away from the immediate scene. An open door provides a clue that a patient has left the vehicle or was thrown from it. If one patient is bleeding or screaming loudly, you may overlook another patient who is unconscious. It is also easy in any emergency situation to overlook a small child or an infant if they are not crying. Accounting for the number of patients who require care is also important for determining the number of ambulances needed. If it appears that there are more patients than you and the others with you can care for, call for additional help immediately. If you start helping the patients right away, you are likely to forget to make the call. Once you have called for additional help, you can quickly assess the patients to determine which ones you will begin caring for first.",
        "MECHANISM OF INJURY AND NATURE OF ILLNESS": "Once you are able to work safely with the patient, observe the scene and the patient to gather information about what has happened and the mechanism of injury or nature of illness. As you gain experience, you will be able to arrive at a scene and quickly scan the area to make a rough determination of the injuries or illnesses you can expect to be dealing with.",
        "Mechanism of Injury": "Mechanism of injury (MOI) refers to the physical events that caused the injury. It is important to determine MOI because it can alert responders to possible hidden or more serious injuries that may not be immediately visible. Some of the most common MOIs an EMR will encounter are vehicle crashes, blunt trauma, falls and penetrating trauma.",
        "CRITICAL FACTS 2": "Common MOIs include motor-vehicle crashes, falls, and blunt or penetrating trauma. Motor-vehicle collisions clearly demonstrate the impact that the energy of motion has to cause damage to the human body. This is referred to as the kinematics of trauma.",
        "Mechanism of Injury - Vehicle Crashes": "The science of the energy of motion (kinetics), and the resulting damage to the human body (trauma), is called the kinematics of trauma. Nowhere is the kinematics of trauma more apparent than in motor-vehicle crashes, which demonstrate all too vividly the effects of speed and rapid changes in speed (acceleration and deceleration) on the human body. When a car crashes into another vehicle or an object such as a tree, the people inside will continue moving at the same speed the car was traveling until something stops them. That \u201csomething\u201d may be a seat belt, a car seat harness, the steering wheel, dashboard or air bag. Even when the person\u2019s body collides with the steering wheel, the person\u2019s internal organs continue to move until they are stopped by the body\u2019s framework\u2014such as the ribs or skull. In a sense, there are three separate events, or collisions: first, the car hits another vehicle or an object and its forward motion is stopped; second, the person hits the interior of the car and stops; and finally the person\u2019s internal organs hit the skeleton or muscular framework of the body and stop. Just as the first collision can cause both obvious damage to the car\u2014the crumpled fender\u2014and hidden damage\u2014the leaking radiator\u2014so the last two collisions can cause both visible and invisible damage to the people in the vehicle. The extent of the damage will depend in part on the speed and weight of the vehicles and the kinetic energy of motion that is absorbed. The wreckage of cars, aircraft or machinery may contain hazards such as sharp pieces of metal or glass, fuel and moving parts. Therefore, do not try to rescue someone from wreckage unless you have the proper training and equipment, such as turnout (or \u201cbunker\u201d) gear, safety glasses, gloves and a helmet. Specialized rescue teams can be called in for extensive or heavy rescue. Care for the patient is provided only after the wreckage has been stabilized. Gather as much information as you can, and make sure more advanced medical personnel have been called. There are five types of motor-vehicle crashes, and each yields a different possible pattern of injuries: head-on, rear-end, side impact, rotational impact and rollover.",
        "Mechanism of Injury - Head-On Crash": "In a head-on crash, the driver will keep moving when the vehicle stops, and either will be thrown upward against the steering wheel and windshield, or downward under the steering wheel. In some cases, the driver may actually be thrown partially or completely through the windshield. If you see damage to the dashboard and windshield, you should anticipate that the driver may have abdominal, chest and head injuries. These can include abdominal injuries to the liver and spleen; serious chest injuries, such as fractured ribs, ruptured lungs and torn arteries; and head injuries including facial injuries. Keep in mind that the person\u2019s neck and brain may also be injured, and this sometimes happens without any bleeding or bruising on the face.",
        "Mechanism of Injury - Rear-End Crash": "In a rear-end collision, the rear vehicle pushes the vehicle in the front forward. The driver and any passengers will feel their heads and necks whipped back at first, and then they will be jolted forward as the car stops. The backward motion of the head and neck often leads to a strained neck, or what is often called a whiplash injury. After this sudden acceleration, the car will usually come to an abrupt stop because of the damage to the vehicle. This sudden stopping may cause injuries.",
        "Mechanism of Injury - Side Impact": "If a vehicle hits the side of another car, the door and frame of the car can be pushed into the bodies of the driver and passengers. There may be injuries to any parts of the person\u2019s body, especially if the crash was forceful enough to crush the side of the car. If the person was not wearing a seat belt, the person may have been thrown against other passengers or against the far side of the car, so injuries can be found on both sides of the body.",
        "Mechanism of Injury - Rotational Impact": "Rotational impact occurs when the vehicle is thrown off center. It is the result of the vehicle striking an object and rotating around it. This can cause a variety of injury patterns, usually due to the person being struck by stationary objects inside the vehicle, such as the steering wheel, doorposts, windows or dashboard.",
        "Mechanism of Injury - Rollover": "When a car rolls over, the driver and/or passenger(s) inside experiences a series of impacts. Each time the car starts to turn, the person is thrown in a new direction, possibly colliding with the door, the steering wheel, the roof of the car and any passengers. Injuries to many parts of the body are possible. If the person was not wearing a seat belt, the person may be ejected from the car through an open or broken window or door. This puts the person at greater risk, because the car may roll onto them. If the crash takes place on a road, the person may be ejected in front of oncoming traffic. Responders should check around the scene in case there are other people who have been ejected. Sometimes these individuals can land at some distance from the car. They may also be under the car.",
        "Mechanism of Injury - Unstable Vehicles": "Any movement of the vehicle during patient care or extrication can prove dangerous or even deadly to patients with severe injuries, or could result in injury to rescue personnel. Local fire department and rescue squad personnel specially trained in vehicle stabilization and extrication will respond to the scene when notified. To make the rescue setting as safe as possible, it is important to ensure the vehicle is stable. You can assume a vehicle is unstable if it is:\n\uf0a7 Positioned on a tilted surface.\n\uf0a7 Stacked on top of another vehicle, even partly.\n\uf0a7 Positioned on a slippery surface.\n\uf0a7 Overturned or on its side. Vehicles must be stabilized in order to attempt to remove a patient. Placing blocks or wedges against the wheels of the vehicle will greatly reduce the chance of the vehicle moving. This process is called chocking. You can use items such as rocks, logs, wooden blocks and spare tires. If a strong rope or chain is available, it can be attached to the frame of the vehicle and then secured to strong anchor points, such as large trees, guardrails or another vehicle. Letting the air out of the vehicle\u2019s tires also reduces the possibility of movement. For further details on how to stabilize a vehicle, see Chapter 28.",
        "Mechanism of Injury - Seat Belts and Air Bags": "In all types of motor-vehicle crashes, the benefits of seat belts and air bags far outweigh the risks, but there are also possible injuries associated with them. If the lap belt is fastened too low on the person\u2019s body, across the base of the pelvis, it can dislocate the hips. If it is fastened too high, it can cause injury to the abdomen. Worn without a shoulder strap, a lap belt will keep the person from being ejected from the car but still allows a person\u2019s head to strike the dashboard; a back-seat passenger can also strike the back of the front seat as a result of lap belt-only usage. A shoulder strap prevents these injuries but can cause injuries to the shoulder, chest and abdomen.\nAir bags may be in the front of the car only, or may be in the door panels, roof rails and the side of seat backs. They are designed to inflate very rapidly just before the initial impact and then deflate again just as quickly. Because they deflate so quickly, they may not stop all forward motion of the driver\u2019s head and chest, so it is important to check to see if the driver also hit the steering wheel. If the steering wheel is damaged, the driver may have serious abdominal or chest injuries, even if the air bag was activated. Be sure to lift the air bag to examine the steering wheel for evidence of damage. Air bags can also cause injuries to the head, face, eyes, spine and arms, especially if the person is less than 5'2\" tall. These injuries can prove fatal.\nIn some collisions, the air bag is not deployed and may present a hazard during extrication. If the patient is pinned directly behind an undeployed air bag, both of the vehicle\u2019s battery cables should be disconnected following established safety protocols. Ideally, the system should be deactivated before any attempts are made to extricate the patient. Do not mechanically cut through or displace the steering column until the system has been deactivated. The air bag module should not be cut or drilled into. Also, heat should not be applied to the area of the steering wheel hub; an undeployed air bag inflates in a normal manner if the chemicals sealed inside reach a temperature above 350\u00ba F or 177\u00ba C. For further details on an undeployed air bag, see Chapter 28.",
        "CRITICAL FACTS 3": "A vehicle is unstable when it is on a tilted or slippery surface, atop another vehicle, overturned or on its side.",
        "Mechanism of Injury - Additional Hazards": "Other hazards at a motor-vehicle crash include fire, leaking fluids, downed power lines and special considerations for alternative-fueled vehicles, such as hybrid and electric vehicles. For further details on alternative-fueled vehicles, see Chapter 28.",
        "Mechanism of Injury - Motorcycle Crashes": "Motorcycle riders do not have the protection of a vehicle body around them, so in a crash situation they are at particular risk for severe injuries. Motorcycle crashes may result in head-on impact, angular impact, ejection from the motorcycle or injury from \u201claying the bike down\u201d (sliding down on one side of the bike).\nIf a crash is head-on, the sudden deceleration causes the rider to be thrown into or over the handlebars. Hitting the handlebars may cause injuries to the chest, abdomen or legs, depending on the rider\u2019s position. If the person is completely ejected from the bike, there may be internal injuries and head, neck, back and extremity injuries. Without a helmet, the rider is more likely to have serious or fatal head injuries.\nOften when motorcycles crash, it is because the bike and rider come in contact with a protruding object, such as a tree branch, road sign or fence post, or another vehicle and often at high speeds. The rider may be injured by the object and then suffer further injuries as the bike falls or slides.\nWhen a motorcycle rider realizes that a crash is likely, the rider may try to slow down the bike and reduce the risk by deliberately laying the bike down on its side, placing a leg between the bike and the road. This leads to injuries to the soft tissues of the leg, which can go quite deep, depending partly on what protective clothing the rider is wearing. If the lower leg is trapped against the exhaust pipe or engine, the patient can also have serious burns.",
        "Mechanism of Injury - Recreational Vehicle Crashes": "Since all-terrain vehicles (ATVs) are frequently ridden off-road or on uneven ground and are not very stable, they are prone to tipping over. In an ATV crash, expect to see injuries similar to those seen in motorcycle crashes. The rider is often ejected from the vehicle and the ATV may roll over onto the rider.\nSnowmobile riders involved in a crash often experience serious head and neck injuries, and the snowmobile may roll over onto the rider. Winter weather may make it difficult for the rider to see protruding objects or wires and this can lead to collisions and injuries.",
        "Mechanism of Injury - Blunt Injuries": "When someone is struck by or falls against a blunt object\u2014one with no sharp edges or points\u2014the resulting injuries are often closed wounds. This type of wound is known as a blunt injury or blunt trauma. This means that although the soft tissues of skin, muscle, nerves and blood vessels may be damaged, the skin is not broken and there is no visible bleeding. The patient may look unharmed, but there may be serious, even fatal, injuries to the internal organs as well as significant internal bleeding. The extent of the injuries may not be immediately visible and may only appear after a period of time. The injuries may also be more extensive than they appear.\nThe responder should look for:\n\uf0a7 Contusions or bruises\u2014Swelling, discoloration and pain where the person was hit.\n\uf0a7 Hematoma \u2014A large, bluish lump formed by blood collecting under the skin (Fig. 6-7).\nSmall- or medium-sized contusions need to only have cold packs applied. Larger contusions and bruising or hematomas may indicate that there are more serious hidden injuries. It is also important to check for possible bone fractures, especially if there is a lot of swelling or pain or if the body part is deformed.",
        "Mechanism of Injury - Falls": "Falls are another common cause of injury. The severity of the injuries caused by a fall is determined by:\n\uf0a7\tThe distance the patient fell (the speed of the fall increases when the person falls from a greater height).\n\uf0a7\tThe surface the patient landed on (a soft, yielding surface will reduce the injuries).\n\uf0a7\tAny objects in the way that might have slowed the fall or, on the other hand, injured the patient during the fall.\n\uf0a7\tThe position of the patient\u2019s body on landing.\nIf the patient falls from a height of more than 15 feet onto a hard surface, injuries may be severe, even if the patient looks unharmed at first glance. You may discover fractured bones in the feet, ankles, legs, pelvis and spine. In falls from a greater height, the patient may also have damage to internal organs.\nIt is a natural reflex to throw out your hands when you are falling. When a fall involves the hands hitting the ground, the person\u2019s wrists may be fractured and, if the person falls from a great enough height, there also might be a fracture or injury to the elbow and shoulder.\nA person falling headfirst usually throws out the arms, so injuries or fractures in the arms and shoulders are typical. The head may be pushed forward or backward on landing, or may be pressed down by the person\u2019s body, and any of these can cause serious injury to the head and spine. The rest of the body will then hit the ground, and injuries to the chest and pelvis can happen during this phase of the fall.",
        "Mechanism of Injury - Penetrating Injuries": "A penetrating injury occurs when the patient is hit by or falls onto something that can penetrate or cut through the skin. This will cause an open wound (or wounds, as there may be both an entrance and exit wound) and bleeding.\nThe path of the projectile through the body usually determines the severity of the injury. For example, if a knife or bullet does not damage any internal organs or major blood vessels, the resulting injuries may be fairly minor, but a stabbing or shotgun blast that hits the heart or lungs or severs an artery can quickly lead to a fatality. In addition to the path of the object, the speed with which the projectile travels through the body is also a determining factor: the faster the object is moving, the more widespread the damage done. If the patient falls onto something sharp, or is stabbed with a knife or another object, this is termed a low-velocity penetrating trauma. If the weapon or object used is available at the scene, it can provide some hints as to the extent of the injuries. A knife, for example, only harms the tissues it actually contacts, so knowing how long the knife is will indicate how deep the injuries may be. Knowing the angle of penetration will also give you clues about possible injuries.\nBecause it hits the body at greater speed, a bullet or pellet fired from a handgun, rifle or shotgun will cause damage to the body well beyond its actual pathway through the body. This is because it carries with it a wave of pressure that compresses tissues around it as it speeds through the body. Always check for a possible exit wound, which may be larger than the entrance wound, because this helps to determine the bullet\u2019s pathway through the body. The most serious, and most often fatal, gunshots are to the head, chest and abdomen. While bullets that hit the arms and legs are less likely to be quickly fatal, they can cause severe bleeding and permanent damage to the limbs. Keep in mind that a small entrance hole, which may not bleed very much, may hide dramatic and serious internal injuries.",
        "Mechanism of Injury - Blast Injuries": "Another type of injury is a blast injury, which is caused by an explosion. There are three phases to an explosion and, therefore, three possible MOIs from it:\n\uf0a7\tIn the primary phase, the energy released during the explosion sends a wave of pressure expanding outward from the center of the blast. Individuals hit by this pressure can experience injury to any body part that is air-filled, especially the lungs, stomach, intestines and inner ears. In some cases, this can be fatal, even though the person may show no external injuries.\n\uf0a7\tIn the secondary phase, the debris around the center of the blast is blown outward and can cause injury when it strikes the person\u2014often with considerable speed and force. These blunt or penetrating injuries will generally be visible and easily recognized. If some of the debris is on fire, the person may be burned.\n\uf0a7\tIn the tertiary phase, the person is knocked to the ground or against a wall or other objects by the force of the explosion. Depending on how far away the person is, and how large the explosion, the injuries may be similar to those sustained by someone ejected during a car crash.",
        "Nature of Illness": "In some situations, you may be called to a scene because a person is ill. Or, if you are called to an emergency and there is no evidence of trauma, but the patient has signs and symptoms of a problem, you may suspect an illness or a medical condition. Recognizing the nature of illness helps you to plan the steps to provide immediate care. A conscious patient may be able to describe the symptoms, or there may be obvious signs (e.g., labored breathing, vomiting). If the patient is unable to speak, ask any bystanders or family what they have observed about the patient, and about any pre-existing conditions. Determining the nature of illness can be made more difficult if the patient or others do not tell the truth. If a person overdosed on drugs, for example, the family may deny knowing what caused the problem and may lie about drug use if you ask about it directly. It is important to scan the scene for items that may provide clues about the problem. Look for prescription and nonprescription medications, evidence of alcohol or recreational drug use, and medical equipment in regular use. Consider the patient\u2019s location and environment as well. For example, has the patient been in the woods or long grass? Then you might need to examine the patient for snake or spider bites. Is the weather extremely hot and humid? Heat stroke or other heat-related illnesses are a possibility. Simply observing the patient can also tell you a great deal. Patients with chest pain or breathing problems often lean forward while sitting in what is called the tripod position. Patients with abdominal pain often pull their knees up toward their chest, either lying down or sitting with their back against a hard surface. Loss of bladder or bowel control can indicate that the patient has had a stroke or a seizure. Any observations should be recorded, as they not only help you evaluate the situation, but may help the healthcare provider who will see the patient in an entirely different environment.",
        "ADDITIONAL RESOURCES": "Once you have sized up the scene and determined the mechanism of injury or nature of illness, you will be able to decide what additional resources are needed to keep you and the patient safe or to provide care. The number of resources will depend on any hazards at the scene, the number of injured or ill persons, as well as the nature of injuries or illnesses. Chemical and biological suits can provide protection against HAZMATs and biological threats of varying degrees. Specialized rescue equipment may be necessary for difficult or complicated extrications.",
        "Calling for Additional Resources": "You may need to call for: \uf0a7 Advanced life support (ALS), to provide a higher level of care for patients with a severe illness or trauma. Air medical transport (e.g., helicopter), to provide the fastest transport to the appropriate hospital or trauma center.Utilities (e.g., power/gas company), to assess, turn off or isolate dangerous downed power lines or leaking pipes. Fire department, to contain or extinguish fires from any source. Law enforcement, to direct or reroute traffic, or to maintain control with any potentially violent bystanders, patients or perpetrators.",
        "CRITICAL FACTS 4": "You may be called to a scene because a person is ill and there is no evidence of trauma. Recognizing the nature of illness helps you to plan the steps to provide immediate care.",
        "Hazardous Materials": "HAZMATs are any chemical substances or materials that can pose a threat to the health, safety and property of an individual. Any HAZMAT poses a special risk for responding personnel. When you approach an emergency scene, look for clues that indicate the presence of HAZMATs. These include:\n\uf0a7\tSigns (placards) on vehicles, storage facilities or railroad cars identifying the presence of hazardous materials.\n\uf0a7\tClouds of vapor.\n\uf0a7\tSpilled liquids or solids.\n\uf0a7\tUnusual odors.\n\uf0a7\tLeaking containers, bottles or gas cylinders.\n\uf0a7\tChemical transport tanks or containers.\nThose who transport or store HAZMATS in specific quantities are required by the U.S. Department of Transportation to post placards identifying the specific hazardous material, by name or number, and its specific dangers.\nIn order to identify the material, it is helpful to have binoculars on hand. Binoculars allow you to view the scene from a safe distance. If you do not see a placard but suspect a HAZMAT is present, try to get information before you approach the scene. Do not approach a HAZMAT scene unless you are trained to do so and have appropriate PPE such as a self-contained breathing apparatus (SCBA) and chemical protective suit.\nIf you find clues that there may be HAZMATs on the scene:\uf0a7\tNotify dispatch so that the appropriate personnel may be brought to the scene.\n\uf0a7\tDo not approach the scene.\n\uf0a7\tRemain uphill and upwind a safe distance from the scene (Table 6-1).\n\uf0a7\tAwait specialized resources.\nFor more information on HAZMAT emergencies, including training and guides that are available, refer to Chapter 29.",
        "Violence": "Violence can take place in a wide variety of settings, but certain factors make it much more likely to occur. These include scenes of domestic violence, fights in bars, gang fights, street fights, potential suicide, or any situation where angry bystanders or family members are present. At scenes where there has been arguing, fighting or threats, the potential for violence is increased. Look for anything that indicates violence has taken place, such as broken glass, overturned furniture, weapons, or alcohol or drug use. The risk of violence may be increased in situations where there is yelling, swearing, threatening, pacing, or when a person is using clenched fists or throwing objects. There may be other signs of tension, for example an awkward silence in a situation where you expect a lot of activity and noise. You may also discover a history of aggressive behavior, which increases the risk of violence.\nThere are times when restraining a patient may be necessary, to ensure the safety of the patient, yourself and bystanders. Restraint should be used as a last resort, however, and must be carried out only after consultation with law enforcement and medical direction. Use only as much force as is necessary to restrain the patient, and always follow local protocols. Always keep your personal safety in mind when restraining patients. For further information on the use of restraint, refer to Chapter 5.\nIf you arrive at the scene of violence or a crime, do not try to reach any patient until you are sure the scene is safe. Someone who has been shot, stabbed or sustained other injuries from violence may have severe injuries but, until the scene is safe there is nothing you can do to provide care. For the scene to be safe, law enforcement personnel must make it secure. Wait for law enforcement to arrive and secure the scene before attempting to provide care unless you are part of a team working under specific protocols with responding law enforcement agencies. Police usually gather evidence at a crime scene, so do not touch anything except what you must to provide care. Once law enforcement secures the crime scene and allows you to enter to provide care, make sure that they are aware of your presence and actions. Always have and use appropriate PPE",
        "CRITICAL FACTS 5": "Once you have sized up the scene and determined the mechanism of injury or nature of illness, you will be able to decide what additional resources are needed to keep you and the patient safe or to provide care. The number of resources will depend on any hazards at the scene, the number of injured or ill persons, as well as the nature of injuries or illnesses.",
        "Responding to Specific Emergency Situations - Hazardous materials": "Hazardous materials: If you suspect hazardous materials, stay a safe distance away, upwind and uphill. Do not create sparks. Notify dispatch immediately.",
        "Responding to Specific Emergency Situations - Motor-vehicle crashes": "Do not attempt a rescue until wreckage has been stabilized.",
        "Domestic Violence": "Domestic violence situations are among the most potentially dangerous scenes you may encounter as an emergency medical responder (EMR). Domestic violence crosses all boundaries, affecting people of all ages, races, education, socioeconomic classes and sexual orientations. However, there are certain circumstances that may indicate that domestic violence may be a factor. Any of the following conditions should lead you to suspect domestic violence and respond accordingly: \u2022 The injured person will not admit to being abused. \u2022 The injuries sustained do not fit the history, and the patient seems to be ashamed or embarrassed about the injuries. \u2022 You observe injuries that involve contusions and lacerations of the face, head, neck, breasts and abdomen. \u2022 The suspected perpetrator of the violence is unwilling to allow the injured person to give a history or be alone with emergency medical services (EMS) personnel. \u2022 There are excessive delays between the injury and seeking treatment. \u2022 The patient repeatedly uses EMS services. \u2022 The injuries occur during pregnancy. \u2022 Substance abuse is involved. \u2022 There are frequent suicide gestures. Law enforcement agencies generally send two officers to answer domestic disturbances, to reduce the potential of danger. EMRs should take a similar approach to domestic disturbances, with heightened awareness to all possible clues. For example, the calling party denies calling EMS personnel when you arrive at the door. This may be a clue that should lead you to suspect potential danger and heighten your awareness when responding to the scene. If law enforcement has not been called, call them right away and do not approach until the police arrive and secure the scene. Your personal safety always outweighs the need to respond. Once inside, your awareness must continue. While the police may have already secured the scene, it is appropriate for you to do so also; visually check everyone for weapons. Determine who is in the residence and where they are. Once identified, any bystanders should be asked to leave. Do not allow residents to get between you and an exit route, and do not let yourself be backed into a corner. Know where your team members are at all times and ensure that they are equally aware of what else is going on. Look at body cues such as clenched fists, flared nostrils and flushed cheeks. If there are weapons present, ask law enforcement to intervene. Remember that while you were originally called to help, your presence, along with that of law enforcement, may change the dynamics of the scene. Stay calm. Take your time and take nothing for granted. Assume control of the situation slowly. Introduce yourself, speaking directly to the patient. Explain what you are doing. Ask open-ended questions, allowing the patient to talk. Restore control to the patient. Do not be judgmental. If you can, separate yourself and the patient from the suspected perpetrator.",
        "PUTTING IT ALL TOGETHER": "Use the information you received from the dispatcher to begin your planning, but remember that it may be inaccurate or outdated. Make sure you have whatever protective equipment you will need available. Your first priority is your own safety, so look first for any hazards that might put you at risk. After your own safety, your next priority is to keep patients and bystanders safe. This may mean redirecting traffic or preventing people from intruding on the scene. In some cases, it may mean moving the patient. A safe scene may change to a dangerous one quickly. As you care for the patient, be aware of your surroundings and be prepared to take any necessary steps to ensure your safety. Analyze the scene to determine the number and locations of patients and also the MOI or nature of illness. Then create a plan to provide appropriate care. If your assessment tells you that you will need help, call the appropriate personnel before beginning to provide care for the patient.",
        "Dealing with Hazards at the Scene": "In addition to the specific emergency situations already discussed, other hazardous scenes require special consideration (Table 6-2). Remember to always expect the unexpected and make sure the scene is safe before entering. If it is not, notify the necessary agencies to do what is necessary to provide you with a safe working environment.",
        "Dealing with Hazards at the Scene - Traffic": "Traffic is often the most common danger you and other emergency personnel will encounter. If you drive to a collision scene, always try to park where your vehicle will not block other emergency vehicle traffic, such as an ambulance that needs to reach the scene. The only time you should park in a roadway or block traffic is:\n\uf0a7 To protect an injured person.\n\uf0a7 To protect any responders, including yourself.\n\uf0a7 To warn oncoming traffic, if the situation is not clearly visible.\nOthers can help you put reflectors, traffic cones, flares or lights along the road. These items should be placed well back from the scene to enable oncoming motorists to stop or slow down in time.",
        "Fire": "Any fire can be dangerous. Make sure the local fire department has been summoned. Only firefighters, who are highly trained and properly equipped against fire and smoke, should approach a fire. Do not let others approach. Gather information to help the responding fire and EMS units. Find out the possible number of people trapped, their location, the fire\u2019s cause, and whether any explosives or chemicals are present. Give this information to emergency personnel when they arrive. If you are not trained to fight fires or lack the necessary equipment, follow these basic guidelines:\n\uf0a7\tDo not approach a burning vehicle.\n\uf0a7\tNever enter a burning or smoke-filled building. If you are in a building that is on fire, always check doors before opening them with the back of your hand. If a door is hot to the touch, do not open it. \uf0a7 Avoid smoke and fumes by staying close to the floor. \uf0a7 Never use an elevator in a building that may be burning.",
        "Downed Electrical Lines": "Downed electrical lines also present a major hazard to responders. Always look for downed wires at a scene, and always treat them as dangerous. If you find downed wires, follow these guidelines: \uf0a7 Move the crowd back from the danger zone. The safe area should be established at a point twice the length of the span of the wire (i.e., the distance between the poles). \uf0a7 Never attempt to move downed wires. \uf0a7 Notify the fire department and the power company immediately. Always assume that downed wires are energized, or live. Even if they are not energized at first, they may become energized later. \uf0a7 If downed wires are in contact with a vehicle, do not touch the vehicle and do not let others touch it. Tell anyone in the vehicle to stay still and stay inside the vehicle. Never attempt to remove people from a vehicle with downed wires across it, no matter how seriously injured they may seem. \uf0a7 Do not touch any metal fence, metal structure or body of water in contact with a downed wire. Wait for the power company to shut off the power source.",
        "Water and Ice": "Water and ice also can be serious hazards. To help a conscious person in the water, always follow the basic rule of \u201creach, throw, row then go.\u201d You may reach out to someone in trouble with a branch, a pole or even your hand, being careful not to be pulled into the water. When the person grasps the object, lean back and pull the person to safety. If you cannot reach the person, try to throw the person something nearby that floats. If you have a rope available, attach an object that floats to one end, such as a life jacket, plastic jug, ice chest or empty gas can. Never enter a body of water to rescue someone unless you have been trained in water rescue, and then only as a last resort. If possible, you can use a boat to get closer (row), but not close enough that the patient can grab the side of the boat and tip it. The \u201cgo\u201d part of this technique is only for those who can perform deep-water rescue. Fast-moving water is extremely dangerous and often occurs with floods, hurricanes and low head dams. Ice is also treacherous. It can break under your weight, and the cold water beneath can quickly overcome even the best swimmers. Never enter fast-moving water or venture out on ice unless you are trained in this type of rescue. Such rescues require careful planning and proper equipment. Wait until trained personnel arrive.",
        "Unsafe Structures": "Buildings and other structures, such as mines, wells and unreinforced trenches, can become unsafe because of fire, explosions, natural disasters, deterioration or other causes. An unsafe building or structure is one in which: \uf0a7 The air may contain debris or hazardous gases. \uf0a7 There is a possibility of being trapped or injured by collapsed walls, weakened floors and other debris. Try to establish the exact or probable location of anyone in the structure. Gather as much information as you can, call for appropriate help and wait for the arrival of personnel who are properly trained and equipped.",
        "Natural Disasters": "Natural disasters include tornadoes, hurricanes, earthquakes, forest fires and floods. Rescue efforts after a natural disaster are usually coordinated by local resources until they become overwhelmed. Then the rescue efforts are coordinated by a government agency such as the local, regional or state emergency management agency. If the disaster is large enough or a federal disaster is declared, it may be coordinated with the assistance of the Federal Emergency Management Agency (FEMA). Typically, you first would report to the incident commander or the individual they designate to be in charge at the scene, then work with the disaster response team and follow the rescue plan. Natural disasters pose more risks than you might realize. Often, more injuries and deaths result from electricity, HAZMATs, rising water and other dangers than from the disaster itself. When responding to a natural disaster, be sure to carefully size up the scene, avoid obvious hazards and use caution when operating rescue equipment. Never use gasoline-powered equipment, such as chain saws, generators and pumps, in confined spaces.",
        "Hostile Situations": "Environmental factors, such as HAZMATs, electricity and unsafe structures, are not the only dangers you may encounter. You may sometimes encounter a hostile patient or family member. Any unusual or hostile behavior, including rage, may be a result of the emergency, injury, illness or fear. Many patients are afraid of losing control and may show this as anger. Hostile behavior also may result from the use of alcohol or other drugs, lack of oxygen or an underlying medical condition. If a patient needing care is hostile toward you, try to calmly explain who you are and that you are there to help. Remember that you cannot provide care without the patient\u2019s consent. If the person accepts your offer to help, keep talking as you assess the patient\u2019s condition. When the patient realizes you are not a threat, the hostility usually goes away. If the patient refuses your care or threatens you, withdraw from the scene. Never try to restrain, argue with or force care on a patient. If the patient does not let you provide care, wait for more advanced medical personnel to arrive. Sometimes a close friend or a family member will be able to reassure a hostile patient and convince the patient to accept your care. However, family members or friends who are angry or hysterical can make your job more difficult. Sometimes they may not allow you to provide care. At other times, they may try to move the patient before they have been stabilized. A terrified parent may cling to a child and refuse to let you help. When family members act this way, they often feel confused, guilty and frightened. Be understanding and explain the care you are providing. By remaining calm and professional, you will help calm them. Hostile crowds are a threat that can develop when you least expect it. As a rule, you cannot reason with a hostile crowd. If you decide the crowd at a scene is hostile, wait at a safe distance until law enforcement and additional EMS personnel arrive. Approach the scene only when police officers declare it safe and ask you to help. Never approach a hostile crowd unless you are trained in crowd management and supported by other trained personnel.",
        "Suicide": "Never enter a suicide scene unless police have made it secure. If the person is obviously dead, be careful not to touch anything at the scene such as a weapon, medicine bottle, suicide note or other evidence. If the scene is safe and the person is still alive, provide emergency care as needed. Concentrate on your care for the patient and leave the rest to law enforcement personnel. Never approach an armed suicidal person unless you are a law enforcement officer trained in crisis intervention. Approach only if you have been summoned to provide care once the scene has been secured. If you happen to be on the scene when an unarmed individual threatens suicide, try to reassure and calm the person. Make sure that appropriate personnel have been notified. You cannot physically restrain a suicidal person without medical or legal authorization. Listen to the person and try to keep the person talking until help arrives. Try to be understanding. Do not dare the person to act, or trivialize the person\u2019s feelings. Unless your personal safety is threatened, never leave a suicidal person alone.",
        "Hostage Situation": "If you encounter a hostage situation, your first priority is to not become a hostage yourself. Do not approach the scene unless you are specially trained to handle these situations. Assess the scene from a safe distance and call for law enforcement personnel. A police officer trained in hostage negotiations should take charge. Try to get any information from bystanders that may help law enforcement personnel. Ask about the number of hostages, any weapons seen and other possible hazards. Report any information to the first law enforcement official on the scene. Remain at a safe distance until law enforcement personnel summon you."
    },
    {
        "KEY TERMS": "All-hazards approach: An approach to disaster readiness that involves the capability of responding to any type of disaster with a range of equipment and resources., Asymptomatic: A situation in which a patient has no symptoms., Atropine: An anticholinergic drug with multiple effects; used in antidotes to counteract the effects of nerve agents and to counter the effects of organophosphate poisoning., Bioterrorism: The deliberate release of agents typically found in nature, such as viruses, bacteria and other pathogens, to cause illness or death in people, animals or plants., Blast lung: The most common fatal primary blast injury, describing damage to the lungs caused by the over-pressurization wave from high-order explosives., B NICE: An acronym for the five main types of terrorist weapons: biological contamination, nuclear detonation, incendiary fires, toxic chemical release and conventional explosions., CBRNE: The current acronym used by the Department of Homeland Security to describe the main types of weapons of mass destruction: chemical, biological, radiological/nuclear and explosive., DuoDote\u2122: A kit with pre-measured doses of antidote used to counteract the effects of nerve agents., High-order explosives (HE): Explosives such as TNT, nitroglycerin, etc., that produce a defining supersonic over-pressurization shockwave., Incendiary weapons: Devices designed to burn at extremely high temperatures, such as napalm and white phosphorus; mostly designed to be used against equipment, though some (e.g., napalm) are designed to be used against people., Low-order explosives (LE): Explosives such as pipe bombs, gunpowder, etc., that create a subsonic explosion., Morbidity: Illness; effects of a condition or disease., Mortality: Death due to a certain condition or disease., Nerve agents: Toxic chemical warfare agents that interrupt the chemical function of nerves., Pralidoxime chloride (Protopam Chloride; 2-PAM Cl): A drug contained in antidote kits used to counteract the effects of nerve agents; commonly called 2-PAM chloride., Primary effects: The effects of the impact of the over-pressurization wave from high-order explosives on body surfaces., Secondary effects: The impact of flying debris and bomb fragments against any body part., Tertiary effects: The results of individuals being thrown by the blast wind caused by explosive and incendiary devices; can involve any body part., WMD: Weapons of mass destruction.",
        "INTRODUCTION": "The reality of potential terrorist attacks has grown progressively since the Oklahoma City bombing in 1995, but nothing has ever shown more powerfully or more poignantly how quickly a terrorist attack can take place, and how devastating its effects, than the September 11, 2001, attacks on the World Trade Center and the Pentagon. Terrorism is not a new phenomenon. The United States has witnessed a number of acts of terrorism over the years: the 1993 World Trade Center bombing; the 1998 bombings of U.S. embassies in several East African countries; the USS Cole suicide bombing in 2000 in Yemen; the Boston Marathon bombing in 2013; and the attacks in San Bernardino (2015), the Orlando nightclub (2016) and the Fort Lauderdale airport (2017), to name a few. Not all disasters that have affected U.S. citizens were caused by terrorists. Some of the more destructive are natural disasters, such as hurricanes, floods, earthquakes, wildland fires and tornadoes. Disasters can also be the result of outbreaks of communicable diseases/pandemics or contamination of food or water supply. Biological disasters can result from naturally occurring outbreaks or because of bioterrorism. With the growing threat of natural, biological and human-caused disasters, the knowledge of how to deal with such tragedies is just as important to responders as any other rescue call you may receive. The goal of this chapter is to ensure you are able to deal successfully with such events through careful preparation, ensuring safety for yourself and others, and understanding the nature of and appropriate response to disasters.",
        "PREPARING FOR DISASTERS AND TERRORIST INCIDENTS": "Preparedness for disasters and terrorist incidents involves many different agencies working together in a coordinated effort, to meet a common goal. This is true at the local level, with police, fire, emergency medical services (EMS) personnel, public health, transportation and other town or county agencies; it is also true of organizations at the regional, federal and private levels. The organizational structure and roles each of these agencies plays in disaster response are ultimately coordinated at the federal level by the Federal Emergency Management Agency (FEMA). FEMA coordinates the response to and recovery from disasters in the United States when the disaster is large enough to overwhelm local and state resources. FEMA also works collaboratively with other organizations such as state and local emergency management agencies and federal agencies and emergency response organizations such as the American Red Cross. In 2008, FEMA developed and introduced the National Response Framework (NRF), which guides all organizations involved in disaster management on how to respond to disasters and emergencies. The NRF identifies the National Disaster Medical System (NDMS) as the system to augment the nation\u2019s medical response capabilities. The NDMS is a system that supports federal agencies in managing and coordinating medical response to major emergencies and disasters. One responsibility of the NDMS is to oversee several different types of disaster medical teams, including Disaster Medical Assistance Teams (DMATs). DMATs are groups of professional and paraprofessional medical as well as administrative and logistical personnel who provide medical care during a disaster.",
        "CRITICAL FACTS": "Preparedness for disasters and terrorist incidents involves many different agencies working together in a coordinated effort to meet a common goal. In 2008, FEMA introduced the NRF, which guides all disaster management organizations in proper response. The NDMS is the system that augments the nation\u2019s medical response capabilities.",
        "CRITICAL FACTS 2": "NIMS is a comprehensive national framework for managing incidents. It outlines the structures for response activities for command and management. NIMS provides a consistent, nationwide response.",
        "Warning Systems and Disaster Communications Systems": "During a disaster, one of the most critical aspects of response is the capability to communicate information about the disaster to the public. The Emergency Alert System (EAS) is a nationwide public warning system to alert and warn the public. It requires all broadcasters (cable television systems, wireless cable systems, satellite radio services, etc.) to direct the communications to the president, so that the president is able to address the American public during a national emergency. State and local authorities may also use the system for critical emergency information such as America\u2019s Missing: Broadcast Emergency Response (AMBER) alerts and weather information targeted to a specific area. Once the president has been informed, as well as other officials at the federal, state and local levels, the public is made aware of the disaster: The EAS is administered by the Department of Homeland Security (DHS) through the Federal Emergency Management Agency (FEMA) and the National Oceanic and Atmospheric Administration\u2019s National Weather Service (NWS). It is regulated through the Federal Communications Commission (FCC). Once communications reach those authorized in the federal government, national alerts and warnings to the public are communicated through the EAS to state and local governments, so that emergency management officials can alert the public at the local level and mobilize the necessary responding agencies",
        "INCIDENT MANAGEMENT": "The National Incident Management System (NIMS) is a comprehensive national framework for managing incidents. It outlines the structures for response activities for command and management. NIMS provides a consistent, nationwide response at all levels: federal, state, tribal and local governments; the private sector; and nongovernmental organizations (NGOs). With this structure, agencies at all levels can work together in a consistent manner, to respond to incidents of any type or size. NIMS provides a core set of common concepts, principles, terminology and technologies in these areas: \uf0a7 Incident command system (ICS) \uf0a7 Multiagency coordination system (MACS) \uf0a7 Unified command \uf0a7 Training \uf0a7 Identification and management of resources \uf0a7 Mutual aid and assistance \uf0a7 Situational awareness \uf0a7 Qualifications and certification \uf0a7 Collection, tracking and reporting of incident information \uf0a7 Crisis action planning \uf0a7 Exercises One of these components, the ICS, is a management system that allows effective incident management by bringing together facilities, equipment, personnel, procedures and communications within a single organizational structure, so that everyone involved in a disaster has an understanding of their roles and is able to respond effectively and efficiently: This system is used by all levels of government, as well as many NGOs and private organizations. Incident command is structured in five main functional areas: \uf0a7 Command \uf0a7 Operations \uf0a7 Planning \uf0a7 Logistics \uf0a7 Finance/administration Among other roles within the ICS is the incident commander, who is responsible for all activities including resources and operations at the incident site: The incident commander also delegates duties to other responding staff. (See Chapter 30 for further information about the ICS.) All emergency medical responders (EMRs) are required by Homeland Security Presidential Directive-5 (HSPD-5) to complete specific ICS training. For more information, please visit training.fema.gov/IS/crslist.asp.",
        "Emergency Support Functions (ESFs)": "Also within the structure of NIMS are 16 emergency support functions (ESFs), mechanisms for grouping the functions most frequently used to provide emergency management support during emergency/disaster incidents and planned events. Additional ESFs may be part of the Communities Comprehensive Emergency Management Plan that could include Animal Services, Special/Functional Needs, Damage Assessment, as well as Business and Industry. Following is a list of the ESFs:",
        "ESF #1\u2014Transportation": "Aviation/airspace management and control; transportation safety; restoration/recovery of transportation infrastructure; movement restrictions; damage and impact assessment",
        "ESF #2\u2014Communications": "Coordination with telecommunications and information technology industries; restoration and repair of telecommunications infrastructure; protection, restoration and sustainment of national cyber and information technology resources; oversight of communications within the federal incident management and response structures",
        "ESF #3\u2014Public Works and Engineering": "Infrastructure protection and emergency repair; infrastructure restoration; engineering services and construction management; emergency contracting support for lifesaving and life-sustaining services including water supplies",
        "ESF #4\u2014Firefighting": "Coordination of federal firefighting activities; support to wildland, rural and urban firefighting operations",
        "ESF #5\u2014Emergency Management Information and Planning": "Coordination of incident management and response efforts; issuance of mission assignments; resource and human capital; incident action planning; financial management",
        "ESF #6\u2014Mass Care, Emergency Assistance, Housing and Human Services": "Mass care; emergency assistance; disaster housing; human services",
        "ESF #7\u2014Logistics Management and Resource Support": "Comprehensive, national incident logistics planning, management and sustainment capability; resource support (facility space, office equipment and supplies, contracting services, etc.)",
        "ESF #8\u2014Public Health and Medical Services": "Public health; medical; mental health services; mass fatality management",
        "ESF #9\u2014Search and Rescue": "Lifesaving assistance; search and rescue operations",
        "ESF #10\u2014Hazardous Materials Response": "Hazardous materials (chemical, biological, radiological, etc.) response; environmental short- and long-term cleanup",
        "ESF #11\u2014Agriculture and Natural Resources": "Nutrition assistance; animal and plant disease and pest response; food safety and security; natural and cultural resources and historic properties protection and restoration; safety and well-being of household pets",
        "ESF #12\u2014Energy": "Energy infrastructure assessment, repair and restoration; energy industry utilities coordination; energy forecast",
        "ESF #13\u2014Public Safety and Security": "Facility and resource security; security planning and technical resource assistance; public safety and security support; support for access, traffic and crowd control",
        "ESF #14\u2014Long-Term Community Recovery": "Social and economic community impact assessment; long-term community recovery assistance to states, local governments and the private sector; analysis and review of mitigation program implementation",
        "ESF #15\u2014External Affairs": "Emergency public information and protective action guidance; media and community relations; congressional and international affairs; tribal and insular affairs",
        "ESF #16\u2014Law Enforcement": "Establishment of procedures for the command, control and coordination of all state and local law enforcement personnel and equipment to support impacted local law enforcement agencies",
        "EMR Support": "EMRs typically are supported by ESF #8 (Public Health and Medical Services) but may also coordinate with ESFs #4 and #9 (Firefighting and Search and Rescue), depending on the complexity",
        "CRITICAL FACTS 3": "If you are the first responder on the scene of a disaster, you may be called upon to assume a leadership role. If someone else has assumed this role, it is your responsibility to assist the leader or assume another role. It may be triaging patients, providing medical care, providing patient reception at staging facilities or preparing patients for evacuation.",
        "THE ROLE OF THE EMERGENCY MEDICAL RESPONDER": "At the scene of a disaster, if you are the first responder on the scene, you may be called upon to assume a leadership role. If someone else has assumed this role, it is your responsibility to assist the leader or assume another role, usually in triaging patients, providing medical care, providing patient reception at staging facilities or preparing patients for evacuation. Upon arriving on the scene, assess for scene hazards, the number of patients, patient priorities, the need for extrication, the number of ambulances or other transport vehicles needed, and any other factors that affect the scene, as well as the need for resources and where to stage those resources. Radio your report with a request for any additional resources needed and then set up functions to accommodate resources as they arrive, including staging, supply, extrication, triage, treatment, transportation and rehab.",
        "Mutual Aid": "Mutual aid is a formal agreement among emergency responders to lend assistance across the various jurisdictions of public services such as fire departments, EMS operations and law enforcement during an emergency situation or disaster that exceeds local resources. Aid must be requested. The following general information must be supplied by the requesting community: \u2022 A description of the personnel, equipment and other resources required \u2022 The estimated length of time resources may be required \u2022 The areas of experience, training and abilities of the personnel, and the capabilities of the equipment to be furnished. The person, service or agency receiving the request must then let the community in which the disaster took place know the estimated time when assistance can arrive at the designated location, as well as the names of the people designated as supervisory personnel. The following rules will apply during the rescue efforts: \u2022 The personnel and equipment of the assisting team are under the direction and control of the requesting community while at the disaster site. \u2022 Emergency personnel continue under the command and control of their regular leaders, but the organizational units come under the operational control of the emergency services authorities of the community receiving assistance. The receiving party is responsible for informing the responding party when their services will no longer be required. \u2022 All equipment and personnel provided by the assisting team while at the site of an emergency remain under the control and direction of its own designated representative, who can remove any or all equipment or personnel from the site at any time the representative deems it appropriate. \u2022 An assisting team\u2019s priority lies with its own jurisdiction, and the team must continue to offer reasonable protection and services. Therefore, the assisting team has the right to withdraw any and all aid provided, after giving the disaster area notification of the need to do so.",
        "DISASTER RESPONSE": "Responding to a disaster call may prove to be the most challenging and mentally stressful scene you ever attend. Every incident is different, and it is impossible to cover all of the specific steps and considerations for a specific scene. You will need to be prepared to address various issues and precautions simultaneously. The types of disasters you may respond to are varied, but fall into three main categories: natural disasters, human-caused disasters and biological disasters.",
        "Natural Disasters": "The devastating effects of natural disasters have been felt worldwide. Damage caused by earthquakes, hurricanes/tropical storms, landslides, thunderstorms, tsunamis, winter storms, tornadoes, heat waves, floods, wildfires and volcanic eruptions can leave entire communities completely incapacitated, with large numbers of people seriously injured. Massive infrastructure damage may occur, resulting in entire communities seeking shelter, food and other assistance.",
        "Human-Caused Disasters": "Human-caused disasters include terrorist attacks using chemical, biological, radiological/nuclear and explosive weapons; fire (residential or environmental); hazardous material (HAZMAT) incidents; as well as large-scale multiple-casualty incidents (MCIs) such as transportation mishaps.",
        "Biological Disasters": "Biological disasters are not just the creative writing of science fiction. One need only look back at the flu epidemic of 1918 to be reminded of how real they are. In that epidemic, as many as 600,000 Americans lost their lives, as did some 40 million people worldwide. We have a lot more knowledge about dealing with a biological disaster today, but as we are warned by the World Health Organization, other epidemics such as the avian flu or the next flu pandemic could be only months away. Outbreaks of communicable diseases/pandemics, as well as contamination of food or water supply by pathogens, are all very real possibilities. In addition to the threat of naturally occurring outbreaks, biological disasters can also be the result of bioterrorism.",
        "EMS Operations During Terrorist Attacks, Public Health Emergencies, WMD Incidents and Disaster Events": "In any kind of large-scale disaster, it is important to use an all-hazards approach , which means being prepared with the equipment and resources needed to respond to many different types of disasters. Regardless of the type of disaster, until you are aware of the specific hazards involved, distance yourself from the scene and only approach when it is safe to do so. Continue to monitor the scene, as there may be secondary explosions, for example, or traps meant to injure and possibly kill responders. If you are arriving on the scene of an armed attack, communicate immediately with law enforcement. Initiate incident command or, if it has already been initiated, expand as assigned and communicate your findings to the ICS. Within the ICS, the necessary emergency services are called and responsibility for different sections can be assigned to the appropriate personnel as they arrive. Establish a perimeter around the area in order to protect yourself and other responders as well as the public from injury. If you are at the scene of a terrorist incident, establish an escape plan and a mobilization point. Designate the role of incident safety officer and assess command post security.",
        "Evacuations": "In the case where a disaster has been predicted, such as a wildland fire, hurricane or flood, steps must be taken to evacuate a community. Local and state emergency management offices have the authority to order and implement evacuations. The keys to a successful evacuation are communication and organization to avoid panic and the possibility of injury to people and property. Therefore, alerts regarding the evacuation must be made often and with clarity to residents who are affected by the need to leave their homes. There may be some who will not believe the level of danger the impending disaster may have on them or their property, and who may wish to remain in their homes. This reaction is normal, but it is imperative to maintain communication with these people and convince them of the level of danger they will face if they remain. Evacuation warnings should communicate the following points: \u2022 The nature of the disaster and the estimated time until it will impact the area \u2022 The level of devastation the disaster is expected to cause, to help convince people to leave \u2022 The routes assigned as safe for their evacuation \u2022 The appropriate destinations where food, shelter and water are available All possible means of communication should be used, including Mass Notification Systems, Reverse 9-1-1, radio, television, loudspeakers and public address systems in buildings, etc. Again, the sense of urgency and clarity are the deciding factors for whether people choose to flee or not.",
        "CRITICAL FACTS 4": "In any kind of large-scale disaster, it is important to use an all-hazards approach, which means being prepared with the equipment and resources needed to respond to many different types of disasters.",
        "WMD (CHEMICAL, BIOLOGICAL, RADIOLOGICAL/NUCLEAR AND EXPLOSIVE INCIDENTS)": "Terrorism has been around for many years, yet the threat of terrorism is something increasingly on the minds of Americans in recent years. The FBI defines terrorism according to the U.S. Code of Federal Regulations (CFR): Terrorism includes the unlawful use of force and violence against persons or property to intimidate or coerce a government, the civilian population, or any segment thereof, in furtherance of political or social objectives.\u201d While these terrible crimes seem senseless, the terrorists who commit them have specific goals they are trying to achieve. They seek to incite fear, confusion and panic, as well as to inflict destruction on both physical and political infrastructure, and through these actions cause intimidation to those in authority and others. Terrorists may be motivated to inflict such destruction and fear for different reasons, including political and religious beliefs, environmental causes, racial bias or a desire for revenge. When terrorists strike, their most likely weapons of choice are guns and explosives, as these are relatively inexpensive, easy to obtain and use, and easy to transport. Less often, they may turn to weapons of mass destruction (WMD), which, by their nature, cause widespread fear and destruction. EMRs need to be aware of public reaction when faced with WMD. While this type of weapon is used less frequently, their power lies in their ability to inflict significant fear and panic. These weapons are commonly classified by the acronym CBRNE: \uf0a7 Chemical \uf0a7 Biological \uf0a7 Radiological/ Nuclear \uf0a7 Explosives This terminology is used by the Department of Homeland Security and understood internationally. Another system of classifying WMD is B NICE, which stands for biological, nuclear, incendiary, chemical and explosive. This system of classification is similar to CBRNE, but it includes incendiary weapons (e.g., napalm, magnesium, phosphorous, etc.) as a separate type, whereas these devices are included under the term \u201cexplosives\u201d under CBRNE. The terms are, in general, used interchangeably.",
        "Chemical Weapons": "A chemical emergency occurs when a hazardous chemical has been released and the release has the potential for harming people\u2019s health. In the case of a terrorist attack, the chemicals are released with the deliberate purpose of causing harm. Chemical agents are difficult to turn into weapons, as they disperse easily in open environments. This can reduce their destructive power. However, the public perceives chemical weapons as highly effective, thus terrorists achieve their goal. The other major characteristic of chemical agents is that they affect the body quickly, with symptoms often appearing immediately, which is different from the impact of biological or nuclear agents, which may not occur until days after the event.",
        "CRITICAL FACTS 6": "The FBI defines terrorism as \u201cthe unlawful use of force and violence against persons or property to intimidate or coerce a government, the civilian population or any segment thereof, in furtherance of political or social objectives.\u201d There are four classifications of WMD: chemical, biological, radiological/nuclear and explosives. The common acronym for these classifications is CBRNE.",
        "Chemical Weapons - Providing Care": "Steps to provide care for patients exposed to chemical weapons vary according to the type of chemical. This is one of the great challenges in responding to a chemical incident; symptoms are not always obvious, and identifying the substance is not always possible. If you are unable to identify the chemical, prepare yourself for the worst-case possibilities concerning toxicity when selecting personal protective equipment (PPE) and decontamination procedures. Assess the patient for traditional challenges such as airway and circulation concerns, and check for obvious symptoms such as neuromuscular, dermatological and vascular findings. If necessary, maintain spinal motion restriction and apply a cervical collar. Administer supplemental oxygen based on local protocols, and assist ventilation with a bag-valve-mask (BVM) resuscitator if necessary. Prior to transportation, report the patient\u2019s condition, treatment and estimated time of arrival to the base station and receiving medical facility. If a chemical has been ingested, have several towels and open plastic bags ready to quickly clean up and isolate the patient\u2019s toxic vomit. Consult with the base station physician or regional Poison Control Center for advice regarding triage of multiple patients. Asymptomatic patients who are discharged should be advised to seek medical care promptly if symptoms develop. Chemical agents can be categorized into five types: nerve agents, blister agents, blood agents, pulmonary agents and incapacitating agents.",
        "Chemical Weapons - Nerve Agents": "Nerve agents, such as tabun (GA) and methylphosphonothioic acid (VX), are particularly toxic chemical agents that disrupt the chemical recovery phase following a neuromuscular signal. Nerve agents are liquid when at normal temperatures but turn into a combination vapor/liquid when dispersed. They are usually odorless, although they may smell like fruit or fish. Symptoms vary depending on the dose. A strong dose can cause death within minutes, if inhaled or absorbed into the skin. Signs and symptoms include runny nose, watery eyes, twitching, pinpoint pupils, painful eyes, blurred vision, drooling, excessive sweating, coughing, weakness, drowsiness, headache, nausea, vomiting, abdominal pain, slow or fast heart rate, abnormally high or low blood pressure and more. Exposure causes irritation or severe damage to the eyes and respiratory tract, and may cause redness or severe blistering of the skin with larger doses. The blisters are similar to those caused by second-degree burns. These signs do not appear immediately but arise after several hours or a day, depending on the dose. When a patient has been exposed to a nerve agent, in general the priorities are to decontaminate, ventilate (expose to fresh air), administer antidotes, administer valium (to prevent seizures) and provide supportive therapy. Depending on the type of agent, different antidotes are available.",
        "Chemical Weapons - Blister Agents": "Blister agents, also called vesicants, include sulfur mustard (HD) and phosgene oxime (CX). These agents cause the skin and mucous membranes to form blisters on contact. Sulfur mustard can sometimes be detected by its odor of garlic, onions or horseradish, but it can be difficult to detect because the smell is faint. When exposed to sulfur mustard, either in liquid or vapor form, patients experience irritation or severe damage to the eyes and respiratory tract. Sulfur mustard may cause redness or severe blistering of the skin with larger doses. As with the blisters from nerve agents, these blisters resemble second-degree burns. Also, as with nerve agents, signs appear from several hours to a day after exposure, depending on the dose. If the patient has had a significant exposure, there may also be systemic effects that cause damage to bone marrow and the epithelial lining of the gastrointestinal (GI) tract. There are no known antidotes or treatments for exposure to blister agents; treatment of both the blisters and respiratory effects is supportive and nonspecific. Care includes decontamination by discarding contaminated clothing, and cleaning equipment with soap, water and diluted bleach (0.5\u20131.0 percent). Do not use bleach on patients.",
        "Chemical Weapons - Blood Agents": "Blood agents, such as cyanide, attack the body\u2019s cellular metabolism. They do not actually affect the blood, as was once thought, but disrupt cellular respiration. Cyanide can enter the body by being ingested, injected or inhaled, but not by being absorbed into the skin. Despite its devastating effects, if it dissipates into the air, it rapidly becomes harmless. Cyanide can be recognized by its odor of bitter almonds, though not everyone is able to detect it. Cyanide\u2019s effect of poisoning the cells prevents them from taking up oxygen, which in turn leads to asphyxia and cyanosis (blue tinge to the skin caused by a lack of oxygen). Cyanide is a quick-acting agent, and can cause death within 5 to 8 minutes if the exposure is severe. Treatment for cyanide poisoning is by antidote, using a Cyanokit\u00ae (hydroxocobalamin), sodium nitrite or sodium thiosulfate, all of which must be administered immediately and intravenously.",
        "Chemical Weapons - Pulmonary Agents": "Pulmonary agents include phosgene (CG), which causes lung injury by forming hydrochloric acid (HCl) when it contacts mucous membranes, thereby irritating and damaging lung tissue. When phosgene explodes, it turns into a colorless, watery vapor with a smell that has been described as that of new-mown hay. Signs and symptoms are severe illness and even death from pulmonary edema and acute respiratory distress syndrome. There is no specific antidote for phosgene. The only way to provide care is to remove the person from the agent and resuscitate. EMRs should take measures to protect themselves in a situation where phosgene may be present, by using a chemical protective mask with a charcoal canister.",
        "Chemical Weapons - Incapacitating Agents": "An incapacitating agent is defined by the Department of Defense (DOD) as \u201can agent that produces temporary physiological or mental effects, or both, which will render individuals incapable of concerted effort in the performance of their assigned duties\u201d (Source: University of Albany) . These agents, which include MACE, tear gas and pepper spray, contain a hallucinogenic agent, 3-quinuclidinyl benzilate, also referred to as BZ or QNB. They are usually nonlethal and generally not used by terrorists, but may be used, for example, by law enforcement authorities to control a violent crowd. The BZ may be dispersed as a fine aerosol or dissolved in dimethyl sulfoxide (DMSO) and absorbed into the skin. Effects may be delayed for 30 minutes to 24 hours. Effects are both peripheral (external) and systemic (throughout the body). Peripheral effects include pupil dilation, dry mouth and skin, and flushing of the skin, particularly the face and neck. Symptoms may appear similar to those seen in someone exposed to certain nerve agents and then treated with an excess of atropine . Systemic effects include disturbances to consciousness, delusions and hallucinations, impaired memory and poor judgment, disorientation and ataxia (uncoordinated gait or manner of walking). Overall, effects depend on the dose and may last for up to 4 days. Monitor the patient who has been incapacitated by one of these agents and take precautions to prevent yourself from being exposed.",
        "Biological Weapons": "Bioterrorism is the deliberate release of agents typically found in nature, such as viruses, bacteria or other pathogens (agents), for the purpose of causing illness, disease or death in people, animals or plants. Often these agents can be changed, increasing their potency and making them resistant to current medications, or even increasing their ability to be spread into the environment.",
        "Types of Biological Agents/Diseases": "Many diseases and biological agents have been determined to be a threat. These are categorized into three groups according to their level of threat, from highest to lowest: \uf0a7 Class A biological agents/diseases include anthrax, plague, smallpox, tularemia, viral hemorrhagic fevers (e.g., Ebola) and botulism. These agents and diseases pose the greatest threat to public health and national security, as they can be easily spread from person to person and result in high mortality (death) rates. \uf0a7 Class B biological agents/diseases include brucellosis, Q fever, glanders, alphaviruses, food pathogens (e.g., salmonella, Shigella, E. coli ), water pathogens (e.g., Vibrio cholerae and Cryptosporidium ), Ricin toxin, staphylococcal enterotoxin B and epsilon toxin of Clostridium perfringens . This class of agents and diseases poses a moderate level of risk, as they are moderately easy to spread and result in moderate morbidity (illness) rates and low mortality rates. \uf0a7 Class C biological agents/diseases are those considered to be emerging infectious diseases, such as hantavirus, Nipah virus, yellow fever, multidrug-resistant tuberculosis and tickborne viruses. These agents have the potential to be engineered for mass dissemination. They are easy to spread and have the potential for high mortality and morbidity rates. When a bioterrorism event has occurred, often there is a single suspected case of an uncommon disease or there are single or multiple suspected cases of a common disease or syndrome that do not respond to treatment as expected. Clusters of a similar illness may occur in the same timeframe in different locales. There may be unusual clinical, geographical, seasonal or temporal presentations of a disease and/or unusual transmission routes; an unexplained increase in the incidence of an endemic disease; or an unusual illness that affects a large, disparate population or is unusual for a population or age group. You may see an unusual pattern of illness or death among animals or humans, or a sudden increase in nonspecific illnesses such as pneumonia, bleeding disorders, unexplained rashes and mucosal or skin irritation (particularly in adults), neuromuscular symptoms (such as muscle weakness and paralysis) or diarrhea. For most of these diseases/agents, patients initially experience flu-like symptoms such as fever, aches and listlessness or fatigue.",
        "Biological Weapons - Providing Care": "While the early signs and symptoms may be similar for different diseases/agents, treatment will depend on the nature of the agent. For example, those caused by a virus cannot be treated with antibiotics, while those caused by a bacterium may be treated with antibiotics.Often, though, when these illnesses/diseases are caused by a terrorist act, you will not know the cause right away. While it is essential to take steps to recognize the specific agent, provide supportive care right away, including assessing the patient for traditional challenges such as airway and circulation concerns, and checking for obvious symptoms such as neuromuscular, dermatological and vascular findings. Once examined by a physician, the patient will likely be given specific antibiotics or antitoxins. Immunizations may also be given as a preventative measure for certain agents. Although most biological agents are not highly contagious, a few are, so it is essential to isolate the patient, protect yourself with the proper PPE, and use standard exposure control procedures including high efficiency particulate air (HEPA) filter mask and gloves.",
        "Radiological/Nuclear Weapons": "The effects of a nuclear weapon detonation depend on the yield and success of the detonation. For example, a poorly maintained or manufactured bomb might produce no explosion, yet still spread radioactive material. Or the device could have a partial nuclear detonation, which would have a much greater impact than, for example, the explosive that destroyed the Oklahoma City Federal Building in 1995. The detonation of a nuclear device, regardless of size, could prove catastrophic. A nuclear explosion has several damaging effects, caused by the air blast, heat, ionizing radiation, ground shock and secondary radiation. There are four types of radiation exposure. These include patients who: 1. Received a significant dose from an external source, including large radiation sources over a short period of time, or smaller radioactive sources over a long period of time. 2. Received internal contamination from inhalation and/or ingestion of radioactive material. 3. Have external contamination of the body surface and/or clothing by liquids or particles. 4. Were exposed through a combination of the above. In general, determining that someone has been exposed to radiation can be difficult. However, acute radiation syndrome follows a predictable pattern that unfolds over several days or weeks after substantial exposure or catastrophic events. Patients may present individually over a longer period of time after exposure to unknown radiation sources. Specific symptoms of concern, especially following a 2- to 3-week period with nausea and vomiting, are thermal burn-like skin lesions without documented heat exposure, a tendency to bleed.",
        "Radiological/Nuclear Weapons - Providing Care": "Assess and treat life-threatening injuries immediately. Move patients away from the hot zone (the area in which the most danger exists) using proper patient transfer techniques to prevent further injury. Stay within the controlled zone if contamination is suspected. Expose wounds and cover with sterile dressings, decontaminating open wounds as required. Patients should be monitored at the control line for possible contamination only after they are medically stable. Remove contaminated clothing only if removal can be accomplished without causing further injury. Contaminated patients who do not have life-threatening or serious injuries may be decontaminated on site, starting with the removal of their clothing. Do not remove patients from a backboard or other extrication device if one was used when packaging for transport. It is essential to use standard precautions to help prevent the spread of contamination from injured patients to yourself or other emergency personnel. Notify proper authorities and the hospital of all pertinent information about patients and the scene. Ask for any special instructions the hospital may have, such as using an entrance other than the routine emergency department entrance for the purposes of radiological contamination control.",
        "Explosives and Incendiary Weapons": "Traditional weapons and explosives still present a very real threat for use in terrorist attacks on the United States. As an EMR, understanding the unique types of injuries associated with explosives is imperative to ensure appropriate treatment and handling of patients at a blast site. There are two major types of explosives: \uf0a7 High-order explosives (HE) , e.g., TNT, C-4, Semtex, nitroglycerin, dynamite and ammonium nitrate fuel oil (ANFO), which produce a defining supersonic over-pressurization shock wave \uf0a7 Low-order explosives (LE) , including pipe bombs, gunpowder and most pure petroleum-based bombs such as Molotov cocktails or aircraft improvised as guided missiles, which create a subsonic explosion Blasts can also be caused by explosive and incendiary (fire) bombs, which are characterized based on their source. Manufactured weapons are military issued, mass produced and quality tested, and are exclusively HE. Improvised weapons are produced in small quantities, or use a device outside its intended purpose, such as converting a commercial aircraft into a guided missile. There are three basic mechanisms of blast injury: \uf0a7 Primary effects are unique to HE, and result from the impact of the over-pressurization wave on body surfaces. The most common injuries are to the lungs, GI tract, eyes, head and middle ear. \uf0a7 Secondary effects are caused by flying debris and bomb fragments; any body part may be affected. \uf0a7 Tertiary effects may occur from individuals being thrown by the blast wind, and also can involve any body part. Injury patterns will depend on whether you are dealing with HE or LE blasts as well as on the position of the body when the blast occurs. Patients who are standing or lying perpendicular to the blast will suffer greater injuries compared with those who are lying directly toward or away from the blast. Lung injuries include blast lung , the most common fatal primary blast injury. Blast lung is caused by the HE over-pressurization wave. Middle ear injury most commonly includes tympanic membrane (eardrum) perforation. Abdominal injuries include bowel perforation, hemorrhage, mesenteric shear injuries, solid organ lacerations and testicular rupture. Injuries to the head include concussion or mild traumatic brain injury (MTBI). Other injuries include air embolism, compartment syndrome, rhabdomyolysis (skeletal muscle tissue damage) and acute renal failure. Also consider the possibility of exposure to inhaled toxins and poisonings (e.g., carbon monoxide [CO], cyanide [CN], methemoglobin [MetHgb]) in both industrial and criminal explosions. Wounds can also be contaminated, as with tetanus.",
        "Explosives and Incendiary Weapons - Providing Care": "After performing a preliminary evaluation and establishing scene safety, EMRs should initiate rescues of severely injured and/or trapped patients, evacuate ambulatory patients, perform triage and treat life-threatening injuries. Leave fatalities and their surroundings undisturbed, and avoid disturbing areas not directly involved in rescue activities. Initiate documentation of the scene as soon as conditions permit. The site of a bomb blast is a crime scene and, as an EMR, although your primary responsibility is to rescue living people and provide treatment for life-threatening injuries, it is also important to preserve evidence and avoid disturbing areas not directly involved in the rescue activities, including those areas containing fatalities.",
        "RESPONSE TO A CBRNE WMD INCIDENT - Preparation": "Planning for a WMD incident involves several aspects of preparation, including medical direction, personal preparation, equipment, transportation and communications. Medical direction will be provided on a massive scale during a WMD incident. Your EMS system needs to include a larger number of care providers from within your region as well as medical control systems from different areas. Disrupted communications systems can make it difficult to activate and summon appropriate medical services; therefore, preparing emergency measures as standing orders is the most effective manner in which to activate a plan. This leaves communication channels available for scene updates, incoming patient reports and the essential communications required in extraordinary circumstances. In all WMD case scenarios, the massive numbers of responders involved could lead to scene confusion. It is imperative, especially in cases where interagency coordination is required, that all levels of support services define their respective roles and responsibilities at the scene and are managed by the ICS. Regional pre-planning, coordination and rehearsal are recommended in order to ensure all involved services are familiar with their roles and arrive at the scene prepared to perform those services without conflict or delay. Planning must include an assessment of hazards, exposure potential, respiratory protection needs, entry conditions, exit routes and decontamination strategies. The types of weapons used at a CBRNE incident: cover a broad spectrum of dangers, including the possibility of exposure to pathogens, chemicals and radiation. Because of this, it is important for EMRs to understand the threats at the scene and why it is critical to take proper precautions first. For example, it is critical to have necessary antidotes ready if there is a risk of exposure to nerve agents.",
        "RESPONSE TO A CBRNE WMD INCIDENT - Equipment and Supplies": "Inventory of equipment and supplies will vary depending on the type of WMD used in an attack. In order to be able to respond as quickly as possible with the appropriate equipment, medications and personnel, lists of locations of traditional storage areas must be kept and remain accessible to neighboring communities, to allow the dispatch center to quickly access the resources regionally, statewide or nationwide. In a large-scale incident, it is necessary to rely on other services to supply the proper equipment and, in most cases, knowledge, to CBRNE calls. Nerve agents require large amounts of certain drugs as well as ventilators. If you are called to the site of a chemical incident, you may require specialized PPE such as self-contained breathing apparatus (SCBA) or HAZMAT suits. If you are responding to the scene of a large explosion, you may require heavy rescue equipment, search and rescue units, devices for electronic detection and trained search dogs. The proper protocols and procedures regarding mutual assistance setups and the deployment of equipment must be followed in accordance with your community\u2019s plan.",
        "RESPONSE TO A CBRNE WMD INCIDENT - Arrival on Scene": "On-site incident management allows responders to work together as effectively as possible. As a responder, the responsibility for preparing the site for rescue efforts may fall on you. If you are among the first to arrive on the scene of a WMD incident, your speedy and accurate assessment of the scene and the actions you take to establish incident command as quickly and efficiently as possible are the most important steps you can take in saving lives and helping the injured. Your instincts as an EMR will be to help patients first. However, your scene size-up to measure the scope of the disaster, and the information you collect to identify the appropriate resources, are your first priorities. When approaching the scene, consider the time since the incident, your distance from it and any necessary shielding. Remember, EMRs may be targets, so you must be wary of potential secondary attacks. Provide an initial on-scene report to dispatch, with a description of the incident along with the need for specialized resources, initial actions taken, number of injured, and the nature and quantity of additional resources required. Look for outward signs and characteristics of terrorist incidents, such as mass casualties presenting with identical symptoms that have no identifiable cause. Attempt to identify the weapon used by looking for outward signs of the use of WMD, such as strange odors like bitter almond, peaches or fresh-cut grass. Consider the necessary protective actions according to the type of weapons: CBRNE. Determine the number of people involved and implement local protocols for mass casualty incidents as necessary. As part of your assessment, evaluate the need for additional resources. Evaluate and alter plans as necessary, including consideration of changing weather and a change to incidents occurring at the site such as secondary attacks or injuries to responders.",
        "Search and Rescue": "A variety of specialized services can be used when a search and rescue mission is required following a disaster. This may include building collapse, avalanche or ships lost at sea. Search and rescue capabilities include distress monitoring, communications, location of distressed personnel, coordination and execution of rescue operations including extrication or evacuation, along with the provisioning of medical assistance and civilian services through the use of public and private resources to assist persons and property in potential or actual distress. Emergency support function #9 (ESF #9) provides the following specialized search and rescue services during incidents or potential incidents requiring a coordinated federal response: \u2022 Structure Collapse (Urban) Search and Rescue (US&R) \u2022 Waterborne Search and Rescue \u2022 Inland/Wilderness Search and Rescue \u2022 Aeronautical Search and Rescue",
        "RESPONSE TO A CBRNE WMD INCIDENT - Scene Safety": "Identifying the weapon involved is a major part of responding to a WMD scene. Once you are aware of the hazards you are responding to, you can protect yourself, fellow responders and the public effectively. Approach the scene from upwind and uphill if chemical, biological or nuclear weapons are suspected. Avoid confined spaces where chemical or biological agents may be trapped due to poor ventilation. Be suspicious of a potential terrorist attack when called to a well-populated area, as these are typical targets for attacks. The possibility that secondary devices may have been planted at the scene is a real and serious threat to the teams responding to a CBRNE call. With this is mind, as with all calls, your own safety must be your top priority. Remain aware of the dangers to your health when you are entering a scene and while you are offering assistance to patients. Establishing what substances have been released, how and where, will help to best ascertain the proper PPE required, procedures to follow and the appropriate patient treatment. Unlike other EMS calls, if terrorists are involved, it is possible they will try to sabotage your efforts to respond. Therefore, hospital facilities must take security measures to limit the traffic in and out of the area, setting safe perimeters around the hospital and allowing access only to those with proper authorization. Secondary devices may be used by terrorists to keep EMRs from responding, making it advisable for all units and agencies involved to be familiar with and able to operate under the ICS. Ascertain the proper PPE needed to enter the scene, using an all-hazards safety approach. If you are approaching a patient who is suspected of having a communicable disease, make sure to use a HEPA or N95 mask, gloves, eye protection and gown for personal protection. This information must also be conveyed to the medical facility to which the patient is being transported, so that they may prepare for appropriate isolation.",
        "RESPONSE TO A CBRNE WMD INCIDENT - Providing Care": "As you provide care, make sure to keep patients informed of your actions and protect them from further harm. Be alert to specific signs and symptoms associated with the different types of weapons. Because of the potentially large numbers of patients who will need care in a short span of time, you may quickly be in a situation where the ratio of patients to providers is much higher than to which you are accustomed. In the case of mass casualties at a CBRNE scene, you may be faced with multiple scenarios. Each scenario, be it chemical, biological, radiation/nuclear or explosive, will require a different approach to treatment, potential for contamination and other considerations. Treating patients at such a scene is different from any other scene to which you may be called. Written protocols will address the signs and symptoms associated with each type of WMD and instruct you on the recommended treatment. You must understand the danger each presents and then follow the recommended precautions before entering the scene, as well as how to provide care during and following the response. You may find that the types of injuries and patients you encounter are similar in nature, due to the effects of the incident. Massive soft tissue wounds and burns are common injuries resulting from explosions or nuclear ignition. Medications may be required to treat patients who have been affected by chemical dispersal. You may also face unique patient care challenges you would not normally encounter in other emergency situations. For example, you may need to administer high-dose atropine for nerve agents. Also different from usual routines is that patients may remain in your care for much longer than you are used to, and you may need to address their overall needs (nutrition, hydration and personal hygiene). You may also find it especially difficult to attend to so many patients who are expected to die. While this may not be unusual for EMRs, the difference in the WMD situation is that you may be with patients longer and witness their conditions worsening to the point of death in front of you, without being able to do anything to prevent their deaths. When patients die, you also need to provide isolation and storage until other, living patients have been evacuated from the area. When carrying out triage, the concept of \u201cgreater good\u201d applies. This means that you must treat everyone according to their injury or illness, and not according to who they are; this includes terrorists or criminals.",
        "PROVIDING SELF-CARE AND PEER CARE FOR NERVE AGENTS - Poisoning by Nerve Agents": "Nerve agents are the most toxic of chemical agents and are hazardous in both their liquid and vapor states. They are potent enough to cause death within minutes after exposure. The clinical effects from nerve agent exposure are caused by excess acetylcholine, a chemical in the brain. The initial effects of exposure to a nerve agent depend on the dose and route. The routes include inhalation via gas, absorption through the skin, and ingestion from liquids or food. The dose and amount of exposure to the agent work together to cause varying effects.",
        "Nerve Agents\u2014Liquid": "Exposure to a small droplet of liquid on the skin may produce few physical findings, whereas a large amount causes effects within minutes. Sweating, blanching (whitening of the skin) and occasional muscle twitching at the site may be present soon after exposure of a small amount, but may no longer be present at the onset of GI effects. Signs of a large amount of exposure are the same as after vapor exposure, and these appear within minutes. Commonly there is an asymptomatic period of 1 to 30 minutes before symptoms appear, including loss of consciousness, seizure activity, apnea (periods when breathing stops) and muscular flaccidity (loss of tone). Effects can be delayed for as long as 18 hours after contact with small amounts, and are initially GI related and not life threatening. Generally, the longer symptoms are delayed, the less likely it is that effects from exposure are severe.",
        "Nerve Agents\u2014Vapor": "Effects from nerve agent vapor begin within seconds to several minutes after exposure. After exposure to a very low amount of vapor, miosis (constriction of the pupil of the eye) and other effects may not begin for several minutes, and miosis may not end for 15 to 30 minutes after the patient is removed from the vapor. Effects may continue to progress for a period of time, but usually not for more than a few minutes after exposure stops. The effects caused by a mild vapor exposure may be easily confused with an upper respiratory illness or even allergies. Miosis, if present, will help to distinguish these. Likewise, GI symptoms from another illness may be confused with those from nerve agent effects. When assessing someone who has been exposed to a nerve agent, several potential findings will help you deduce required treatment. Triage as \u201cimmediate\u201d if the patient is unconscious, convulsing, breathing with difficulty or has apnea, and is possibly flaccid. Consider a patient \u201cexpectant\u201d if the patient shows all of the above symptoms, but has no pulse or blood pressure and is therefore not expected to survive. Categorize as \u201cminimal\u201d a patient who is walking, talking, breathing and whose circulation is intact. Consider the person \u201cdelayed\u201d if further medical observation, large amounts of antidotes or artificial ventilation is required after triage.",
        "Poisoning by Nerve Agents - Providing Care": "Ventilation is required when patients demonstrate obvious symptoms. In this situation, remove secretions, maintain an open airway, use artificial ventilation if necessary and possible, and repeat atropine immediately as directed. The means of ventilation depends on the equipment available at the scene. As these patients generally experience bronchoconstriction and lots of secretions, expect high airway resistance (50 to 70 cm of water), which make initial ventilation difficult. Expect a noticeable decrease in resistance after atropine has been administered. Secretions may thicken with atropine and may make ventilation efforts difficult. If this occurs, frequent suctioning is required for up to 3 hours. Patients whose skin or clothing is contaminated with a liquid nerve agent can contaminate you by direct contact or through off-gasing vapor. Decontamination of the skin is not required after exposure to vapor alone, but clothing should be removed because it may contain \u201ctrapped\u201d vapor. Atropine and pralidoxime chloride (Protopam Chloride; 2-PAM Cl) are antidotes for nerve agent toxicity. Pralidoxime must be administered within a short time\u2014between minutes and a few hours following exposure (depending on the specific agent) to be effective. When the nerve agent has been ingested, exposure may continue for some time, due to slow absorption from the lower bowel, which can result in fatal relapses despite what appears to be an initial improvement. Continued medical monitoring and transport are mandatory for patients who have ingested a nerve agent. Decontamination is critical for skin exposure and should be done with standard decontamination procedures. Patient monitoring should be directed to the same signs and symptoms as with all nerve agent exposures. Keep a record of any medications used.",
        "Nerve Agent Antidote Auto-Injector Kit": "There is currently one main nerve agent antidote kit: the DuoDote\u2122. DuoDote\u2122 is an auto-injector that provides simple, accurate drug administration of a premeasured, controlled dose of medication used to relieve, counteract or reverse the effects of poisons or drugs such as nerve agents. In 2007, the U.S. Food and Drug Administration (FDA) approved DuoDote\u2122 for use by trained EMS personnel to treat civilians exposed to nerve agents. It contains both atropine and 2-PAM chloride in one auto-injector syringe. Atropine increases heart rate, dries secretions, decreases gastric upset and dilates pupils. 2-PAM chloride reverses some effects of nerve agent poisoning such as muscle twitching and difficulty breathing. If you or a peer show signs or symptoms that indicate the presence of nerve agent poisoning, and if you are authorized to do so by medical direction, administer a nerve agent auto-injector kit. If you self-administer the antidote and there is no improvement in 10 minutes, look for a fellow EMR or caregiver at the site to assist in evaluating your condition before further antidote is given. If you are severely ill (e.g., gasping respirations, twitching, etc.), a fellow caregiver should administer the antidote immediately. Always follow medical direction and the manufacturer\u2019s instructions for use of any nerve agent antidote auto-injector.",
        "Administration of DuoDote\u2122 Kit": "1. Tear open the plastic pouch at any of the notches. 2. Remove the DuoDote\u2122 Auto-Injector from the pouch. 3. Place the DuoDote\u2122 Auto-Injector in your writing hand. 4. Firmly grasp the center of the DuoDote\u2122 Auto-Injector with the green tip (needle end) pointing down. Do not touch the green end. 5. Pull off the gray safety release. 6. Quickly and firmly push the green tip straight down (at a 90-degree angle) against the mid-outer thigh. The DuoDote\u2122 Auto-Injector can inject through clothing, but pockets must be empty. 7. Continue to push firmly until you feel the DuoDote\u2122 Auto-Injector trigger. 8. Remove the DuoDote\u2122 Auto-Injector from the thigh and look at the green tip. If the needle is not visible, the injection has not been made. Check to be sure the gray safety release has been removed, and repeat from step 4. You must press hard enough to ensure that the injection has been made. 9. Push the needle against a hard surface to bend the needle back against the DuoDote\u2122 Auto-Injector. 10. Put the used DuoDote\u2122 Auto-Injector back into the plastic pouch. Keep the DuoDote\u2122 Auto-Injector with the patient.",
        "PUTTING IT ALL TOGETHER": "One of the most challenging roles for an EMR is to be called to respond to a disaster, whether an intentional one such as a terrorist attack, possibly using WMD, or a manmade disaster like a hurricane. The only way to respond to such catastrophic events is to be properly trained and prepared to respond. WMD can be divided into five major categories, collectively referred to as CBRNE: chemical, CRITICAL FACTSIf you or a peer show signs or symptoms that indicate the presence of nerve agent poisoning, and if you are authorized to do so by medical direction, administer a nerve agent auto-injector kit. biological, radiological/nuclear and explosive. Each of these types of weapons has unique characteristics in the nature of the damage it can inflict, the hazards with which they are associated, the signs and symptoms of exposure, and the specific care required to help people involved in the disaster. In any wide-scale disaster such as these, it is critical to be prepared with sufficient appropriately You Are the Emergency Medical Responder There is some question about the cause of the explosion, but police strongly suspect that it was a terrorist act using a WMD, most likely a high-order explosive. While waiting at the staging area, you notice a large trash bag near a dumpster in close proximity to staged apparatus. You should be alert for what other types of situations, and how would you react upon their discovery?trained personnel, equipment and supplies, communication systems and the appropriate protocols, so that all personnel know what to do. It is important to understand the nature of nerve agents, how they enter the body, and the signs and symptoms they produce. In the event of exposure to poisoning by a nerve agent, you may be required to provide self-care or care to a peer.",
        "Preparing for a Public Health Disaster\u2014Pandemic Flu": "Pandemic influenza (or pandemic flu) is virulent human influenza A virus that causes a global outbreak of serious illness in humans. As there is little natural immunity, the disease spreads easily and is sustainable from person to person. In situations where the fatality rate is higher than expected during a normal flu season, this type of influenza virus can seriously impact the nation, affecting and even halting its healthcare delivery system, transportation system, economy and social structure. As an EMR, your services are in high demand during a public health disaster. Yet you and your unit may be faced with some of the same challenges many businesses and organizations do during such times, such as increased employee absenteeism, disruption of supply chains, and increased rates of illness and death. Both 9-1-1 systems and EMS personnel are well integrated into the nation\u2019s pandemic influenza planning, and response is essential to the nation\u2019s health and safety in the event of a pandemic. The National Strategy for Pandemic Influenza identifies responsibilities for federal, state and local governments as well as nongovernmental organizations, businesses and individuals, and is built on three pillars: \uf0a7 Preparedness and communication: Acts taken before a pandemic to ensure preparedness, and the communication and coordination of roles and responsibilities to all levels of government, segments of society and individuals \uf0a7 Surveillance and detection: Domestic and international systems set up to detect the earliest warning possible to protect the population \uf0a7 Response and containment: Actions to limit the spread of the outbreak and to mitigate the health, social and economic impacts of a pandemic Both EMS and 9-1-1 system planning for pandemic influenza should be carried out in the context of the following phases of pandemic influenza identified by the World Health Organization (WHO) and the U.S. government: \uf0a7 Early detection \uf0a7 Treatment with antiviral medications \uf0a7 The use of infection control measures to prevent transmission \uf0a7 Vaccination Interventions used to help contain the spread of the virus include the following: \uf0a7 Treatment with influenza antiviral medications and isolation of all persons with confirmed or probable pandemic influenza \uf0a7 Voluntary home quarantine of members of households with confirmed or probable influenza case(s) \uf0a7 Dismissal of students from school and school-based activities, and closure of childcare programs, coupled with protecting children and teenagers through social distancing in the community \uf0a7 Use of social distancing measures to reduce contact between adults in the community and workplace, including cancellation of large public gatherings and alteration of workplace environments and schedules to offer a healthy workplace without disrupting essential services Disease surveillance plays an important role in pandemic influenza mitigation, and both EMS and 9-1-1 systems play a large part in maintaining and collecting patient information such as fever, reporting updated information on an emerging pathogen (e.g., during the SARS epidemic, questions pertaining to foreign travel were pertinent), and identifying probable signs and symptoms of an emerging viral strain.",
        "Personal Preparedness": "In a disaster or emergency situation, EMRs are likely to be concerned with the well-being of their own families and friends. It is important for their own reassurance, and for the purposes of educating the public, that responders understand how to prepare on an individual basis for disasters. The American Red Cross suggests three basic steps to prepare to respond to a disaster or life-threatening emergency: 1. Get a kit. 2. Make a plan. 3. Be informed.",
        "Personal Preparedness - Get a Kit": "When assembling or restocking your kit, store at least 3 days\u2019 worth of food, water and supplies in an easy-to-carry preparedness kit. Keep extra supplies on hand at home in case you cannot leave the affected area. Keep your kit where it is easily accessible. Remember to check your kit every 6 months and replace expired or outdated items. Whether you purchase an official Red Cross preparedness kit or assemble your own, you should include what you need to provide comfort for everyday scrapes or life-threatening emergencies. A standard preparedness kit should include water, food, medications, radio, first aid kit, personal documents, contact information, map, money, clothing, sanitary supplies, pet supplies and tools.",
        "Personal Preparedness - Make a Plan": "When preparing for a disaster, always talk with your family, plan, and learn how and when to turn off utilities and use lifesaving tools such as fire extinguishers. Tell everyone where emergency information and supplies are stored. Provide copies of the family\u2019s preparedness plan to each member of the family. Ensure that information is always up-to-date, and practice evacuations, following the routes outlined in your plan. Identify alternative routes and make sure to include pets in your evacuation plans. As an element of your preparedness plan, choose an out-of-area contact to call in case of an emergency. Tell all family and friends that this out-of-area contact is the person they should all phone to relay messages. Your contact should live far enough away that the person will not be affected by the disaster. You should also predetermine two meeting places, to save time and minimize confusion: 1) right outside your home, e.g., in cases such as a home fire; and 2) outside your neighborhood or town, for when you cannot return home or you must evacuate.",
        "Personal Preparedness - Be Informed": "In addition to preparing a kit and making a plan, you should also know different ways to get informed, including ways you and your family would get information during a disaster or emergency, learning about the disasters that may occur in your area by knowing your region and learning first aid. Visit the Red Cross website (redcross.org/get-help/how-to-prepare-for-emergencies) for information on how to prepare for emergencies."
    },
    {
        "INTRODUCTION": "As an emergency medical responder (EMR), you may find yourself involved in a situation in which there are chemical or other harmful or toxic substances. EMRs must be trained to quickly identify such situations and activate specially trained personnel to deal with them. The possibility of being involved in a hazardous material (HAZMAT) incident should be an everyday concern of all personnel involved in the emergency medical services (EMS) system. Most people think that a HAZMAT incident only involves train and truck crashes, but hazardous materials can also be found in the home, school, industry Cold zone: Also called the support zone, this area is the outer perimeter of the zones most directly affected by an emergency involving hazardous materials. Emergency Response Guidebook : A resource available from the U.S. Department of Transportation (DOT) to help identify hazardous materials and appropriate care for those exposed to them. Flammability: The degree to which a substance may ignite. Hazardous material (HAZMAT) incident: Any situation that deals with the unplanned release of hazardous material. Hot zone: Also called the exclusion zone, this is the area in which the most danger exists from a HAZMAT incident. Reactivity: The degree to which a substance may react when exposed to other substances. Safety Data Sheet (SDS): A sheet (provided by the manufacturer) that identifies the substance, physical properties and any associated hazards (e.g., fire, explosion and health hazards) for a given material, as well as emergency first aid; formerly called a Material Safety Data Sheet (MSDS). Shipping papers: Documents drivers must carry by law when transporting hazardous materials; list the names, possible associated dangers and four-digit identification numbers of the substances. Staging area: Location established where resources can be placed while awaiting tactical assignment. Toxicity: The degree to which a substance is poisonous or toxic. Warm zone: Also called the contamination reduction zone; the area immediately outside the hot zone.",
        "KEY TERMS": "Cold zone: Also called the support zone, this area is the outer perimeter of the zones most directly affected by an emergency involving hazardous materials., Emergency Response Guidebook: A resource available from the U.S. Department of Transportation (DOT) to help identify hazardous materials and appropriate care for those exposed to them., Flammability: The degree to which a substance may ignite., Hazardous material (HAZMAT) incident: Any situation that deals with the unplanned release of hazardous material., Hot zone: Also called the exclusion zone, this is the area in which the most danger exists from a HAZMAT incident., Reactivity: The degree to which a substance may react when exposed to other substances., Safety Data Sheet (SDS): A sheet (provided by the manufacturer) that identifies the substance, physical properties and any associated hazards (e.g., fire, explosion and health hazards) for a given material, as well as emergency first aid; formerly called a Material Safety Data Sheet (MSDS)., Shipping papers: Documents drivers must carry by law when transporting hazardous materials; list the names, possible associated dangers and four-digit identification numbers of the substances., Staging area: Location established where resources can be placed while awaiting tactical assignment., Toxicity: The degree to which a substance is poisonous or toxic., Warm zone: Also called the contamination reduction zone; the area immediately outside the hot zone.",
        "HAZARDOUS MATERIALS": "Hazardous materials are everywhere. A hazardous material (HAZMAT) is any chemical substance or material that can pose a threat to the health, safety and property of an individual. These materials are wastes, chemicals and other dangerous products, including explosives, poisonous gases, corrosives, radioactive materials, compressed gases. oxidizers, and flammable solids and liquids. For example, hospitals may have radioactive materials if they practice nuclear medicine. Farms and lawn and garden companies stock fertilizers, insecticides and pesticides. Various waste products from any number of manufacturers may also be considered toxic or hazardous. If you work as part of an EMS system, you should participate in a First Responder/Emergency Medical Responder Awareness Level Hazardous Materials training program. This program provides training in recognizing a HAZMAT incident and how to approach it safely. Terms you should familiarize yourself with when dealing with a HAZMAT incident include: \uf0a7 Flammability . The degree to which a substance may ignite. \uf0a7 HAZMAT. Any chemical substance or material that can pose a threat or risk to life, health, safety or property if not properly handled or contained.\uf0a7 Safety Data Sheets  (SDSs). Sheets (provided by the manufacturer) that identify the substance, physical properties and any associated hazards (e.g., fire, explosion and health hazards) for a given material, as well as emergency first aid. \uf0a7 Reactivity . The degree to which a substance may react when exposed to other substances. \uf0a7 Shipping papers . Documents drivers must carry by law when transporting hazardous materials; the papers list the names, associated dangers and four-digit identification numbers of the substances. \uf0a7 Staging area . The location established where resources can be placed while awaiting tactical assignment. \uf0a7 Toxicity . The degree to which a substance is poisonous or toxic.",
        "Identifying Hazardous Materials": "Resources In addition to Safety Data Sheets provided by manufacturers, the U.S. Department of Transportation (DOT) has several books available to help identify hazardous materials and appropriate care procedures. The Emergency Response Guidebook is one such reference book (Fig. 29-2). The guidebook is available in English and Spanish and can be downloaded to mobile devices for easy and quick access to information on handling hazardous materials. The Chemical Transportation Emergency Center (CHEMTREC) can provide further information and guidance on hazardous materials. The CHEMTREC 24-Hour HAZMAT Communications Center toll-free phone number is 800-424-9300. CAMEO\u00ae is an online library of more than 6000 data sheets containing response-related information and recommendations for hazardous materials that are commonly transported, used and/or stored in the United States. It is designed to plan for and respond to chemical emergencies and was developed by the Environmental Protection Agency\u2019s (EPA\u2019s) Office of Emergency Management (OEM) and the National Oceanic and Atmospheric Administration\u2019s (NOAA\u2019s) Office of Response and Restoration (OR&R). The National Institute for Occupational Safety and Health (NIOSH) is the federal agency responsible for conducting research and making recommendations for the prevention of work-related injury and illness. NIOSH provides free resources on various chemicals and also publishes a pocket guide to chemical hazards.",
        "Regulatory Requirements": "EMRs should review the Occupational Safety and Health Administration (OSHA) and EPA safety guidelines as well as the National Fire Protection Association (NFPA) HAZMAT requirements for EMS providers.",
        "Placards and Shipping Papers": "Placards, or signs, are required by federal law to be placed on any vehicles that contain specific quantities of hazardous materials. In addition, manufacturers and others associated with the production and distribution of these materials are required by law to display the appropriate placard. Placards often clearly identify the danger of the substance. Terms such as \u201cexplosive,\u201d \u201cflammable,\u201d \u201ccorrosive\u201d and \u201cradioactive\u201d are frequently used. Universally recognized symbols are also used. Shipping papers, also called manifests or waybills, are a means of identifying hazardous substances being transported from one location to another.",
        "HAZMAT INCIDENTS": "A hazardous material (HAZMAT) incident is any situation that deals with the release of hazardous material. When dealing with a HAZMAT incident, you work within a structured system that provides guidance in managing this type of scene.",
        "Preparing for a HAZMAT Incident and Activating the Plan": "Establishing command at a HAZMAT incident may be your responsibility as an EMR. The following steps should be taken in preparation for the worst-case scenarios developing at the scene:\n\uf0a7 Establish a clear chain of command.\n\uf0a7 A single command officer must be assigned to maintain control of the situation and to make decisions at every stage of the rescue. The rescue team must be aware of who is in command and when decision-making powers are transferred to another officer.\n\uf0a7 Establish a system of communication that is accessible and familiar to all responders.\n\uf0a7 Establish a receiving facility that is as close to the scene as possible, and that is able to receive and handle the number of patients and continued decontamination processes required.\nOnce the plan has been established, the EMR must stay in command until relieved by someone higher in the chain of command. The following information must be transferred to the new command officer:\n\uf0a7 Nature of the substance and problems\n\uf0a7 Identity of the hazardous materials\n\uf0a7 Kind of containers and their condition\n\uf0a7 Weather conditions, especially wind direction\n\uf0a7 Time since the emergency occurred\n\uf0a7 Stage of the rescue and what steps are already in place\n\uf0a7 Number of patients involved\n\uf0a7 Possibility of additional patients",
        "CRITICAL FACTS": "Indications of the presence of hazardous materials include placards; spilled, splattered or boiling materials; unusual odors; vapor clouds; and containers that are leaking, in deteriorating condition or are otherwise atypical.",
        "Recognizing a HAZMAT Incident": "When approaching any scene, you should be aware of dangers involving chemicals. Whether a motor-vehicle collision or an industrial emergency, you should be able to recognize clues that indicate the presence of hazardous materials. These include:\n\uf0a7 Signs (placards) on vehicles or storage facilities.\n\uf0a7 Spilled liquids or solids.\n\uf0a7 Unusual odors.\n\uf0a7 Clouds of vapor, including colored vapor.\n\uf0a7 Smoking or burning materials.\n\uf0a7 Boiling or spattering of materials.\n\uf0a7 Unusual condition of containers (e.g., unexpected peeling or deterioration).\n\uf0a7 Leaking containers with possible frost near the leak. Also, observe for clues of possible terrorism. In some cases, such as a nuclear attack or explosion, the possibility that a terrorist attack has taken place will be more obvious. However, when dealing with a chemical or biological attack, it may be more difficult to confirm your suspicions. There are some general clues you can use when approaching a disaster scene:\n\uf0a7 When called to an incident at well-populated areas such as airports, subways, government buildings, schools or large public gatherings, always use caution and suspect the possibility that terrorism exists.\n\uf0a7 When called to a scene where numerous patients are suffering from an unidentifiable illness, the possibility you are entering a potentially dangerous environment is also high.\n\uf0a7 When called to a scene where animals in the area are dead or appear incapacitated, the possibility of chemical exposure may exist. This includes the presence of odors resembling those of bitter almonds, peaches, mustard, freshly cut grass, garlic, or pungent or sweet odors.\nUnfortunately, in those cases where biological agents have been released, it is not always obvious there is danger. Pathogens can enter a person\u2019s system and not be evident until symptoms become evident, sometimes days after exposure. Often it becomes difficult to contain the spread of an outbreak, particularly through the community of caregivers who may be infected in the vicinity of the attack.\nWhen called to a HAZMAT incident, it may be your responsibility as an EMR to help lay the groundwork for the rescue scene. As a responder you should:\n\uf0a7 Be able to identify the unsafe materials and the scene as a HAZMAT incident.\n\uf0a7 Help establish or assign a safe location to position yourself and the rescue team.\n\uf0a7 Always approach a suspected or real HAZMAT incident from upwind and uphill.\n\uf0a7 Help establish the command and control zones as well as a medical treatment area.\n\uf0a7 Always ask yourself:\n yWhat has been done?\n yWhat is being done?\n yWhat actions need to be taken next?",
        "Identifying the Hazardous Substance": "Once a HAZMAT incident has been identified, and you are in a safe position, try to identify the hazardous substances and the seriousness of the incident. Look for placards; NFPA numbers; warning signs like \u201cflammable,\u201d \u201cexplosive,\u201d \u201ccorrosive\u201d or \u201cradioactive\u201d; shipping papers; or areas where materials or containers are held or stored. By law, any business holding materials considered hazardous must have permits to hold or contain those materials. Containers should be identified in order to assess the danger level of leaks or further contamination. Containers can include:\n\uf0a7 Rooms, buildings or outside areas.\n\uf0a7 Aboveground tanks and vats.\n\uf0a7 Individual containers, cartons and packages.\nAs already mentioned, placards will identify the exact substances in question. When dealing with a vehicular incident, shipping papers will be held by the driver as reference to the substances involved.\nWhen in doubt, remember that the Emergency Response Guidebook, CHEMTREC, CAMEO and NIOSH resources are available to you as well. The HAZMAT team ultimately will be responsible for identifying the substance, but in your role as an EMR you could be able to provide the initial identification. If arriving on the scene, collect the information and report to dispatch.\nCRITICAL FACTSStay away from a HAZMAT scene unless you are properly trained and have the proper equipment.",
        "SCENE SAFETY AND PERSONAL PROTECTIVE EQUIPMENT": "Unless you have received special training in handling hazardous materials and have the necessary equipment to do so without danger, you should stay well away from the area. While en route to a potential HAZMAT incident, obtain as much prearrival information as possible from dispatch. When on the scene, stay out of low areas where vapors and liquids may collect, and always stay upwind and uphill of the scene. Be alert for wind changes that could cause vapors to blow toward you and other responders. Do not attempt to be a hero. It is not uncommon for responding ambulance crews approaching the scene to recognize a HAZMAT placard and immediately move to a safe area and call for additional resources. Many fire departments have specially trained teams to handle incidents involving hazardous materials. While awaiting help, you may be tasked to keep people away from the danger zone. Especially in the case of radiation exposure, the following safety precautions must be taken to ensure scene safety: \uf0a7 From a distance, survey the area for the radiation symbol on vehicles, buildings or containers. \uf0a7 Determine the source of the radiation without moving closer to the scene. \uf0a7 Position your vehicle upwind and uphill of the leak. \uf0a7 Do not park near liquid spills or containers that may be cracked or leaking. \uf0a7 Be aware of the possibility of contamination from other substances. \uf0a7 When radiation is suspected, immediately don a positive-pressure self-contained breathing apparatus (SCBA) and protective clothing. Wear double gloves and two pairs of paper shoe covers under heavy rubber boots.\n\uf0a7 If radiation is suspected, do not attempt a rescue. Radiation cannot be felt, smelled or heard. EMRs could be exposed to lethal doses without any immediate signs or symptoms.\nFor your own personal protection consider:\n\uf0a7 The time you have been exposed to the radiation source.\n\uf0a7 The distance between you and the source.\n\uf0a7 The density of your protective clothing.\n\uf0a7 The amount of radioactive material you and the patient have been exposed to.\nWhenever possible, remove yourself and the patient from the contaminated area or the contaminated material from the patient. The longer the time, the closer the distance and the more materials you are exposed to, the worse the situation and the more protection you will require to decrease your risk of exposure.\nSome hazardous materials, such as natural gas, are flammable and can cause an explosion. Even turning on a light switch or using a telephone or radio may create a spark that sets off an explosion. When you call for additional resources, use a telephone or radio well away from the scene.\nIn certain situations, you may come across methamphetamine (meth) labs. Meth labs are very hazardous due to inhalation hazards and the possibility of absorption of dangerous compounds to all exposed. An even greater hazard is the instability and highly explosive nature of these labs. Meth labs can be set up in homes, trailers and even the trunks of cars. Even a small electrical spark, such as the flick of a light switch, near the types of compounds found in these locations could cause a significant explosion. Always use caution if you suspect that there might be a meth lab at the location you are attempting to access.",
        "Establishing Safety Zones": "To decrease the risk of the HAZMAT incident expanding, it is necessary to establish a safety zone. Three control zones are created in these situations, including:\n\uf0a7 The hot zone or exclusion zone. This is the area in which the most danger exists. Entry is only allowed with the proper PPE. The only reason to be inside the hot zone is for rescue, treatment for any conditions that are life threatening and initial decontamination.\n\uf0a7 The warm zone or contamination reduction zone. This is the area immediately outside the hot zone. PPE is necessary here as well. This is where complete decontamination of the patient takes place. The purpose of this zone is for lifesaving emergency care\u2014for example, airway management and immobilization.\n\uf0a7 The cold zone or support zone. This the outer perimeter; entry into this area is not permitted unless all contaminated PPE and equipment are removed.",
        "CRITICAL FACTS 3": "If you must work near a radiation source, think about your personal protection as well as your patient\u2019s. Consider how much time you have spent near the source, the distance between you and the source, the density of your PPE, and the amount of radioactive material you and the patient are exposed to.\nIn HAZMAT situations, three control zones are designated, from most to least dangerous: hot, warm and cold. Entry into these zones is established by the amount of training a responder or member of the rescue team has completed. The warm and hot zones can only be entered by those who have received OSHA Hazardous Waste Operations and Emergency Response (HAZWOPER) training at the first responder awareness level and who are dressed in appropriate PPE and SCBA.",
        "Contamination and Routes of Exposure": "A patient may have suffered from contamination via several possible routes, including topical (through the skin), respiratory (inhaled), gastrointestinal (ingested) or parenteral (intramuscular [IM], intravenous [IV] or subcutaneous [sub-Q]). Potential signs and symptoms for each are as follows: \uf0a7 Cardiovascular: Abnormally rapid heart rhythms, specifically in the lower chambers of the heart (ventricular arrhythmias), including rapid or irregular heartbeats. Both are life threatening. Blood pressure lower than 90/60 mmHg (hypotension). \uf0a7 Respiratory: Swelling and/or fluid accumulation in the lungs (acute pulmonary edema) or larynx (laryngeal edema), which can lead to impaired gas exchange and respiratory failure. Abnormal contraction of the smooth muscle of the bronchi, causing an acute narrowing and obstruction of the respiratory airway (bronchospasm) or a high-pitched, whistling breathing caused by a blockage in the throat or larynx (stridor), cough, dyspnea and chest pain. Respiratory symptoms may be delayed. \uf0a7 Central nervous system: Stupor, lethargy, coma and the possibility of seizures. \uf0a7 Gastrointestinal (GI): GI bleeding due to liquefaction necrosis (irreversible death of cells) of the GI tract. \uf0a7 Eye: Vapor contamination can result in chemical conjunctivitis. Necrosis and blindness can result from exposure to liquids and anhydrous (ammonia) gas.",
        "HAZMAT\u2014Recognition, Identification and Determination": "Hazardous materials are often present at incident sites and in emergency settings. An EMR who is first on scene to a possible hazardous materials spill should follow these three steps: recognition, identification and determination. The first and most basic issue is recognition of the presence of a hazardous material. Prompt recognition and awareness of hazardous materials is very important to the safety of the public and for the safety of the responders. Contact dispatch and report specific details of the scene. Once the presence of a hazardous material has been determined, its specific identity and characteristics can be established. This is known as identification. The EMR should relay information regarding placard colors and numbers, and any label information. Shipping papers that include SDSs will also help to identify the hazardous material(s). Determination of the extent of involvement a hazardous material plays in an incident is necessary to determine if it is responsible for injuries or damage at the scene of the incident. Often, hazardous materials may be present but pose no immediate, serious threat. It cannot be overemphasized that until it has been determined that hazardous materials are not responsible for injuries or damage at an incident, EMRs should take every precaution to protect themselves and the public from exposure.",
        "Decontamination": "There are several methods of decontamination, including gross, dilution, absorption, neutralization and isolation/disposal. Initial or \u201cgross\u201d decontamination is performed as the person enters the warm zone. Any immediate life-threatening conditions are addressed during this stage. Soap and copious amounts of water are used, and any clothing, equipment and tools must be left in the hot zone. At this point, a primary assessment is carried out. Dilution refers to the method of reducing the concentration of a contaminant to a safe level. Isolation/disposal refers to the method of decontamination in which contaminated equipment and materials are bagged or covered and set aside, usually for subsequent shipment to an approved landfill for disposal. Absorption is the process of using material that will absorb and hold contaminants such as corrosive and liquid chemicals. Neutralization involves chemically altering a substance to render it harmless or make it less harmful.",
        "CRITICAL FACTS 4": "Possible routes of exposure and contamination include topical, respiratory, gastrointestinal and parenteral. Methods of decontamination include gross, dilution, absorption, neutralization and isolation/disposal. When assessing and treating a patient in a HAZMAT incident, it is important to concentrate on the life-threatening signs and symptoms as opposed to strictly dealing with the contamination and exposure itself.",
        "Emergency Medical Treatment - Establishing a Location": "Establishing a clear perimeter between zones is of critical importance to prevent the spread of contamination. When selecting the location for the command post and staging area, it is necessary to position support equipment upwind and uphill of the hot zone. Equipment that may be required during the rescue process should be kept in the staging areas beyond the crowd control line. Access to the different zones must be safely controlled, limiting access as much as possible.",
        "Emergency Medical Treatment - Providing Care": "When you arrive at the scene, park upwind and uphill from the scene at a safe distance. Keep bystanders and any other unnecessary people away from the scene. Isolate the scene and establish hot, warm and cold zones, keeping people out of areas accordingly. Do not enter these zones unless you are trained to an OSHA HAZWOPER first responder awareness level or higher, and you have appropriate PPE and SCBA. Avoid any contact with the hazardous material. If there is no risk to EMS personnel, HAZMAT teams should move patients to a safe zone. Determine the number of patients involved in the incident and evaluate the need for additional resources. Follow safety practices that minimize your exposure and that of other people at the scene. When assessing and treating a patient in a HAZMAT incident, it is important to concentrate on the life-threatening signs and symptoms as opposed to strictly dealing with the contamination and exposure itself. Removing the patient from a scene involving hazardous materials should be done as quickly as possible to decrease exposure. Assessment and management of the patient should then be carried out as you would normally. When radiation is a concern, contact the national Poison Help line at 800-222-1222 or consult with medical direction.",
        "PUTTING IT ALL TOGETHER": "Hazardous materials are everywhere around us and there is always a possibility of a HAZMAT incident. As an EMR, you may find yourself involved in a situation in which there are chemical or other harmful or toxic substances. EMRs must be trained to quickly identify such situations and activate specially trained personnel to deal with the situation."
    },
    {
        "KEY TERMS": "Air medical transport: A type of transport to a medical facility or between medical facilities by helicopter or fixed-wing aircraft., Audible warning devices: Devices in an emergency vehicle to warn oncoming and side traffic of the vehicle\u2019s approach; includes both sirens and air horns., Emergency medical dispatcher (EMD): A telecommunicator who has received special training for triaging a request for medical service and allocating appropriate resources to the scene of an incident, and for providing prearrival medical instructions to patients or bystanders before more advanced medical personnel arrive., Jump kit: A bag or box containing equipment used by the emergency medical responder (EMR) when responding to a medical emergency; includes items such as resuscitation masks and airway adjuncts, disposable latex-free gloves, blood pressure cuffs and bandages., Landing zone (LZ): A term from military jargon used to describe any area where an aircraft, such as an air medical helicopter, can land safely., Packaging: The process of getting a patient ready to be transferred safely from the scene to an ambulance or a helicopter., Transferring: The responsibility of transporting a patient to an ambulance, as well as transferring information about the patient and incident to advanced medical personnel who take over care., Trauma alert criteria: An assessment system used by emergency medical services (EMS) providers to rapidly identify those patients determined to have sustained severe injuries that warrant immediate evacuation for specialized medical treatment; based on several factors including status of airway, breathing and circulation, as well as Glasgow Coma Scale score, certain types of injuries present and the patient\u2019s age; separate criteria for pediatric and adult patients., Visual warning devices: Warning lights in an emergency vehicle that, used together with audible warning devices, alert other drivers of the vehicle\u2019s approach.",
        "INTRODUCTION": "In earlier chapters, you learned how to care for persons who are injured or ill. Although these skills are important for emergency medical responders (EMRs) to learn, certain nonmedical operational skills are just as important. In this chapter, you will learn about emergency medical services (EMS) support and operations, including the phases of an ambulance or other transport vehicle call and air medical response. As an EMR, you may never be involved in all of these situations but, as a functioning part of the EMS system, you should have a brief overview of some of the aspects of out-of-hospital care.",
        "ROLES OF THE EMR IN THE EMS SYSTEM": "The term EMR can mean different things to different people. In general, EMRs are individuals who have been trained to provide a minimum standard of care according to the current national scope of practice and EMS educational standards. While EMRs may function as regular members of an ambulance crew in some states, in other states and areas they have other roles. There are also several types of EMRs, ranging from those who stabilize and transport patients to those who can provide prehospital medical care in the field, but do not transport.",
        "Traditional EMRs": "When we talk about traditional EMRs, we generally refer to people who function within the 9-1-1 system. These traditional EMRs are usually affiliated with a service, such as EMS systems, law enforcement, fire rescue, search and rescue or sometimes lifeguarding and ski patrol. Another area in emergency medical response is hazardous material (HAZMAT) or hazardous waste operations and emergency response (HAZWOPER).",
        "Nontraditional EMRs": "Nontraditional EMRs have had the same training as traditional EMRs but work in less traditional settings. These people include athletic trainers, park rangers, trip leaders and others. You also find these EMRs working as members of industrial medical emergency response teams (MERTs), or those involved in rope rescue, specialized trench rescue or confined space rescue. Any EMR, traditional or nontraditional, should be familiar with the EMS system and their role in it.",
        "PHASES OF A RESPONSE": "A typical EMS response has nine phases. They are: 1. Preparation for an emergency call. 2. Dispatch. 3. En route to the scene. 4. Arrival at the scene and patient contact. 5. Transferring the patient to the ambulance. 6. En route to the receiving facility. 7. Arrival at the receiving facility. 8. Clear medical facility. 9. Available for next emergency call.",
        "Phase 1: Preparation for an Emergency Call": "To be ready to respond to a scene, it is important to spend time preparing yourself, your equipment and your vehicle. As an EMR, you have a responsibility to keep yourself physically fit and mentally prepared for the challenges of responding to an emergency. Part of preparing for the call involves the initial training you receive as an EMR. It is important to remember that the end of your EMR training is the beginning of having a duty to respond to emergencies. You have a responsibility to continue your training through refresher, national competency and continuing education programs. Some EMRs take more advanced training to become emergency medical technicians (EMTs) and then perhaps advanced emergency medical technicians (AEMTs) or paramedics. In preparing to respond to an emergency, you should have basic medical equipment on hand. Jump kits come in a variety of sizes and shapes and are commercially available. The contents may be regulated by a certifying agency or by your unit. In either case, be familiar with the contents and layout of the jump kits used by your unit or organization. In some areas, EMRs work in a system in which they may be involved in transporting the patient to the receiving facility. If this is the case, the EMR will have to prepare and inspect the ambulance or transport vehicle before every shift. Local EMS systems and state regulations determine what equipment and supplies must be in the vehicle, and any vehicle safety and readiness inspections required. In other areas or circumstances, EMRs may be the only emergency personnel responding to a scene. You should review state and local policies, rules and regulations regarding the minimum staffing requirements in your area.",
        "CRITICAL FACTS": "A typical EMS response has nine phases, from preparation for an emergency call to availability for the next emergency call.",
        "Phase 2: Dispatch": "In many areas of the country, a communications center/public safety answering point (PSAP) has a central access number such as 9-1-1 for ambulance, police or fire rescue personnel. Specially trained personnel, known as emergency medical dispatchers (EMDs), often staff these communications centers and are available on a 24-hour basis. They assist by obtaining the caller\u2019s location and information critical to dispatching the appropriate personnel and equipment. They are specially trained to help the caller care for patients until emergency personnel arrive. During the call, the EMD will ask the caller specific questions that will determine the appropriate emergency personnel to dispatch. The EMD will ask the nature of the emergency and the mechanism of injury (MOI) or nature of illness. The EMD will ask for the caller\u2019s name, location and call-back number. Additional information, such as the exact location of the patient (e.g., second floor, back apartment), number of patients and the severity of the injuries, can be relayed to those responding to the emergency after the initial dispatch has been issued. Also, the EMD will obtain information from the caller relating to unusual situations, conditions or problems at the scene. This will ensure that the appropriate personnel arrive at the scene as quickly and safely as possible. In cases of possible cardiac arrest, the EMD will ask if an automated external defibrillator (AED) is available and being used. A call taker is used by most communications centers that handle many calls. The call taker processes the information from the caller and provides the EMD information. The information is then transferred to the dispatcher, who transmits the data to the appropriate units. The call taker stays on the phone, providing prearrival information and gathering further information as the situation unfolds. Environments in which a call taker and dispatcher perform identical functions include rural areas or a communications center with a minimal call load.",
        "Phase 3: En Route to the Scene": "To help a patient, you must be able to reach the scene safely. The most important skill to use at this time is common sense. Walk with purpose\u2014do not run\u2014to any emergency scene or your vehicle. Pacing yourself allows you to think clearly, survey the area and plan for arrival at the scene. It also reduces the risk of injuries from tripping and falling. If you are in a vehicle, whether a personal or emergency vehicle, you must always use a safety belt. Some areas require all personnel working in the EMS system to attend an emergency vehicle operator-training program. If you function in an EMS system that requires response in a private vehicle, become aware of the state and local laws and regulations that govern operation of private vehicles as emergency vehicles in that area. In all cases, when responding to an emergency, EMRs should use appropriate driving behavior, including consideration for the safety of others. Emergency response to the scene does not exempt any emergency personnel from traffic laws. The driver must know the traffic laws that govern the use of lights, sirens and intersection procedures.",
        "Phase 4: Arrival at the Scene and Patient Contact": "In this phase of response, you should be slow and cautious in your approach. If you have access to the appropriate communications equipment, notify the EMD of your arrival. As you enter the area, size up the scene and the situation. If the scene is not safe, notify dispatch to send personnel from the agencies necessary to make it safe. Never endanger your life or the life of anyone else responding or already at the scene. When approaching the scene, follow standard precautions before making any contact with the patient. Use disposable latex-free gloves, gown, mask and protective eyewear when appropriate. Be sure to ask yourself critical questions. Is the scene safe? Are there any hazards to the responders or the patients? Look up, look down and look all around. What was the MOI or nature of illness? Is there any severe, life-threatening bleeding? How many patients are there? Do you need any additional help? Safety issues may necessitate assistance from law enforcement with crowd control. Assess as much as possible from inside your vehicle. Ensure your vehicle can leave the scene quickly if needed. For example, have your vehicle pointing toward the exit of a dead-end street, so you do not waste time leaving a dangerous situation. There may be local protocols for when you should leave your vehicle given certain circumstances. If protocols indicate you should wait for law enforcement personnel to arrive, do not exit the vehicle before their arrival. After the scene size-up has been completed, primary, secondary and ongoing patient assessments will begin. Additionally, history taking, including baseline vital signs and initial care, will be provided to stabilize the patient(s) prior to transport.",
        "Phase 5: Transferring the Patient to the Ambulance": "Though transport is not a traditional role for an EMR, at times you may be part of the ambulance crew or be asked to help transfer a patient to the ambulance. By the time the ambulance arrives, you may have completed the primary assessment, the physical exam, the patient\u2019s history and begun care. You may have recorded the vital signs and started packaging the patient for transfer. Packaging refers to getting the patient ready for transport, and moving the patient onto the stretcher to support the patient during transport. Transferring the patient means more than moving the patient to the ambulance. You also have a responsibility to transfer information about the patient and the incident to more advanced medical personnel who take over care.",
        "Phase 6: En Route to the Receiving Facility": "Once the patient is loaded into the ambulance, all personnel should wear safety belts or safety restraints. The communications center is notified, and the crew member in charge of caring for the patient determines whether the trip to the receiving facility will be fast, at a normal speed or slow. The transport crew members provide ongoing medical care and psychological support for the patient until arrival at the hospital. They may ask additional questions, document the history and care of the patient, and continue to monitor vital signs. As soon as possible, the transport crew notifies the receiving facility about the patient and the expected time of arrival. The receiving facility is informed if there are any changes in the patient\u2019s status or condition. The driver may have to adjust the driving speed to meet what the crew member in charge says about the patient\u2019s needs.",
        "Phase 7: Arrival at the Receiving Facility": "During this phase, transport crew members transfer the patient to the care of the nurses and physicians at the receiving facility. Crew members never leave patients unattended during a call or during the transfer of care. At the hospital, crew members give information about the scene and the patient. They also complete whatever documentation is necessary to meet local and state standards and their organization\u2019s protocols. If necessary, crew members begin some of the post-run responsibilities such as exchanging or restocking medical supplies. The cleaning of the ambulance is also performed during this phase. Personnel should wear disposable latex-free gloves and follow local procedures for disposal of soiled linen and supplies. The ambulance stretcher should be cleaned and made ready for the next call. Members of the crew should wash their hands thoroughly after every response.",
        "Phases 8 and 9: Clear Medical Facility and Available for Next Emergency Call": "When returning to the station (phase 8), the operator of the vehicle should notify the communications center. During the ride back to the station, personnel should take the opportunity to review details of the run and discuss how things could have been done differently or more efficiently. The ride back provides opportunities for crew members to air concerns or diffuse any stress that may have developed during the response. Doing these things helps the crew to prepare physically and emotionally for the next response. In the last phase of response (phase 9), the emergency vehicle should be refueled if necessary and any repairs or adjustments should be made. Fuel tanks should never be allowed to get below half full. If necessary, restock any disposable items in the vehicle\u2019s medical supplies. Reports and any unfinished paperwork should be completed, and the communications center should be notified that the unit is back in service and ready for another call. Always follow local procedures established by your service or organization. Once back at the station, crew members should also prepare themselves for the next response. Preparation may include removing and laundering contaminated clothing as soon as possible. Uniforms or clothing soiled with the patient\u2019s blood or OPIM should not be taken home to be laundered; they should be laundered by a laundry service that deals with contaminated clothing or as specified in the organization\u2019s protocols.",
        "AIR MEDICAL TRANSPORT CONSIDERATIONS": "In certain situations, it is sometimes best for the patient to be transported to the receiving medical facility by helicopter. This type of transport enables severely injured or ill persons to be transported quickly to specialty centers and large treatment facilities. Geography and other circumstances play a large role in this type of transport decision, and emergency personnel should follow local and state protocols.",
        "CRITICAL FACTS 3": "Helicopters can be the best transportation choice when dealing with severely injured or ill persons who need quick transport to specialty centers or large treatment facilities. Geography and circumstances play a role in the decision, and local and state protocols should always be followed.",
        "When to Request Air Medical Transport": "In most situations where air medical transport is requested, it is needed because one or more patients is in critical condition. During air medical operations you must always keep the safety of everyone present the top priority. Trauma alerts and air medical transport may be required for a number of different MOIs and natures of illness. Specific trauma alert criteria vary from state to state and are driven by local protocols. Also, the Centers for Disease Control and Prevention (CDC) has published national guidelines for field triage of trauma patients that should be used as part of the decision-making process. The guidelines call for patients to be transported to the highest level of care within the system. These include patients who fit at least one of the criterion in each of the following two areas:\n\uf0a7 Vital signs and level of consciousness:\n yGlasgow Coma Scale \u2264 13\n ySystolic blood pressure of < 90 mmHg\n yRespiratory rate of < 10 or > 29 breaths per minute (< 20 in infants aged < 1 year) or a need for ventilatory support\n\uf0a7 Anatomic:\n yAll penetrating injuries to the head, neck, torso and extremities proximal to the elbow or knee\n yChest wall instability or deformity (e.g., flail chest). Two or more proximal long-bone fractures\nyCrushed, de-gloved, mangled or pulseless extremity\nyAmputation proximal to the wrist or ankle\nyPelvic fractures\nyOpen or depressed skull fractures\nyParalysis\nPatients who fit one of the following MOI criteria should be transported to a trauma center, but it need not be the highest level of care:\n\uf0a7 Falls:\nyAdults: > 20 feet (one story = 10 feet)\nyChildren: > 10 feet or two to three times the height of the child\n\uf0a7 High-risk motor-vehicle crash:\nyIntrusion, including roof: > 12 inches occupant site; > 18 inches any site\nyEjection (partial or complete) from motor vehicle\nyDeath in the same passenger compartment\nyVehicle telemetry data consistent with a high risk for injury\n\uf0a7 Automobile versus pedestrian/bicyclist thrown, run over or with significant (> 20 mph) impact\n\uf0a7 Motorcycle crash > 20 mph\nAdditionally, the following special patients, along with system considerations, should be considered for transport to a trauma center for evaluation and initial management:\n\uf0a7 Older adults:\nyRisk for injury/death increases after age 55\nySystolic blood pressure < 110 mmHg might represent shock after age 65\nyLow-impact mechanisms (e.g., ground-level falls) might result in severe injury\n\uf0a7 Children:\nyShould be triaged preferentially to pediatric-capable trauma centers\n\uf0a7 Anticoagulants and bleeding disorders:\nyPatients with a head injury are at high risk for rapid deterioration\n\uf0a7 Burns:\nyWithout other trauma mechanism: triage to burn facility\nyWith trauma mechanism: triage to trauma center\n\uf0a7 Pregnancy > 20 weeks\n\uf0a7 EMS provider judgment\nAir medical transport should also be considered for the following:\n\uf0a7 A situation where there are multiple injured or ill people\n\uf0a7 Critical stroke and cardiac alert patients, if ground transport by ambulance exceeds 45 minutes to the receiving facility\n\uf0a7 Critical trauma patients, who should be transported by air transport if ambulance transport to the trauma center exceeds 30 minutes\nThe distance to be traveled and the time it will take to transport the patient(s) must be considered. Patients with conditions that are time-critical include those with chest or abdominal injuries with signs of respiratory shock or distress; patients in shock or experiencing an acute stroke; patients who have sustained any serious injury and show altered vital signs; patients with head injuries with altered mental status; and those patients with a penetrating injury or in any other situation where time is obviously critical (such as a severe poisoning [e.g., carbon monoxide], heart attack, stroke or amputation).\nRequesting air medical transport is reasonable when:\n\uf0a7 It will take more than 30 minutes by ambulance to transport the patient to a trauma center.\n\uf0a7 It will take longer to transport the patient to a trauma center by ambulance than by air transport.\n\uf0a7 The patient\u2019s transport will be delayed by more than 30 minutes because of the need for extrication.\n\uf0a7 The patient will require rapid transport to a specialty center. This could include a burn center or pediatric, comprehensive stroke or trauma center.",
        "Advantages": "In some situations, you may need to request air transport for your patient because they are unstable and the length of time for ground transport would lower the chances of survival. If the helicopter is carrying a medical crew, air transport allows for quicker access to more advanced emergency care. The medical crews on air transport are highly trained and can include nurses, paramedics and/or physicians. There is also specialized equipment that the medical crews are trained to use, including monitoring devices, intubation and advanced airway equipment, and chest decompression kits. Collisions or crashes that occur off-road or in remote areas may not be accessible by road vehicles; use of a helicopter allows for patient evacuation. Another advantage of using air transport is that many large hospital centers and trauma centers have helipads to allow for helicopter landings.",
        "Disadvantages": "Helicopter transport is affected by weather conditions. If conditions are unfavorable, such as high winds or low visibility, the patient cannot be transported. The altitude available for a safe rescue may be vital in determining whether the rescue is feasible. If there is not enough room for the helicopter to hover or land safely, the rescue is not possible. There may be airspeed restrictions imposed by air control authorities in certain designated areas that could impede the aircraft\u2019s arrival at the receiving medical facility. Another possible disadvantage is that helicopter size varies considerably, depending on the model. Smaller helicopters may not be able to accommodate patients and responders, as well as necessary equipment. Landing in mountainous terrain or among forested areas can be very difficult for a helicopter pilot. The area must be safe and there must be a viable landing site. Air transport is also significantly more costly than ground transportation.",
        "Activation": "Air medical activation must follow local and state guidelines. There are also state statutes, which vary across the country. It is essential that you review your state\u2019s protocols for activation of the helicopter emergency medical system (HEMS). In addition, rules vary according to institution, locale and state. There are also ordinance standards for each city, county and/or district. However, resources should be consistent with the standards developed by the Commission for the Accreditation of Medical Transport Systems.",
        "Indications for Patient Transport": "In general, air medical transport is used for several reasons including medical (e.g., stroke or cardiac alert) and trauma. With these types of emergencies, time is of the essence. This type of transport may be needed in situations involving spinal injuries, burns, organ procurement, high-risk obstetrics and premature babies. Helicopters are also used in the field in search and rescue missions. They are able to cover more terrain than land vehicles and can be used to rescue patients from inaccessible locations.",
        "Considerations with Air Medical Transport - Types": "There are two main types of air medical transport, rotorcraft and fixed-wing. Rotorcrafts (e.g., helicopters) are used to get into areas that are not accessible to any other type of rescue craft. Their maneuverability allows them to move up and down and side to side as needed, allowing for special rescue procedures such as hoisting. Fixed-wing crafts (e.g., planes, jets) are used to transport over long distances, usually between medical facilities.",
        "Considerations with Air Medical Transport - Weather": "Weather plays a significant role in the use of aircraft for rescue and transport. Pilots must have a minimum amount of visibility, and air temperature affects the altitude at which the helicopter can hover.",
        "Considerations with Air Medical Transport - Space and Load": "The amount of space available in a helicopter depends on the type of helicopter and its maximum takeoff and landing weights. When calculating space, responders must take into account how many patients require transport, the responders who must accompany the patient(s) and any essential lifesaving equipment. In calculating weight, the pilot must take into account not only the passengers and equipment, but the fuel load as well.",
        "Considerations with Air Medical Transport - Control Systems": "Flying helicopters is an extremely demanding task because of their complex function. The pilot must coordinate the lift of the vehicle with the forward or side-to-side movement, if any, or the altitude and air temperature if attempting to hover. Because of the design of the vehicle, the pilot cannot see below the helicopter, which is why guidance is always needed.",
        "Landing Zones": "Choosing a safe landing zone (LZ) for a helicopter is paramount. The pilot cannot see the area directly below the aircraft and must be guided. The pilot must also have a visual reference point at all times. Ideal conditions for LZs include: \uf0a7 A minimum 10,000-square-foot area (100 feet by 100 feet). Some pilots prefer a rectangular landing area to allow for a 45-degree approach. Some aircraft may need a larger area. \uf0a7 Flat land. Firm land: Avoid dusty ground or powdery snow if possible, as these conditions can impair vision as the helicopter rotors churn up the wind. Also, loose rocks can become dangerous projectiles when a helicopter lands or takes off. There is no guarantee that ice on a body of water would ever be strong enough for a helicopter landing. An area clear of any obstacles: An area clear of any obstacles, such as trees or utility poles. An area clear of any type of vehicular traffic or pedestrians: An area clear of any type of vehicular traffic or pedestrians. Landing Zone Coordinator: One person should be in charge of the LZ, coordinating the scene. To prevent distraction or confusion, this is the only person who should be communicating with the pilot. The coordinator should ensure that the LZ is well marked with cones or a flameless light source in all four corners. Nighttime landings can be guided with vehicle lights or any other nonflame light source, but the lights should always remain at ground level, never directed toward the pilot. Coordinator Protection: To help with the helicopter landing, the coordinator should be protected with a fastened helmet, hearing and eye protection, long sleeves and pants. The coordinator is then stationed outside the landing perimeter, usually with their back to the wind unless the pilot instructs an alternate landing approach. If possible, people should also be stationed at the left and the right outside the landing perimeter. Any bystanders not involved in the landing should be kept a minimum of 200 feet away from the site.",
        "Patient Transfer": "Interacting with Flight Personnel If you are transferring a patient to the care of flight personnel, you will have to provide all the information you have obtained about the situation. This includes patient history, injury or illness history, presentation of the patient when you came upon the scene, any changes while waiting for the helicopter, and status and vital signs.",
        "Patient Packaging and Preparation": "Preparation for transport may include securing the patient\u2019s airway, immobilizing, splinting and the completion of emergency care procedures necessary for safely transferring a patient from the scene to an ambulance or helicopter.",
        "Scene Safety": "It is essential that no loose objects be allowed within the LZ. They may become projectiles, causing damage or injury. Objects such as medical equipment, linens or sheets, bags and other loose objects can become airborne from the rotary winds (rotor wash) and may strike the rotor blades or get sucked up into engine intakes causing a breakdown or injuries. Secure everything that can be secured and move anything else as far away as possible from the LZ. If the land is sandy or dusty, it should be wet down to limit the amount of dirt and dust churned up by the rotor wash. Only those personnel who must approach the aircraft should be permitted within the LZ, and only after the pilot has signaled that it is safe to approach. Make eye contact with the pilot to confirm your permission to approach, and maintain eye contact until you have arrived at the door of the helicopter. Tail rotors are very dangerous, and a person assigned as a tail rotor guard may be posted to prevent people from coming near or approaching the aircraft from the rear. Allow the medical crew from the aircraft to approach you instead. Approaching from the front or side allows the pilot to see the responders. Your posture should be crouched over somewhat and, if there is an incline of any sort, you must approach from the lowest point and always from the side or front, never the rear. Even if approaching from the side, you must remain in the pilot\u2019s view. You should not be wearing a hat of any type; only a fastened helmet is permitted. Do not wear billowing clothing. If carrying equipment, such as an IV pole, this must be kept low and parallel to the ground so it does not get struck by the blades.",
        "Special Tactics": "Responders may be called to participate in rescues using mechanical hoists or special insertion and extrication (SPIE) lines. Because these responders have special training, your role would be to ensure that the area is as safe as possible for the specialty team.",
        "EMERGENCY VEHICLE SAFETY - Apparatus Preparedness": "Part of being prepared to respond to emergencies is being able to depend on your equipment and transportation. This means performing regular daily checks, more often if the situation warrants it. While checking for adequate tire inflation, also check the tires for wear and tear as well as anything unusual, like nails or debris in the tire. Ensure that warning devices (lights, siren, horn) are in working order. Check with your employer and/or state regarding checklists for required vehicle maintenance. Such checklists should include items such as checking the fluid circulation system and wiper fluid levels.",
        "EMERGENCY VEHICLE SAFETY - Equipment Preparedness": "You should also ensure that the appropriate safety equipment is available and in working order. Personal protective equipment (PPE) must be in full working condition for you to do your job effectively and safely. Depending on what is required in your situation, PPE may include helmets, work gloves, steel-tipped boots and structural firefighting protective clothing. It also includes protective eyewear, hearing protection, appropriate outerwear for the season and the task, portable radio and body armor if considered necessary. Rescues often take place in the dark or in inclement weather, where visibility may be poor. It is important for you to wear reflective clothing, ideally a reflective safety vest, but reflective tape on your clothing and other gear also works well.",
        "EMERGENCY VEHICLE SAFETY - Safety Issues During Response": "During a response, safety is paramount. All personnel must be properly seated and use safety belts. All equipment in the cab area, rear of ambulance and any compartment areas should be appropriately secured.",
        "EMERGENCY VEHICLE SAFETY - Consideration of Use of Lights and Sirens": "Emergency response to a scene does not exempt any emergency personnel from traffic laws. It is the driver\u2019s responsibility to make sure they know the traffic laws that govern the use of lights, sirens and intersection procedures.",
        "EMERGENCY VEHICLE SAFETY - Risk/Benefit Analysis": "Use of lights and sirens is becoming increasingly questioned in emergency rescue services. Numerous studies have been conducted about the effectiveness versus the safety aspect of the practice. Learn your agency\u2019s protocols for when the patient\u2019s condition and situation warrants use of lights and sirens.",
        "EMERGENCY VEHICLE SAFETY - Audible Warning Devices": "Audible warning devices include both the siren and the air horn. You should be familiar with your agency\u2019s requirements concerning the use of both. The purpose of using your siren is to warn traffic in front of you that you are approaching and to warn oncoming and side traffic of your presence. It is also used to ask for the right of way. Because today\u2019s vehicles are better insulated from outside noise and because many drivers and passengers listen to loud music or have loud conversations inside, do not assume they can hear you approach. The outside environment may also be noisy and affect their ability to hear a siren. Alternatively, they may hear you but not fully realize from which direction you are coming. If you feel that your siren was not heard, do not come up behind a vehicle and turn your siren on suddenly, as this may startle the driver and cause a crash. Also, be aware that the siren can have an effect on you in the ambulance. There can be a hypnotizing effect that may make you pay less attention to your surroundings and your driving. Your air horn can be used to clear traffic in a single situation, like an intersection. Like the siren, do not use the air horn behind or close to another vehicle as it may startle the driver into losing control. Do not use it continuously, but it can be used with or without your siren, depending on what the local and state laws are for your area.",
        "EMERGENCY VEHICLE SAFETY - Visual Warning Devices": "Using visual warning devices, such as warning lights and emergency lights, depends on local and state laws. It is highly recommended that you do not use emergency lights without your siren; they should be used together or not at all. Headlights should be on, day or night, but high beams should not be used as emergency lights as they can blind oncoming drivers, as well as drivers in front of you through their rearview mirror. If using a siren and/or lights, many drivers choose to turn them off a few blocks before the destination to avoid attracting attention.",
        "EMERGENCY VEHICLE SAFETY - Respond with Due Regard": "Rescue vehicle drivers should obey traffic laws, be careful at intersections and only drive in emergency mode when lights and sirens are employed. Factors such as weather, road conditions and traffic must be taken into consideration when making driving decisions.",
        "High-Risk Situations - Intersections": "Collisions at intersections can occur when the rescue driver has a green light and does not expect a driver to run a late yellow light or a red light, or when a pedestrian or cyclist may be crossing and not be visible to the driver due to other vehicles. Slow down and come to a complete stop at intersections, and ensure that all drivers are aware of your presence before proceeding. Another dangerous situation arises when more than one emergency vehicle is responding, either in the same direction or from different directions. Ensure that all emergency vehicles are obvious to all motorists and to people around the intersections, so they know to expect more than one emergency vehicle.",
        "High-Risk Situations - Highway Access": "Always use caution when entering roads or highways. Be especially careful when using the shoulder in rush hour or gridlock situations. Follow the rules of the road and do not assume other drivers are aware of your presence. State laws differ in regards to how other drivers should respond when emergency vehicles are approaching. For example, some states require that drivers pull to the right to allow the emergency vehicle to pass without a problem, while other states do not require drivers to pull to the right. Know your state\u2019s laws to ensure your safety and the safety of those around you.",
        "High-Risk Situations - Speed Considerations": "You should only travel at increased speed, beyond posted speed limits, when using lights and sirens, and only if permitted by local and state laws. If driving at a high speed, weather and road conditions must also be taken into consideration, and extra caution should be taken when going around curves, going over hills, going down hills, turning corners and braking.",
        "High-Risk Situations - Driving Distractions": "Be sure to eliminate all possible distractions, as your ability to concentrate and drive safely is of utmost importance. Typical distracting factors include mobile computers, Global Positioning Systems (GPSs), mobile radios, vehicle stereo, wireless devices, and eating and drinking.",
        "Inclement Weather": "Driving in inclement weather can make emergency response more stressful. Be sure to leave extra distance between you and the car in front of you\u2014especially on wet pavement, which usually requires double the normal distance to ensure enough braking room. If driving on ice or snow, count on about five times the normal distance needed. Most drivers are aware of the risk of skidding on ice, but hydroplaning\u2014riding on a film of water\u2014is a very real risk in rain. If you do begin to hydroplane, corrective actions are similar to those of skidding on ice: take your foot off the accelerator and, unless you have an anti-lock braking system (ABS), pump the brake gently. Do not try to turn out of the hydroplane. When driving in fog or any other situation where vision is greatly diminished, you must slow down; do not brake suddenly in case someone is following too closely behind you. Use your headlights, but not your high beams. If legal in your locale or state, use your four-way flashers/hazard lights if driving slower than the posted limit. If about to use your brake, warn those behind you by tapping your brake, activating your brake lights.",
        "Aggressive Drivers": "Aggressive drivers can be found anywhere, at any time. They have less concern for other drivers and are generally frustrated. An aggressive driver is someone who not only threatens other drivers, Aggressive drivers may disregard ambulances and other emergency vehicles. Be cautious when confronted with an aggressive driver and do not react to the driver\u2019s behavior or actions. Back off if needed and do not assume an aggressive driver will obey the rules of the road. When encountering an aggressive driver, notify law enforcement immediately. Obtain a tag number and vehicle description, if it is safe to do so.",
        "Unpaved Roadways": "Unpaved roadways, such as dirt roads or gravel-covered surfaces, can pose unsafe driving conditions that include marginal traction; muddy, slick conditions during rainy weather; and uneven surfaces. Always drive with extra caution on unpaved roads, and never drive faster than conditions safely permit when driving on any road surface.",
        "Responding Alone": "In many traffic-related emergencies requiring fire rescue units to respond, they will position their larger vehicles in such a way as to protect the scene and allow for emergency care. When responding alone, or when you are first on scene, be especially careful when approaching and when exiting your vehicle. Check your mirrors, look back for traffic and open your door slowly especially if it opens toward traffic. Wear proper reflective gear. Request assistance from law enforcement personnel to assist with traffic control.",
        "Fatigue": "There may be times when an EMS vehicle driver feels sleepy while driving, especially on long transports. This may be especially true on longer shifts. Avoid caffeine and sugar; they may provide energy in the short term, but cause a rebound drop in energy a few hours later, which can make you feel even more sleepy as well as disturb sleep. Fresh air is a better alternative, as is 10 minutes of deep breathing. Open the vehicle\u2019s window or get out of the vehicle if you can for a few minutes. Stretching also helps. If you take prescribed medications that cause sleepiness and impair your ability to perform your job safely, seek help and avoid driving when the medication is interfering. If you are using antihistamines, choose ones that cause less drowsiness.",
        "360-Degree Assessment": "When approaching an emergency, dangers can be present all around you. Be sure to scan up, down and behind you, as well as looking forward and side-to-side as you size up the scene. This will help you more thoroughly assess the entire situation.",
        "Downed Electrical Lines": "When a vehicle is in contact with an electrical wire, consider the wire energized (live) until you know otherwise. Water is an effective conductor of electricity, so be especially careful of downed electrical wires in a wet or rainy environment. When you arrive at the scene, your first priority is to ensure your safety and that of others in the immediate area. A safety area should be established at a point twice the length of the span (distance between the poles). of the wire. Attempt to reach and move patients only after the power company has been notified and has secured any electrical current from reaching downed wires or cables. Tell occupants inside an involved vehicle to remain in the vehicle. If needed, you may be able to give them instructions on how to provide some basic first aid care for any injured patients in the vehicle until they can be safely reached by professional responders. Do not attempt to deal with any electrical hazards unless you are specifically trained to do so and have the proper equipment. Once the current has been shut down, the vehicle can be safely approached.",
        "Leaking Fuel or Fluids": "Check to see if there is any fuel or fluid leaking from the vehicle. Check for a source that could ignite a fire. If there is a source, the fire department must be notified if you have not done so already.",
        "Smoke or Fire": "If smoke or fire is present, the fire department must be notified if you have not already done so. If you attempt a rescue, approach the vehicle from the side only, to lessen the risk should explosion occur.",
        "Broken Glass": "Broken glass from windows or windshields can be anywhere on the scene. If it poses a risk and cannot be avoided, covering it may reduce the chances of injury.",
        "Trapped or Ejected Patients": "As you size up the scene, check for trapped patients. If a patient is trapped in a vehicle, the fire and rescue department may have specialized extrication equipment to help get the patient safely out of the vehicle. Also, look around the area to see if any patients were ejected from the vehicle upon impact.",
        "Mechanism of Injury/Nature of Illness": "As you approach the patient, consider the MOI or nature of illness. Doing so involves trying to find out what happened. Look around the scene for clues as to what caused the emergency and the extent of the damage. Consider the force that may have been involved in creating an injury. This will cause you to think about the possible type and extent of the patient\u2019s injuries. Take in the whole picture. How a motor vehicle is crushed or nearby objects such as shattered glass, a fallen ladder or a spilled medicine container may suggest what happened. If the patient is unconscious, considering the MOI or nature of illness may be the only way you can determine what happened.",
        "Patient Care in the Ambulance": "All personnel, including the driver and others riding in the ambulance, must be properly seated and secured with safety belts for their own safety as well as for the safety of others in the vehicle, unless they are moving about for essential tasks. in the patient compartment. Do not remove your safety belt just before arrival to save time, as research shows the last few minutes of the emergency response drive are the most dangerous to team members.\nIf safety belts must be removed while you are in the patient compartment to provide care to the patient, precautions must be taken regarding how you position yourself and how you move. Always hold on to something secure inside the compartment when moving about unsecured.\nPatients should always be properly secured while in the patient compartment. All stretcher straps are to be appropriately in place and tightened.\nPatient care in the ambulance can be hazardous because of the movement necessary by the responder. While remaining as safe as possible, the responder must be able to carry out certain procedures. Check the protocols in your local area or state regarding which procedures these might be, as they may require that the ambulance not be in motion at that time.\nMove deliberately and slowly, keeping your feet well placed, shoulder width apart, on the floor to maintain stability. Responders should practice the idea that three of five essential body parts should be safely \u201chugging\u201d the ambulance at all times. The five body parts are the two hands, two feet and backside, which should be seated as much as possible during ambulance movement. If you hook your foot around the stretcher bar as you are seated, this gives an extra measure of safety and security.\nCPR may be necessary en route to the hospital. This requires extra care for the responder. Maintain balance as much as possible and have the driver call out if any bumpy areas (e.g., railroad tracks or potholes) or severe turns are coming up, so that you may brace yourself.\nWhile performing CPR, spread your feet to shoulder width to maintain a more secure stance and bend your knees to lower your center of gravity. If possible, have someone help you by holding on to your belt to stabilize you. That other person should be secured with a seat belt.",
        "Securing Equipment": "All moveable equipment in the cab must be secured for your safety. In the event of a motor-vehicle collision, all unsecured items have the potential of becoming life-threatening projectiles. This includes personal items left on the dashboard, such as pens and notebooks.\nUnless using a piece of equipment, it must be securely stored to prevent injury in the case of a sudden stop, swerve or motor-vehicle crash. This includes everything from heavier monitoring equipment and AEDs to lighter clipboards and cups.",
        "LEAVING THE SCENE": "Before you leave the scene, ensure all hazards have been mitigated. Pick up and dispose of all equipment and trash properly. All used sharps must be placed in a closed, puncture-resistant, leak-proof, tamper-proof biohazard sharps container. All contaminated clothing, products or material must be placed in a biohazard container. All containers must be stored in a safe manner and, if leakage occurs, they must be placed in a second leak-proof container. Check with your local and state laws about proper disposal of these contaminated items. All reusable equipment must be collected from the scene for cleaning and restocking. All disposable equipment must be discarded in appropriate containers and replaced with new equipment after the emergency. Turn the scene over to the appropriate authority prior to leaving. There may be situations when EMRs must turn over care of their patient to other emergency personnel, including law enforcement, fire suppression, highway department and other personnel. The names of the initial responders should be given to the crew taking over care and should be recorded on the prehospital care report for any possible follow ups. While generally one only transfers care to a higher-level certified emergency responder, there may be situations that necessitate turning over care to a lower certified responder. For example, in a multi-casualty incident (MCI), responders may be required to move on to the next patient for assessment, leaving the patient with a lower certified responder, after an appropriate briefing.",
        "EMS EQUIPMENT": "Maintaining equipment readiness is essential. If you are involved in transporting patients to the receiving facility, you will have to prepare and inspect the ambulance before every shift. Local EMS systems and state regulations determine what equipment and supplies must be in the vehicle.",
        "EMS EQUIPMENT - Jump Kit": "In preparing to respond to an emergency, you should have basic medical equipment on hand. Always have a jump kit fully stocked and ready to go should an emergency occur. Do not overfill the jump kit, but minimum supplies should include: \uf0a7 Airways (oral).\n\uf0a7 Suction equipment.\n\uf0a7 Artificial-ventilation devices (e.g., resuscitation mask or bag-valve-mask [BVM] resuscitator).\n\uf0a7 Basic wound supplies (e.g., dressings and bandages).\n\uf0a7 Supplies for severe, life-threatening bleeding (tourniquets, pressure dressings and hemostatic dressings).\nOther supplies to include are:\n\uf0a7 PPE, such as disposable latex-free gloves, protective eyewear, masks and face shields.\n\uf0a7 Maps.\n\uf0a7 Scissors.\n\uf0a7 Blood pressure cuff.\n\uf0a7 Stethoscope.\n\uf0a7 Flashlight.\n\uf0a7 Note pad and pen.\n\uf0a7 Hand sanitizer.\n\uf0a7 Any other equipment required by local or state standards.",
        "PUTTING IT ALL TOGETHER": "EMRs are individuals who have been trained to a minimum standard of care according to the current national scope of practice and EMS educational standards. They may function in traditional roles as regular members of an ambulance crew in some states, while in others they may work in nontraditional settings as trip leaders or athletic trainers. There are also several types of EMRs, including those with additional training who are able to transport patients as well as provide advanced, prehospital medical care. A typical EMS response has nine phases: preparation for an emergency call, dispatch, en route to the scene, arrival at the scene and patient contact, transferring the patient to the ambulance, en route to the receiving facility, arrival at the receiving facility, clear medical facility and available for next emergency call. In certain situations, it may be best for patients to be transported to a medical facility by air. This method enables severely injured or ill persons to be transported quickly to specialty centers and large treatment facilities. Geography and other circumstances play a large role in this type of transport decision, and emergency personnel should follow local and state protocols. To be prepared to answer emergencies, EMRs must be able to depend on their equipment and transportation. This means performing regular checks of the vehicle\u2019s tires and audible and visual warning devices to make sure everything is in working order, and ensuring that all necessary equipment and supplies are on hand.",
        "Operational Safety and Security Measures - Personnel": "The beginning of each shift should involve a briefing, either in person or through written notes, about any issues involving crew safety. These issues could involve personal threats against the unit or specific responders, or be general threats. Security measures should have been discussed previously in training and reviewed as needed.",
        "Operational Safety and Security Measures - Vehicles": "The threat of stolen vehicles is very real. Under no circumstances should an ambulance or rescue vehicle be left running or unattended with the key in the ignition. All vehicles must be monitored, whether in or out of service. Any vehicles that are no longer to be used for emergency or rescue purposes must be stripped of all emergency equipment, lights, sirens and markings. All use of ambulances and rescue vehicles must be tracked to avoid unauthorized use. If ambulances or rescue vehicles need repair or servicing outside of authorized areas, they must be secured in such a way that they cannot be used by unauthorized personnel."
    },
    {
        "Key Terms": "Ankle drag: A method of moving a patient by grasping the patient\u2019s ankles; also known as the foot drag., Backboard: A piece of equipment used to secure a patient when extricating them from the scene and moving them to a stretcher for transport., Blanket drag: A method of moving a patient, using a blanket, in an emergency situation where equipment is limited and the patient is suspected of having a head, neck or spinal injury., Body mechanics: The field of physiology that studies muscular actions and the function of the muscles in maintaining posture., Clothes drag: A type of emergency move that uses the patient\u2019s clothing; used for a patient suspected of having a head, neck or spinal injury., Direct carry: A method of moving a patient from a bed to a stretcher or vice versa; performed by two responders., Direct ground lift: A nonemergency method of lifting a patient directly from the ground; performed by several responders., Draw sheet: A method of moving a patient from a bed to a stretcher or vice versa by using the stretcher\u2019s bottom sheet., Extremity lift: A two-responder, nonemergency lift in which one responder supports the patient\u2019s arms and the other the patient\u2019s legs., Firefighter\u2019s carry: A type of carry during which the patient is supported over the responder\u2019s shoulders., Firefighter\u2019s drag: A method of moving a patient in which the patient is bound to the responder\u2019s neck and held underneath the responder; the responder moves the patient by crawling., Log roll: A method of moving a patient while keeping the patient\u2019s body aligned because of a suspected head, neck or spinal injury., Pack-strap carry: A type of carry in which the patient is supported upright, across the responder\u2019s back., Position of comfort: The position a patient naturally assumes when feeling ill or in pain; the position depends on the mechanism of injury or nature of illness., Power grip: A hand position for lifting that requires the full surface of the palms and fingers to come in contact with the object being lifted., Power lift: A lift technique that provides a stable move for the patient and protects the person lifting from serious injury., Reasonable force: The minimal force necessary to keep a patient from harming themselves or others., Recovery position: A side-lying posture used to help maintain a clear airway in an unresponsive patient who is uninjured and breathing normally., Restraint: A method of limiting a patient\u2019s movements, usually by physical means such as a padded cloth strap; may also be achieved by chemical means, such as medication., Shoulder drag: A type of emergency move that is a variation of the clothes drag., Squat lift: A lift technique that is useful when one of the lifter\u2019s legs or ankles is weaker than the other., Stair chair: Equipment used for patient transport in a sitting position., Stretcher: Equipment used for patient transport in a supine position., Supine: The body position of lying flat on the back., Two-person seat carry: A nonemergency method of carrying a patient by creating a \u201cseat\u201d with the arms of two responders., Walking assist: A method of assisting a patient to walk by supporting one of the patient\u2019s arms over the responder\u2019s shoulder (or each of the patient\u2019s arms over the shoulder of one responder on each side).",
        "INTRODUCTION": "At some point in many emergency situations, you will need to lift and move a patient. Sometimes this will be to provide easier access to administer first aid. At other times, you will need to move the patient to a safer location. You may also need to move a patient to transport them to the hospital. This chapter will teach you how to quickly and safely lift and move patients.",
        "ROLE OF THE EMERGENCY MEDICAL RESPONDER": "When providing care, you will usually not face hazards that require you to immediately move patients. In most cases, you can provide care where you find the patient. Moving a patient needlessly can lead to further injury. For example, moving a patient who has a painful, swollen, deformed leg without taking the time to immobilize it could result in an open fracture if the end of the bone were to tear the skin. Soft tissue damage, damage to the nerves, blood loss and infection could all result unnecessarily. Needless movement of a patient with a head, neck or spinal injury could cause paralysis or even death. However, there are some situations in which moving a patient would be appropriate, but only when you can do so safely . These situations are when you need to protect a patient from immediate danger (e.g., a fire or flood), reach another patient who may have a more serious injury or illness, and provide proper care (e.g., moving a patient who needs CPR onto a hard, flat surface).",
        "Safety Precautions": "Before you act, always size up the scene and consider the factors affecting the situation:\n\uf0a7\tAny dangerous conditions at the scene\n\uf0a7\tThe distance a patient must be moved\n\uf0a7\tThe size of the patient\n\uf0a7\tYour physical ability\n\uf0a7\tWhether others can help you\n\uf0a7\tThe mechanism of injury (MOI) and patient\u2019s possible condition\n\uf0a7\tAny aids or equipment to facilitate patient transport at the scene\nFailing to consider these factors could cause injury. If you were to become injured, you might be unable to move the patient and could risk complicating the situation and making things worse.",
        "Know Your Own Physical Limitations": "Lifting and moving a patient requires physical strength and a high level of fitness. If you improperly lift a patient, you can permanently injure yourself. Adequate weight training, stretching and cardiovascular exercises will help ensure that you are ready for the physical demands of an emergency situation. You should only move a patient by yourself if you can do so safely and comfortably. Know your own physical limitations and, when in doubt, ask for assistance from other responders.",
        "Body Mechanics": "Body mechanics refers to the field of physiology that studies muscular actions and the function of the muscles in maintaining the posture of the body. In other words, it is the study of using your body in the safest and most efficient way to achieve a desired outcome. Make sure to employ the following principles of body mechanics when lifting and moving a patient: \uf0a7 Keep your back straight. Lift with the legs, not the back. Use the muscles in the legs, hips and buttocks and contract the muscles of your abdomen. \uf0a7 Maintain a firm grip on the stretcher or the patient, as well as any other pieces of equipment being used to move the patient, being sure to never let go. Keep the patient\u2019s weight as close to your body as possible and maintain a low center of gravity. Follow the manufacturer\u2019s operating instructions for the stretcher and equipment you are using. \uf0a7 Avoid twisting your body as you lift. \uf0a7 Maintain a firm footing, and walk in small measured steps. \uf0a7 When possible, move forward rather than backward. \uf0a7 Use good posture. Poor posture can fatigue your back and abdominal muscles, making you more prone to injuries. When standing, your ears, shoulders and hips should be aligned vertically, your knees should be bent slightly and your pelvis tucked slightly forward. When sitting, your weight should be distributed evenly and your ears, shoulders and hips should be aligned.",
        "PRINCIPLES OF MOVING PATIENTS": "There are a number of different ways to move a patient to safety, and no one way is best. Any of the following moves is acceptable, providing that you can move a patient without injuring yourself or causing further injury to the patient. All team members should be trained in the proper techniques and have practiced them until the moves become automatic. Communicate your next moves clearly and frequently with your partner, the patient and other emergency medical services (EMS) personnel. If the patient is conscious, explain what you are doing or what you are about to do. Tell the patient what is expected of them, such as not reaching out to grab anything.",
        "Back in Locked-In Position": "Always begin your lift facing the patient or object and with your back in a locked-in position. Keep your legs shoulder-width apart, head up, back straight and shoulders square. Keep the weight of the patient or object as close to your body as possible. Tighten the muscles in your back and abdomen and keep your back straight while you lift. Keep your arms locked and avoid twisting while carrying.",
        "Power Grip": "The power grip allows for maximum stability and strength from your hands. To perform the power grip, grab the object so that both palms and fingers come in complete contact with the object. All of your fingers should be bent at the same angle.",
        "Power Lift": "The power lift technique provides a stable move for the patient while protecting you from serious injury. To perform the power lift correctly, remember Before you act, always size up the scene and consider the factors affecting the situation, including any dangerous conditions, your physical ability and the patient\u2019s possible condition. to keep your back locked and avoid bending at the waist.\n\uf0a7 Position your feet, making sure they are on a flat surface and are a comfortable distance apart (usually shoulder width), and turned slightly outward to provide maximum comfort and stability.\n\uf0a7 Bend your knees. You should not feel like you are falling forward.\n\uf0a7 Tighten your back and abdominal muscles. Keep your back as straight as possible and do not twist or turn. Make sure your feet are flat and your weight is evenly distributed.\n\uf0a7 Position your hands. Use the power grip once your hands are in position. Grip the object in the way that is most comfortable and stable. For most people, that is approximately 10 inches apart.\n\uf0a7 Lift, keeping your back locked, and make sure your upper body lifts before your hips do.\n\uf0a7 Reverse the process to lower.",
        "Squat Lift": "The squat lift is an alternative to the power lift and is useful if one of your legs or ankles is weaker than the other. Remember to avoid bending at the waist when performing this lift.\n\uf0a7 Stand with your weaker leg slightly forward. The foot on the weaker side should remain flat on the ground throughout the lift sequence.\n\uf0a7 Squat down until you can grasp the object. Use the power grip.\n\uf0a7 Push yourself up with your stronger leg. Keep your back locked and lead with your head, lifting your upper body before your hips.\n\uf0a7 Reverse the procedure to lower.",
        "Reaching": "General Guidelines\nEmergency medical responders (EMRs) will often have to reach for equipment or patients. To minimize the risk of injury, try to reposition the object to avoid reaching and lifting. If that is not possible, reach no more than 20 inches in front of your body. When reaching, keep your back in the locked position and do not twist. Support your upper body with your free arm. When reaching overhead, do not lean back from the waist (hyperextending).\nCorrect Reaching for Log Rolling\nThe log roll is usually performed when the patient is suspected of having a spinal injury. Ideally, four people working in tandem perform it. One responder is located at the patient\u2019s head, while two or three others perform the actual move. The patient\u2019s arms should be at their side with the legs straight and together. The responder at the patient\u2019s head directs the movement and maintains spinal motion. To perform a log roll: (A) Have one responder maintain spinal motion restriction of the head while (B) three responders perform the actual move. (C) Roll the patient in tandem, (D) placing the backboard against the patient and (E) returning the patient in tandem, always maintaining spinal motion restriction.",
        "Pushing and Pulling": "There may be instances when you will need to push or pull an object. Push rather than pull whenever possible. If pulling an object is necessary, keep your back locked and bend your knees slightly. Keep the load between your shoulders and hips, and close to your body. This will keep the pull line centered with your body. If you need to push an object, try to push from the area between your waist and shoulders whenever possible. If the weight is below waist level, push from a kneeling position, keeping your elbows bent and your arms close to your body. This will increase the force you can apply. Avoid pushing or pulling objects overhead, as there is an inherent risk and likelihood of injury.",
        "Carrying": "To minimize injury both to yourself and to the patient, follow these guidelines when carrying a patient: \uf0a7 Before lifting or carrying, estimate the total weight to be lifted or carried. Do not forget to include the weight of any equipment used in addition to the weight of the patient. \uf0a7 Know your own physical abilities and limitations. Do not overestimate your abilities or those of your team members. Call for additional assistance if required. Do not proceed with a patient move until you can do so safely, regardless of your first instinct. \uf0a7 Communicate clearly and frequently with your partner, the patient and other EMRs. \uf0a7 When you carry, keep the weight as close to your body as possible, with your back in the locked-in position. \uf0a7 Bend and flex at your hips and knees rather than at your waist.",
        "EMERGENCY MOVES": "In any emergency move, take care to protect the head, neck and spine. If you suspect the patient of having a head, neck or spinal injury, only the clothes drag or blanket drag are safe ways to move the patient.",
        "Indications for Emergency Moves": "In general, treat patients at the scene rather than moving them to provide care. However, some situations require emergency moves. These include the following: \uf0a7 Avoiding immediate danger: Danger to you or the patient from fire, close proximity of explosives or other imminent hazards, lack of oxygen, risk of drowning, possible explosion, collapsing structure or other reasons such as uncontrolled traffic hazards, civil unrest or extreme weather conditions. \uf0a7 Gaining access to other patients: A person with minor injuries may need to be moved quickly to allow you to reach other patients who may have life-threatening conditions. \uf0a7 Providing proper care: A patient with a medical emergency, such as cardiac arrest or heat stroke, may need to be moved to provide proper care. For example, someone in cardiac arrest needs CPR, which should be performed on a firm, flat surface with the patient positioned on the back. If the person collapses on a bed or in a small bathroom, the surface or space may not be adequate to provide appropriate care. Moves used by EMRs include assists, carries and drags. One or two people can do most of these moves and most of them do not require equipment (the exception is the direct ground lift, which calls for three people). This is important because, with most emergency moves, equipment is not often immediately available and time is critical. The greatest danger in moving a patient quickly is the possibility of aggravating a spinal injury. In an emergency, make every effort to pull the patient in the direction of the long axis of the body to provide as much protection to the head, neck and spine as possible. It is impossible to remove a patient from a vehicle quickly with an emergency move and at the same time provide much protection to the head, neck and spine. In any emergency move, take care to protect the head, neck and spine. If you suspect the patient of having a head, neck or spinal injury, only the clothes drag or blanket drag are safe ways to move the patient.",
        "Clothes Drag": "The clothes drag is an appropriate emergency move for a person suspected of having a head, neck or spinal injury (see Skill Sheet 5-1). This move helps keep the head and neck stabilized. To carry out a clothes drag, gather the patient\u2019s clothing behind the neck. Using the clothing, pull the patient to safety. During the move, cradle the patient\u2019s head by both the clothing and your hands. Move carefully, since you will be moving backward. Keep your back as straight as possible and bend your legs. This type of emergency move is exhausting and may result in back strain for the responder, even when done properly.",
        "Blanket Drag": "The blanket drag is a good way to move a patient in an emergency situation when stabilization equipment is unavailable or the situation dictates that there is not enough time or space to use stabilization equipment (see Skill Sheet 5-2). The blanket drag is appropriate for a patient suspected of having a head, neck or spinal injury. Position a blanket (or tarp, drape, bedspread or sheet) next to the patient. Keep the patient between you and the blanket. Gather half the blanket and place it against the patient\u2019s side. Being careful to keep about 2 feet of blanket above the patient\u2019s head, roll the patient toward your knees, reach across and position the blanket directly next to the patient. Gently roll the patient as a unit onto the blanket, being careful not to twist the patient\u2019s spinal column. After smoothing out the blanket, wrap it around the patient, gather up the excess at the patient\u2019s head, and drag, being sure to keep the patient\u2019s head as low as possible. Move carefully because you are moving backward, and keep your back as straight as possible.",
        "Shoulder Drag": "The shoulder drag is a variation of the clothes drag, in which you reach under the patient\u2019s armpits (from the back), grasp the patient\u2019s forearms and drag the patient. Keep your back as straight as possible and do not twist (see Skill Sheet 5-3). This move is exhausting and should be done carefully, since you are moving backward. The move may result in back strain. This move is not safe for a patient suspected of having a head, neck or spinal injury.",
        "Ankle Drag": "For the ankle drag (also known as the foot drag), firmly grasp the patient\u2019s ankles and move backward (see Skill Sheet 5-4). Be careful to pull on the long axis of the body and not bump the patient\u2019s head. Keep your back as straight as possible and do not twist. Move carefully because you are moving backward, which may result in back strain. This move is not safe for a patient suspected of having a head, neck or spinal injury.",
        "Firefighter\u2019s Drag": "For the firefighter\u2019s drag, position the patient on the back. Bind the patient\u2019s hands together gently at the wrists (see Skill Sheet 5-5). you can strap a belt or other device behind the patient\u2019s scapulae, loop it through the straps on your air pack and fasten. Straddle the patient on your hands and knees, and slip your head through the patient\u2019s arms. Place the patient\u2019s bound wrists behind your head. Keeping your back as straight as possible, and keeping the patient centered under you, slowly crawl forward, carrying the patient with you (Fig. 5-10). Be careful not to bump the patient\u2019s head. This move is not safe for a patient suspected of having a head, neck or spinal injury.",
        "Firefighter\u2019s Carry": "The firefighter\u2019s carry is not appropriate for patients with suspected head, neck, spinal or abdominal injuries, since the patient\u2019s body is twisted, the head is not supported and the patient\u2019s abdomen bears the weight during the movement. To perform the carry for a patient who is lying face-up, grasp the patient\u2019s wrists (see Skill Sheet 5-6). While standing on the patient\u2019s toes, pull the patient over a shoulder. Finally, pass an arm between the legs and grasp the arm nearest you. Alternatively, you can kneel in front of a seated patient, place one shoulder against the patient\u2019s abdomen and hoist the patient across your shoulders. Pull the patient over a shoulder. The patient\u2019s feet should be on one side and the head on the other. Pass your arm between the patient\u2019s legs and grasp the patient\u2019s arm that is closest to you. Keep your back as straight as possible, lift with your legs and stand up.",
        "Pack-Strap Carry": "The pack-strap carry can be used on both conscious and unconscious patients. Using it on an unconscious patient requires a second responder to help position the patient on your back. To perform the pack-strap carry, have the patient stand, or have a second responder support the patient (see Skill Sheet 5-7). Position yourself with your back to the patient, back straight and knees bent so that your shoulders fit into the patient\u2019s armpits. Cross the patient\u2019s arms in front of you and grasp the patient\u2019s wrists. Lean forward slightly and pull the patient up onto your back. Stand and walk to safety. Depending on the size of the patient, you may be able to hold both the patient\u2019s wrists with one hand. This leaves your other hand free to help maintain balance, open doors and remove obstructions. This move is not safe for a patient suspected of having a head, neck or spinal injury.",
        "NONEMERGENCY MOVES": "Uses A nonemergency move requires no special equipment and is generally performed with other responders. Do not use nonemergency moves if there is a possibility of a spinal injury. A nonemergency move is used to move a patient from one location to another, such as from the incident scene to an ambulance or other transport vehicle or to a stretcher, from a bed to a stretcher or from the floor to a chair. It may also be used to move a patient to a different position as part of the medical treatment. The best way to move a patient in a nonemergency situation is the easiest way that will not cause injury or pain. Nonemergency moves are used most frequently with patients with altered mental status, patients with inadequate breathing, patients who are in shock or patients in other situations that are potentially dangerous. Examples include a patient who is on a beach with the tide coming in or one who is lying on the ground in a busy traffic area.",
        "Walking Assist": "Walking Assist The most basic move is the walking assist . It is frequently used to help patients who simply need assistance to walk to safety (see Skill Sheet 5-8). Either one or two responders can use this method with a conscious patient. To carry out a walking assist, place the patient\u2019s arm across your shoulders and hold it in place with one hand. Support the patient with your other hand around the patient\u2019s waist. In this way, your body acts as a crutch, supporting the patient\u2019s weight while you both walk. A second responder, if present, can support the patient in the same way from the other side.",
        "Two-Person Seat Carry": "The two-person seat carry is a method of moving a patient that requires a second responder. To perform the two-person seat carry, put one arm under the patient\u2019s thighs and the other across the patient\u2019s back (see Skill Sheet 5-9). Interlock your arms with those of a second responder, under the patient\u2019s legs and across the patient\u2019s back. The patient places their arms over the responders\u2019 shoulders. The patient is then lifted in the \u201cseat\u201d formed by the responders\u2019 arms. Keep your back straight and lift with your legs. Do not use this move for a patient suspected of having a head, neck or spinal injury.",
        "Direct Ground Lift": "The direct ground lift requires at least three responders. The three responders line up on one side of the patient and kneel close to the patient (see Skill Sheet 5-10). The patient should cross arms over the chest. The responder kneeling at the patient\u2019s head places one arm under the patient\u2019s shoulders, cradling the head, and places the other arm under the patient\u2019s upper back. The next responder places one arm under the patient\u2019s waist and the other under the buttocks. The third responder cradles the patient\u2019s hips and legs. On a signal from the responder at the patient\u2019s head, all three responders lift the patient to their knees and support the patient by rolling the patient against their chests. On the next signal, all will rise to their feet and move the patient to the stretcher. Reverse the steps to lower the patient. Responders should keep their backs straight and lift with their legs.",
        "Extremity Lift": "In the extremity lift, one responder kneels behind the patient, keeping the back straight, reaches under the patient\u2019s arms and grasps the patient\u2019s opposite wrist (see Skill Sheet 5-11). The second responder kneels between the patient\u2019s legs and firmly grasps around the patient\u2019s knees and thighs. On a signal from the responder at the patient\u2019s head, both responders move from a crouching position to a standing position. The responders then move the patient to a stretcher.",
        "Moving Patients from a Bed to a Stretcher": "There are two techniques designed for moving a patient from a bed to a stretcher or vice versa: the direct carry and the draw sheet.",
        "Direct Carry": "Position the stretcher at a right angle to the bed, with the head of the stretcher at the foot of the bed. Two responders position themselves beside the bed on the same side as the stretcher. One responder slides their arms around the patient\u2019s shoulders and back, and the second responder cradles the patient\u2019s waist and hips. On a signal from the responder at the patient\u2019s head, the responders lift the patient simultaneously and curl the patient\u2019s body in toward their chest. With a minimum of steps, the responders can then turn and place the patient on the stretcher. Responders should keep their backs straight, lift with their legs and not twist their bodies.",
        "Draw Sheet": "To transfer a patient from the stretcher to the bed, the responders loosen the bottom sheet on the stretcher and position the stretcher along the side of the bed. Responders stand beside the stretcher and on the other side of the bed. The responders on the bed side of the patient lean over the bed and grasp the sheet firmly at the patient\u2019s head and hips. The responders on the stretcher side grasp the sheets in the same place. They then slide the patient into the bed. If there are more responders available, they should be positioned to help support the patient\u2019s legs by grasping the sheet in the same manner as the initial responders.",
        "EQUIPMENT": "To best decide on the most suitable equipment for patients under different conditions, it is important to familiarize yourself with the different types available and match the appropriate equipment for the size and condition of each patient.",
        "CRITICAL FACTS": "There are two techniques designed for moving a patient from a bed to a stretcher or vice versa: the direct carry and the draw sheet.",
        "Stretchers": "There are several types of stretchers designed to deal with patient transport:\n\uf0a7 Wheeled stretchers are most commonly used when moving patients from a situation in which transport by ambulance for more advanced medical care is required. They are equipped with a collapsible undercarriage for ease of loading. Some models are pneumatic or electronic and help reduce the amount of manual lifting involved in patient transport. They use a hydraulic lift system to raise and lower the frame.\n\uf0a7 Portable stretchers are lightweight and often are used as auxiliary stretchers in ambulances. They are designed for use with additional patients, as well as for maneuvering in areas where space is limited.\n\uf0a7 The bariatric stretcher was designed to accommodate a weight of up to 1600 pounds.\n\uf0a7 Basket stretchers, also known as Stokes baskets, get their name because of their basket-like shape. They are capable of safely transporting and securing patients requiring a backboard. There are two types: a welded metal frame with a chicken wire web and a tubular aluminum frame that has been riveted to a molded polyethylene shell.\n\uf0a7 Flexible stretchers are made of canvas or synthetic materials and are designed to allow easy transport of patients from confined spaces, narrow hallways and in situations with multiple steps or rough terrain.\n\uf0a7 Scoop or orthopedic stretchers are designed for patients weighing up to 300 pounds, and are made to be assembled and disassembled around the patient.",
        "Stair Chair": "A stair chair is used when a wheeled stretcher is deemed too long for the rescue or extrication. It is especially useful when there is a small elevator or staircase in which a long stretcher will not fit. It is recommended that three responders be present when using the stair chair to ensure patient safety, two to act as carriers and one to serve as a spotter to watch for potential difficulties.",
        "Backboards": "Backboards are used to move a patient from the scene of the incident to a stretcher or other transport device. Backboards can also be used to provide spinal motion restriction of a patient\u2019s head, neck and spine and are considered a standard piece of EMS equipment.\nA short backboard is an SMR device used for non-critical patients who are already in a sitting position. The vest type and/or corset design is most commonly used to secure patients in this situation, and allows the patient\u2019s head, chest and lower back to be strapped in. The Kendrick Extrication Device (KED) is a vest-type device that is commonly used to stabilize patients in vehicle collisions who are in an upright position. It is used together with a cervical collar.\nThe full-body vacuum mattress can be used as either a backboard or moving device once the patient is secured. This design allows the mattress to conform to whatever shape is required to accommodate the patient\u2019s condition. It avoids the need for additional padding and becomes rigid once fully deflated.",
        "PATIENT POSITIONING AND PACKAGING FOR TRANSPORT": "Make patients as comfortable as possible while awaiting transport. Unless a life-threatening emergency dictates the necessity, do not move an injured patient. A patient is usually moved by EMRs once the patient has been examined, evaluated and stabilized. There are times when a patient\u2019s condition will dictate the position you place the patient in.",
        "Position of Comfort - Indications for Use": "Patients with various injuries or illnesses may be placed in a position of comfort, which is the position that is most comfortable, unless the injury or illness prevents it. This might include a patient who is in pain, is experiencing breathing problems, is nauseated or is vomiting.",
        "Position of Comfort - Techniques": "Someone with abdominal pain will be more comfortable on the side with knees drawn up. If a patient is experiencing breathing difficulties, the patient may be more comfortable sitting up rather than lying down. A patient who is nauseated or vomiting should be allowed to remain in whatever position is most comfortable. However, you should monitor the patient closely and position yourself to monitor and manage the patient\u2019s airway. An alert but nauseated person should be transported in a sitting-up position. If the patient is unresponsive, or you cannot maintain an open and clear airway because of fluids or vomit, transport the patient on their side in a recovery position.",
        "Recovery Positions": "Indications for Use While recovery positions are not generally used in an EMS or healthcare setting, it is important to understand how and when to use them. For patients who are unresponsive, but breathing normally with no suspected head, neck, spinal, hip or pelvic injury, move the patient into a side-lying recovery position after completing your assessment and gathering a patient history, based on local protocols. Patients with a suspected head, neck, spinal, hip or pelvic injury should not be placed in a recovery position unless you are unable to manage the airway effectively or you are alone and need to leave the patient to call for additional resources.",
        "Recovery Positions - Techniques": "To place a supine adult or child in a recovery position:\n\uf0a7\tKneel at the patient\u2019s side.\n\uf0a7\tLift the patient\u2019s arm that is closest to you up next to their head.\n\uf0a7\tTake the patient\u2019s arm that is farthest from you and place it next to their side.\n\uf0a7\tGrasp their leg that is closest to you and bend it up.\n\uf0a7\tPlace one of your hands on the patient\u2019s shoulder and your other hand on their hip that is farthest from you.\n\uf0a7\tUsing a smooth motion, roll the patient toward you by pulling their shoulder and hip with your hands. Make sure the patient\u2019s head remains in contact with their extended arm.\n\uf0a7\tStop all movement when the patient is on their side.\n\uf0a7\tPlace their knee on top of the other knee so that both knees are in a bent position.\n\uf0a7\tPlace the patient\u2019s free hand under their chin to help support their head and airway.\nTo place an infant in a recovery position:\n\uf0a7\tPlace the infant in a recovery position as would be done for an older child.\n\uf0a7\tYou also can hold an infant in a recovery position by:\n\tyCarefully positioning the infant face-down along your forearm.\n\tySupporting the infant\u2019s head and neck with your other hand while keeping the infant\u2019s mouth and nose clear.",
        "CRITICAL FACTS 2": "You should use a side-lying recovery position for patients who are unresponsive but breathing normally. Patients with a suspected head, neck, spinal, hip or pelvic injury should not be placed in a recovery position unless you are unable to manage the airway effectively or you are alone and need to leave the patient to call for additional resources.",
        "Supine Position": "Indications for Use\nIn a supine position, the patient is lying face-up. The supine position should be used when assessing an unconscious patient, when a patient needs CPR or assisted ventilation, or when a patient has suspected head, neck or spinal injuries. In order to perform CPR effectively, for example, a patient must be lying in a supine position. Transport a patient in shock in a supine position.",
        "Supine Position - Techniques": "A log roll is performed to transfer a patient to a supine position. Ideally, four responders should perform it. The most experienced member of the team should be at the patient\u2019s head. The responder at the head will be the lead for the move and will provide spinal motion restriction of the head and neck during the move. To provide SMR of the head, place your hands on either side of the patient\u2019s head at the jawline, with your fingers behind the head at the base of the skull. The second responder kneels at the patient\u2019s shoulders and upper back area. The third responder kneels at the patient\u2019s hips. The fourth responder kneels on the opposite side to position the backboard or other extrication device. The responder at the patient\u2019s head leads the move. On that responder\u2019s count, the other responders roll the patient as a team onto the patient\u2019s side, while the lead responder keeps the patient\u2019s head stable. The responder on the opposite side of the patient positions the backboard under the patient.",
        "MEDICAL RESTRAINT": "If a patient is aggressive or violent and in need of emergency care, they may need to be restrained. However, an EMR should avoid restraining a patient unless the patient presents a danger to themselves or to others. Also, be aware that some state laws require EMRs to have police authorization before they can use restraints. If you are not authorized to use restraints, ensure your safety and wait for someone with proper authority to arrive at the scene. Even if you are authorized to use restraints, it is still best to have police present, if possible. Seek approval from medical direction. Be aware of and follow local protocols involving the use of patient restraints. Restraining a patient without justification can give rise to a claim of assault and battery.",
        "MEDICAL RESTRAINT - Altered Mental Status": "Patients sometimes become aggressive or violent as a result of illness or trauma. Any condition that reduces the amount of oxygen to the brain, such as head injuries, can cause a significant change in behavior. Too little oxygen could make a normally calm patient suddenly become anxious or even violent. Physical illness as a result of substance abuse, diabetic emergencies, heat or cold exposure, or problems with the nervous system associated with aging can lead to alterations in behavior. Patients who are in an altered mental state may need to be restrained.",
        "MEDICAL RESTRAINT - Reasonable Force": "When restraining a patient, an EMR should always use reasonable force \u2014the minimum force necessary to keep a patient from injuring themselves or others. A force is considered reasonable if it is as great as or minimally greater than the force the patient is exerting to resist. The amount of force you should use depends on:\n\uf0a7\tThe height and weight of the patient.\n\uf0a7\tThe mental state of the patient.\n\uf0a7\tThe type of behavior the patient is manifesting.\uf0a7\tThe type of restraint to be used (e.g., humane restraints that are padded and made of cloth, leather or wide roller gauze versus metal handcuffs, which are not considered humane).",
        "MEDICAL RESTRAINT - Using Restraints": "If restraints must be used, be sure that you have adequate assistance. You will need at least four responders trained in the use of restraints, plus an additional EMR who can advise the patient what is taking place. Plan out your actions before you take them. You must know ahead of time what each responder will be doing so you can act quickly and safely. Remember that both medical and law enforcement personnel need to be consulted prior to the use of restraints. Always follow local protocols.\nUse only the force necessary to successfully apply the restraint. Estimate the range of motion of the patient\u2019s arms and legs, and stay beyond range until ready. Once the decision has been made to restrain the patient, act quickly. Have one EMR talk to the patient throughout restraining. Approach the patient with four responders simultaneously, one preassigned to each limb. Use only restraints that have been preapproved by medical direction. Restraints should be humane\u2014made of leather or cloth. In addition, use only commercial wrist- and ankle-restraining straps.\nNever secure a patient in a prone position. You must have access to the patient\u2019s airways at all times. A patient in a prone position will not be able to adequately breathe because the weight of the body will force the organs toward the diaphragm, which could lead to hypoxia (lack of oxygen) and other conditions. The lack of oxygen may cause the patient to become more aggressive. Be sure to monitor the patient\u2019s condition frequently.Restraint should be reserved only for situations where the patient presents a danger to themselves or to others. If state laws prohibit you from using restraints, ensure your safety and wait for proper authorities to arrive on the scene.",
        "CRITICAL FACTS 3": "When restraining a patient, use reasonable force. Force is considered reasonable if it is as great as or minimally greater than the force the patient is exerting to resist.",
        "MEDICAL RESTRAINT - Types of Restraints": "In circumstances where you need to restrain a patient, you will be using physical restraints, such as soft leather or cloth straps. There are also medications that act as a chemical form of restraint, but these must only be administered under medical authorization and by personnel trained to do so. Patients who are chemically restrained must be transported in an advanced life support (ALS) unit and should be monitored closely. Never leave any restrained patient unattended.",
        "PUTTING IT ALL TOGETHER": "Take the time to size up the scene upon arrival and determine if moving the patient is necessary before attempting to do so. Remember that your safety and the safety of your team always come first. This is especially true in incidents involving hazardous materials. Avoid the common mistake of moving an injured or ill person unnecessarily. If you recognize a potentially life-threatening situation that requires the patient be moved immediately, use one of the techniques described in this chapter. Use the safest and easiest method to rapidly move the patient without causing injury to either yourself or the patient. Practice the lifts, moves and carries ahead of time so that they will be automatic to you when you need to use them. It is important for you to familiarize yourself with some of the typical equipment used in local EMS systems. Practice using the different types of stretchers, backboards and extrication devices, as you could be called on to use them at any time. If it becomes necessary to restrain a patient, follow the prescribed protocol carefully and ensure you have law enforcement and medical authorization before restraining a patient. Document the situation carefully to avoid future legal problems.",
        "Skill Sheet - Clothes Drag": "NOTE: The clothes drag is an appropriate emergency move for a patient suspected of having a head, neck or spinal injury. STEP 1: Position the patient on their back. STEP 2: Kneel behind the patient\u2019s head. STEP 3: Gather the patient\u2019s clothing behind the neck. STEP 4: Using the clothing, pull the patient to safety. Additional Instructions: Cradle the patient\u2019s head with the clothing and your hands, move carefully backward, keep your back straight and bend your legs.",
        "Skill Sheet - Blanket Drag": "NOTE: The blanket drag is appropriate for a patient suspected of having a head, neck or spinal injury. STEP 1: Position a blanket next to the patient. STEP 2: Keep the patient between you and the blanket. STEP 3: Gather half the blanket and place it against the patient\u2019s side. Keep about 2 feet of blanket above the patient\u2019s head. STEP 4: Roll the patient toward your knees and position the blanket next to the patient. STEP 5: Gently roll the patient onto the blanket as a unit. STEP 6: Smooth out the blanket and wrap it around the patient. STEP 7: Gather the excess at the patient\u2019s head and drag the blanket. Keep the patient\u2019s head low and move carefully backward, keeping your back straight.",
        "Skill Sheet - Shoulder Drag": "NOTE: This move is not safe for a patient suspected of having a head, neck or spinal injury. STEP 1: Reach under the patient\u2019s armpits from the back, grasp their forearms, and drag. Keep your back straight and do not twist. STEP 2: Carefully move backward.",
        "Skill Sheet - Ankle Drag": "NOTE: This move is not safe for a patient suspected of having a head, neck or spinal injury. STEP 1: Firmly grasp the patient\u2019s ankles and move backward. Pull on the long axis of the body and avoid bumping the patient\u2019s head. STEP 2: Move backward carefully, keeping your back straight and not twisting.",
        "Skill Sheet - Firefighter\u2019s Drag": "NOTE: This move is not safe for a patient suspected of having a head, neck or spinal injury. STEP 1: Position the patient on the back and bind their wrists gently. STEP 2: Straddle the patient and slip your head through their arms. STEP 3: Place the patient\u2019s bound wrists behind your head. STEP 4: Crawl forward slowly, carrying the patient. Keep your back straight and the patient centered under you. Avoid bumping the head.",
        "Skill Sheet - Firefighter\u2019s Carry": "NOTE: This carry is not appropriate for patients with suspected head, neck, spinal or abdominal injuries. STEP 1: Grasp the patient\u2019s wrists. STEP 2: While standing on their toes, pull the patient over a shoulder. STEP 3: Pass an arm between the legs and grasp the arm nearest you. Alternate method: Kneel in front of a seated patient, place one shoulder against their abdomen, and hoist them over your shoulders. STEP 4: Pull the patient over a shoulder. STEP 5: Ensure the patient\u2019s feet are on one side and the head on the other. STEP 6: Lift with your legs and stand up while keeping your back straight.",
        "Skill Sheet - Pack-Strap Carry": "NOTE: This move is not safe for a patient suspected of having a head, neck or spinal injury. Usable on conscious and unconscious patients. STEP 1: Have the patient stand, or get help supporting them. STEP 2: Face away from the patient, bend your knees, and fit your shoulders into their armpits. STEP 3: Cross the patient\u2019s arms in front of you and grasp their wrists. STEP 4: Lean forward and pull the patient onto your back. STEP 5: Stand and walk to safety.",
        "Skill Sheet - Walking Assist": "NOTE: Can be used by one or two responders with a conscious patient. STEP 1: Place the patient\u2019s arm across your shoulders and hold it in place. STEP 2: Support the patient with your other hand around their waist. A second responder can assist similarly from the other side.",
        "Skill Sheet - Two-Person Seat Carry": "NOTE: Not for patients with suspected head, neck or spinal injury. STEP 1: Put one arm under the patient\u2019s thighs and one across their back. STEP 2: Interlock your arms with the second responder under the thighs and back. The patient places arms over the responders\u2019 shoulders. STEP 3: Lift the patient in the arm-formed seat. Keep backs straight and lift with legs.",
        "Skill Sheet - Direct Ground Lift": "NOTE: Requires at least three responders. STEP 1: All responders kneel on one side of the patient. The patient crosses arms over the chest. STEP 2: Responder at the head cradles the head and upper back. STEP 3: Second responder places arms under waist and buttocks. STEP 4: Third responder cradles hips and legs. STEP 5: On signal, lift the patient to knees and roll them against chests. STEP 6: Carefully stand and transfer to stretcher. Reverse steps to lower. Keep backs straight and lift with legs.",
        "Skill Sheet - Extremity Lift": "NOTE: Requires two responders. STEP 1: First responder kneels behind the patient and grasps under arms and opposite wrists. STEP 2: Second responder kneels between the patient\u2019s legs and grasps behind the knees and thighs. STEP 3: On signal, both responders move to standing position. STEP 4: Move the patient to the stretcher."
    },
    {
        "LEARNING OBJECTIVES": "After reading this chapter, and completing the class activities, you will have the information needed to: \u2022 Summarize the history and origins of the emergency medical services (EMS) system. \u2022 Describe the components of an EMS system, and discuss factors related to 'right to practice.' \u2022 Explain the different levels of EMS training. \u2022 Discuss the continuity of care and the importance of working with other responders.\u2022 Define who an emergency medical responder (EMR) is. \u2022 List the roles and responsibilities of an EMR. \u2022 Describe the personal characteristics and professional behavior expected of an EMR. \u2022 Discuss medical oversight. \u2022 Discuss factors related to the 'right to practice.'",
        "KEY TERMS": "Advanced emergency medical technician (AEMT): A person trained to give basic and limited advanced emergency medical care and transportation for critical and emergent patients who access the emergency medical services (EMS) system., Certification: Certification is achieved by obtaining and maintaining the National EMS Certification (or state certification), taking an approved EMS course and meeting other requirements; this does not grant the right to practice as licensure may in some states., Direct medical control: A type of medical direction, also called 'on-line,' 'base-station,' 'immediate' or 'concurrent medical control'; under this type of medical direction, the physician speaks directly with emergency care providers at the scene of an emergency., Emergency medical responder (EMR): A person trained in emergency care who may be called on to give such care as a routine part of their job (paid or volunteer) until more advanced emergency medical services (EMS) personnel take over; EMRs are often the first trained professionals to respond to emergencies., Emergency medical services (EMS) system: A network of community resources and medical personnel that provides emergency medical care to people who are injured or suddenly fall ill., Emergency medical technician (EMT): A person who gives basic emergency medical care and transportation for critical and emergent patients who access the EMS system; EMTs are typically authorized to function after completing local and state certification requirements; formerly referred to as EMT-Basic., Indirect medical control: A type of medical direction, also called 'off-line,' 'retrospective' or 'prospective' medical control; this type of medical direction includes education, protocol review and quality improvement for emergency care providers., Licensure: Required acknowledgment that the bearer has permission to practice in the licensing state; offers the highest level of public protection; may be revoked at the state level should the bearer no longer meet the required standards., Local credentialing: Local requirements EMRs must meet in order to maintain employment or obtain certain protocols so that they may practice., Medical direction: The monitoring of care provided by out-of-hospital providers to injured or ill persons, usually by a medical director., Medical director: A physician who provides oversight and assumes responsibility for the care of injured or ill persons provided in out-of-hospital settings., Paramedic: An allied health professional whose primary focus is to give advanced emergency medical care for critical and emergent patients who access the EMS system. Paramedics may also give nonemergency, community-based care based on state and local community paramedicine or mobile integrated healthcare programs., Prehospital care: Emergency medical care provided before a patient arrives at a hospital or medical facility., Protocols: Standardized procedures to be followed when providing care to injured or ill persons., Scope of practice: The range of duties and skills that are allowed and expected to be performed when necessary, according to the professional\u2019s level of training, while using reasonable care and skill., Standing orders: Protocols issued by the medical director allowing specific skills to be performed or specific medications to be administered in certain situations.",
        "INTRODUCTION": "The emergency medical services (EMS) system, along with its front-line-trained emergency medical responders (EMRs), plays a vital role in the health and safety of the population. By providing emergency services rapidly and effectively, EMRs save many lives and minimize damage caused by injuries. The role of the EMR can vary, however, depending on the state and the location of practice. It is important for every EMR to understand the role of practice and any limitations, to be able to provide timely and skillful care. As an EMR, you provide a link between the first actions of bystanders and more advanced care. An EMR is a person trained in emergency care, paid or volunteer, who is often summoned to provide initial care in an emergency. As the first trained professional on the scene, your actions are often critical. They may determine whether a seriously injured or ill person survives. By taking this course, you will gain the knowledge, skills and confidence to provide appropriate care when you are called upon to help a person who has sustained an injury or sudden illness. You will learn how to assess a patient\u2019s condition and how to recognize and care for life-threatening emergencies. You will also learn how to minimize a patient\u2019s discomfort and prevent further complications until more advanced medical personnel take over.",
        "THE EMS SYSTEM - History and Origins": "In the early 1960s in the United States, firefighters in some regions were taught how to perform CPR and basic first aid. There were two reasons for this. First, it prepared them to provide emergency care to colleagues injured in action. Second, because firefighters are based in communities all across the country, they were a practical choice to be available to answer emergency calls. Although some firefighters received training in CPR and first aid, there was no organized EMS network in the early 1960s. This meant that there was no standardized or regulated training to ensure comparable emergency care education between the different regions. This patchwork of resources resulted in response times and quality of care that differed between locations. Also, by not having a directed, formal EMS system, educational requirements differed by location. In 1966, the National Academy of Sciences/National Research Council (NAS/NRC) documented the problem in a white paper that found the quality of emergency care in the United States to be dismal. Entitled \u201cAccidental Death and Disability: The Neglected Disease of Modern Society,\u201d the white paper criticized both ambulance services and hospital emergency departments. In response to this white paper, in 1973, the U.S. Congress enacted the Emergency Medical Services Act, which created a multi-tiered, nationwide system of emergency healthcare. Among other things, the legislation called for standardized training within the EMS system.",
        "Types of EMS Systems": "Today, several types of EMS services operate in the United States: \uf0a7 Fire-based services: These services are operated directly by a local, county or regional fire-rescue department. Approximately half of all communities in the United States depend on fire departments to provide emergency services. \uf0a7 Private services: These are for-profit and not-for-profit companies that have been hired (often on a contract basis) by local governmental agencies to perform EMS services in specific geographic areas. \uf0a7 Hospital-based services: These services are those that are backed up, monitored and run by a local hospital. \uf0a7 Third services: These are provided by community-based EMS departments that are not a subset of a fire or police department. Many large cities employ the third-service model. \uf0a7 Other systems: These include other police and private systems that do not fit one of the models above, such as a private corporate response system servicing an industrial complex. At each of these levels, the delivery of care may be different, but the goal is always the same: to provide care according to community needs and resources.",
        "Regulating Agencies": "Working with federal partners, the National Highway Traffic Safety Administration\u2019s (NHTSA) Office of EMS advances a national vision for EMS through projects and research, fosters collaboration among federal agencies involved in EMS planning, measures the health of the nation\u2019s EMS systems, and delivers the data EMS leaders need to help advance their systems. Its mission is to reduce death and disability by providing leadership and coordination to the EMS community in assessing, planning, developing and promoting comprehensive, evidence-based emergency medical services and 9-1-1 systems. In addition to NHTSA\u2019s oversight of the EMS system, each state and territory has a lead EMS office of its own. These can fall under the individual state health or public safety department. In some states, the EMS office is independent. State EMS agencies are responsible for the overall planning, coordination and regulation of the EMS system within the state as well as licensing or certifying EMS providers. Their responsibilities may include leading statewide trauma systems; licensing and certifying EMS services, vehicles and personnel; developing and enforcing statewide protocols for EMS providers in addition to the national requirements; administering or coordinating regional EMS programs; operating or coordinating statewide communications systems; coordinating and distributing federal and state grants; and planning and coordinating disaster and mass casualty responses, as well as homeland security medical initiatives.",
        "Components of an EMS System - NHTSA Technical Assistance Program Assessment Standards": "As part of its role to oversee the national EMS system, NHTSA has designated 10 components that make up an effective EMS system and has identified a method of assessing those areas. NHTSA\u2019s statewide EMS Technical Assistance Program allows states to request a team of outside experts, a Technical Assistance Team (TAT), to conduct a comprehensive assessment of each statewide EMS program. The assessment provides an overview of the current program in comparison to a set of standards. This evaluation outlines the program\u2019s strengths and weaknesses, as well as recommendations for improvement. Almost all states and territories have utilized this process, and states may also request a reassessment by making joint requests to their state Highway Safety Office and NHTSA Regional Office. By measuring the progress of EMS systems against the standard set by NHTSA, states can ensure the EMS system is effective nationwide.",
        "Technical Assistance Program Assessment Standards,": "State agencies have regulations and policies in place that govern their EMS systems, and these vary across states. As an Emergency Medical Responder (EMR), it is your responsibility to understand the applicable regulations in your state of practice. To ensure that all patients receive the necessary care, states must maintain central control of EMS resources, which includes providing properly trained personnel and essential equipment like vehicles, tools, and medical supplies. All EMS personnel must be adequately trained, with EMR as the basic level, and state agencies must monitor and regularly evaluate these training programs. Safe and reliable transportation services must be available to ensure all citizens have equal access to emergency care. EMS systems also require a network of appropriate receiving facilities tailored to meet diverse medical needs\u2014ranging from emergency departments to specialized trauma, burn, stroke, or pediatric centers. A designated communications system, typically 9-1-1, is essential for public access and coordination among EMS providers, though alternate numbers may be used in some regions. Public information and education programs are also important, providing guidance on injury prevention and the proper use of EMS services. Oversight by a physician medical director is required for each EMS system to ensure quality and compliance. In addition, trauma systems must be in place to route patients quickly and effectively to the appropriate facilities based on their needs. Finally, EMS systems must undergo continuous evaluation and improvement, guided by each state's governing body, to ensure high-quality care and system effectiveness.",
        "Access to the EMS System": "The 9-1-1 service was created in the United States in 1968 as a nationwide telephone number for the public to use to report emergencies and request emergency assistance. It gives the public direct access to an emergency communications center called a public safety answering point (PSAP), which is responsible for taking appropriate action. The numbers 9-1-1 were chosen because they best fit the needs of the public and the telephone companies. They are easy to remember and dial, and they have never been used as an office, area or service code. Most of the population and geography of the United States is covered by some type of 9-1-1 service. Today, an estimated 240 million calls are made to 9-1-1 each year in the United States. In many areas, 70 percent or more are from a wireless device. People who call 9-1-1 using a mobile phone should remember the following tips, to assist the PSAP in finding their location: \u2022 Callers should tell the call taker the location of the emergency right away. \u2022 They should then give the call taker the mobile phone number so that they can call back if the call gets disconnected. This is especially important if callers do not have a contract for service with a mobile phone service provider, because in these cases dispatch centers will have no way of obtaining the mobile phone number and may be unable to contact them. \u2022 Callers should learn to use the designated number in their state for highway crashes or other non-life-threatening incidents, if there is one. States often reserve specific numbers for these types of incidents. For example, \u201c#77\u201d is the number used for highway crashes in a number of states. The number to call for non-life-threatening incidents in each state may be located in the front of the phone book or found online. \u2022 Callers should not program their mobile phone to automatically dial 9-1-1 when one button, such as the \u201c9\u201d key, is pressed. Mobile 9-1-1 calls often occur when autodial keys are pressed unintentionally. This causes problems for PSAPs. \u2022 Callers should turn off the autodial 9-1-1 feature if the mobile phone came preprogrammed with it already turned on. They can check their user manual to find out how. \u2022 Callers should lock their keypad when they are not using the mobile phone. This action prevents accidental calls to 9-1-1. The next generation of 9-1-1 systems\u2014NG91 1\u2014 is now being implemented across the nation to create a faster, more flexible, resilient and scalable system that allows 9-1-1 to keep up with communication technology used by the public. NG91 1 is a system that allows digital information (e.g., audio, photos, video, text messages) to flow seamlessly from the public, through the 9-1-1 network, and on to emergency responders. While many of these new functions are not currently available in most states, progress is being made rapidly.",
        "Levels of EMS Training - National EMS Education Agenda for the Future: A Systems Approach": "The need for standards in EMS care was identified back in the 1960s. At that time, the National Standard Curricula (NSC) were developed by the U.S. Department of Transportation (DOT) and NHTSA, in response to a mandate by Congress. Between 1966 and 1973, NSC were developed for EMT-Basics, Intermediates and Paramedics. These curricula standardized aspects such as course planning and structure, objectives, lessons, content and hours of instruction. In 1996, the NHTSA and the Health Resources and Services Administration (HRSA) published a document entitled the EMS Agenda for the Future (the Agenda ). The purpose of this document was to create a common vision for the future of EMS systems. The document was designed to be used by national, state and local governments, as well as by private organizations, in order to guide planning, decision making and policy around EMS care. One of several areas addressed in the Agenda was the EMS education system. NHTSA, along with more than 30 EMS-related organizations, implemented steps to address the education section of the Agenda . The plan for this implementation was entitled the National EMS Education and Practice Blueprint (known as the Blueprint ), and represents an important component of the EMS education system. The purpose of this document was to establish nationally recognized levels of EMS providers and scopes of practice, a framework for future curriculum-development projects, and a standardized way for states to handle legal recognition and reciprocity. In 1998, a group under the NHTSA met to develop procedures to revise the Blueprint and developed a document entitled the EMS Education Agenda for the Future: A Systems Approach (the Education Agenda ). The Education Agenda proposed an education system with five components: 1. National EMS Core Content 2. National EMS Scope of Practice Model 3. National EMS Education Standards 4. National EMS Education Program Accreditation 5. National EMS Certification The main benefit of this systematic approach was the resulting consistency of instructional quality it would achieve through the system\u2019s three main components: the National EMS Education Standards, the National EMS Education Program Accreditation and the National EMS Certification. The National EMS Education Standards replaced the NSC and set minimum learning objectives for each level of practice. National EMS Certification now is available for all levels of providers and entails a standardized examination process to ensure entry-level competence of EMS providers.",
        "National Scope of Practice": "The scope of practice of an EMR is defined as the range of duties and skills that the EMR is allowed and expected to perform when necessary, while using reasonable care and skill according to the EMR\u2019s level of training. While the scope of practice does not have regulatory authority, it does provide guidance to states. The EMR is governed by legal, ethical and medical standards. Since practices may differ by region, responders must be aware of the variations that exist for their level of training, certification and/or licensure in their region. Whenever the national scope of practice is updated for any level of EMS responder, responder duties and skills will be impacted.",
        "CRITICAL FACT 4": "The scope of practice of an EMR is defined as the range of duties and skills that the EMR is allowed and expected to perform when necessary, while using reasonable care and skill according to the EMR\u2019s level of training and the terms of certification and/or licensure in the location where they practice. An EMR\u2019s responsibilities are to ensure safety, gain safe access to the patient, determine threats to the patient\u2019s life, summon more advanced medical personnel and assist them as needed, and provide needed care for the patient.",
        "Emergency medical responder (EMR)": "EMRs have the basic knowledge and skills needed to provide emergency care to people who are injured or who have become ill. They are certified to provide care until a more highly trained professional\u2014such as an EMT\u2014takes over. EMR is the initial training level within the EMS system.",
        "Emergency medical technician (EMT)": "EMTs have the next highest level of training. An EMT gives basic emergency medical care and transportation for critical and emergent patients who access the EMS system. EMTs are typically authorized to function after completing local and state certification requirements; formerly referred to as EMT-Basic",
        "Advanced emergency medical technician (AEMT)": "AEMTs receive more training than EMTs, which allows them to give basic and limited advanced emergency medical care and transportation for critical and emergent patients who access the EMS system, such as insertion of IVs, the administration of a limited number of emergency medications and insertion of some advanced airway devices. This level of care used to be called EMT-Intermediate.",
        "Paramedic": "Paramedics have more in-depth training than AEMTs, including more knowledge about performing physical exams. They may perform more invasive procedures than any other prehospital care provider. Paramedics are considered allied health professionals whose primary focus is to give advanced emergency medical care for critical and emergent patients. They may also give nonemergency, community-based care based on state and local community paramedicine or mobile integrated healthcare programs. This level of care used to be called EMT-Paramedic.",
        "Working with Other Responders and Continuity of Care": "Continuity of care in an emergency situation can be compared to a course of action. As an EMR, you are often the first on the scene and begin the course of action. While providing care, you will collect all the information you require to pass on to the next level of personnel when they arrive or to the receiving facility if you are providing transport. A smooth transition of care depends on the proper and thorough relay of information. As an EMR, you will be working and communicating with other medical personnel including EMTs, AEMTs and paramedics as well as other public safety personnel, emergency management, home healthcare providers and others.",
        "Who Is an EMR?": "An EMR is a person trained in emergency care who may be called on to provide such care as a routine part of their job, whether that job is voluntary or paid. EMRs have a duty to respond to the scene of a medical emergency and to provide emergency care to the injured or ill person. They are recognized and certified to provide emergency care to the general public until more advanced medical personnel take over. Some occupations, such as law enforcement and firefighting, require personnel to respond to and assist at the scene of an emergency. These personnel are dispatched through an emergency number, such as 9-1-1, and often share common communications networks. When someone dials 9-1-1, this will contact police, fire or EMS personnel. These are typically considered public safety personnel. However, EMRs do not necessarily work for public safety agencies. People in many occupations other than public safety are called to help in the event of an injury or sudden illness, such as: \uf0a7 Athletic trainers. \uf0a7 Camp leaders. \uf0a7 Emergency management personnel. \uf0a7 First aid station members. \uf0a7 Industrial response teams. \uf0a7 Lifeguards. \uf0a7 Ski patrol members. In an emergency, these people are often required to provide the same minimum standard of care as traditional EMRs. Their duty is to assess the patient\u2019s condition and provide necessary care, make sure that any necessary additional help has been summoned, assist other medical personnel at the scene and document their actions.",
        "EMR Responsibilities": "To be an EMR means to accept certain responsibilities beyond providing care. Since you will often be the first trained professional to arrive at many emergencies, your primary responsibilities center on safety and early emergency care. Your major responsibilities are to: \uf0a7 Ensure safety for yourself and any bystanders. Your first responsibility is not to make the situation worse by getting hurt or letting bystanders get hurt. By making sure the scene is safe as you approach it, you can avoid unnecessary injuries. \uf0a7 Gain safe access to the patient. Carefully approach the patient unless the scene is too dangerous for you to handle without help. Electrical or chemical hazards, unsafe structures and other dangers may make it difficult to reach the patient. Recognize when a rescue requires specially trained emergency personnel. \uf0a7 Determine any threats to the patient\u2019s life. Check first for immediate life-threatening conditions, and care for any you find. Next, look for other conditions that could threaten the patient\u2019s life or health if not addressed. \uf0a7 Summon more advanced medical personnel as needed. After you quickly assess the patient, notify more advanced EMS personnel of the situation, if someone has not done so already. \uf0a7 Provide needed care for the patient. Remain with the patient and provide whatever care you can until more advanced medical personnel take over. \uf0a7 Assist more advanced medical personnel. Transfer your information about the patient and the emergency to more advanced medical personnel. Tell them what happened, how you found the patient, any problems you found and any care you provided. Assist them as needed within your level of training, and help with care for any other patients. When possible, try to anticipate the needs of those providing care. In addition to these major responsibilities, you have secondary responsibilities that include: \uf0a7 Summoning additional help, such as special rescue teams and utility crews, when needed. \uf0a7 Controlling or directing bystanders or asking them for help. \uf0a7 Taking additional steps, if necessary, to protect bystanders from dangers, such as traffic or fire. \uf0a7 Recording what you saw, heard and did at the scene. \uf0a7 Reassuring the patient\u2019s family or friends.",
        "Maintaining Certification": "As an EMR, you have an obligation to remain up-to-date on the knowledge, skills and use of equipment needed for you to fulfill your role competently and effectively. Your employer should provide you with the requirements for your area. Some areas require a higher level of knowledge for their EMRs, above and beyond the basic requirements. As an EMR, you have an obligation to remain up-to-date on the knowledge, skills and use of equipment needed for you to fulfill your role competently and effectively.",
        "Continuing Education": "The field of healthcare, particularly emergency care, changes quickly as newer and better techniques and methods are discovered. EMRs must keep up-to-date on all of the new developments that affect them and the care they provide. As an EMR, you will be required to participate in various types of continuing education (CE) programs as outlined by the certifying body and your region.",
        "Criminal Implications": "The National EMS Scope of Practice Model places limitations on your scope of practice to ensure that what you do is in the interest of public protection and safety. Standards for EMR education, certification, licensure and credentialing are all mechanisms that set the parameters of practice. Criminal implications may arise for you if you perform procedures that are outside of what you are trained to do, what you are certified as competent to do, what you are legally licensed to do or what you have been credentialed (authorized by a medical director) to do. EMRs must not be placed in situations in which they are expected to perform procedures they have not been sufficiently trained to do or for which they have insufficient experience. There are also criminal implications for falsification of care or training records, or for allowing your certification to lapse and continuing to practice.",
        "Fees": "One of your areas of responsibility is paying required fees. There is a fee to obtain licensure and recertification, and there may be fees for certain exams. You will also be required to obtain continuing education units (CEUs) to maintain your knowledge and skills. Fees vary widely from state to state and are usually your responsibility, though employers may sometimes assist with them.",
        "Personal Characteristics and Professional Behavior": "The responsibilities of EMRs require that they demonstrate certain characteristics. These include: \uf0a7 Maintaining a caring and professional attitude. Injured or ill people are sometimes difficult to work with. Be compassionate; try to understand their concerns and fears. Realize that anger shown by an injured or ill person often results from fear. A lay responder who helps at the emergency may also be afraid. Try to be reassuring. Even though lay responders may not have done everything perfectly, be sure to thank them for taking action. Recognition and praise help to affirm their willingness to act. Also be careful about what you say. Do not volunteer distressing news about the emergency to the patient or to the patient\u2019s family or friends. \uf0a7 Controlling your fears. Try not to reveal your anxieties to the patient or bystanders. The presence of blood, vomit, unpleasant odors, or torn or burned skin is disturbing to most people. You may need to compose yourself before acting. If you must, turn away for a moment and take a few deep breaths before providing care. \uf0a7 Presenting a professional appearance. This helps ease a patient\u2019s fears and inspires confidence. \uf0a7 Keeping your knowledge and skills up-to-date. Involve yourself in continuing education, professional reading and refresher training. \uf0a7 Maintaining a safe and healthy lifestyle. Job stresses can adversely affect your health. As an EMR, it is important to maintain a safe and healthy lifestyle both on and off the job. Exercise, diet and common sense safety practices can help you manage physical, mental and emotional stress, and may help you be more effective as an EMR.",
        "Medical Director": "Medical direction is the process by which a physician directs the care provided by out-of-hospital providers to injured or ill people. Usually this monitoring is done by a medical director, who provides oversight and assumes responsibility for the care provided. The physician also oversees training and the development of protocols (standardized procedures to be followed when providing care to injured or ill people).",
        "Medical Control": "Since it is impossible for the medical director to be present at every incident outside the hospital, the physician directs care through standing orders. Standing orders allow EMS personnel to provide certain types of care or treatment without speaking to the physician. This kind of medical direction is called indirect medical control. Indirect medical control, or \u201coffline\u201d medical direction, includes education, protocol review and quality improvement for emergency care providers.Other procedures that are not covered by standing orders require EMRs to speak directly with the physician. This contact can be made via mobile phone, radio or telephone following local requirements. This kind of medical direction is called direct medical control, or \u201conline\u201d medical direction.",
        "Legislation and Scope of Practice": "EMRs must follow state regulations that determine what they can and cannot do. Each state has very specific laws and rules governing how EMS personnel may practice in the out-of-hospital setting.",
        "State EMS Office Oversight": "EMRs must be licensed or certified through the state EMS office, the licensing or certifying agency, before being allowed to work in that state. EMRs should be familiar with these laws and regulations. Typical legal concerns and issues are addressed in Chapter 3.",
        "Medical Direction": "Medical direction is provided by the medical director, who assumes responsibility for care provided.",
        "Levels of Credentialing": "There are three aspects to credentialing of EMRs, all with the goal of protecting the public: certification, licensure and local credentialing.",
        "Certification": "Certification is achieved by obtaining and maintaining the National EMS Certification (or state certification), taking an approved EMS course and meeting other requirements. This does not grant you the right to practice as licensure may in some states. EMS personnel generally need to recertify every 2 years, to ensure that they maintain a high degree of competency by re-affirming their knowledge, skills and abilities as well as learning any new skills or information.",
        "Licensure": "Licensure is an acknowledgement that the bearer has permission to practice in the licensing state. It is the highest level of public protection, which is granted at the state level. It is generally a requirement, with a few exceptions, for work on federal land or in the military. States often have requirements in addition to those required for certification, before they grant licensure. The state is the final authority for public protection; therefore, states can revoke state licensure if appropriate.",
        "Local Credentialing": "Often, EMS providers must meet local credentialing requirements in order to maintain employment or obtain certain protocols so that they may practice. Most employers also have additional requirements as part of an orientation program that would be similar to a local credentialing process.",
        "Administrative Requirements": "EMRs must follow any policies and procedures based on national, state, local or employer requirements. For example, the Health Insurance Portability and Accountability Act (HIPAA) is national; protocols can be state or local; and specifics of uniform (e.g., level of training and credentialing recognition) could be employer requirements.",
        "Research": "The field of emergency care and emergency medicine is constantly evolving. Quality improvement (QI), or continuous quality improvement (CQI), based on research, allows for continuing assessment and reassessment of all aspects of the EMS system. This includes viewing and evaluating the system internally, from the personnel\u2019s and administration\u2019s point of view. Emergency Medical Responseand also externally, from the public\u2019s point of view. It also entails keeping personnel and equipment up-to-date with the latest standards of care, ensuring that personnel are adequately trained and skilled in using new knowledge. One example is the continuous evaluation of CPR procedures. As new recommendations come about and become the recognized standard through an evidence-based guidelines process, EMS systems across the country must ensure that employees and volunteers are up-to-date and comfortable performing new techniques. The goal of an EMS system is to provide the highest quality of care possible throughout the country, equally accessible to all citizens. Through research, QI programs can assess whether that goal is being met.",
        "PUTTING IT ALL TOGETHER": "Since the EMS system was established in the United States, it has undergone significant changes as it has grown and adapted to citizens\u2019 needs. However, this growth needs to continue as the field of emergency and prehospital care continues to evolve.The primary role of an EMR is to provide emergency care at the scene, while working with other services and healthcare personnel. It is important to understand that the role of the EMR does not stop at providing care. EMRs must continue to grow and learn along with the field. They must remain certified and retain their licensure in order to practice in their chosen state and, as such, must maintain the necessary standards as outlined by that state. To be an effective EMR, you must not only be able to keep up the professional side of your work, but your personal side. EMRs have a responsibility to remain fit and healthy in order to perform their duties accordingly. This means maintaining a healthy lifestyle, and being aware of your choices and how they would and could affect your performance on the job. The size and scope of the EMS system in each state may vary according to population, needs and resources. However, all systems have some things in common: namely, their need for certification and licensure, and their goal of providing equal access to prehospital care to all citizens."
    },
    {
        "Introduction": "To be an effective emergency medical responder (EMR), you need to prepare for an emergency medical services (EMS) call, review dispatch information, respond safely to the scene, perform a scene size-up, perform initial patient assessment and provide emergency care, update responding EMS units and transfer care to other EMS personnel, and complete postrun activities. This chapter describes the phases of an EMS call and the tasks required to complete each of these phases safely. The second part of this chapter describes your role in helicopter medivac operations. It describes helicopter safety guidelines, how to set up a landing zone, and how to assist with loading patients into a helicopter.",
        "Preparing for a Call": "In your primary role as a law enforcement officer, firefighter, lifeguard, or security guard, you are also on call as an EMR. In preparing yourself for a call, you must understand your role as a member of the emergency medical system. You may respond using a fire department vehicle, a law enforcement vehicle, your personal vehicle, or on foot. It is important to ensure these vehicles are ready to respond at all times. Follow a regular schedule to inspect and maintain all vehicles. Your department should provide a checklist to follow to ensure that everything is in working order, such as checking tire pressure, fluid levels, and fuel levels. Be prepared to respond promptly, using the most direct route available. Make sure you have the proper equipment to perform your job, including the medical equipment in your EMR life support kit, your personal safety equipment, and equipment to safeguard the incident scene. Suggested contents of an EMR life support kit are shown in Figure 19-1 and listed in Table 19-1. This equipment must be stocked and maintained on a regular basis according to the schedule specified by your agency.",
        "Suggested Contents of an EMR Life Support Kit": "When you respond to an EMS call, make sure each task is carefully completed to ensure a safe and positive outcome to the incident.\nPersonal Safety: It includes five pairs of gloves, five face masks, and a bottle of hand sanitizer to minimize contamination and protect both patients and responders.\nResuscitation: A mouth-to-mask resuscitation device, a portable hand-powered suction unit, plus sets of oral and nasal airways support breathing and airway management.\nBandaging and Dressing: Essential wound-care materials include ten 1-inch (3 cm) gauze adhesive strips, ten 4-inch by 4-inch (10 cm by 10 cm) gauze pads, five 5-inch by 9-inch (13 cm by 23 cm) gauze pads, two universal 10-inch by 30-inch (25 cm by 76 cm) trauma dressings, one occlusive dressing, four 3-inch by 15-foot (8 cm by 5 m) gauze rolls, four 4.5-inch by 15-foot (11 cm by 5 m) gauze rolls, six triangular bandages, one roll of 2-inch (5 cm) adhesive tape, and a burn sheet.\nPatient Immobilization: To stabilize head, neck, and limbs, the kit provides two (each) small, medium, and large cervical collars\u2014or two adjustable collars\u2014and three rigid conforming splints (or similar alternatives like air splints or cardboard splints).\nExtrication: A spring-loaded center punch and heavy leather gloves assist in safely freeing patients from confined spaces.\nMiscellaneous: Additional supplies include two disposable blankets, two cold packs, a pair of bandage scissors, and an obstetric kit.\nOther Equipment: Personal protective clothing (helmet, eye protection, EMS jacket), a reflective vest, a 5 lb (2 kg) ABC dry chemical fire extinguisher, an Emergency Response Guidebook, six flares, and a pair of binoculars can also be carried.\nOptional Items (depending on local protocols): Oral glucose and intranasal naloxone.",
        "Dispatch": "The dispatch facility is a center that citizens can call to request emergency medical care. Most centers are part of a 9-1-1 system that is responsible for receiving emergency calls at a public safety answering point (PSAP) and then dispatching fire, police, and EMS. You should understand how the dispatch facility used by your department operates. Your job will be easier if the dispatcher obtains the proper information from the caller. Dispatchers should also be able to instruct callers on how to perform lifesaving techniques such as cardiopulmonary resuscitation until you arrive. You may receive your dispatch information by telephone, radio, pager, computer terminal, or written printout. Regardless of the transmission method, the information should include the nature of the call, the name and location of the patient, the number of patients, and any special conditions at the scene. The dispatcher should also obtain a callback number in case you need more information from the caller. Without adequate dispatch information, you will not be able to respond properly.",
        "Response to the Scene": "Your first priority in responding to the scene is to get there quickly and safely. Consider traffic patterns and the time of day before you select the best route to the scene. Before you begin to respond, be sure you know how to get to the location of the call. Be certain that all personnel are properly seated and secured with approved seat belts. Keep all equipment secured so it does not injure someone in the event of a sudden stop or crash. Use emergency lights and sirens according to your state laws and according to the regulations of your agency. Remember that emergency lights and sirens allow you to request the right of way; they do not guarantee it. Be especially careful at intersections and railroad crossings. Do not exceed a safe speed for the vehicle you are operating. Be aware that distractions such as radios, mobile devices, and global positioning systems (GPS) can contribute to vehicle crashes. Reduce your speed on unpaved roads, on wet or icy roads, and during periods of darkness or reduced visibility. Follow all safety procedures specified by your department. Above all else, drive defensively so you are not involved in a crash. Remember, your goal is to arrive on the scene safSafetyely.",
        "Safety": "Emergency lights and sirens allow you to request the right of way but do not guarantee it. Drive defensively and safely.",
        "Arrival at the Scene": "When you arrive at the scene, remember to place your vehicle in a safe location to minimize the chance of injury. Consider how best to position your vehicle to effectively use your warning lights. Remember to perform a scene size-up as outlined in the patient assessment sequence. Look for safety hazards such as downed power lines, leaking fuel, broken glass, and fire, as described in, as well as potential biologic hazards. Control the flow of traffic to ensure the safety of responders, patients, and bystanders. Determine the number of patients and determine whether you need to call for additional resources. Be as efficient and as organized as you can. Provide patient care using the knowledge and skills you have learned in this course. Call for additional resources if needed.",
        "Safety_0": "Always take standard precautions to prevent contamination by the patient\u2019s body fluids.",
        "Perform Patient Assessment and Provide Emergency Care": "Many of the activities you perform at the scene of an emergency are related to the assessment and treatment of patients. The knowledge and skills needed to perform patient assessment and provide treatment are detailed throughout this book. These skills are mentioned here only to give you an idea of where they fit within the phases of responding to an emergency call.",
        "Transferring the Care of the Patient to Other EMS Personnel": "As more highly trained EMS personnel arrive on the scene, you will have to transfer care of the patient to them. Update the responding EMS units by providing them a brief report of the situation as you initially observed it and tell them the results of your patient assessment and what care you have provided. Ask them if they have any questions for you. Finally, offer to assist other EMS personnel in caring for the patient.",
        "Postrun Activities": "You may think you are done with a call after you have cared for the patient and provided assistance to other EMS personnel; however, your job is not done until you have completed the paper or electronic patient care report. Documentation is important, as emphasized in Chapter 1, EMS Systems, and Chapter 5, Communications and Documentation. In addition to completing the report, you must also clean your equipment and replace needed supplies. Only after you have completed these activities should you resume regular duties or notify your dispatcher or supervisor that you are ready for another call.",
        "Helicopter Operations": "Helicopters are used by EMS systems to reach patients, transport patients to medical facilities, and evacuate patients from otherwise inaccessible areas. Helicopters can respond at speeds greater than 100 miles per hour (mph). They can travel above traffic congestion and into wilderness areas. They usually carry specialized equipment, and the personnel staffing them may include emergency medical technicians (EMTs), paramedics, registered nurses, and physicians. These personnel may be able to perform advanced life support (ALS) skills that are unavailable on ground ambulances. Helicopters are requested for patients with severe injuries or acute illnesses who may benefit from a higher level of care or more rapid transport to an appropriate medical facility. However, helicopters are limited by bad weather such as thunderstorms, blizzards, and other conditions that reduce visibility. In addition, the amount of weight helicopters can carry may be decreased in very hot temperatures and at high elevations. Adequate safe landing zones are necessary in order for helicopters to gain access to patients.\n\nIf your EMS system uses a helicopter, obtain a copy of the ground operations procedures or schedule an orientation session with helicopter personnel so you will be prepared during an emergency\n\nAs an EMR, you may be responsible for making the initial call for helicopter assistance or for setting up and preparing a landing site in the field. You need to know how to request a helicopter response as well as the criteria for calling a helicopter for trauma patients, medical patients, and wilderness response.",
        "Voices of Experience": "I had been an EMT for more than a year and worked for a local fire department in a mountain district outside of town. It was snowing and 6 inches (15 cm) of snow were already on the ground when we got a call for a 1-month-old infant with difficulty breathing. When I got to the house, the familiar red flashing lights marked the driveway and colored the falling snow.\n\nInside the home, the battalion chief looked relieved that I had arrived, but he was still very concerned. An infant girl, lying on her mother\u2019s lap, was having difficulty breathing. I administered high-flow oxygen and knew to sit the child upright. I auscultated her lungs and heard diffuse rhonchi. I gathered the SAMPLE history from the mother and recognized a possible return of recent pneumonia.\n\nI continually reassessed the patient. The oxygen seemed to help initially, and the infant\u2019s color and respiratory effort improved. The ALS ambulance had come up from town, but was unable to make it up the steep 2-mile (3-km) hill to the house. We weighed the risks and benefits of bringing the paramedic up to us, but we still had to transport the patient down. We decided that the infant was doing better at this time and, because we were not supposed to transport patients, we would wait until the ambulance with four-wheel drive arrived. The ALS ambulance went back to town and the second four-wheel drive ambulance was en route.\n\nMinutes kept passing and the patient was getting tired; the improving trend started to reverse and the infant was back to her original presentation. Anxiously awaiting the paramedics, I made a deal with myself that if the child had any change in respiratory rate or rhythm, I would begin positive-pressure ventilation. I opened the pediatric kit and assembled the appropriate bag valve mask.\n\nWhen the paramedics arrived, I was just about to begin ventilating. I gave a quick report, and we dashed out to the ambulance. On the way to the hospital, we started to ventilate and administer bronchodilators with significant improvement.\n\nThe paramedic questioned why we did not take the patient down to the first ambulance. I explained that we made that decision because of the child\u2019s initial improvement, and the issue of not being a transporting agency. He told me it is good to prioritize patient and crew safety, but \u201cAlways do what is in the best interest of your patient.\u201d Then, he looked me squarely in the eyes and said, \u201cIn EMS, you must always move forward toward higher levels of care. You cannot count on your interventions to fix the problem.\u201d Lesson learned and never forgotten!",
        "Helicopter Safety Guidelines": "Helicopters can provide lifesaving transport for patients with serious injuries to an appropriate medical facility. However, helicopters are also dangerous to untrained personnel. The main rotor of the helicopter spins at more than 300 revolutions per minute (rpm) and may be just 4 feet (1 m) above the ground. The tail rotor spins at more than 3,000 rpm and may be invisible to an unwary person. Additionally, the rotors can generate a 'wash,' or blast of air, equivalent to winds of 60 to 80 mph. If you approach without caution, you may be severely injured by walking upright or by raising an arm above the head. It is important to understand safe helicopter operations.",
        "Setting Up Landing Zones": "When choosing a landing site, remember that pilots usually land and take off into the wind. The size of a landing zone will vary and depends on the size of the helicopter. Most civilian helicopters need a landing zone of at least 100 feet \u00d7 100 feet (30 m \u00d7 30 m), or 10,000 square feet (929 square m). Military aircraft may need a larger area. The landing zone should be as flat as possible and free of debris that could become airborne in the 60-mph winds generated by the helicopter. Check carefully for any nearby electrical wires, which may be invisible to the pilot. If the site slopes or has any obstacles, notify the pilot. Check with your helicopter service to see how you should secure and mark the perimeter of the site. Avoid using flags or other objects that can be blown away by the force of the helicopter rotor wash. Do not use fusees (red signal flares) because they create a fire hazard. Turn off unnecessary white lights and avoid flashing emergency lights because they interfere with the pilot\u2019s vision during landing and takeoff. Keep vehicles clear of the landing zone. Close the windows and doors of any nearby vehicles and remove any loose objects on the vehicles that could become airborne. Some helicopter services request that a charged hose line be available for fire emergencies.",
        "Safety_1": "1. Be alert for electrical wires when identifying a landing zone for a helicopter.\n2.Always approach helicopters from the front so the pilot can see you. Approaching a helicopter from the rear is dangerous because the tail rotor is nearly invisible when spinning.\n3. Do not approach the helicopter until the pilot signals that it is safe to do so.\n4. Helicopters are very noisy and you may not be able to hear a shouted warning. Maintain eye contact with the pilot.\n5. Keep low when you approach the helicopter to avoid the spinning rotor blades.\n 6. Follow the directions of the helicopter crew.",
        "Loading Patients Into Helicopters": "Certain safety precautions must be followed during the loading of a helicopter patient. Secure all loose clothing, sheets, and instruments such as stethoscopes. Use eye protection and a helmet, if available, to prevent debris from getting into your eyes. Approach a helicopter from the front and only after the pilot or a crew member signals that it is safe.",
        "Safety_2": "Keep the following guidelines in mind during helicopter operations:\nDO NOT approach the helicopter landing zone unless necessary.\nDO NOT approach a helicopter from the upside if it is on a slope.\nDO NOT run near a helicopter.\nDO NOT raise your hand when approaching a helicopter.\nThe helicopter crew may need help carrying equipment to the patient. Follow\ntheir instructions. Give your patient care report to the crew, away from the\nhelicopter\u2019s noise, and offer your assistance. It is more difficult to load a\nhelicopter stretcher than an ambulance stretcher. Because loose sheets or\nblankets can blow off the stretcher, patients need to be packaged (prepared)\nproperly and securely.\nAs an EMR, you can provide ground support and assistance during helicopter\noperations, provided that you take proper safety precautions.",
        "Prep Kit": "Ready for Review\nIn preparing yourself for a call, you must understand your role as a member of the emergency medical system and be prepared to respond promptly.\n\nAs an emergency medical responder (EMR), you need the proper equipment on an emergency call, including the medical equipment in your life support kit, your personal safety equipment, and equipment to safeguard the incident scene.\n\nThe phases of an emergency call include dispatch, response to the scene, arrival at the scene, performing an initial patient assessment and emergency care, updating responding emergency medical services (EMS) units and transferring care of the patient to other EMS personnel, and postrun activities.\n\nIf you will be working with a medical helicopter, you need to know proper safety precautions and loading procedures for helicopter transport.\n\nBy learning the simple but important skills involving EMS operations, you can become an effective member of the EMS system in your community.",
        "Vital Vocabulary": "fusees: Warning devices or flares that burn with a red color; usually used in scene protection at motor vehicle crash sites."
    },
    {
        "Introduction": "This chapter provides information that will help you understand the factors that may affect your physical or emotional well-being as an emergency medical responder (EMR). You and your patients and their families can experience various degrees of stress and grief during and following a medical emergency. This chapter addresses methods for recognizing, preventing, and reducing stress from emergency incidents. It also discusses hazards you may encounter from infectious diseases and outlines procedures you must follow to reduce your risk of infection. Finally, this chapter covers scene safety and how to prevent injury to yourself and further injury to your patients.\n\nTo fulfill your duties as an EMR, you must be in good physical condition. As a new EMR, you should have a complete physical examination to ensure that you are healthy enough to do your job. Most public safety departments require this examination as part of their hiring process. If your department does not have this requirement, you should still have periodic physical examinations to ensure continuing good health.",
        "Emotional Aspects of Emergency Medical Care": "Providing emergency medical care as an EMR is stressful. You will experience stress while handling emergency incidents. You may also experience signs of stress following these incidents. In addition, your patients, their families and friends, and bystanders will often show signs and symptoms of stress. Because stress cannot be completely eliminated, you must learn how to avoid unnecessary stress and how to prevent your stress level from getting too high. Some of the stress-reduction techniques discussed in this chapter will also be helpful when dealing with your patients and their families and friends. Although all emergency medical calls produce a certain level of stress, some types of calls are more stressful than others. Your past experiences may make it difficult for you to deal with certain types of calls. For example, if a patient with severe injuries reminds you of a close family member, you may have difficulty treating the patient without experiencing a high level of stress. This is especially true if an emergency call involves a very young or a very old patient. Calls involving critical patients; death; unusual danger; violence; unusual sights, smells, or sounds; or mass casualties are also likely to produce high levels of stress. Likewise, past experiences may also play a part in reducing (or increasing) your stress during the care of a patient.\n\nBecause you work in a stressful environment, you must make a conscious effort to prevent and reduce unnecessary stress. You can do this in several different ways: learn to recognize the signs and symptoms of stress, adjust your lifestyle to include stress-reducing activities, and learn what services and resources are available to help you.",
        "Safety": "Do not underestimate the effect that stress can have on you. As a firefighter, EMS provider, or law enforcement officer, you may see more suffering in a year than many people will see in their entire lifetime.",
        "Normal Reactions to Stress": "You need to understand how stress can affect you and the people for whom you provide emergency medical care. It is important to realize that a wide variety of stressful events may trigger a grief reaction. These events include a major incident, a serious illness, drug or alcohol addiction, incarceration, the end of a relationship or divorce, loss of a job or income, or a major rejection. Dying is one of the most stressful events people experience. Anyone involved with a person suffering a significant loss will go through some sort of grieving process. This includes a patient, his or her family, and caregivers, including emergency first responders.\n\nOne well-recognized model for understanding people\u2019s reactions to grief and stress was proposed by Dr. Elisabeth K\u00fcbler-Ross. This model defines five stages of grief\u2014denial, anger, bargaining, depression, and acceptance. In studying this model, it is important to understand that people will experience grief in a variety of ways. Some people will exhibit no outward signs of grief. Other people will experience only some of these stages. People do not experience these stages of grief in any order. They can occur at any time during the grieving process.\n\nDenial (\u201cNot me!\u201d). The first stage in the grieving process is denial. A person experiencing denial cannot believe what is happening. This stage may serve as a protection for the person experiencing the situation, and it may also serve as a protection for you as the caregiver. Realize that this reaction is normal.\n\nAnger (\u201cWhy me?\u201d). The second stage of the grieving process is anger. Understanding that anger is a normal reaction to stress can help you deal with anger that is directed toward you by a patient or the patient\u2019s family. Do not become defensive; this anger is likely a result of the situation and not a result of your patient care. This realization can enable you to tolerate the situation without letting the patient\u2019s anger distract you from performing your duties of providing care.\n\nBargaining (\u201cOkay, but...\u201d). The third stage of the grieving process is bargaining. Bargaining is the act of trying to make a deal to postpone death and dying. If you encounter a patient or family member who is in this stage, try to respond with a truthful and helpful comment such as, \u201cWe are doing everything we can and the paramedics will be here in just a few minutes.\u201d Remember that bargaining may be a normal part of the grieving process.\n\nDepression (\u201cHeavy-hearted\u201d). The fourth stage of the grieving process is depression. Depression is often characterized by sadness or despair. A person who is unusually silent or who seems to retreat into his or her own world may have reached this stage. This may also be the point at which a person begins to accept the situation. It is not surprising that patients and their families get depressed about a situation that involves death and dying\u2014nor is it surprising that you as a rescuer also get depressed tends to consider death a failure of medical care rather than a natural event that happens to everyone. A certain amount of depression is a natural reaction to a major threat or loss. The depression can be mild or severe, and it can be of short duration or long-lasting. If you have depression that continues, it is important for you to contact qualified professionals who can help you. \n\nAcceptance: the final stage of the grieving process is acceptance. Acceptance does not mean that you are satisfied with the situation. It means that you understand that death and dying cannot be changed. It may require a lot of time to work through the grieving process and arrive at this stage. As an EMS provider, you may see acceptance in family members who have had time to realize that their loved one\u2019s illness is terminal. However, not all people who experience grief are able to work through it and accept the loss.\n\nBy understanding these five stages\nyou can better understand the grief reaction experienced by patients, their families, and their friends. You can also better understand your own reaction to stressful situations. Some helpful techniques for dealing with patients in stressful situations are presented in Chapter 12, Behavioral Emergencies. These techniques will help you to develop more comfort and skill when dealing with stressful situations.",
        "Words of Wisdom": "As you go through the anger phase of the grieving process, you may want to direct your anger at the patient, the patient\u2019s family, your coworkers, or your own family. Anger is a normal reaction to unpleasant events. Sometimes it helps to talk out your anger with coworkers, family members, or a counselor. By talking through your anger, you avoid keeping it bottled up inside where it can cause unhealthy physical symptoms or emotional reactions. Directing the energy from your anger in positive ways may help you move forward. For example, at the scene of a motor vehicle crash, you may be angry that a child has been injured. Focusing your energy on providing the best medical care for the injured child may help you work through your feelings.",
        "Stress Management": "Stress management has three components: recognizing stress, preventing stress, and reducing stress.",
        "Recognizing Stress": "An important step in managing stress in yourself and others is the ability to recognize its signs and symptoms. Only then can you take steps to prevent or reduce stress.",
        "Signs and Symptoms": "The following warning signs should help you recognize stress in your coworkers, friends, or yourself:\nIrritability (often directed at coworkers, family, and friends)\nInability to concentrate\nChange in normal disposition\nDifficulty in sleeping or nightmares (may be hard to recognize because many emergency care personnel work a pattern of rotating hours that makes normal sleep patterns hard to maintain)\nAnxiety\nIndecisiveness\nGuilt\nLoss of appetite or overeating\nLoss of interest in sexual relations\nLoss of interest in work\nIsolation\nFeelings of hopelessness\nAlcohol or drug misuse or abuse\nPhysical symptoms",
        "Preventing Stress": "Three simple-to-remember techniques that can prevent stress are: eat, drink, and be merry (in a healthy, stress-reducing manner).\nEat. A healthy, well-balanced diet helps prevent and reduce stress. According to the American Heart Association, a healthy daily diet should include 6 to 8 eight servings of grains and whole grains, 4 to 5 servings of vegetables, 4 to 5 servings of fruits, 2 to 3 servings of fat-free or low-fat dairy products, less than 6 ounces (28 g) of lean meats, poultry, and seafood, and 2 to 3 servings of fats and oils. In addition, they recommend 4 to 5 servings of nuts, seeds, and legumes and 5 or fewer servings of sweets per week. An illustration of a healthy diet compiled by the United States Department of Agriculture (USDA) is shown. The amount of food you need is related to your size, your weight, and your level of physical activity. The steps you can take to plan a healthy diet are illustrated. Many people need to cut down on the amount of sweets in their diet. Eating large quantities of sweets puts your energy level on a roller coaster. Your blood glucose level quickly rises, but in a few hours the level drops and you crave more sweets. To maintain more consistent glucose levels, it is much better to eat an adequate amount of whole grain breads, cereals, rice, and pasta. These food products provide energy over a longer period of time and help to reduce the highs and lows brought on by consumption of excess sugars. Reducing your intake of sugars now may help you reduce your chance of developing type 2 diabetes later in life.EMS providers often find it hard to maintain regular meal schedules. By planning your food intake and having healthy foods available, you can improve your eating habits. Healthy eating not only helps to cut down on your stress level, it also helps reduce your risk of heart and blood vessel diseases, which are the most common causes of death in public safety workers. Keeping your weight at recommended levels helps your body better cope with stress.\nDrink. Active EMS providers need to drink adequate amounts of fluids every day. Law enforcement officers, firefighters, and EMS providers who work in hot environments or wear hot bunker gear or ballistic vests are at special risk for dehydration. The average adult loses about eight glasses of water a day through sweat, exhaling, and elimination. Water in adequate quantities is essential for maintaining proper body function. Natural fruit juices are another good source of fluids. It is important to keep your body hydrated while you are on duty. When you are working in a hot environment or are involved in a strenuous incident, rehydrate yourself by regularly consuming adequate amounts of water or a sports drink. It is better to prevent dehydration by drinking adequate amounts of water than it is to try to take in enough water to recover from dehydration. Avoid consuming excessive amounts of caffeine and alcohol. Caffeine is a drug that causes adrenaline to be released in your body. Adrenaline raises your blood pressure and increases your stress level. By limiting your intake of caffeine-containing beverages such as coffee, tea, cola drinks, and energy drinks, you can reduce your tendency toward stress. Caffeine and alcohol also cause dehydration. Using tobacco products and drinking alcoholic beverages are discouraged. Although alcoholic drinks seem to relax you, they can cause depression and reduce your ability to deal with stress. Some people who drink alcohol become addicted to it. Drinking too much alcohol can end your career.\nBe merry. When a person is happy, he or she generally is not experiencing an elevated level of stress. It is important to learn to balance your lifestyle. Assess both your work environment and your home environment. At work, address problems promptly before they produce major stress. When you are off duty, remember to get an adequate amount of sleep and make time for personal activities. If you are working in a volunteer agency, it is best that personnel not be on call all the time.\n\nOther ways to prevent stress include spending time with your friends and family. In your recreational activities, include friends who are not coworkers. Develop hobbies or activities that are not related to your job. Exercise regularly. Exercise is a great stress reliever. Swimming, running, and bicycling are three types of excellent aerobic exercise. Meditation and religious activities also reduce stress for many people. People who can balance the pressures of work with relaxing activities at home usually enjoy life much more than people who can never leave the stories and stress of work behind. If you are feeling stress away from your job, consider seeking assistance from a mental health professional.",
        "Safety_0": "Because public safety services must be provided 24 hours a day, many law enforcement, fire, EMS, and security personnel work rotating shifts. Firefighters and emergency medical providers may work shifts that are 24 hours or longer with a variety of days off. Emergency responders may be required to alternate between day and night shifts. These work schedules disrupt normal sleep patterns. In addition, many people in public safety work overtime shifts, have a second job, or commute long distances to work. This combination of factors often means that many public safety personnel do not get enough sleep. Scientific studies have shown that most people need about 8 hours of uninterrupted sleep per night. If you are not meeting this need, your mental and physical health may suffer and you will be less able to deal with stress. In addition, the care you give to patients may be compromised. It is important to make getting enough sleep a priority in your life.",
        "Reducing Stress": "If pressures at work or home are causing you continual stress, you may benefit from the help of a mental health professional. Mental health professionals include psychologists, psychiatrists, social workers, and specially trained clergy. They are trained to listen in a nonjudgmental way and to help you find ways to diminish your stress. You may be able to connect with a mental health professional through your department\u2019s employee assistance program. Your medical insurance usually covers this type of care. Contact your employee assistance representative if you are experiencing continuing signs or symptoms of stress.\n\nCritical incident stress management (CISM) is a program available through some public safety departments. It consists of preincident stress education, on-scene peer support, and critical incident stress debriefings (CISDs): 1. Preincident stress education provides information about the stresses you will encounter and the reactions you may experience. It is designed to help you understand the normal stress responses you may experience when encountering an abnormal emergency situation. 2. On-scene peer support and disaster support services provide aid for you on the scene of especially stressful incidents. Examples are major disasters or situations that involve the death of a coworker or a child. 3. A debriefing after a stressful emergency situation may help to alleviate the stress reactions caused by the situation. A debriefing is a meeting between emergency responders and specially trained leaders. The purpose of a debriefing is to allow an open discussion of feelings, fears, and reactions to the high-stress situation. A debriefing is not an investigation or an interrogation. Debriefings are usually held within 24 to 72 hours after a major incident. The specially trained leaders can offer suggestions and information on overcoming stress.\n\nFind out if your department has an employee assistance program. Contact this program\u2019s representative if you are involved in a high-stress incident such as a call that involves a very young or very old patient, a mass-casualty incident, or a situation that involves unusual violence. If you think you might be experiencing signs or symptoms of stress from such an incident, contact your supervisor or a stress counselor. More information about stress debriefing is presented in Chapter 12, Behavioral Emergencies.",
        "Voices of Experience": "It was a very scary moment\u2014the husband had a shotgun. It was the middle of the night, and we were dispatched to a domestic violence event. The scene was not secure, so we staged a mile from the scene and waited until police arrived and declared the scene secure. The wife was complaining of head and neck injuries and had been beaten pretty badly. She stated her husband had come home from a bar and started beating her. The husband was not around and could not be found, although his vehicle was still in the driveway. The wife stated that her husband ran out the door when he heard sirens coming. The neighbors had called 9-1-1 as a result of all of the yelling and noise coming from this home. We treated the wife for her injuries. As we proceeded outside to load her into the ambulance, the husband jumped out from the backseat of his car and came toward us. It was a very scary moment\u2014the husband had a shotgun and was waiting to shoot his wife and anyone treating her. Luckily the police were walking with us, and they were able to subdue the husband and secure his firearm. We then proceeded to load the wife into the ambulance and left the scene heading toward hospital. We drove down the road, stopped, and finished treating our patient with an IV and pain medication. The call could have been so much worse, but fortunately we had police on scene, and they quickly took care of the shooter and kept us safe. Any domestic violence scene, even one that is considered secure, can change quickly and without warning. Situations occurring in the middle of the night may also contribute to questionable security. Always watch your back in any situation, as the scene could change for the worse quickly and at any time.",
        "Workforce Safety": "As an EMR, you will encounter a wide variety of hazards at emergency scenes. It is important for you to recognize these hazards and to know what steps to take to minimize the risk they pose to your patients, your partners, and yourself. This section covers common hazards you will encounter, including infectious diseases, traffic, crime and violence, crowds, electrical hazards, fire, hazardous materials, unstable objects, sharp objects, animals, environmental conditions, and special rescue situations.",
        "Infectious Diseases and Standard Precautions": "In recent years, Ebola virus disease (Ebola), the acquired immunodeficiency syndrome (AIDS) epidemic, and the growing concern about hepatitis, influenza, tuberculosis (TB), and methicillin-resistant Staphylococcus aureus (MRSA) have increased awareness of infectious (communicable) diseases. It is important for you to have some understanding of the most common infectious diseases to allow you to protect yourself from unnecessary exposure to these diseases. It will also prevent you from becoming unduly alarmed when you encounter these diseases. Infectious diseases can be contracted in several different ways, such as eating infected food and through contact with infected blood or infected body fluid. Exposure can take place through a small cut, direct contact with a mucous membrane, or from unprotected sex.\n\nThe three most common routes for transmission of infectious diseases are \nThe three most common routes for transmission of infectious diseases are contact with infected blood, contact with airborne droplets, and direct contact with infectious agents. The disease-causing agents that are spread through contact with infected blood are called blood-borne pathogens. Human immunodeficiency virus (HIV), the virus that causes AIDS, and the viruses that cause hepatitis B and hepatitis C are blood-borne pathogens. Other infectious diseases are spread through contact with droplets of airborne pathogens. Influenza, TB, and severe acute respiratory syndrome (SARS) fall within this group. A third group of infectious diseases is spread by direct contact. One example is MRSA, an infection that is spread by direct contact with the patient\u2019s skin or with contaminated clothing or towels.",
        "Blood-borne Pathogens": "HIV is transmitted by contact with infected blood, semen, or vaginal secretions. There is no scientific documentation that the virus is transmitted by contact with sweat, saliva, tears, sputum, urine, feces, vomitus, or nasal secretions, unless these fluids contain visible signs of blood. Exposure can take place in the following ways: The patient\u2019s blood is splashed or sprayed into your eyes, nose, or mouth or into an open sore or cut. You have blood from the infected patient on your hands and then touch your own eyes, nose, mouth, or an open sore or cut. A needle that was used to inject the patient breaks your skin. Broken glass at a motor vehicle collision or other incident that is covered with blood from an infected patient penetrates your glove and skin. Remember that some patients who are infected with HIV do not know they are infected. Others who are infected do not show any symptoms. This is why the Centers for Disease Control and Prevention (CDC) recommends that health care workers wear certain types of gloves any time they are likely to come into contact with secretions or blood from any patient. Whenever you are on the job, you should also cover any open wounds you have.\n\nHepatitis B is also spread by direct contact with infected blood, although it is far more contagious than HIV. EMRs should follow the standard precautions described in the following section to reduce their chance of contracting hepatitis B. Check with your medical director about receiving injections of hepatitis vaccine to protect you against this infection. This vaccine should be made available to you. Meningitis and syphilis are two other diseases that can be spread by contact with contaminated blood.",
        "Airborne Pathogens": "TB is a contagious disease that is spread by droplets from the respiratory system. When an infected person coughs or sneezes, the TB virus is spread through the air. Although TB is often hard to distinguish from other diseases, patients who pose the highest risk usually have a cough. This disease is dangerous to EMRs because drug-resistant strains of TB have evolved. To minimize your exposure when you encounter a patient with a cough, wear a face mask or a high-efficiency particulate air (HEPA) respirator and put an oxygen mask on the patient. If no oxygen mask is available, place a face mask on the patient. You should have a skin test for TB every year.\n\nInfluenza, whooping cough, and SARS are other diseases that are spread through airborne droplets. Influenza is caused by viruses that change over time. When certain conditions are right, a new strain of the influenza virus may cause many people in a community to become sick. The H1N1 strain of Influenza (swine flu) has caused concern because few people have immunity to this strain of virus. When a new strain of an influenza virus develops, your department will need to follow the latest recommendations from the CDC for your protection.",
        "Direct Contact": "MRSA infection is caused by the bacterium Staphylococcus aureus\u2014often called staph. MRSA is a strain of staph that is resistant to the broad-spectrum antibiotics commonly used for treatment. Most MRSA infections occur in health care settings such as hospitals, dialysis centers, and nursing homes. It most commonly occurs in people with weakened immune systems, where it can be fatal. However, MRSA can also occur in otherwise healthy people. In healthy people, MRSA may show up as a skin sore. As an EMR, you need to be sure you follow standard precautions to avoid contracting MRSA from your patients. In addition, you need to avoid sharing your towels, razors, and other personal care items. Wash your towels in hot water and dry them thoroughly. Ebola is an example of a disease that is spread by direct contact. The Ebola virus can be spread from an infected person to others by direct contact through broken skin or through mucous membranes such as the eyes, nose, or mouth. The body fluids that can spread this infection include blood, urine, breast milk, and semen. Ebola can also be spread through unprotected contact with a dead person. Although this disease is not normally present in North America, there have been cases of an infected person bringing the disease into the United States from a country where there was an Ebola epidemic. Any emergency provider who will be caring for patients known to have a highly contagious disease such as Ebola must have special training in handling infected patients.",
        "Safety_1": "The most important step you can take to remain healthy and reduce the transmission of disease is to wash your hands. Bacteria and viruses are picked up when you touch any contaminated surface. Examples include keyboards, doorknobs, steering wheels, telephones, head sets, and EMS equipment. Once bacteria and/or viruses are on your hands, touching your eyes, mouth, or nose with your fingers can introduce these microorganisms into your body. Wash your hands before and after eating, before and after using the toilet, after blowing your nose or sneezing into your hands, before and after preparing food, and before and after touching a patient. After you touch something that might be contaminated, wash your hands as soon as possible. Wearing gloves does not excuse you from the need to wash your hands regularly. Wash your hands with clean, warm, running water. Apply soap and rub your hands together to make a substantial lather. The soap does not have to be antibacterial; regular soap is sufficient. Be sure to scrub all the surfaces; wash between your fingers, and under your nails, as well as the backs of your hands. Keep rubbing your hands together for at least 20 seconds, about the time it takes to sing \u201cHappy Birthday!\u201d Thoroughly rinse your hands and dry them with a paper towel.",
        "Standard Precautions": "Federal regulations require all health care workers, including EMRs, to assume that all patients are potentially infected with blood-borne pathogens. These regulations require that all health care workers use protective equipment to prevent possible exposure to blood and certain body fluids. You will not always be able to tell whether a patient\u2019s body fluids contain blood. Therefore, the CDC recommends that all health care workers use the following standard precautions:\n1. Always wear approved latex or nitrile gloves when handling patients, and change gloves after contact with each patient. Wash your hands with soap and water immediately after removing gloves. If soap and water are not available, a hand sanitizer can be used as a temporary cleansing agent until soap and warm water are available. Note that leather gloves are not considered safe\u2014leather is porous and traps fluids.\n2. Always wear a protective mask, eyewear, or a face shield when you anticipate that blood or other body fluids may splatter. Wear a gown/apron, head covering, and shoe covers if you anticipate splashes of blood or other body fluids such as those that occur with childbirth and major trauma.\n3. Wash your hands and other skin surfaces immediately and thoroughly with soap and water if they become contaminated with blood and other body fluids. Change contaminated clothes and wash exposed skin thoroughly.\n4. Do not recap, cut, or bend used needles. Place them directly in a puncture-resistant container designed for sharps.\n5. Even though saliva has not been proven to transmit HIV, you should use a face shield, pocket mask, or other airway adjunct if the patient needs resuscitation.\n\nProper removal of gloves is important to minimize the spread of pathogens Skill Drill 2-1\n1. Begin by partially removing one glove. With the other gloved hand, pinch the first glove at the wrist, being careful to touch only the outside of the glove, and start to roll it back off the hand, inside out Step 1.\n2. Remove the second glove by pinching the exterior with the partially gloved hand Step 2.\n3. Pull the second glove inside out toward the fingertips Step 3. Grasp both gloves with your free hand, touching only the clean interior surfaces and gently remove the gloves Step 4.\n\nFederal agencies such as the Occupational Safety and Health Administration (OSHA) and state agencies such as state public health departments have regulations about standard precautions. Because these regulations are constantly changing, it is important for your department to stay updated on these regulations and provide continuing education to keep you current with the latest changes related to infectious disease precautions.",
        "Immunizations": "Certain immunizations are recommended for EMS providers. These include influenza, tetanus prophylaxis, and hepatitis B vaccines. You also should check the status of your varicella (chickenpox) vaccine and your measles, mumps, and rubella (German measles) vaccines. Tuberculin testing may also be recommended. Your medical director can determine which immunizations and tests are needed for members of your department. Being properly immunized protects you from contracting these diseases from patients. In certain cases such as influenza, it also helps to protect patients from getting influenza from you.",
        "Responding to the Scene": "Scene safety is a most important consideration to you as an EMR. You must consider your safety and the safety of all the other people at the scene of an emergency. An injured or dead EMR cannot help those in need. He or she becomes someone who needs help, increasing the difficulty of a rescue. Drive safely and always fasten your seat belt when you are in your vehicle. Paying close attention to safety factors can help prevent unnecessary illness, injuries, and death.",
        "Safety_2": "If your clothing comes in contact with body fluid from a patient, remove the clothing as soon as possible. If body fluids have contacted you through your clothing, take a shower, washing thoroughly with hot, soapy water. Your clothing should be placed in a marked plastic bag or handled so that the body fluids are contained. Clothing should be washed as soon as possible in hot, soapy water. Always follow the protocols of your department and the CDC's most recent recommendations for these situations.",
        "Dispatch": "Safety begins when you are dispatched to an emergency. Be sure you have correct dispatch information, including the address, before you begin your response. Use your dispatch information to anticipate hazards that may be present and to determine the best way to approach the scene of the emergency.",
        "Response": "Vehicle crashes are a major cause of death and disability in law enforcement officials, firefighters, and EMS providers. As you respond to the scene of an emergency, remember the safety information that you learned in your driving courses. Drive safely and always fasten your seat belt when you are in your vehicle. Your seat belt can save your life only when it is fastened. Plan the best route and drive quickly but safely to the scene. Be especially careful during periods of rain, snow, or high wind. Slow down your response to make sure you arrive safely. All emergency responders who will be driving should complete an emergency vehicle operator\u2019s course.",
        "Proper Removal of Medical": "Step 1 Partially remove the first glove by pinching at the wrist. Be careful to touch only the outside of the glove.\nStep 2 Remove the second glove by pinching the exterior with the partially gloved hand.\nStep 3 Pull the second glove inside out toward the fingertips.\nStep 4 Grasp both gloves with your free hand, touching only the clean interior surfaces, and gently remove the gloves.",
        "Safety_3": "Simple, portable safety equipment can help prevent injuries and illnesses. Medical gloves, masks, and eye protection prevent the spread of infectious diseases. Brightly colored clothing or vests make you more visible to drivers in the daytime; reflective striping or vests make you more visible in the dark. Heavy gloves can help prevent cuts at a motor vehicle crash scene. A hard hat or helmet is needed when you are at an industrial or motor vehicle collision scene. Some situations require additional safety equipment. Do not hesitate to call for additional equipment as needed.",
        "Parking Your Vehicle": "When you arrive at the emergency scene, park your vehicle so that it protects the area from traffic hazards. Check to be sure that the emergency warning lights are operating correctly. Be careful when getting out of your vehicle, especially if you must step into a traffic area. Federal safety standards require approved safety vests any time you are working on an active highway. These vests enhance your visibility in the daytime, and the reflective material on your safety vest helps make you more visible in the dark. If your vehicle is not needed to protect the incident scene, park it out of the way of traffic. Leave room for other arriving vehicles such as ambulances to be positioned near the patient. Above all else, make sure that you have protected the emergency scene from further incidents",
        "Safety_4": "Unless your headlights are needed to light up the scene, turn them off when parked at the scene. Your headlights can blind approaching vehicles, making it difficult for the drivers to see rescue personnel walking around the scene.",
        "Assessing the Scene": "As you approach the emergency scene, scan the entire area carefully to determine what hazards are present. Consider the following hazards based on the type of emergency; address them in the most appropriate order. For example, assess the scene of a motor vehicle crash for downed electrical wires before you check for broken glass.",
        "Traffic": "Consider whether traffic is a problem. Sometimes the most important first step you need to take at a motor vehicle crash scene is to control traffic to prevent further collisions. If you need more help to handle traffic, call for assistance before you get out of your vehicle.",
        "Crime or Violence": "If your dispatch information leads you to believe that the incident involves violence or a crime, follow your department\u2019s protocols for approaching the scene. If you are trained in law enforcement procedures, follow your local protocols. If you are not a law enforcement official, proceed very carefully. If you have any doubts about the safety of the scene, it is better to wait at a safe distance and request help from law enforcement officials. If the scene involves a crime, remember to take a mental picture of the scene and avoid disturbing anything at the scene unless it is absolutely necessary to move objects to provide patient care.",
        "Crowds": "Crowds may range in size from a few neighbors or bystanders to a huge mass gathering at a large parade or sporting event. The mood of a crowd may range from friendly and helpful to hostile. Friendly neighborhood crowds may interfere very little with your duties. Unfriendly, unruly, or hostile crowds may require a police presence before you are able to begin assessing and treating patients. Assess the crowd\u2019s mood before you get in a position from which there is no exit. Request help from law enforcement officials before the crowd is out of control. Safety considerations may require you to wait for the arrival of police before you approach the patient.",
        "Electrical Hazards": "Electrical hazards can be present at many types of emergency scenes. Patients located inside buildings may be in contact with a wide variety of electrical hazards. These can range from a faulty extension cord in a house to high-voltage machinery in an industrial setting. Patients located outside may be in contact with high-voltage electrical power lines that have fallen because of a motor vehicle crash or a storm. Assess the emergency scene for any indications of electrical problems. Inside a building, look for cords, electrical wires, or electrical appliances near or in contact with the patient. When you are outside, look for damaged electrical poles and downed electrical wires. Do not approach an emergency scene if there are indications of electrical problems. Keep all other people away from the source of the hazard. Because electricity is invisible, make sure that the electrical current has been turned off by a qualified person before you get close to the source of the current. Always wear a helmet with a chin strap and face shield in situations that may involve electrical hazards.",
        "Fire": "Fire is a hazard to both you and the patient. Contact with a power source can result in severe injury or death. Anytime there appears to be a fire, immediately call for fire department assistance. If you are a trained firefighter, follow rescue and firefighting procedures for your department. If you are not a trained firefighter, do not exceed the limits of your training because any attempt to rescue a person from a burning building is a high-risk undertaking. Do not enter a burning building without proper turnout gear and self-contained breathing apparatus. Recent fire research has shown that during a fire, keeping doors and windows closed until hose streams are in place will slow the growth and spread of fire. Do not open doors and windows before the firefighters arrive. Vehicles that have been involved in collisions also may present a fire hazard from fuel or other spilled fluids. Keep all ignition sources such as cigarettes and road flares away. Carefully assess the fire hazard before you determine your course of action",
        "Hazardous Materials": "Hazardous materials (sometimes referred to as HazMats) may be found almost anywhere. Motor vehicle crashes with large trucks may involve hazardous materials. Hazardous materials may also be found in homes, businesses, and industries. Federal regulations require vehicles that are transporting a certain quantity of hazardous materials to be marked with specific placards. Be aware that small quantities of certain hazardous materials may be transported without displaying placards. If you believe that a crash may involve hazardous materials, stop uphill and upwind at some distance from the crash. Then determine whether the vehicle is marked with a placard. A pair of binoculars in the life support kit is helpful for this. The placard indicates the class of material being transported. You should carry an Emergency Response Guidebook to assist you in determining the hazard involved and follow your department protocols. Also note the presence of leaking fluids. The presence of odors or fumes may be the first indication of hazardous materials located in buildings. If you believe that a hazardous material is present, call for assistance from the agency that handles hazardous materials in your community. Remain far away from any suspected HazMat incident so you do not become an additional casualty.",
        "Unstable Objects": "Unstable objects may include vehicles, trees, poles, buildings, cliffs, and piles of materials. Motor vehicle collisions, wind storms, ice storms, explosions Fires, building collapses, and earthquakes may result in unstable objects. After a collision, a motor vehicle may be located in an unstable position. You may need to stabilize the vehicle before you assess the patient or begin patient extrication. Do not attempt to enter or get under an unstable vehicle. Undeployed air bags are another hazard after a motor vehicle collision. Motor vehicle collisions may result in other unstable objects, including trees or poles that were hit in the collision. Fires and explosions can result in unstable buildings. Assess a building for stability before attempting to enter it. If you are in doubt about the safety of the building, follow your local protocols and call for trained personnel rather than attempting to enter an unsafe building alone.",
        "Sharp Objects": "Sharp objects are frequently present at an emergency scene. These objects range from broken glass at the scene of a motor vehicle crash to hypodermic needles in the pocket of a drug addict. Being aware of sharp objects can reduce the chance of injury to you and to your patients. Latex and nitrile medical gloves can help prevent the spread of disease from blood contamination, but they provide no protection against sharp objects. When glass or other sharp objects are present, wear heavy leather or firefighting gloves over your medical gloves to prevent injuries.",
        "Safety_6": "After working at a scene that involves potential infectious exposure, you should clean and disinfect your equipment. Cleaning refers to the removal of dirt, dust, blood, or other visible contaminants. Disinfection requires special chemicals that kill pathogenic agents when applied directly to a surface. Disposable equipment and supplies should be disposed of in a manner that prevents contamination of other objects. Follow your local protocols and the latest recommendations of the CDC and OSHA. It is also important to complete the appropriate documentation of the exposure.",
        "Animals": "Animals, whether they are house pets, farm stock, or wild, are found indoors and outdoors. Pets can become very upset in the confusion of a medical emergency. When you need to enter a house to take care of a patient, be sure excited pets have been secured in another part of the house away from the patient. People often travel with their pets, so pets can be part of the scene of a motor vehicle crash. Service dogs may be possessive of their owners. Farm animals, too, can be a safety hazard; be careful when entering a field that may contain livestock. Animals may present hazards such as bites, kicking, or even trampling. Careful assessment of the incident scene can prevent unnecessary injuries.",
        "Environmental Conditions": "Weather cannot be changed or controlled; therefore, you should consider the effect weather will have on rescue operations. Dress appropriately for the expected weather and be prepared for precipitation and temperature extremes for you and your patients. Be alert for possible damage from high winds. Keep your patients dry and comfortable. Darkness makes it hard to see all the hazards that may be present, so use any emergency lighting that is available. A bright flashlight is a valuable tool in many rescue situations.",
        "Special Rescue Situations": "Special safety considerations are required in situations involving water rescue, ice rescue, confined space or below-grade rescue, terrorism, and mass-casualty incidents. These situations are covered in Chapter 20, Vehicle Extrication and Special Rescue. Do not enter an emergency situation that is unsafe unless you have the proper training and equipment.",
        "Prep Kit Ready for Review": "EMRs should understand the role that stress plays in the lives of emergency care providers and patients who have experienced a sudden illness or injury. Stress is a normal part of an EMR\u2019s life. Five stages of the grieving process following different kinds of loss including death and dying are denial, anger, bargaining, depression, and acceptance. Patients and rescue personnel may experience some or all of these stages. People experience these stages in different orders and at different rates. Stress management consists of recognizing, preventing, and reducing critical incident stress.\nScene safety is an important part of your job. You should understand how airborne and blood-borne diseases are spread and how standard precautions prevent the spread of infection. You should also know the steps you can take to protect yourself from infectious diseases. As you arrive on the scene of a collision or illness, you must assess the scene for a wide variety of hazards. Potential hazards include traffic, crime, crowds, unstable objects, sharp objects, electrical problems, fire, hazardous materials, animals, environmental conditions, special rescue situations, and infectious disease exposure. You should understand the safety equipment and precautions needed for the various types of rescue situations.",
        "Vital Vocabulary": "acceptance: The stage of the grieving process when the person experiencing grief recognizes the finality of the grief-causing event., anger: The stage of the grieving process when the person experiencing grief becomes upset or angry at the grief-causing event or other situation., bargaining: The stage of the grief reaction when the person experiencing grief barters to change the grief-causing event., critical incident stress debriefing (CISD): A system of psychological support designed to reduce stress on emergency personnel after a major stress-producing incident., critical incident stress management (CISM): A process that confronts the responses to critical incidents and defuses them, directing the emergency services personnel toward physical and emotional equilibrium., denial: A stage of a grief reaction when the person experiencing grief rejects the grief-causing event., depression: A stage of the grief reaction when the person expresses despair\u2014an absence of cheerfulness and hope\u2014as a result of a grief-causing event., on-scene peer support: Stress counselors at the scene of stressful incidents who help emergency personnel deal with stress., pathogens: Microorganisms that are capable of causing disease., preincident stress education: Training about stress and stress reactions conducted for public safety personnel before they are exposed to stressful situations., standard precautions: An infection control concept that treats all body fluids as potentially infectious."
    },
    {
        "Introduction": "As an emergency medical responder (EMR), you need to know some basic legal principles that guide how you provide care to patients. Knowing these principles can help you provide the best possible care for your patients and prevent situations that could result in legal difficulties for you, your public service agency, or your department. Because some laws differ from one location to another, you will need to learn the specific laws of your state and your local jurisdiction (the area in which you work). It is easy to become concerned about the legal consequences of providing emergency medical care or immediate care or treatment. Remember the following concepts when providing patient care:\nAbove all else, do no harm.\nProvide all your care in good faith, keeping the patient\u2019s best interest uppermost in your mind.\nProvide proper, consistent care; be compassionate; and maintain your composure.\nThese concepts can help prevent many of the legal issues that are discussed in this chapter.",
        "Duty to Act": "The first legal principle to consider is the duty to act. An uninvolved citizen (bystander) who arrives on the scene of a motor vehicle crash is not required by law to stop and give emergency care to injured people. However, if you are employed by an agency that has designated you as an EMR and you are dispatched to the scene of an injury or illness, then you do have a duty to act. You must proceed quickly to the scene and provide emergency medical care within the limits of your training and available equipment. Any failure to respond or provide necessary emergency medical care leaves both you and your agency vulnerable to legal action.",
        "Standard of Care": "What level of care are you expected to give to a patient? As a trained EMR, you cannot provide the same level of care as a physician, but you are responsible for providing the level of care that a person with similar training would provide under similar circumstances. You are expected to use your knowledge and skills to the best of your ability under the circumstances. The circumstances under which you must provide care may affect the standard of care. The standard of care is the manner in which you must act or behave. To comply with the standard of care, you must meet two criteria: (1) You must treat the patient to the best of your ability and (2) you must provide care that a reasonable, prudent person with similar training would provide under similar circumstances. It is important to know your local standards of care and what statutes affect your community. Failure to provide proper care because of a wrongful act could result in legal action being taken against your public safety agency or against you as an individual health care provider. A wrongful act is called a tort by the legal community.",
        "Scope of Care": "The scope of care you give as an EMR is defined on several levels. The Emergency Medical Responder Education Standards, originally developed by the US Department of Transportation, specify the skills taught in this course and the way those skills should be performed. These standards have evolved into the current National Emergency Medical Services (EMS) Education Standards. States also have scope of care laws that may modify the specifications in the education standards. In most states, a law outlines the roles and responsibilities of EMRs. You may be required to operate under the license of your medical director. The medical director for your department may use medical protocols or standing orders to specify your scope of care. In some cases, online medical direction is provided by radio or a wireless communication device. Your state gives you the responsibility to practice within the limits specified within the law. You have a professional responsibility to your patients, to your medical director, and to the public you serve.",
        "Ethical Responsibilities and Competence": "Your community and your department have entrusted you, as an EMR, with certain moral and ethical responsibilities. This moral responsibility means that the community expects you to follow the established codes of what is right and wrong. It is your ethical responsibility as an EMR to follow these codes. Treating a patient ethically means doing so in a manner that conforms to accepted professional standards of conduct. These standards include staying up to date on the EMR skills and knowledge you need to provide good patient care. You are also responsible for reviewing your performance and assessing the techniques you use. Evaluate your response times and try to follow up patient care outcomes with your medical director or hospital personnel. Always look for ways to improve your performance. Continuing education classes and refresher courses are designed to keep your knowledge and skills current. It is in your best interest to make the most of these opportunities. It is also a good idea to participate in quality improvement activities within your department. Ethical behavior requires honesty. Your reports should accurately reflect the conditions found at the scene. Always provide complete and correct reports to other EMS providers. If you make a mistake on the report or document information incorrectly, then do not try to cover it up. Never change a report except to correct an error. Remember, the actions you take in the first few minutes of an emergency may make the difference between life and death for a patient. Your ethical behavior and competence will be invaluable to both you and your patient.",
        "Consent for Treatment": "Consent simply means giving approval or permission. Legally, however, several types of consent exist. In expressed consent, the patient actually lets you know\u2014verbally or nonverbally\u2014that he or she is willing to accept the treatment you provide. Expressed consent is based on the idea that the patient has the right to determine what will be done to his or her body. The patient must be of legal age (in most states, older than 18 years) and able to make a rational decision. As you approach a patient, be sure the patient understands who you are, tell him or her what you are going to do, and be sure he or she agrees to treatment. For example, if you say, \u201cYou have a cut on your arm. I need to bandage it to stop the bleeding,\u201d and the response is \u201cOK,\u201d then the patient has given you expressed consent. Expressed consent is sometimes called actual consent or informed consent. In situations in which a patient is under the influence of alcohol or other drugs, has a mental impairment, or has a medical condition that affects his or her mental status, it may be hard to determine whether the patient is capable of making decisions about his or her health care. In these situations, carefully explain to the patient what needs to be done and try to provide the care the patient needs. Any patient who does not specifically refuse emergency medical care can be treated under the principle of implied consent. The principle of implied consent is best understood in the situation of an unconscious patient. Because an unconscious patient is unable to communicate, the law assumes the patient would agree to treatment if he or she were able to do so. Therefore, never hesitate to treat an unconscious patient.",
        "Consent for Minors": "A minor is a person who has not yet reached the legal age designated by a particular state. Under the law, minors (usually people younger than 18 years) are not considered capable of speaking for themselves. Many states have laws that permit a minor to have the rights of an adult if the minor is considered emancipated. Learn the laws of your state related to the issues surrounding emancipated minors. In most cases, emergency medical treatment of a minor by a physician must wait until a parent or legal guardian consents to the treatment. If a minor requires emergency medical care in the field (out of the hospital) and you cannot quickly get the permission of a parent or legal guardian, then do not hesitate to give appropriate emergency medical care. Never delay or withhold emergency medical treatment of a minor just to obtain permission from a parent or legal guardian. Let hospital officials determine what treatment can be postponed until permission is obtained. Remember, good prehospital patient care is your first responsibility. By following the course of action that is best for the patient, you will stand on firm legal ground.",
        "Consent of Patients With a Mental Illness": "An adult who is conscious, alert, and mentally in control, or competent, may legally refuse to be treated\u2014even if doing so may result in serious injury or death. The legal issues are more complicated if the patient who refuses to be treated appears to be out of touch with reality and is a danger to himself or herself or others. The difficult part, even for highly trained medical personnel, is determining whether such a patient is rational. Generally, if the person appears to be a threat to himself or herself or others, then arrangements need to be made to place this person under medical care. The legal means by which these arrangements are made vary from state to state. You and other members of the EMS system should know your local policies for handling patients who refuse to be treated and who do not appear to be making rational and reasonable decisions. Do not hesitate to involve law enforcement agencies, because this process may require the issuance of a warrant or an order of protective custody.",
        "Patient Refusal of Care": "A competent adult has a legal right to refuse treatment from emergency medical personnel at any time. You can continue to talk with a person who refuses treatment and try to help him or her understand the consequences of this action. Explain the treatment to the person, why it is needed, the potential risks if treatment is not provided, and any alternative treatments that may help. Sometimes another EMS provider or a law enforcement officer may have more success in convincing a patient that he or she needs to receive treatment. If the patient is firm in his or her refusal, then tell the patient that he or she should call EMS again if the patient changes his or her mind. Carefully document patient refusals on your patient care report according to your agency protocols. Many agencies require a second person to witness this refusal. Follow all local EMR protocols related to patient care refusal.",
        "Advance Directives": "An advance directive is a document that specifies what a person would like to be done if the person becomes unable to make his or her own medical decisions. Three kinds of advance directives exist. The first is called a living will. A living will is a written document drawn up by a patient, a physician, and a lawyer. A living will states the types of medical care a person wants or wants withheld if the person is unable to make his or her own treatment decisions. Living wills are often written when a patient has a terminal (incurable) condition. A living will does not let the person select someone to make decisions for them. A second type of advance directive is a durable power of attorney for health care or medical power of attorney. A durable power of attorney for health care allows a patient to designate another person to make decisions about medical care for the patient if he or she is unable to make decisions for himself or herself. The person designated to be a patient\u2019s health care representative is often a family member. This representative may be referred to as the patient\u2019s health care agent or health care proxy. A do not resuscitate (DNR) order is the third type of advance directive. It is a written request giving permission to medical personnel to withhold resuscitation in the event of cardiac arrest. Advance directives may include DNR orders but are not required to include them. DNR orders are most frequently used for patients who are in hospitals or nursing homes. DNR orders are most common in cases of terminal disease or medical futility (as discussed in the consensus statement from the International Liaison Committee on Resuscitation [ILCOR]). If you are unable to determine whether an advance directive is legally valid, then begin appropriate medical care and leave the questions about advance directives to physicians. Some states have systems, such as bracelets, to identify patients with advance directives. Know your local policies and protocols.",
        "Legal Concepts": "As an EMR, it is important for you to understand some legal concepts that relate to your work. These concepts include abandonment, people dead at the scene, negligence, and confidentiality. Each of them is explained in the following section.",
        "Abandonment": "Abandonment occurs when a trained person begins emergency medical care and then leaves the patient before another trained person arrives to take over. After you have started treatment, you must continue that treatment until a person who has skills and/or training at the same or a higher level arrives on the scene and takes over or until you deliver the patient to another medical care provider at a medical facility. Never leave a patient without care after you begin treatment. The most common abandonment scenario occurs when an EMS provider responds to a call, examines the patient, assesses the patient\u2019s condition, fails to transport the patient to a hospital, and finds out later that the patient died. Emergency medical care began, but the patient was abandoned.",
        "People Dead at the Scene": "If you see any signs that a person is alive when you arrive on the scene, then begin providing necessary care. People who are obviously dead should be handled according to the laws of your state and the protocols of your service. Generally, you cannot assume a person is dead unless one or more of the following conditions exist:\nDecapitation. Decapitation means that the head is separated from the body. When this occurs, there is obviously no chance of saving the patient.\nRigor mortis. Rigor mortis is the temporary stiffening of muscles that occurs several hours after death. The presence of this stiffening indicates the patient is dead and cannot be resuscitated.\nTissue decomposition. Body tissue begins to decompose and flesh begins to decay only after a person has been dead for more than 1 day.\nDependent lividity. Dependent lividity is the red or purple color that occurs on the parts of the patient\u2019s body that are closest to the ground. It is caused by blood seeping into the tissues on the dependent, or lower, part of the person\u2019s body. Dependent lividity occurs after a person has been dead for several hours.\n\nIf one or more of these signs are present, then you can usually consider the patient to be dead. Know the protocol your department uses in dealing with patients who are dead on the scene.",
        "Words of Wisdom": "Four legal concepts you should understand: 1. Abandonment\n2. People dead at the scene\n3. Negligence\n4. Confidentiality",
        "Voices of Experience": "I can recall thinking to myself that this was not what I had come into this profession to do. I was the attendant-in-charge dispatched to a rollover motor vehicle collision at about 0230 hours one dreary, rainy night. Dispatch information told me a sport utility vehicle (SUV) was involved and our county sheriff\u2019s department was already at the scene. We were sent to direct aid with an adjoining fire department engine that arrived on scene first. We arrived on scene a couple of minutes after the engine and discovered there were multiple patients. I made contact with the engine company lieutenant and became the medical group supervisor. The story was a sad one. The sheriff deputy already had taken the driver of the SUV into custody. He told me there were four occupants in the SUV who were taking methamphetamines and drinking alcohol. They were not wearing any vehicle restraints. When the sheriff had tried to pull the vehicle over, the driver evaded the pursuit and in the ensuing chase, the SUV rolled over and ejected three of the four occupants. I began triage and found one passenger on the roadside, screaming in pain from an open femur fracture. There were already EMTs preparing her for transport. I immediately called for a second EMS unit. The other two occupants had been thrown from the vehicle in opposite directions. They were approximately 25 feet (8 m) from the vehicle, sustaining fatal injuries. These two patients were teenagers. To this day, I can recall thinking to myself that this was not what I had come into this profession to do. I didn\u2019t like the tremendous responsibility of declaring someone dead. I was there to save the lives of people. Look at this tragedy; these two young people had no futures ahead of them. Did their parents know where they were? I persuaded the sheriff\u2019s department to release the driver into my care for evaluation at the emergency department. Due to the mechanism of injury and the deaths of the other occupants as risk factors, it was important to have the driver examined for any hidden injuries. As I transferred the patient to the bed in the emergency department, a vial of methamphetamines fell out of his pocket. He lay there laughing, displaying no remorse for the deaths of his \u201cfriends.\u201d As an EMS provider, it is difficult to respond to situations like this one. Ethically, it can be a challenge to treat patients who act irresponsibly and put their own lives and the lives of others in unnecessary danger. However, we must put our own personal feelings aside and treat the patient regardless of our feelings. In situations like this one, it is helpful to have the assistance of a law enforcement officer to ensure scene safety while the patients are triaged and treated. Police assistance is especially important in cases where drug and alcohol use may affect the behavior of the patients.",
        "Negligence": "Negligence is the failure of a medical care provider at any level to meet the required standard of care in his or her treatment of a patient. Remember, the standard of care represents the manner in which a reasonable, similarly trained provider would have acted in a similar situation. For a legal claim for negligence to be sustained, four conditions must be present:\n1. Duty to act\n2. Breach of duty\n3. Resulting injuries\n4. Proximate cause\nAs an EMR who has been dispatched or otherwise called to the scene of an incident to provide patient care, you will have a duty to act to help the patient. This means that you have a duty to provide care within your scope of training and certification in a manner in which a reasonable similarly trained and certified provider would under similar circumstances. Failure to provide such care represents breach of duty. If the patient becomes injured as a result of your actions, then you may be considered negligent and therefore considered responsible for causing those injuries. The proximate cause element of the legal claim means that your act of negligence has to be directly responsible for the patient\u2019s resulting injury for you to be held responsible. For example, if you drag a patient with a neck injury out of a vehicle without properly immobilizing him or her and that patient becomes paralyzed as a direct result of your moving him or her, then you could be considered negligent and responsible for causing the spinal cord injury. If the patient later fell during physical therapy while recovering from the spinal cord injury and broke his or her leg as a result",
        "Confidentiality": "Most patient information is confidential. Confidential information includes the patient history, assessment findings, and treatment provided, as well as your communication with the patient. This information should be shared only with other medical personnel who are directly involved in the patient\u2019s care. Do not discuss this private information with your family or friends. Most departments have strict policies prohibiting the release of any patient information over social media.\n\nIn certain situations, you may release confidential information to designated people. In most states, records may be released when a legal subpoena is presented or the patient signs a written release. The patient must be mentally competent and fully understand the nature of the release.\n\nSome information about a patient\u2019s care may be classified as public information. This information often includes the patient\u2019s name, address, and age and the hospital to which he or she was transported. Learn what patient information is considered public information in your state. Public information can be released to the news media through your department\u2019s approved process.",
        "HIPAA": "HIPAA is the acronym for the Health Insurance Portability and Accountability Act of 1996. Although this act had many aims, including improving the portability and continuity of health insurance coverage and combating waste and fraud in health insurance and in the provision of health care, the section of the act that most affects EMS relates to patient privacy. The aim of this section was to strengthen laws for the protection of the privacy of health care information and to safeguard patient confidentiality. It provides guidance on what type of information is protected, the responsibility of health care providers regarding that protection, and the penalties for breaching that protection.\n\nMost personal health information is protected and should not be released without the patient\u2019s permission. If you are not sure, then do not give any information to anyone other than those directly involved in the care of the patient. For specific policies, each EMS service is required to have a manual and a privacy officer who can answer questions. You can expect to receive further training on how this act impacts your specific response agency and resource hospital.",
        "Words of Wisdom 2": "In this time of ever-present digital devices and cell phones with cameras, realize that patient confidentiality extends to photographs and videos. Do not take or send images of a patient without permission of both the patient and your supervisor.",
        "Good Samaritan Laws": "Most states have adopted Good Samaritan laws, which protect citizens from liability for errors or omissions in giving good faith emergency medical care. These laws vary from state to state, and they may or may not apply to EMRs in your state. Recently, legal experts have noted that Good Samaritan laws may no longer be needed because they provide little or no legal protection for an EMS provider. Any properly trained EMR who practices the skills and procedures learned in an EMR course should not be overly concerned about lack of protection under Good Samaritan statutes.",
        "Regulations": "As an EMR, you are subject to a variety of federal, state, local, and agency regulations. Become familiar with these regulations so you can follow them. The most important regulations guide your ability to work as an EMR. You may have to become registered or certified as an EMR through a state agency or you may have to register through the National Registry of Emergency Medical Technicians. It is your responsibility to keep any required certification or registration up to date.",
        "Reportable Events": "State and federal agencies have requirements for reporting certain events, including crimes and certain infectious diseases. Reportable crimes include knife wounds, gunshot wounds, motor vehicle crashes, suspected child abuse, domestic violence, elder abuse, dog bites, and rape. Learn which crimes are reportable in your area and know your agency\u2019s procedures for reporting these crimes. It is important that you learn how this process is handled in your agency and what you are required to do. Failure to notify proper authorities of reportable events may result in penalties against you or your agency.",
        "Crime Scene Operations": "Many emergency medical situations are also crime scenes. As an EMR, keep the following considerations in mind:\n1. Protect yourself. Be sure the scene is safe before you try to enter.\n2. If you determine that a crime scene is unsafe, then wait in a safe location until law enforcement personnel tell you the scene is safe for entry.\n3. Your first priority is patient care. Nothing except your personal safety should interfere with that effort.\n4. When you assess the scene, document anything you see that seems unusual.\n5. Move the patient only if necessary, such as for rapid transport to the hospital, for administration of CPR, or for treatment of severe shock. If you must move the patient, then take a mental \u201csnapshot\u201d of the scene.\n6. Touch only what you need to touch to gain access to the patient.\n7. Preserve the crime scene for further investigation. Do not move furniture or objects unless they interfere with your ability to provide care. If you must move anything out of the way, then move it no further than necessary to provide care.\n8. Be careful not to cut through knife or bullet holes in the patient\u2019s clothing.\n9. Be careful where you put your equipment to avoid changing or destroying evidence.\n10. Keep nonessential people, such as curious bystanders, away from the scene.\n11. Work with the appropriate law enforcement authorities on the scene to ensure that everyone has the information they need.\n12. After you have attended to a patient at a crime scene, write a short report about the incident as soon as possible and make a sketch of the scene that shows how and where you found the patient. This may be useful information if you are required to recall the incident 2 or 3 years later.",
        "Documentation": "After you have finished treating the patient, record your observations about the scene, the patient\u2019s condition, and the treatment you provided. Complete your documentation according to the policies of your organization. These policies should follow appropriate local and state laws. Your documentation is important because it is the initial account describing the patient\u2019s condition and the care administered. You will not be able to remember the treatment you provide to each patient without documentation. It also serves as a legal record of your treatment, and it will be required in the event of a lawsuit. Documentation also provides a basis for evaluating the quality of care you provided. Documentation should be clear, concise, accurate, and readable. Documentation may be completed using a paper form or an electronic device. More information on documentation is presented in Chapter 5, Communications and Documentation. \n\nDocumentation should include the following information: \nThe condition of the patient when found \nThe patient\u2019s description of the injury or illness\nThe patient\u2019s initial and repeat vital signs\nThe treatment you gave the patient\nThe agency and personnel who took over treatment of the patient\nAny reportable conditions present \nAny infectious disease exposure\nAnything unusual regarding the situation",
        "Prep Kit Ready for Review": "As an EMR, you have a duty to act when you are dispatched on a call as a part of your official duties. You are held to a certain standard of care, which is related to your level of training, and you are expected to perform to the level to which a similarly trained person would perform under similar circumstances. You should understand the differences among expressed consent, implied consent, consent for minors, consent of mentally ill persons, and the right to refuse care.\nAdvance directives: Advance directives consist of living wills, durable powers of attorney, and do not resuscitate orders. They give a patient the right to have care withheld and to appoint someone to act for him or her if he or she is not able to act. If emergency medical responders cannot determine the validity of these documents, it is best to begin treatment for these patients.\nYou should understand the concepts of abandonment, negligence, and confidentiality, as well as the purpose of Good Samaritan laws. You must understand the importance of federal and state regulations that govern your performance as an emergency medical responder. You must also understand your department\u2019s operational regulations. Certain events that deal with contagious diseases, abuse, or illegal acts must be reported to the proper authorities. You should know how to deal with these reportable events.\nCrime scene operations are complex environments. Follow proper procedures to ensure that the patient receives good medical care and that the crime scene is not compromised for the law enforcement investigation. Your job is not complete until the patient report is completed. Always document your findings and treatment. This provides good patient care and adequate legal documentation.\nBy understanding and following these legal concepts, you will build the foundation for the skills you need to be an effective EMR.",
        "Vital Vocabulary": "abandonment: Failure of the emergency medical responder to continue emergency medical treatment until relieved by someone with the same or a higher level of training., advance directive: A legal document that indicates what a person wants done if he or she cannot make his or her own medical decisions. Advance directives include living wills, durable powers of attorney for health care, and do not resuscitate orders., certification: A process in which a person, institution, or a program is evaluated and recognized as meeting certain predetermined standards to provide safe and ethical patient care., competent: Able to make rational decisions about personal well-being., consent: In the context of emergency medical services, permission to provide care., dependent lividity: Blood settling to the lowest point of the body after death, causing discoloration of the skin., do not resuscitate (DNR) order: A written request giving permission to medical personnel not to attempt resuscitation in the event of cardiac arrest., durable power of attorney for health care: A legal document that allows a patient to designate another person to make medical decisions for him or her if the patient is unable to make his or her own treatment decisions., duty to act: An emergency medical responder\u2019s legal responsibility to respond quickly to an emergency scene and provide medical care (within the limits of training and available equipment)., expressed consent: Consent actually given by a person, either verbally or nonverbally, authorizing the emergency medical responder to provide care or transportation., Good Samaritan laws: Laws that encourage citizens to voluntarily help an injured or suddenly ill person by minimizing the liability for any errors or omissions in providing good faith emergency care., implied consent: Consent to receive emergency medical care that is assumed because the individual is unconscious, underage, or so badly injured or ill that he or she cannot respond., living will: A legal document that states the types of medical care a person wants or wants withheld if he or she is unable to make his or her own treatment decisions. Living wills may include do not resuscitate orders., negligence: Deviation from the accepted standard of care resulting in further injury to the patient., standard of care: The manner in which an individual must act or behave when giving care., standing orders: Written documents, signed by the emergency medical service system\u2019s medical director, that outline specific directions, permissions, and sometimes prohibitions regarding patient care; also called protocols."
    },
    {
        "Introduction": "As an emergency medical responder (EMR), you must analyze a situation, quickly evaluate a patient\u2019s condition (under stressful circumstances and often by yourself), and carry out effective, lifesaving emergency medical procedures. These procedures sometimes include lifting, moving, or positioning patients as well as assisting other emergency medical services (EMS) providers in moving patients and preparing them for transport.\n\nUsually you will not have to move patients. In most situations, you can treat the patient in the position found and later assist other EMS personnel in moving the patient. In some cases, however, the patient\u2019s survival may depend on your knowledge of emergency movement techniques. You may have to move patients for their own protection (for example, to remove a patient from a burning building), or you may have to move patients before you can provide needed emergency care (for example, to administer cardiopulmonary resuscitation [CPR] to a patient in cardiac arrest who was found in a bathroom). You can perform some of the techniques presented in this chapter with no equipment, whereas other techniques require simple objects that are often available at emergency scenes. With other techniques, you can assist other EMS providers in using the specialized equipment they bring to the emergency scene.",
        "General Principles": "Every time you move a patient, keep the following general guidelines in mind:\n1. Do no further harm to the patient.\n2. Move the patient only when necessary.\n3. Move the patient as few times as possible.\n4. Move the patient\u2019s body as a unit.\n5. Use proper lifting and moving techniques to ensure your own safety.\n6. Have one rescuer give commands when moving a patient (usually the rescuer at the patient\u2019s head).\nAlso consider the following recommendations:\nDelay moving the patient, if possible, until additional EMS personnel arrive.\nTreat the patient before moving him or her unless the patient is in an unsafe environment.\nTry not to step over the patient (your shoes may drop sand, dirt, or mud onto the patient or you might fall onto the patient).\nExplain to the patient what you are going to do and how. If the patient\u2019s condition permits, he or she may be able to assist you.\nUnless you must move patients for treatment or protection, leave them in the position in which you found them. There is usually no reason to hurry the moving process. If you suspect the patient has sustained trauma to the head or spine, keep the patient\u2019s head and spine immobilized so he or she does not move (discussed later in the chapter).",
        "Safety": "Whatever technique you use for moving patients, keep these rules of good body mechanics in mind: \nKnow your own physical limitations and capabilities. Do not try to lift too heavy a load.\nKeep yourself balanced when lifting or moving a patient.\nMaintain a firm footing.\nLift and lower the patient by bending your legs, not your back. Keep your back as straight as possible at all times and use your large leg muscles to do the work.\nTry to keep your arms close to your body for strength and balance.\nMove the patient as few times as possible.",
        "Recovery Position": "Place unconscious patients who have not sustained suspected trauma in the sidelying recovery position to help keep the airway open. The recovery position also allows secretions to drain from their mouth.",
        "Body Mechanics": "Your top priority is to ensure your own safety. Improperly lifting or moving a patient can result in injury to you or to the patient. By exercising good body mechanics, you reduce the possibility of injuring yourself. Good body mechanics means using the strength of the large muscles in your legs to lift patients instead of using your back muscles. This practice prevents strains and injuries to weaker muscles, especially in your back. Get as close to the patient as possible so that your back is in a straight and upright position, and keep your back straight as you lift. Do not lift when your back is bent over a patient. Lift without twisting your body. Keep your feet in a secure position and be sure you have a firm footing before you start to lift or move a patient. To lift safely, keep certain guidelines in mind. Before attempting to move a patient, assess the weight of the patient. Know your physical limitations and do not attempt to lift or move a patient who is too heavy for you to handle safely. Call for additional personnel if needed for your safety and the safety of the patient. Discuss the route of travel prior to lifting. Because you will sometimes need to assist other EMS providers, practice with them so that lifts are handled in a coordinated and helpful manner.\n\nAs you lift, make sure you communicate with the other members of the lifting team. Failure to give clear commands or failure to lift at the same time can result in serious injuries to both rescuers and patients. You can never practice too much; perfect your lifts and moves until they become smooth for you and your partner and for the patient.",
        "Emergency Movement of Patients": "How do you decide when emergency movement of a patient is necessary? Immediately move a patient in the following situations: Danger of fire, explosion, or structural collapse exists. Hazardous materials are present. The emergency scene cannot be protected. It is otherwise impossible to gain access to other patients who need lifesaving care. The patient has experienced cardiac arrest and must be moved so you can begin CPR.",
        "Emergency Drags": "If the patient is lying on the floor or ground during an emergency situation, you may have to drag the person away from the scene instead of trying to lift and carry the patient. Make every effort to pull the patient in the direction of the long axis of the body to protect the spine as much as possible.",
        "Clothes Drag": "The clothes drag is the simplest way to move the patient in an emergency. If the patient is too heavy for you to lift and carry, grasp the patient\u2019s clothing in the neck and shoulder area, rest the patient\u2019s head on your arms for protection, and drag the patient out of danger.",
        "Cardiac Patients and the Clothes Drag": "In most situations, you can easily determine whether emergency movement is necessary. Cases involving patients in cardiac arrest are the exception. Patients in cardiac arrest are often found in a bathroom or small bedroom. You will have to judge whether basic life support (BLS) or advanced life support (ALS) can be adequately provided in that space. If the room is not large enough, move the patient as soon as you have determined he or she has experienced cardiac arrest. Drag the patient from the tight space to a larger room (such as a living or dining room) that has space to perform CPR and ALS procedures. Quickly move furniture out of the way so you and other EMS personnel have room to work. You will be able to provide care with increased efficiency, which will more than make up for the time it took to move the patient. Take time to make adequate room before you begin CPR!",
        "Words of Wisdom": "To eliminate distractions at the scene, take a second to turn off any\ntelevisions, radios, or music players. Emergency scenes are calmer\nand less stressful when you are not competing against a loud television\nprogram or music to be heard.",
        "Blanket Drag": "If the patient is not dressed or is dressed in clothing that could tear easily\nduring the clothes drag (for example, a nightgown), move the patient by using\na large sheet, blanket, or rug (\nblanket drag\n). Place the sheet, blanket, rug, or\nsimilar item on the floor and roll the patient onto it. Pull the patient to safety by\ndragging the sheet or blanket. You can also use the blanket drag to move a\npatient who weighs more than you do \nFigure 3-5\n.\n94",
        "Arm-to-Arm Drag": "If the patient is on the floor, you can place your hands under the patient\u2019s armpits from the back of the patient and grasp the patient\u2019s forearms. The arm-to-arm drag allows you to move the patient by carrying the weight of the upper part of the patient\u2019s body as the lower trunk and legs drag on the floor. This drag enables you to move a heavy patient and it offers some protection for the patient\u2019s head and neck.",
        "Firefighter Drag": "The firefighter drag enables you to move a patient who is heavier than you are because you do not have to lift or carry the patient. Tie the patient\u2019s wrists together with any material that is handy\u2014such as a cravat (a folded triangular bandage), strip of gauze, belt, or necktie\u2014being careful not to impair circulation. Then get down on your hands and knees and straddle the patient. Pass the patient\u2019s tied hands around your neck, straighten your arms, and drag the patient across the floor by crawling on your hands and knees.",
        "Emergency Drag From a Vehicle": "Sometimes you have to use emergency movement techniques in life-threatening situations when no equipment is immediately available (for example, to remove a patient from a motor vehicle that is on fire or to administer CPR). All the basic movement principles apply, but the techniques need to be slightly modified because the patient is sitting instead of lying down. Emergency drags from a vehicle can be performed with one or more rescuers.",
        "One Rescuer": "Grasp the patient under the arms and cradle the patient\u2019s head between your arms. Pull the patient down into a horizontal position as you ease him or her from the vehicle. Although there is no effective way to remove a patient from a vehicle by yourself without causing some movement, it is important to prevent excessive movement of the patient\u2019s neck.",
        "Two or More Rescuers": "If you must immediately remove a patient from a vehicle and two or more rescuers are present, have one rescuer support the patient\u2019s head and neck, while the second rescuer moves the patient by lifting under the arms. The patient can then be removed in line with the long axis of the body, with the head and neck manually stabilized in a neutral position. If time permits and if you have one available, use a long backboard for patient removal. Procedures for using a long backboard are covered later in this chapter.",
        "Carries for Nonambulatory Patients": "Many patients are unable or should not be allowed to move without your assistance. Patients who are unable to move because of injury or illness must be carried to safety. This section describes several useful carrying techniques for nonambulatory patients. Whatever technique you use, remember to follow the rules of good body mechanics.",
        "Two-person extremity carry": "enables two rescuers with no equipment to move a patient in tight or narrow spaces, such as mobile home corridors, small hallways, and narrow spaces between buildings. The focus of this carry is to use the patient\u2019s extremities to move the patient. First, the rescuers help the patient sit up. Rescuer One kneels behind the patient, reaches under the patient\u2019s arms, and grasps the patient\u2019s wrists. Rescuer Two then backs in between the patient\u2019s legs, reaches around, and grasps the patient behind the knees. At a command from Rescuer One, the two rescuers stand up and carry the patient away, walking straight ahead.",
        "Two-Person Seat Carry": "With the two-person seat carry, two rescuers use their arms and bodies to form a seat for the patient. The rescuers kneel on opposite sides of the patient near the patient\u2019s hips. The rescuers then raise the patient to a sitting position and link arms behind the patient\u2019s back. The rescuers then place the other arm under the patient\u2019s knees and link with each other. If possible, the patient puts his or her arms around the necks and shoulders of the rescuers for additional support. Although the two-person seat carry requires two rescuers, it does not require any equipment.",
        "Cradle-in-Arms Carry": "The cradle-in-arms carry can be used by one rescuer to carry a child. Kneel beside the patient and place one arm around the child\u2019s back and the other arm under the thighs. Lift slightly and roll the child into the hollow formed by your arms and chest. Be sure to use your leg muscles to stand.",
        "Safety_0": "Keep your back as straight as possible and use the large muscles in your legs to do the lifting!",
        "Two-Person Chair Carry": "In the two-person chair carry, two rescuers use a chair to support the weight of the patient. Do not use a folding chair. Test the strength of the chair using a healthy person before moving an ill or injured patient using the chair. The chair carry is especially useful for taking patients up or down stairways or through a narrow hallway. An additional benefit is that because the patient is able to hold on to the chair (and should be encouraged to do so), he or she feels much more secure than with the two-person seat carry. Rescuer One stands behind the seated patient, reaches down, and grasps the back of the chair close to the seat. Rescuer One then tilts the chair slightly backward on its rear legs so Rescuer Two can step back in between the legs of the chair and grasp the chair\u2019s front legs. The patient\u2019s legs should be between the legs of the chair. When both rescuers are correctly positioned, Rescuer One gives the command to lift and walk away.",
        "Pack-Strap Carry": "The pack-strap carry is a one-person carry that allows you to carry a patient while keeping one hand free. Have the patient stand (or have other rescue personnel support the patient) and back into the patient so your shoulders fit into the patient\u2019s armpits. Grasp the patient\u2019s wrists and cross the arms over your chest. Now you can hold both wrists in one hand and your other hand remains free. Optimal weight distribution occurs when the patient\u2019s armpits are over your shoulders. Squat deeply to avoid potential injury to your back and pull the patient onto your back. After you position the patient correctly, bend forward to lift the patient off the ground, stand up, and walk away.",
        "Safety_1": "Because the two-person chair carry may force the patient\u2019s head forward, have Rescuer Two watch the patient for airway problems.",
        "Direct Ground Lift": "Use the direct ground lift to move a patient who is on the ground or the floor to an ambulance stretcher. Use this lift only for those patients who have not sustained a traumatic injury. The direct ground lift requires you to bend over the patient and lift with your back in a bent position. This positioning of your body results in poor body mechanics; therefore, avoid this lift whenever possible. Using a long backboard or portable stretcher is much better for your back and may be more comfortable for the patient. The steps for performing the direct ground lift are described in Skill Drill 3-2.\n\n1. Assess the patient. Do not use this lift if the patient has any possible head, spine, or leg injuries.  \n2. Rescuer One kneels at the patient\u2019s chest on the right or left side. Rescuer Two kneels at the patient\u2019s hips on the same side as Rescuer One Step 1.  \n3. Place the patient\u2019s arms on the chest.  \n4. Rescuer One places one arm under the patient\u2019s neck and shoulder to cradle the patient\u2019s head and then places the other arm under the patient\u2019s lower back. Rescuer Two places one arm under the patient\u2019s knees and the other arm above the buttocks Step 2.  \n5. Rescuer One gives the command: \u201cReady? Roll!\u201d and both rescuers roll their forearms up so the patient is as close to them as possible.  \n6. Rescuer One gives the command: \u201cReady? Lift!\u201d and both rescuers lift the patient to their knees and roll the patient as close to their bodies as possible.  \n7. Rescuer One gives the command: \u201cReady? Stand!\u201d and both rescuers stand and move the patient to the stretcher Step 3.  \n8. To lower the patient to the stretcher, the rescuers reverse the steps listed above Step 4.",
        "Safety_2": "The direct ground lift requires you to use poor body mechanics, so avoid using it whenever possible. Never use the direct ground lift with a patient who may have sustained any injury to the head, spine, or legs.",
        "Transferring a Patient From Bed to Stretcher": "Patients who are ill are often found in their beds. If EMS personnel need to transport these patients to the hospital, they may request your assistance with transferring a patient from the bed to the ambulance stretcher using the draw sheet method Figure 3-14. \n\nPlace the stretcher next to the bed, making sure it is at the same height as the bed and that the rails are lowered and straps unbuckled. Hold the stretcher to keep it from moving. Loosen the bottom sheet underneath the patient or log roll the patient onto a blanket. Reach across the stretcher and grasp the sheet and blanket firmly at the patient\u2019s head, chest, hips, and knees. Gently slide the patient onto the stretcher.\n\nAn alternate method for moving a patient is to loosen the bottom sheet of the patient\u2019s bed, place the ambulance stretcher parallel with the bed, and reach across the stretcher to pull the sheet and the patient onto the stretcher. However, use this method with caution because it requires you to reach across the stretcher to get to the patient. This action results in poor body mechanics; therefore, avoid using it whenever possible.",
        "Skill Drill 3-1: Direct Ground Lift": "Step 1 Kneel at the patient\u2019s side.\nStep2 Place arms under the patient.\n Step 3 Lift the patient.\n Step4 Move the patient to the stretcher.",
        "Walking Assists for Ambulatory Patients": "Frequently, patients simply need assistance to walk to safety. Either one or two rescuers can perform this task. Choose a technique after you have assessed the patient\u2019s condition and the scene of the incident. The technique you might use to help a patient walk to a chair is probably not appropriate to help a patient walk up a highway embankment.",
        "One-Person Walking Assist": "Use the one-person walking assist if the patient is able to bear his or her own weight. Help the patient stand. Have the patient place one arm around your neck and hold the patient\u2019s wrist (which he or she should drape over your shoulder). Put your free arm around the patient\u2019s waist and help the patient to walk.",
        "Two-Person Walking Assist": "The two-person walking assist is the same as the one-person walking assist, except that two rescuers are needed. This technique is useful if the patient cannot bear weight. The two rescuers completely support the patient.",
        "Safety_3": "Do not use any of the lifts or carries explained in this chapter if you suspect the patient has a spinal injury\u2014unless, of course, it is necessary to remove the patient from an immediately life-threatening situation.",
        "Voices of Experience": "Throughout the move, we stayed in constant communication with each other and with the patient.\n\n\u201cHow are you going to get me to the ambulance? I\u2019m a big guy!\u201d \nGood question, I thought. He was 350 pounds (159 kg) and had experienced a stroke while in the shower in a dark, upstairs motel room. The stroke had rendered him nonambulatory. He had no clothes to grab onto and was positioned on the floor between the bed and the wall in a right lateral recumbent position. He also needed manual stabilization because of a fall. There was a four-person fire crew, my partner, and myself on scene. The small space was limiting in that not all of us would fit around the patient to appropriately care for or move him.With everyone working together, we used two sheets from the bed: one to cover him and one to position under him. The sheet under the patient would be used for the draw sheet method. The patient was moved with the long axis of his body onto the backboard while manual stabilization was maintained. A firefighter put his tarp/carry-all under the backboard prior to moving the patient, giving us more handles to safely carry him after he was secured to the backboard. The limited space around the patient allowed for only one crew member at the patient\u2019s head and one at the feet. The two of them worked together to push and pull, respectively, with the tarp/carry-all to move the patient across the balcony to the landing of the stairs. On the landing, we were able to add two crew members: one on the patient\u2019s right side and one on the left. One of the two remaining crew members went to the bottom of the stairs to position and stabilize the gurney while the other stood behind the person who was going backwards down the stairs while moving the patient to ensure the safety of his fellow crew member. For any successful patient move, the cornerstone is communication. Prior to walking down the stairs, we discussed how the move would be executed and shared our plan with the patient. Throughout the move, we stayed in constant communication with each other and with the patient. This communication reduced the chance of injuring him or ourselves. We successfully made it to the gurney, where we continued to work as a team using a four-person lift to elevate the gurney and load the patient into the ambulance. \u201cI didn\u2019t think you were going to be able to do it, but that wasn\u2019t bad at all!\u201d That was the nicest thing I had heard all night.",
        "Equipment": "Most of the lifts and moves described in the previous section are performed without the use of any specialized equipment. However, EMS departments commonly use various types of patient-moving equipment. To be able to assist other EMS providers, familiarize yourself with the following equipment.",
        "Wheeled Ambulance Stretchers": "Wheeled ambulance stretchers are carried by ambulances and are one of the most commonly used EMS devices. These stretchers are also called cots. Each type of stretcher has its own set of levers and controls for raising and lowering the stretcher to different heights. The head end of the stretcher can be raised to elevate the patient\u2019s head. These stretchers have belts to secure the patient. Some EMS departments use electronic stretchers, commonly called ambulance stretchers, which can be raised and lowered using a battery-powered system. These stretchers reduce the strain on EMS providers and operate smoothly for patient comfort. If you regularly work with the same EMS unit, it will be helpful for you to learn how their particular type of stretcher operates.\n\nStretchers can be rolled or they can be carried by two or four people. If the surface is smooth, a wheeled stretcher can be rolled with one person guiding the head end and one person pulling the foot end. If the loaded stretcher must be carried, it is best to use four people, one person at each corner. The use of four people offers more stability and less strength is required to carry the stretcher. If the stretcher must be carried through a narrow area, only two people will be able to carry it. The two rescuers should face each other from opposite ends of the stretcher. Carrying the stretcher with two people requires that each person be strong enough to maintain the balance of the stretcher. As an EMR, you may also be asked to assist with loading a patient into the ambulance. Learn the method of loading ambulance stretchers that your EMS unit uses and practice this procedure with the EMS unit. It is important to lift as a team to avoid injury to yourself or to the other rescuers.",
        "Patient-moving equipment includes the following:": "\nWheeled ambulance stretcher\nPortable stretcher\nStair chair\nLong backboard\nShort backboard (vest-type immobilizer)\nScoop stretcher",
        "Portable stretcher": "Use a portable stretcher when you cannot move the wheeled ambulance stretcher into a small space. They are smaller and lighter to carry than wheeled stretchers. You can carry a portable stretcher in the same ways that you carry a wheeled stretcher.",
        "Stair chair": "A stair chair is a portable moving device that is used to carry a patient in a sitting position. The stair chair is useful for patients who are short of breath or who are more comfortable in a sitting position. They are small, lightweight, and easy to carry in narrow spaces. Do not use the stair chair with patients who have experienced any type of trauma. When carrying a stair chair, the rescuers face each other and lift on a set command. If you are going to assist your local EMS unit with this device, learn how to unfold it and how to assist with carrying it. ",
        "Immobilization Devices": "Use backboards to immobilize patients who have neck or back injuries. You can also use such devices to assist in lifting patients and as an aide in immobilizing lower extremity injuries. This section discusses three types of backboard devices: long backboards, short backboard devices, and scoop stretchers.",
        "Long Backboards": "Use long backboards to move patients who have experienced trauma, especially if they may have neck or back injuries. You can also use long backboards for lifting and moving patients who are in small places or who need to be moved off the ground or floor. Long backboards make lifting a patient much easier for the rescuers. Most long backboards are made of plastic or fiberglass. Secure the patient with straps after he or she is placed on the long backboard; if the patient has sustained back or neck injuries, immobilize the head. Procedures for assisting EMS providers with these devices are covered later in this chapter. One type of long backboard is pictured in Figure 3-20.",
        "Special Populations": "When you move older patients, remember some of them have fragile bones that have been weakened by osteoporosis. Move older patients carefully to avoid further injuries.",
        "Short Backboard Devices": "Short backboard devices are used to immobilize the head and spine of patients found in a sitting position who may have sustained head or spine injuries. Short backboard devices are usually made of plastic. Some of these devices are in the form of a vest-like garment that wraps around the patient Figure 3-21. Procedures to help you assist other EMS providers in applying these devices are covered later in this chapter.",
        "Words of Wisdom_4": "You may be asked to assist with the removal of deceased patients, especially in mass-casualty incidents. Usually deceased patients are placed in specially designed body bags before removal. Body bags are flexible and difficult to carry. Removal of a deceased person is much easier for rescuers if the body is placed on a backboard or portable stretcher after being placed in a body bag. This process also greatly reduces the chance of injury to rescuers. It also creates a more respectful image of the deceased person for family members, bystanders, and members of the media.",
        "Scoop Stretchers": "A scoop stretcher or orthopaedic stretcher is a rigid device that separates into a right half and a left half. Apply these devices by placing one half on each side of the patient and then attaching the two halves together. These devices are helpful when moving patients out of small spaces. Do not use a scoop stretcher if the patient has sustained head or spine injuries. One type of scoop stretcher is shown in Figure 3-22. If your EMS department uses scoop stretchers, practice using them. The steps for applying a scoop stretcher are shown in Skill Drill 3-2.\nStep 1 With the scoop stretcher separated, measure the length of the scoop and adjust to the proper length.\nStep 2 Position the stretcher, one side at a time. Lift the patient\u2019s side slightly by pulling on the far hip and upper arm, while your partner slides the stretcher into place.\nStep 3 Lock the stretcher ends together by engaging its locking mechanisms one at a time and continue to lift the patient slightly as needed to avoid pinching the patient and/or your fingers.\n Step 4 Apply and tighten the straps to secure the patient to the scoop stretcher before transferring it to the stretcher.",
        "Using a Scoop Stretcher": "Step 1 Adjust the length of the stretcher. \nStep 2 Lift the patient slightly and slide the stretcher into place, one side at a time. \nStep 3 Lock the stretcher ends together and avoid pinching both the patient and/or your fingers\nStep 4_7: \n\nSecure the patient to the scoop stretcher, and transfer it to the stretcher.",
        "Words of Wisdom_8": "In an emergency situation, you can use the following objects for improvised backboards:\nWide, sturdy planks\nDoors\nIroning boards\nSturdy folding tables\nFull-length lawn chair recliners\nSurfboards\nSnowboards",
        "Treatment of Patients With Suspected Head or Spine Injuries": "Any time a patient has sustained a traumatic injury, you should suspect injury to the head, neck, or spine. Improper treatment can lead to permanent damage or paralysis. Immobilize the patient\u2019s head and neck in a neutral position using your hands (manual stabilization), a blanket roll, or foam blocks. It is also important that you be able to assist other EMS personnel in caring for patients who may have sustained head or spine injuries. The following sections show you how to immobilize a patient\u2019s head and neck and how to assist other EMS providers in placing a patient on a backboard.",
        "Applying a Cervical Collar": "Use a cervical collar to minimize (but not completely prevent) movement of the patient\u2019s head and neck. These collars do not totally prevent head and neck movement; rather, they minimize the movement. After you apply a cervical collar, it is still necessary for you to manually stabilize the patient\u2019s head and neck.\n\nSoft cervical collars do not provide sufficient support for trauma patients. Many different types of rigid cervical collars for trauma patients are available.",
        "Applying a cervical collar.": "A. Stabilize head and neck. B. Insert back part of collar. C. Apply front part of collar. D. Secure collar together.",
        "Movement of Patients Using Backboards": "Placing a patient on a backboard is not your primary responsibility, but you may be required to assist other EMS personnel with this task. Therefore, be familiar with the proper handling of patients who must be moved on backboards. Any patient who has sustained spinal trauma in a motor vehicle crash or fall and any person who has sustained gunshot wounds to the trunk should be transported on a backboard. Although the specific technique you will use depends on the circumstances, the general principles described in the remainder of this chapter are relevant in nearly all cases.\n\nThe following principles of patient movement are especially important if you suspect the patient has a spinal injury:\n1. Move the patient as a unit.\n2. Transport the patient faceup (supine), the only position that provides adequate spinal immobilization. However, because patients secured to backboards often vomit, be prepared to turn the patient and backboard quickly as a unit to permit the vomitus to drain from the patient\u2019s mouth.\n3. Keep the patient\u2019s head and neck in a neutral position.\n4. Be sure all rescuers understand what is to be done before attempting any movement.\n5. Be sure one rescuer is responsible for giving commands.",
        "Special Populations_9": "Many older patients have irregular curves in their spine. When immobilizing these patients, you may need to add extra padding to conform to the unusual shape of their spine.",
        "Words of Wisdom_10": "In some EMS departments, there may be times when emergency medical technicians or paramedics evaluate a patient who has had his or her neck or back immobilized and are able to remove the immobilization from the patient by following a well-defined protocol. This is not something that you should consider. As an EMR, you should keep a patient immobilized until he or she has been evaluated by a more highly qualified medical person.",
        "Assisting With Short Backboard Devices": "Short backboard devices are used to immobilize patients found in a sitting position who have sustained trauma to the head, neck, or spine. Short backboard devices allow rescuers to immobilize the patient before moving.\n\nAfter the short backboard device is applied, the patient is carefully placed on a long backboard. As an EMR, you will not be applying a short backboard device by yourself. However, you may need to assist with the application of this device. Skill Drill 3-3 illustrates how one common type of short backboard device is applied. \n\n1 Position Responder One behind the patient to stabilize the head. Responder Two then applies a cervical collar \n2 While maintaining neutral, in-line manual stabilization, Responder One leans the patient forward and Responder Two inserts the device behind the patient, starting with the head portion. Responder One then carefully eases the patient onto the backboard. \n3 Responder Two fastens the middle strap of the device and then fastens the rest of the straps. \n4 Responder Two then places the wings of the device around the patient\u2019s head. \n 5 Responder One maintains in-line manual stabilization until Responder Two has secured the head strap of the device.",
        "Log Rolling": "Log rolling is the primary technique you will use to move a patient onto a long backboard. It is usually easy to accomplish, but it requires a team of four rescuers for safety and effectiveness\u2014three to move the patient and one to maneuver the backboard. Log rolling is the movement technique of choice in all patients with suspected spinal injury. Because log rolling requires sufficient space for four rescuers, it is not always possible to perform it correctly. That is why the principles of movement, rather than specific rules, are stressed here. The procedure for the four-person log roll is shown, Step 1 Rescuers get into position to roll the patient \n Step 2 Roll the patient onto his or her side. \nStep 3 The fourth person slides the backboard toward the patient\n Step 4 Once Rescuer One gives the command, rescuers roll the patient onto the backboard\n Step 5 Center the patient on the backboard. Secure the patient before moving\n\nWhen using any patient movement technique, everyone must understand who is directing the maneuver, especially if you suspect the patient has a spinal injury. The rescuer holding the patient\u2019s head (Rescuer One) should always give the commands so all rescuers can better coordinate their actions. The specific wording of the command is not important, as long as every team member understands what the command is. Each member of the team must understand his or her specific position and function.\n\nAll patient movement commands have two parts: a question and the order for movement. Rescuer One says, \u201cThe command will be \u2018Ready? Roll!\u2019\u201d When everyone is ready to roll the patient, Rescuer One says, \u201cReady?\u201d (This question is followed by a short pause to allow for response from the team.) Then Rescuer One says, \u201cRoll!\u201d\n\nIn any log-rolling technique, you must move the patient as a unit. Keep the patient\u2019s head in a neutral position at all times. Do not allow the head to rotate, move backward (extend), or move forward (flex). Sometimes this is simply stated as, \u201cKeep the nose in line with the belly button at all times.\u201d",
        "Straddle Lift": "Use the straddle lift to place a patient on a backboard if you do not have enough space to perform a log roll. Modified versions of the straddle lift are commonly used to remove patients from motor vehicles. The straddle lift requires five rescuers: one at the head and neck, one to straddle the shoulders and chest, one to straddle the hips and thighs, one to straddle the legs, and one to insert the backboard under the patient after the other four have lifted the patient 0.5 inch (1 cm) to 1 inch (3 cm) off the ground.\n\nThe most difficult part of the straddle lift technique is coordinating the lifting so the patient is raised just enough to slide the backboard under the patient. Because such team coordination can be difficult, it is important to practice this lift frequently.",
        "Straddle Slide": "In the straddle slide, a modification of the straddle lift technique, the rescuers move the patient rather than the backboard. This technique may be useful when the patient is in an extremely narrow space and cannot otherwise be moved to a backboard. The rescuers\u2019 positions are the same as for the straddle lift. Each rescuer should have a firm grip on the patient (or the patient\u2019s clothing). Lift the patient as a unit just enough to be able to slide (break the resistance with the ground) him or her forward onto the waiting backboard. Slide the patient forward about 10 inches (25 cm) at a time. Trying to slide the patient a distance of greater than 10 inches to 12 inches (25 cm to 30 cm) at a time can cause coordination problems among the team.\n\nEach rescuer should lean forward slightly and use a swinging motion to bring the patient onto the backboard. Rescuer One (who is at the patient\u2019s head) faces the other rescuers and moves backward during each movement. Rescuer One must not allow the patient\u2019s head to be driven into his or her knees!",
        "Safety_21": "When you are using the up-and-forward movement, make it a single, smooth action. Lifting the patient up and then forward can strain your muscles.",
        "Straps and Strapping Techniques": "Secure every patient who is on a backboard with straps to avoid having him or\nher slide or slip off the backboard. There are many ways to strap a patient to a\nbackboard. The straps should be long enough to go around \nthe backboard and\na large patient. Straps that are 6 feet to 9 feet (2 m to 3 m) long with seat belt-\ntype buckles work well \nFigure 3-27\n.\n\nFigure 3-27\n Seat belt-type straps.\n\u00a9 American Academy of Orthopaedic Surgeons.\nOnce the patient is centered on the board, secure the upper torso with straps.\nConsider padding voids between the patient and the backboard. Next, secure\nthe pelvis and upper legs, using padding as needed. To reduce the chance of\nhead movement, secure the straps around the wrist and hip area and the\nknees before securing the head to the backboard. Strap placement is shown in\nFigure 3-28\n. Different EMS systems use many different types of straps and\nstrapping techniques. Learn and implement the method used by your EMS\ndepartment.\n131",
        "Strap placement for effective immobilization on a backboard": "A. Arms. B. Upper legs. C. Below the knees.",
        "Head Immobilization": "After a patient has been secured to the backboard, immobilize the head and neck using commercially available devices (such as foam blocks) or improvised devices (such as a blanket roll). The use of a blanket roll is explained here because it works well and because a blanket is almost always available. Assemble the blanket roll ahead of time. Fold and roll the blanket (with towels as bulk filler) as shown in Skill Drill 3-5.Step 1. Fold the blanket into a long rectangular shape. Step 2. Insert a rolled towel and roll the blanket from each end. Step 3. Roll the ends together. Step 4. Place extra cravats in between the two rolled ends. Step 5. Tie the rolled ends together with two cravats.\n\nTo place the blanket roll under a patient\u2019s head, one rescuer unrolls it enough to fit around the patient\u2019s head as another rescuer maintains manual stabilization. The rescuer holding the patient\u2019s head (Rescuer One) carefully slides his or her hands out from between the blanket and immobilization is maintained by the blanket roll. Skill Drill 3-6\n1. Rescuer One stabilizes the patient\u2019s head Step 1. 2. Both rescuers apply a cervical collar Step 2. 3. Place straps around the backboard and the patient Step 3. 4. Insert the blanket roll under the patient\u2019s head. 5. Roll the blanket snugly against the patient\u2019s neck and shoulders Step 4. 6. Tie two cravats around the blanket roll. 7. Continue to stabilize the patient\u2019s head. 8. Tie two more cravats around the blanket roll and backboard Step 5. 9. Assess sensory and motor function after immobilization.\n\nProvide motion restriction throughout the entire procedure (first by manual stabilization of the patient\u2019s head, then by immobilization using the blanket roll). The blanket roll must be fitted securely against the patient\u2019s shoulders to widen the base of support for the patient\u2019s head. Secure the blanket roll to the head with two cravats tied around the blanket roll: one over the patient\u2019s forehead and the other under the chin. Use two more cravats in the same positions to bind the head and the blanket roll to the backboard. The patient\u2019s head and neck are now adequately stabilized against the backboard. This head immobilization technique, coupled with proper placement of straps around the backboard, adequately immobilizes the spine of an injured patient and packages the patient for movement as a unit. Foam blocks are quick to apply and provide good immobilization of the patient\u2019s head and neck.\n\nIn an extreme emergency where a patient must be moved from a dangerous environment and a commercially available backboard is unavailable, improvise. Make sure the improvised backboard is strong enough to hold the patient without breaking. Use improvised devices only when a patient must be moved to prevent further injury or death and when a commercially available backboard is not available.",
        "Application of a commercial device to immobilize a patient\u2019s head and neck.": "A. Apply the foam blocks. \nB. Secure the device\nC. Apply the immobilization straps.\nD. The head is immobilized.",
        "Treatment": "Carefully monitor all immobilized patients for airway problems.",
        "Prep Kit-Ready for Review": "In most situations, you can treat the patient in the position found and later assist other emergency medical services (EMS) personnel in moving the patient. In some situations, however, the patient\u2019s survival may depend on your knowledge of emergency movement techniques.\nEvery time you move a patient, keep the following general guidelines in mind: Do no further harm to the patient.\nMove the patient only when necessary.\nMove the patient as few times as possible.\nMove the patient\u2019s body as a unit.\nUse proper lifting and moving techniques to ensure your own safety.\nHave one rescuer give commands when moving a patient.\nAlways use good body mechanics when you move patients, including:\nKnow your own physical limitations and capabilities.\nKeep yourself balanced when lifting or moving a patient.\nMaintain a firm footing.\nLift and lower the patient by bending your legs, not your back. Keep your back as straight as possible at all times and use your leg muscles to do the work.\nTry to keep your arms close to your body for strength and balance.\nPlace unconscious patients who have not sustained trauma in the recovery position.\nIf a patient is lying on the floor or ground during an emergency situation, you may have to drag the person away from the scene instead of trying to lift and carry the person. Make every effort to pull the patient in the direction of the long axis of the body to protect the patient\u2019s spine. Do not lift or move a patient if you suspect a spinal injury, unless it is necessary to remove the patient from a life-threatening situation. EMS departments typically use wheeled ambulance stretchers, portable stretchers, stair chairs, long backboards, short backboards, and scoop stretchers to immobilize and move patients. Any time a patient has sustained a traumatic injury, you should suspect injury to the head, neck, or spine. Keep the patient\u2019s head in a neutral position and immobilized. Use a cervical collar to prevent excessive movement of the head and neck. Log rolling is the primary technique you will use to move a patient onto a backboard. Secure every patient who is on a backboard with straps to avoid having him or her slide or slip off the backboard. After you secure a patient to the backboard, immobilize the head and neck using commercially available devices or improvised devices.",
        "Vital Vocabulary": "arm-to-arm drag: An emergency move that consists of the rescuer grasping the patient\u2019s arms from behind; used to remove a patient from a hazardous environment., blanket drag: An emergency move in which a rescuer encloses a patient in a blanket and drags the patient to safety., cervical collar: A neck brace that partially immobilizes the neck following injury., clothes drag: An emergency move used to remove a patient from a hazardous environment; performed by grasping the patient\u2019s clothes and moving the patient head first from the unsafe area., cradle-in-arms carry: A one-rescuer patient movement technique used primarily for children; the patient is cradled in the hollow formed by the rescuer\u2019s arms and chest., extremities: The arms and legs., firefighter drag: A method of moving a patient without lifting or carrying him or her; used when the patient is heavier than the rescuer., log rolling: A technique used to move a patient onto a long backboard., one-person walking assist: A method used if the patient is able to bear his or her own weight., pack-strap carry: A one-person carry that allows the rescuer to carry a patient while keeping\none hand free., portable stretcher: A lightweight, nonwheeled device for transporting a patient; used in small\nspaces where the wheeled ambulance stretcher cannot be used., recovery position: A sidelying position that helps an unconscious patient maintain an open\nairway., scoop stretcher: A firm device used to carry a patient; can be split into halves and applied to\nthe patient from both sides., stair chair: A small portable device used for transporting a patient in a sitting position., straddle lift: A method used to place a patient on a backboard if there is not enough\nspace to perform a log roll., straddle slide: A method of placing a patient on a long backboard by straddling both the\nboard and patient and sliding the patient onto the board., two-person chair carry: A method of carrying a patient in which two rescuers use a chair to support\nthe weight of the patient., two-person extremity carry: A method of carrying a patient out of tight quarters using two rescuers and\nno equipment., two-person seat carry: A method of carrying a patient in which two rescuers link arms behind the\npatient\u2019s back and under the patient\u2019s knees; requires no equipment., two-person walking assist: A method used when a patient cannot bear his or her own weight; two\nrescuers completely support the patient."
    },
    {
        "Introduction": "A vital part of your role as an emergency medical responder (EMR) involves communication and documentation. Communication is the transmission of information to another person. Effective communication is important during every phase of a call. The dispatcher must communicate the location and type of call to designated responders. As an EMR, you need to communicate with patients, bystanders, family members, dispatchers, and other members of the public safety community. After you have completed a call, you must document the condition of the patient and the treatment given to the patient. Documentation is the written or electronically reported portion of a patient care interaction. This chapter describes a variety of communications systems and techniques and provides guidelines for creating written documentation for patient care.",
        "Data and Communications Systems": "The purpose of a communications system is to send information from one location to another when it is impossible to communicate face-to-face. The results of using a communications system will be only as accurate as the information that is put into the system. As an EMR, you should have a basic idea of how your department\u2019s communications system works. Communications systems can be divided into two categories: those that transmit voice communications and those that transmit data.",
        "Words of Wisdom": "It is important for different agencies that are working together to have the ability to communicate with one another. This concept is called interoperability.",
        "Voice Systems": "Voice communications systems transmit the spoken word from one location to another. The two types of voice systems most commonly used in public safety agencies are radio systems and telephone systems.",
        "Radio Systems": "Most EMRs use some type of radio communications system. It is important that you have a working knowledge of the basics of a radio communications system and that you understand how to properly operate the radio system used by your department. Radio communications are regulated by the Federal Communications Commission (FCC). A channel is an assigned frequency or frequencies used to carry voice and/or data communications. Frequencies are assigned according to the function of your organization. EMRs who are part of a law enforcement agency are usually assigned different frequencies than EMRs who are part of a fire department. Many public safety agencies use a trunked communications system, a computer-controlled radio system that allows the sharing of a few radio frequencies among a large group of users. Each functional group using the trunked system is assigned to a specific \u201ctalk group.\u201d Trunked systems permit more efficient use of the limited radio frequencies available to public safety agencies. These systems can transmit voice communications as well as other forms of digital communications. If your agency uses a trunked radio system, then you need to learn how to use it. Several different types of radios exist. A base station is a powerful two-way radio that is located in a fixed place and attached to one or more antennas. Dispatchers use base stations to send and receive messages to and from the service area. A base station may be attached to several different antennas to reach all parts of a geographic service area. Base stations may be designed to transmit and receive on multiple frequencies. Some systems are designed so that different frequencies are used for different functions of communications.\n\nA mobile radio is mounted in a vehicle, such as a fire truck, and draws electricity from the electrical system of the vehicle. It has an external antenna, which is usually mounted on the roof or cab of the vehicle. The operating console is mounted so the driver or passenger of the vehicle can conveniently operate the radio. Mobile radios can be used to send and receive voice messages and data.\n\nA portable radio is a handheld, self-contained unit that includes a two-way radio with a battery, a built-in microphone, and a built-in antenna. Most portable radios are capable of operating on multiple channels. One drawback of many portable radios is that the controls are small and hard to see in darkness; therefore, EMS providers who use these radios must become extremely familiar with the controls and operation. Portable radios are low-powered devices and are often used with a repeater system. A repeater is a device that receives a weak radio signal, strengthens that signal, and then automatically rebroadcasts it. Repeaters are used to cover geographic areas where radio signals are too weak for effective communications. These geographic areas are sometimes called dead spots.",
        "Telephone Systems": "Telephone systems primarily send voice communications. Public safety agencies may use phone systems to send dispatch information or to handle routine administrative communications. Landline phone systems are tied together through an above-ground or below-ground hardwired system. Mobile phones rely on radio waves between a mobile phone and a cellular tower to create and receive messages. Smartphones use advanced operating systems that combine the features of a cellular phone with those of a personal computer and global positioning systems (GPS).",
        "Data Systems": "Communications systems are increasingly used to send and receive data through radios, phones, and the Internet. Many different types of data can be sent between EMS personnel and communications centers. Computer-generated routing information is an example of data that are useful for EMS personnel. \nPaging systems can transmit text messages or voice communications. Pagers are radio receivers that are silent unless activated by a dispatcher. Some departments use paging systems to alert members to emergency incidents.\nA mobile data terminal (MDT) transmits data messages through a radio system and is frequently incorporated into a mobile radio system. MDTs reduce the amount of time the radio frequency is in use.\nA fax machine is sometimes used to send written data or images over a phone or radio system. Some public safety providers use fax machines totransmit dispatch information. Telemetry is a process used by advanced life support providers to transmit electrocardiograms and other patient data to online medical control. Telemetry can operate through a phone system or through a radio system. Digital messaging is technology that includes email, text messages, and social media, which are increasingly used by EMRs to send and receive information within public safety agencies. Remember, most patient information is confidential.\n\nAs an EMR, you may not use all these types of communications in your department, but you should understand how various communications devices operate. It is more important for you to understand how to send and receive data than it is to understand how the system is built.",
        "The Functions of Radio Communications": "Throughout the different phases of an EMS call, communications systems are used for different functions. Calls for medical assistance can be divided into six phases: dispatch, response to the scene, arrival at the scene, updating responding EMS units, transfer of patient care to other EMS personnel, and postrun activities. During these phases, it is important to communicate certain findings to other members of the EMS or public safety team.",
        "Dispatch": "The function of dispatch can be accomplished using a phone system, a paging system, a fax, or a radio system. Dispatch may use voice, text messaging, or an MDT to alert you to an emergency. It is your responsibility to keep your equipment ready to receive a call whenever you are on duty. Listen carefully to voice messages to ensure that you receive the information correctly. If you are not sure that you have received all the dispatch information correctly, then ask the dispatcher to repeat it. If you receive dispatch information via an MDT, text message, or a fax, then you can refer to the message to verify the location and type of call.",
        "Phases of an EMS call:": "1. Dispatch 2. Response to the scene 3. Arrival at the scene 4. Updating responding EMS units 5. Transfer of patient care to other EMS personnel 6. Postrun activities",
        "Response to the Scene": "To respond quickly and efficiently to the scene of an emergency, you need to know your response area. Learn how to use maps or GPS devices to help get you to the scene. Listen carefully to your dispatcher; he or she may be able to give you further information about the location of the call or the condition of the patient while you are en route. If you are delayed in responding to the incident (for example, because your vehicle will not start or you encounter traffic, a blocked railroad crossing, weather conditions, or other unexpected delays), then notify your dispatcher of the situation. Your message will enable the dispatcher to contact and send another unit to the same call if necessary",
        "Words of Wisdom_1": "To ensure you take the fastest route, do not start responding to a call until you know where you are going.",
        "Arrival at the Scene": "As you arrive at the scene, perform a scene size-up\u2014which includes a visual survey or an overview of the incident and its surroundings. Your scene size-up of the entire incident gives you an impression of the overall situation, including the number of patients involved and the severity of their injuries. After you have performed a scene size-up, give the communications center a brief verbal description of the scene. For a simple call with one patient, your patient care report will be more concise than the report you deliver for a more complex call. Your report should verify the location of the incident, the type of incident, any hazards present, the number of patients, and any additional assistance required. Next, determine if you need to call for additional resources. It is better to request assistance and find you do not need it than to wait and then call for help after determining the need is urgent",
        "Update Responding EMS Units": "In some EMS systems, you will be expected to update responding EMS units about the condition of your patient. Your report should include the age and sex of the patient; the chief complaint; the level of responsiveness; and the status of the patient\u2019s airway, breathing, and circulation. Let the responding EMS unit know what equipment you need brought in to the patient. By providing this update, you are helping other EMS units know what to expect when they arrive on the scene.",
        "Transfer of Patient Care to Other EMS Personnel": "With many EMS incidents, you will be the first trained person to arrive on the scene. You will have performed a primary assessment and started some treatment before emergency medical technicians (EMTs) or paramedics arrive. When EMTs or paramedics arrive, it is important for you to provide them with a handoff report. Describe your findings concisely and accurately. The easiest way to report your patient assessment results is to use the same systematic approach you follow during patient assessment (see Chapter 8, Patient Assessment, for more information) \n1. Provide the age and sex of the patient.\n2. Describe the history of the incident.\n3. Describe the patient\u2019s chief complaint.\n4. Describe the patient\u2019s level of responsiveness.\n5. Describe how you found the patient.\n6. Report the status of the patient\u2019s vital signs, airway, breathing, and circulation (including severe bleeding).\n7. Describe the results of the physical examination.\n8. Report any pertinent medical conditions using the SAMPLE (Signs and symptoms, Allergies, Medications, Pertinent past medical history, Last oral intake, and Events leading to injury or illness) format.\n9. Report the interventions you provided and how the patient responded to them.\n\nWorking in a systematic manner as you assess the patient will help ensure that you do not overlook any significant symptoms, signs, or injuries. This process will help to make the handoff report complete and accurate. EMTs and paramedics contact online medical control to secure permission to perform certain skills, to get direction regarding patient care, and to give the hospital their patient care reports. As an EMR, you may be present when other EMS providers contact the online medical control through their radio or cellular phone systems. In most EMS systems, EMRs are not required to contact medical control for the basic skills they are permitted to perform. If your EMS system uses online medical control for EMRs, then you will need to learn how and when to contact medical control",
        "Postrun Activities": "After you have turned over the care of the patient to other EMS providers, you need to report your status to your communications center. Let the communications center know how long it will take you to get your unit ready for service and when you will be available for another call. Providing a written report of a call is covered later in this chapter in the section on documentation. The rules, or protocols, for communicating with others during each phase of an EMS call may vary from one system to another. Learn and follow the standard procedures and protocols of your department",
        "Guidelines for Effective Radio Communications": "Guidelines for Effective Radio Communications\nMonitor the channel before transmitting to avoid interfering with other radio traffic.\nPlan your message before pushing the transmit switch. This step will keep your transmissions brief and precise. Use a standard format for your transmissions.\nPress the push-to-talk (PTT) button on the radio, then wait for 1 second before starting your message. Otherwise, the first part of your message may be cut off before the transmitter is working at full power.\nHold the microphone about 2 to 3 inches (5 to 8 cm) from your mouth. Speak clearly and evenly, but never shout into the microphone. Speak at a moderate, understandable rate, in a clear, even voice.\nIdentify the person or unit you are calling first, then identify your unit as the sender. You will rarely work alone, so say \u201cwe\u201d instead of \u201cI\u201d when describing yourself.\nAcknowledge a transmission as soon as you can by saying \u201cGo ahead\u201d and then \u201cOver and out\u201d when you are finished (or whatever terminology is commonly used in your area). If you cannot take a long message, simply say \u201cStand by\u201d until you are ready.\nUse plain English. Avoid meaningless phrases (\u201cBe advised\u201d), slang, or complex codes. Avoid words that are difficult to hear, such as \u201cyes\u201d and \u201cno.\u201d Use \u201caffirmative\u201d and \u201cnegative.\u201d\nBe brief. If your message takes more than 30 seconds to send, pause after 30 seconds and say, \u201cDo you copy?\u201d The other party can then ask for clarification if needed. Also, the pause lets other EMS providers with emergency traffic to break through if necessary.\nAvoid voicing negative emotions, such as anger or irritation, when transmitting. Courtesy is assumed, making it unnecessary to say \u201cplease\u201d and \u201cthank you,\u201d which wastes air time. Listen to other communications in your system to get a good idea of the common phrases and their uses.\nWhen transmitting a number with two or more digits, say the entire number first and then each digit separately. For example, say \u201csixty-seven,\u201d followed by \u201csix-seven.\nDo not use profanity on the radio. It is a violation of FCC rules and can result in substantial fines and even loss of your organization\u2019s radio license.\nUse EMS frequencies for EMS communications. Do not use these frequencies for any other type of communications\nReduce background noise as much as possible. Move away from wind, noisy motors, or tools. Close the window if you are in a moving ambulance. When possible, shut off the siren during radio transmissions.",
        "Verbal Communication": "As an EMS provider, you need to communicate effectively. Verbal communication is an essential part of providing high-quality patient care. Most verbal communication occurs through face-to-face conversations. Effective communication means that the person receiving the message understands exactly what the person who sent the message meant. This process requires feedback; the receiver needs to communicate to the sender that the message has been received and understood.\n\nBoth external and internal distractions can negatively affect your ability to communicate. External distractions include noise and the use of electronic devices. Internal distractions include letting yourself think about a personal matter while at the scene. Communication can also be affected if an EMR lacks empathy for a patient or shows prejudice against a certain type or group of people. Effective communication requires you to be patient and to think carefully about your interactions with others. To achieve effective patient communication, always maintain your composure, show empathy, and keep an open mind.\n\nAs an EMR, you should master certain communication skills that will enable you to communicate effectively with EMS personnel and other public safety providers, as well as the patient and his or her family. You must be able to determine what the patient needs and then explain this information to others. The following section includes guidelines for effective communication with patients. Most of these guidelines will also promote effective communication with other public safety personnel.",
        "Guidelines for Effective Communication With Patients": "Your communication skills will be put to the test when you communicate with patients and/or family members in emergency situations. Remember that someone who is sick or injured is scared and might not understand what you are doing and saying. Therefore, your gestures, body movements, and attitude toward the patient are critically important in gaining the trust of both the patient and family. It cannot be stressed enough that maintaining your composure and showing that you care are a vital part of patient care during stressful situations. The following guidelines for communication will help you calm and reassure your patients",
        "Introduce Yourself": "Introduce yourself by name and title. This gives the patient, family members, and bystanders an idea of who you are and lets them know your qualifications. Many citizens in your community may not understand that trained EMRs arrive in a variety of vehicles, including fire trucks, police vehicles, and private vehicles. Introducing yourself helps put the patient at ease and makes your job of assessing and treating the patient easier.",
        "Ask the Patient\u2019s Name and Use It": "Ask the patient what he or she wishes to be called. Knowing the patient\u2019s name helps you to establish contact with him or her. Use the patient\u2019s first name only if the patient is a child or the patient asks you to use his or her first name. For example, if a young man says his name is \u201cRon,\u201d then he probably wants to be called \u201cRon.\u201d Otherwise, use a courtesy title such as \u201cMrs. Smith\u201d or \u201cMr. Jones.\u201d Avoid using terms such as \u201cPops\u201d or \u201cDear;\u201d these are disrespectful terms and many patients find them irritating.",
        "Make and Keep Eye Contact": "Look into the patient\u2019s eyes as you talk. Doing so shows the patient that you are focused on his or her needs and that you are speaking to the patient. Maintain eye contact as you listen to the patient. Emergency scenes can be noisy and confusing. By maintaining good eye contact, you help the patient focus on communicating with you.",
        "Use Language the Patient Can Understand": "Use language that is clear and accurate. Avoid using technical medical terms that may frighten or confuse the patient. It is disrespectful to talk down to a patient. Use feedback to determine whether the level of your language is appropriate for the patient.",
        "Speak Slowly and Clearly": "In the middle of an emergency call, it is easy for both you and patients to feel rushed. It is important for you to slow down and to speak in a clear voice. By slowing down and speaking clearly, you can avoid having to repeat questions and explanations. This will save you time in the long run and reduce communication errors.",
        "Tell the Truth": "It is important to tell patients the truth. Telling the truth helps build trust with a patient. If you fail to tell the truth, then the patient will not believe what you say in the future. There may be times when you do not need to tell the patient all the details in response to a question. There will also be times when you do not know the answer to a patient\u2019s question. In these cases, \u201cI don\u2019t know\u201d is an acceptable answer.",
        "Allow Time for the Patient to Respond": "Rushing a patient can negatively affect communication and delay the exchange of critical information. Because emergency situations can be hectic, use a calm approach. Patients who are sick or injured may be confused and may not be thinking clearly. Some patients may need time to answer even simple questions. Ask one question at a time and allow enough time for the patient to respond to each question.",
        "Limit the Number of People Talking With the Patient": "Designate one EMS provider to talk with the patient. This allows the patient to focus on the questions from one person. It avoids the confusion that results when multiple people are trying to question the patient at the same time. If other EMS providers have questions for the patient, then these questions can be addressed to the designated EMS provider.",
        "Be Aware of Your Body Language": "Your body language is a type of nonverbal communication. Do not talk down to a patient. If a patient is sitting or lying on the ground, then kneel down or position yourself to get close to the same level as the patient\u2019s face. Get close enough to the patient for comfortable conversation. However, avoid getting so close that you invade the comfort zone of the patient. Pay attention to your stance. Crossing your arms in front of you may be interpreted by the patient as an uncaring attitude.",
        "Act and Speak in a Calm, Confident Manner": "Emergency scenes can be noisy, confusing, and frightening for patients. Remember that although the situation is not an emergency for you, the event taking place is an emergency for the patient. Your role is to give medical care that helps bring the emergency phase of this situation to an end. You need to convey a calm, caring, confident manner to the people present at the scene. Try to make the patient physically comfortable and relaxed.",
        "Respect the Cultural Norms of the Patient": "The actions that are considered respectful toward other people vary from one culture to another. Although it is impossible to learn the norms of all cultures, make an effort to learn the respectful actions toward the cultures that are represented within your community. Knowing which actions are acceptable and which actions are upsetting will enable you to give better care, make your job easier, and create a more positive relationship with these members of your community.",
        "Use Open-Ended and Closed-Ended Questions Appropriately": "When you must question patients to obtain information, structure your questions in one of two formats. The first type of question is an open-ended question, which allows a patient to answer in his or her own words. It helps you to get a sense of the patient\u2019s thoughts. An example of an open-ended question is, \u201cCan you tell me what happened to you?\u201d\n\nThe second type of question is a closed-ended question, which you can use when you are looking for specific information. Often, you will receive a \u201cYes\u201d or \u201cNo\u201d in response. An example of a closed-ended question is, \u201cDoes your arm hurt?\u201d",
        "Treat All Patients as if They Were Members of Your Family": "Treat every patient the way you would like a member of your family to be treated. Remember that every patient you treat is someone\u2019s mother, father, sister, brother, daughter, or son. This guideline will help you communicate effectively with patients of all ages.",
        "Treatment": "Treat all patients as if they were members of your family.",
        "Communicating With Patients With Special Needs": "Communicating with patients who have special needs requires additional considerations. Patients with special needs include patients who are hard of hearing or deaf, patients who are visually impaired, non\u2013English-speaking patients, geriatric patients, pediatric patients, patients with a developmental disability, and patients displaying disruptive behavior.",
        "Communicating With Patients Who Are Hearing Impaired": "One of the major challenges you will face as an EMR is communicating with a person who is hard of hearing or deaf. Most people have few skills for interacting with people with hearing loss and may feel hesitant when asked to do so. A patient of any age may be unable to hear you for a variety of reasons: hereditary deafness; long-term hearing loss caused by illness, ear infections, or injury; or temporary deafness caused by an explosion or other loud noise. A patient with long-term hearing impairment usually develops skills to help compensate for the loss of hearing, such as the ability to read lips. A patient who is temporarily deaf does not have such skills.\n\nIn either case, your job is to address the medical needs of the patient. Ask, \u201cCan you hear me?\u201d A patient who is deaf may respond by pointing at his or her ears or using other non-verbal cues. A patient who is temporarily deaf may feel anxious and panicky because he or she suddenly cannot hear. Help him or her focus on the issue by pointing at your ear and shaking your head to show the patient that you are trying to assess whether he or she can hear. Another option is to write out the question, \u201cCan you hear?\u201d on a piece of paper and show it to the patient.\n\nAfter you determine the patient is hearing impaired or deaf, do not continue to rely on verbal communication; use other methods. A patient with long-term deafness may try to communicate with you by using sign language (using the hands and fingers to communicate). If you do not know sign language, then use writing and gestures to communicate.\n\nAs you examine the patient for injury, use your own body to show the patient how to inform you whether he or she has pain in a particular location. Touch a place on your body and make a face to show pain. Then look at the patient and repeat the step on the patient\u2019s body. Most people will understand what you are trying to do. Do a complete patient assessment on every patient, whether or not he or she can communicate with you.\n\nKeep the patient informed by making gestures to show that certain things are happening (for example, when the ambulance arrives). Touching is an important part of communication and reassurance for patients who are hard of hearing or deaf, as well as for hearing patients. For example, hold the patient\u2019s hand so he or she knows you are there to help.\n\nWhen working with patients who are hard of hearing or deaf, use the following techniques:\nIdentify yourself by showing the patient your patch or badge.\nTouch the patient; a patient who is hard of hearing or deaf needs human contact just as much as a hearing patient.\nFace the patient when you speak so he or she can see your lips and facial expressions.\nSpeak slowly and clearly; do not shout.\nWatch the patient\u2019s face for expressions of understanding or uncertainty.\nRepeat or rephrase your comments in clear, simple language.\nIf all of these attempts at communication fail, then write down your questions and offer paper and a pencil to the patient to respond.\nSome people are both deaf and blind. This double loss may make it difficult for you to treat the patient. Take your time, be patient, and use touch as a way of communicating.\n\nIf the patient is a hearing child of parents who are deaf, then be sure to communicate with the parents about the child\u2019s condition and your actions. Like all parents in similar circumstances, parents who are deaf must consent for you to treat their child. They have a right to know what is being done and are just as upset as hearing parents would be. If the patient is a child who is deaf and has hearing parents, then you need to involve the parents even more than usual. They can assist you in communicating with the child.\n\nIf the patient is a parent who is deaf and has a hearing child, then resist the urge to use the child as an interpreter unless the child is obviously mature and capable. Young children cannot understand medical terminology, and misinterpretation can have serious results. Communicate directly with the patient, using whatever methods are most effective.",
        "Communicating With Patients Who Are Visually Impaired": "During your initial overview of the scene, look for signs that suggest the patient may be visually impaired. These signs may include the presence of eyeglasses, a cane, or a service animal. As you approach, introduce yourself to the patient. If you think the patient is visually impaired, then ask, 'Can you see?' A patient who is visually impaired may feel vulnerable, especially during the chaos of an emergency scene. Explain what you are doing to the patient. Tell patients when they will feel movement or hear noise and explain any treatments they require. The patient may have learned to use other senses such as hearing, touch, and smell to compensate for the loss of sight. The sounds and smells of the scene may be disorienting. The patient may rely on you to make sense of everything. Tell the patient what is happening, identify noises, and describe the situation and surroundings, particularly if you must move the patient. Learn the patient\u2019s name and use it throughout your examination and treatment, just as you would with a sighted patient. Touch the patient to provide emotional support. If the patient has a service animal such as a dog, then he or she may initially be more concerned about the dog than about his or her own injuries. Recognize that the dog and the patient are a unique team who depend on each other. Let the patient direct the dog or tell you how to handle the dog. Restate your question or redirect the patient\u2019s attention to the issue at hand. Service dogs are usually not aggressive; try to keep the patient and the dog together. If a patient who is visually impaired must be moved and can walk, then ask the patient to hold on to your elbow and stand slightly to your side and rear. Tell the patient about obstructions, steps, and curbs as you lead the way. Do not make the mistake of talking louder when communicating with patients who are visually impaired. Visual impairment and hearing impairment are not related. When you have a patient who is visually impaired, it may be helpful to maintain physical or verbal contact with the person to let him or her know that you are still there.",
        "Communicating With Non\u2013English-Speaking Patients": "In many communities across the country, English is not the first or even the most common language. If your patient speaks a language other than English and you cannot understand each other, then you must find ways to communicate so you can meet your responsibility as an EMR to provide the appropriate standard of care. To achieve successful cross-cultural communication, you may be able to adapt some of the techniques recommended for communicating with a patient who is hard of hearing or deaf, such as hand gestures, finger-pointing, and facial expressions. Determine how much English the patient speaks and whether a family member or a friend can act as an interpreter. If your jurisdiction has a large non\u2013English-speaking population, then memorize common phrases and questions so you can use them when treating these patients. Your community may offer language assistance services that you can access by phone, an electronic device, or through the dispatcher.",
        "Special Populations": "If you encounter a non\u2013English-speaking patient with whom you cannot communicate, then seek out a family member or friend to act as your interpreter.",
        "Communicating With Geriatric Patients": "Older people tend to require EMS more frequently than younger people. As people age, they are more likely to experience both decreased vision and hearing. When you encounter older people who have hearing or visual impairment, use the same communication skills you would for any other patient with a similar condition. Do not assume all older patients have physical or mental impairments. Many older people are alert and healthy. Assess all patients carefully and give them time to respond to your questions. Be aware of how older patients respond to you; it may give you clues as to how best to communicate with them.",
        "Communicating With Pediatric Patients": "Caring for ill or injured children is stressful for most EMS providers. Children are often frightened, anxious, and unable to communicate clearly; their parents or caregivers are usually frightened and anxious as well. Familiar objects and faces can help calm a child. Let a child keep a favorite doll, toy, or blanket to give the child some sense of comfort. Because children often take cues from their parents, use the parents to help you reassure and calm the child. Talk to both the parents and the child as much as possible and explain to them what is happening. Ask a parent to hold the child if the illness or injury permits. Speak to the child in a professional yet friendly manner. Tell the child your first name and explain what you are doing. Try to reassure the child that you are there to help in every possible way. Avoid standing over the child; instead, squat, kneel, or sit down so that you are on the child\u2019s level and establish eye contact. Ask the child simple questions about the pain, and ask for his or her help in pointing out any painful areas. Children can see through lies and deception, so be honest with them. You may be surprised at the remarkable level of understanding you can receive from an ill or injured child.",
        "Communicating With Patients With a Developmental Disability": "You may find it difficult to communicate with patients who have a developmental disability. Ask the family or caregiver about the patient\u2019s typical level of communication. Speak slowly, using short sentences and simple words. You may need to repeat statements several times or to rephrase them until the patient understands what you want. Again, offer emotional support by taking time to touch your patients. Because the chaos surrounding an injury or illness may confuse or frighten these patients, use extra care in dealing with patients with a developmental disability. You may be able to adapt many of the techniques recommended for communicating with children.",
        "Patients Displaying Disruptive Behavior": "Disruptive behavior can present a danger to you, the patient, and other people at the scene and can cause delays in treatment. At some time in your career, you will encounter a person who challenges your patience and communication skills.\n\nTo manage any patient who acts in a disruptive way, take the following steps:\n1. Assess the situation. Try to determine the cause of the patient\u2019s disruptive behavior.\n2. Protect the patient and yourself.\n3. Stay between the patient and an exit whenever possible.\n4. Do not take your eyes off the patient or turn your back.\n5. If the patient has a weapon, then stay clear and wait for law enforcement personnel\u2014no matter how badly injured the patient seems to be.\n6. As soon as your personal safety is ensured, carry out the appropriate emergency medical care.\n\nThere may be times when you are unable to approach a patient; the person will not allow anyone to come near, despite all efforts to help. Sometimes family members or friends of the disruptive patient may insist that you take the person to the hospital, but EMS personnel cannot take a competent patient to the hospital against his or her expressed wishes (unless you are a law enforcement officer). Some frightened, agitated, drugged, or disruptive patients can cause serious injury to you, bystanders, or themselves. It is best to wait for assistance from law enforcement in these situations.",
        "Medical Terminology": "Medical terminology is a collection of technical terms used by medical personnel to identify anatomic parts of the body, specify illnesses and injuries, and indicate treatments. Medical terminology is intended to clarify language so that one person can communicate clearly to another. Using proper medical terminology allows you to communicate a clear message, avoid errors, and save time.\n\nAs an EMR, you are not expected to understand all the medical terminology used by a physician. Your job is to communicate your message to other medical providers as clearly as possible. Do not use medical terms if you are unsure of their meaning. It is much better to report that a patient is short of breath, gasping, and breathing at a rate of 32 breaths per minute than to try to remember the correct word for shortness of breath. Using the incorrect word will result in confusion.\n\nThe first few chapters have already introduced you to some medical terms. Chapter 6, The Human Body, will introduce you to many new terms. Note that a new word will be accompanied by a definition of the word. As new terminology is introduced, look at the parts of each word. The center of a word contains the stem or root. There may be a prefix at the beginning of the word and a suffix at the end of the word. Each of these parts helps you to determine and remember the meaning of the word. By learning a few of these commonly occurring prefixes and suffixes, you will gain some insight into new words you encounter. For example, the prefix hyper- means above or excessive. Hypertension means excessive tension or pressure. Therefore, hypertension is the medical term for what we commonly call high blood pressure.",
        "Table 5-2 Prefixes Commonly Used in Medical Terminology": "Table 5-2 lists several prefixes commonly used in medical terminology, each indicating a specific meaning. **Brady-** denotes \u201cslow,\u201d whereas **Tachy-** indicates \u201crapid or swift.\u201d **Therm-** refers to quantities of heat, **Hyper-** refers to something \u201cabove, excessive, or beyond,\u201d and **Hypo-** refers to \u201cbelow\u201d or \u201cdeficient.\u201d **Naso-** denotes the nose, and **Oro-** relates to the mouth. **Arterio-** concerns arteries, while **Cardio-** means \u201cheart.\u201d The prefixes **Hem-**, **hema-**, and **hemo-** all relate to \u201cblood.\u201d **Neuro-** denotes the nervous system or nervous tissue, and **Vaso-** signifies a vessel, such as a blood vessel.",
        "Voices of Experience": "We were quickly dismissed from the courtroom, after a serious scolding from the judge about our service\u2019s lack of professionalism.\n\nNo matter what an EMR\u2019s public safety responsibilities are, documentation is one of his or her most important duties. Nowhere is documentation more important than when one responds to medical emergencies and renders patient care and/or transport.\n\nMy most humiliating moment in EMS was early in my career (over 30 years ago) when I was subpoenaed to our local state district court for a civil case concerning a motor vehicle crash that had happened several years earlier. Not only did I not remember anything about the incident, but my employer had lost the run report. Our testimony was brief and disappointing. My partner and I testified truthfully that we did not remember the case and that our run report had been lost. Everyone in the courtroom laughed at us. Everyone, that is, except the attorneys and the judge. We were quickly dismissed from the courtroom, after a serious scolding from the judge about our service\u2019s lack of professionalism.\n\nThe courtroom is not the only place where documentation is important. First and foremost, the caregivers who receive the patient need to know the results of your assessments, your interventions, and how the patient responded. The trending of this information over a period of time is as important as the information itself.\n\nIn my current full-time position as EMS Licensing Program Manager for the State of Louisiana, I read a number of patient reports as part of complaint investigations. Every EMS complaint that my agency has investigated has been made or broken by the quality of documentation. Some seemingly insignificant fact is frequently omitted. I cannot overemphasize the importance of completeness as well as accuracy and legibility. If something is missing in a patient contact report, then the legal assumption is that it was not done, not that you forgot to write it down. This is especially important when documenting patient assessments and interventions. If there is some legitimate reason that you deviated from protocol, or the standard of care, then it must be explained. Therefore, I ask all EMRs to remember to document patient encounters accurately, completely, and legibly.",
        "Documentation": "Documentation is the second major type of communication that you will use in your daily work as an EMR. Documentation is a process for verifying your actions using written records or computer-based (electronic) records. By recording the actions you took at an emergency incident, you provide a record for others and a document you can refer to in the future if necessary. Documentation is helpful to you because you will not be able to remember all the details of every call. It also provides a legal record for the actions you took. It is often said that if you did not document it, then it was not done. Documentation also provides a basis to evaluate the quality of care you gave. Remember, the call is not over until the paperwork is completed.\nProper documentation includes the following:\nThe age and sex of the patient The history of the incident The condition of the patient when found The patient\u2019s description of the injury or illness The patient\u2019s chief complaint The patient\u2019s level of responsiveness The status of initial and subsequent vital signs: airway, breathing, and circulation (including severe bleeding)\nThe results of the physical examination\nPertinent medical conditions using the SAMPLE format (discussed in Chapter 8, Patient Assessment)\nThe treatment you gave the patient Any change in the patient\u2019s condition after treatment\nThe agency and personnel who took over treatment of the patient\nThe following times: the time you were dispatched, the time you arrived on the scene, the time other EMS providers arrived on the scene, the time you departed the scene.\nAny reportable conditions present\nAny infectious disease exposure\nAnything unusual about the situation\nAny other helpful facts\n\nInclude all these items in your handoff report. Complete your patient care report as soon as possible after each call. Your documentation should be clear, concise, and accurate. Follow the standards of your organization. Some agencies use a paper-based reporting system, whereas others use a computer-based (electronic) system. Each type of system works well, provided that you complete the reports accurately. If you make a mistake on the form, then draw a line through it and correct it.\n\nYour organization may rely on patient care reports for documenting reportable events. As discussed in Chapter 4, Medical, Legal, and Ethical Issues, reportable events include certain infectious diseases and crimes such as knife wounds, gunshot wounds, motor vehicle collisions, suspected child abuse, domestic violence, elder abuse, dog bites, and rape. Learn which crimes are reportable in your area, your agency\u2019s procedures on reporting these crimes, and what you are required to do.",
        "Prep Kit-Ready for Review": "Communications systems allow you to send information from one location to another when it is impossible to communicate face-to-face. Excellent communication skills are crucial during every phase of a call. It is important for you to have a basic idea of how your department\u2019s communications system works. The two types of voice communications systems are radio systems and telephone systems. As an EMR, you will use two-way radio communications, which include mobile and handheld portable radios. You must know when to use these devices and what type of information you can transmit.\nThroughout the different phases of an EMS call, communications systems are used for different functions. The six phases of an EMS call include dispatch, response to the scene, arrival at the scene, updating responding EMS units, transfer of patient care to other EMS personnel, and postrun activities.\nThe protocols for communicating with others during each phase of an EMS call may vary from one system to another. Learn and follow the standard procedures and protocols of your department.\nIn addition to radio and telephone commu-nications, you must have excellent person-to-person communication skills. Be able to effectively interact with the patient and any family members, friends, or bystanders. Always maintain your composure, show empathy, and keep an open mind. Remember that people who are sick or injured may not understand what you are doing or saying. Therefore, your body language and attitude are important in gaining the trust of both the patient and the family. Take special care of patients such as children, geriatric patients, patients who are hearing impaired, patients who are visually impaired, non\u2013English-speaking patients, patients with a developmental disability, and patients displaying disruptive behavior.\nMedical terminology is used to clarify language so that one provider can communicate to another the anatomic location of an injury, signs and symptoms of a disease, and treatment given. Do not use medical terms if you are unsure of their meaning.\nAlong with your radio report and oral report, you must also complete a formal handoff report that will be given to other EMS professionals at the scene. Documentation provides a legal record of the actions you took and provides a basis to evaluate the quality of care given. Remember that the call is not over until the paperwork is completed.",
        "Vital Vocabulary": "base station: A powerful two-way radio that is permanently mounted in a communications center., channel: An assigned frequency or frequencies that are used to carry voice and/or data communications., communication: The transmission of information to another person., digital messaging: Technology that includes email, text messages, and social media, which are increasingly used by emergency medical responders to send and receive various types of information., documentation: The recorded portion of the emergency medical responder\u2019s patient interaction, either written or electronic., fax machine: A device used to send or receive printed text documents or images over a telephone or radio communications system., mobile data terminal (MDT): A computer terminal mounted in a vehicle that sends and receives data through a radio communications system., mobile radio: A two-way radio that is permanently mounted in an emergency vehicle that draws electricity from the electrical system of the vehicle., paging systems: Communications systems used to send voice or text messages over a radio system to specially designed radio receivers., portable radio: A handheld, battery-operated, two-way radio., repeater: A radio system that automatically retransmits a radio signal on a different frequency., telemetry: A process in which electronic signals are transmitted and received by radio or telephone; commonly used for sending electrocardiogram tracings., trunked communications system: A computer-controlled radio system that allows the sharing of a few radio frequencies among a large group of users."
    },
    {
        "Introduction": "The first part of this chapter covers the steps you can take as an emergency medical responder (EMR) to perform simple extrication procedures and to assist other rescuers with patient extrication. The extrication process consists of seven steps, beginning with your arrival on the scene and ending with the removal of the patient from a position of entrapment. As an EMR, you are directly involved in the first four of the seven extrication steps, but you should be aware of the entire process. You cannot provide effective assistance unless you fully understand what must be done and how each step is accomplished. By learning these steps, you can provide valuable care for the patient until other rescuers arrive. After the arrival of additional rescuers, your role may change to assisting them in administering further care.\n\nThe second part of this chapter covers special rescue situations. These challenging situations can be life threatening to both the rescuer and the patient. Special rescue situations include water rescue, diving injuries, ice rescue, confined space rescue, farm emergencies, and bus crashes. This chapter provides you with the guidelines for handling these situations. In each situation, your first objective is to maintain your personal safety. Do not perform any rescue procedures that could endanger either yourself or the patient.",
        "Extrication": "This section describes simple techniques you can use to access, treat, and remove patients who are trapped inside crashed vehicles. As an EMR, it is essential for you to think quickly and to use the principles and guidelines that are presented here. You will also need several hours of practical exercises to become skilled in the process of extrication.\n\nYour EMR course should include a demonstration of the entire extrication operation. Become familiar with extrication equipment, its use, and the hazards involved in the extrication process. You should know what equipment is available in your community and how to summon this equipment. Rescue personnel usually use extrication techniques for motor vehicle crashes, but many of these same principles are applicable in other situations. Resourcefulness, common sense, and a knowledge gained through training are key attributes of the EMR and underlie every act of patient care.\n\nThe safety of all rescuers and patients is an important consideration during the extrication process.Ideally, you should wear protective equipment similar to a firefighter\u2019s outfit: full bunker gear consisting of a coat, pants, boots, helmet with face shield, and gloves. Minimally, you should wear a helmet with a face shield or goggles and gloves.\n\nA situation in which a patient is trapped in a motor vehicle can be complex enough to tax the skills and resources of even the most highly trained and well-equipped emergency medical services (EMS) system. To ensure the best patient care, many different agencies may need to cooperate: law enforcement, the fire department, EMS, and sometimes the utility company and a wrecker operator. It requires coordination and practice to achieve the cooperation and mutual understanding that is needed for a safe, smooth extrication effort. As the first trained rescuer on the scene, the actions you take can make the difference between an organized and a disorganized rescue effort, perhaps even the difference between life and death! You set the stage and you have an essential role in the extrication process.",
        "Safety": "At an extrication scene, your objective is to help extricate and treat the patient efficiently, but do not rush. Moving too fast can be dangerous for you and for the patient. Experienced rescuers seldom run; they walk briskly.",
        "Words of Wisdom": "The steps in the vehicle extrication process include the following:\n1. Conduct a scene size-up or an overview of the incident and its surroundings.\n2. Stabilize the scene, control any hazards, and stabilize the vehicle.\n3. Gain access to the patients.\n4. Provide initial emergency care.\n5. Help disentangle the patients.\n6. Help prepare the patients for removal.\n7. Help remove the patients.",
        "Step One: Conduct a Scene Size-up": "As soon as the dispatcher tells you of the incident, begin to plan for what you are likely to find on arrival. For instance, you may know that a certain type of crash frequently occurs at a particular intersection or along a specific stretch of highway. Do not, however, become complacent about responding to the \u201csame old thing.\u201d Use your knowledge, but be flexible.\nIf the dispatch information is complete, you will know the types of vehicles involved (for example, two cars or a truck and motorcycle) and whether there are any injured or trapped people, burning vehicles, or HazMat present.\n\nAs you approach the scene and before you exit your vehicle, perform a scene size-up, which includes a visual overview of the entire incident and its surroundings. Remember, you must locate the patients before you can treat them! Rapidly determine the extent of the incident, estimate the number of patients, and try to locate any hazards that may be present. Then call for whatever additional resources you may need to manage the incident.",
        "Step Two: Stabilization of the Scene and Any Hazards": "It is especially important to keep a sharp lookout for hazards that can result in injury, disability, or death to a patient, yourself, other emergency personnel, or bystanders. Some of the most common hazards found at motor vehicle crash scenes include infectious diseases, traffic, bystanders, spilled fuel or other HazMat, automotive batteries, downed electrical wires, unstable vehicles, and vehicle fires.",
        "Infectious Diseases": "Many patients involved in motor vehicle crashes will have soft-tissue injuries and active bleeding from open wounds or from their mouth or nose. Take standard precautions at all motor vehicle crash scenes. If sharp glass or metal is present, you should wear heavy-duty leather gloves over your latex or vinyl gloves; otherwise, vinyl or latex gloves should offer sufficient protection. If there is the danger of splattering blood, consider using face protection.",
        "Traffic Hazards": "First, park your vehicle and other emergency vehicles so that they protect the scene and warn oncoming traffic to avoid the crash site. In most situations, park your vehicle in a location that does not obstruct open traffic lanes, but do not hesitate to use your vehicle to block traffic to protect yourself, your patients, and other rescuers. If other emergency personnel are already on the scene, ask them where you should park your vehicle. Consider the design of your vehicle\u2019s warning lights and park so you can use them to their best advantage. Do not leave your trunk lid open after removing your emergency equipment as the lid may block your warning lights. Remember to wear an approved safety vest and other personal protective equipment. Another way to protect the scene is to ignite fusees (or warning flares) as soon as possible. Place the fusees up and down the road to warn oncoming traffic and give other drivers time to slow down safely. After you have taken these protective measures, survey the scene for other hazards. Always keep fusees away from flammable liquids.",
        "Bystanders": "Keep bystanders away from the crash scene to minimize the danger to themselves and patients. It is not usually enough to ask everyone to stay away. Give specific directions such as, \u201cMove back to the other side of the road,\u201d or \u201cMove back onto the sidewalk.\u201d Sometimes you can pick one or two bystanders and ask them to assist you in keeping others away from the scene. If available, either a rope or police or fire barrier tape is very effective for establishing an off-limits area. Bystanders respond appropriately to such barriers and usually will not cross them after they are set up.",
        "Spilled Fuel": "Gasoline or diesel fuel spills are common during motor vehicle crashes. Expect to find a fuel spill if a motor vehicle has been hit near the rear, is on its side, or is upside down. If a fuel spill is present (or if the vehicle is in a position that suggests a fuel spill could occur), call the fire department to minimize the fire hazard and to clean up any spilled fuel. If the patient is trapped in a motor vehicle that is leaking fuel and the fire department has not arrived, consider covering the fuel with dirt. This reduces the amount of vapor coming from the spill, which, in turn, reduces the danger of fire. Fuel vapors tend to stay close to the ground and will travel with the wind. Be sure to call the fire department whenever you suspect a fuel spill. In addition to fuel, other potentially hazardous fluids may leak from a wrecked vehicle, including motor oil, transmission fluid, power steering fluid, and antifreeze.",
        "Safety_0": "Keep all sources of ignition, such as cigarettes and flares, well away from a fuel spill.",
        "Motor Vehicle Batteries": "Motor vehicle batteries are hazardous, and you must avoid contact with them. In a front-end crash, the battery may already be broken open and acid may be leaking. Reduce the possibility of an electrical short circuit by turning off the vehicle\u2019s ignition. Do not attempt to disconnect the battery unless you have received special training in the proper way to do this and have the necessary tools. You could be injured by a short circuit, explosion, or contact with battery acid. Remember that hybrid vehicles and electric vehicles have large quantities of batteries. These batteries operate at much higher voltage than regular automotive batteries and present a greater risk of electric shock. Approach hybrid and electric vehicles cautiously unless you have received special training.",
        "Downed Electrical Wires": "Downed electrical wires may be caused by high winds, ice buildup, a vehicle crashing into a utility pole, a fallen tree, or a building fire. Sometimes, downed electrical wires explode in arcs of spectacular flashes and sparks; other times, they simply lie across the vehicle, fully charged with electricity and capable of causing injury or death.\n\nLocate the wires but avoid contact. If a vehicle has a downed wire across it and passengers are trapped inside, immediately instruct them to stay inside the vehicle. Then summon the utility company and fire department. Move bystanders back in all directions, to at least the distance between two power poles. Do not forget that electrical hazards can come from other sources as well, including traffic light control boxes and underground power feeds. Be sure to check everywhere, including under the vehicles, for electrical hazards. However, do not attempt to manage electrical hazards at vehicle crash scenes.",
        "Safety_1": "Treat all downed wires as if they are charged (live) until you receive specific clearance from the electric company. Even if the lights are out along the street where the wires are down, never assume that the wires are de-energized. Be especially alert for downed wires after a storm that has blown down trees and tree limbs.",
        "Words of Wisdom_2": "Remember these guidelines when you encounter a motor vehicle that is in contact with electrical wires: If the wire is draped over the vehicle, instruct trapped persons to remain inside the vehicle. Any attempt to remove either the wire or the passengers may result in serious injury or death to yourself as well as the passengers. Keep all bystanders away from the vehicle. Call the utility company for assistance. Call the fire department for assistance.",
        "Unstable Vehicles": "Assume that every vehicle involved in a crash is unstable, unless you have manually stabilized it. A vehicle that is positioned on a hill, on its side, upside down, or teetering over the edge of an embankment or bridge is obviously unstable. However, no matter how stable the vehicle appears to be, it may suddenly roll away or topple over. Be sure to check and ensure the stability of every vehicle before you attempt to enter it or treat the passengers inside.",
        "Safety_3": "Even vehicles that are positioned upright on all four wheels should be stabilized.",
        "Vehicle on Its Wheels": "If the vehicle is upright and on its wheels, you can ensure stability by chocking the front or back of each wheel with hubcaps or pieces of wood. If you can gain access to the inside of the vehicle, place the transmission in park and set the parking brake to prevent the vehicle from moving. You can also deflate the tires by safely cutting or pulling the valve stems.",
        "Safety_4": "If wooden blocks or hubcaps are not available for chocking the wheels, improvise by using materials found at the scene.",
        "Vehicle on Its Side or Upside Down.": "A vehicle that is positioned on its side is extremely unstable. Fortunately, this position is unusual. Stabilizing a vehicle on its side is beyond the range of skills and equipment for many EMRs and should be handled by a specially trained rescue crew or the fire department. Many fire departments and rescue crews carry wooden cribbing, step chocks, or special jacks to manage this situation. If you must enter a vehicle that is on its side to respond to a life-threatening situation, do not climb on the vehicle. Carefully break the rear window glass and enter through the back of the vehicle. Bend over or crouch down to stay close to the ground. This will help prevent upsetting the vehicle\u2019s center of gravity. Your purpose is to keep the vehicle in the position found. Do not move it. Any movement could cause the vehicle to move. Gaining access to a patient is further discussed later in this chapter. An upside-down vehicle is relatively stable. The primary hazard in this situation is spilled fuel, which must be handled by the fire department.",
        "Vehicle Fires": "Even though fires happen infrequently at motor vehicle crash sites, they are a cause of great concern among EMS personnel. There are two types of fires related to motor vehicle crashes: impact fires and postimpact fires. Impact fires occur when the fuel tank ruptures during the crash. The vehicle is usually rapidly engulfed in flames, and it soon becomes impossible to approach it for a rescue attempt. Passengers rescued from this type of fire are usually saved by bystanders and witnesses to the crash who act immediately to remove them. Postimpact fires are often caused by electrical short circuits and can be prevented by turning off the ignition, as discussed previously. These fires usually do not develop into major fires if prompt action is taken. Should a fire occur, first turn off the ignition. Then attempt to extinguish the fire with a portable fire extinguisher. Remove the passengers from the vehicle as soon as possible.",
        "Safety_5": "Be alert for vehicles that are powered by alternative fuels, which present special electrical and fire hazards. These include propane-powered vehicles, compressed natural gas-powered vehicles, battery-powered vehicles, and hybrid vehicles.",
        "Emergency Actions for Motor Vehicle Fires.": "If you arrive at a crash scene and find a motor vehicle on fire with people trapped inside, remember the following procedures: Use your dry chemical fire extinguisher. Most dry chemical fire extinguishers can be used on ordinary combustibles, flammable liquids, or electrical fires. Be sure you know how to use the extinguisher in your vehicle.\nImmediately have someone else gather fire extinguishers from other vehicles at the scene.\nDo not wait until your extinguisher runs out.\n Use your extinguisher to keep flames out of the passenger compartment. Direct the extinguisher to the base of the fire\u2014not at the passenger compartment.\n Do not be overly worried about discharging the extinguisher onto the passengers; the dry chemical powder is nontoxic. However, the dry chemical can be corrosive, so you should watch for respiratory conditions.\n Remove the patients as quickly as possible, but take care because they may have sustained injuries. Move everyone at least 50 feet (15 m) away from any vehicle that is on fire. \nStay away from the front and rear ends of a burning vehicle. Modern bumpers contain air-filled cylinders that can explode forcefully when exposed to fire.",
        "Safety_6": "Do not mistake hot water vapor from a damaged radiator for smoke from an engine compartment fire. If the smoke disappears rapidly (10 feet to 15 feet [3 m to 5 m] away from the vehicle), it is probably steam and not smoke.",
        "Step Three: Gain Access to the Patients": "The third step in the extrication process is to gain access to the patients. You cannot begin to examine and treat the patients until you have gained access to them. This section discusses the two methods you can use to achieve access. First, try to gain access through the doors. If this does not work, try to gain access through a window.",
        "Access Through Doors": "Before you can provide patient care, you must gain access to the patient. Between 85% and 90% of all patients involved in a motor vehicle crash can be reached simply by stabilizing the vehicle and then opening a door or window. Try all the doors first, even if they appear to be badly damaged. It is an embarrassing waste of time and energy to open a jammed door with heavy rescue equipment when another door can be opened easily and without any equipment. Attempt to unlock and open the least damaged door first. Make sure that the locking mechanism is released. Then try the outside and inside handles at the same time.",
        "Access Through Windows": "If you believe that any passenger\u2019s condition is serious enough to require immediate care (for example, if the passengers are not sitting up and talking) and you cannot enter through a door, you should break a window.\n\nDo not try to break and enter through the windshield because it is made of plastic-laminated glass. The side and rear windows are made of tempered glass and will break easily into small pieces when hit with a sharp, pointed object such as a tire iron, spring-loaded center punch, or fire ax. Because these windows do not pose a safety threat, they should be your primary access route.\n\nA spring-loaded center punch (available from many hardware stores) should be carried in your EMR life support kit. It can be used rapidly, takes up little room in the kit, and is nearly always successful in breaking the side and rear windows on the first try.\n\nIf you must break a window to open a door or gain access, try to break one that is the farthest from the patient. However, if the patient\u2019s condition warrants your immediate entry, do not hesitate to break the closest side or rear window, even if the glass will fall onto a patient. If the patient can cover his or her own face when you are breaking glass, this may help to prevent injuries from glass shards.\n\nTempered pieces of glass do not usually pose a danger to people trapped in vehicles. Advise EMS personnel if a passenger is covered with broken glass so they can notify the hospital emergency department. If there is glass on a passenger, pick off the glass\u2014do not brush it off. After breaking the window, use your gloved hands to pull out the remaining glass from the window frame so it does not fall onto any passengers or injure any rescuers. If you are using something other than a spring-loaded center punch to break the window, always aim for a lower corner. That way, the window frame will help prevent the tool (such as a tire iron, fire ax, or large screwdriver) from sailing into the vehicle and hitting the person inside.\n\nAfter you have broken the glass and removed the remaining pieces of glass from the frame, try to unlock the door again. Release the locking mechanism, and then use both the inside and outside door handles at the same time. This will often enable you to force a jammed locking mechanism, even in a door that appears to be badly damaged. To access a vehicle through the window, follow the steps in Skill Drill 20-1: 1. Wear heavy-duty leather gloves and eye protection, if available. 2. Place the spring-loaded center punch at the lower corner of the window Step 1. 3. Press on the center punch to break the window Step 2. 4. With gloved hands, remove the broken glass to the outside of the vehicle Step 3. 5. Enter the vehicle through the window Step 4.\n\nUsing the simple techniques described and illustrated in this section, you should be able to gain access to nearly all patients involved in a motor vehicle crash, even those who are trapped in an upside-down vehicle.\n\nWhen you gain access to a crashed vehicle, be alert for airbags that have not deployed. Airbags are mounted in the steering wheel on the driver\u2019s side and in the dashboard on the passenger\u2019s side. In some newer vehicles, supplemental airbags may also be mounted on the sides of the vehicle or around the rear seats. If the airbags did not deploy during the crash, they represent a hazard to rescuers because they may unexpectedly deploy and cause injuries. Avoid getting in front of an airbag that has not deployed until trained rescuers can assure you that it does not pose a hazard to you or to the patient. If you cannot gain access to the vehicle, you must do what you can to assist the patient. This means stabilizing the vehicle and protecting the scene until the proper equipment arrives.",
        "Words of Wisdom_7": "Remember: Try before you pry!",
        "Safety_8": "Always warn trapped vehicle passengers that you are going to break the glass.",
        "Skill Drill 20-1: Accessing the Vehicle Through the Window": "Step 1: Use a gloved hand to place the spring-loaded center punch at the lower corner of the window.\nStep 2: Press on the center punch to break the window.\nStep 3: Remove the glass to the outside of the vehicle.\nStep 4: Enter the vehicle through the window.",
        "Safety_9": "Most cars and pickup trucks have both driver side and passenger side airbags. Some newer vehicles have supplemental airbags mounted in various places. Airbags that do not activate during a crash present a danger to rescuers until they are deactivated.",
        "Words of Wisdom_10": "Do not forget to check the trunk of the vehicle. This step is especially important in border areas where significant numbers of illegal immigrants are transported in vehicle trunks to avoid detection.",
        "Step Four: Initial Emergency Care": "After you gain access to the passengers, immediately begin emergency medical care. Conduct a patient assessment on every patient. After you determine the status of each patient, you should monitor the ABCs (airway, breathing, and circulation), control bleeding, treat for shock, manually stabilize the cervical spine, and provide emotional support. Stay calm, and do not forget to maintain the patient\u2019s body temperature by covering the patient with a blanket. If you have time, you can conduct a secondary assessment (physical exam), as discussed in Chapter 9, Patient Assessment. Leave the patients in the vehicle unless it is on fire or the patients are otherwise in immediate danger. Maintain manual stabilization until the patients are properly packaged (prepared) and can be removed from the vehicle by other trained rescuers.\n\nSkill Drill 20-2 shows how to perform initial airway management when the patient is in a vehicle:\n1. Place one hand under the patient\u2019s chin and your other hand on the back of the patient\u2019s head Step 1.\n2. Raise the patient\u2019s head to a neutral position to open the airway.",
        "Airway Management in a Vehicle": "Step 1: Place one hand under the patient\u2019s chin and your other hand on the back of the patient\u2019s head\nStep2 Raise the patient\u2019s head to a neutral position to open the airway.",
        "Step Five: Patient Disentanglement": "Extrication operates on the principle of \u201cremoving the vehicle from around the patient.\u201d\nThis process usually requires tools and specialized equipment, such as air chisels, manual or powered hydraulic rescue equipment, and airbags. In some serious extrication situations, disentanglement can take up to 30 minutes and requires advanced training. In some situations, you can make the patient more comfortable and give yourself more room to work by carefully moving the front seat back or by raising the adjustable steering wheel. Serious entrapment situations require teamwork. \n\nModern rescue crews use the concept of the Golden Hour when managing serious trauma situations. The concept of the Golden Hour (sometimes called the Golden Period) means that the less time spent at the scene with a",
        "Step Six: Preparation for Patient Removal": "As disentanglement proceeds, help prepare the patient for removal from the vehicle by applying dressings, bandages, and splints as needed and maintaining manual stabilization of the head and cervical spine. If you are trained in the procedures and equipment for full spinal immobilization, you may be able to assist in this effort. For example, if you are properly trained and local protocols allow, you can help move and secure the patient onto a long backboard for removal.\n\nIt is important to realize that the access route to the patient may not be adequate as an extrication route. The extrication route must be large enough to permit the safe removal of the packaged patient, whereas the access route may be relatively small.",
        "Step Seven: Patient Removal": "After the patient is packaged, he or she is removed from the vehicle and placed onto the stretcher of the transporting ambulance. Remember, although you are directly involved in only the first four of the seven extrication steps, your actions and assistance can have a vital impact on the entire operation.",
        "Review of the Extrication Process": "Your familiarity with the phases of the extrication effort may enable you to assist the rescue and extrication crews. Take the time to find out about the rescue and extrication resources in your community. Ask the crews how you can assist them; they will probably be pleased to have your help and support.\n\nRemember these steps when you arrive on the scene of a motor vehicle crash with trapped passengers:\nCall for additional resources and extrication help.\n\nSpecify the number and types of vehicles involved.\n\nDo not stand idly by while waiting for help. You should:\n\nIdentify and contain safety hazards.\n\nPark your vehicle so that its headlights and warning lights can be used to protect and light the scene.\n\nClear a working area around the site of the crash before you or rescue personnel attempt to stabilize the vehicle(s).\n\nUse your head! Think and use what tools you already have.\n\nRemember to try opening the doors first, rather than breaking windows.\n\nAfter you gain access to the patient, assess and monitor his or her condition.\n\nAbove all, remain calm.",
        "Water and Ice Rescue": "You may encounter situations in which a person needs to be rescued from the water. The person may be fatigued, may have sustained an underwater diving injury, may have gotten caught in a strong current, or may have fallen through the ice in the winter. A book of this scope cannot teach you the skills of a certified lifesaver. However, the following information does describe some simple techniques you can use to perform a water or ice rescue without endangering your own safety.",
        "Water Rescue": "When you see a person struggling in the water, your first impulse may be to jump in to assist. However, that action may not result in a successful rescue and can endanger your own life. If you are faced with a water rescue situation, remember to reach, throw, row, go. If you follow these steps, you may be able to perform a successful water rescue without entering the water. It may even be possible for someone who cannot swim to rescue a person who is drowning.",
        "Safety_11": "In many communities, a flash flood is a common occurrence. Flash floods occur as the result of sudden and continuing rainstorms that overwhelm the ability of streams and storm sewer systems to handle the runoff. Flash floods may cause water to quickly flow over roadways in low-lying areas. Most rescues during floods occur because motorists drive into low-lying areas that are flooded. Be cautious about driving through standing water, and be aware of the dangers posed by floodwaters that cover roadways. These floodwaters can contain strong currents and can be deadly. Do not venture into floodwaters without proper training and equipment.\n\nCurrents in streams or strong currents (rip tides) at ocean beaches can pull both the distressed person and the rescuer rapidly away from shore.",
        "Reach": "Use any readily available object to reach the distressed person in the water. If the person is close to shore, a branch, pole, oar, or paddle may be long enough. If you are at a swimming pool, there may be a specially designed pole available for this purpose. Use it.",
        "Throw": "If you cannot reach the person, throw something that can float or that the victim can grab. At a swimming pool, dock, or supervised beach, a flotation device (such as a ring buoy) may be available. If a flotation device is available, throw it to the person in distress. Some public safety departments carry a specially constructed rescue throw bag that contains a rope that can be thrown to a distressed person in the water. If your department carries a throw rope, you need instruction and practice in its use. If no buoy or throw bag is available, improvise. Throw a rope, plastic milk jug, or a sealed polystyrene plastic (Styrofoam) cooler. Even a spare tire can support several people in the water.",
        "Words of Wisdom_12": "If you use something like a plastic milk jug or picnic jug to throw to a person in the water, fill the container with about 1 inch (3 cm) of water to add weight before you seal it and throw it to the person.",
        "Row": "If you cannot reach the person by throwing something that floats, you may be able to row out to the drowning person if a small boat or canoe is available. Consider this option only if you know how to operate or propel the craft properly. Protect yourself by wearing an approved personal flotation device.",
        "Safety_7": "Currents in streams or strong currents (riptides) at ocean beaches can pull both the distressed person and the rescuer rapidly away from shore. In an area below a dam, rapids, or a waterfall, deadly currents may be present. Never attempt to enter the water under these conditions if you are untrained. If you do, it is likely that both you and the distressed person will need to be rescued.",
        "Go": "As a last resort, you may have to go into the water to save the person. Enter the water only if you are a capable swimmer trained in lifesaving techniques. Remove heavy clothing before entering the water. Take a flotation device with you if one is available.",
        "Turning a Patient in the Water": "Step 1: Support the back and head with one hand. Place your other hand on the front of the patient.\nStep 2 Carefully turn the patient as a unit.\nStep 3 Stabilize the patient\u2019s head and neck.",
        "Initial Treatment of a Person in the Water": "If you are involved in a water rescue situation, your primary concerns for the patient are to open an airway, establish breathing and circulation, and stabilize the head and neck in case of spinal cord injuries. Turn a patient faceup who is facedown in the water.\n\n1. Support the back and head with one hand and place your other hand on the front of the patient to keep the head and neck stabilized Step 1. 2. Keep the head in the neutral position and carefully turn the patient as a unit Step 2. 3. Stabilize the patient\u2019s head and neck Step 3.\n\nUse the jaw-thrust maneuver to open the airway. Do not hyperextend the neck because of the high risk of associated spinal cord injuries. Look, listen, and feel for signs of breathing. If the patient is not breathing, start rescue breathing while the patient is still in the water. Ventilation will be much easier if you can stand on the bottom of the body of water. \n\nIf the patient has experienced cardiac arrest quickly stabilize the head and neck, and remove the patient from the water. Place the patient on a hard surface before you begin cardiopulmonary resuscitation (CPR) (see Chapter 8, Professional Rescuer CPR).\n\nTreat a patient who is unconscious in the water as if a spinal cord injury was present. Also assume the presence of a spinal cord injury if a conscious patient in the water reports numbness or tingling in the arms or legs, is unable to move the extremities, or reports neck pain. Support the patient by floating a backboard in the water under the patient. Strap the patient to the backboard, stabilize the head and neck, and remove the patient from the water. If a rigid device is unavailable and the patient must be removed from the water before EMS personnel arrive, six people can lift and support the patient using their hands.",
        "Words of Wisdom_15": "If a backboard is unavailable, you can use a chaise lounge, door, or piece of plywood to provide rigid support under the patient. One rescuer should give the commands to lift, move, and set down the patient.",
        "Diving Injuries": "As an EMR, you may be called to care for people who are injured while diving. Most recreational divers use self-contained underwater breathing apparatus (scuba). Scuba gear consists of an air tank, a regulator, a mouthpiece, and a face mask. Commercial divers use either scuba gear or equipment that supplies air through a hose. Most underwater diving emergencies occur in coastal regions or in areas with large lakes. Diving injuries can cause trauma, near drowning, or specialized injuries. In situations involving trauma or drowning, remove the patient from the water and treat the patient using information and skills you have already learned. Two specialized injuries are associated with diving: air embolism and decompression sickness (the bends). Usually, it will not be possible for you to differentiate between these two conditions. Both are caused by air bubbles being released in the body as a result of the changes in pressure while diving. If an air bubble affects the brain or spinal cord, the signs and symptoms may be similar to those of a stroke. These include dizziness, difficulty speaking, difficulty seeing, and a decreased level of consciousness. The patients may have difficulty in maintaining an open airway. If the air bubble causes a collapsed lung, the signs and symptoms will include chest pain, shortness of breath, and pink or bloody froth coming from the mouth or nose. If the air bubble obstructs blood flow to the abdomen, the patient will experience severe abdominal pain and may be bent over. If the air bubble involves a joint, there will be severe pain in that joint. To treat a patient with a suspected air embolism or decompression sickness, maintain the patient\u2019s airway, breathing, circulation, and normal body temperature. Oxygen should be administered as soon as it is available. Only administer oxygen if you have received the proper training and have the approval of your medical director. Some physicians recommend placing the patient on his or her left side with the head of the patient slightly lowered. This may help to prevent further damage if there is an air bubble in the central nervous system. A patient with diving injuries may need to be transported to a hospital that is equipped with a hyperbaric (recompression) chamber. If you live in an area where diving injuries occur, you should receive specialized training and be familiar with the local protocols of your EMS system.",
        "Ice Rescue": "Ice rescue is extremely hazardous because ice is changeable and should always be considered unsafe. Think safety first; do not exceed the limits of your training and do not put yourself at undue risk. You cannot save anyone if you fall through the ice yourself. As soon as you arrive at the scene of an ice rescue, visually mark the location where the person was last seen. This will enable other rescuers to concentrate their efforts on a limited area. Know who is responsible for ice rescue in your community and call this team as soon as possible.\n\nThe basic rules of ice rescue are the same as water rescue: reach, throw, row, go. Reach for the person using anything that will extend your natural stretch, such as a ladder, a pike pole, a tree branch, or a backboard. Next, throw a flotation device, throw rope, or anything that floats to pull in the person. Third, row or propel a small boat to the person if you can break through the ice, or use a toboggan to get across the ice. Using a toboggan will spread your weight over a wider area and reduce your chances of falling through the ice. Be sure that you have a rope and that the boat or toboggan is secured to the shore as well. Finally, if you must go, secure yourself to shore with a rope around your waist, lie on your stomach, and proceed across the ice. Spreading your weight over a wider area reduces your chances of falling through the ice.\n\nA motor vehicle on the ice presents a risky situation. Instruct the vehicle\u2019s occupants to avoid unnecessary movement. If the vehicle has not gone through the ice, instruct the occupants to open the vehicle\u2019s doors. This may help to slow the sinking of the vehicle if the ice breaks. If the doors cannot be opened, instruct the occupants to open the windows so they have a better escape route. If you must approach the vehicle, remember that the added weight of rescuers can cause movement of the vehicle. Do not place your head inside the vehicle because if it sinks, you may be unable to get out.\n\nDuring ice rescues, both the people on the ice or in the water and the rescuers are at risk for hypothermia. Keep all rescuers as warm as possible. Rescue personnel who are not directly involved in the rescue operation should remain in a warm vehicle until they are needed. Remove wet clothing from rescued people, and dry off and warm them as soon as possible after they are removed from the water. Remember that people can survive for an extended period of time in cold water. If the patient has no pulse, start CPR and continue until the patient has been transported to a hospital.",
        "Confined Space Rescue": "Confined spaces are structures designed to keep something in or out. Confined spaces may be below ground, ground level, or elevated structures. Below-ground confined spaces include manholes, utility vaults or storage tanks, old mines, cisterns, and wells. Ground-level confined spaces include industrial tanks and farm storage silos. Elevated confined spaces include water towers and storage tanks.\n\nRescue situations involving confined spaces have two deadly hazards. The first hazard is respiratory. The confined space may have insufficient oxygen to support life, or it may be filled with a poisonous gas. Never enter a confined space without the proper respiratory protection or else you risk becoming a patient yourself.\n\nThe second hazard in a confined space is the danger of collapse. In a mine, for example, rescuers may need to shore up (support) the confined space before they can safely enter. Confined space rescue requires a specially trained team. As soon as you determine there is a confined space situation, call for additional assistance and do not enter the space until help arrives.\n\nIf a worker in a confined space begins to feel sick because of a lack of oxygen or the presence of a poisonous gas, coworkers may assume the worker is having a heart attack. Therefore, the call you receive may be for a \u201csick person.\u201d When you arrive on the scene, take time to assess the scene carefully. If a patient is in a confined space, do not enter unless you are trained in confined space rescue and have adequate respiratory equipment to work in this deadly environment. Otherwise, wait for properly equipped and specially trained personnel to access, treat, and remove the patient.",
        "Safety_16": "More rescuers than patients die in confined space incidents. According to the Centers for Disease Control and Prevention, more than 60% of all deaths in confined space incidents involve rescuers. Do not enter a confined space without proper breathing apparatus and special training.",
        "Voices of Experience": "With everyone\u2019s help the patient was placed on oxygen, his fracture splinted, and a full spinal package completed. The call came in as a possible back injury. It seemed to be a routine call on an average day at a large manufacturing facility where I was working part time as a paramedic in the medical clinic. Routine, that is, until I found out that the patient was three stories high on a remote part of the roof with limited access. The report came from a coworker stating that an electrician had fallen approximately 15 feet (5 m) from a scaffold, striking a large pipe on the way to the roof. En route to the scene, I met the plant safety officer. He told me that there was some confusion as to the exact location of the injured person and he was not sure which access would get us there. Because of the unknowns of the call and the access problems, we decided to call our local fire/rescue department; they are well trained in unusual patient evacuations. Meanwhile, I was on the radio with the coworker, trying to find out the status of the patient. Fortunately, at this facility we have security personnel who are cross-trained as EMRs. The next report received was from a security/EMR staff member who had just arrived at the scene. He was able to tell us which access point to use and gave me a report stating that the patient was lying supine with a reduced level of consciousness. At this time, he was only responding to verbal stimulation. He had an open airway with no obvious bleeding. The secondary assessment showed a possible fracture to the left lower leg with stable vital signs. I arrived at the scene along with two other security/EMR personnel. They had the long backboard, spinal packaging equipment, and a Stokes litter. My rapid trauma assessment found the patient just as the first EMR had reported. By now fire and rescue personnel had arrived and began to set up a vertical lower off the side of the structure. With everyone\u2019s help the patient was placed on oxygen, his fracture splinted, and a full spinal package completed. The patient was placed in the Stokes litter and successfully lowered as the EMS unit waited. He was transported to a local trauma center where he was treated and had a complete recovery from his injuries. This was a great example, showing that having well-trained EMRs available with a good incident command system in place and local mutual aid response can lead to the best possible outcome for the patient.",
        "Farm Rescue": "Farms are located in most parts of the country. They range from a few acres of land with limited machinery and a small number of animals to large complexes that contain many acres of land, heavy-duty machinery, and large animals. Farm emergencies pose a wide variety of challenges for rescuers. Because many farmers work by themselves, the reporting of emergencies may be delayed. Once notification of an incident is received, there may be a lengthy response in getting to a farm. After rescuers arrive at a farm, it may be hard to pinpoint the exact location of the emergency. Poorly maintained roads, nonexistent roads, and muddy soil may require you to leave your vehicle some distance from the patient. All of these factors can delay your response in getting to the patient.\n\nFarms contain a wide variety of hazards. Animals can seriously injure farmers and pose a serious risk to rescuers. Be alert for the dangers posed by animals. Also, farms contain a wide range of chemicals that can be hazardous. These include pesticides, herbicides (weed-killing chemicals), and fertilizers such as anhydrous ammonia. Any of these chemicals, if improperly handled, can create a dangerous situation for farmers and rescuers. HazMat incidents are not always on highways. Additional information regarding pesticides can be found in Chapter 11, Poisoning and Substance Abuse. In addition, farms use a large number of electrically powered machines. Be alert for the shock hazard posed by the presence of electrical lines and electrical devices on any part of a farm. Some injuries involve tall barns or silos and often require rescuers who are trained in high-angle rescue techniques. Some farm silos are sealed and are designed to operate in an oxygen-deficient atmosphere. Always treat silos as a hazardous confined space. Under certain conditions, gases given off by the contents of a silo can explode. Some farms also contain below-grade manure storage pits. These pits may be filled with poisonous gases or be deficient in oxygen. Do not enter any confined space or enclosed below-grade structure without proper self-contained breathing apparatus and proper training. Farm silos represent high-angle hazards, confined space hazards, and explosive hazards.\n\nFarms also contain a wide variety of machinery. Machinery is used in every step of growing crops and raising animals. Accidents with farm machinery usually involve rollovers of farm tractors, entrapment in machinery, or severing of body tissue by sharp objects Tractor rollovers are more common with older tractors, which do not have roll bars or reinforced cabs. Rollovers most commonly occur on steep slopes and often result in the operator being pinned beneath the tractor. Entrapments can occur with a number of crop-harvesting equipment or mechanized animal feeding systems. Power take-off systems can catch clothing and can quickly entrap a person. Farm machinery is involved in many farm rescue situations.\n\nAs an EMR, your role in farm rescues consists of stabilizing the scene and providing initial medical care for the patient. Follow the seven steps of extrication\n\nPerform a careful scene size-up to determine the scope of the incident. Shut off any electric power and turn off any machinery that is still running, if possible. Call for adequate assistance from fire, rescue, and EMS organizations. In some communities, rescue personnel use farm implement mechanics for assistance with complex farm rescues. Helicopter transport of the patient may be beneficial. Remember, it is better to call for help and not need it than it is to delay adequate help from arriving at the scene. \n\n Stabilize any hazards that you can while keeping yourself and the patient safe. Realize that you do not have the training and equipment to stabilize all rescue scenes. If possible, gain access to the patient. Provide initial emergency care to the patient: establish responsiveness, support the patient\u2019s ABCs, control bleeding, and maintain the patient\u2019s body temperature. It is important to talk with the patient and provide emotional support. As other rescuers arrive on the scene, help them to disentangle the patient, prepare the patient for removal, and remove the patient.\n\nYour actions at a farm rescue incident can make a lifesaving difference to the patient. Farm rescues can be challenging, but they require you to follow the same steps of patient care and extrication that you would use for other types of emergencies. Above all, remember your safety and the safety of the patient.",
        "The Seven Steps of Extrication": "1. Conduct a scene size-up or an overview of the incident and its surroundings and call for sufficient help. 2. Stabilize the scene, control any hazards, and stabilize the vehicle. 3. Gain access to the patients, if possible. 4. Provide initial emergency care. 5. Help disentangle the patients. 6. Help prepare the patients for removal. 7. Help remove the patients.",
        "Bus Rescue": "Buses operate in most communities. School buses transport students to school and to school-sponsored events. Cities operate fleets of municipal buses over established routes. Charter buses transport people of all ages to special events and on vacation trips. Specially equipped buses transport people with limited mobility. Interstate buses transport people all over the country.\nBecause of the large numbers of people being transported by buses, significant potential exists for bus crashes to occur in any community. Bus crashes range from minor incidents with no injuries to mass-casualty incidents; therefore, you need to understand some guidelines for providing care to patients involved in bus crashes. A mass-casualty incident refers to any accident or situation involving more patients than you can handle with the initial resources available.\n\nIf you are an EMR at a bus crash, perform a scene size-up or an overview of the scene and call for adequate police, fire, and EMS resources. Establish an incident command system if there are multiple casualties. Set up a one-way traffic pattern for responding vehicles to avoid congestion and gridlock at the emergency scene. For example, you might direct all responding emergency vehicles to approach the scene from the east and depart the scene traveling toward the west. If multiple patients must be removed from a bus, pass equipment into the bus through one door or window and remove the patients through a second door or window. This will improve the efficiency of the extrication process. If confronted with a large number of patients, triage the patients using the START triage system. This system is used for sorting and treating patients in mass-casualty situations.",
        "Prep Kit Ready for Review": "\nAs an emergency medical responder, you should be able to perform the first four steps in the extrication process and assist other rescuers with steps five through seven\nWater rescue, ice rescue, underwater diving injuries, confined space rescue, farm rescue, and bus crashes are situations that require extensive skills and special training. It is important to help the patient, but not at the expense of your own safety.\nIn water and ice rescue situations, there are four simple steps you can take to help the person without endangering yourself: reach out to the person with an object, throw a flotation device to the person, row to the person in a boat, or go to the person if you are adequately trained to do so (reach, throw, row, go).\nYou may not be able to distinguish between the two major medical emergencies created by underwater diving incidents (air embolism and decompression sickness), but you can provide basic care and summon appropriate assistance.\nIn confined space rescue, your primary goals are to call for additional assistance and prevent other people, including yourself, from becoming patients.\nFarm emergencies and bus crashes are complex rescue situations; however, if you follow simple steps, you can often stabilize these situations and provide initial aid to patients.",
        "Vital Vocabulary": "air embolism: A bubble of air obstructing a blood vessel., chocking: Placing a piece of wood or metal in front of or behind a wheel to prevent vehicle movement., decompression sickness (the bends): A condition seen in divers in which gas, especially nitrogen, forms bubbles in blood vessels, obstructing them., entrapment: To be caught (trapped) within a vehicle, room, or container with no way out or to have a limb or other body part trapped., extrication: Removal from a difficult situation or position; removal of a patient from a wrecked vehicle or other place of entrapment., flotation device: A life ring, life buoy, or other floating device used in water rescue., fusees: Warning devices or flares that burn with a red color; usually used in scene protection at motor vehicle crash sites., Golden Hour: A concept of emergency patient care that attempts to place a trauma patient into definitive medical care in the shortest period of time to achieve the best possible outcome; also called the Golden Period., hazardous materials (HazMat): Substances that are toxic, poisonous, radioactive, flammable, or explosive and can cause injury or death with exposure., mass-casualty incidents: Accidents or situations involving more patients than you can handle with the initial resources available., reach, throw, row, go: A sequence of four actions that should be taken in water rescue situations., rescue throw bag: A water rescue device consisting of a small cloth bag and a waterproof rope used for rescuing people from the water., riptide: Unusually strong surface currents flowing outward from a seashore that can present a hazard to swimmers., tempered glass: Safety glass that breaks into small pieces when hit with a sharp, pointed object., wooden cribbing: Wooden boards (either 2 inch \u00d7 4 inch [5 cm \u00d7 10 cm] or 4 inch \u00d7 4 inch [10 cm \u00d7 10 cm] used for vehicle stabilization or bracing."
    },
    {
        "Introduction": "An emergency medical responder (EMR) is often the first medically trained person to arrive on the scene of an emergency. As an EMR, the care you give could mean the difference between life and death. Your care is usually followed by care given by emergency medical technicians (EMTs), paramedics, nurses, physicians, and other allied health professionals.",
        "The EMS System": "The EMS system was developed to improve patient outcomes. Evidence showed that patients who received appropriate emergency medical care before they reached the hospital had a better chance of surviving a major injury or sudden illness than patients who did not receive such care. It is important that you understand the operation and complexity of your EMS system. Personnel from different agencies may provide emergency medical services. For some agencies, providing emergency medical services is a major function. Other agencies have a minimal yet vital role in providing emergency medical care.\n\nProblems during an EMS operation often result from a lack of coordination between resources and personnel. Agencies and personnel need to share an understanding of their roles for an EMS system to operate smoothly. This understanding develops through close cooperation, careful planning, communication, and continual effort. You can best understand the EMS system by examining the sequence of events as an injured or ill patient is cared for in the system.",
        "Reporting": "The first step in reporting an emergency is recognizing that an emergency exists. The patient, a relative, or bystander sees a serious illness or injury and decides to call for help. Most emergency calls are made using cellular phones. Other calls are made using landline telephones, two-way radios, or personal emergency call systems. An emergency response communications center or public safety answering point (PSAP) usually receives the telephone call reporting an incident. The communications center may be a fire, police, or EMS agency, a 9-1-1 center, or a seven-digit emergency telephone number used by one or all of the emergency agencies. Enhanced 9-1-1 centers use computers to determine the location of landline telephones as soon as the telephone in the 9-1-1 center is answered.",
        "Dispatch": "Once the emergency response communications center is notified of an incident, appropriate equipment and personnel are dispatched to the scene. Agencies, personnel, and equipment that are involved in the emergency medical first response vary by community.",
        "First Response": "Firefighters (paid or volunteer) or law enforcement personnel, because of their location or speed in responding, are in many cases the first EMRs on scene. Most communities have many EMRs but few EMTs and even fewer paramedics. Emergency medical responders may be employed as lifeguards, security officers, teachers, or workers in an industrial setting. A community with four or five fire stations may have only two or three ambulances. The patient\u2019s first and perhaps most crucial contact with the EMS system occurs when the trained EMR arrives. For example, a key survival factor for people in cardiac arrest is the length of time between when the heartbeat stops and when manual cardiopulmonary resuscitation (CPR) starts.",
        "EMS Response": "The arrival of an emergency medical vehicle (usually an ambulance) staffed by EMTs or paramedics is the patient\u2019s second contact with the EMS system. A properly equipped vehicle and the EMT staff make up a basic life support (BLS) unit. Each EMT has completed at least 150 hours of training. Many complete even longer training courses. EMTs continue the care begun by EMRs. EMTs stabilize the patient\u2019s condition further and prepare the patient for transport to the emergency department of the hospital. Well-trained emergency personnel who can carefully move the patient and provide proper treatment increase the chance that the patient will arrive at the emergency department in the best possible condition. \n\nAdvanced emergency medical technicians (AEMTs) are able to perform limited advanced life support (ALS) skills. They have completed at least 300 hours of training. Advanced EMTs may work alone or with a paramedic on an ALS unit.\n\nParamedics provide advanced life support services. They have received at least 1,000 hours of additional training. They can administer intravenous fluids and certain medications. They can also monitor and treat heart conditions with medications and defibrillation. Defibrillation is the administration of an electric shock to the heart of a patient who is experiencing a highly irregular heartbeat, known as ventricular fibrillation. Defibrillation may also be done by specially trained EMTs and EMRs. Paramedics are also trained to place special airway tubes (endotracheal tubes) to keep the patient\u2019s airway open.\n\nEach level of skill builds on the one that precedes it: the paramedic\u2019s skills originate from those of the EMT, and the techniques used by the EMT depend on those of the EMR. All skill levels are based on what is learned in the EMR course: airway maintenance; bleeding control; and prevention, recognition, and treatment of shock.\n\nThe EMS system involves more than emergency medical care. For example, law enforcement personnel may provide protection and control at the scene of an incident. Fire units provide fire protection, specialized rescue, and patient extrication.",
        "Hospital Care": "The patient\u2019s third contact with the EMS system occurs in the hospital, primarily in the emergency department. After being treated at the scene, the patient is transported to an appropriate hospital, where definitive treatment can be provided. It may be necessary to transport some patients to the closest appropriate medical facility first. An appropriate medical facility may be a hospital, trauma center, or medical clinic. They will be stabilized there and then transported to a hospital that provides specialized treatment. Specialized treatment facilities include trauma centers, spinal cord injury centers, hand centers, cardiac centers, stroke centers, burn centers, pediatric centers, poison control centers, and perinatal centers. You must learn and follow your local patient transportation protocols.",
        "Public Health and EMS": "The EMS system holds a unique place in our society. In most communities, it is considered part of the public safety function of government. EMS can also be considered a part of public health because these services are available to all people in a community. It is important for you to understand the basic functions of public health agencies because EMS personnel need to interact with public health practitioners.\n\nPublic health departments monitor restaurant cleanliness, conduct immunization programs, and determine the incidence of contagious diseases such as influenza, tuberculosis, and hepatitis. Public health departments also work to prevent the incidence or progression of diseases. They monitor the spread of contagious diseases and inform other members of the medical community about the scope of a disease. When people\u2019s actions can affect the spread of a disease, public health personnel work hard to educate the community about how to limit the spread of that disease.\n\nBecause prevention is better than treatment, public health and public safety departments provide education and screening programs to help prevent injuries and illness. They conduct car seat installation programs, programs to encourage seat belt use, alcohol awareness programs, programs to encourage bicycle and motorcycle helmet use, blood pressure screenings, and diabetes screenings. Public health departments provide support to EMS in certain situations. For example, EMS personnel may receive vaccinations at a public health clinic. In some cases, EMS may be called upon to support certain functions of a public health department. In the event of an epidemic such as influenza, EMS systems may need to work with public health departments to determine the number of people who are sick. The Centers for Disease Control and Prevention (CDC) is one public health agency that monitors the incidence of diseases. They also provide the standard precaution guidelines we use to prevent the spread of contagious diseases.",
        "The History of EMS": "As an EMS provider, you should have some understanding of the history of EMS. Many advances in civilian EMS have followed progress initially established in the military medical system. Horse-drawn ambulances were first used to remove wounded patients from the battlefield during the Civil War. Traction splints were first used in World War I, which greatly reduced the death rate from fractured femurs (thigh bones). During World War II, well-trained medical corpsmen and field hospitals helped reduce battlefield mortality (deaths). In the 1950s, during the Korean Conflict, timely helicopter evacuations to mobile army surgical hospitals (MASH units) further reduced battlefield mortality. Additional medical advances were made in the 1960s and 1970s during the Vietnam War. Improved tourniquets, chemical blood clotting agents, and fluid resuscitation protocols helped improve survival during the conflicts in Iraq and Afghanistan.\n\nIn the United States during the 1950s and 1960s, funeral homes, hospitals, and volunteer rescue squads provided most ambulance service. The only training available for ambulance attendants was basic first aid. Even interns who staffed hospital-based ambulances had no special training for their prehospital duties. Hearses were commonly used to transport ill and injured patients. The mortality rate from trauma to civilians was much higher than the mortality experienced by military personnel.\n\nSome physicians recognized that civilian prehospital medical care lagged behind military emergency medical care. They urged the National Academy of Sciences to investigate this situation. In 1966, the National Academy of Sciences/National Research Council produced a landmark paper, Accidental Death and Disability: The Neglected Disease of Modern Society. This paper described the deficiencies in emergency medical care. It recommended the development of a national course of instruction for prehospital emergency care personnel. It also called for nationally accepted textbooks, ambulance vehicle design guidelines, ambulance equipment guidelines, state regulations for ambulance services, and improvements in hospital emergency departments.\n\nAs a result of this effort, in the early 1970s the US Department of Transportation developed a national standard curriculum for training EMS providers. This curriculum was the grandfather of the education guidelines in use today, the National EMS Education Standards.\n\nDuring the 1980s, the use of ALS within EMS became common. Today paramedics are able to perform many procedures that were limited to physicians in the early days of EMS. Currently, cities, counties, fire departments, third-party EMS departments, rescue squads, and hospitals provide most EMS. EMS providers are now trained through standardized courses conducted at accredited training centers. Certified personnel use standardized vehicles to transport patients to hospital emergency departments. Hospital emergency departments provide a high level of care for emergency patients.",
        "Words of Wisdom": "In order to prevent confusion, in this text the term provider is used to refer to an EMS provider at any level: an EMR, EMT, or paramedic. The term public safety provider includes firefighters, law enforcement personnel, and EMS providers. The term rescuer refers to public safety providers engaged in the rescue and care of patients at an incident.",
        "Ten Standard Components of an EMS System": "EMS systems can be organized in many different ways. Different agencies may provide different parts of the system. For example, first responders in one community may be law enforcement officers. In another community, the first responders may be firefighters. Both function similarly from a medical care perspective.\n\nThe National Highway Traffic Safety Administration (NHTSA) of the US Department of Transportation evaluates EMS systems based on the following 10 criteria, which are used primarily in the administration of an EMS system:\n1. Regulation and policy\n2. Resource management\n3. Human resources and training\n4. Transportation equipment and systems\n5. Medical and support facilities\n6. Communications system\n7. Public information and education\n8. Medical direction\n9. Trauma system and development\n10. Evaluation",
        "A Word About Transportation": "As an EMR, your primary goal is to provide immediate care for a sick or injured patient. As more highly trained EMTs or paramedics arrive on the scene, you will assist them in treating the patient and preparing the patient for transportation. Although other EMS personnel usually transport patients, you need to understand when a patient must be transported quickly to a hospital or other medical facility.\n\nTransport. This means that a patient\u2019s condition requires care by medical professionals, but speed in getting the patient to a medical facility is not the most important factor. For example, this might describe the transportation needed by a patient who has sustained an isolated injury to an extremity but whose condition is otherwise stable. \nPrompt transport. This phrase is used when a patient\u2019s condition is serious enough that the patient needs to be taken to an appropriate medical facility in a fairly short period of time. If the patient is not transported fairly quickly, the condition may get worse and the patient may die.\nRapid transport. This phrase is used when EMS personnel are unable to give the patient adequate lifesaving care in the field. The patient may die unless he or she is transported immediately to an appropriate medical facility. This phrase is rarely used in this book\n\nEMS personnel must work closely with their medical director to establish transportation protocols that ensure that patients are transported to the closest medical facility capable of providing adequate care. To provide the best possible care for the patient, all members of the EMS team must remember that they are key components in the total system. Smooth operation of the team ensures the best care for the patient.",
        "EMR Training": "This book is written for an emergency medical responder training course. Although the book alone can teach you many things, it is best to use it as part of an approved EMR course. In this EMR course, you will learn how to examine patients and how to use basic emergency medical skills. These skills are divided into two main groups: (1) those needed to treat injured trauma patients and (2) those needed to care for patients experiencing illness or serious medical problems. The skills and knowledge you will gain from this course provide the foundation for the entire EMS system. Your actions can prevent a minor situation from becoming serious and will sometimes determine whether a patient lives or dies.\n\nYou will learn the following skills to stabilize conditions and treat persons who have been injured:\nControlling airway, breathing, and circulation (Chapters 7 and 8)\nControlling external bleeding (hemorrhage) (Chapter 14)\nTreating shock (Chapter 14)\nTreating wounds (Chapter 14)\nSplinting injuries to stabilize extremities (Chapter 15)\nIn addition to these trauma skills, you will learn to recognize, stabilize, and provide initial treatment for the following medical conditions:\nHeart attacks (Chapter 10)\nSeizures (Chapter 10)\nProblems associated with excessive heat or cold (Chapter 13)\nAlcohol and drug abuse (Chapter 11)\nPoisonings (Chapter 11)\nBites and stings (Chapter 11)\nAltered mental status (Chapter 10)\nBehavioral or psychological crises (Chapter 12)\nEmergency childbirth (Chapter 16)",
        "Goals of EMR Training": "It is important for you to understand the basic goals of EMR training. This training aims to teach you how to evaluate, stabilize, and treat patients using a minimum of specialized equipment. As an EMR, you will find yourself in situations in which little or no emergency medical equipment is readily available. You must know how to improvise using materials and objects already present at an emergency scene to serve in place of otherwise unavailable medical equipment. Finally, EMR training teaches you what you can do to help EMTs and paramedics when they arrive on the scene.",
        "Know What You Should Not Do": "The first lesson you must learn as an EMR is what not to do. For example, it may be better for you to leave a patient in the position found rather than attempt to move him or her without the proper equipment or an adequate number of trained personnel. Sometimes the first priority at an emergency scene is to stabilize the scene or call for more help before beginning patient care. It is also critical that you not judge a patient based on his or her cultural background, religion, color, gender, sexual orientation, age, or socioeconomic status. Doing so may undermine the quality of care you provide. Treat all your patients as you would treat a member of your own family.",
        "Know How to Use Your EMR Life Support Kit": "The second goal of EMR training is to teach you to treat patients using limited emergency medical supplies. An EMR life support kit should be small enough to fit in the trunk of an automobile or on almost any police, fire, or rescue vehicle. Although the contents of the kit are limited, such supplies are all you need to provide immediate care for most patients you will encounter.",
        "Suggested Contents of an EMR Life Support Kit": "Table 1-1 suggests the following contents for an EMR Life Support Kit. Under **patient examination equipment**, there is one flashlight. **Personal safety equipment** includes five pairs of nitrile or latex gloves, five face masks, and one bottle of hand sanitizer. **Resuscitation equipment** comprises one mouth-to-mask resuscitation device, one portable hand-powered suction device, one set of oral airways, and one set of nasal airways. **Bandaging and dressing equipment** includes ten gauze adhesive strips (1\u202fin [2.5\u202fcm]), ten gauze pads (4\u202fin \u00d7 4\u202fin [10\u202fcm \u00d7 10\u202fcm]), five gauze pads (5\u202fin \u00d7 9\u202fin [13\u202fcm \u00d7 23\u202fcm]), universal trauma dressings (10\u202fin \u00d7 30\u202fin [25\u202fcm \u00d7 76\u202fcm]), an occlusive dressing for sealing chest wounds, four conforming gauze rolls (3\u202fin \u00d7 15\u202fin [8\u202fcm \u00d7 38\u202fcm]), four conforming gauze rolls (4.5\u202fin \u00d7 15\u202fin [11\u202fcm \u00d7 38\u202fcm]), triangular bandages, one roll of 2-in (5-cm) adhesive tape, and one burn sheet. **Patient immobilization equipment** includes two of each cervical collar (small, medium, large) or two adjustable cervical collars, plus three rigid conforming splints (SAM splints) or one set of air splints for arms and legs, or two (each) cardboard splints (18\u202fin and 24\u202fin). **Extrication equipment** consists of one spring-loaded center punch and a pair of heavy leather gloves. **Miscellaneous equipment** features two disposable blankets, two cold packs, and one pair of bandage scissors. **Other provider equipment** comprises one set of personal protective clothing (helmet, eye protection, EMS jacket), one ANSI-approved reflective vest, one 5-lb ABC dry chemical fire extinguisher, one Emergency Response Guidebook, six flares, and one set of binoculars.",
        "Know How to Improvise": "The third goal of EMR training is to teach you how to improvise. As a trained EMR, you will often be in situations with little or no emergency medical equipment. Therefore, it is important that you know how to improvise. This book gives examples of improvisation that can be applied to real-life situations. You will learn, for example, how to use articles of clothing and handkerchiefs to stop bleeding and how to use wooden boards, magazines, or newspapers to immobilize injured extremities.",
        "Know How to Assist Other EMS Providers": "Finally, EMR training teaches you how to assist EMTs and paramedics once they arrive on the scene. Many procedures that EMTs and paramedics use require at least three people to be performed correctly. Thus you may have to assist with these procedures and you must know what to do.",
        "Additional Skills": "EMRs operate in a variety of settings. Many problems encountered in urban areas differ sharply from those found in rural settings. Regional variations in climate not only affect the situations you encounter but also require you to use different skills and equipment in treating patients. Certain skills and equipment mentioned in this book are beyond the essential, minimum knowledge you need to successfully complete an EMR course. However, these supplemental skills and equipment may be required in your local EMS system.",
        "Roles and Responsibilities of the EMR": "As an EMR, you have several roles and responsibilities. Depending on the emergency situation, you may need to:\nMaintain your body in a healthy physical and mental condition.\nMaintain equipment in a ready state.\nRespond promptly and safely to the scene of an accident or sudden illness.\nEnsure that the scene is safe from hazards.\nProtect yourself.\nProtect the incident scene and patients from further harm.\nSummon appropriate assistance (EMTs, fire department, rescue squad).\nGain access to the patient.\nPerform patient assessment.\nAdminister emergency medical care.\nProvide reassurance to patients and family members.\nMove patients only when necessary.\nSeek and then direct help from bystanders, if necessary.\nControl activities of bystanders.\nAssist EMTs and paramedics, as necessary.\nMaintain continuity of patient care. \nDocument your care. \nKeep your knowledge and skills up to date. \n\nConcern for the patient is primary; you should perform all activities with the patient\u2019s well-being in mind. Prompt response to the scene is essential if you are to provide quality care to the patient. It is important that you know your response area well so you can quickly determine the most efficient route to the emergency scene.\n\nWhen you reach the emergency scene, park your vehicle so that it does not create an additional hazard. The emergency scene should be protected, with the least possible disruption of traffic. Do not block the roadway unnecessarily. Assess the scene for hazards such as downed electrical wires, gasoline spills, or unstable vehicles. When operating on highways, take steps to control traffic to prevent additional crashes and injuries. These steps are necessary to ensure that patients experience no further injuries and that rescuers (other than EMS personnel) and bystanders are not hurt.\n\nIf the equipment and personnel already dispatched to the scene cannot cope with the incident, you must immediately summon additional help. It may take some time for additional equipment and personnel to reach the scene, especially in rural areas or in communities with systems staffed by volunteers.\n\nOnce you have taken the preceding steps, you must gain access to the patient. This may be as simple as opening the door to a car or house or as difficult as squeezing through the back window of a wrecked automobile. Next, examine the patient to determine the extent of the injury or illness. This assessment of a patient is called the patient assessment sequence. Once the patient assessment is completed, you must stabilize the patient\u2019s condition to prevent it from getting worse. To do this, you will use techniques you learned in the training and the equipment available. Correctly applying these techniques can have a positive effect on the patient\u2019s condition.\n\nWhen EMTs or paramedics arrive to assist, it is important to tell them what you know about the patient\u2019s condition and what you have done to stabilize or treat it. Your next task is to assist the EMTs or paramedics. In some communities or situations, you may be asked to accompany the patient in the ambulance. If CPR is being performed, you may need to assist or relieve the EMT or paramedic, especially if the hospital is far from the scene. In some EMS systems, you may be qualified to drive the ambulance to the hospital so EMS personnel with more advanced training can devote all their efforts to patient care.",
        "Voices of Experience": "\u201cBecause of you, I am here today.\u201d\nOne day, while running errands, I stopped by the local coffee shop for my usual double latte with extra cream and sugar. While standing in line waiting to place my order, I saw my neighbor, Mrs. Jones. We were talking about her family (who did not live nearby) when she started to experience some type of medical emergency. I was very concerned by this and asked Mrs. Jones if she was okay. She responded, \u201cMy, what a gorgeous day it is outside,\u201d and began to fall down. I quickly caught her, lowered her to a chair, and told someone to call 9-1-1. After the EMS crew arrived and I told them what I saw, I left.\nAs I was walking back home, I thought, \u201cI have lived here for 25 years and think it\u2019s time I gave something back to the community.\u201d That afternoon I called the EMS system that transported Mrs. Jones. They helped me sign up for an EMR course at the local community center. Upon completion of the course, I volunteered for a couple shifts a month for the EMS system. During the course, I learned how to protect myself while responding to a medical emergency or a traumatic event. I also learned how the EMS system works, how they are notified, how to prepare myself to respond to a call safely and effectively, which skills and procedures I can and cannot do, and what happens when the patient is transported to the hospital. These are all parts of an effective EMS system, starting with personnel training and moving to vehicle staffing and transport of patients. It is important to remember that the system is like a circle that is complete only when the patient is discharged from the facility.\nThat day at the coffee shop, the EMS crew showed up about 2 or 3 minutes after they were called. They assessed the situation, called for a higher level of care, loaded the patient on the stretcher, and, due to the long transport time, met ALS providers on the way. What I didn\u2019t see was what happened when Mrs. Jones arrived at the hospital. A couple of days later, I saw Mrs. Jones back at the coffee shop. She came over to me, gave me a big hug, and said, \u201cThank you for saving my life. I had an ischemic stroke, but because of you, I am here today.\u201d",
        "The Importance of Documentation": "Once your role in treating the patient is finished, it is important that you record your observations about the scene, the patient\u2019s condition, and the treatment you provided. Documentation should be clear, concise, accurate, and according to the accepted policies of your organization. Documentation is important because you will not be able to remember the treatment you give to all patients. It also serves as a legal record of your treatment and may be required in the event of a lawsuit. Documentation also provides a basis to evaluate the quality of care given.\n\nDocumentation should include:\n- The condition of the patient when found\n- The patient\u2019s description of the injury or illness\n- The initial and later vital signs\n- The treatment you gave the patient\n- The agency and personnel who took over treatment of the patient\n- Any other helpful facts",
        "Attitude and Conduct": "As an EMR, you will be judged on your attitude and conduct, as well as on the medical care you administer. It is important to understand that professional behavior has a positive impact on your patients. To be a good EMR, you need to reflect certain characteristics. You need to be honest and conduct yourself with integrity. You need to be aware of the patient\u2019s feelings and have empathy for your patients. You need to be motivated to get the job done and to understand the limits of your training and skills. You must advocate for patients. Unresponsive patients are totally dependent on your skills, knowledge, and the concern you bring to the emergency scene. Because you will often be the first medically trained person to arrive on the scene of an emergency, it is important to be calm and caring. You will gain the confidence of patients and bystanders more easily by using a courteous and caring tone of voice. Introduce yourself by name and title or position. Show an interest in your patients. Avoid embarrassing your patients and help protect their privacy. Talk with your patients and let them know what you are doing. A good rule of thumb to follow is to treat all your patients the way you would treat a close family member. This attitude will go a long way in helping patients through the emergency and will make your job easier, too.\n\nRemember, medical information about patients is confidential and should not be discussed with your family or friends. This information should be shared only with other medical personnel who are involved in the care of that patient. Your appearance should be neat and professional at all times. You should be well groomed and clean. A uniform helps identify you as an EMR. If you are a volunteer who responds from home, always identify yourself as an EMR. Your professional attitude and neat appearance help provide much needed reassurance to patients",
        "Medical Oversight": "The overall leader of the medical care team is the physician or medical director. To ensure that the patient receives appropriate medical treatment, it is important that EMRs receive direction from a physician. Each EMS agency should have a physician who directs training courses, helps set medical policies and procedures, and ensures quality management of the EMS system. This type of medical direction is known as indirect (or off-line) medical control. A second type of medical control is known as direct (or online) medical control. A physician who is in contact with prehospital EMS providers, usually paramedics or EMTs, by two-way radio or wireless telephone provides online medical control. In cases where large numbers of people are injured, physicians may respond to the scene of the incident to provide on-scene medical control.",
        "Quality Improvement": "Quality improvement is a process used by medical care systems to evaluate the effectiveness and safety of current treatments and procedures. It is also used to determine the effectiveness and safety of new treatments and procedures. This process is used to evaluate all parts of the health care system, including EMS. The Institute of Medicine has identified six components of the quality improvement process. These are: \nSafety. The actions of EMRs must not cause harm to patients, bystanders, or EMS providers. \nEffectiveness. EMS care should be based on scientific knowledge and provide the desired benefit to the patient. Refrain from any treatment that does not benefit the patient.\nPatient-centeredness. Emergency medical care must be responsive to the patient\u2019s needs. Be responsive to the patient\u2019s physical needs as well as to his or her values, religion, and heritage.\nTimeliness. Provide care in a timely manner. Timely patient care is an especially important component of EMS.\nEfficiency. Always strive to deliver care without wasting supplies, equipment, or time.\nEquitability. Strive to deliver your best care to all people. This means patient care should not vary between people of different genders, different sexual orientations, different ethnic backgrounds, different geographic locations, or different socioeconomic levels.\n\nEMS systems should have quality improvement programs to evaluate the care they provide. Evaluations should include the six components listed above. They should consider if errors have occurred because of a gap in skills or knowledge. Your organization uses protocols, continuing medical education, and call debriefing to help improve the quality of care being given to your patients. As part of the quality improvement process, you may be asked to participate in a research study or in data collection in your service. EMS research is an important part of the quality improvement process to ensure good patient care.",
        "Your Certification": "Most states require certification, registration, or licensure of emergency medical care providers. Certification is the process by which a person, institution, or program is evaluated and recognized as meeting certain standards to ensure safe and ethical patient care. Your state has a lead agency that administers regulations relating to EMS operations. Once certified as an EMR, you must follow the national or state standards for your level of practice. Your employer may set additional requirements for your conduct and practice. You must keep your certification current by meeting continuing education requirements and keeping your skills up to date. Failure to keep your certification current can result in penalties.",
        "Prep Kit-Ready for Review": "The EMR is often the first medically trained person to arrive on the scene. The initial care provided is essential because it is available sooner than more advanced emergency medical care and could mean the difference between life and death.\nEMRs should understand the EMS system. The typical sequence of events of the EMS system is reporting, dispatch, emergency medical response, EMS vehicle response, and hospital care.\nThe four basic goals of EMR training are to know what not to do, how to provide care using your EMR life support kit, how to improvise, and how to assist other EMS providers.\nAs an EMR, your primary goal is to provide immediate care for a sick or injured patient. As more highly trained personnel (EMTs or paramedics) arrive on the scene, you will assist them in treating and preparing the patient for transportation.\nOnce your role in treating the patient is finished, it is important that you record your observations about the scene, the patient\u2019s condition, and the treatment you provided. Documentation should be clear, concise, accurate, and according to the accepted policies of your organization.\nRemember that medical information about a patient is confidential and should be shared only with other medical personnel who are involved in the care of that particular patient.\nThe overall leader of the medical care team is the physician or medical director. To ensure that the patient receives appropriate medical treatment, it is important that EMRs receive direction from a physician.\nQuality improvement helps to determine the level of care rendered by an EMS service. It measures care in six component areas: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equitability. EMS systems should have an ongoing quality improvement program.",
        "Vital Vocabulary": "advanced emergency medical technician (AEMT): A person who is able to perform basic life support skills and limited advanced life support skills., advanced life support (ALS): The use of specialized equipment (such as cardiac monitors and defibrillators) and specialized techniques (such as intravenous fluid administration, drug infusion, and endotracheal intubation) to stabilize a patient\u2019s condition., appropriate medical facility: A hospital or medical clinic with adequate medical resources to provide continuing care to sick or injured patients who are transported after field treatment by emergency medical responders., basic life support (BLS): Emergency lifesaving procedures performed without advanced emergency procedures to stabilize the condition of patients who have experienced sudden illness or injury., certification: The process by which a person, institution, or program is evaluated and recognized as meeting certain standards to ensure safe and ethical patient care., defibrillation: Process of delivering an electric shock through a person\u2019s chest wall and heart for the purpose of ending lethal heart rhythms such as ventricular fibrillation and to help establish normal heart contraction rhythms., emergency medical responder (EMR): The first medically trained person to arrive on the scene., emergency medical technician (EMT): A person who is trained and certified to provide basic life support and certain other noninvasive prehospital medical procedures., emergency response communications center: A fire, police, or emergency medical services agency; a 9-1-1 center; or a seven-digit telephone number used by one or all of the emergency agencies to receive and dispatch requests for emergency care; also called a public safety answering point., paramedic: A person trained and certified to provide advanced life support., public safety answering point (PSAP): A fire, police, or emergency medical services agency; a 9-1-1 center; or a seven-digit telephone number used by one or all of the emergency agencies to receive and dispatch requests for emergency care; also called an emergency response communications center."
    },
    {
        "Introduction": "This chapter covers hazardous materials incidents, mass-casualty incidents, the National Incident Management System (NIMS), and terrorism awareness. You should be able to identify the signs of a hazardous materials incident and prevent injury to yourself and to others in the first minutes of the incident. Because you may be called to assist with a mass-casualty incident, you should understand the purpose of an incident management system and the framework of the NIMS. Your knowledge of basic triage and your ability to use the START triage system are also important. The last section of this chapter is designed to increase your awareness of terrorism. In addition to defining terrorism, you will learn the types of structures terrorists might target and how terrorists might use explosive, incendiary, chemical, biologic, and radiologic agents to cause mass destruction. You will also learn the importance of safety, preparedness, and the use of the incident command system (ICS).",
        "Hazardous Materials Incidents": "Hazardous materials (HazMat) are any substances that are toxic, poisonous, radioactive, flammable, or explosive and can cause injury or death with exposure. During a HazMat incident, your top priority is to protect yourself and bystanders from exposure and contamination.\n A very important step when handling any HazMat incident is to identify the substances involved. Federal law requires all vehicles containing certain quantities of hazardous materials to display a HazMat placard, which is a large diamond-shaped indicator placed on all sides of transport vehicles that carry hazardous materials. When you see a HazMat placard, you know that a potential problem could exist. You will have to find the proper response to the problem before beginning patient treatment. The placard should also have a four-digit identification number, which can be used to identify the substance and to obtain emergency information.\n The Emergency Response Guidebook, published by the US Department of Transportation, lists the most common hazardous materials, their four-digit identification numbers, and the proper emergency actions to take to control the scene.: It also describes the emergency medical care of patients who become ill or injured after exposure to these substances: This guidebook is updated every 3 to 4 years. You should carry an up-to-date copy of this guidebook in your vehicle. You can download a free copy of the guidebook at the Pipeline and Hazardous Materials Safety Administration website.\n Unless you have received specialized training in handling hazardous materials and can take the necessary precautions to protect yourself, you should keep away from the contaminated area or hot zone. As soon as you recognize that a hazardous materials incident exists, notify your dispatcher so other responders will be aware of the situation.\n Once the trained HazMat rescuers have been properly protected, these rescuers need to identify the source of the hazardous materials and remove anyone who has been exposed to the hazard. Sometimes HazMat teams can stop the escape of the hazardous material by shutting off a leak or by absorbing spilled chemicals. Once people have been removed from the contaminated area, they need to be decontaminated by trained personnel, assessed for any injuries, given necessary emergency medical care, and transported to a hospital.\n Very few specific antidotes or treatments exist for most HazMat injuries. Consequently, the emergency treatment you can provide to patients who have been exposed to hazardous materials is usually aimed at supportive care. Because most fatalities and serious injuries sustained in HazMat incidents result from breathing problems, you must constantly reevaluate the patient\u2019s vital signs, including breathing status, so that a patient whose condition worsens can be moved to a higher triage level. \nBecause of the unique aspects of responding to and working at a HazMat incident, as an emergency medical responder (EMR), you should receive specific additional training in hazardous waste operations and emergency response (often referred to as HAZWOPER) to the emergency medical response level.",
        "Words of Wisdom": "Anyone who is working at the scene of a hazardous materials emergency should understand the terminology used to differentiate separate parts of the HazMat scene:\nHot zone\n. The contaminated area where people can be exposed to sharp metal edges, broken glass, toxic substances, lethal rays, or ignition or explosion of hazardous materials.\nWarm zone\n. The control area where personnel and equipment decontamination and hot zone support take place.\nCold zone\n. The control safe area that contains the command post and other support functions needed in the incident.\nOnly specially trained and equipped personnel should be in the hot zone and the warm zone.",
        "Mass-Casualty Incidents": "As an EMR, you may face situations in which there is more than one sick or injured person. These situations, known as mass-casualty incidents (or multiple-casualty incidents), may range from a serious motor vehicle crash with three or four injured people to a building explosion with dozens of injured people. A mass-casualty incident is defined as any time there are more patients than resources (ambulances), either on scene or en route, ready to treat and transport patients. In these types of situations, how do you determine which patient to treat first?\n\nYou must first be able to recognize the situation as a mass-casualty incident. These incidents require a very different method of operation from routine emergency medical calls. During some mass-casualty incidents, you may be on the scene 15 to 20 minutes before additional assistance arrives, and it may be 45 to 60 minutes before enough rescue resources are available.\n\nNo easy formula exists for deciding when to shift from normal operations into the techniques of the mass-casualty incident. Simulations provide realistic situations, but there are many variables, including the severity of the crash, access routes, available resources, response times, levels of emergency training, and overall experience of the EMS system.\n\nYour goal should be to provide the greatest medical benefit for the greatest number of people and to match patients\u2019 medical needs with appropriate treatment and transportation. To accomplish this goal, you must identify those patients most in need of treatment and those who can wait",
        "The Visual Survey: The Eye Sees It All": "As you are on the way to the scene, you should mentally prepare yourself for what you may find. You should ask yourself the following questions: Where will additional assistance come from? How long will it take for them to arrive? When you arrive at the scene of a major incident, force yourself to stay as calm as possible. Make a visual assessment of the entire accident scene. This visual survey, as part of the scene size-up, gives you an initial impression of the overall situation, including the potential number of patients involved and, possibly, the severity of their injuries. The visual survey enables you to estimate how much and what kind of assistance you will need to handle the situation.",
        "Your Initial Radio Report: Creating a Verbal Image": "The initial radio report is often the most important radio message of a major emergency because it sets the emotional and operational stage for everything that follows. As you prepare for that first vital report, use clear language, be concise, be calm, and do not shout into the equipment. Give the communications center a concise verbal picture of the scene. The key points to communicate are as follows:\n1. Location of the incident\n2. Type of incident\n3. Any hazards\n4. Approximate number of patients\n5. Types of assistance required\nBe as specific with your requests as possible. A good rule of thumb in mass-casualty situations is to request one ambulance for every five patients. For example, for 35 patients, request seven ambulances; for 23 patients, request five ambulances; and so forth. After taking several deep breaths (to give yourself time to absorb what you have seen and to try to calm your voice), you might give the following radio report about an intercity bus crash: \u201cThis is a major crash involving a truck and an intercity bus on Highway 233, about 2 miles west of Route 510. There are approximately 35 victims. There are multiple people trapped. Repeat: This is a major crash. I am requesting the fire department, rescue squad, and seven ambulances at this time. Dispatch additional police units to assist.\u201d Follow the protocols of your department when calling for additional resources.\n1. Determine the perimeters for emergency vehicles only and exclude all other vehicles.\n2. Establish a one-way route for emergency traffic to approach the scene and a separate one-way route for emergency traffic to exit the scene. This will prevent roads from becoming blocked for incoming units.\n3. Allow adequate room for emergency vehicles that need to be close to the scene.\n4. Keep vehicles and personnel at a designated staging area nearby, if they are not needed at the scene.",
        "Words of Wisdom 2": "Recent studies show that the failure to provide adequate traffic control at an emergency scene is a common and often fatal error in mass-casualty incidents. Immediately after radioing for additional assistance, you should establish a traffic control plan. Establishing a one-way traffic pattern will help to avoid confusion and congestion at the incident site. This process should take only a few minutes.",
        "Casualty Sorting: Creating Order Out of Chaos": "The sorting of patients into groups according to their need for medical treatment is called triage. Triage is a French word that has come to mean casualty sorting in the emergency medical care field. The purpose of casualty sorting is to determine the order in which patients should be treated based on the severity of their injuries so that the most good can be done for the most people.\n\nIdeally, your casualty-sorting system should be simple and fast, based on the skills and knowledge you already have. Do not worry about making a specific diagnosis before categorizing patients; a casualty-sorting system is meant to provide the basis for a system of rapid, lifesaving actions. A casualty-sorting system focuses your activities in the middle of a chaotic and confusing environment. You must identify and separate patients rapidly, according to the severity of their injuries and their need for treatment.\n\nAvoid spending undue time treating the first or second patient you see. Remember, your job is to get to each patient as quickly as possible, conduct a primary assessment, and assign patients to broad triage categories based on their need for treatment.\n\nYou should not stop during this assessment, except to correct airway and severe bleeding problems quickly.\n\nYour job is to sort (triage) the patients. Other rescuers will provide follow-up treatment.\n\nDifferent communities use many variations of triage systems, and you will need to learn the specific role that you have in your community\u2019s triage plan. Many EMS systems rely on the START triage system because it is simple and easy to remember and implement. The Simple Triage And Rapid Treatment (START) system lets EMRs triage each patient in 60 seconds or less, based on three primary observations: breathing, circulation, and mental status.\n\nThe START triage system is designed to help rescuers find the most seriously injured patients. As more rescue personnel arrive, patients can be triaged again for further evaluation, treatment, stabilization, and transportation. This system also allows EMRs to open blocked airways and stop severe bleeding quickly.",
        "Words of Wisdom 3": "The experience of responding to a mass-casualty incident can be very stressful for all responders. Certain roles, such as triage officer, are especially stressful. When you are triaging patients, use your triage protocols to guide you through this process. You are expected to do your best, but realize that there is no perfect way to handle an overwhelming incident. After a mass-casualty event, it may be helpful for you to talk with your peers, a mentor, a supervisor, or a counselor. Many departments offer an employee assistance program to help employees cope with a wide variety of stressful situations.",
        "Triage Tagging: Telling Others What You Have Found": "Patients are tagged so that other rescuers arriving at the scene can easily recognize their triage level. Patients are tagged using colored surveyor\u2019s tape or colored paper tags, and this is based on the method determined by your local EMS system",
        "The Four Colors of Triage.": "The START triage system consists of four categories of triage, each with its own color code: Priority One (red tag). Immediate care: injuries are life threatening. These patients cannot be stabilized at the scene and need to be transported to an appropriate medical facility as soon as possible. An example of a red tag patient might be a patient who has sustained severe chest trauma, is breathing at a rate of greater than 30 times a minute, and is pale and sweaty.\n\nPriority Two (yellow tag). Urgent care: care can be delayed up to 1 hour. These patients have sustained serious injuries, but they can survive a delay of up to 1 hour in getting to an appropriate medical facility. An example of a yellow tag patient might be a person who is in pain from a deformity to the femur but is responsive to your verbal commands and is not showing signs and symptoms of shock.\n\nPriority Three (green tag).: Delayed care, minor care, or hold (walking wounded): care can be delayed up to 3 hours. These patients are the ones who are able to walk to a designated area away from the immediate area of the incident. They may have isolated upper extremity injuries, cuts, and bruises, but they are responsive and are not showing signs and symptoms of shock.\n\nPriority Four (gray or black tag).: Patient is dead; no care is required. These patients have suffered injuries that are obviously incompatible with life, or they have no pulse or respirations.",
        "The First Step in START: Get Up and Walk": "The first step in START is to ask everyone who can get up and walk to move away from the immediate rescue scene to a designated safe area. If patients can get up and walk, they rarely have life-threatening injuries. These patients are the walking wounded, designated as Priority Three (green tag/delayed care). A patient who reports pain when he or she attempts to walk or move should not be forced to move. Now you can concentrate on the patients who are left in the rescue scene.",
        "The Second Step in START Triage: Begin Where You Stand": "Begin the second step of the START triage system by moving from where you stand. Move in an orderly and systematic manner through the remaining patients, stopping at each patient to provide a quick assessment and tagging. The stop at each patient should never take more than 1 minute. Your job is to find and tag the Priority One patients\u2014those who require immediate attention. Examine these patients, treat life-threatening airway and breathing conditions, tag the patients with a red tag, and move on.",
        "How to Evaluate Patients Using Breathing, Circulation, and Mental Status": "The START triage system is based on the three observations: breathing, circulation, and mental status. Each patient must be evaluated quickly, in a systematic manner, starting with breathing.",
        "Breathing: It All Starts Here.": "If the patient is breathing, you need to determine the breathing rate. Patients with breathing rates of greater than 30 breaths per minute are tagged Priority One or Immediate (red tags). These patients are showing one of the primary signs of shock and need immediate medical care as soon as it is available. If the patient is breathing at a rate of less than 30 breaths per minute, move on to the circulation and mental status observations to complete your 60-second survey. If the patient is not breathing, quickly clear the mouth of any foreign matter. Use the head tilt\u2013chin lift maneuver to open the airway. In a mass-casualty situation, you may have to ignore the usual cervical spine guidelines when you are opening airways during the triage process. This is the only time in emergency medical care when you may not have time to stabilize every injured patient\u2019s spine properly. Open the airway, position the patient to maintain the airway, and\u2014if the patient breathes\u2014tag the patient Priority One, Immediate (red tag). Patients who need help maintaining an open airway are Priority One (red tags). If you are in doubt as to the patient\u2019s ability to breathe, tag the patient as Priority One (red tag). If the patient is not breathing and does not start to breathe with simple airway maneuvers, tag the patient Priority Four, Deceased (gray/black tag).",
        "Circulation: Is Oxygen Getting Around?": "The second part of the triage test is the patient\u2019s circulation. The best field method for checking circulation (to see if the heart is able to circulate blood, adequately) is to check the Carotid Pulse. The carotid pulse is close to the heart. It is large and easily felt in the neck. To check the carotid pulse, place your index and middle fingers on the larynx and slide your fingers into the groove between the larynx and the muscles at the side of the neck. You must keep your fingers there for 5 to 10 seconds to find and measure the pulse rate. If the carotid pulse is weak or irregular, tag the patient Priority One, Immediate (red tag). If the carotid pulse is strong, or a radial pulse is present, move on to the mental status observation, the third step of the triage system. Treat patients with a weak carotid pulse for shock by laying the patient supine. Then try to stop any severe bleeding. Do not spend time controlling the bleeding yourself. Get the patient to assist with controlling the bleeding or ask one of the walking wounded, Priority Three (green tag) patients, to help. These patients are often eager to assist with emergency treatment. If the pulse is absent, tag the patient with a Priority Four, Deceased (gray/black tag).",
        "Mental Status: Open Your Eyes.": "The final part of the triage test is the mental status of the patient. This observation is performed on patients who have adequate breathing and adequate circulation. First, determine whether the patient responds to verbal stimuli. Ask the patient to follow a simple command: \u201cOpen your eyes;\u201d \u201cClose your eyes;\u201d \u201cSqueeze my hand.\u201d Patients who can follow these simple commands and have adequate breathing and adequate circulation are tagged Priority Two, Delayed (yellow tag). According to the AVPU scale, such patients are considered to be alert and responsive to verbal stimuli. A patient who cannot follow this type of simple command is unresponsive to verbal stimuli, according to the AVPU scale. Tag these patients as Priority One, Immediate (red tag).",
        "START Is Just the Beginning": "In every situation involving the sorting of casualties, your goal is to find, stabilize, and move Priority One patients first. The START triage system is designed to help you find the most seriously injured patients. As more rescue personnel arrive at the scene, the patients will be triaged again for further evaluation, treatment, stabilization, and transportation. As more EMS personnel arrive, you should turn over the responsibilities of triage to a person with more training. Each mass-casualty scene should have a person designated as the triage officer. Remember, injured patients do not always remain in the same condition. The process of shock may continue and some conditions will become more serious as time goes by. As time and resources permit, go back and reassess the condition of Priority Two and Priority Three patients to detect changes in their conditions that may require upgrading the patients to Priority One (red tag) attention.",
        "Special Populations": "Patients with life-threatening internal injuries may be quiet patients. Do not think that all quiet patients are stable or uninjured.",
        "Working at a Mass-Casualty Incident": "You may or may not be the first person to arrive at the scene of a mass-casualty incident. If other rescuers are already at the scene when you arrive, be sure to report to the incident commander before going to work. Because many activities are going on at the same time, the incident commander will assign you to an area where your help and skills can best be used. The incident commander, based on training and local protocols, is in charge of the rescue operation. An effective incident command system (ICS) depends on. integrated, agreed-upon protocols and procedures involving fire department, law enforcement, and EMS personnel. An explanation of the NIMS is presented in the next section of this chapter.\n\nIf you are the first on the scene, you will have to make the initial overview, clearly and accurately report the situation to your dispatcher, and conduct the initial START triage. In addition, you most likely will be called on to participate in many other ways during mass-casualty incidents.\n\nAs more highly trained rescue and EMS personnel arrive at the scene, accurately report your findings to the person in charge by using a format similar to that used in the initial arrival report. Note the following information:\nApproximate number of patients\nNumber of patients you have triaged into each of the four levels\nAdditional assistance required\nOther important information\n\nAfter you have reported this information, you may be assigned to provide emergency medical care to patients, to help move patients, or to assist with ambulance or helicopter transportation. You may also be asked to assist with traffic control or to help provide fire protection, depending on your training.",
        "Treatment": "At a mass-casualty incident, remember you are trying to do the most good for the most patients. Do not get sidetracked by spending too much time treating the first patient you encounter.",
        "National Incident Management System": "The National Incident Management System (NIMS) has been developed by the US Department of Homeland Security to provide a comprehensive, consistent, and unified approach to handling emergency incidents. NIMS is designed to effectively and efficiently handle the immediate response mitigation, and long-term recovery of small and massive natural and man-made incidents. Effective implementation of NIMS helps local government agencies work with regional, state, and federal agencies during all phases of a major emergency incident.\n\nNIMS expands on the ICS in your department, which may cover only one type of agency. NIMS is designed to address a unified command structure that includes all types of agencies responding to any type of man-made or natural disaster. To accomplish this, NIMS is flexible and yet contains standardized components.\n\nThe five components of NIMS and ICS are:\n1. Preparedness\n2. Communications and information management\n3. Resource management\n4. Command and management\n5. Ongoing management and maintenance\n\nThese components are illustrated in Figure 21-7. The incident command system is part of the command and management component of NIMS. The incident command system consists of six major features. These are:\n1. Standardization\n2. Command\n3. Planning/organizational structure\n4. Facilities and resources\n5. Communications information management\n6. Professionalism\n\nAs an EMR, your role falls within the command and management component of NIMS. You should understand the function of the ICS and understand your role within the ICS. In large incidents, you may be working with people from other agencies, so you need to understand how the Multiagency Coordination Systems ensure unified operating procedures. You should also understand the function of public information systems in releasing information about an emergency incident. The other components shown in Figure 21-7 are vital parts of NIMS, but your role as an EMR is not as directly related to these functions.\n\nThe federal government requires many agencies to use NIMS, and you may be required to become trained in this system.\n\nDifferent levels of training are offered through traditional and online courses. It is recommended that EMRs be certified in the following courses: ICS-100: Introduction to ICS, or FEMA IS-700: NIMS, An Introduction. Additional information on NIMS is available at the Federal Emergency Management Agency (FEMA) website. Take advantage of training in incident management. It helps you understand and work within the incident management system.",
        "Terrorism Awareness": "Terrorism is the systematic use of violence by a group to intimidate a population or government to achieve a political goal. Terrorism receives considerable public attention and is a high-profile crime. Domestic terrorism is caused by a country\u2019s own citizens. International terrorism is cause by people from another country. The bombing of an abortion clinic by an American citizen is considered a domestic terrorist event. The attacks on the World Trade Center and the Pentagon on September 11, 2001, were international terrorist events. A terrorist event may involve limited property damage with no injuries or it may involve the deaths of many people. The success of terrorist events is measured by the intimidation produced, not just by the value of the property lost or the number of lives lost. Terrorists might use a wide variety of methods to incite terror, including the use of guns, explosives, fire, chemicals, viruses, bacteria, and radiation.\n\nAs you study the agents and methods used by terrorists, realize that the type of events created intentionally by terrorists can also occur accidentally. For example, on April 15, 2013, the Boston Marathon bombings were the result of terrorists intentionally detonating two pressure cooker bombs. This event killed three people and injured an estimated 264 others. Compare that event with the one that occurred 2 days later on April 17, 2013, in West, Texas, at the West Fertilizer Company, where an accidental fire detonated about 30 tons of fertilizer grade ammonium nitrate, resulting in the death of 15 people and injuring more than 260 others.\n\nThe causes of these two events were very different, but the result of both incidents was multiple fatalities and injuries to a large number of people. Both incidents required a cautious approach and evaluation of the scene, a large response of emergency personnel, the triage of a large number of victims, and a carefully executed plan for treatment and transportation of many injured people.\n\nMost agents used by terrorists are many of the same agents that produce hazards for EMRs in everyday accidents and emergencies. A building collapse caused by a natural gas explosion and a building collapse caused by a terrorist attack are both collapsed buildings. They share many of the same hazards and require many of the same safety precautions for rescuers. The accidental release of a chemical causes a HazMat emergency; an intentional release of the same chemical by terrorists becomes a terrorist event. Still, the safety precautions required for rescuers at both events are the same. A radiation leak from a nuclear power plant releases the same type of radiation that would be released by a terrorist. It is important to understand the agents and methods that are used by terrorists and to compare them with the agents that normally exist in communities. Many of the safety precautions used in accidental emergencies are the same precautions needed when dealing with terrorist events.",
        "Weapons of Mass Destruction": "A weapon of mass destruction (WMD) is any agent designed to bring about mass death, casualties, and/or massive damage to property and infrastructure (such as bridges, tunnels, airports, electrical power plants, and seaports). These instruments of death and destruction include explosive, chemical, biologic, and nuclear weapons. To date, the preferred WMD for terrorists has been explosive devices. Terrorist groups have favored tactics that use truck or car bombs or pedestrian suicide bombers. Many previous terrorist attempts to use either chemical or biologic weapons to their full capacity have been unsuccessful. Nonetheless, as an EMR, you should understand the destructive potential of these weapons.",
        "Potential Targets and Risks": "To understand the threat that terrorists pose to people and places, you need to consider the places that terrorists might identify as targets for terrorist activities. Remember, terrorists strive to incite fear to achieve a political or ideological goal, and their motives do not limit their choice of targets. Bridges, tunnels, pipelines, and harbors constitute infrastructure targets. The Washington Monument and the Statute of Liberty are examples of symbolic targets. Housing developments and automobile dealerships have been targeted by ecoterrorists. Computer networks and data systems might be targets for cyberterrorists. Farms and agricultural installations might be targets for terrorists trying to destroy or taint the nation\u2019s food sources. Civilian targets such as schools, government buildings, churches, and shopping centers represent high-visibility targets for terrorists. Taken collectively, a wide variety of places, representing most components of society, might be considered as targets In an open society in which people are largely free to move around as they wish, a person committed to performing a terrorist act can access most of the components of the infrastructure and turn any one of them into a target.\n\nDespite measures to heightened security, a terrorist event can occur at any time. You should always be alert for hazards\u2014those associated with a terrorist event as well as those connected to any other emergency. In any discussion of the risks of terrorist attacks, it is important to consider the number of terror-related deaths compared with other major causes of death.\nTable 21-1 compares the number of deaths from terrorist events with deaths from other common causes. This comparison is not intended to minimize the tragedies of September 11, 2001; rather, it is intended to help you gain some perspective and realize that terrorist events do not occur every day. Although you should be prepared for terrorist events, the majority of the emergency medical calls you answer will be for the other types of events listed in Table 21-1.",
        "Agents and Devices": "A wide variety of agents and devices can be used to incite terror, including explosive devices, incendiary devices, chemical agents, biologic agents, and radiologic agents. You need to understand how these devices are used and what safety precautions you need to take to ensure scene safety for yourself, other rescuers, and bystanders.",
        "Explosives and Incendiary Devices": "Explosives are used to produce a concussion that destroys property and inflicts injury and death. Some explosive devices, also known as incendiary devices, are designed to start fires. Incendiary devices can be as simple as a homemade firebomb or as complex as a highly technical device that may have been stolen from the military. An explosive device can be hand carried or transported in a heavy truck. Often the first indication that an explosive or incendiary device is present is the explosion or fire that results from the deployment of the device. In some parts of the world, suicide terrorists carry explosive devices on their person and set them off to kill themselves and others.",
        "Voices of Experience": "\nWhen the time comes, you must do what you have been trained to do.\nI had just finished my regular 8-hour paramedic shift in Lorain, Ohio. It was 2400 hours, and I was about halfway through my 20-minute drive home, when I heard a distant thud to the south, toward Elyria. When I looked in the direction of the sound, I thought I saw a glow reflecting off the clouds in the distance. The EMS agency I worked for covered both Lorain and Elyria, so I took the next right turn and headed toward the glow.\nThere had been an explosion at the Aztec chemical plant, which was inconveniently located in the middle of a city of about 50,000 residents. This occurred in the days before everyone had cell phones, and I didn\u2019t want to interfere with priority traffic by talking on the radio. One of the most important rules to remember as an emergency medical responder, and one of the most easily forgotten in the excitement of the moment is: Don\u2019t make things worse!\nAs I drove toward the scene, I looked for flags or smoke to check the wind direction. I was in luck; I was upwind. When I got into town, I could hear from the radio traffic that both fire and medical incident command were up and running. When there was a lull in radio traffic, I called dispatch and was directed to report to dispatch at the central station. When I arrived at dispatch, I was told to wait for an assignment with several other off-duty personnel who were already there. After about an hour, we were sent to various schools where evacuation shelters were being set up by the Red Cross. Although the fire department had not been able to identify the chemicals released, there were reports of respiratory distress.\n\nMy partner and I took a squad and reported to one of the designated schools. What we saw on our arrival was amazing. Volunteers from the Red Cross were calmly and efficiently setting up things. They had already designated areas for decontamination, canteen, families, and intake. They had set up coolers, water, chairs, and cots, and they were bringing in food\u2014and the explosion had occurred less than 2 hours before. Most of the volunteers were older adults, and they operated in a calm, friendly, and professional manner.\n\nWe were asked to set up a medical station to evaluate people who weren\u2019t feeling well. The chemical released was eventually reported to be a mild respiratory irritant. The explosion was caused by a worker, who was the only one to die in the blast. By morning, everyone was allowed to go back home.\n\nIt doesn\u2019t matter what caused a mass-casualty incident\u2014accident, terrorism, or criminal violence\u2014the principles remain the same. Emergency medical responders must respond quickly, but more importantly, they must respond wisely, calmly, and efficiently. The greatest service you can perform at a disorganized scene is to create order out of chaos, calm out of calamity. To do so, you must consciously work to control your emotions as well as your physiologic response to stress. Slow down, breathe slowly and deeply, and lower your voice. Tunnel vision is your worst enemy. Force yourself to look around, in all directions and dimensions, and use all of your senses. These skills do not come naturally\u2014to be good in a crisis you must train and retrain, and when the time comes, you must do what you have been trained to do.",
        "WMD Safety Considerations": "\nIn times of increased concern about terrorist activity, travelers and the general public are urged to be alert for bags or luggage left unattended. Be aware of suspicious vehicles and report them to the proper law enforcement officials. If you are called to respond to an explosion, be alert for safety hazards that may have been created by the explosion or by a terrorist. Do not enter any area that may be unsafe until properly trained personnel are able to assess the risks. Be alert for the possibility of a second explosive device that is timed to explode when rescuers are on the scene. Use the same safety skills you developed for other types of emergency situations to keep yourself safe. When dealing with a WMD scene, it is safe to assume you will not be able to enter where the event has occurred\u2014nor do you want to. The best location for staging is upwind and uphill from the incident. Wait for assistance from those who are trained in assessing and managing WMD scenes.",
        "Chemical Agents": "Many different types of chemicals can be used as terrorist weapons. Industrial-process chemicals can be used to intentionally inflict harm on people. For example, chlorine is a gas that is used in many industrial processes and in water purification, but it was also used as a poisonous gas in World War I. Many of the chemical agents that could be used by terrorists are the same chemicals that create HazMat incidents when accidentally released. Chemical agents are liquids or gases that are used to kill or injure and can be divided into the following categories: \nPulmonary (choking) agents\n Metabolic agents\n Insecticides\n Nerve agents\n Blister agents",
        "Pulmonary Agents": "Pulmonary agents are gases that cause immediate harm and injury. Their primary route of entry into the body is through the airway into the lungs. Once these chemicals are inhaled, they damage lung tissue, which causes fluid to escape into the lungs and leads to pulmonary edema. Pulmonary agents cause intense coughing, gasping, shortness of breath, and difficulty breathing. Two common pulmonary agents are chlorine and phosgene. Phosgene gas is produced by burning Freon, which is found in most domestic air conditioners. The odor of this gas is similar to freshly mowed grass. The symptoms of phosgene gas exposure may be delayed for several hours after inhalation of the gas.\nAlthough pulmonary agents could be weapons of choice for terrorists, these chemicals are also present in a variety of domestic and industrial settings and might also be encountered following an accidental release. The safety precautions for an accidental release are the same as the precautions for an intentional release by terrorists: keep a safe distance away until properly trained HazMat personnel can handle the situation.",
        "Metabolic Agents": "Metabolic agents affect the body\u2019s ability to use oxygen at the cellular level. The most common metabolic agents are cyanides. Cyanides are produced in large quantities and used in gold and silver mining, photography, and plastics processing. Cyanide is also produced by the combustion of plastics and textiles, so there is the potential for cyanide poisoning in any house fire. Contact with cyanides produces shortness of breath, flushed skin, rapid heartbeat, seizures, coma, and cardiac arrest. The safety precautions for an accidental release of cyanide are the same as the precautions for an intentional release by terrorists: keep a safe distance away until properly trained HazMat personnel can handle the situation.",
        "Insecticides": "Insecticides are a class of poisonous chemicals that are inhaled or absorbed through the skin. Many insecticides belong to a class of chemicals called organophosphates. Absorption of these chemicals produces the following symptoms: salivation, sweating, lacrimation (excessive tearing), urination, diarrhea, gastric upset, and emesis (vomiting). The acronym for these symptoms is the word SLUDGE. Because insecticides are readily available, they could be used as agents by terrorists. It is important to realize that far more emergency providers have experienced accidental contact with insecticides in routine calls than during terrorist-related events. If you encounter an incident involving an insecticide, keep bystanders far enough away to prevent additional contact with the chemical. If you encounter an emergency involving multiple people with SLUDGE-like symptoms, assume you are dealing with poisoning from this type of chemical and call for assistance from a trained HazMat team. Do not make contact with contaminated patients until they have been through decontamination by trained personnel to prevent the spread of contamination.",
        "Nerve agents": "Nerve agents are among the most deadly chemicals developed. These chemicals can kill large numbers of people with small quantities and cause cardiac arrest within seconds to minutes of exposure. Discovered by scientists in search of a superior pesticide, nerve agents are much stronger organophosphates than those found in insecticides. Nerve agents, like insecticides, block an essential enzyme in the nervous system and cause the SLUDGE-like symptoms listed in Table 21-2. Four of the most commonly mentioned nerve agents are sarin, soman, tabun, and V agent (VX). In an emergency situation, your primary responsibility is to keep yourself, other rescuers, and bystanders from becoming contaminated. A well-trained HazMat team in special protective equipment is needed to remove and decontaminate people exposed to these agents. The DuoDote kit is a nerve agent antidote kit (NAAK) that contains two drugs in a single auto-injector, which counteract the effects of nerve agents.",
        "Blister Agents": "When blister agents come in contact with the skin, they produce burn-like blisters. If the vapors of these agents are inhaled, they cause burns of the respiratory system. Blister agents produce pain, skin irritation, eye irritation, severe shortness of breath, and severe coughing. Blister agents include sulfur mustard and Lewisite. As with other chemical agents, blister agents pose a threat to rescuers. Only well-trained and properly dressed rescuers with self-contained breathing apparatus should approach a scene that might contain these agents.",
        "Characteristics of some chemical agents.": "Chemical agents can be grouped into four main categories: pulmonary, metabolic, nerve, and blister agents. Pulmonary agents such as chlorine or phosgene often smell like bleach or freshly cut grass, irritate the airway, and can cause severe pulmonary edema either immediately or after a delay. Metabolic agents, including hydrogen cyanide and cyanogen chloride, may smell like almonds or be irritating and can kill within minutes by disrupting cellular oxygen use, though some have antidotes. Nerve agents (tabun, sarin, soman, and VX) may have no odor or a faint fruity smell, kill rapidly by blocking essential nervous system functions, and can be absorbed through both vapor and skin contact; their effects are potentially reversible with the correct antidotes. Blister agents such as sulfur mustard and lewisite can smell like garlic or geranium, typically produce burn-like blisters on the skin and airway damage if inhaled, and may take effect immediately or after a delay.",
        "Biologic Agents": "agents are naturally occurring substances that produce diseases. They may be bacteria, such as anthrax or the plague, or viruses, such as smallpox or hemorrhagic fever. Many biologic agents caused epidemics of disease in the past. Some of these agents, such as smallpox, have been wiped out; the last natural case of smallpox was seen in 1977. However, the smallpox organism has been maintained in laboratories and could be used intentionally to infect people. Although biologic agents are hard to disperse to large numbers of people, there is some concern that they could be used as a deadly weapon by terrorists.\n\nIf terrorists intentionally dispersed a biologic agent, the organism would have to come in contact with people in sufficient quantities to produce an illness. These diseases have an incubation period, which is the time between exposure to a disease organism to the time the person begins to show symptoms of the disease. This means that if people were exposed to an infectious organism today, it might be several days before they would show signs of the disease. The first awareness of a biologic terrorist incident would probably come from hospital emergency departments and public health departments. Your role in biologic incidents is to report unusual patterns of illness and keep up to date on current information from your medical director and public health department.\n\nSafety considerations for EMRs include being alert for unusual patterns of diseases with flulike symptoms. You should make every effort to review current information about disease trends from your medical director and public health department. Practice appropriate standard precautions for the signs and symptoms exhibited by every patient. If you have any indications that a call might involve a biologic agent, call for specially trained assistance and wait in a safe location.\n\nYou need to be aware of when you should suspect the use of biologic agents. If the agent is in the form of a powder, such as in the October 2001 attacks involving anthrax mailed in letters, the incident must be handled by HazMat specialists. Patients who have come into direct contact with the agent need to be decontaminated before any EMS contact or treatment is initiated.",
        "Safety": "Remember, hazardous chemical releases and terrorist events often result in large numbers of patients who are experiencing the same symptoms at the same time. For example, the report of multiple patients reporting difficulty breathing in the subway at rush hour, when no hint of smoke is evident, is cause for suspicion. You must resist the urge to rush into scenes when there are multiple victims from an unknown cause.",
        "Common Signs of Acute Radiation Sickness": "Low exposure: Nausea, vomiting, diarrhea\n\nModerate exposure: Superficial burns, hair loss, depletion of the immune system (death of white blood cells), cancer\n\nSevere exposure: Partial- and full-thickness burns, cancer, death",
        "Radiologic Agents": "Ionizing radiation is a kind of energy that is formed by the decay of a naturally occurring or man-made radioactive source. Radiation is used in hospitals, research facilities, and nuclear power plants, and it is also used for military weapons. Exposure to excess amounts of radiation can cause delayed illnesses, such as an increase in the rate of certain cancers. Exposure to large amounts of radiation can cause people to become violently ill within a few hours of exposure and may cause death within hours or days. Radiation is a hidden hazard that is similar to electricity. You cannot see, feel, or detect radiation with any of your normal body senses. Special instruments are needed to detect and measure the amount of radiation that is present\n\nSome concern exists that terrorists could detonate an explosive device containing a small amount of radioactive material (known as a dirty bomb). Such an explosion would spread radioactive material over the area of the explosion, and thereby contaminate anyone in the vicinity. In a situation like this, rescuers would have no means of determining whether radioactivity was present unless special monitors were used to check for radiation. Unless there was a warning issued about such an event, rescuers might not know about the presence of radiation.\n\nAs an EMR, you need to be alert to warnings about incidents involving radiation. If the presence of radiation is suspected, you should stay away from a blast or suspicious site until specially trained teams check for the presence of radiation with special monitoring devices. Know what agencies in your community are equipped to handle such an event.",
        "Words of Wisdom_0": "One way to remember the classes of substances that could be used by terrorists is with the acronym B-NICE:\nB\n\u2003Biologic\nN\n\u2003Nuclear\nI\n\u2003Incendiary devices\nC\n\u2003Chemicals\nE\n\u2003Explosives",
        "Your Response to Terrorist Events": "The threat of terrorist activity is frightening to most people. It is important that all emergency responders have some awareness and knowledge of the various tactics and agents terrorists might use. Emergency response personnel need to develop an all-hazards approach for managing these emergencies. Keep in mind that agents used by terrorists could be the same agents that you are already trained to deal with: explosions, fires, toxic chemicals, hazardous materials, infectious diseases, and radiation. Although you may feel apprehensive about dealing with a terrorist event, remember the same safety rules apply in all emergencies: good scene safety and diligent use of standard precautions.\n\nTo prepare for a terrorist event, master the skills that enable you to be a good EMR. Be prepared and know the limits of your training. Many types of terrorist events require you to stay a certain distance away to avoid contaminating additional people. Teams with special training are required to manage\n\nTerrorist events can affect large numbers of people. Establish an ICS as soon as possible. Know your role in working within the ICS. Treat these incidents as mass-casualty situations. Establish good working relationships with appropriate local, state, and federal agencies.\n\nEMRs have a vital role in working at terrorist events. You can do the most good by following your training and not exceeding the level of skills you have. Always be alert for your safety, the safety of other rescuers, and the safety of patients. Remember, you cannot be an effective rescuer if you become a victim yourself.",
        "Safety_1": "Be alert for a secondary explosive device at a terrorist incident. If you are called to a terrorist incident, be aware of places where a secondary device could be hidden, including abandoned vehicles, trash dumpsters, debris piles, newspaper boxes, mailboxes, and storm sewers.",
        "Words of Wisdom_2": "Terrorism is no longer something that happens \u201csomewhere else,\u201d as the bombing in Oklahoma City and the attacks on the World Trade Center and the Pentagon proved. As an EMR, be aware of the possibility of a terrorist event. Realize that a major incident may be dispatched as a routine call. Your skill in assessing scene safety could be vital in saving lives. Be especially alert for clues that point toward special hazards and take advantage of training offered in your local community.",
        "Prep Kit-Ready for Review": "Because you may be the first trained person on the scene of an incident involving hazardous materials, you must be able to identify the signs of a potential hazardous materials incident and respond appropriately.\n\nDuring a HazMat incident, your top priority is to recognize that a hazard is present and protect yourself and bystanders from exposure and contamination from the hazardous material.\n\nYou should understand the role of an EMR during the first few minutes of a mass-casualty incident.\n\nThe START triage system is a simple triage system that you can use at mass-casualty incidents. It serves to sort patients into groups so that the most serious patients are treated and transported first.\n\nThe National Incident Management System is designed to provide a unified approach to emergency incidents of any size that involve multiple agencies anywhere in the United States. All emergency responders need to have some understanding of this system.\n\nTerrorist attacks, although rare, are a concern for emergency providers. The goal of terrorists is to intimidate a population or government to achieve a goal. Terrorists may use a wide variety of methods to incite terror, including the use of explosives, fire, chemicals, viruses, bacteria, and radiation.\n\nChemical agents are man-made substances that can have devastating effects on living organisms. These agents consist of pulmonary, metabolic, insecticides, nerve, and blister agents.\n\nBiologic agents are organisms that cause disease. They are generally found in nature and can be weaponized to maximize the number of people exposed to the germ.\n\nRadiologic weapons can create a massive amount of destruction. This type of weapon includes radiologic dispersal devices, also known as dirty bombs\n\nEMRs need to consider their safety, the safety of other rescuers, and the safety of bystanders whenever dealing with a terrorist-related event. Your responsibility as an EMR in many of these situations is to identify potential threats, ensure safety, and call for specially trained personnel to deal with these threats.",
        "Vital Vocabulary": "biologic agents: Naturally occurring substances that cause disease. Terrorists may use bacteria, viruses, or toxins to intentionally cause epidemics of disease., blister agents: Chemicals that cause the skin to blister., casualty sorting: The sorting of patients to determine the order in which patients should be treated and transported; also called triage., chemical agents: Compounds that can be used by terrorists to inflict harm., cold zone: The control area that contains the command post and other support functions needed in the incident., decontamination: The process of reducing or preventing the spread of contaminants at a hazardous materials event., dirty bomb: An explosive device using conventional explosives that is designed to spread radioactive material over a wide area., explosives: Substances that release energy in a sudden and uncontrolled manner when detonated., hazardous materials (HazMat): Substances that are toxic, poisonous, radioactive, flammable, or explosive and can cause injury or death with exposure., hot zone: A contaminated area., incendiary devices: Substances or weapons designed to start a fire., incident command system (ICS): A system of people, procedures, and equipment designed to improve emergency response operations at situations of all types and complexities., incubation period: The time between exposure to a disease organism to the time the person begins to show symptoms of the disease., insecticides: Chemicals that are formulated to kill insects but that can intentionally or accidentally cause injury or death to humans when inhaled or absorbed through the skin., mass-casualty incidents: Accidents or situations involving more patients than you can handle with the initial resources available; also known as multiple-casualty incidents., metabolic agents: Substances that are intended to produce injury or death by disrupting the body\u2019s ability to use oxygen and chemical reactions at the cellular level., National Incident Management System (NIMS): A system developed by the US Department of Homeland Security for managing an emergency incident, which may require the response of many different agencies; designed to provide a comprehensive, efficient, and effective management approach from initial response through recovery., nerve agents: Deadly toxic substances that attack the central nervous system., pulmonary agents: Substances that produce respiratory distress or illness., radiation: The electromagnetic energy that is released from a radioactive material or a dirty bomb., START triage: A system of casualty sorting using Simple Triage And Rapid Treatment., terrorism: A systematic use of violence to intimidate or to achieve a political goal., triage: The sorting of patients into groups according to the severity of their injuries; used to determine priorities for medical treatment and transport; also called casualty sorting., warm zone: The control area where personnel and equipment decontamination and hot zone support take place., weapon of mass destruction (WMD): Any agent designed to bring about mass death, casualties, and/or massive damage to property and infrastructure (bridges, tunnels, airports, electrical power plants, and seaports)."
    },
    {
        "Common Units of Measurement": "This section lists common units of measurement used in healthcare, including Millimeters of Mercury (mmHg) for blood pressure, Millimoles per Litre (mmol/L) for blood glucose levels, Milligrams (mg) for medications like ASA and Nitro, Litres per minute (lpm) for oxygen flow rates, Drips per millilitre (gtts/ml) for dripset size, and Drips per minute (gtts/minute) for the number of droplets through the dripset in one minute.",
        "Assisted Ventilations": "This section outlines assisted ventilation rates for adults and children/infants based on specific respiratory issues. For adults, the ventilation rate is 1 breath every 5-6 seconds when respirations are absent but a pulse is present, greater than 30 breaths per minute, less than 10 breaths per minute, or signs of hypoxia or respiratory distress. For children/infants, the rate is 1 breath every 3-5 seconds under similar conditions. Ventilations are timed between or with the patient's own breaths, and OPA/NPA can be used after the first two successful ventilations.",
        "Weight Estimation for Pediatric Patients": "This section provides an age-based weight estimation formula for pediatric patients up to 10 years old: 2 times the age in years plus 8 equals the estimated weight in kilograms. It notes that parent or caregiver estimations are generally more accurate than age-based calculations.",
        "A-T-M-I-S-T A-M-B-O": "This section details the verbal handover process using the mnemonic ATMIST and AMBO. ATMIST includes Age, Time, Mechanism, Injuries, Signs, and Treatment, which are the details to mention during the verbal handover. AMBO covers Allergies, Medication, Background, and Other Information, also to be included in the verbal handover."
    },
    {
        "BC EMALB Examination Guidelines compared to PAC National Occupational Skill Competency Profiles": "This section compares the BC EMALB Examination Guidelines with the Red Cross Emergency Care Manual's PAC NOCP. It outlines differences in guidelines such as the minimum systolic blood pressure to give Nitro (110 mmHg and HR between 50-150 vs. 100 mmHg), Nitro dose frequency (every 3 minutes vs. every 5 minutes), and the use of Glucogel for unresponsive patients (contraindicated if unresponsive vs. administer if local protocols allow). Other differences include burn cooling times (15-20 minutes vs. at least 10 minutes), pulse check duration (up to 45 seconds vs. 60 seconds), and stroke mnemonics (F-A-S-T vs. F-A-S-T with different connotation). The table also highlights that realigning gross deformity is only necessary if circulation is compromised in BC, whereas in PAC NOCP, it is required only if more than 30 minutes to care. Open chest wound treatment differs, with BC using vented-occlusive dressings and PAC NOCP using non-occlusive dressings only. Hypothermic CPR-AED protocols differ, with BC not analyzing or shocking after three shocks and PAC NOCP following AED prompts.",
        "Critical Findings": "This section lists critical findings and their implications/conditions along with corresponding interventions. Key findings include GCS 13 or less indicating decreased LOC, breathing over 30 times/minute suggesting tachypnea, and breathing less than 10 times/minute indicating dyspnea/bradypnea. Hypotension is indicated by adult blood pressure less than 80 mmHg systolic, and hypoglycemia by blood glucose less than 4 mmol/L. Hypoxia/hypoxemia is suggested by oxygen saturation (SpO2) less than 95%, and severe hypothermia by body core temperature below <30\u00b0C. Unresponsive patients are indicated by an APGAR score below 4, and limb-threatening injuries by a pulseless limb. Urgent tachycardia is indicated by an adult pulse rate over 160 bpm, and bradycardia by an adult pulse rate slower than normal but > 60 bpm."
    },
    {
        "National EMS Education Standard Competencies": "Preparatory \nApplies fundamental knowledge of the emergency medical services (EMS) system, safety/well-being of the emergency medical technician (EMT), medical/legal and ethical issues to the provision of emergency care. Therapeutic Communication\nPrinciples of communicating with patients in a manner that achieves a positive relationship\nInterviewing techniques\nAdjusting communication strategies for age, stage of development, patients with special needs, and differing cultures\nVerbal defusing strategies\nFamily presence issues EMS System Communication\nCommunication needed to \nCall for resources\nTransfer care of the patient\nInteract within the team structure\nEMS communication system\nCommunication with other health care professionals\nTeam communication and dynamics Documentation\nRecording patient findings\nPrinciples of medical documentation and report writing Medical Terminology \nUses foundational anatomical and medical terms and abbreviations in written and oral communication with colleagues and other health care professionals",
        "Introduction": "Communication is the transmission of information to another person.\nVerbal\nNonverbal (through body language)\nVerbal communication skills are important.\nEnables you to gather critical information, coordinate with other responders, and interact with other health care professionals Documentation \nPatient\u2019s permanent medical record\nDemonstrates appropriate care was delivered\nHelps others in patient\u2019s future care\nComplete patient records \nGuarantee proper transfer of responsibility \nComply with requirements of health departments and law enforcement agencies \nFulfill your organization\u2019s administrative needs Computer, radio and telephone communications\nLink the EMT to EMS, fire department, and law enforcement\nYou must know:\nWhat your system can and cannot do\nHow to use the system efficiently and effectively",
        "Therapeutic Communication": "Uses various communication techniques and strategies:\nBoth verbal and nonverbal\nEncourages patients to express how they feel\nAchieves a positive relationship with each patient Shannon-Weaver communication model\nSender takes a thought\nEncodes it into a message\nSends the message to the receiver\nReceiver decodes the message\nSends feedback to the sender FIGURE 4-1 Shannon\u2013Weaver communication model. \u00a9 Jones & Bartlett Learning.",
        "Age, Culture, and Personal Experience": "Influences how a person communicates\nBody language and eye contact are greatly affected by culture.\nIn some cultures, expressing emotion is a weakness.\nIn other cultures, it is impolite to look away while speaking. Tone, pace, and volume of language \nReflect mood of the person and perceived importance of the message \nEthnocentrism: considering your own cultural values more important than those of others\nCultural imposition: forcing your values onto others",
        "Nonverbal Communication": "Body language provides more information than words alone. \nEven without exchanging any words, you should be able to tell the mood of your patient. \nFacial expressions, body language, and eye contact are powerful communication tools. \nHelp people understand messages being sent When treating a potentially hostile patient, be aware of your own body language.\nStay calm and try to defuse the situation: \nAssess the safety of the scene. \nDo not assume an aggressive posture. \nMake good eye contact, but do not stare. \nSpeak calmly, confidently, and slowly \nNever threaten the patient, either verbally or physically. Physical factors \nLiteral noise, or sounds in the environment, lighting, distance, or physical obstacles may affect your communication. \nCultural norms often dictate the amount of space, or proximity, between people when communicating. \nGestures, body movements, and attitude toward the patient are critically important.",
        "Verbal Communication": "Asking questions is a fundamental aspect of prehospital care. \nOpen-ended questions require some level of detail.\nUse whenever possible.\nExample: \u201cWhat seems to be bothering you?\u201d Closed-ended questions can be answered in very short responses.\nResponse is sometimes a single word.\nUse if patients cannot provide long answers.\nExample: \u201cAre you having trouble breathing?\u201d",
        "Communication Tools Facilitation": "Pause\nReflection \nEmpathy\nClarification Confrontation\nInterpretation\nExplanation \nSummary",
        "Interviewing Techniques When interviewing a patient, consider using touch to show caring and compassion.": "Use consciously and sparingly.\nAvoid touching the torso, chest, and face. FIGURE 4-3 Using touch conveys a sense of caring and compassion. \u00a9 Jones & Bartlett Learning.",
        "Interviewing Techniques to Avoid Providing false assurance or reassurance": "Giving unsolicited advice \nAsking leading or biased questions \nTalking too much Interrupting \nUsing \u201cwhy\u201d questions \nUsing authoritative language \nSpeaking in professional jargon",
        "Presence of Family, Friends, and Bystanders Friends and family may be valuable during the patient interview process.": "Allow the patient to answer even if well-meaning family members attempt to answer for the individual. \nDo not be afraid to ask others to step aside for a moment.",
        "Golden Rules": "Make and keep eye contact at all times.\nProvide your name and use the patient\u2019s proper name.\nTell the patient the truth.\nUse language the patient can understand.\nBe careful what you say about the patient to others.\nBe aware of your body language. Speak slowly, clearly, and distinctly. \nIf the patient is hard of hearing, face the patient so he or she can read your lips.\nAllow the patient time to answer or respond.\nAct and speak in a calm, confident manner.",
        "Ability to understand and manage your emotions and properly respond to others\u2019 emotions": "Helps with:\nDefusing conflict\nBuilding rapport\nCommunicating effectively\nManaging difficult situations Attributes of emotional intelligence\nSelf-awareness\nSelf-regulation\nMotivation\nEmpathy\nSocial skills Improving emotional intelligence\nAssess how you react to a stressful situation.\nPractice mindfulness.\nFocus attention on the present moment.\nTake responsibility for your actions.\nConsider how your actions will affect others. Behavioral change stairway model\nDeveloped by the FBI to manage hostage situations\nAdapted for crisis management\nEmploy active listening.\nDisplay empathy.\nBuild a rapport.\nExert influence.\nInitiate behavior change.",
        "Communicating With Older Patients": "Identify yourself.\nPresent yourself as competent, confident, and caring. \nDo not assume that an older patient is senile or confused. FIGURE 4-5 You need a great deal of compassion and patience when caring for older patients. Never assume that a patient is senile or confused. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS. You may encounter hostility, irritability, and some confusion. \nDo not assume this is normal behavior.\nApproach an older patient slowly and calmly. \nAllow plenty of time for the patient to respond to your questions. Watch for signs of confusion, anxiety, or impaired hearing or vision. \nThe patient should feel confident that you are in charge and that everything possible is being done for him or her. \nBe patient! Older patients:\nOften do not feel much pain\nMay not be fully aware of important changes in their body systems\nYou must be especially vigilant for objective changes. When possible, give patients time to pack a few personal items before leaving for hospital.\nLocate hearing aids, glasses, and dentures before departure.\nOlder patients are often worried about the safety of their home, valuable items, and pets.",
        "Communicating With Children": "Fear is most obvious and severe in children.\nChildren may be frightened by:\nYour uniform\nThe ambulance\nA crowd of people gathered around them Let a child keep a favorite toy, doll, security blanket.\nIf possible, have a family member or friend nearby.\nIf practical, let the parent or guardian hold the child during evaluation and treatment. Be honest.\nChildren easily see through lies or deception.\nTell the child ahead of time if something will hurt.\nRespect the child\u2019s modesty. Speak in a professional, friendly way.\nMaintain eye contact.\nPosition yourself at the child\u2019s level. FIGURE 4-6 Maintain eye contact with a child to let the child know that you are there to help and that you can be trusted. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS.",
        "Communicating With Hearing-Impaired Patients": "Most have normal intelligence and are not embarrassed by their disability.\nPosition yourself so the patient can see your lips.\nHearing aids\nBe careful that they are not lost during an accident.\nThey may be forgotten if the patient is confused.\nAsk family about use of a hearing aid. Steps to take to efficiently communicate with patients who are hard of hearing:\nHave paper and pen available.\nIf the patient can read lips, face the patient and speak slowly and distinctly.\nNever shout. Steps (cont\u2019d):\nListen carefully, ask short questions, and give short answers.\nLearn some simple sign language. FIGURE 4-7 Learn simple phrases in sign language. Signing requires movement and is best learned by attending a sign language class. A. Sick. B. Hurt. C. Help. A, B, C: \u00a9 Jones & Bartlett Learning.",
        "Communicating With Visually Impaired Patients": "Ask the patient if he or she can see at all.\nVisually impaired patients are not necessarily completely blind.\nExpect the patient to have normal intelligence.\nExplain everything you are doing as you are doing it. Stay in physical contact with the patient as you begin your care.\nIf the patient can walk to ambulance, place his or her hand on your arm.\nTransport mobility aids such as a cane with the patient to the hospital. Guide dogs\nEasily identified by special harnesses \nIf possible, transport dog with patient.\nAlleviates stress for both patient and dog\nOtherwise, arrange for care of the dog. FIGURE 4-8 A guide dog is easily identified by its special harness. Courtesy of the Guide Dog Foundation for the Blind. Photographed by Christopher Appoldt.",
        "Non\u2013English-Speaking Patients": "You must find a way to obtain a medical history.\nFind out if the patient speaks some English.\nUse short, simple questions.\nPoint to parts of the body.\nHave a family member or friend interpret. Consider learning some common phrases in another language that is used in your area. \nPocket cards that show the pronunciation of terms are available. \nUse a smartphone app or website to help you translate.\nRemember to request a translator at the hospital.",
        "Communications where disruption will result in failure of the task at hand": "Shared mental model\nA mental model is the picture an individual has in their head of \u201cwhat\u2019s going on.\u201d\nAll team members must share a mental model.",
        "Mission-Critical Communications": "Shared mental model (cont\u2019d)\nQuestions to answer:\nWhat is the focused priority for the patient?\nWhat is the history of prior care?\nWhat is the patient\u2019s current state?\nWhat is the patent\u2019s immediate needs?",
        "Patient Care Hand-Over": "Effective communication is essential to efficient, effective, and appropriate patient care.\nTransfer of pertinent patient information and responsibility for patient care. Giving the hand-over report\nInitiate eye contact.\nManage the environment.\nMinimize noise, interruptions, and distractions.\nEnsure the ABCs. Provide a structured report.\nSBAR (situation, background, assessment, recap/treatment)\nSBAT (situation, background, assessment, treatment)\nProvide documentation.\nShould include patient\u2019s priority condition, prior care, current state, and immediate needs",
        "Receiving the Hand-Over Report Maintain eye contact.": "Manage the environment.\nEnsure understanding.\nSummarize.\nGather supplementary patient documentation.",
        "Written Communications and Documentation": "Patient care report (PCR)\nAlso known as prehospital care report\nLegal document\nRecords all care from dispatch to hospital arrival\nThere are two types of PCRs: written and electronic. The PCR serves six functions:\nContinuity of care \nCompliance and legal documentation\nAdministrative information\nReimbursement\nEducation\nData collection for continuous quality improvement and research",
        "Information Collected on a PCR": "Information collected on the PCR: \nChief complaint \nMechanism of injury and illness\nLevel of consciousness or mental status\nVital signs\nInitial and ongoing assessment\nPatient demographics\nTransport information",
        "Administrative information gathered from a PCR includes when:": "The incident was reported \nThe EMS unit was notified \nThe EMS unit arrived at the scene \nThe EMS unit left the scene \nThe EMS unit arrived at the receiving facility \nPatient care was transferred \nThe unit is back in service",
        "Types of Forms Traditional written form with:": "Checkboxes\nNarrative section\nComputerized version FIGURE 4-12 An electronic PCR (ePCR). Courtesy of the Utah Department of Health.",
        "Standardized Narrative Formats": "CHART method\nChief complaint or chief concern\nHistory\nAssessments\nTreatment (Rx)\nTransport SOAP\nSubjective\nObjective\nAssessment \nPlan All narrative sections should contain:\nTime of events\nAssessment findings\nEmergency medical care provided\nChanges in the patient after treatment\nObservations at the scene\nFinal patient disposition\nRefusal of care\nStaff person who continued care",
        "Health Information Exchanges": "Improves sharing of data between EMS and other health care providers\nAllows\nAccess to relevant health data\nUnnecessary duplication of effort in data entry\nAccess to patient outcomes related to hospital care\nContribution and access to electronic health information on a regular basis and during a disaster",
        "Most HIEs follow the SAFR framework.": "Search\nHospital and other records\nAlert\nNotifies hospitals of incoming patients\nFile\nIncorporates data directly into the patient\u2019s health records\nReconcile\nOutcomes and other data provided to EMS agencies for billing and QI",
        "If you leave something out or record it incorrectly, do not try to cover it up.": "Falsification:\nResults in poor patient care\nMay result in suspension and/or legal action FIGURE 4-13 If you make a mistake on a handwritten report, the proper way to correct it is to draw a single horizontal line through the error, initial it, and write the correct information next to it. \u00a9 Jones & Bartlett Learning.",
        "Reporting Errors": "If you discover an error as you are writing your report, draw a single horizontal line through the error, initial it, and write the correct information next to it.\nIf an error is discovered after you submit your report, follow the same process.",
        "Documenting Refusal of Care A common source of lawsuits": "Thorough documentation is crucial.\nDocument any assessment findings and emergency medical care given.\nHave patient sign a refusal of care form.\nHave family member, police officer, or bystander also sign as witness.\nComplete the PCR.",
        "Special Reporting Situations Depending on local requirements:": "Gunshot wounds\nDog bites\nSome infectious diseases\nSuspected physical or sexual abuse\nMultiple-casualty incident (MCI)",
        "Communications Systems and Equipment Radio and telephone communications link you and your team with other members of the EMS, fire, and law enforcement communities.": "Help the entire team work together more effectively \nProvide an important layer of safety and protection",
        "Base Station Radios Contains a transmitter and a receiver in a fixed place": "Two-way radio consists of a transmitter and a receiver.\nA dedicated line, also known as a hotline, is used for specific point-to-point contact.",
        "Mobile and Portable Radios": "Mobile radio is installed in a vehicle.\nUsed to communicate with:\nDispatcher\nMedical control\nAmbulances often have more than one. FIGURE 4-15 Some ambulances have more than one mobile radio to allow communications with hospitals, mutual aid jurisdictions, and other agencies. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS. Portable radios are hand-held devices.\nEssential at the scene of an MCI\nHelpful when away from the ambulance to communicate with:\nDispatch\nAnother unit\nMedical control",
        "Repeater-Based Systems": "A repeater is a special base station radio.\nReceives messages and signals on one frequency\nAutomatically retransmits them on a second frequency\nAllows two mobile or portable units that cannot reach each other directly to communicate using its greater power and antenna FIGURE 4-17 A message is sent from the control center to the transmitter by a landline. The radio carrier wave is picked up by the repeater for rebroadcast to outlying units. Return radio traffic is picked up by the repeater and rebroadcast to the control center. \u00a9 Jones & Bartlett Learning.",
        "Digital Equipment Telemetry allows electronic signals to be converted into coded, audible signals.": "Signals can be transmitted by radio or telephone to a receiver with a decoder at the hospital. \nData from cardiac monitors can be transmitted via Bluetooth-enabled mobile devices.",
        "Cellular/Satellite Telephones EMTs often communicate with receiving facilities by cellular telephone.": "Simply low-power portable radios\nSatellite phones (satphones) are another option.\nA scanner is a radio receiver that scans across several frequencies.\nConversations can be easily overheard.",
        "Other Communications Equipment": "Ambulances usually have an external public address system.\nEMS systems may use a variety of two-way radio hardware.\nSimplex is push to talk, release to listen.\nDuplex is simultaneous talk\u2013listen. \nMultiplex utilizes two or more frequencies \nMED channels are reserved for EMS use. Trunking systems assign many frequencies.\nAn interoperable communications system allows all of the agencies involved to share valuable information in real time. \nMobile data terminals inside ambulance \nReceive data directly from dispatch center\nAllow for expanded communication capabilities (eg, maps)",
        "Radio Communications The Federal Communications Commission (FCC) regulates all radio operations in the United States": "Allocates specific radio frequencies \nLicenses call signs \nEstablishes licensing standards and operating specifications \nEstablishes limitations for transmitter output\nMonitors radio operations",
        "Responding to the Scene": "The dispatcher\nReceives and determines the relative importance of the 9-1-1 call\nAssigns appropriate EMS response unit(s) FIGURE 4-19 You will be assigned to a call by the dispatcher. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS. The dispatcher (cont\u2019d)\nSelects, dispatches, and directs the appropriate EMS response unit(s)\nCoordinates with other public safety services\nProvides emergency medical instructions to the telephone caller EMTs report any problems that took place during a run to the dispatcher.\nEMTs inform the dispatcher upon arrival at the scene. FIGURE 4-20 The patient report should be given in an objective, accurate, and professional manner. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS.",
        "Communicating With Medical Control and Hospitals": "The principal reason for radio communication is to facilitate communication between you and medical control. \nMedical control may be located at the receiving hospital, at another facility, or sometimes even in another city or state. Consulting with medical control serves several purposes: \nNotifies the hospital of an incoming patient \nProvides an opportunity to request advice or orders from medical control \nAdvises the hospital of special situations",
        "Giving a Patient Report": "The report commonly includes the following 10 elements: \nYour unit identification and level of services \nAny special \u201calert\u201d indicated by the patient\u2019s condition\nThe receiving hospital and your estimated time of arrival (ETA) \nThe patient\u2019s age and gender \nThe patient\u2019s chief complaint The report commonly includes the following 10 elements (cont\u2019d): \nA brief history of the patient's problem\nA brief report of physical findings \nA brief summary of the care given \nA brief description of the patient\u2019s response to treatment\nAny questions or orders from the receiving facility",
        "The Role of Medical Control": "Medical control is either off-line (indirect) or online (direct). \nYou may need to call medical control for permission to:\nAdminister certain treatments. \nDetermine the transport destination of patients. \nStop treatment and/or not transport a patient. In most areas, medical control is provided by the physicians working at the receiving hospital. \nMany variations have developed across the country. \nFreestanding center\nIndividual physician",
        "Calling Medical Control": "There are a number of ways to control access on ambulance-to-hospital channels. \nThe dispatcher monitors and assigns appropriate, clear medical control channels.\nCentralized medical emergency dispatch or resource coordination centers Be precise and deliver important information. \nNever use codes unless directed to do so by local protocol. FIGURE 4-21 Medical control must be readily available on the radio or telephone at the hospital. \u00a9 Andrei Malov/Dreamstime.com. Repeat orders back word for word and then receive confirmation.\nDo not blindly follow an order that does not make sense to you.",
        "Information Regarding Special Situations": "You may initiate communication with hospitals to advise them of an extraordinary call or situation.\nExample special situations:\nHazardous materials situations\nRescues in progress \nMultiple-casualty incidents Keep several points in mind:\nThe earlier the notification, the better.\nProvide an estimate of the number of patients.\nIdentify any special needs. \nFollow your system\u2019s plan.",
        "Like other EMS equipment, radio equipment must be serviced.": "At the beginning of your shift, check the radio equipment.\nRadio equipment may fail during a run.\nFollow your backup plan. Maintenance of Radio Equipment"
    },
    {
        "National EMS Education Standard Competencies": "EMS Operations\nKnowledge of operational roles and responsibilities to ensure patient, public, and personnel safety.\nIncident Management\nEstablish and work within the incident management system. Multiple-Casualty Incidents\nTriage principles\nResource management\nTriage\nPerforming\nRetriage\nDestination decisions\nPosttraumatic and cumulative stress Hazardous Materials Awareness\nRisks and responsibilities of operating in a cold zone at a hazardous material or other special incident.",
        "Introduction": "Disasters and mass-casualty incidents (MCIs) can be overwhelming.\nThree or more patients\nLack of resources\nIncident command system (ICS)\nMakes it possible to do the greatest good for the greatest number National Incident Management System (NIMS)\nPromotes efficient coordination of emergency incidents at the regional, state, and national levels",
        "National Incident Management System": "Implemented in 2004\nProvides a framework to enable federal, state, and local governments to work together\nIncludes private-sector and nongovernmental organizations Organizational structure must be flexible enough to be rapidly adaptable.\nProvides standardization in:\nTerminology\nResource classification\nPersonnel training\nCertification Major NIMS components\nCommunications and information management\nResource management\nCommand and management",
        "Incident Command System": "Sometimes referred to as the incident management system\nThe purpose of the ICS is:\nEnsure responder and public safety\nAchieve incident management goals\nEnsure the efficient use of resources Controls duplication of effort and freelancing\nLimits the span of control\nOne supervisor for three to seven workers\nOrganizational levels include sections, branches, divisions, and groups. FIGURE 40-1 The ICS organizational structure may include sections, branches, divisions, and groups. \u00a9 Jones & Bartlett Learning. Roles and responsibilities\nCommand\nFinance\nLogistics\nOperations\nPlanning\nCommand staff Command\nIncident commander (IC) is in charge of the overall incident.\nIt is important to know who the IC is, how to communicate with the IC, and where the command post is located. \nAn IC may turn over command to someone with more experience in a critical area. Finance\nResponsible for documenting all expenditures at an incident for reimbursement\nLogistics\nResponsible for communications equipment, facilities, food and water, fuel, lighting, and medical equipment/supplies Operations\nAt a very large or complex incident, responsible for managing the tactical operations usually handled by the IC\nSupervises the people working at the scene\nPlanning\nSolves problems as they arise\nDevelops an incident action plan Command staff\nThe safety officer monitors the scene for conditions or operations that may present a hazard.\nThe public information officer (PIO) provides the media with clear and understandable information.\nThe liaison officer relays information and concerns among command, the general staff, and other agencies.",
        "Communications and Information Management Communication has historically been the weak point at most major incidents.": "It is recommended that communications be integrated.\nAll agencies should be able to communicate quickly and effortlessly via radios.\nCommunications allow for accountability and instant communication.",
        "Mobilization and Deployment": "Check in with the incident commander when you arrive.\nReport to your supervisor for an initial briefing.\nRecord keeping allows for tracking of time spent on the actual incident for reimbursement purposes. Accountability means keeping your supervisor advised of your location, actions, and completed tasks.\nOnce the incident has been stabilized, the IC will determine which resources are needed and when to begin demobilization.",
        "Preparedness": "Involves the decisions made and basic planning done before an incident occurs\nInvolves decisions and planning about the most likely natural disasters for the area\nYour EMS agency should have written disaster plans that you are regularly trained to carry out.",
        "Scene size-up": "Make an initial assessment and some preliminary decisions.\nDriven by three basic questions:\nWhat do I have?\nWhat do I need?\nWhat do I need to do?",
        "EMS Response Within the Incident Command System": "FIGURE 40-3 This mobile emergency room is staffed by\nEMTs, paramedics, and physicians who are able to provide advanced life support to multiple patients simultaneously on the scene of a mass-casualty incident. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS.",
        "Establishing command": "Command should be established by the most senior official.\nNotification to other responders should go out.\nNecessary resources should be requested.\nCommand must be established early.",
        "Communications": "If possible, use face-to-face communications to limit radio traffic.\nIf you communicate via radio, do not use 10-codes or signals.\nEquipment must be reliable, durable, and field-tested.\nBe sure there are backups in place.",
        "The Medical Branch of Incident Command": "Medical incident command is also known as the medical (or EMS) branch of the ICS.\nPrimary roles of triage, treatment, and transport of injured people FIGURE 40-4 Components of the medical branch within the incident command system. \u00a9 Jones & Bartlett Learning. Triage supervisor\nIn charge of counting and prioritizing patients\nEnsures that every patient receives initial assessment of his or her condition\nDo not begin treatment until all patients are triaged. Treatment supervisor\nLocates and sets up the treatment area with a tier for each priority of patient\nEnsures that secondary triage is performed and that adequate patient care is given\nAssists with moving patients to the transportation area Transportation supervisor\nCoordinates the transportation and distribution of patients to appropriate receiving hospitals\nDocuments and tracks the number of transport vehicles, patients transported, and the facility destination Staging supervisor\nShould be assigned when scenes require a multivehicle or multiagency response\nEmergency vehicles must have permission to enter the scene and only drive in the directed area. \nThe staging area should be established away from the scene. Physicians on scene\nMake difficult triage decisions.\nProvide secondary triage decisions in the treatment area.\nProvide on-scene medical direction for EMTs.\nProvide care in the treatment sector as appropriate. Rehabilitation supervisor\nEstablishes an area that provides protection from the elements and situation\nRehabilitation is where a responder\u2019s needs for rest, fluids, food, and protection from the elements are met.\nMonitors responders for signs of stress Extrication and special rescue\nDetermines the type of equipment and resources needed for the situation\nUsually function under the EMS branch of the ICS Morgue supervisor\nWorks with area medical examiners, coroners, disaster mortuary assistance teams, and law enforcement agencies to coordinate removal of bodies and body parts\nThe morgue area should be out of view of the living patients and other responders.",
        "Mass-Casualty Incidents": "A mass-casualty incident (MCI):\nInvolves three or more patients\nPlaces great demand on the EMS system\nHas the potential to produce multiple casualties All systems have different protocols for when to declare an MCI and initiate the ICS.\nYou and your team cannot treat and transport all injured patients at the same time.\nNever leave the scene with patients if there are still other patients who are sick or wounded. If there are multiple patients and not enough resources to handle them without abandoning victims, you should:\nDeclare an MCI.\nRequest additional resources.\nInitiate the ICS and triage procedures.",
        "\u201cTriage\u201d means \u201cto sort\u201d patients based on the severity of their injuries.": "Assessment is brief and patient condition categories are basic.\nPrimary triage is done in the field.\nSecondary triage is done as patients are brought to the treatment area. Four common categories give the order of treatment and transport.\nImmediate (red)\nDelayed (yellow)\nMinor or minimal (green; hold)\nExpectant (black; likely to die or dead) Tagging patients early assists in tracking them and can help keep an accurate record of their condition.\nTags should be weatherproof, easily read, and color-coded. FIGURE 40-10 Triage tags (from left to right). A. Waterproof triage tape. B. Triage tag: back. C. Triage tag: front. \u00a9 Jones & Bartlett Learning. START triage\nSimple Triage And Rapid Treatment\nFirst step is to call out to patients and direct them to an easily identifiable landmark.\nInjured persons are the walking wounded.\nSecond step is directed toward nonwalking patients. \nAssess respiratory rate, hemodynamic status, and neurologic status. JumpSTART triage for pediatric patients\nIntended for use in children younger than 8 years or who appear to weigh less than 100 lb\nBegin by identifying the walking wounded.\nSeveral differences within the respiratory status assessment compared with START\nAssess the approximate rate of respirations, hemodynamic status, and neurologic status. Triage special considerations\nPatients who are hysterical and disruptive to rescue efforts may need to be handled as an immediate priority.\nA responder who becomes sick or injured during the rescue effort should be handled as an immediate priority.\nIdentify patients as contaminated or decontaminated in hazmat incidents. Destination decisions\nAll patients triaged as immediate (red) or delayed (yellow) should be transported by ground or air ambulance.\nIn large situations, a bus may transport the walking wounded.\nImmediate-priority patients should be transported two at a time until all are transported from the site. Destination decisions (cont\u2019d)\nThen patients in the delayed category can be transported two or three at a time.\nFinally, the slightly injured are transported.\nExpectant patients who are still alive would receive treatment and transport last.\nDead victims are handled or transported according to the SOP for the area.",
        "Disaster Management": "A disaster is a widespread event.\nDisrupts the functions and resources of the community\nThreatens lives and properties\nMany disasters may not involve personal injuries, but many disasters (floods, fires, hurricanes) result in widespread injuries. Your role is to respond when requested and report to the IC for assigned tasks.\nA casualty collection area may be established in a disaster with an overwhelming number of casualties.\nCoordinated through the ICS in the same way as all other branches and areas of the operation",
        "Introduction to Hazardous Materials": "When you arrive at a possible hazmat incident, first step back and assess the situation.\nRushing into unsafe scenes can be catastrophic. \nIf overcome, you will be unable to assist patients. According the HAZWOPER, first responders at the awareness level should have sufficient training or experience to demonstrate the following competencies:\nAn understanding of what hazardous substances are and the risks associated with them\nAn understanding of the potential outcomes of an incident Areas of training or experience (cont\u2019d):\nThe ability to recognize the presence of hazardous substances\nThe ability to identify the hazardous substances, if possible\nAn understanding of the role of the first responder awareness individual\nThe ability to determine the need for additional resources and to notify the communication center",
        "Recognizing a Hazardous Material": "A hazardous material poses an unreasonable risk of damage or injury if it is not properly controlled during handling, storage, manufacture, processing, packing, use and disposal, and transportation.\nTake time to look at the whole scene.\nIdentify critical visual indicators. Hazardous materials may be involved in any of the following situations:\nTruck or train crash in which a substance is leaking from a tank truck or tank car\nLeak, fire, or other emergency at an industrial plant, refinery, or other complex\nLeak or rupture of an underground natural gas pipe Hazardous materials may be involved in (cont\u2019d):\nDeterioration of underground fuel tanks and seepage of oil or gasoline into the ground\nBuildup of methane or other by-products of waste decomposition in sewers\nMotor vehicle crash resulting in a ruptured gas tank FIGURE 40-12 Two examples of hazardous materials incidents. A. Burning container of flammable liquid. B. Crashed tanker truck. A: Courtesy of Rob L. Jackson/US Marines; B: Courtesy of George Roarty/Virginia Department of Emergency Management. Occupancy and location\nA wide variety of chemicals are stored in locations such as:\nWarehouses\nHospitals and laboratories\nIndustrial complexes\nResidential garages\nBowling alleys\nHome improvement and garden centers\nRestaurants Senses\nThe senses that can be safely used are those of sight and sound.\nUsing any of your senses that bring you in proximity to the chemical should be done with caution or avoided.\nClues that are seen or heard from a distance may enable you to take precautionary steps.",
        "A container is any vessel or receptacle that holds a material.": "Often the container type, size, and material of construction provide important clues about the nature of the substance inside.\nTwo categories: bulk and nonbulk Container volume\nBulk storage containers are found in buildings that rely on and need to store large quantities of a particular chemical.\nThese containers are often surrounded by a secondary containment system to help control an accidental release.\nLarge-volume horizontal tanks are also common. Container volume (cont\u2019d)\nTotes have capacities ranging from 119 gallons to 703 gallons.\nContain any type of chemical, including flammable liquids, corrosives, food-grade liquids, or oxidizers\nNo secondary containment system FIGURE 40-15 A tote is a commonly encountered bulk\nstorage vessel. Courtesy of Tank Service, Inc. Container volume (cont\u2019d)\nIntermodal tanks are both shipping and storage vessels.\nHold between 5,000 and 6,000 gallons\nCan be pressurized or nonpressurized FIGURE 40-16 An intermodal tank. Courtesy of UBH International Ltd. Nonbulk storage vessels\nHold commonly used commercial and industrial chemicals\nDrums are easily recognizable, barrel-like containers.\nGenerally, the nature of the chemical dictates the construction of the drum. Nonbulk storage vessels (cont\u2019d)\nBags are commonly used to store solids and powders.\nMay be constructed of plastic, paper, or plastic-lined paper\nPesticide bags must be labeled with specific information. Nonbulk storage vessels (cont\u2019d)\nCarboys transport and store corrosives and other types of chemicals.\nGlass, plastic, or steel container that holds 5 to 15 gallons of product\nOften placed in a protective wood, foam, fiberglass, or steel box FIGURE 40-18 A carboy is used to transport and store\ncorrosive chemicals. Courtesy of EMD Chemicals, Inc. Nonbulk storage vessels (cont\u2019d)\nUninsulated compressed gas cylinders are used to store substances such as nitrogen, argon, helium, and oxygen.",
        "Department of Transportation Marking System": "Labels, placards, and other markings are used on buildings, packages, boxes, and containers.\nMarking systems indicate the presence of a hazardous material from a safe distance and provide clues about the substance. FIGURE 40-19 The Department of Transportation uses labels, placards, and markings (such as these found in the Emergency Response Guidebook) to give a general idea of the hazard inside a particular container or cargo tank. Courtesy of the US Department of Transportation. Placards are diamond-shaped indicators.\nPlaced on four sides of transport vehicles\nLabels are smaller versions of placards.\nPlaced on four sides of individual boxes and smaller packages FIGURE 40-20 A placard is a large diamond-shaped indicator that is placed on all sides of transport vehicles that carry hazardous materials. \u00a9 Mark Winfrey/Shutterstock.",
        "Other Considerations The DOT system does not require that all chemical shipments be marked.": "In most cases, the package or cargo tank must contain a certain amount of hazardous material before a placard is required.\nSome chemicals are so hazardous that shipping any amount requires the use of labels or placards.",
        "References": "The Emergency Response Guidebook\nOffers a certain amount of guidance for responders operating at a hazmat incident\nProvides information on approximately 4,000 chemicals FIGURE 40-22 The Emergency Response Guidebook is a reference used as a base for your initial actions at a hazardous materials incident. Courtesy of the US Department of Transportation. Material safety data sheets (MSDS)\nCommon source of information about a particular chemical\nProvides basic information about:\nThe chemical makeup of a substance\nThe potential hazards it presents\nAppropriate first aid in the event of an exposure\nOther pertinent data for safe handling Shipping papers\nRequired whenever materials are transported from one place to another\nInclude names and addresses of the shipper and the receiver, identify the material being shipped, and specify the quantity and weight of each part of the shipment Chemical Transportation Emergency Center (CHEMTREC)\nCHEMTREC is operated by the American Chemistry Council. \nServes as an invaluable technical information resource for first responders of all disciplines who are called upon to respond to chemical incidents",
        "Despite the availability of resources, identification may still be difficult.": "Presence of the following may help:\nVisible cloud or strange-looking smoke from the escaping substance\nLeak or spill from a tank, container, truck, or railroad car\nUnusual, strong, noxious, harsh odor in the area If any signs suggest that a hazmat incident has occurred, stop at a safe distance and park upwind or uphill.\nCall for the hazmat team, try to rapidly assess the situation, and try to provide as much information as possible.\nDo not reenter the scene and do not leave the area until you have been cleared.\nAvoid all contact with the material.",
        "Hazmat Scene Operations": "Use the ambulance\u2019s public address system.\nAlert individuals near the scene and direct them to move.\nEstablish control zones.\nSecuring access helps ensure that no one will accidentally enter the contaminated area. Establish control zones (cont\u2019d)\nYou should be prepared to expand or contract the control zones if necessary. FIGURE 40-25 Control zones spread outward from the center of a hazardous materials incident. \u00a9 Jones & Bartlett Learning. Hot zone\nArea immediately surrounding the release\nMost contaminated area\nAll personnel must be decontaminated when they leave the hot zone. FIGURE 40-27 The decontamination zone is where firefighters\u2019 and hazmat team members\u2019 outer protective gear is rinsed and washed before removal. Courtesy of Airman 1st Class Scherrie Gates/US Air Force. Warm zone\nWhere personnel and equipment transition into and out of the hot zone\nContains control points for access to the hot zone and the decontamination area\nDecontamination is the process of removing or neutralizing and properly disposing of hazardous materials. Cold zone\nSafe area where personnel do not need to wear any special protective clothing for safe operation\nIncludes personnel staging, the command post, EMS providers, and the area for medical monitoring, support, and/or treatment after decontamination Role of the EMT\nYour job is to report to a designated area outside of the hot and warm zones and provide:\nTriage\nTreatment\nTransport\nRehabilitation",
        "Classification of Hazardous Materials": "NFPA 704, Hazardous Materials Classification standard classifies hazardous materials according to:\nHealth hazard or toxicity levels\nFire hazard\nChemical reactive hazard\nSpecial hazards Toxicity levels\nMeasures the health risk that a substance poses to someone who comes into contact with it\nThe higher the number, the greater the toxicity.",
        "Personal Protective Equipment Level": "PPE levels indicate the amount and type of protective gear that you need to prevent injury from a substance.\nLevel A\nMost hazardous\nRequires fully encapsulated, chemical-resistant protective clothing that provides full body protection, as well as SCBA and special, sealed equipment Level B\nRequires nonencapsulated protective clothing or clothing that is designed to protect against a particular hazard\nRequires breathing devices that contain their own air supply, such as SCBA, and eye protection Level C\nRequires the use of nonpermeable clothing and eye protection\nFace masks that filter all inhaled outside air\nLevel D\nRequires a work uniform, such as coveralls, that affords minimal protection\nAll levels require the use of gloves. FIGURE 40-28 Four levels of protection. A. Level A protection. B. Level B protection. C. Level C protection. D. Level D protection. A, B: \u00a9 Jones & Bartlett Learning. Photographed by Glen E. Ellman. C: Courtesy of The DuPont Company. \nD: \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS.",
        "Caring for Patients": "It is practical only to provide the simplest assessment and essential care in the hazard zone and the decontamination area because of :\nDangers\nTime constraints\nBulky protective gear Your care of patients must address the following two issues:\nAny trauma that has resulted from other related mechanisms, such as vehicle collision, fire, or explosion\nThe injury and harm that have resulted from exposure to the toxic hazardous substance Most serious injuries and deaths from hazardous materials result from airway and breathing problems.\nIn some cases, the hazmat team may find patients who need immediate treatment before the decontamination area has been set up. You will need to increase the amount of protective clothing you wear, including:\nSCBA\nTwo pairs of gloves\nGoggles or a face shield\nA protective coat\nRespiratory protection\nA disposable, fluid-impervious apron"
    },
    {
        "National EMS Education Standard Competencies Applies fundamental knowledge of patient safety to the provision of emergency care.": "Applies fundamental knowledge of transferring patient care; how to interact within the team structure; and team communication and dynamics.",
        "Introduction You are a critical member of the emergency health care team.": "A key goal of EMS Agenda 2050 is EMS systems that are inherently safe. \nMinimize exposure to injury, infections, illness, or stress.\nCulture of safety\nJust culture",
        "An Era of Team Health Care Community paramedicine and mobile integrated healthcare (MIH) teams may be the best examples of the team concept of continuum of care.": "The structure and effectiveness of emergency health care teams differs from system to system.",
        "Types of Teams": "Regular teams\nEMTs consistently interact with the same partner or team. \nTemporary teams\nEMTs work with providers with whom they do not regularly interact or may not even know. Special teams\nFire team\nRescue team\nHazardous materials (hazmat) team\nTactical EMS team\nSpecial event EMS team\nEMS bike team\nIn-hospital patient care technicians\nMIH technicians",
        "Groups Versus Teams": "A group consists of individual health care providers working independently to help the patient.\nTriage\nTreatment\nTransport A team consists of a group of health care providers who are assigned specific roles and are working interdependently in a coordinated manner under a designated leader. Five essential elements of a group\nA common goal\nAn image of themselves as a \u201cgroup\u201d\nA sense of continuity of the group\nA set of shared values\nDifferent roles within the group",
        "Dependent, Independent, and Interdependent Groups Dependent groups": "Each individual is told what to do, and often how to do it, by his or her supervisor or group leader.\nIndependent groups\nEach individual is responsible for his or her own area. \nInterdependent groups\nEveryone works together with shared responsibilities, accountability, and a common goal.",
        "Effective Team Performance": "A shared goal\nClear roles and responsibilities\nDiverse and competent skill sets\nEffective collaboration and communication\nSupportive and coordinated leadership Communication and team dynamics fostered from crew resource management and team situational awareness\nCRM recommends the use of the PACE mnemonic:\nProbe\nAlert\nChallenge\nEmergency",
        "Transfer of Patient Care Transfers introduce the possibility of patient care errors.": "General guidelines for a smooth transfer:\nUninterrupted critical care\nMinimal interference\nRespectful interaction\nCommon priorities\nCommon language or system",
        "BLS and ALS Providers Working Together BLS and ALS care cannot exist without each other.": "BLS efforts must continue throughout the continuum of care.\nWhat may be a \u201cparamedic only\u201d skill in your EMS system may be common for an EMT to perform in another.",
        "Assisting with ALS Skills Assisting follows a four-step process:": "Patient preparation\nEquipment\nPerforming the procedure\nContinuing care",
        "Critical Thinking and Decision Making in EMS": "Effective decisions are based on:\nSound, up-to-date knowledge\nInformation provided by the patient\nThe patient\u2019s history\nPhysical examination Stages of the decision-making process\nPrearrival\nArrival\nDuring the call\nAfter the call Decision traps\nBias\nAnchoring\nOverconfidence",
        "Troubleshooting Team Conflicts The patient comes first.": "Do not engage.\nKeep your cool.\nSeparate the person from the issue.\nChoose your battles."
    },
    {
        "National EMS Education Standard Competencies EMS Operations": "Knowledge of operational roles and responsibilities to ensure patient, public, and personnel safety.\nVehicle Extrication\nSafe vehicle extrication\nUse of simple hand tools",
        "Introduction You will usually not be responsible for rescue and extrication.": "Rescue involves many different processes and environments.\nRequires training beyond the EMT level",
        "Safety Extrication requires mental and physical preparation.": "Priority is to provide patient care.\nConsider the safety of yourself and team first.\nEquipment and gear should be appropriate to anticipated hazards.",
        "Can become hazards after a collision": "Shock-absorbing bumpers may be \u201cloaded\u201d and can release and injure you.\nApproach vehicles from the side. \nManufacturers are required to install airbags in all new cars.\nAirbags fill with a nonharmful gas on impact and quickly deflate.",
        "Airbags are located in the steering wheel and the dash in front of the passenger.": "Side-impact airbags may be located in the doors or seats.\nAirbags should be deployed and deflated by the time you arrive.\nNondeployed airbags may spontaneously inflate while you provide patient care.",
        "Vehicle Safety Systems": "Haze inside vehicles in which the airbags have deployed is caused by cornstarch or talc. \nUse protective gear, including eye protection, to reduce the risk of eye or lung irritation from this substance.",
        "Fundamentals of Extrication": "Your primary concern is safety.\nYour primary roles are to: \nProvide emergency medical care.\nPrevent further injury to the patient.\nYou may provide care as extrication goes on around you. Extrication is the removal from entrapment or a dangerous situation or position.\nEntrapment is a condition in which a person is caught within a closed area with no way out or has a limb or other body part trapped.",
        "EMS personnel are responsible for:": "Assessing and providing medical care\nTriaging and packaging patients\nProviding additional assessment and care as needed once patients are removed\nProviding transport to the ED",
        "The rescue team is responsible for:": "Securing and stabilizing the vehicle\nProviding safe entrance and access to the patients\nExtricating any patients",
        "Law enforcement personnel are responsible for:": "Controlling traffic \nMaintaining order at the scene\nEstablishing and maintaining a perimeter",
        "Firefighters are responsible for:": "Extinguishing fire\nPreventing additional ignition\nEnsuring scene safety\nRemoving spilled fuel FIGURE 39-2 EMS providers, the rescue team, law\nenforcement officers, and firefighters have distinct\nresponsibilities at a rescue scene and must cooperate to\nmanage the incident. \u00a9 Brian Logan Photography/Shutterstock.",
        "Preparation Preparing for an incident requiring extrication involves preincident training with rescue personnel.": "Rescue personnel must routinely check extrication tools and their response vehicles.",
        "En Route to the Scene": "En Route to the Scene Procedures and safety precautions similar to those in the phases of an ambulance call are used when responding to a rescue incident.",
        "Arrival and Scene Size-up": "Position the ambulance to block the scene from oncoming traffic.\nUse only essential warning lights.\nChoose a location that will allow safe access and exit.\nPut on PPE and look for passing cars before exiting your vehicle. Make sure the scene is properly marked and protected.\nRequest assistance from law enforcement; they should ensure the road is closed.\nYour job is patient care, but you may need to direct traffic until other units arrive.\nSize-up is the ongoing process of information gathering and scene evaluation. During a 360\u00b0 walk around, look for:\nMechanism of injury\nDowned electrical lines\nLeaking fuels or fluids During a 360\u00b0 walk around, look for: (cont\u2019d)\nSmoke or fire\nBroken glass\nTrapped or ejected patients\nThe number of patients and vehicles involved While looking at the vehicle, note damage. \nBent steering wheel may indicate significant face and/or thoracic trauma. \nImprints in the dashboard may indicate lower extremity injuries. \nLift deployed airbags to see if there is deformity to the steering wheel or dashboard, which may indicate the patient struck the structure after the airbag deflated. Note damage to vehicle (cont\u2019d)\nUnrestrained patients may have contact injuries as well as secondary injuries.\nCheck windshield for a spider-web pattern of shattered glass, indicating possible head, face, or neck injuries. \nInclude findings in your documentation.\nUse the information to maintain a high index of suspicion. Evaluate the need for additional resources, such as:\nExtrication equipment\nFire department\nLaw enforcement\nHazmat unit\nUtility company\nAdvanced life support units\nAir transport Other potential hazards\nLook for spilled fuel and other flammables.\nElectrical short or damaged battery\nRain, sleet, snow\nCrashes that occur on hills\nViolence",
        "Coordinate your efforts with rescue teams and law enforcement.": "Communicate with the rescue team.\nStart talking to the incident commander as soon as you arrive.\nYou become a member of the rescue team.",
        "Hazard Control": "Downed electrical lines are a common hazard at vehicle crash scenes.\nNever attempt to move them.\nInstruct the patient to remain in the vehicle until power is shut off.\nRemain in the safe zone, outside of the danger zone (hot zone). FIGURE 39-4 Remain outside the danger zone (hot zone). \u00a9 Jones & Bartlett Learning. Family members and bystanders can also create hazards.\nThe vehicle can also be a hazard.\nAutomobile on its side or roof can be a danger.\nRescue personnel can stabilize the car.\nEnsure that the car is in \u201cpark\u201d with the parking brake set and the ignition turned off.\nBoth battery cables should be disconnected to minimize the possibility of sparks or fire. Alternative fuel vehicles\nPowered by electricity and electricity/gasoline hybrids, or fuels such as propane, natural gas, methanol, or hydrogen.\nDisconnect the battery in all cases.\nBatteries may be in the trunk or under the seats.\nMay be more than one battery Hybrid vehicle systems\nHave batteries with a higher voltage\nMay take up to 10 minutes to deenergize after the main battery is turned off\nAvoid high-voltage cables (typically orange) and components. \nDamaged high-voltage batteries may give off toxic fumes. \nDo not approach the vehicle if unusual odor is detected.\nRetreat if you experience burning in eyes or throat.",
        "Support Operations Support operations include:": "Lighting the scene\nEstablishing tool and equipment staging areas\nMarking helicopter landing zones\nFire and rescue personnel will work together on these functions.",
        "Gaining Access": "Critical phase of extrication\nMake sure that the vehicle is stable and hazards are eliminated or controlled.\nExact way to gain access depends on the situation\nIdentify safest, most efficient way to gain access.\nIf there are multiple patients, locate and rapidly triage each patient. FIGURE 39-6 The exact way to gain access depends on many factors, including the terrain, the way in which the vehicle is situated, and the weather. \u00a9 ZUMA Press Inc/Alamy Stock Photo. To determine the exact location and position of the patient, consider:\nIs the patient in a vehicle or in some other structure?\nIs the vehicle or structure damaged?\nWhat hazards exist that pose a risk?\nIn what position is the vehicle? On what type of surface? Is it apt to roll or tip? As patients\u2019 conditions change, you may have to change your course of action.\nRapid vehicle extrication may be needed to quickly remove a patient if the environment is threatening or if the patient needs CPR.\nA team of experienced EMTs should be able to perform rapid extrication in 1 minute or less. Keep the patient safe.\nA heavy, fire-resistant blanket can protect from breaking glass, flying particles, tools, or other hazards.\nA long backboard may be used as a shield.\nTalk to the patient, and explain your steps.\nKeep heat, noise, and force to a minimum. FIGURE 39-7 Always explain to the patient why you are\nthere and what you are doing. \u00a9 Norte Photo/Getty Images News/Getty Images. Simple access\nTrying to access the patient as quickly and simply as possible without using tools or breaking glass\nCars are built for easy entry and exit.\nThe rescue team should provide access.\nIf the rescue team has not yet arrived, use tools available on the ambulance. \nUse all door handles or roll down the windows before using other methods. Complex access\nRequires special tools, such as hand, pneumatic, and hydraulic devices\nRequires special training\nIncludes breaking windows or removing roof\nThese advanced skills are typically performed by a specialized team. FIGURE 39-9 Complex access often requires the use of pneumatic and/or hydraulic devices. \u00a9 Keith D. Cullom.",
        "Emergency Care Perform a primary assessment and provide care before further extrication:": "Control any exsanguinating hemorrhage.\nProvide manual stabilization to the spine.\nOpen the airway.\nProvide high-flow oxygen.\nAssist or provide for adequate ventilation.\nControl any significant external bleeding.\nTreat all critical injuries.",
        "Removal of the Patient": "Coordinate with rescue personnel to determine the best removal route.\nMultistep process that is intensive in terms of the number of rescue personnel involved, the equipment used, and the effort required to prevent further injury or harm You should participate in the preparation for patient removal.\nDetermine the urgency of extrication.\nDetermine the position to best protect the patient.\nDetermine how you will move the patient to the backboard and then the stretcher.\nDetermine the extent of the injuries. Your input is essential so that the rescue team plans an extrication that protects the patient from further harm. \nOften you will be placed in the vehicle alongside the patient.",
        "Transfer of the Patient": "Perform a complete primary assessment once the patient is free.\nMake certain that the spine is manually stabilized.\nApply a cervical collar if not already done.\nMove the patient in a series of smooth, slow, controlled steps with designated stops. One person should be in charge.\nChoose a path that requires the least manipulation.\nEnsure that everyone understands the steps and is ready.\nMove only on the team leader\u2019s command.\nMove the patient as a unit.\nContinue to protect the patient from any hazards. FIGURE 39-10 Once the patient has been accessed,\nrapidly assess the patient and make sure that the spine is manually stabilized. Apply a cervical collar if this was not previously done. \u00a9 Keith D. Cullom.",
        "Termination Termination involves returning emergency units to service.": "All equipment used on the scene must be checked.\nCheck and clean the ambulance, replacing used supplies.\nComplete all necessary reports.",
        "Specialized Rescue Situations": "Sometimes a patient can be reached only by special teams.\nSpecialized team skills include:\nCave rescue\nConfined space rescue\nCross-field and trail rescue (park rangers)\nDive rescue Specialized team skills include: (cont\u2019d)\nMissing person search and rescue\nMine rescue\nMountain-, rock-, and ice-climbing rescue\nSki slope and cross-country or trail snow rescue\nStructural collapse rescue Specialized team skills include: (cont\u2019d)\nSpecial weapons and tactics (SWAT) team \nTechnical rope rescue (low- and high-angle rescue)\nTrench rescue\nWater and small craft rescue\nWhite water rescue",
        "Technical Rescue Situations": "Personnel need special technical skills and equipment.\nNot safe to include untrained personnel\nA rescue group is trained and on call for certain types of technical rescues.\nMade up of individuals from one or more departments\nMany members are also trained as EMTs. Check with the incident commander to see if the technical rescue group has been summoned.\nThe incident commander has overall command of the scene in the field.\nOne member must clearly be in charge.\nA lack of identifiable leadership hinders rescue efforts.\nIf no incident commander is present, follow local guidelines. When you arrive, you will be directed or led to the staging area.\nTake a long backboard and/or a basket stretcher, jump kits, and other equipment.\nSet up your equipment at the staging area.\nPerform a primary assessment as soon as the rescue team brings the patient to you.\nPackaging and carrying the patient back to the ambulance requires a joint effort.",
        "Search and Rescue": "An ambulance is usually summoned to the command post when a person is lost outdoors and a search effort is initiated.\nYour role is to stand by at the command post until the missing person or persons are found.\nOnce you are briefed on the situation, isolate and prepare the equipment you may need.\nLeave the prepared equipment in the back of the ambulance to protect it from the weather. You may be asked to stay with the family of the lost individual.\nGather medical history and communicate to those in charge.\nOnly the incident commander should communicate any news or progress to the family.\nSet your radio at a discreet volume. Once the missing person is found, you will be guided by search personnel to the location where you can begin treatment. \nYou may need to relocate the ambulance or use an all-terrain vehicle.\nEnsure that the equipment is evenly distributed among providers.\nEnsure a pace is maintained such that all can stay together easily.",
        "Trench Rescue": "Many cave-ins and trench collapses have poor outcomes for victims.\nCollapses usually involve large areas of falling dirt that weigh approximately 100 lb per cubic foot.\nVictims cannot fully expand their lungs and may become hypoxic. Risk of secondary collapse is a concern.\nSafety measures can reduce the potential for injury.\nPark response vehicles at least 500 feet from the scene.\nAll vehicles should be turned off.\nRoad traffic should be diverted from the 500-foot area. Other hazards include downed electrical wires and broken glass or water lines.\nConstruction equipment may be unstable and could fall into the cave-in or trench.\nWitnesses to the incident should be identified.\nMay be valuable in providing information Assist nontrapped individuals from the area.\nDo not enter a trench deeper than 4 feet without proper shoring in place.\nDuring extrication of survivors, medical personnel trained in cave-in and trench collapse will provide most medical care.\nBe prepared to receive patients after extrication.",
        "Tactical Emergency Medical Support": "Law enforcement officers usually ensure scene safety.\nSometimes a special weapons and tactics (SWAT) team is needed to secure an area.\nHostage incidents\nBarricaded subjects\nSnipers\nMany communities have incorporated specially trained EMTs, paramedics, nurses, and physicians into police SWAT units. When called to the scene, determine the location of the command post and report to the incident commander.\nLights and siren should be turned off.\nThe command post is usually located in an area that cannot be seen by the suspect and is out of range of possible gunfire.\nRemain in this area. Planning measures are key.\nHave the incident commander identify the specific location of the incident.\nThe incident commander should determine a safe location to meet up with the SWAT team if an injury occurs.\nDesignate helicopter landing zones.\nIdentify the quickest route to the closest hospital, burn center, or trauma center.",
        "Structure Fires": "In most areas, an ambulance is dispatched with the fire department apparatus.\nAsk the incident commander where the ambulance should be staged.\nDetermine if there are any injured patients or if you have been called to stand by. Search and rescue in a burning building requires special training and equipment.\nSometimes a scene may be further complicated by hazardous materials."
    },
    {
        "National EMS Education Standard Competencies": "EMS Operations\nKnowledge of operational roles and responsibilities to ensure patient, public, and personnel safety. Mass-Casualty Incidents Due to Terrorism and Disaster\nRisks and responsibilities of operating on the scene of a natural or man-made disaster",
        "Introduction You may be called on to respond to a terrorist event during your career.": "It is difficult to plan for and anticipate a response to many terrorist events.\nSeveral key principles apply to every response.",
        "What Is Terrorism?": "Terrorist forces have been at work since early civilizations.\nTerrorism involves violent acts or acts dangerous to human life that violate federal or state law and appears to be intended to: \nIntimidate or coerce a civilian population\nInfluence the policy of a government by intimidation or coercion\nAffect the conduct of a government by mass destruction, assassination, or kidnapping International terrorism occurs primarily outside of the United States. \nDomestic terrorism occurs primarily within the United States.\nOnly a small percentage of groups actually turn to terrorism to achieve their goals. Religious extremist groups/doomsday cults\nMay participate in apocalyptic violence\nExtremist political groups\nSeek political, religious, economic, and social freedom FIGURE 41-1 The bombing at the Boston Marathon in 2013 was an example of domestic terrorism. \u00a9 Bill Greene/The Boston Globe/Getty Images. Cyber terrorists\nAttack a population\u2019s technological infrastructure\nSingle-issue groups\nInclude antiabortion groups, animal rights groups, anarchists, racists, ecoterrorists FIGURE 41-2 Demonstrators being held back by police in Times Square in 2011. \u00a9 EMMANUEL DUNAND/AFP/Getty Images.",
        "Active Shooter Events": "\u201cLone wolf\u201d terrorist attack\nFrequent threat in the United States\nMotives of the attacker are not always clear.\nAttacks may target\nSchools\nMusic festivals\nShopping centers FIGURE 41-3 The Pulse nightclub shooting in Orlando in 2016 was an example of a lone wolf terrorist attack. The Pulse nightclub shooting in Orlando in 2016 was an example of a lone wolf terrorist attack. Hartford Consensus recommends using the acronym THREAT:\nThreat suppression\nHemorrhage control\nRapid extrication to safety\nAssessment by medical providers\nTransport to definitive care EMS crews may be equipped with ballistic vests and helmets. \nMay be paired with law enforcement to assist with the treatment and evacuation of injured people form an active scene\nInteragency training is a key component.",
        "Many lone wolf terrorist attacks involve firearms rather than explosives.": "This has prompted discussion of:\nGun laws\nMental health\nEducation of the public and first responders on how to treat casualties",
        "Weapons of Mass Destruction": "Also called weapons of mass casualty\nAny agent designed to bring about:\nMass death\nCasualties\nMassive damage to property and infrastructure B-NICE and CBRNE are mnemonics for the kinds of WMDs.\nB-NICE\nBiologic\nNuclear\nIncendiary\nChemical\nExplosive CBRNE\nChemical\nBiologic\nRadiologic\nNuclear\nExplosive Explosives have been the preferred WMD.\nChemical agents consist of:\nVesicants (blister agents)\nRespiratory agents (choking agents)\nNerve agents\nMetabolic agents (cyanides) Biologic terrorism/warfare\nBiologic agents are organisms that cause disease.\nThe primary types are:\nViruses\nBacteria\nToxins Nuclear/radiologic terrorism\nOnly two publicly known incidents: Hiroshima and Nagasaki\nThese materials are far easier for a determined terrorist to acquire and require less expertise to use.\n\u201cDirty bombs\u201d can cause widespread panic.",
        "EMT Response to Terrorism": "The basic foundations of patient care remain the same.\nTreatment can and will vary.\nAlways remember situational awareness.\nRecognizing a terrorist event\nPlanning of acts of terror is covert.\nYou must know the current threat level issued by the Department of Homeland Security (DHS). National Terrorism Advisory System (NTAS)\nAlerts from the NTAS contain a summary of the threat and the actions that first responders, government agencies, and the public can take to maintain safety. On every call, you must make the following observations:\nType of location\nType of call\nNumber of patients\nVictims\u2019 statements\nPreincident indicators",
        "Response Actions": "Scene safety\nStage your vehicle a safe distance away.\nWait for law enforcement personnel.\nIf you have any doubt, do not enter.\nThe best location for staging is upwind and uphill from the incident.\nSecondary device \nAdditional explosives set to explode after the initial bomb FIGURE 41-6 Park your vehicle at a safe location. \u00a9 Dennis MacDonald/Alamy. Responder safety\nThe best form of protection is preventing yourself from coming in contact with the agent.\nContamination occurs when you have direct contact with the WMD.\nCross-contamination occurs when you come in contact with a contaminated person. Notification procedures\nNotify the dispatcher of:\nThe nature of the event\nAny additional resources that may be required\nThe estimated number of patients\nThe upwind or optimal route of approach\nEstablish a staging area.\nTrained responders in PPE are the only persons equipped to handle the WMD incident. Establishing command\nYou may need to establish command until additional personnel arrive.\nYou and other EMTs may function as:\nMedical branch directors\nTriage, treatment, or transportation supervisors\nLogistics officers\nCommand and general staff Reassessing scene safety\nConstantly assess and reassess the scene for safety.\nThis is an important component of situational awareness.",
        "Chemical Agents": "Liquids or gases that are dispersed to kill or injure\nPersistent (nonvolatile) agents can remain on a surface for long periods.\nNonpersistent (volatile) agents evaporate rapidly. Route of exposure is how the agent most effectively enters the body.\nAgents with a vapor hazard enter through the respiratory tract in the form of vapors.\nAgents with a contact hazard (or skin hazard) give off very little vapor or no vapors and enter the body through the skin.",
        "Primary route is the skin (contact).": "If vesicants are left on the skin long enough, they produce vapors that can enter the respiratory tract.\nCause burnlike blisters to form on the victim\u2019s skin and in the respiratory tract\nUsually cause the most damage to damp or moist areas of the body Signs of vesicant exposure on the skin:\nSkin irritation, burning, and reddening\nImmediate, intense skin pain\nFormation of large blisters\nGray discoloration of skin\nSwollen and closed or irritated eyes\nPermanent eye injury (including blindness) Sulfur mustard (H)\nBrown-yellow oily substance\nGenerally considered very persistent\nBegins an irreversible process of damage to the cells\nAttacks vulnerable cells within the bone marrow and depletes the body\u2019s ability to reproduce white blood cells\nSulfur mustard vapors can be inhaled, creating upper and lower airway compromise. Lewisite (L) and phosgene oxime (CX)\nProduce blister wounds very similar to those caused by mustard\nProduce immediate intense pain and discomfort when contact is made\nThe patient may have a gray discoloration at the contaminated site. Vesicant agent treatment\nNo antidotes for mustard or CX exposure\nEnsure that the patient has been decontaminated before treatment is initiated.\nIf agent has been inhaled, the patient may require prompt airway support. \nInitiate transport as soon as possible.\nGenerally, burn centers are best equipped to handle the wounds and infections.",
        "Pulmonary Agents": "Gases that cause immediate harm to persons exposed to them\nPrimary route is through the respiratory tract.\nOnce inside the lungs, they damage the lung tissue and fluid leaks into the lungs.\nPulmonary edema develops, resulting in difficulty breathing because of severely impaired gas exchange. Chlorine (Cl)\nFirst chemical agent ever used in warfare\nInitially, produces upper airway irritation and a choking sensation\nPatient may later experience:\nShortness of breath\nChest tightness\nHoarseness and stridor\nGasping and coughing\nPulmonary edema Phosgene\nProduct of combustion\nVery potent agent with a delayed onset of symptoms\nInitially, a mild exposure may include:\nNausea\nChest tightness\nSevere cough\nDyspnea on exertion\nPulmonary edema Pulmonary agent treatment\nRemove the patient from the contaminated atmosphere.\nManage the ABCs aggressively.\nPay particular attention to oxygenation, ventilation, and suctioning.\nDo not allow the patient to be active.\nThere are no antidotes.\nConsider requesting ALS.",
        "Among the most deadly chemicals developed": "Can cause cardiac arrest within seconds to minutes of exposure\nOrganophosphates\nFound in household bug sprays and agricultural sprays\nBlock an essential enzyme in the nervous system Nerve agents all produce similar symptoms but have varying routes of entry.\nUse SLUDGEM and DUMBELS Nerve agent treatment\nDuoDote Auto-Injector (Antidote Treatment Nerve Agent Auto-Injector [ATNAA])",
        "Metabolic Agents": "Hydrogen cyanide (AC) and cyanogen chloride (CK) affect the body\u2019s ability to use oxygen.\nCommonly found in many industrial settings\nAssociated with dizziness, light-headedness, headache, and vomiting High doses will produce\nShortness of breath/gasping respirations\nRespiratory distress or arrest \nTachypnea\nFlushed skin\nTachycardia High doses will produce (cont\u2019d)\nAltered mental status\nSeizures\nComa\nApnea\nCardiac arrest Cyanide agent treatment\nAll of the patient\u2019s clothes must be removed to prevent off-gassing in the ambulance.\nSupport the patient\u2019s ABCs.\nInitiate transport immediately if antidote by ALS is not available.",
        "Biologic Agents": "Can be almost completely undetectable\nDiseases caused will be similar to other minor illnesses.\nMay be spread in various ways\nDissemination is the means by which a terrorist will spread the agent.\nA disease vector is an animal that spreads disease to another animal. How easily the disease is able to spread from one human to another human is called communicability.\nIncubation is the period of time between the person becoming exposed to the agent and the appearance of the first symptoms.",
        "Viruses": "Germs that require a living host to multiply and survive\nInvades healthy cells and replicates itself to spread through the host\nMoves from host to host by direct methods or through vectors Smallpox is highly contagious.\nYou must wear examination gloves, a HEPA-filtered respirator, and eye protection.\nObserve the size, shape, and location of the lesions. FIGURE 41-11 In smallpox, all the lesions are identical in\ntheir development. In other skin disorders, the lesions will\nbe in various stages of healing and development. Courtesy of CDC. Viral hemorrhagic fever (VHF)\nCauses the blood in the body to seep out from the tissues and blood vessels\nThe patient will have flulike symptoms, progressing to more serious symptoms such as internal and external hemorrhaging.\nAll standard precautions must be taken.",
        "Do not require a host to multiply and live": "More complex than viruses and can grow up to 100 times larger\nMost can be fought with antibiotics.\nMost will generally begin with flulike symptoms. Inhalation and cutaneous anthrax\nAnthrax is caused by a deadly bacterium that lays dormant in a spore.\nRoutes of entry are inhalation, cutaneous, and gastrointestinal.\nPulmonary anthrax is the deadliest.\nAntibiotics can be used to treat anthrax successfully.\nA vaccine is available. Plague\nNatural vectors are rodents and fleas.\nBubonic plague infects the lymphatic system and creates buboes.\nPneumonic plague is a lung infection that results from inhalation of plague bacteria. FIGURE 41-14 A. Plague bubo at lymph node under arm. B. Plague bubo at lymph node on neck. A, B: Courtesy of CDC.",
        "Neurotoxins": "Most deadly substances known to humans\nProduced from plants, marine animals, molds, and bacteria\nRoute of entry is ingestion, inhalation, or injection.\nNot contagious and have a faster onset of symptoms Botulinum toxin\nMost potent neurotoxin\nProduced by bacteria\nAffects the nervous system\u2019s ability to function\nVoluntary muscle control diminishes.\nEventually the toxin causes muscle paralysis, leading to respiratory arrest. Ricin\nDerived from mash from the castor bean\nCauses pulmonary edema and respiratory and circulatory failure, leading to death\nQuite stable and extremely toxic\nTreatment is supportive and includes both respiratory support and cardiovascular support as needed.",
        "Other EMT Roles": "Syndromic surveillance\nMonitoring of patients presenting to EDs and alternative care facilities\nPatients with signs and symptoms that resemble influenza are important.\nQuality assurance and dispatch need to be aware of an unusual number of calls from patients with unexplainable symptom clusters. Points of distribution (POD)\nEstablished in the time of need for the mass distribution of antibiotics, antidotes, vaccinations, and other medications and supplies\nPush packs distributed by the Centers for Disease Control and Prevention Strategic National Stockpile \nPush packs have a delivery time of 12 hours anywhere in the country.",
        "Radiologic/Nuclear Devices": "Ionizing radiation is emitted in the form of rays, or particles.\nAlpha, beta, gamma (x-ray), and neutron radiation\nAlpha is the least harmful type.\nBeta is slightly more penetrating.\nGamma rays are faster and stronger.\nNeutron particles are the most powerful. FIGURE 41-17 The penetrating potential of radiation. A. Alpha. B. Beta. C. Gamma. D. Neutron. A-D: \u00a9 Jones & Bartlett Learning. Once radiologic material has been used, the remaining material is called radiologic waste.\nThese materials can be found at:\nHospitals and health care facilities with radiology departments \nColleges and universities\nNuclear power plants \nChemical and industrial sites Radiologic dispersal devices (RDDs)\nAny container designed to disperse radioactive material\nA \u201cdirty bomb\u201d can injure victims with the radioactive or explosive material.\nThe dirty bomb is an ineffective WMD. Nuclear energy is artificially made by altering (splitting) radioactive atoms.\nThe result is an immense amount of energy that usually takes the form of heat.\nNuclear material is used in:\nMedicine\nWeapons\nNaval vessels\nPower plants Nuclear weapons\nKept only in secure facilities\nThe likelihood of a nuclear attack is extremely remote.\nThe whereabouts of many small nuclear devices are unknown.\nSpecial Atomic Demolition Munition (SADM) Patients exposed to excessive radiation are considered victims of acute radiation toxicity. \nEffects of radiation exposure will vary depending on the amount of radiation and the route of entry.\nRadiation can be introduced into the body by all routes of entry. Being exposed to a radiation source does not make a patient contaminated or radioactive.\nHowever, when patients have a radioactive source on their body, they must be initially cared for by a hazmat responder.\nAfter decontamination, you may begin treatment with the ABCs.\nWear appropriate PPE, and place all body fluids in containers for proper disposal. There is no protective gear designed to completely shield you from radiation.\nThe less time that you are exposed to the source, the less the effects will be.\nMake certain that responders are stationed far enough from the incident.\nAlways assume it is the strongest form of radiation and use concrete shielding.",
        "Incendiary and Explosive Devices": "Incendiary (used to start fires) and explosive devices come in various shapes and sizes.\nIt is important to identify an object you believe is a potential device.\nNotify the authorities, and safely evacuate the area.\nAlways remember that there is the possibility of a secondary device when you respond to the scene. Primary blast injury\nDirect effects of the pressure wave on the body\nSeen almost exclusively in the hollow organs\nAn injury to the lungs causes the greatest morbidity and mortality.\nSecondary blast injury\nPenetrating or nonpenetrating injury that results from flying debris Tertiary blast injury\nWhole body displacement and subsequent impact with environmental objects\nAlso includes crush injury\nQuaternary blast injury\nAny other injury caused by a blast The physics of an explosion\nWhen a substance is detonated, a solid or liquid is chemically converted into gas under high pressure.\nThis generates a spherical blast wave.\nFlying debris and high winds commonly cause conventional blunt and penetrating trauma. Hollow organs such as the middle ear, lung, and GI tract are most susceptible to pressure changes.\nThe ear is the organ system most sensitive to blast injuries.\nPrimary pulmonary blast injuries occur as contusions and hemorrhages. Blast lung is the most common cause of death from blast injury. \nNeurologic injuries and head trauma are also common causes of death from blast injuries.\nExtremity injuries, including traumatic amputations, are common."
    },
    {
        "National EMS Education Standard Competencies": "Preparatory\nApplies fundamental knowledge of the emergency medical services (EMS) system, safety/well-being of the emergency medical technician (EMT), medical/legal, and ethical issues to the provision of emergency care. Emergency Medical Services (EMS) Systems\nEMS systems\nHistory of EMS\nRoles/responsibilities/professionalism of EMS personnel\nQuality improvement\nPatient safety Research\nImpact of research on emergency medical responder (EMR) care\nData collection\nEvidence-based decision making\nPublic Health\nUses simple knowledge of the principles of illness and injury prevention to emergency care",
        "Introduction The text is the primary resource for the emergency medical technician (EMT) course.": "EMS is a system.\nChapter 1 discusses that system\u2019s key components.",
        "Course Description": "EMS system\nTeam of health care professionals\nProvides emergency care and transport\nIs governed by state laws FIGURE 1-1 As an EMT, you are part of a larger team that responds to a variety of calls and provides a wide range of prehospital emergency care. \u00a9 Corbis/Getty. After you complete this course, you are eligible to take either:\nThe National Registry of EMTs exam\nYour state\u2019s certification exam\nAfter you pass this exam, you are eligible to apply for state licensure. Most states have four training and licensure levels:\nEMR\nEMT\nAEMT\nParamedic An EMR has very basic training.\nProvides care before ambulance arrives\nMay assist in ambulance FIGURE 1-4 Emergency medical responders, such as law\nenforcement officers, are trained to provide immediate\nbasic life support until EMTs arrive on the scene. \u00a9 Hunterstock/Thinkstock. An EMT has training in basic life support (BLS), including:\nAutomated external defibrillation\nAirway adjuncts\nAssisting patients with certain medications An AEMT has training in specific aspects of advanced life support (ALS), including:\nIntravenous (IV) therapy\nAdministration of a limited number of emergency medications A paramedic has extensive ALS training, including:\nEndotracheal intubation\nEmergency pharmacology\nCardiac monitoring\nOther advanced assessment and treatment skills",
        "EMT course includes four learning activities:": "Reading assignments, lecture presentations, and classroom discussions\n Step-by-step demonstrations\n Summary skills sheets\n Case presentations and scenarios",
        "EMT Training: Focus and Requirements EMTs are the backbone of EMS system in the United States.": "EMTs provide emergency care to the sick and injured.",
        "Licensure Requirements": "*\tRequirements differ from state to state. General requirements to be an EMT are:\nHigh school diploma or equivalent\nProof of immunization \nSuccessful completion of a background check and drug screening\nValid driver\u2019s license Successful completion of required courses and certification exams \nDemonstration of the mental and physical abilities necessary to perform the job\nCompliance with other state, local, and employer provisions Americans With Disabilities Act (ADA)\nProhibits employers from failing to provide full and equal employment\nTitle I of the ADA \nProtects EMTs with disabilities who are seeking employment\nMay require modifying the work environment or how the job is performed\nBackground checks",
        "Overview of the EMS System": "History of EMS\nOrigins include:\nVolunteer ambulances in World War I\nField care in World War II\nField medic and rapid helicopter evacuation in Korean conflict 1966\nAccidental Death and Disability: The Neglected Disease of Modern Society established EMS\nEarly 1970s\nDOT published the first EMT training curriculum.\n1973\nEmergency Medical Services Act\n1971\nAAOS published the first EMT textbook. National standardization efforts \n1970s \u2013 DOT\u2019s National Standard Curriculum \n1980s \u2013 Advanced levels of EMTs\n1990s \u2013 NHTSA\u2019s EMS Agenda for the Future\n2019 \u2013 NHTSA\u2019s EMS Agenda 2050",
        "Levels of Training": "Federal level:\nNational EMS Scope of Practice Model provides guidelines. \nState level:\nLaws regulate EMS operations.\nLocal level:\nMedical director provides oversight and support. FIGURE 1-3 Hierarchies of the 2019 National EMS Scope of Practice Model. \u00a9 Jones & Bartlett Learning.",
        "Public BLS and Immediate Aid Millions of laypeople are trained in BLS/CPR.": "Automated external defibrillators (AEDs) are used by laypeople.",
        "Emergency Medical Responders Include law enforcement officers and firefighters": "Initiate immediate care and assist EMTs on their arrival\nFocus on providing BLS and urgent care with limited equipment",
        "Emergency Medical Technicians EMT course requires about 150\u2013200 hours.": "The EMT has knowledge and skills to provide basic emergency care.\nThe EMT assumes responsibility for assessment, care, packaging, and transport of the patient.",
        "Advanced Emergency Medical Technicians Training adds knowledge and skills in specific aspects of ALS, including:": "IV therapy\nAdvanced airway adjuncts\nAdministration of limited number of medications",
        "Paramedics Extensive training": "1,000 to more than 1,300 hours in the classroom and in internships \nTraining covers a wide range of ALS skills. FIGURE 1-5 Paramedic education and training cover a wide range of advanced life support skills. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS.",
        "Components of the EMS System Comprehensive, quality, convenient care": "Evidence-based clinical care\nEfficient, well-rounded care\nPreventive care\nComprehensive and easily accessible patient records",
        "Public Access 9-1-1 system": "Access public safety \nDispatchers \nObtain information and dispatch resources\nEmergency medical dispatch (EMD) system\nProvides medical instruction\nMobile apps assist with layperson CPR and AED location",
        "Human Resources Focuses on people who deliver care": "EMS Agenda 2050 encourages an environment where people want to work. FIGURE 1-6 Trained dispatchers obtain information about the call and then send responders to the scene as needed. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS.",
        "Physician medical director": "Authorizes EMTs to provide medical care in field\nMedical director\nActs as liaison\nStanding orders and protocols\nDescribe appropriate care\nEstablish medical direction for providers Medical control can be off-line or online.\nOff-line (indirect)\nStanding orders, training, supervision\nOnline (direct)\nPhysician directions given over the phone or radio",
        "Legislation and Regulation Training, protocols, and practices follow state legislation.": "Senior EMS official handles administrative tasks: \nScheduling\nPersonnel\nBudgets\nPurchasing\nVehicle maintenance",
        "Integration of Health Services Prehospital care is coordinated with hospital care.": "Prehospital care is continued in the emergency department (ED).\nIntegration ensures comprehensive continuity of care for the patient.",
        "Mobile Integrated Health Care": "Method of delivering health care \nUtilizes the prehospital spectrum\nEvolved with the goal to facilitate improved access to health care at an affordable price\nHealth care provided within the community by team of professionals",
        "MIH created additional training levels for EMS providers, including community paramedicine.": "Paramedics receive advanced training to provide services within a community.\nCommunity paramedics provide additional services.",
        "Computer systems are used for documentation of patient care.": "Electronically stored information can be used to improve care. Information Systems",
        "Evaluation Medical director is responsible for maintaining quality control.": "Adopting a Just Culture\nPromotes a learning culture that holds employees accountable for behavioral choices by balancing fairness and accountability",
        "Continuous Quality Improvement (CQI) Reviews and performs audits of the EMS system to identify areas of improvement and/or assign remedial training": "Minimizing errors is the goal.\nUses a plan-do-study-act cycle FIGURE 1-7 Plan-do-study-act cycle. Reproduced with permission from \u201cModel for improvement.\u201d Boston, Massachusetts: Institute for Healthcare Improvement; 2020. Available at  ttp://www.ihi.org/resources/Pages/HowtoImprove/default.aspx.",
        "Patient Safety Minimize medical errors that occur as a result of a rules-based failure, a knowledge-based failure, or a skill-based failure (or a combination).": "Requires the efforts of both the EMS agency and EMS personnel",
        "System Finance": "Finance systems vary depending on the organization involved.\nPersonnel may be paid, volunteer, or a mix.\nEMTs may be asked to:\nGather insurance information. \nSecure signatures. \nObtain permission from patients to bill insurance.",
        "In 2020, the Centers for Medicare and Medicaid Services (CMS) implemented a pilot program called Emergency Triage, Treat, and Transport (ET3).": "Reimburse EMS systems for providing the right patient care at the right time.\nSet up a payment model for patient transport to alternative destinations.",
        "Education Systems EMS instructors": "Licensed in most states\nMost EMS training programs must adhere national standards. \nContinuing education, refresher courses, computer-based or manikin-based self-education exercises  \nMeasures intended to maintain and update an EMT\u2019s skills and knowledge",
        "Prevention and public education": "Two components of the EMS system with a focus on public health\nEmphasis is on prevention.\nEMS works with public health agencies on:\nPrimary prevention\nSecondary prevention",
        "EMS Research Helps determine the shape of EMS": "Evidence-based medicine (EBM)\nFocuses on procedures that have proven useful in improving patient outcomes\nMany EMS systems and states consult the National Model EMS Clinical Guidelines from the National Association of State EMS Officials.\nBased on a review of current research and expert consensus",
        "Roles and Responsibilities of the EMT": "Keep vehicles and equipment ready.\nEnsure safety.\nBe familiar with emergency vehicle operation.\nProvide on-scene leadership.\nPerform scene evaluation. Call for additional resources as needed.\nGain patient access.\nPerform a patient assessment.\nGive emergency medical care while awaiting additional medical resources. Give emotional support.\nMaintain continuity of care.\nResolve emergency incidents.\nUphold medical and legal standards.\nEnsure and protect patient privacy. Give administrative support.\nConstantly continue professional development.\nCultivate and sustain community relations.\nGive back to the profession.",
        "Professional Attributes": "Integrity\nEmpathy\nSelf-motivation\nAppearance and hygiene\nSelf-confidence FIGURE 1-8 A professional appearance and demeanor help build confidence and ease patient anxiety \u00a9 Jones & Bartlett Learning. Time management\nCommunications\nTeamwork and diplomacy\nRespect\nPatient advocacy\nCareful delivery of care Every patient is entitled to compassion, respect, and the best care.\nEMTs are bound by patient confidentiality.\nBe familiar with requirements of the Health Insurance Portability and Accountability Act (HIPAA)."
    },
    {
        "National EMS Education Standard Competencies Shock and Resuscitation": "Applies a fundamental knowledge of the causes, pathophysiology, and management of shock, respiratory failure or arrest, cardiac failure or arrest, and postresuscitation management.",
        "Introduction The principles of basic life support (BLS) were introduced in 1960.": "Specific techniques have been reviewed and revised regularly.\nThe most recent review (2020) was conducted by the International Liaison Committee on Resuscitation (ILCOR).",
        "Elements of BLS": "Noninvasive emergency life-saving care\nUsed to treat medical conditions including:\nAirway obstruction\nRespiratory arrest\nCardiac arrest Focus is on the ABCs.\nAirway (obstruction)\nBreathing (respiratory arrest)\nCirculation (cardiac arrest or severe bleeding) Ideally, only seconds should pass between the time you recognize a patient needs BLS and the start of treatment.\nPermanent brain damage is possible if brain is without oxygen for 4 to 6 minutes. FIGURE 14-2 Time is critical for patients who are not breathing. If the brain is deprived of oxygen for 4 to 6 minutes, brain damage is possible. \u00a9 Jones & Bartlett Learning. Cardiopulmonary resuscitation (CPR)\nReestablishes circulation and artificial ventilation in a patient who is not breathing and has no pulse CPR steps\nRestore circulation (perform chest compressions). \nOpen the airway.\nRestore breathing (provide rescue breathing). FIGURE 14-3 You must quickly identify patients in respiratory and/or cardiac arrest so that BLS measures can begin immediately. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS. BLS differs from advanced life support (ALS).\nALS involves:\nCardiac monitoring\nIntravenous fluids and medications\nAdvanced airway adjuncts",
        "The System Components of CPR": "FIGURE 14-4 The six links of the chain of survival. Data from the American Heart Association. AHA chain of survival\nRecognition and activation of the emergency response system\nImmediate, high-quality CPR\nRapid defibrillation\nBasic and advanced emergency medical services\nALS and post-arrest care\nRecovery",
        "Assessing the Need for BLS": "Always begin by surveying the scene.\nComplete primary assessment as soon as possible.\nEvaluate ABCs.\nDetermine unresponsiveness.\nShould take less than 10 seconds Basic principles of BLS are same for infants, children, and adults.\nAlthough cardiac arrest in adults usually occurs before respiratory arrest, the reverse is true for infants and children. FIGURE 14-5 Assess an unresponsive patient by first attempting to rouse him or her by tapping on the shoulder. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS.",
        "Automated External Defibrillation": "Vital link in the chain of survival\nShould be applied to cardiac arrest patients as soon as available\nIf you witness cardiac arrest, begin CPR and apply the AED as soon as it is available. Children\nApply after first five cycles of CPR.\nUse pediatric-sized pads and dose-attenuating system. \nIf neither is available, then use an AED with adult-sized pads with anterior-posterior placement. Special situations\nPacemakers and implanted defibrillators\nWet patients\nTransdermal medication patches",
        "Positioning the Patient For CPR to be effective, patient must be supine on firm, flat surface.": "Must be enough space for two rescuers to perform CPR \nLog roll patient onto long backboard.",
        "Quickly check for breathing and a pulse.": "Visualize the chest for signs of breathing.\nPalpate for a carotid pulse. FIGURE 14-6 Feel for the carotid artery by locating the larynx, then slide your index and middle fingers toward one side. You can feel the pulse in the groove between the larynx and sternocleidomastoid muscle. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS. Provide external chest compressions. \nApply rhythmic pressure and relaxation to lower half of sternum.\nCompressions squeeze heart, acting as a pump to circulate blood.\nAvoid leaning on the chest in between compressions. Administer chest compressions (cont\u2019d)\nAllow the chest to completely recoil between compressions. \nProper hand positioning is crucial. \nInjuries can be minimized by proper technique and hand placement. FIGURE 14-7 The heart lies slightly to the left of the\nmiddle of the chest between the sternum and spine. \u00a9 Jones & Bartlett Learning. FIGURE 14-8 A. Compression and relaxation should be rhythmic and of equal duration (a 1:1 ratio). B. Pressure on the sternum must be released so that the sternum can return to its normal resting position between compressions. A, B: \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS.",
        "Head tilt\u2013chin lift maneuver Jaw-thrust maneuver FIGURE 14-11 To perform the head tilt\u2013chin lift maneuver, place one hand on the patient\u2019s forehead and apply firm backward pressure with your palm to tilt the head back. Next, place the tips of the index and middle fingers of your other hand under the lower jaw near the bony part of the chin. Lift the chin upward, bringing the entire lower jaw": "with it, helping to tilt the head back. \u00a9 Jones & Bartlett Learning. FIGURE 14-12 To perform the jaw-thrust maneuver, maintain the head in neutral alignment and place your fingers behind the angles of the lower jaw, and move the jaw upward. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS.",
        "Opening the Airway and Providing Artificial Ventilation": "If the patient is adequately breathing, and there are no signs injury to the head, spine, hip, or pelvis, place the patient in the recovery position.\nMaintains clear airway\nAllows vomitus to drain from mouth\nRoll the patient as a unit. FIGURE 14-14 When you provide ventilations, use a bag-mask device. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS. FIGURE 14-15 A. This stoma connects the trachea directly to the skin. B. Use a bag-mask device to ventilate a patient with a stoma. A, B: \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS.",
        "Recovery position FIGURE 14-13 The recovery position is used to maintain": "an open airway in an adequately breathing patient with a\ndecreased level of consciousness who has no spinal injury.\nIt allows vomitus, blood, and any other secretions to drain\nfrom the mouth. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS.",
        "The combination of lack of oxygen and too much carbon dioxide in the blood is lethal.": "If patient is not breathing, ventilations can be given by one or two EMS providers. \nUse a barrier device.",
        "For a patient with a stoma, place a bag-mask device or pocket mask device directly over the stoma.": "Artificial ventilation may result in gastric distention.\nHave a suction unit available in case patient vomits.",
        "One-Rescuer Adult CPR Single rescuer gives both chest compressions and artificial ventilations.": "Ratio of compressions to ventilations is 30:2.",
        "Two-Rescuer Adult CPR Always preferable to one-rescuer CPR": "Less tiring\nFacilitates effective chest compressions\nSwitching rescuers during CPR is critical to maintain high-quality compressions.\nRecommended to switch positions every 2 minutes",
        "Devices and Techniques to Assist Circulation": "Active compression-decompression CPR\nInvolves compressing the chest and then actively pulling it back up to its neutral position\nImpedance threshold device (ITD) \nLimits air entering lungs during recoil phase between chest compressions FIGURE 14-17 An active compression-decompression CPR device. Provided with permission by ZOLL Medical FIGURE 14-18 An impedance threshold device Courtesy of Advanced Circulatory Systems, Inc. Mechanical piston device\nAllows rescuer to configure the depth and rate of compression\nLoad-distributing band CPR or vest CPR\nA circumferential chest compression device composed of constricting band and backboard\nManual chest compressions remain the standard of care. FIGURE 14-20 A load-distributing band. Provided with permission by ZOLL Medical.",
        "Infant and Child CPR": "Cardiac arrest in infants and children follows respiratory arrest.\nAirway and breathing are the focus of pediatric BLS. Causes of child respiratory problems:\nInjury\nInfections\nForeign body\nSubmersion\nElectrocution\nPoisoning/overdose\nSIDS Determine unresponsiveness.\nGently tap on the shoulder and speak loudly. \nCheck for breathing and a pulse.\nAssessment occurs simultaneously.\nShould take no longer than 10 seconds Foreign body obstruction in children is common.\nPlace an unresponsive, breathing child in the recovery position.\nThe techniques for opening the airway are modified for pediatric patients. \nPlace a wedge under the upper chest and shoulders when supine. Provide rescue breathing. \nNot breathing and has a pulse: \n1 breath every 2 to 3 seconds \nNot breathing and no pulse:\n2 breaths after every 30 compressions",
        "Interrupting CPR": "CPR is a crucial, life-saving procedure.\nIf no ALS available at scene:\nProvide transport per local protocols.\nConsider requesting ALS rendezvous en route to hospital. Try not to interrupt CPR for more than a few seconds.\nChest compression fraction\nThe total percentage of time during a resuscitation attempt in which chest compressions are being performed\nShould be at least 80% (the higher the better)",
        "When Not to Start CPR": "If the scene is not safe\nIf the patient has obvious signs of death\nRigor mortis (stiffening of body)\nDependent lividity (livor mortis)\nPutrefaction or decomposition of body\nEvidence of nonsurvivable injury Dependent lividity FIGURE 14-25 Dependent lividity is an obvious sign of death, caused by blood settling to the areas of the body not in firm contact with the ground. The lividity in this figure is seen as purple discoloration of the back, except in areas that are in firm contact with the ground (scapula and buttock). \u00a9 American Academy of Orthopaedic Surgeons. If the patient and physician have previously agreed on do not resuscitate (DNR) orders:\nWhen in doubt, begin CPR.",
        "When to Stop CPR Once you begin CPR, continue until:": "S Patient Starts breathing and has a pulse.\nT Patient is Transferred to another provider of equal or higher-level training.\nO You are Out of strength.\nP Physician directs to discontinue.",
        "Foreign Body Airway Obstruction in Adults": "Airway obstruction may be caused by:\nRelaxation of throat muscles\nVomited or regurgitated stomach contents\nBlood\nDamaged tissue\nDentures\nForeign bodies In adults, usually occurs during a meal\nIn children, usually occurs during a meal or at play\nPatient with mild airway obstruction is able to exchange air but with signs of respiratory distress. Sudden, severe obstruction is usually easy to recognize in responsive patients.\nIn unresponsive patients, suspect obstruction if maneuvers to open airway and ventilate are ineffective.\nAbdominal-thrust maneuver (Heimlich) is recommended in responsive adults and children older than 1 year. FIGURE 14-28 The abdominal thrust maneuver in a\nresponsive adult. Stand behind the patient and wrap your\narms around the patient\u2019s abdomen. Place the thumb side\nof one fist against the patient\u2019s abdomen while holding\nyour fist with your other hand. Press your fists into the\npatient\u2019s abdomen, using inward and upward thrusts. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS. Instead of abdominal-thrust maneuver, use chest thrusts for the following responsive patients:\nWomen in advanced stages of pregnancy\nObese patients FIGURE 14-29 Removal of a foreign body obstruction in\na responsive adult using chest thrusts. Stand behind the\npatient and wrap your arms around the patient\u2019s chest.\nPlace the thumb side of one fist against the chest while\nholding your fist with your other hand. Press your fists into\nthe patient\u2019s chest with backward thrusts. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS. Unresponsive patients:\nDetermine unresponsiveness.\nCheck for breathing and a pulse. \nIf pulse is present and breathing is absent, attempt ventilation.\nIf two attempts do not produce visible chest rise, perform 30 compressions, open airway, and look in mouth.\nAttempt to carefully remove any visible object.",
        "Foreign Body Airway Obstruction in Infants and Children": "Common problem\nIf there are signs and symptoms of airway obstruction, do not waste time trying to dislodge a foreign body.\nOn responsive, standing or sitting child, perform Heimlich maneuver. \nOn unresponsive child older than 1 year, manage in the same manner as an adult. FIGURE 14-31 To perform the abdominal thrust maneuver\non a child, kneel behind the child on one knee, wrap your\narms around the child\u2019s body, and place your fist just above\nthe umbilicus and well below the lower tip of the sternum \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS. FIGURE 14-32 A. Hold the infant facedown with the body resting on your forearm. Support the jaw and face with your hand and keep the head lower than the rest of the body. Give the infant five back slaps between the shoulder blades, using the heel of your hand. B. Give the infant five quick chest thrusts, using two fingers placed on the lower half of the sternum. A, B: \u00a9 Jones & Bartlett Learning.",
        "Responsive infants": "Do not use abdominal thrusts.\nPerform back slaps and chest thrusts (compressions).",
        "In unresponsive infants, begin CPR, beginning with chest compressions.": "Do not check for a pulse before starting compressions. \nOpen the airway and look in the mouth. \nRemove the object if seen.\nResume chest compressions if no object is seen.",
        "Special Resuscitation Circumstances Opioid overdose": "Standard resuscitation measures take priority over naloxone administration. \nCardiac arrest in pregnancy\nPriorities are to provide high-quality CPR and relieve pressure off the aorta and vena cava.",
        "Grief Support for Family Members and Loved Ones": "Family members may experience a psychologic crisis that turns into a medical crisis. \nFamily members and loved ones will remember this event in detail for the rest of their lives.\nKeep the family informed throughout the resuscitation process.",
        "After resuscitation has stopped, helpful measures include:": "Take the family to a quiet, private place.\nUse clear language and speak in a warm, sensitive, and caring manner. \nExhibit calm, reassuring authority.\nUse the patient\u2019s name. \nUse eye contact and appropriate touch.",
        "After resuscitation has stopped, helpful measures include (cont\u2019d):": "Expect emotion.\nBe supportive but do not hover.\nAsk if a friend or family member can be called.\nEnsure that children are not ignored.",
        "Education and Training for the EMT CPR skills can deteriorate over time.": "Practice often using manikin-based training.\nCPR self-instruction through a video and/or computer-based modules with hands-on practice.",
        "Education and Training for the Public You are a patient advocate.": "You must do your part to facilitate the training of laypeople in the critical skills of CPR and AED operation."
    },
    {
        "National EMS Education Standard Competencies EMS Operations": "Knowledge of operational roles and responsibilities to ensure patient, public, and personnel safety.",
        "Introduction In the course of a call, you will have to move patients to provide emergency medical care and transport.": "To move patients without injury, you need to learn the proper techniques.\nKnowledge of proper body mechanics and a power grip is important.",
        "Wheeled ambulance stretcher": "Also called an ambulance stretcher or gurney\nMost commonly used device FIGURE 8-1 The wheeled ambulance stretcher is specially designed to roll along the ground. \u00a9 Keith Brofsky/Photodisc/Getty Images The wheeled ambulance stretcher weighs 40\u2013145 lb.\nGenerally not taken up or down stairs or where the patient must be carried for any significant distance Moving a patient by rolling, using a stretcher or other wheeled device, is preferred when the situation allows and helps prevent injuries from carrying.\nBefore going on a call, familiarize yourself with the specific features of the stretcher your ambulance carries. General features\nHead end and foot end\nStrong metal frame to which all other parts are attached\nHinges at center allow for elevation of head/back. \nGuardrails prevent the patient from rolling out. General features (cont\u2019d)\nUndercarriage frame allows adjustment to any height.\nMattress must be fluid resistant.\nThe patient is secured with straps.\nHelp protect the patient from further injury.",
        "Backboards": "Long, flat, and made of rigid rectangular material (mostly plastic)\nUsed to carry and immobilize patients with suspected spinal injury or other trauma FIGURE 8-2 A backboard is used to transfer patients who\nmust be moved in a supine or immobilized position. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS. Commonly used for patients found lying down\nUsed to move patients out of awkward places\n6\u20137 feet long\nHoles serve as handles and as a place to secure straps.",
        "Moving and Positioning the Patient": "When you move a patient, take care that injury does not occur:\nTo you\nTo your team\nTo the patient\nPatient lifting and moving are technical skills that require repeated training and practice. Using proper body mechanics and maintaining physical fitness greatly reduce the chance of injury. \nMove patients in an orderly, planned, and unhurried manner.\nMaster the skills necessary for the equipment you will be using.",
        "Body Mechanics": "Anatomy review FIGURE 8-3 When you stand upright, the weight of anything that you lift and carry in your hands is borne by the shoulder girdle, the spinal column, the pelvis, and the legs. \u00a9 Jones & Bartlett Learning. Lifting position\nShoulder girdle should be aligned over pelvis.\nHands should be held close to legs.\nForce then goes essentially straight down spinal column.\nVery little strain occurs. This is the correct way to lift. FIGURE 8-4 If your body is properly aligned when you\nlift, the line of force exerted against the spine occurs in an\nessentially straight line down the vertebrae. In this way, the\nvertebrae support the lift. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS. You may injure your back:\nIf you lift while leaning forward\nIf you lift with your back straight but bent significantly forward at the hips Lifting technique\nLegs should be spread about 15 inches apart (shoulder width).\nPlace feet so the center of gravity is balanced.\nWith your back held upright, bring your upper body down by bending the legs.\nGrasp the patient/stretcher. Lifting technique (cont\u2019d)\nLift the patient by raising your upper body and arms and straightening your legs until standing.\nKeep the weight close to your body.\nKeep your arms the same distance apart. The power grip gets maximum force from the hands.\nPalms up\nHands about 10 inches apart\nAll fingers at same angle\nFully support handle on curved palm FIGURE 8-5 To perform the power grip, grasp the handle\nof the stretcher or backboard with your palms up and your\nthumbs extending up. Make sure your hands are about\n10 inches (25 cm) apart and that your fingers are all at the\nsame angle. The underside of the handle should be fully\nsupported by the palms of your hands. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS. When directly lifting a patient, tightly grip the patient in a place and manner that will ensure that you will not lose your grasp on the patient.",
        "Principles of Safe Reaching and Pulling": "Body drag\nThe same body mechanics and principles apply to moving, lifting, and carrying a patient.\nKeep your back locked by tightening your abdominal muscles.\nKneel.\nExtend your arms no more than 15\u201320 inches in front of you.\nAlternate between pulling the patient by flexing your arms and repositioning yourself. FIGURE 8-7 A body drag with an EMT on each side of the patient. \u00a9 Jones & Bartlett Learning. To drag a patient across a bed:\nKneel on the bed to avoid reaching beyond the recommended distance.\nDrag the patient to within 15\u201320 inches.\nComplete the drag while standing at the side of the bed.\nUse the sheet or blanket under the patient rather than dragging the patient by his or her clothing. In the hospital, transfer the patient from the stretcher to a bed with a body drag.\nThe stretcher should be the same height or slightly higher than the bed.\nYou and a partner should kneel on the bed and drag in increments. Log roll the patient onto his or her side to place a patient on a backboard. FIGURE 8-8 Placing a patient onto a backboard \u00a9 Jones & Bartlett Learning Log rolling (cont\u2019d)\nKneel as close to the patient\u2019s side as possible.\nKeep your back straight and lean solely from the hips.\nRoll the patient without stopping until the patient is resting on his or her side and braced against your thighs.\nPulling toward you allows your legs to prevent the patient from rolling over completely.",
        "Principles of Safe Lifting and Carrying": "Whenever possible, use a device that can be rolled.\nWhen a wheeled device is not available, make sure that you understand and follow the guidelines for carrying a patient on a stretcher. Patient weight \nEstimate the patient\u2019s weight before lifting.\nAdults often weigh 120\u2013220 lb.\nTwo EMTs should be able to safely lift this weight.\nTry to use four providers to lift when possible. \nMore stability \nRequires less strength Patient weight (cont\u2019d)\nDo not attempt to lift a patient who weighs more than 250 lb with fewer than four providers.\nKnow the weight limitations of the equipment and how to handle patients who exceed the weight limitations.\nSpecial bariatric techniques and equipment are used when patients weigh more than 350 lb (159 kg). Lifting and carrying a patient on a backboard or stretcher \nMore of the patient\u2019s weight rests on the head half of the device than on the foot half.\nThe diamond carry and the one-handed carry use one EMT at the head and the foot, and one on each side of the patient\u2019s torso. FIGURE 8-9 The diamond carry requires four providers: one at the head of the backboard, one at the foot end, and one at each side of the patient\u2019s torso. \u00a9 Jones & Bartlett Learning. Lifting and carrying a patient on a backboard or stretcher (cont\u2019d)\nUse four providers\u2014one provider at each corner of the stretcher to provide an even lift.\nWhen rolling the wheeled ambulance stretcher, make sure that it is in the fully elevated position. Moving a patient with a stair chair\nUse a stair chair to carry a conscious patient up or down a flight of stairs \nThis lightweight, wheeled folding chair has a molded seat, adjustable safety straps, and fold-out handles at both the head and feet. FIGURE 8-11 A wheeled stair chair can be used to transfer\na conscious patient up or down a flight of stairs. \u00a9 Jones & Bartlett Learning Moving a patient on stairs with a stretcher \nA backboard should be used instead for a patient who:\nIs unresponsive\nMust be moved in supine position\nMust be immobilized Moving a patient on stairs with a stretcher (cont\u2019d)\nCarry the patient on the backboard down to the prepared stretcher. \nPlace the strongest EMTs at the head and foot ends, with the taller person at the foot end.\nPlace both the backboard and the patient on the stretcher; secure both to the stretcher with additional straps. Loading a wheeled stretcher into an ambulance\nEnsure the frame is held firmly between two hands so it does not tip. FIGURE 8-12 Make sure that you hold the main frame of the stretcher when it is elevated so that even when the patient moves, the stretcher does not tip over. \u00a9 Jones & Bartlett Learning. Loading a wheeled stretcher into an ambulance (cont\u2019d)\nNewer models are self-loading, allowing you to push the stretcher into the ambulance.\nOther models need to be lowered and lifted to the height of the floor of ambulance.\nClamps in the ambulance hold the stretcher in place.",
        "Directions and Commands": "Team actions must be coordinated.\nTeam leader\nIndicates where each team member should be\nRapidly describes the sequence of steps to perform before lifting Preparatory commands are used.\nExample:\nTeam leader says, \u201cAll ready to stop,\u201d to get team\u2019s attention.\nTeam leader says, \u201cStop!\u201d in a louder voice.\nCountdowns are also used. Carefully plan ahead.\nSelect the methods that will involve the least amount of lifting and carrying. \nConsider whether there is an option that will cause less strain.",
        "Emergency Moves": "Use when there is potential for danger.\nUse when you cannot properly assess the patient or provide immediate care because of the patient\u2019s location or position. Use techniques to help prevent aggravation of patient spinal injury.\nClothes drag\nBlanket drag\nArm drag\nArm-to-arm drag FIGURE 8-14 Dragging methods. A. Emergency clothes drag. B. Blanket drag. C. Arm drag. D. Arm-to-arm drag. A-D: \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS To remove an unconscious patient from a vehicle alone:\nMove the patient\u2019s legs clear of the pedals.\nRotate the patient so the back is toward the open car door.\nPlace your arms through the armpits and support the head against your body.\nDrag the patient from the seat to a safe location. FIGURE 8-15 One-person technique for moving an unresponsive patient from a vehicle. A. Grasp the patient under the arms. B. Lower the patient down into a supine position. A, B: \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS.",
        "Urgent Moves": "Necessary to move patient:\nWith altered level of consciousness\nWith inadequate ventilation\nIn shock\nIn extreme weather conditions\nRapid extrication technique requires a team of knowledgeable EMTs. Rapid extrication technique should be used only if urgency exists.\nThe patient can be moved within 1 minute.\nThis techniques increases the risk of damage if the patient has a spinal injury.\nLook at all options before using an urgent move.",
        "Nonurgent Moves": "Used when both the scene and the patient are stable\nCarefully plan how to move the patient.\nTeam leader should plan the move.\nPersonnel\nObstacles identified\nEquipment\nProcedure and path Choose between:\nDirect ground lift \nFor patients with no suspected spinal injury who are supine\nPatients who need to be carried over some distance\nEMTs stand side by side to lift and carry the patients. Extremity lift \nFor those patients with no suspected spinal injury who are supine or sitting\nHelpful when the patient is in a small space\nOne EMT is at the patient\u2019s head and the other at the patient\u2019s feet.\nCoordinate moves verbally. Transfer moves\nDirect carry \nMove supine patient from bed to stretcher using a direct carry method\nDraw sheet method\nMove patient from bed to stretcher using a sheet or blanket\nScoop stretcher",
        "Geriatrics": "Most patients transported by EMS are geriatric patients.\nSkeletal changes may cause brittle bones, rigidity, and spinal curvatures that present special challenges.\nAllay the patient\u2019s fears with a sympathetic and compassionate approach. Kyphosis Spondylosis \u00a9 Dr. P. Marazzi/Photo Researchers, Inc. \u00a9 Dr. P. Marazzi/Photo Researchers, Inc.",
        "Bariatrics": "Refers to management of obesity\n76 million US adults are obese.\n30\u201340% of adults are obese.\nApproximately 17% of children are obese.\nBack injuries account for the largest number of missed days of work. Stretchers and equipment are being produced with higher capacities.\nDoes not address danger to users of that equipment \nMechanical ambulance lifts are uncommon in the United States.",
        "Additional Patient-Moving Equipment": "Bariatric stretchers\nSpecialized for overweight or obese patients\nWider wheelbase for increased stability FIGURE 8-20 A bariatric stretcher. Courtesy of Stryker Medical, a division of Stryker Corporation. Pneumatic and electronic-powered wheeled stretchers\nLimit the risk of injury to providers and patients FIGURE 8-21 An electronic stretcher Courtesy of Stryker Medical, a division of Stryker Corporation. Portable/folding stretchers\nStrong, rectangular tubular metal frame with fabric stretched across it\nUsed in areas that are difficult to reach FIGURE 8-22 A portable stretcher. \u00a9 Steve Gorton/Getty. Flexible stretchers\nExcellent for storage and carrying\nConform around a patient\u2019s sides\nUseful for confined spaces FIGURE 8-23 A flexible stretcher. \u00a9 American Academy of Orthopaedic Surgeons. Short backboards \nUsed to immobilize seated patients\nExample: the KED vest-type device FIGURE 8-24 The Kendrick extrication device (KED) is a vest-type immobilization device. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS. Vacuum mattresses\nAlternative to backboards for immobilizing geriatric and pediatric patients\nAir is removed from the device, allowing it to mold around the patient.\nProvides immobilization, comfort, and thermal insulation Basket stretchers\nRigid stretcher \nUsed for patient removal in remote locations, including in water rescues and technical rope rescues FIGURE 8-26 A basket stretcher. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS. Basket stretchers (cont\u2019d)\nIf the patient has a spinal injury, secure the patient to the backboard and place it inside the basket stretcher to carry the patient out of the location.\nWhen you return to ambulance, lift the backboard out of basket stretcher and place it on the wheeled stretcher. Scoop stretchers\nSplits into two or four pieces\nPieces fit around patient who is lying on flat surface, and then reconnect.\nBoth sides of the patient must be accessible.\nThe patient must be stabilized and secured on a scoop stretcher. Neonatal isolette\nNeonates cannot be transported on a wheeled stretcher.\nThe isolette keeps the neonate warm, and protects the child from noise, draft, infection, and excess handling.\nThe isolette may be secured to a wheeled ambulance stretcher or freestanding.",
        "Decontamination Decontaminate equipment after use for:": "Your safety\nThe safety of the crew\nThe safety of the patient\nPreventing the spread of disease",
        "Patient Positioning": "Proper position depends on the chief complaint.\nA patient reporting chest pain or respiratory distress should be placed in a position of comfort\u2014typically a Fowler or semi-Fowler position. \nPatients in shock should be placed supine. Proper position (cont\u2019d)\nPatients in late stages of pregnancy should be positioned and transported on their left side.\nAn unresponsive patient with no suspected spinal injury should be placed in the recovery position. \nA patient who is nauseated or vomiting should be transported in a position of comfort.",
        "Medical Restraints": "Evaluate for correctible causes of combativeness.\nHead injury, hypoxia, hypoglycemia\nFollow local protocols.\nRestraint requires five personnel.\nRestrain the patient in a supine position. \nPositional asphyxia may develop in the prone position. Apply a restraint to each extremity.\nAssess ABCs, mental status, and distal circulation after restraints are applied.\nDocument all information.",
        "Personnel Considerations Questions to ask before moving patient:": "Am I physically strong enough to lift/move this patient?\nIs there adequate room to get the proper stance to lift the patient?\nDo I need additional personnel for lifting assistance?\nInjured EMTs cannot help anyone."
    },
    {
        "National EMS Education Standard Competencies": "Special Patient Populations\nApplies a fundamental knowledge of growth, development, and aging and assessment findings to provide basic emergency care and transportation for a patient with special needs. Patients With Special Challenges\nHealth care implications of\nHomelessness\nPoverty\nBariatrics\nTechnology dependent Patients With Special Challenges (cont\u2019d)\nHealth care implications of (cont\u2019d)\nHospice/terminally ill\nTracheostomy care/dysfunction\nHome care\nSensory deficit/loss\nDevelopmental disability Trauma\nApplies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely injured patient. Special Considerations in Trauma\nPathophysiology, assessment, and management of trauma in the\nCognitively impaired patient",
        "Introduction": "Today, more people with chronic diseases live at home.\nShorter hospitalization\nImprovements in medicine and technology\nPatients with special challenges:\nPatients with diseases resulting in altered body function\nPatients with sensory deficits\nGeriatric patients with chronic diseases Some patients depend on mechanical ventilation, intravenous pumps, and other devices.\nDo not be distracted by the equipment!\nFocus on the patient.",
        "Developmental disability": "Conditions that may impair development with physical ability, learning, language development, or behavioral coping skills.\nIntellectual disability\nSubset of developmental disability\nSignificant limitations in intellectual functioning and skills needed for daily living Possible causes\nGenetic factors\nCongenital infections\nMalnutrition\nEnvironmental factors\nFetal alcohol syndrome\nTraumatic brain injury \nPoisoning Rely on patients and family members for information. \nPatient may have difficulty adjusting to change or a break in routine.\nPatients with intellectual disabilities are susceptible to the same diseases as other patients.",
        "Autism Spectrum Disorder": "Intellectual disability characterized deficits in social communication along with restrictive, repetitive patterns of behavior, interests, and activities. Often have abnormal sensory responses\nMay not feel cold, heat, or pain as others do\nMay respond to pain by laughing, humming, singing, or removing clothing\nMay have increased sensitivity to noise or physical stimulation\nKeep the environment calm and minimize stimulation. Increased sensitivity to noise or physical stimulation (cont\u2019d)\nDemonstration of examination techniques on a trusted individual may comfort the patient.\nUse short, direct and simple phrases when communicating.\nAllow extra time for the patient to process the communication if possible.",
        "A genetic chromosomal defect that can occur during fetal development": "Results in mild to severe intellectual impairment\nIncreased maternal age and family history are known risk factors. Physical abnormalities\nRound head with flat occiput\nEnlarged, protruding tongue\nSlanted, wide-set eyes FIGURE 37-1 A child with Down syndrome. \u00a9 PhotoCreate/Shutterstock. Increased risk for medical complications\nLeukemia\nCongenital heart defects\nIntubation may be difficult due to large tongues and small oral and nasal cavities.\nMask ventilation can be challenging.\nJaw-thrust maneuver or a nasopharyngeal airway may be necessary. Management of seizures is the same for any other patent.\nThe atlantoaxial joint is unstable in approximately 15% of patients with Down syndrome. \nIncreased risk of complications when they experience trauma",
        "Patient Interaction Approach in a calm, friendly manner.": "Establish rapport.\nIntroduce your team members.\nExplain what you are doing.\nMove slowly but deliberately.\nStay at eye level with the patient.",
        "Brain Injury Patients with a prior brain injury may be difficult to treat.": "Talk with patient and family. \nEstablish what is considered normal for the patient.\nExplain procedures and reassure patient.",
        "Possible causes": "Congenital defect\nDisease\nInjury\nDegeneration of the eyeball optic nerve or nerve pathway Range in degree of visual impairment \nSome patients lose peripheral or central vision.\nSome can distinguish light from dark or shapes.\nVisual impairments may be difficult to recognize. Patient interaction\nMake yourself known when you enter.\nIntroduce yourself and your team.\nRetrieve any visual aids and give them to your patient.\nPatient may feel vulnerable and disoriented.\nDescribe the situation and surroundings to the patient. Transport considerations\nTake cane or walker, if used.\nMake arrangements for care or accompaniment of service animal.\nPatients should be gently guided, never pulled or pushed. \nCommunicate obstacles in advance.",
        "Hearing Impairment": "Problems range from slight hearing loss to total deafness.\nMany older people have some hearing loss.\nSensorineural deafness is caused by nerve damage.\nConductive hearing loss is caused by faulty transmission of sound waves. Clues that a person could be hearing impaired \nPresence of hearing aids\nPoor pronunciation of words\nFailure to respond to your presence or questions",
        "Communication With Hearing Impaired Patient": "Assist the patient with finding and inserting any hearing aids.\nFace the patient while you communicate.\nDo not exaggerate your lip movements or look away.\nPosition yourself approximately 18 inches directly in front of the patient. Do not speak louder; try lowering the pitch of your voice. \nAmerican Sign Language may be useful.\nProvide paper and a pencil.\nOnly one person ask questions.\n\u201cReverse stethoscope\u201d FIGURE 37-3 Consider learning common terms in American Sign Language related to illness and injury. A. Sick. B. Hurt. C. Help A, B, C: \u00a9 Jones & Bartlett Learning. Photographed by Glen E. Ellman.",
        "Hearing aids make sound louder.": "May be external or internal\nSeveral types are available.\nBehind-the-ear, conventional body, in-the-canal, in-the-ear\nDevice should fit snugly.\nIf whistling occurs, it may not be in far enough. FIGURE 37-4 Different types of hearing aids. A. Behind-the-ear. B. Conventional body. C. In-the-canal. D. In-the-ear.\nE. Completely in-the-canal. A: \u00a9 Piotr Marcinski/Shutterstock; B: \u00a9 Stine Lise Nielsen/Shutterstock; C: \u00a9 Steve Hamblin/Alamy; \nD: \u00a9 Terry Smith Images/Alamy; E: \u00a9 Jiri Hera/Shutterstock.",
        "Group of disorders characterized by poorly controlled body movement": "Possible causes\nDamage to the developing brain in utero\nOxygen deprivation at birth\nTraumatic brain injury \nInfection such as meningitis during early childhood Symptoms\nPoor posture \nUncontrolled, spastic movements\nVisual and hearing impairments\nDifficulty communicating\nUnsteady gait FIGURE 37-5 A person with cerebral palsy. \u00a9 Sally and Richard Greenhill/Alamy. Considerations\nObserve airway closely and suction as needed. \nDo not assume intellectual disability.\nUnderdeveloped limbs are prone to injury.\nAtaxic or unsteady gait makes patients prone to falls. \nPatient may have special pillow or chair. Considerations (cont\u2019d)\nPad the patient to ensure comfort.\nNever force extremities into position. \nWhenever possible, take walkers or wheelchairs along during transport. \nBe prepared for a seizure, and keep suctioning available.",
        "Birth defect caused by incomplete closure of spinal column": "Spinal cord is exposed. \nOpening can be closed surgically, but often leaves spinal damage. FIGURE 37-6 Spina bifida is one of the most common\ndisabling birth defects in the United States. \u00a9 Biophoto Associates/Photo Researchers, Inc. Associated conditions\nHydrocephalus (requires shunt)\nPartial or full paralysis of the lower extremities\nLoss of bowel and bladder control\nExtreme latex allergy",
        "Paralysis": "Inability to voluntarily move body parts\nCauses: stroke, trauma, birth defects\nMay have normal sensation or hyperesthesia\nMay cause communication challenges\nDiaphragm may not function correctly (requires ventilator). Specialized equipment \nUrinary catheters\nTracheostomy tubes\nColostomy bags\nFeeding tubes\nDifficulty swallowing may require suctioning.\nAsk patients how it is best to move them before you transport them.",
        "Bariatric Patients": "Obesity: person has excessive body fat.\nObese: 30% over ideal body weight\nSevere obesity: 2\u20133 times over the ideal weight\nImbalance between calories consumed and calories used\nMay be attributed to low metabolic rate or genetic predisposition Quality of life is negatively affected.\nAssociated health problems\nMobility difficulties\nDiabetes\nHypertension\nHeart disease\nStroke",
        "Interaction with Patients with Obesity": "Patient may be embarrassed.\nPlan early for extra help or equipment.\nFind easiest and safest exit.\nDo not risk dropping the patient or injuring a team member. Treat the patient with dignity and respect.\nAsk your patient how it is best to move him or her before attempting to do so. \nAvoid trying to lift the patient by one limb, which would risk injury to overtaxed joints. \nCoordinate and communicate all moves to all team members prior to starting to lift. If the move becomes uncontrolled at any point, stop, reposition, and resume. \nLook for pinch or pressure points from equipment (deep venous thrombosis).\nLarge patients may have difficulty breathing if you lay them in a supine position. Specialized equipment is available.\nBecome familiar with the resources available in your area. \nPlan egress routes.\nNotify the receiving facility early.",
        "Tracheostomy Tubes": "Tracheal stoma provides a path between the neck and the trachea.\nKept open by plastic tracheostomy tube  \nTubes bypass nose and mouth\nTemporary or permanent\nFor patients who depend on home automatic ventilators and have chronic pulmonary illness Tubes are prone to obstruction by mucus or foreign bodies\nEmergency event FIGURE 37-7 Some patients require a tracheostomy tube to breathe. Portex\u00ae Blue Line\u00ae Ultra Tracheostomy courtesy of Smiths Medical. DOPE mnemonic helps recognize causes of obstruction.\nDisplacement, dislodged, or damaged tube\nObstruction of the tube \nPneumothorax\nEquipment failure Common problems\nBleeding or air leaking around the tube\nTube can become loose or dislodged.\nOpening around the tube may become infected. Management\nMaintain an open airway.\nSuction tube if necessary to clear a mucus plug.\nMaintain the patient in a position of comfort.\nAdminister supplemental oxygen.\nProvide transport to the hospital.",
        "Two types of oxygen delivery devices": "Oxygen from a gas cylinder\nOxygen concentrator\nCompressed oxygen cylinders\nDo not require oxygen or complex machinery\nHeavy, bulky, and can be difficult to transport\nWill run out of gas\nPatients coordinate pickup and delivery of cylinders. Home oxygen concentrator\nTakes ambient air and scrubs out the nitrogen\nCan provide an unlimited supply of oxygen\nRequires a reliable source of electricity\nPatient must have a backup compressed gas cylinder in case of power failure. Ask the patient:\nWhy they are on home oxygen\nHow long they have been on home oxygen\nBaseline home oxygen requirement\nBaseline oxygen saturation",
        "Mechanical Ventilators": "Used when patients cannot breathe without assistance\nPossible causes\nCongenital defect\nChronic lung disease\nTraumatic brain injury\nMuscular dystrophy If ventilator malfunctions:\nRemove patient from ventilator.\nApply a tracheostomy collar.\nDesigned to cover the tracheostomy hole\nMay not be available in prehospital setting\nCan improvise by placing a face mask over the stoma Caregivers will know how the equipment works. FIGURE 37-10 A home ventilator. \u00a9 ResMed 2010. Used with permission.",
        "Apnea Monitors": "Used for infants who:\nAre premature and have severe gastroesophageal reflux \nHave family history of SIDS \nExperienced a life-threatening event Used 2 weeks to 2 months after birth to monitor the respiratory system\nSounds an alarm if the infant experiences bradycardia or apnea\nAttached with electrodes or belt around the infant\u2019s chest or stomach\nProvides a pulse oximetry reading",
        "Internal Cardiac Pacemakers Implanted under skin to regulate heart rate": "On nondominant side of the patient\u2019s chest \nMay include automated implanted defibrillator \nNever place defibrillator paddles or pacing patches directly over the implanted device.\nGather information about the type of cardiac pacemaker when obtaining history.",
        "Left Ventricular Assist Devices Takes over the function of either one or both heart ventricles": "Typically used as a bridge to heart transplantation\nMay be difficult to palpate a pulse\nProvide support measures and basic care.\nUse the caregiver as a resource.\nBe prepared to provide CPR.",
        "External Defibrillator Vest Vest with built-in monitoring electrodes and defibrillation pads": "Worn by the patient under his or her clothing \nAttached to a monitor that provides alerts and delivers a shock\nIf patient is in cardiac arrest, vest should remain in place while you perform CPR.",
        "Central Venous Catheter": "Catheter with its tip placed in vena cava to provide venous access\nUsed for many types of home care patients \nCommon locations\nChest\nUpper arm\nSubclavicular area FIGURE 37-13 Patients who require frequent intravenous\nmedications may have a central line in place. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS. Common problems \nBroken lines\nInfections around the lines\nClotted lines\nBleeding around the line or from the tubing attached to the line",
        "Gastrostomy Tubes": "Placed into the stomach for patients who cannot ingest fluids, food, or medication by mouth \nMay be inserted through the nose or mouth into the stomach\nMay be placed surgically directly into the stomach through the abdominal wall FIGURE 37-14 Gastric tubes may be placed through the\nskin into the stomach for children or adults who cannot be\nfed by mouth. \u00a9 DELOCHE/age fotostock. May become dislodged \nImmediately stop the flow of any fluids.\nAssess for signs or symptoms of bleeding into the stomach.\nVague abdominal discomfort\nNausea\nVomiting (especially \u201ccoffee ground\u201d emesis)\nBlood in emesis Increased risk of aspiration\nAlways have suction readily available.\nPatients with difficulty breathing should be transported while sitting or lying on their right side with head elevated 30\u00b0.\nContinue tube feeding unless the tube is dysfunctional, dislodged, or partially dislodged.",
        "Shunts": "For patients with chronic neurologic conditions \nTubes that drain excess cerebrospinal fluid \nFluid reservoir\nDevice beneath skin on side of head, behind the ear\nShould alert you to the presence of a shunt Types \nVentricular peritoneum shunt\nVentricular atrium shunt\nBlocked/infected shunt may cause changes in mental status and respiratory arrest.\nInfection may occur within 2 months of insertion. Signs of distress\nHigh-pitched cry or bulging fontanelles\nHeadache\nProjectile vomiting\nAltered mental status\nIrritability\nFever\nNausea Signs of distress (cont\u2019d)\nDifficulty with coordination (walking)\nBlurred vision\nSeizures\nRedness along shunt track\nBradycardia\nHeart dysrhythmias",
        "Vagus Nerve Stimulators": "Treatment for seizures not controlled with medication\nSurgically implanted \nStimulate the vagus nerve to prevent seizure activity Used in children older than 12 years\nLocated under the patient\u2019s skin \nAbout the size of a silver dollar\nIf you encounter a patient with this device, contact medical control or follow your local protocols.",
        "Colostomy or ileostomy": "Procedure that creates opening between the small or large intestine and the surface of the body \nAllows for elimination of waste products into a clear, external bag or pouch \nEmptied or changed frequently",
        "Assess for dehydration if the patient has been complaining of diarrhea or vomiting.": "Area around the stoma is prone to infection. \nSigns of infection:\nRedness\nWarm skin around the stoma\nTenderness over the colostomy or ileostomy site",
        "Urostomy": "Surgical procedure that connects the urinary system to the surface of the skin\nAllows urine to drain through a stoma in the abdominal wall\nContact medical control or follow local protocols for care of a patient with a colostomy, ileostomy, or urostomy bag.",
        "Patient Assessment Guidelines Interaction with caregiver is an important part of patient assessment process.": "They are experts on caring for these patients.\nDetermine patient\u2019s normal baseline status before assessment.\nAsk, \u201cWhat is different today?\u201d",
        "Occurs within home environment": "Represents a spectrum of populations\nInfants, older adults, chronic illness, developmental disabilities\nServices: delivering meals, cleaning, laundry, maintenance, physical therapy, personal care EMS may be called to residence by home care provider.\nObtain baseline health status and history from home care provider.",
        "Hospice Care and Terminally Ill Patients": "Terminally ill may receive hospice care at a hospice facility or at home.\nMost have DNR order.\nMay have medical orders for scope of treatment Comfort care \nPalliative care (pain medications)\nImproves quality of life before patient dies\nFollow local protocol, patient\u2019s wishes, legal documents. \nBring documentation to the hospital. \nShow compassion, understanding, and sensitivity. Ascertain the family\u2019s wishes regarding transport.\nAllow family member to accompany the patient.\nFollow local protocols for handling the death of a patient.",
        "Poverty and Homelessness": "Unable to provide for basic needs\nDisease prevention strategies are absent.\nLeads to increased probability of disease\nHomeless population includes:\nPatients with mental illness or prior brain trauma\nDomestic violence victims\nAddicts\nImpoverished families Advocate for all patients. \nAll health care facilities must provide assessment and treatment regardless of the patient\u2019s ability to pay.\nBecome familiar with social services resources within your community."
    },
    {
        "National EMS Education Standard Competencies": "Preparatory\nApplies fundamental knowledge of the emergency medical services (EMS) system, safety/well-being of the emergency medical technician (EMT), medical/legal, and ethical issues to the provision of emergency care. Medical/Legal and Ethics\nConsent/refusal of care\nConfidentiality\nAdvance directives\nTort and criminal actions\nEvidence preservation\nStatutory responsibilities Medical/Legal and Ethics (cont\u2019d)\nMandatory reporting\nEthical principles/moral obligations\nEnd-of-life issues",
        "Introduction A basic principle of emergency care is to do no further harm.": "A health care provider usually avoids legal exposure if he or she acts:\nIn good faith\nAccording to an appropriate standard of care",
        "Consent is permission to render care.": "A person must give consent for treatment.\nIf the patient is conscious and rational, he or she has a legal right to refuse care. Foundation of consent is decision-making capacity.\nCan understand information provided\nCan make informed choice regarding medical care\nPatient autonomy is the right of the patient to make decisions about his or her health.",
        "Expressed Consent The patient acknowledges he or she wants you to provide care or transport.": "To be valid, the patient must provide informed consent.\nYou have explained the treatment, risks, and benefits to the patient.",
        "Applies to patients who are": "Unconscious\nOtherwise incapable of making an informed decision FIGURE 3-1 When a serious threat to life exists and the patient is unconscious or otherwise unable to give consent, the law assumes that the patient would give consent to care and transport to the hospital. \u00a9 Genaro Molina/Los Angeles Times/Getty Images Should never be used unless there is a threat to life or limb.\nPrinciple of implied consent is known as the emergency doctrine.\nTry to get consent from a spouse or relative.",
        "Involuntary Consent Applies to patients who are:": "Mentally ill\nIn behavioral crisis\nDevelopmentally delayed\nObtain consent from guardian or conservator.\nNot always possible, so understand local provisions",
        "Minors and Consent": "Parent or legal guardian gives consent.\nIn some states, a minor can give consent.\nEmancipated minors (married, armed services, parents)\nTeachers and school officials may act in place of parents. If true emergency exists, and no consent is available:\nTreat the patient.\nConsent is implied. FIGURE 3-2 The law requires that a parent or a legal guardian give consent for treatment or transport of a minor. However, you must never withhold life-saving care. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS",
        "Forcible Restraint": "Sometimes necessary with combative patient\nLegally permissible\nConsult medical control \nMay require law enforcement Once applied do not remove restraints en route unless they pose a risk to the patient.\nConsider calling ALS backup to provide chemical pharmacological restraint.",
        "Conscious, alert adults with decision-making capacity:": "Have the right to refuse treatment\nCan withdraw from treatment at any time, even if the result is death or serious injury\nCalls involving refusal are frequently litigated.\nInvolve online medical control and document this consultation. Assess the patient\u2019s ability to make an informed decision:\nAsk and repeat questions.\nAssess the patient\u2019s answers. \nObserve the patient\u2019s behavior. \nIf the patient appears confused or delusional, you cannot assume that the decision to refuse is an informed refusal. Providing treatment is a much more defensible position than failing to treat a patient.\nDo not endanger yourself.\nUse the assistance of law enforcement. Before you leave a scene where a patient, parent, or caregiver has refused care:\nEncourage the individual again to allow care.\nAsk the individual to sign a refusal of care form.\nA witness is valuable in these situations.\nDocument all refusals.",
        "Confidential information includes:": "Patient history \nAssessment findings \nTreatment provided \nInformation generally cannot be disclosed except:\nIf the patient signs a release\nIf a legal subpoena is presented\nIf it is needed by billing personnel Health Insurance Portability and Accountability Act of 1996 (HIPAA)\nContains a section on patient privacy\nStrengthens privacy laws\nSafeguards patient confidentiality\nConsiders information to be protected health information (PHI) Failure to abide by the provisions of HIPAA laws can result in civil and/or criminal action.\nThe general public is often permitted by law to record identifying and protected patient information and images. Social media\nAvoid agency logos, uniforms, vehicles, or other markings associated with your agency while off duty.\nConduct yourself professionally on and off duty.\nFree speech does not mean that everyone has a right to say anything under any circumstances and without repercussions.",
        "An advance directive specifies treatment should the patient become unconscious or unable to make decisions.": "A do not resuscitate (DNR) order is an advance directive that gives permission not to resuscitate.\n\u201cDo not resuscitate\u201d does not mean \u201cdo not treat.\u201d Other names for advance directives:\nLiving will\nHealth care directive\nDNR orders must meet the following requirements:\nStatement of the patient\u2019s medical problem(s) \nSignature of the patient or legal guardian \nSignature of physician or health care provider \nNot expired FIGURE 3-4 A. An example of a wallet-sized DNR order. \u00a9 Jones & Bartlett Learning. Physician orders for life-sustaining treatment (POLST) and medical orders for life-sustaining treatment (MOLST): \nExplicitly describe acceptable interventions for the patient\nMust be signed by an authorized medical provider\nContact medical control for guidance. Some patients may have named surrogates to make decisions for them.\nDurable powers of attorney for health care\nAlso known as health care proxies\nDue to the growing number of hospice home health programs, you may face this situation.",
        "Physical Signs of Death": "A physician determines the cause of death.\nPresumptive signs of death:\nUnresponsiveness to painful stimuli\nLack of a carotid pulse or heartbeat\nAbsence of breath sounds\nNo deep tendon or corneal reflexes Presumptive signs of death (cont\u2019d):\nAbsence of eye movement\nNo systolic blood pressure\nProfound cyanosis\nLowered or decreased body temperature Definitive signs of death:\nA body in parts (decapitation)\nDependent lividity (blood settling) FIGURE 3-5 Dependent lividity is an obvious sign of death caused by discoloration of the body from pooling of the blood to the lower parts of the body. \u00a9 American Academy of Orthopaedic Surgeons. Definitive signs of death (cont\u2019d):\nRigor mortis (stiffening)\nOccurs between 2\u201312 hours after death\nAlgor mortis\nCooling of the body until it matches the ambient environment \nPutrefaction (decomposition)\nOccurs between 40\u201396 hours after death",
        "Medical Examiner Cases": "Involvement depends on nature/scene of death.\nExaminer notified in cases of:\nDead on arrival (DOA)/dead on scene (DOS)\nDeath without previous medical care\nSuicide\nViolent death\nPoisoning, known or suspected Examiner notified in cases of (cont\u2019d):\nDeath from accidents\nSuspicion of a criminal act\nInfant and child deaths",
        "Special Situations": "Organ donors\nExpressed a wish to donate their organs\nEvidenced by information on: \nOrgan donor card and/or\nDriver\u2019s license \nYour priority is to save the patient\u2019s life.\nRemember that organs need oxygen. FIGURE 3-7 The patient may be carrying a donor card or\ndriver\u2019s license indicating that he or she wishes to be an\norgan donor. Courtesy of the U.S. Department of Health and Human Services. Medical identification insignia\nBracelet, necklace, keychain, or card indicating:\nDNR order\nAllergies\nDiabetes, epilepsy, or other serious condition\nSome patients wear a medical bracelet with a USB flash drive. FIGURE 3-8 The patient may be carrying a medical identification card or wearing a bracelet or necklace that indicates important medical information and possible DNR orders. In the case of MedicAlert, the EMS provider can obtain stored patient history information from the MedicAlert Foundation. \u00a9 Lucas Oleniuk/Contributor/Toronto Star/Getty Images",
        "Outlines the care you are able to provide": "Usually defined by state law\nMedical director further defines by developing:\nProtocols\nStanding orders Carrying out procedures outside scope of practice may be considered:\nNegligence\nCriminal offense",
        "Manner in which you must act or behave": "You must be concerned about the safety and welfare of others. FIGURE 3-9 Act or behave toward others in a way that shows your concern about their safety and welfare. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS. Standards of care are established by: \nLocal custom\nLaw\nStatutes, ordinances, administrative regulation, or case law \nProfessional or institutional standards\nExample: AHA CPR guidelines\nTextbooks \nExample: NHTSA Standards of care established by (cont\u2019d): \nStandards imposed by states\nMedical Practices Act\nCertification\nLicensure\nCredentialing",
        "Duty to Act Individual\u2019s responsibility to provide patient care": "Duty to act applies:\nOnce your ambulance responds to a call\nOnce treatment is begun",
        "Failure to provide same care that person with similar training would provide in same or similar situation All four of the following elements must be present for negligence to apply:": "Duty\nBreach of duty\nDamages\nCausation Res ipsa loquitur\nThe cause of the injury was in the control of the EMT, generally does not occur unless there is negligence.\nNegligence per se\nThe conduct of the person being sued is alleged to that occurred in clear violation of a statute.\nTorts\nCivil wrongs",
        "Abandonment Unilateral termination of care by EMT without:": "Patient\u2019s consent\nMaking provisions for continuing care\nAbandonment may take place: \nAt the scene \nIn the emergency department\nAlways obtain a signature on your patient care record",
        "Assault and Battery, and Kidnapping": "Assault: unlawfully placing person in fear of immediate bodily harm\nExample: restraint\nBattery: unlawfully touching a person\nExample: providing care without consent Kidnapping: seizing, confining, abducting, or carrying away by force\nExample: transport against will\nFalse imprisonment: unauthorized confinement of a person",
        "Defamation Communication of false information that damages reputation of a person": "Libel: written\nSlander: spoken",
        "Good Samaritan Laws and Immunity": "If you reasonably help another person, you will not be held liable for errors or omissions.\nGood Samaritan conditions to be met:\nGood faith\nWithout expectation of compensation\nWithin scope of training\nDid not act in grossly negligent manner Gross negligence: conduct that constitutes willful or reckless disregard\nImmunity statutes apply to EMS systems that are considered governmental agencies.\nSovereign immunity: provides limitations on liability and immunity is not complete",
        "Records and Reports": "Compile a record of all incidents involving sick or injured patients.\nImportant safeguard against legal complications\nCourts consider:\nAn action not recorded was not performed.\nIncomplete or untidy reports is evidence of poor emergency medical care. National EMS Information System (NEMSIS) \nProvides the ability to collect, store, and share standardized EMS data \nUsed to improve the speed and accuracy of data collection",
        "Special Mandatory Reporting Requirements": "Most states have a reporting obligation:\nAbuse of children, older persons, and others\nInjury during commission of a felony\nDrug-related injuries\nChildbirth Most states have a reporting obligation (cont\u2019d):\nAttempted suicides\nDog bites\nCommunicable diseases\nAssaults\nDomestic violence Most states have a reporting obligation (cont\u2019d):\nSexual assault or rape\nExposures to infectious disease\nTransport of patients in restraints\nScene of a crime\nThe deceased",
        "Ethical Responsibilities": "Ethics: philosophy of right and wrong, moral duties, and ideal professional behavior\nMorality: code of conduct affecting character, conduct, and conscience\nBioethics: specifically addresses issues that arise in the practice of health care Require you to evaluate and apply ethical standards\nYour own\nThose of the profession\nAllow rules, laws, and policies to guide your decision making.",
        "The EMT in Court": "You can end up in court as:\nA witness\nA defendant\nCase can be civil or criminal. FIGURE 3-12 Court discussions will be based on your\ndocumentation. Make sure your documentation is\nthorough and accurate. \u00a9 Brand X Pictures/Creatas. Whenever called to testify, notify:\nYour service director\nLegal counsel\nAs witness:\nRemain neutral.\nReview run report before court. As a defendant, an attorney is required.\nDefenses may include:\nStatute of limitations \nGovernmental immunity\nContributory negligence Discovery allows both sides to obtain more information through:\nInterrogatories \nWritten requests or questions\nDepositions\nOral requests or questions Most cases are settled following the discovery phase during the settlement phase.\nIf not settled, the case goes to trial.\nDamages that may be awarded:\nCompensatory damages\nPunitive damages Any EMT charged with a criminal offense should secure the services of a highly experienced criminal attorney immediately."
    },
    {
        "National EMS Education Standard Competencies": "Medicine\nApplies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely ill patient. Infectious Diseases\nAwareness of\nHow to decontaminate equipment after treating a patient \nAssessment and management of\nHow to decontaminate the ambulance and equipment after treating a patient Preparatory\nApplies fundamental knowledge of the emergency medical services (EMS) system, safety/well-being of the emergency medical technician (EMT), medical/legal, and ethical issues to the provision of emergency care. Workforce Safety and Wellness\nStandard safety precautions\nPersonal protective equipment\nStress management\nDealing with death and dying\nPrevention of response-related injuries Workforce Safety and Wellness (cont'd)\nPrevention of work-related injuries\nLifting and moving patients\nDisease transmission\nPrinciples of wellness and resilience",
        "Introduction To take care of others, we must take care of ourselves.": "Recognition of hazards:\nPersonal neglect\nEnvironmental and human-made threats\nMental and physical stress",
        "Health is a complex interaction between physical, mental, and emotional connections.": "Chronic physical, mental, or emotional stresses can worsen or increase the chance for developing health conditions.",
        "Not all reactions to stress are negative.": "Eustress (good stress) creates a positive response.\nDistress causes a negative stress response.",
        "Wellness is the active pursuit of a state of good health.": "Resilience is the capacity of an individual to cope with and recover from distress.\nEat a healthy and well-balanced diet.\nEnsure a minimum of 7 to 9 hours of sleep.\nStrengthen positive relationships with family and friends.",
        "Build relationships with peers and colleagues.": "Incorporate daily stretching, movement, and exercise.\nBuild habits of mindfulness and positivity.",
        "Strategies to Manage Stress": "Minimize or eliminate stressors.\nChange partners to avoid a negative or hostile personality.\nChange work hours.\nChange the work environment.\nCut back on overtime. Change your attitude about the stressor.\nTalk about your feelings.\nSeek professional counseling if needed.\nDo not obsess over frustrating situations.\nTry to adopt a relaxed, philosophical outlook. Expand your social support system.\nDevelop friends and interests outside emergency services.\nLimit intake of caffeine, alcohol, and tobacco.",
        "Nutrition Eat regular, well-balanced meals.": "Limit consumption of sugars, fats, sodium, and alcohol.\nMaintain adequate fluid intake. FIGURE 2-1 The USDA\u2019s MyPlate icon emphasizes healthy portions of vegetables, fruits, grains, proteins, and dairy. Courtesy of the USDA Center for Nutrition Policy and Promotion.",
        "Exercise and Relaxation Regular exercise enhances the benefits of good nutrition and adequate hydration.": "Good physical condition allows you to handle stress more easily.\nEngage in at least 30 minutes of moderate or vigorous physical activity 5 days per week.",
        "The National Sleep Foundation and the American Academy of Sleep Medicine recommend 7 to 9 hours of sleep per night.": "Half of EMS personnel get less than 6 hours of sleep per 24 hours and report severe mental and physical fatigue.\nEvidence-based guidelines for fatigue management have been developed under the US DOT and through the National Association of State EMS Officials. Recommendations to combat fatigue\nGet an adequate duration and quality of sleep.\nTake 20- to 30- minute naps during shift work.\nIncrease physical activity.\nBe careful about caffeine consumption.\nEngage in mental exercise. Recommendations to improve sleep quality\nAvoid caffeine and nicotine for at least 4 hours before bedtime.\nEnsure your sleep environment is dark, quiet, and cool.\nExercise early and allow enough time to relax.\nNap early.\nAvoid heavy presleep meals.\nBalance fluid intake. Establish a calming presleep routine.\nSleep when truly tired.\nDon\u2019t watch the clock.\nKeep a consistent sleep schedule.\nExpose yourself to natural light during your waking hours.",
        "Disease Prevention and Health Promotion": "Disease prevention\nFocuses on medical care and prevention to avoid the effects of disease\nHealth promotion\nFocuses on personal practices and social habits to improve one\u2019s health Smoking, vaping or chewing nicotine can lead to cardiovascular and respiratory illness, as well as cancer.\nStrategies are available to assist with quitting nicotine containing products. Alcohol abuse\nAcceptable alcohol consumption is described to be one drink per day for women and two drinks per day for men.\nExcessive alcohol use can adversely affect many body systems and increase the risk of developing certain cancers. Drug use\nBoth prescription medications and illegal or illicit drugs may be abused or misused.\nMany EMS agencies drug test their employees for illegal and prescription drugs.",
        "Balancing Work, Family, and Health Rotate your schedule to give yourself time off.": "Take vacations.\nSeek help when stress becomes more than you can handle.",
        "Infectious and Communicable Diseases": "Infectious disease is caused by organisms within the body.\nCommunicable disease can be spread\nFrom person to person\nFrom one species to another Infection risk can be minimized by\nImmunizations\nProtective techniques\nHandwashing \nTerminology\nPathogen\nContamination\nExposure\nPPE",
        "Routes of Transmission Routes include:": "Direct contact (eg, bloodborne pathogens)\nIndirect contact (eg, needlesticks)\nAirborne transmission (eg, sneezing)\nFoodborne transmission (eg, contaminated food)\nVector-borne transmission (eg, fleas)",
        "Risk Reduction and Prevention for Infectious and Communicable Diseases All EMTs are trained in handling bloodborne pathogens.": "CDC developed standard precautions:\nHand hygiene\nPersonal protective equipment\nGloves\nGown\nMask, eye protection, face shield",
        "Donning and Doffing PPE Donning: putting on full PPE": "Doffing: removal of full PPE\nPerform in a consistent sequence to reduce the risk of contamination.",
        "Proper Hand Hygiene": "Handwashing is the simplest, yet most effective way to control disease transmission.\nWash hands before and after patient contact, even if you wear gloves. FIGURE 2-8 When washing your hands, rub your hands\ntogether for at least 20 seconds to work up a lather. Pay\nparticular attention to your fingernails, the areas between\nfingers, and the back of the hands. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS. If there is no running water, use a waterless handwashing substitute. FIGURE 2-9 Use a waterless handwashing solution if\nrunning water is not available. Be sure to wash your hands\nwith soap and water once you arrive at the hospital. \u00a9 Svanblar/ShutterStock.",
        "Wear gloves if there is any possibility for exposure to blood or body fluids.": "Vinyl, nitrile, and latex gloves are effective protection. FIGURE 2-10 Use heavy-duty utility gloves to clean the\nunit. You should not use lightweight latex or vinyl gloves for cleaning. \u00a9 Jones & Bartlett Learning. Removing gloves requires a special technique. \nAvoid contaminating yourself with materials on the outside of the gloves.",
        "Eye Protection and Face Shields Eye protection protects from blood splatters.": "Prescription glasses are not adequate.\nGoggles or face shields are best. FIGURE 2-11 Wear eye protection with side shields to prevent blood splatter or airborne droplets from getting into your eyes. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS.",
        "Gowns Provide protection from extensive blood splatter.": "Worn in situations such as:\nAerosol-generating procedures\nField delivery of a baby\nMajor trauma",
        "Masks, Respirators, and Barrier Devices": "Standard surgical mask for fluid spatter\nSurgical mask on patient with communicable disease\nMask with particulate air respirator on yourself if disease is tuberculosis FIGURE 2-13 Wear a particulate respirator to protect yourself from airborne disease transmission. \u00a9 European Centre for Disease Prevention and Control (ECDC) 2020 Mouth-to-mouth resuscitation may transmit disease.\nWith an infected patient, use:\nPocket mask\nBag-mask device\nDispose of these devices according to local guidelines. FIGURE 2-14 Barrier devices such as a pocket mask\nprovide protection when providing mouth-to-mask\nventilation. These devices should not be used, however, if\nthere is active community spread of virus by airborne route. \u00a9 Bart J/ShutterStock.",
        "Proper Disposal of Sharps Proper disposal helps avoid HIV and hepatitis": "Do not recap, break, or bend needles.\nDispose of used sharp items in an approved closed container. FIGURE 2-15 Properly dispose of sharps in a closed, rigid, marked container. \u00a9 Jones and Bartlett Learning. Courtesy of MIEMSS.",
        "Employer Responsibilities No guarantee of a 100% risk-free environment": "Risk of exposure to communicable disease is a hazard of your job.\nFollow OSHA and other national guidelines.\nKnow your department\u2019s infection control plan and follow it!",
        "Establishing an Infection Control Routine Infection control should be part of your daily routine.": "Clean the ambulance after each run and on a daily basis.\nCleaning should be done at the hospital whenever possible.",
        "Immunity Even if germs reach you, you may not become infected.": "You may be immune.\nPreventive measures\nMaintain your personal health.\nReceive immunizations.",
        "Immunizations The CDC recommends immunizations for:": "Hepatitis B\nInfluenza\nMeasles, mumps, and rubella (MMR)\nVaricella vaccine or having had chickenpox\nTetanus, diphtheria, pertussis (Tdap)\nSkin test for tuberculosis",
        "General Postexposure Management If you are exposed to a patient\u2019s blood or bodily fluids:": "Turn over patient care to another EMS provider.\nClean the exposed area.\nRinse your eyes if necessary (20 minutes).\nActivate your department\u2019s infection control plan.\nComplete an exposure report.",
        "Scene Safety Begin protecting yourself as soon as you are dispatched.": "Continue to protect yourself once on scene. FIGURE 2-18 Make sure the crash scene is well marked to prevent a second crash that may damage the ambulance or result in injury to you, your partner, or the patient. \u00a9 Glen E. Ellman.",
        "Hazardous materials": "Identify what you can from a distance.\nDo not enter unless safe to do so. FIGURE 2-21 The US Department of Transportation\u2019s Emergency Response Guidebook lists many hazardous materials and the proper procedures for scene control and emergency care of patients. Courtesy of US Department of Transportation.",
        "Electricity": "Beyond the scope of EMT training\nMark off a danger zone.\nLightning\nA repeat strike can occur.\nEither direct hit or ground current is possible.",
        "Fire": "Fire hazards include smoke, oxygen deficiency, high temperatures, toxic gases, and building collapse.\nUse proper protection. FIGURE 2-23 EMTs who are also firefighters should be\ntrained in the use of self-contained breathing apparatus\nand have it available if working near fire scenes. \u00a9 Courtesy of Lance Cpl. Brian Kester/U.S. Marines.",
        "Vehicle crashes": "Common events for EMS providers\nTraffic\nUnstable vehicles\nDowned power lines\nSharp objects\nUse protective gear",
        "Scenes of Violence": "Assaults\nHostage situations\nRiots Mass violence\nKnow who is in command.\nRemain vigilant for the potential for violence.\nAllow law enforcement to clear the scene.\nAt scenes involving projectiles find protection.\nCover\nConcealment Recommendations for preventing violence\nTraining and practice identifying scenes of potential violence\nTraining and practice with deescalation strategies and techniques\nTraining and practice improving interpersonal communication\nDispatch identification and alerting of past or potential threats of violence Recommendations for protection against violence:\nTraining and practice in self-defense and escape techniques\nTraining and practice with physical and chemical escape techniques\nFitting and use of body armor\nTraining and practice in operations with law enforcement",
        "Protective Clothing: Preventing Injury": "Critical to personal safety\nBecome familiar with various types\nCold-weather clothing \nThree layers\nTurnout gear\t\nHeat, fire, sparks, and flashover FIGURE 2-25 Turnout gear, or bunker gear, is protective clothing designed for use in firefighting \u00a9 Jones & Bartlett Learning. Photographed by Glen E. Ellman. Gloves\nHeat, cold, cuts\nMay reduce dexterity\nHelmets\nFalling objects\nBoots\nSteel-toed is preferred FIGURE 2-26 Firefighting gloves protect your hands and wrists from heat, cold, and injury. \u00a9 Jones & Bartlett Learning. Photographed by Glen E. Ellman. FIGURE 2-27 A helmet with top and side impact protection. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS. FIGURE 2-28 Boots should cover and protect your ankles, keeping out stones, debris, and snow. Steel-toed boots are preferred. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS. Eye protection\nGlasses with side shield\nEar protection\nFoam earplugs\nSkin protection\nSunblock\nBody armor\nVests",
        "Caring for Critically Ill and Injured Patients": "Let the patient know who you are and what you are doing.\nLet the patient know you are attending to his or her immediate needs. FIGURE 2-29 Let the patient know immediately that you are there to help. \u00a9 Boston Globe/Boston Globe/Getty Images Communicating with the critical patient:\nAvoid sad and grim comments.\nOrient the patient.\nBe honest.\nDeal with possible initial refusal of care.\nAllow for hope.\nLocate and notify family members. Injured and critically ill children\nAsk a responsible adult to accompany the child.\nDeath of a child\nA tragic event\nHelp the family in any way you can.\nLet the family\u2019s actions be your guide.\nPrepare the parents.",
        "Death and Dying": "Death occurs:\nQuite suddenly\nAfter a prolonged, terminal illness\nThe EMT will face death. Stages of grieving:\nDenial\nAnger, hostility\nBargaining\nDepression\nAcceptance The EMT\u2019s role:\nAsk how you can help.\nReinforce reality.\nBe honest.\nAllow the patient and family to grieve.",
        "Stress Management on the Job": "EMS is a high-stress job.\nImportant to know causes and how to deal with stress\nGeneral adaptation syndrome\nAlarm response to stress\nReaction and resistance\nRecovery\u2014or exhaustion Physiologic signs of stress\nIncreased respirations and heart rate\nIncreased blood pressure\nCool, clammy skin\nDilated pupils\nTensed muscles\nIncreased blood glucose level\nPerspiration\nDecreased blood flow to gastrointestinal tract",
        "Dangerous situations": "Physical and psychological demands\nCritically ill or injured patients\nDead and dying patients\nOverpowering sights, smells, and sounds Multiple patient situations\nAngry or upset patients, family, or bystanders\nUnpredictability and demands of EMS Stressful Situations Many factors influence how a patient reacts to the stress of an EMS incident.\nQuickly and calmly assess the actions of the patient, family members, and bystanders.\nUse a professional tone and show courtesy.\nAllow the patient to express their fear.\nRespect religious customs and needs.",
        "Acute stress reactions": "Occur during a stressful situation\nDelayed stress reactions\nManifest after stressful event\nCumulative stress reactions\nProlonged or excessive stress Physical symptoms of stress\nFatigue\nChanges in appetite\nGI problems\nHeadaches\nInsomnia or hypersomnia\nIrritability \nInability to concentrate\nHyperactivity or underactivity Psychological symptoms\nFear\nDull or nonresponsive behavior\nDepression\nGuilt\nOversensitivity, anger, irritability, and frustration Critical incident stress is caused by acute severe stressors.\nMass-casualty incidents\nSerious injury or traumatic death of a child\nCrashes with injuries caused by an emergency provider while traveling to or from a call\nDeath or serious injury of a coworker in the line of duty",
        "Posttraumatic Stress Disorder": "May develop following a psychologically distressing event\nCharacterized by reexperiencing the event and overresponding to stimuli that recall the event Critical incident stress management \nUsed to help providers relieve stress\nCan occur formally or at an ongoing scene\nFacilitated by trained professionals",
        "Burnout A combination of exhaustion, cynicism, and reduced performance resulting from long-term job stress": "Affects the well-being of the EMT along with that of crew members and patients",
        "Compassion Fatigue Also known as secondary stress disorder": "Characterized by gradual lessening of compassion\nSymptoms:\nHigh absenteeism\nInability to work in teams\nLack of empathy for patients\nJudgmental attitude towards patients",
        "Responder Risk for Suicide Suicide rate among emergency responders is higher than the rest of the population.": "Job stress is considered to be the largest contributing factor to suicide.\nSeveral organizations and mental health services are available to provide emotional support.",
        "Emotional Aspects of Emergency Care At times health care providers have trouble overcoming personal reactions and proceeding without hesitation.": "The struggle to remain calm in the face of horrible circumstances contributes to emotional stress.",
        "Workplace Issues": "Cultural diversity on the job\nYou are expected to work with coworkers of varying backgrounds, beliefs, and values.\nCulture includes nationality, age, disability, sex, sexual orientation, marital status, work experience, and education.\nCommunicate in a way that is sensitive to everyone\u2019s needs.\nRemain curious and openminded. Sexual harassment\nTwo types\nQuid pro quo: request for sexual favors\nHostile work environment: jokes, touching, etc.\nReport harassment to your supervisor immediately and keep notes. Substance abuse\nIncreases risks on the job\nLeads to poor decision making\nSeek help or find a way to confront an addicted coworker.\nEmployee assistance programs (EAPs) are often available. Injury and illness prevention\nProgram should contain:\nManagement leadership\nWorker participation\nHazard identification and assessment\nHazard prevention and control\nEducation and training\nProgram evaluation and improvement"
    },
    {
        "National EMS Education Standard Competencies": "EMS Operations\nKnowledge of operational roles and responsibilities to ensure patient, public, and personnel safety. Principles of Safely Operating a Ground Ambulance\nRisks and responsibilities of emergency response\nRisks and responsibilities of transport\nAir Medical\nSafe air medical operations\nCriteria for utilizing air medical response Medicine\nApplies fundamental knowledge to provide basic emergency care and transportation based on assessment findings for an acutely ill patient. Infectious Diseases\nAwareness of\nHow to decontaminate equipment after treating a patient\nHow to decontaminate the ambulance and equipment after treating a patient",
        "Introduction Today\u2019s ambulances are stocked with standard medical supplies.": "Many are equipped with state-of-the-art technology that transmit data directly to the emergency department.\nToday\u2019s emphasis on rapid response places the EMT in greater danger.",
        "Emergency Vehicle Design": "An ambulance is a vehicle that is used for treating and transporting patients who need emergency medical care to a hospital.\nToday\u2019s ambulance designs are based on NFPA 1917, Standard for Automotive Ambulances, and suggestions from the industry. Components of the modern ambulance:\nDriver\u2019s compartment\nPatient compartment big enough for two EMTs and two supine patients\nEquipment and supplies\nTwo-way radio communication\nDesign for maximum safety, efficiency, and comfort Ambulance licensing or certification standards are established by states.\nThe Star of Life\u00ae emblem is affixed to the sides, rear, and roof of the ambulance. FIGURE 38-5 The Star of Life. Courtesy of National Highway Traffic Safety Administration. FIGURE 38-4 A. The conventional, truck cab-chassis has a modular ambulance body that can be transferred to a newer chassis (type I). B. The standard van ambulance has a forward-control integral cab body (type II). C. The specialty van ambulance has a cab that is mounted on a cut-away van chassis (type III). A: \u00a9 Jones & Bartlett Learning; B: Courtesy of Captain David Jackson, Saginaw Township Fire Department; C: \u00a9 Kevin Norris/ Shutterstock.",
        "Phases of an Ambulance Call": "Phases of an Ambulance Call",
        "Preparation Phase": "Make sure equipment and supplies are in their proper places and ready for use.\nStore new equipment only after proper instruction on its use and consulting with the medical director.\nEquipment should be durable and standardized. Store equipment and supplies according to how urgently and how often they are used.\nItems for life-threatening conditions at the head of the primary stretcher\nItems for cardiac care, external bleeding, and blood pressure at the side of the stretcher Cabinets and drawer fronts should be transparent or labeled. FIGURE 38-8 Containers should be placed in\ncabinets and drawers with transparent fronts for quick identification. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS. Medical equipment\nBasic supplies \nAirway and ventilation equipment\nCPR equipment\nBasic wound care supplies FIGURE 38-9 The ambulance should carry both a mounted suctioning unit and a portable unit. \u00a9 Jones & Bartlett Learning. FIGURE 38-11 A CPR board may be carried on the ambulance. \u00a9 Courtesy of Ferno Washington, Inc. Medical equipment (cont\u2019d)\nSplinting supplies\nChildbirth supplies\nAutomated external defibrillator FIGURE 38-12 Supplies for splinting fractures and\ndislocations should be carried on the ambulance. \u00a9 Jones & Bartlett Learning FIGURE 38-13 A sterile emergency obstetric kit must be carried on the ambulance. \u00a9 Mark C. Ide. Medical equipment (cont\u2019d)\nPatient transfer equipment\nMedications\nJump kit FIGURE 38-16 A portable jump kit should contain\npractically anything you will need during the first 5 minutes with the patient. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS. FIGURE 38-15 The wheeled ambulance stretcher should be locked into place at an appropriate height. Courtesy of Angulo, Raul A. Safety and operations equipment\nPersonal safety equipment\nEquipment for work areas FIGURE 38-17 The ambulance should have a weatherproof compartment that can be reached from outside the patient compartment. It should hold equipment for safeguarding patients and EMTs, controlling traffic, and illuminating work areas. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS. Safety and operations equipment (cont\u2019d)\nPreplanning and navigation equipment\nExtrication equipment Personnel\nAt least one EMT in the patient compartment during transport\nTwo EMTs are strongly recommended.\nSome services have a non-EMT driver and a single EMT in the patient compartment. Perform daily inspections.\nAmbulance inspection\nInspect the cleanliness, quantity, and function of medical equipment and supplies. Review safety precautions.\nReview traffic safety rules and regulations.\nEnsure safety devices are in working order.\nProperly secure oxygen tanks.\nProperly secure all equipment in the cab, rear, and compartments.",
        "Dispatch Phase": "Dispatch must be easy to access and in service 24 hours a day.\nMay be operated by the local EMS or by a shared service\nMay serve only one jurisdiction or may be an area or regional center Dispatcher should gather and record:\nNature of the call\nName, present location, and call-back number\nLocation of patient\nNumber of patients and severity of their conditions\nOther pertinent information",
        "En Route to the Scene Most dangerous phase for EMTs": "Crashes cause many serious injuries.\nFasten seat belts and shoulder harnesses before moving the ambulance.\nReview dispatch information.\nPrepare to assess and care for the patient.",
        "Arrival at the Scene": "Perform a scene size-up and report your findings to dispatch.\nLook for safety hazards.\nEvaluate the need for additional units.\nDetermine the mechanism of injury or nature of illness.\nEvaluate the need for spinal immobilization.\nFollow standard precautions. Mass-casualty incidents\nEstimate and communicate the number of patients to the incident commander.\nRequest additional units through dispatch.\nThe incident command system will be established. Safe parking \nAllow efficient traffic flow and control around an emergency scene.\nPark 100 feet before or past the crash scene.\nDo not park alongside a crash scene.\nPark uphill/upwind of hazardous materials.\nLeave warning lights or devices on.\nKeep a safe distance between the emergency vehicle and operations. FIGURE 38-22 If other responders, such as firefighters or law enforcement officers, are on scene first, park the ambulance about 100 feet (30 m) past the scene on the same side of the road so as to allow an unobstructed departure path. \u00a9 Jones & Bartlett Learning. Safe parking (cont\u2019d)\nStay away from fires, explosive hazards, downed wires, and unstable structures.\nSet the parking brake.\nFacilitate emergency medical care and rapid transport from the scene.\nIf it is necessary to block traffic, work quickly and safely. Traffic control\nProvide care and ensure scene safety first.\nTraffic control is intended to ensure orderly traffic flow, warn other drivers, and prevent another crash.\nPlace warning devices on both sides of the crash.",
        "Transfer Phase The patient must be packaged for transport.": "Secure the patient to a backboard, scoop stretcher, or wheeled ambulance stretcher.\nLift the patient into the compartment.\nSecure the patient with straps. FIGURE 38-23 Secure the patient appropriately for protection during transport. \u00a9 Jim Craigmyle/Corbis/Getty Images.",
        "Transport Phase": "When you are ready to leave with the patient, inform dispatch of:\nNumber of patients\nName of receiving hospital\nBeginning mileage of ambulance Monitor the patient\u2019s condition en route.\nRecheck a stable patient every 15 minutes.\nRecheck an unstable patient every 5 minutes.\nContact the receiving hospital.\nDo not abandon the patient emotionally.\nBe aware of the patient\u2019s level of need.",
        "Delivery Phase Notify dispatch of your arrival at the hospital.": "Report your arrival to the triage nurse or other arrival personnel.\nPhysically transfer the patient.\nPresent a complete verbal report.\nComplete a detailed patient care report.\nRestock items, if possible.",
        "En Route to the Station Inform dispatch whether you are in service and where you are going.": "Back at the station:\nClean and disinfect the ambulance and equipment.\nRestock supplies. FIGURE 38-24 After transferring the patient and relating patient information to the hospital staff, you should restock any items that were used during the run. \u00a9 Jones & Bartlett Learning. Courtesy of MIEMSS.",
        "Postrun Phase": "Complete and file additional written reports.\nInform dispatch again of status, location, and availability.\nPerform routine inspections.\nRefuel the vehicle. Key terms:\nCleaning\nDisinfection\nHigh-level disinfection\nSterilization After each call:\nStrip linens from the stretcher and place them in a plastic bag or designated receptacle.\nDiscard medical waste.\nWash contaminated areas with soap and water. After each call: (cont\u2019d)\nDisinfect all nondisposable equipment used for patient care.\nClean the stretcher with germicidal/virucidal solution or 1:100 bleach dilution.\nClean spillage or other contamination with one of those same solutions.",
        "Defensive Ambulance Driving Techniques": "An ambulance involved in a crash delays patient care and may take lives of EMTs, other motorists, or pedestrians. FIGURE 38-26 Each year, ambulance crashes are the\ncause of thousands of injuries to pedestrians, motorists, ambulance passengers, and EMS personnel. \u00a9 Gary Lloyd, The Decatur Daily/AP Photos. Driver characteristics\nSome states require an emergency vehicle operations course.\nOther characteristics:\nPhysical fitness and alertness\nEmotional maturity and stability\nDue regard for the safety of others and preservation of property Safe driving practices\nSpeed does not save lives; good care does.\nWear seat belts and shoulder restraints.\nBecome familiar with how the vehicle accelerates, corners, sways, and stops.\nStay in the extreme left-hand lane on multilane highways. Siren risk\u2013benefit analysis\nThe decision to activate the emergency lights and siren will depend on:\nLocal protocols\nPatient condition\nAnticipated clinical outcome of the patient Driver anticipation\nAlways assume that motorists around your vehicle have not heard your siren/public address system or seen you.\nAlways drive defensively. Cushion of safety\nMaintain a safe following distance from the vehicles in front of you.\nTry to avoid being tailgated from behind.\nEnsure that the blind spots do not prevent you from seeing vehicles or pedestrians.\nNever get out of the ambulance to confront a driver.\nBe aware of blind spots and scan mirrors frequently. Excessive speed\nUnnecessary, dangerous, and does not increase the patient\u2019s chance of survival\nMakes it difficult to provide care in the patient compartment\nHinders the driver\u2019s reaction time\nIncreases the time and distance needed to stop the ambulance Siren syndrome\nCauses drivers to drive faster in the presence of siren, due to increased anxiety\nVehicle size and distance judgment\nCrashes often occur when the vehicle is backing up, so use a spotter.\nSize and weight influence braking and stopping distances. Road positioning and cornering\nTo keep the ambulance in the proper lane when turning, enter high in the lane, and exit low. FIGURE 38-27 To keep the ambulance in the proper lane\non a curve, you must know the vehicle\u2019s current position and\nprojected path and take the corner at the correct speed. \u00a9 Jones & Bartlett Learning. Weather and road conditions\nAmbulances have a longer braking time and stopping distance.\nThe weight of the ambulance is unevenly distributed, which makes it more prone to roll over.\nBe alert for hydroplaning, water on the roadway, decreased visibility, and ice and slippery surfaces.",
        "Laws and Regulations": "If you are on an emergency call and are using your warning lights and siren, you may be allowed to do the following:\nPark or stand in an illegal location\nProceed through a red light or stop sign\nDrive faster than the speed limit\nDrive against the flow of traffic\nTravel left of center to make an illegal pass An emergency vehicle is never allowed to pass a school bus that has stopped to load or unload children.\nUse of warning lights and siren\nThe unit must be on a true emergency call.\nAudible and visual warning devices must be used simultaneously.\nThe unit must be operated with regard for others\u2019 safety. Right-of-way privileges\nEmergency vehicles have the right to disregard the rules of the road when responding to an emergency.\nDo not endanger people or property under any circumstances.\nGet to know your local right-of-way privileges. Use of escorts\nUse escorts as a guide only when you are in unfamiliar territory.\nIntersection hazards\nIntersection crashes are the most common and most serious.\nIf you cannot wait for traffic lights to change, come to a brief stop and look for pedestrians or other hazards. Highways\nShut down emergency lights and siren until you have reached the far left lane.\nUnpaved roads\nOperate at a lower speed with a firm grip on the steering wheel.\nSchool zones\nIt is unlawful to exceed the speed limit.",
        "Distractions Focus on driving and anticipating roadway hazards.": "Minimize distractions from:\nMobile dispatch terminals and GPS\nMounted mobile radio\nStereo\nCell phone\nEating/drinking",
        "Driving Alone It is your responsibility to focus on figuring out the safest route while mentally preparing for the call.": "Such situations demand your complete attention and focus.",
        "Fatigue Recognize when you are fatigued and alert your partner or supervisor.": "You should be placed out of service for the remainder of the shift or until the fatigue has passed and you feel capable of operating the vehicle safely.",
        "Air Medical Operations": "Air ambulances are used to evacuate medical and trauma patients.\nFixed-wing units\nRotary-wing units (helicopters) FIGURE 38-29 A. Fixed-wing aircraft are generally used\nto transfer patients from one hospital to another over\ndistances greater than 200 to 250 miles. B. A rotary-wing\naircraft, or helicopter, is used to help provide emergency\nmedical care to patients who need to be transported\nquickly over shorter distances. A: \u00a9 Ralph Duenas/www.jetwashimages.com; B: Courtesy of Ed Edahl/FEMA. Specially trained crews accompany air ambulance flights.\nEMTs provide ground support.\nMedical evacuation (medevac) is performed by helicopters.\nCapabilities, protocols, and procedures vary. Why call for a medevac?\nTransport time by ground is too long.\nRoad, traffic, or environmental conditions prohibit the use of ground transport.\nThe patient requires advanced care.\nMultiple patients will overwhelm the resources at the hospital reachable by ground transport. Who receives a medevac?\nPatients with time-dependent injuries or illnesses\nPatients with stroke, heart attack, or spinal cord injury\nSCUBA diving accidents, near-drownings, or skiing and wilderness accidents\nTrauma patients\nCandidates for limb replantation, burn center, hyperbaric chamber, or venomous bite center Whom do you call?\nGenerally, the dispatcher should be notified first.\nIn some regions, EMS may be able to communicate with the flight crew after initiating the medevac request. Establish a landing zone.\nHard or grassy level surface between 60 \u00d7 60 feet and 100 \u00d7 100 feet (recommended) \nCleared of loose debris\nClear of overhead or tall hazards\nMark the landing site using cones or vehicles.\nNever use caution tape or people to mark the site.\nDo not use flares. Establish a landing zone (cont\u2019d)\nMove nonessential persons and vehicles.\nCommunicate the direction of strong wind to the flight crew. FIGURE 38-30 A landing area for an EMS helicopter should be a level surface measuring 100 ft \u00d7 100 ft (30 m \u00d7 30 m). \u00a9 Mark C. Ide. Landing zone safety and patient transfer\nKeep a safe distance from the aircraft whenever it is on the ground and \u201chot.\u201d\nStay away from the tail rotor.\nAlways approach the helicopter from the front. FIGURE 38-31 The main rotor blade of the helicopter is flexible and may dip as low as 4 feet (1.2 m) off the ground depending on the type of helicopter. \u00a9 Jones & Bartlett Learning. Keep the following guidelines in mind:\nBecome familiar with hand signals.\nDo not approach the helicopter unless instructed and accompanied by flight crew.\nMake certain that all equipment and the patient are secured to the stretcher.\nSmoking, open lights or flames, and flares are prohibited within 50 feet.\nWear eye protection. FIGURE 38-32 Some examples of helicopter hand signals. Be familiar with those used within your jurisdiction. \u00a9 Jones & Bartlett Learning.",
        "Special Considerations": "Night landings\nDo not shine spotlights, flashlights, or any other lights in the air to help the pilot.\nDirect low-intensity headlights or lanterns toward the ground.\nIlluminate overhead hazards or obstructions, if possible. Landing on uneven ground\nThe main rotor blade will be closer to the ground on the uphill side.\nApproach from the downhill side only. FIGURE 38-33 Approach a helicopter on a grade only\nfrom the downhill side. \u00a9 Jones & Bartlett Learning. Medevacs at hazmat incidents\nNotify the flight crew.\nConsult about the best approach and distance from the scene.\nLanding zone should be uphill and upwind.\nDecontaminate patients before loading them into the helicopter.",
        "Medevac Issues": "Assess the severity of the weather or environment/terrain.\nMost helicopters are limited to flying below 10,000 feet above sea level.\nMedevac helicopters fly between 130 and 150 mph. Because of the cabin\u2019s confined space, assess the number and size of the patients who can be safely transported in a medevac helicopter.\nTypical medevac flights are extremely expensive compared to ambulance transports."
    },
    {
        "gram (suffix)": "picture",
        "graph (suffix)": "taking a picture",
        "iatrist (suffix)": "a specialist providing specific treatment",
        "otomy (suffix)": "removing a part of, an incision",
        "scopy (suffix)": "use of instrument to view",
        "stomy (suffix)": "create an opening in",
        "plasty": "modifying the shape of or repairing",
        "echo": "ultrasonic waves",
        "ectomy": "removal of",
        "iatry": "medical treatment",
        "iatrist": "a specialist providing a specific medical treatment",
        "ologist": "a specialist of a specific part of the body or disease process",
        "radio": "radiation",
        "centesis": "surgical puncture of a cavity",
        "desis": "surgical fixation, commonly of a bone",
        "pexy": "fixation",
        "rrhaphy": "suture",
        "sect": "to cut",
        "tripsy": "to crush or break",
        "aspiro/o": "removal",
        "auscult/o": "to listen",
        "assay": "to examine or analyze",
        "meter": "instrument for measuring",
        "metry": "process of measuring",
        "opsy": "to view",
        "palp/o": "to touch",
        "tome": "instrument for cutting"
    },
    {
        "geriatric defined": "an individual aged 65 years or older",
        "incontinence defined": "the inability to control bladder or bowel movements",
        "common chief complaints of geriatric patients": "dizziness\nfatigue, weakness\nfalls\npoor ability to sleep or rest\nbody temperature, too hot or cold\nheadache\nloss of appetite\ngi problems",
        "\"gems\" geriatric assessment defined": "geriatric patient \nenvironmental assessment \nmedical assessment \nsocial assessment",
        "polypharmacy defined": "the use of multiple medications at one time\n4-6 medications prescribed at one time is not uncommon for patients of the geriatric population",
        "most common fractures from a fall": "hip or pelvic fractures",
        "risk factors for a fall": "in poor health\nin poor living conditions\nin group living conditions with less frequent monitoring \npolypharmacy\npoor reaction to medication",
        "syncope": "indicates serious need for thorough assessment\nrule out fall secondary to syncope",
        "bereavement defined": "sadness over loss of loved ones, can be exacerbated by old age",
        "when interviewing a geriatric patient, it is important to...": "speak to them directly, not surrounding family\nuse their name, not a nickname or common expression",
        "signs/symptoms of sepsis": "tachycardia\nhot, flushed skin\ntachypnea\nfever\naltered mental status\nlow etco2",
        "herpes zoster defined": "painful rash that causes blisters, also known as shingles\ncommon in geriatric patients who had chickenpox when they were younger",
        "pressure ulcers defined": "sores that are the results of lying in one position in bed for extended periods of time\nin extreme cases necrotic tissue can be found at the site of the sores",
        "consider hypovolemia in geriatric patient if...": "systolic bp less than 120\nthink: dehydration, fluid replacement",
        "presbycusis defined": "progressive inability to hear high frequency noise, or distinguish between different noises",
        "proprioception defined": "sense of body movement and position, independent of vision",
        "more than half of geriatric patients will be...": "hypertensive",
        "osteoporosis defined": "reduction in bone mass as part of the aging process. results in decreased bone strength and greater risk of fractures",
        "ra defined": "ra - rheumatoid arthritis - is the inflammation of  joints and subsequent tissue. it is an autoimmune disorder. hands and feet commonly affected first.",
        "hospice defined": "organization that provides end of life care for a patient, and provides resources to the patients family"
    },
    {
        "how to measure npa?": "measure from tip of nose to earlobe",
        "suggested flow rate of an albuterol neb set?": "6-8 liters per minute",
        "d cylinder volume": "~350 l",
        "e cylinder volume": "~625 l",
        "m cylinder volume": "3000 l",
        "how is an opa measured?": "corner of the mouth to the earlobe",
        "most commonly used artificial airway?": "opa",
        "a bvm will deliver roughly ___ml of air": "600-750 ml",
        "rate and time to deliver ventilations by bvm?": "deliver breath over 1 second with rate at 8 to 10 breaths per minute.",
        "what percentage of oxygen does a bvm without attached o2 provide?": "21%",
        "what is the purpose of an oxygen regulator?": "manage the flow rate and reduce the pressure.",
        "venturi mask": "best device to administer a precise amount of oxygen to a patient",
        "what are the limitations of a flow powered (lpm) cpap device vs a ventilator-based cpap device?": "a flow powered cpap device is dependent on the lpm that can be provided. therefore, if you were to run out of oxygen, your cpap would no longer maintain its pressure.",
        "under what conditions should oxygen delivery specifically be titrated?": "when administering oxygen to a pt. with a history of copd, suspected cva, suspected mi, suspected tbi, neonate resuscitation, rosc, and pt.\u2019s who have achieved 100% spo2.",
        "what signs and symptoms may indicate oxygen administration?": "signs of respiratory distress and/or hypoxia (tachypnea, dyspnea, cyanosis\u2026) poor perfusion, altered mental status, combativeness, adventitious lung sounds, cardiac arrest, and spo2 <94%.",
        "what are some methods at the advance-emt scope to secure an airway for oxygen delivery?": "jaw thrust/head tilt, npa, opa, and supraglottic airway.",
        "what oxygen cylinders are commonly carried on an ambulance?": "d cylinder, e cylinder, and m cylinder.",
        "what harm can be cause to a pt. by hyperoxia?": "the formation of \u201cfree radicals\u201d occurs which are unstable and reactive molecules or atoms that causes damage to cells, dna and other molecules.",
        "if you are using a flow based (lpm) cpap device with a pt. who is taking rapid breaths >35/min, what concern should you consider?": "depending on the pt.\u2019s tidal volume and respiratory rate. it is possible for the pt. to out breathe the cpap device if their minute volume is higher than the lpm supplied.",
        "what flow rate should a nebulizer be set at?": "6-8 lpm.",
        "why is the flow rate of a nebulizer particularly important?": "to have effective medication delivery the flow rate needs to be high enough to aerosolize the medication but not so high that it disrupts delivery of the medication.",
        "when using positive pressure ventilation, what harm can be caused by inappropriate ventilation?": "gastric inflation leading to poor venous return and emesis/airway compromise and barotrauma.",
        "what are the advantages of using positive end expiratory pressure (peep) when ventilating a pt.?": "peep helps recruit more alveoli during positive respirations and allows for increased delivery of oxygen across the capillary membrane of the lungs.",
        "what is the average amount of volume contained in an adult bvm?": "1.5 l",
        "what is the average tidal volume of an adult?": "400-500 ml of air depending on size and sex. female tidal volumes are closer to 400ml.",
        "what are some key characteristics of ppv with a bvm?": "a breath should be delivered at the appropriate rate based on age and the breath should be given over 1 second at a steady pressure to achieve chest rise.",
        "what are contraindications for the application of cpap devices?": "hemodynamic instability, recent or high risk of emesis, altered level of consciousness, and respiratory arrest.",
        "what is a key limitation of a flow powered (lpm) cpap device vs a ventilator-based cpap device?": "a flow powered cpap device is dependent on the lpm that can be provided. therefore, if you were to run out of oxygen, your cpap would no longer maintain its pressure.",
        "what is denitrification and how does oxygen administration play a role in achieving it?": "denitrification is the process by which the available nitrogen in the lungs is \u201cpush out\u201d by administering high volumes/lpm of oxygen to a pt. attempting to increase the \u201csafe apnea\u201d time during an intubation attempt and reduce the risk of desaturation during intubation.",
        "what are some methods at the paramedic scope to secure an airway for oxygen delivery?": "jaw thrust/head tilt, npa, opa, supraglottic airway, intubation and surgical airway.",
        "during cpr of what pt. population should oxygen be withheld?": "neonates",
        "at what flow rate should a nebulizer be set?": "6-8 lpm",
        "if you have an established airway and good oxygen supply to a pt., what can prevent the pt. from being oxygenated?": "either the oxygen is not able to attach to rbcs at the capillary membrane of the lungs or the oxygen is not arriving at the tissue due to an issue with perfusion.",
        "during positive pressure ventilations, what observation should determine the amount of volume no matter the age/size of the pt?": "visible chest rise is an appropriate gauge when delivery ppv in the field.",
        "if ppv ventilations are not working with a bvm, what actions should be considered?": "readjust airway, obstructed airway, disease process (copd/asthma/pneumornia/pneumothorax), consider two handed mask seal, considered bls adjuncts, considered need for advance airway, consider equipment failure."
    },
    {
        "introduction": "an introduction to oxygen (o2). humans, like many other living organisms, require oxygen to maintain metabolic processes (aerobic). oxygen is a gas at room temperature and is available at 20.9 % of ambient air. during a medical emergency, chronic medical condition, or at high altitudes, supplemental oxygen can be vital to improving the condition of a patient. this emt basic study guide will explore the devices for containing and supplying oxygen in the medical environment. it will also review when oxygen administration is indicated or not indicated as a medical intervention.",
        "containers": "there are many different types/sizes of medical oxygen cylinders. the most commonly used in the prehospital environment are d tanks and m tanks. d tanks are small portable cylinders while m is large and generally used to supply oxygen systems in an ambulance. cylinder oxygen level is measured in psi.",
        "important safety considerations": "the oxygen is held under pressure in cylinders. oxygen cylinders are an explosive/projectile hazard if damaged or improperly used. keep oxygen tanks secured, regularly inspect them for damage, and handle them with care. oxygen is flammable. never expose oxygen lines, tanks, or flow to open flame or a heat source.",
        "routes of administration": "the route of administration will depend on the specific needs of the patient. oxygen flow is measured in liters per minute (lpm). a nasal cannula provides the lowest amount of oxygen flow while non-rebreathers (nrb) provide the greatest flow. devices such as the bag valve masks (bvm) provide high flow and positive pressure. other devices, such as nebulizers, use moderate oxygen flow to aerosolize a medication that assists with oxygen administration. if needed, nebulizers can be plumed into nrb for hands-free use, or bvms for positive pressure ventilation.",
        "oxygen delivery devices and flow rates": "nasal cannula (1-6 lpm), nonrebreather (10-15 lpm), bvm (10-15 lpm & ppv), nebulizer (6-8 lpm w/ medication)",
        "oxygen delivery times": "when administering oxygen, it is important to have an understanding of how long you can provide that treatment. for most prehospital care, short patient care times make this concern relatively unimportant. that said, situations such as extended scene times, transport times (interfacility or inclement weather), low oxygen tanks, or difficult/critical patients, may threaten to empty your oxygen tank. the amount of time an oxygen tank will provide depends on its size, its psi, and the flow rate (lpm).",
        "when to administer oxygen": "oxygen is not a harmless drug and its administration should be based on clinical findings. symptoms: shortness of breath, difficulty breathing, lightheadedness, headache. signs: adventitious lung sounds, cyanosis, altered level of consciousness, combativeness, unconsciousness, or cardiac/respiratory arrest. exposure: toxic gas exposure (e.g., carbon monoxide) objective data (spo2): spo2 < 94%.",
        "when to avoid/titrate oxygen administration": "chronic obstructive pulmonary disease (copd). when deciding to administer medication, it is important to have an understanding that not every patient will have the same response. patients with copd (chronic bronchitis or emphysema) may chronically present with oxygen saturations well below 94%. due to their medical condition, these patients have changes to their respiratory drive and are used to lower oxygen saturation. administering oxygen to them based on their spo2 could actually cause the patient to breathe less (respiratory depression). as a result, oxygen should be administered to these patients cautiously. if the patient has no signs/symptoms of poor oxygenation, it may be indicated to withhold oxygen administration.",
        "special considerations": "return of spontaneous circulation (rosc). while under most circumstances, medical and prehospital guidelines encourage oxygen administration above 94%, the american heart association recommends that during post-cardiac arrest care, an oxygen saturation between 92-98% should be the clinical goal. cardiac chest pain. in the instance of cardiac chest pain, some protocols suggest withholding oxygen, if the patient's room air oxygen saturation is above 90%. head injury/cerebral vascular attack (cva). similar calls to titrate oxygen occur in prehospital protocols when there is a high concern for a head injury or suspected cva/stroke.",
        "scenario": "you are dispatched as a two-person bls crew to a person with breathing problems. dispatch information includes: 67 y/o female, cannot catch her breath, conscious. other resources are delayed due to winter weather. you are conveniently 4 blocks away from the call.",
        "scenario continued": "you and your partner arrived to find the patient. from the door, you see tripoding on the edge of a bed and significant work of breathing. she does not greet you or look up when you enter and introduced yourselves. she is unable to give complete verbal responses to questions. you notice that she has a nasal cannula and a long length of tubing that goes to a home oxygen tank next to the bed.",
        "patient assessment and treatment": "your partner starts on a set of vitals. he gets a heart rate of 110 bpm, a blood pressure of 176/102, oxygen saturation of 85%, and respiratory rate of 30 breaths/min with wheezing in all fields.",
        "oxygen administration decision": "upon seeing that oxygen saturation your partner starts reaching for the d tank. you look to the patient's oxygen tank and find it empty. your partner asks, what should we put her on?",
        "oxygen administration decision continued": "you select your oxygen treatment and you start to see some improvement with your patient. heart rate and bp remain the same, spo2 increases to 93% and her respirations are 28 breaths/min. she is still focused on her breathing and answers questions with a head shake.",
        "nebulizer administration": "you see an inhaler next to her bed, it is an expired albuterol inhaler. at this time her neighbor walks in and starts asking how her patient is doing. you take him to the side and ask him if he knows the patient's medical history. he states that she frequently has respiratory problems and he thinks she has emphysema from decades of smoking cigarettes.",
        "adjusting oxygen administration based on patient's condition": "having learned your patient has emphysema or copd, does this change your oxygen administration?",
        "nebulizer oxygen flow rate": "based on the clinical findings, you have your partner starts setting up a nebulizer to plum into the nrb for albuterol administration. what oxygen flow should be used for a nebulizer?",
        "oxygen tank management": "you get a radio update from dispatch that an als ambulance is 30 min out due to high call volume and heavy snow. your vehicle is not equipped to transport the patient. you notice that your d tank is below 500 psi.",
        "oxygen tank management continued": "based on the chart provided on your airway bag and a flow rate of 8 lpm, how much time do you have with this bottle?",
        "spare oxygen tank": "you send your partner to grab the spare d tank and he comes back with one that has 1500 psi. your patient has improved after the first nebulized treatment and is now speaking with ease. vitals are as follows, hr 120 bpm, blood pressure 166/90, rr 18 and nonlabored, wheezing present in lower lobes on auscultation.",
        "oxygen administration for potential decompensation": "if your patient decompensated and required another albuterol treatment, how much time could you flow your new d tank for at 8 lpm? (see chart from the previous question).",
        "conclusion and patient transport": "you place your patient on 2 lpm since she states she is chronically on this amount and als arrives early after clearing from a different call. they take reports, thank you for your help, and transport the patient to the hospital.",
        "answers": "c, c, b, less than 10 minutes",
        "oxygen delivery devices": "nasal canula (1-6 lpm) nonrebreather (10-15 lpm) bvm (10-15 lpm & ppv) nebulizer (6-8 lpm with medication) continuous positive airway pressure (cpap) is another route to deliver oxygen generally used by advanced and als prehospital providers.",
        "flow rate and peep": "when administering oxygen, it is important to have an understanding of how long you can provide that treatment. for most prehospital care, short patient care times make this concern relatively unimportant. that said, situations such as extended scene times, transport times (interfacility or inclement weather), low oxygen tanks, or difficult/critical patients, may threaten to empty your oxygen tank. the amount of time an oxygen tank will provide depends on its size, its psi, and the flow rate (lpm).",
        "when to administer?": "oxygen is not a harmless drug and its administration should be based of clinical findings. symptoms: shortness of breath, difficulty breathing, lightheadedness, headache. signs: adventitious lung sounds, cyanosis, altered level of consciousness, combativeness, unconsciousness, or cardiac/respiratory arrest. exposure: toxic gas exposure (e.g., carbon monoxide) objective data (spo2): spo2 < 94%.",
        "when to avoid/titrate oxygen administration?": "chronic obstructive pulmonary disease. when deciding to administer a medication, it is important to have an understand that not every patient will have the same response. patients with copd (chronic bronchitis or emphysema) may chronically present with oxygen saturations well below 94%. these patients have changes to their respiratory drive due to their condition and are used to lower oxygen saturations. administering oxygen to them based on their spo2 could actually cause the patient to breath less (respiratory depression).",
        "return of spontaneous circulation (rosc)": "while under most circumstances, medical and prehospital guidelines encourage oxygen administration above 94%, the american heart association recommends that during post-cardiac arrest care, an oxygen saturation between 92-98% should be the clinical goal.",
        "cardiac chest pain": "in the instance of cardiac chest pain, some protocols suggest withholding oxygen, if the patients room air oxygen saturation is 90% of above.",
        "head injury/cerebral vascular attack (cva)": "similar calls to titrate oxygen occur in prehospital protocols when there is high concern for a head injury or suspected cva/stroke. oxygen should be administered to patients to achieve 94% oxygen saturation but should not be increased beyond this point.",
        "ventilators": "ventilators. depending on where you work and the credentials you maintain, you may use or be exposed to ventilators. ventilators provide significant control in oxygenating the patient. you can select a specific tidal volume, percentage of oxygen, and choose modes such as cpap, bipap, on-demand, etc.",
        "preoxygenation and delayed sequence intubation (dsi)": "good prehospital medicine frequently involves thinking outside of the box. when it comes to more advanced airway techniques, studies have shown the importance of preoxygenation/denitrification and dsi.",
        "when to administer": "oxygen is not a harmless drug and its administration should be based of clinical findings. symptoms: shortness of breath, difficulty breathing, lightheadedness, headache. signs: adventitious lung sounds, cyanosis, altered level of consciousness, combativeness, unconsciousness, or cardiac/respiratory arrest. exposure: toxic gas exposure (e.g., carbon monoxide) objective data (spo2): spo2 < 94%."
    },
    {
        "document title": "Clinical Procedures",
        "protocol title": "Surgical Cricothyrotomy",
        "overview": "Advanced airway procedures and competency are the cornerstones of paramedicine. True competency involves knowing not only how to control the airway, but when to control the airway, and selecting the best method to do so. A surgical cricothyrotomy should be performed only as a last resort when an airway cannot be definitively secured via oral / nasal intubation or rescue airway device insertion AND the airway cannot be maintained with BLS adjuncts or procedures.",
        "indications": "1. Total airway obstruction not relieved by any other means.\n2. Airway compromise from injuries that make oral or nasal intubation impractical.\n3. No alternative airway device / maneuver is successful.\n4. The patient cannot be oxygenated or ventilated by any other means.",
        "contraindications": "1. Patient less than 8 years old (If less than 8 years old, refer to Needle Cricothyrotomy Clinical Procedure).\n2. Airway able to be maintained via BLS airway management procedures.",
        "complications": "\u2022 Bleeding\n\u2022 Incorrect or unsuccessful tube placement\n\u2022 Pneumothorax and / or pneumomediastinum\n\u2022 Tracheal perforation\n\u2022 Vocal cord injury\n\u2022 Aspiration\n\u2022 Subcutaneous emphysema\n\u2022 Esophageal and / or tracheal perforation\n\u2022 Infection leading to cellulitis and / or sepsis\n\u2022 Phrenic nerve and / or brachial plexus injury",
        "protocol for management": "1. Prepare all equipment for surgical cricothyrotomy:\n    a. All appropriate BSI should be worn to include eye protection, mask, and gloves\n    b. Adult bag valve mask (BVM) connected to 100% oxygen\n    c. Appropriately sized ET tube. Shorten ET tube length by cutting tube just ABOVE point at which cuff inflation line attaches to tube. Remove BVM hub from discarded portion and attach to shortened tube\n    d. Attach 10 cc syringe to ET tube and pre-inflate cuff of tube to ensure no leaks, then deflate, leaving syringe attached\n    e. \u00bd\u201d silk tape, torn into two 8\u201d strips to secure tube upon successful cricothyrotomy\n    f. Connect capnography sensor to monitor\n    g. Check that capnography sensor is working properly and attach to end of shortened ET tube\n    h. Suction setup, turned on, and within reach\n    i. Sterile scalpel (# 10 preferred)\n    j. Antiseptic solution\n    k. Several 4 x 4s, opened\n2. Once all equipment is prepared, a surgical cricothyrotomy attempt should be made.\n    a. Identify the cricothyroid membrane, located subcutaneously between the thyroid cartilage ( Adam\u2019s apple) superiorly and the cricoid cartilage inferiorly\n    b. Cleanse the intended site of procedure with antiseptic solution\n    c. Stabilize the site by placing thumb and index finger of non-dominate hand on either side of the trachea, stretching the skin across the cricoid membrane\n    d. While stabilizing the trachea, use your dominant hand to make a 3 - 4 cm vertical incision through the skin, midline over the cricoid membrane. The skin will spread as the incision is made\n    e. Bleeding will occur, use 4 x 4s as needed to maintain clear visual field\n    f. After visual identification of the cricoid membrane, make a 1 cm horizontal incision by puncturing the cricoid membrane with the scalpel\n    g. Remove scalpel while continuing to hold traction. Turn scalpel over, insert handle into trachea and rotate to enlarge opening. NEVER enlarge incision with scalpel blade\n    h. Remove scalpel and insert \u201chook\u201d or hemostat into tracheal opening to keep insertion site patent. As a last resort, use the index finger of your non-dominant hand, inserting the tip of the finger into the site just enough to keep tracheal incision open. If opening is lost, it can be extremely difficult to relocate definitively, possibly causing false passage of the tube along the outside of the trachea\n    i. Insert shortened ET tube into trachea via incision site. ET tube should only be inserted until the tube cuff can no longer be visualized\n    j. Inflate cuff with 8 - 10 cc of air, ventilate patient with BVM, and check monitor for distinct capnography waveform and numerical value\n    k. If no capnography waveform is present, check equipment (capnography working correctly, no kinks, attached securely) and recheck for proper placement (possible false passage in tracheal lining)\n    l. If capnography waveform is present, continue placement confirmation:\n        \u2022 Observe chest rise upon ventilation\n        \u2022 Auscultate for bilateral breath sounds\n        \u2022 Auscultate abdomen for absent epigastric sounds\n        \u2022 Note condensation in the tube with expirations\n    m. If breath sounds are not heard equally, adjust tube for possible left or right main-stem intubation by pulling tube out one (1) centimeter. Reassess lung sounds. In trauma patients, also assess for possible pneumothorax\n    n. Once lung sounds have been confirmed, secure ET tube with \u00bd\u201d strips of tape crossed around tube and taped to neck. Reassess lung sounds and capnography readings\n    o. Reassess tube placement after all movement of patient or change in capnography readings",
        "pearls": "1. Make incision as small as possible to avoid extensive hemorrhage.\n2. If an appropriately sized tracheostomy tube is available, and provider is familiar with placement, use in place of modified ET tube. Once tracheostomy tube is inserted, remove obturator, attach capnography, and continue procedure as outlined above. Secure tube with included tie strap."
    },
    {
        "document title": "Clinical Procedures",
        "protocol title": "Synchronized Cardioversion",
        "overview": "Synchronized electrical cardioversion uses a therapeutic dose of electric current to the heart, at a specific moment in the cardiac cycle to treat hemodynamically significant supraventricular (or narrow complex) tachycardias, including :  atrial fibrillation and atrial flutter.  It is also used in the emergent treatment of wide complex tachycardias, including ventricular tachycardia, when a pulse is present.",
        "indications": "Synchronized cardioversion is indicated for any type of unstable tachycardia with serious signs and symptoms directly related to the tachycardia.",
        "contraindications": "1. Asystole\n2. Ventricular Fibrillation\n3. Polymorphic Ventricular Tachycardia (Torsades de Pointes)",
        "protocol for management": "1. Remove all clothing covering the patient\u2019s chest and dry if necessary.  If the patient has excessive chest hair, shave hair to ensure proper adhesion.\n2. Attach 4 - Lead ECG electrodes for monitoring during cardioversion.\n3. Connect the multi function pacing / defibrillation pads to the monitor multi-function cable (if not already connected).\n4. Open the pad packaging and apply one edge of the pad securely to the patient.  Roll the pad smoothly from that edge to the other being careful not to trap any air pockets between the gel and skin.  Poor adherence and / or air under the multi-function pads can lead to the possibility of arcing and skin burns.\n5. If it is not possible to place the back multi- function pad on the patient\u2019s back, place it on the standard apex position of the apex-sternum configuration.  Effective defibrillation will result, but pacing with the device is usually less effective.\n6. If possible initiate IV / IO assess patient and consider sedation with Midazolam 0.1 mg / kg slow IVP, maximum single dose 5.0 mg.\n7. Prepare for cardioversion to pulseless arrhythmias; prepare for resuscitation / CPR.\n8. Turn the monitor on and select the lead you wish to view.\n9. Ready the monitor for defibrillation, and then select the desired energy level.\n10. Press the SYNC key.  The selected energy level is displayed on the monitor.   Refer to the Cardiac Care Protocols  for appropriate energy settings as well as specific manufacturer settings/recommendations.\n11. A SYNC marker should be displayed above each detected R-wave to indicate where discharge will occur.\n12. Press the CHARGE button and wait for the SHOCK button to enable.\n13. Press and hold SHOCK until energy is delivered to the patient.  The discharge will occur with the next marked R-wave.  ( NOTE:  MONITORS AUTOMATICALLY DEFAULT BACK TO DEFIBRILLATION MODE, FOLLOWING EACH SYNCHRONIZED SHOCK).\n14. If additional countershocks are necessary, re-adjust the energy level as necessary, press SYNC, and repeat steps 10 - 13.  Note:  SYNC should be displayed prior to pressing the CHARGE button.\n15. If it is necessary to disarm the charged defibrillator, changing the selected energy level should discharge internally all stored energy by the defibrillator."
    },
    {
        "document title": "Clinical Procedures",
        "protocol title": "Nasal Intubation",
        "overview": "Advanced airway procedures and competency are the cornerstones of paramedicine.  \nTrue competency involves knowing not only how to control the airway, but when to \ncontrol the airway, and selecting the best method to do so.  While orotracheal \nintubation is the gold standard of securing the airway, it is not the only means available \nto advanced life support providers.  Nasal intubation, if not done correctly may cause \nhemorrhaging from the nasal passages leading to an uncontrolled airway and \naspiration.",
        "indications": "1. Respiratory failure with decreasing level of consciousness, signs of hypoxia, or \ndeep coma. \n2. Respiratory failure trismus. \n3. Trauma patients without significant mid-facial trauma or mid-face instability.",
        "contraindications": "1. Patient has mid-face instability or frontal lobe head trauma or suspected basilar \nskull fracture. \n2. The patient is apneic and / or in cardiac arrest. \n3. The patient is known or is suspected to have increased intracranial pressure \n(ICP). \n4. Diabetic emergency or suspected narcotic overdose unless patient has not \nresponded to treatment per protocol and the airway is not maintainable with \nBLS adjuncts. \n5. There is a known ingestion of a caustic substance.",
        "protocol for management": "1. Explain procedure to patient, if appropriate. \n2. Patient should be pre-oxygenated, if tolerated, with an appropriately sized Bag \nValve Mask at a rate of 12 - 20 breaths per minute.  The patient\u2019s SpO 2 should \nbe raised as much as possible with manual ventilations prior to intubation \nattempt. \n3. Visually inspect each nare for foreign bodies or large polyps.  Insert an \nappropriately sized nasopharyngeal airway (NPA), lubricated with a water \nbased lubricant (KY Jelly), into the patient\u2019s larger nare, usually the right nare.  \n4. Prepare all equipment for intubation: \n   a. Appropriately sized, non-styletted, ET tube with 10 cc syringe \nattached \n   b. Pre-inflate cuff of tube to ensure no leaks, then deflate, leaving \nsyringe attached \n   a. Starting at the distal tip of tube, bevel out, curl tightly around gloved \nfinger and hold to assist in forming curvature of tube \n   c. Second ET tube, one (1) size smaller for unanticipated smaller nare \npassage way \n   d. 1/2\u201d silk tape torn into two 4\u201d strips to secure tube upon successful \nintubation \n   e. Capnography sensor connected to monitor \n   f. Suction setup turned on and within reach for use with vomited gastric \nsecretions \n   g. One (1) 15 mL bottle of Neo-Synephrine (if available) \n   h. One (1) 5.0 mL uro-jet of Lidocaine 2% Jelly (if available) \n   i. All appropriate BSI / PPE should be worn, to include eye protection, \nmask, and gloves \n5. Place patient in position of comfort. \n6. Once the determination has been made by the provider that the patient has \nbeen sufficiently pre-oxygenated, the NPA should be removed and an \nintubation attempt should be made. \n7. Remove the NPA and apply two (2) full \u201csquirts\u201d of Neo -Synephrine (if \navailable) in nare determined to be used for intubation ensuring to coat full \nlength of nare. \n8. Insert Lidocaine uro-jet (if available) tip in nare determined to be used for \nintubation, pushing tip into nose to rear of nare and pulling out while injecting \njelly solution. \n9. Check that capnography sensor is working properly; attach to end of ET tube. \n10. Insert the ET tube on a flat plane, bevel up, into nare, advancing tube gently, \nbut firmly, into nasal pharynx. \n11. If resistance is met, cephalad traction or rotation of tube may facilitate passage \nof tube past superior turbinate/ sphenoid sinus in rear of nose.  Use only \ngentle, firm pressure to advance the tube.  DO NOT FORCE TUBE IF \nRESISTANCE IS MET. \n12. Once tube has passed superior turbinate, continue advancing tube into lower \nairway until reaching the glottic opening (patient will gag), pull tube back slightly \nuntil gagging stops. \n13. Hold tube in place and listen to patient respirations through end of tube, \nwatching capnography waveform on monitor. \n14. While listening to air movement through the tube, advance tube into trachea \nwhen sound is loudest (inspiration).  Continue to watch capnography waveform \nduring insertion, as it should not change. \n15. If no waveform is present, pull tube back to glottic opening and attempt again.  \nIf intubation is unsuccessful a second time, remove tube and continue BLS \nairway interventions. \n16. If capnography waveform is present, inflate tube cuff with 5 - 10cc of, attach \nBVM and ventilate patient.  Attempt to ven tilate with patient\u2019s spontaneous \nrespirations. \n17. Continue placement confirmation: \n    \uf0b7 Observe chest rise upon ventilation \n    \uf0b7 Auscultate for bilateral lung sounds \n    \uf0b7 Auscultate abdomen for absent epigastric sounds \n    \uf0b7 Note condensation in the tube with passive exhalation \n18. If breath sounds are not heard equally, adjust tube for possible left or right \nmain-stem intubation by pulling tube out one (1) centimeter.  Reassess lung \nsounds.  In trauma patients, also assess for possible pneumothorax. \n19. Once lung sounds confirmed, secure ET tube with strips of tape and reassess \nlung sounds and capnography readings. \n20. Reassess the tube placement after all movement of patient or change in \ncapnography readings."
    },
    {
        "document title": "Clinical Procedures",
        "protocol title": "Patient Restraint  \n(Proposed:  Behavioral/Patient Restraint)",
        "overview": "This procedure is to be used when it is determined that the only way to administer \nproper patient care is through the use of restraints.",
        "indications": "1. Safe & controlled access for medical procedures when involuntary patient \ninterference or resistance is reasonably anticipated. \n2. Evaluation or treatment of combative persons when illness or trauma is \nsuspected to be the cause of the combativeness. \n3. Involuntary treatment of persons without capacity to refuse treatment.",
        "contraindications": "1. When any other form of transport without restraint is available.",
        "protocol for management": "1. Attempt to obtain verbal control of the situation. \n2. Determine if restraints will be needed by provider. \n3. Try to identify other causes for combativeness. \n4. Request Police response for assistance. \n5. INFORM Patient that you intend to restrain them and WHY (do not use this \ntechnique as a threat). \n6. The minimum number of providers needed to restrain a patient is three (3 ); \nhowever five (5) providers are recommend ed.  These five (5) people allow one \n(1) to control each extremity and one (1) for the patient\u2019s head  / airway. \n7. Apply restraints.  ALL restraints used by EMS will be soft restraints.  If police \nrestrain the patient with hard restraints, a police officer MUST ride in the \nambulance with the patient to the hospital. \n8. Soft restraints should be applied so that the circulation of the extremity is not \nimpaired.  It is recommended that providers use triangular bandages.  Doubled 6-\nply roller gauze (3 inch), sheets, and commercial soft restraint are acceptable \nalternatives.   Document physical assessment findings / injuries discovered before \nrestraints were applied. \n9. ALL Patients will be transported in the Supine Position. \na. Place patient onto stretcher.  \nb. Apply chest belt first.  This belt goes under the patient\u2019s arms.  It should \nas high as possible on the patient\u2019s chest . \nc. Apply thigh belt second.  This belt should be applied above the patient\u2019s \nknees. \nd. Apply abdominal / waist strap and shoulder straps. \ne. Insure that once the belt it tightened, it does not cause respiratory \ndistress and that the patient can still take full inspiratory breaths. \nf. Apply 4-point restraints last.  (Each arm and leg as necessary).  The 5-\npoint belt restraints may be enough restraint to control patient. \ng. It is recommended to restrain the arms above the wrists and the legs \nabove the ankles. \nh. It is recommended that the dominant arm of the patient be restrained \nabove his head.  \n i. Tie all restraints to \u201cT -Posts\u201d so tha t the restraint cannot slide. \n10. Once restrained, the patient should remain restrained until arrival at the receiving \nfacility. \n11. Circulatory checks should be performed distal to the restraints every 15 minutes. \n12. If a patient begins to have a seizure, CUT / RELEASE THE RESTRAINTS \nIMMEDIATELY. \n13. When a patient is restrained, documentation must include the following: \na. Evidence of patient\u2019s need for restraint. \nb. That the treatment and necessity of the restraints was in the patient\u2019s \nbest interest. \nc. Type of restraint employed and which extremities were restrained. \nd. Injuries that occurred during or after the restraint. \ne. Circulation checks every 15 minutes recorded with patient vital signs.",
        "pearls": "1. There are reversible, medically treatable conditions that can cause violen t \nbehavior in patients.  Providers should consider these causes (hypoglycemia, \nhypovolemia, overdoses, psychosis, etc.) when restraining a patient.   Refer to \nthe Medical Patient Care Protocols:  Altered Mental Status."
    },
    {
        "document title": "Clinical Procedures",
        "protocol title": "Capnography",
        "overview": "Capnography (PETCO 2 monitoring) is a non -invasive method of measuring CO 2 in exhaled gases.  By tracking the carbon dioxide in a patient\u2019s exhaled breath, capnography enables paramedics to objectively evaluate a patient\u2019s ventilatory status (and indirectly circulatory and metabolic status), while utilizing clinical judgment to assess and treat their patients.  Capnography is to be used as an additional tool to compliment sound clinical skills and patient assessment and is to be used on all intubated patients.",
        "usage requirement": "Capnography is an absolute requirement in all patients that have been  intubated  or had a supra -glottic airway  placed , or had a cricothyrotomy performed.  100% compliance is the goal .",
        "protocol for management": "1. Ensure all airway management equipment in working order and attached appropriately.  \n2. Attach capnography sensor to the endotracheal tube, or airway device, ventilate patient several times, and check monitor for distinct waveform and numerical value.  \n3. If no waveform is present, suspect esophageal intubation.  Remove tube and continue in airwa y algorithm.  \n4. Once tube placement is verified, record the time, waveform, and CO 2 reading. Be sure to note these times on your ePCR.  \n5. Provide ventilatory assistance to maintain CO 2 readings at 35  - 45 Torr (4.6% to 5.9%).  \n6. End tidal CO 2 monitoring is consider ed a vital sign and should be documented as such with serial vital signs (blood pressure, heart rate, respiratory rate, SPO 2,) at least every 5 minutes.",
        "capnogram waveform description": "The capnogram waveform begins before  exhalation and ends with inspiration. Breathing out comes before breathing in.  \n\nA\uf0aeB is post inspiration  / dead space exhalation  \nB is the start of alveolar exhalation  \nB\uf0aeC is the exhalation upstroke where dead space gas mixes  with lung gas  \nC\uf0aeD is the continuation of exhalation, or the plateau (all the gas is alveolar now, rich in CO 2) \nD is the end -tidal value (the peak concentration)  \nD\uf0aeA is the inspiration washout.",
        "pearls": "1. Sensor and readings not affected by administering drugs down ET tube.  \n2. Water, secretions, or vomitus accumulating in sensor can cause inaccurate readings.  \n3. The sensor is easily damaged and should be replaced if inaccurate readings occur.  \n4. An increasing e nd-tidal CO 2 may be the first sign of return of spontaneous circulation (ROSC) because readings within the normal values may indicate organ perfusion.  If you see the CO 2 value \u201cshoot up\u201d, stop CPR and check for pulses.  End tidal  will often overshoot baseline values wh en circulation is restored due to carbon dioxide washout from the tissues.  \n5. Capnography should be used in patients that have been orally  / nasally intubated, had a dual lumen  / supraglottic  airway inserted or had a surgical cricothyrotomy performed .",
        "causes of increased etco2": "Leak in vent circuit\nIncreased metabolic rate\nSodium Bicarbonate\nAdministration\nHypoventilation\nCOPD\nRebreathing\nSeizures\nMuscular paralysis\nFever\nSepsis\nRespiratory depression",
        "causes of decreased etco2": "Hypothermia\nHypotension\nPulmonary hypoperfusion\nCardiac arrest\nVentilatory disconnect\nEsophageal intubation\nHyperventilation\nComplete airway obstruction\nLeak around ET cuff\nHemorrhage\nPoor sampling\nPulmonary embolism",
        "clinical insights and waveform interpretation": "8. While capnography is a direct measurement of ventilation in the lungs, it also indirectly measures metabolism and circulation.  For example, an increased metabolism will increase the production of carbon dioxide increasing the ETCO 2. A decrease in cardiac output will lower the delivery of carbon dioxide to the lungs decreasing the ETCO 2.  \n9. Bronchospasm and obstructive lung disease will produce a characteristic \u201cshark fin\u201d wave form, as the patient has to struggle to exhale, creating a sloping \u201cB -C\u201d upstroke.  The shape is caused by uneven alveolar emptying.  \n10. It has been suggested that in wheezing patients with HF (because the alveoli are still, for the most part, emptying equally), the wave form should be upright.  This can help assist your clinical judgment when attempting to differentiate between obstructive airway wheezing such as COPD and the \"cardiac asthma\" of heart failure ( HF)."
    },
    {
        "document title": "Clinical Procedures",
        "protocol title": "Transcutaneous Pacing",
        "overview": "Non-invasive external transcutaneous cardiac pacing is basically providing an electrical signal to make the heart beat when the body\u2019s conduction system fails.  The body\u2019s anatomical pacemaker, the sino- atrial node, provides the heart\u2019s \u201cintrinsic\u201d rhythm.  When this internal pacemaker fails or is compromised and the body becomes hemodynamically unstable, transcutaneous pacing is the appropriate therapy.  It is accomplished by delivering pulses of electric current through the patient\u2019s chest, which stimulates the heart to contract.",
        "indications": "1. Mobitz Type II second-degree AV block\n2. Third-degree AV block\n3. Hemodynamically unstable bradycardia with signs and symptoms of low perfusion or shock.",
        "contraindications": "None in the presence of indications above",
        "protocol for management": "1. Remove all clothing covering the patient\u2019s chest and dry if necessary.  If the patient has excessive chest hair, shave hair to ensure proper adhesion.\n2. Attach 4 - Lead ECG electrodes for monitoring during pacing.  Adjust the ECG size and lead for a convenient waveform display.  Verify proper R-wave detection according to the specific indication given by your device.\n3. Connect the multi function pacing / defibrillation pads to the monitor multi-function cable (if not already connected).\n4. Open the pad packaging and apply one edge of the pad securely to the patient.  Roll the pad smoothly from that edge to the other being careful not to trap any air pockets between the gel and skin.  Poor adherence and / or air under the multi-function pads can lead to the possibility of arcing and skin burns.\n5. Apply the multi-function pads in the apex/ lateral position of the anterior-lateral configuration. Be sure to check your specific manufacturer\u2019s recommendations for pad placement\n6. Turn on the pacing function on your device.\n7. Set the PACER RATE to a value 10 - 20 ppm higher than the patient\u2019s intrinsic rate.  If no intrinsic rate exists, use 100 ppm.  The pacer rate increments or decrements by a value of 2 ppm on the display when you turn the knob.\n8. Increase the PACER OUTPUT ( mA) until capture is noted.  The output mA value will be displayed on the screen.",
        "determine capture": "Capture refers to the state  when the heart is being paced by the monitor rather than the body\u2019s own pacemaker mechanism.  Capture consists of two parts: electrical and mechanical capture.  You MUST verify capture both electrically and mechanically to ensure appropriate circulatory support of the patient.",
        "electrical capture": "Electrical capture means that the monitor is delivering sufficient electrical current to stimulate the heart as seen on the ECG tracing.  The shape and the size of the paced ECG waveforms can vary depending on the patient and the ECG lead configuration. Electrical capture is obtained when :  (1) Each stimulus marker is followed by a wide QRS complex, (2) There is no underlying intrinsic rhythm, and (3) An extended and sometimes enlarged T-wave appears.\nTypical ECG tracings of effective pacing",
        "mechanical capture": "Mechanical capture is confirmed when the patient\u2019s pulse matches the displayed pace rate.  Because pacing stimuli generally causes muscular contractions that can be mistaken for a pulse, you should never take a pulse on the left side of the body to confirm mechanical capture.  Pectoral muscle contractions due to pacing also do not indicate mechanical capture.  To avoid mistaking muscular response to pacing stimuli for arterial pulsations, use ONLY : (1) Femoral artery, or (2) Right brachial or radial artery for confirming mechanical capture.\nOnce capture has been confirmed, the optimum therapeutic threshold must be determined.  The ideal output current is the lowest value that maintains mechanical capture.  This is usually 10% above threshold.  Threshold is the minimum current that must be exceeded to begin producing ventricular capture.",
        "checking underlying patient rhythm": "Follow the manufacturer\u2019s directions for your specific device to check and determine the patient\u2019s underlying rhythm.",
        "asynchronous pacing": "Some devices allow for the delivery of asynchronous pacing.  If ECG electrodes are not available or there is some circumstance that prevents or interferes with the surface ECG, it may be necessary to operate the pacemaker asynchronously.  Asynchronous pacing should ONLY be performed in an emergency when NO OTHER ALTERNATIVES EXIST.  Follow the manufacturer\u2019s instructions for your specific device to deliver asynchronous pacing.\nNOTE:  Pace stimuli is also delivered asynchronously whenever there is an ECG lead off condition.  Be aware that there is no ECG activity on the display when pacing by this method; you must use other means of determining capture such as checking the patient\u2019s pulse.  When pacing asynchron ously with an ECG LEAD OFF condition, set the rate and output at the known capture level or high enough (100mA) to presume capture.",
        "pediatric pacing": "Non-invasive external transcutaneous cardiac pacing of pediatric patients is done in an identical manner to adult pacing.  Smaller size pediatric multi-function pads should be used for patients weighing less than 33 lbs / 15 kg.  Continuous pacing of neonates can cause skin burns.  If it is necessary to pace for more than 30 minutes, periodic inspection of the underlying skin is strongly advised.",
        "pearls": "1. The outcome of prolonged bradycardic or asystolic cardiac arrest is poor, even with non-invasive pacing.  Indiscriminate pacing of this rhythm is unwarranted, particularly as a late effort in the resuscitatio n.\n2. Human studies have shown that the average current necessary for external pacing is between 65 - 100 milliamperes.\n3. Pulse duration is the time of impulse stimulation.  Early non-invasive pacemakers used short-duration (1 - 2 milliseconds) impulses.  The action potential (electrical impulse including depolarizing and repolarizing) of cardiac muscle cells is longer than that for skeletal muscle, requiring 20 - 40 milliseconds to reach maximum effect.  Studies have found that increasing the duration from 1 to 4 milliseconds resulted in a three-fold reduction in threshold (the current required for stimulation) to produce capture.  Increasing the current from 4 to 40 milliseconds further halves the threshold.\n4. Transcutaneous pacing may be uncomfortable for the patient.  Sedation and pain management should be considered, as needed.\n5. Prolonged transcutaneous pacing may cause burns to the skin.  If possible, pacing should not be continued more than 30 minutes if at all possible."
    },
    {
        "document title": "Clinical Procedures",
        "protocol title": "Orogastric Tube",
        "overview": "An oral gastric tube is used to decompress the stomach of air and / or gastric contents\nafter intubation.",
        "indications": "Decompression of air and suctioning of gastric contents of a cardiac or respiratory arrest\npatient after endotracheal intubation, King LTS-D, or other appropriate alternate airway\ndevice, has been performed and placement verified.",
        "contraindications": "1. Known or suspected esophageal varices\n2. Esophageal stricture\n3. Esophagectomy or partial gastrectomy\n4. Gastric bypass\n5. Penetrating neck trauma",
        "protocol for management": "1. Estimate the length of the tube needed to reach the stomach by measuring the\ntube from the corner of the mouth to the earlobe and down to the xiphoid\nprocess.  Mark the length with tape.\n2. Lubricate the OG tube (16F) with water-soluble lubricant (KY Jelly).\n3. Insert the tube through the oropharynx until the marked depth is reached.\n4. If the tube coils in the posterior pharynx, direct laryngoscopy can be utilized to\nplace the tube in the esophagus.\n5. Verify placement.  Using a 60 ml catheter tip syringe, instill 30 ml of air into the\ntube while auscultating over the epigastrum for sound of rushing air.\n6. Aspirate for gastric contents and assess for cloudy, green, tan, brown, bloody, or\noff-white colored contents consistent with gastric contents.\n7. Secure tube with tape and leave the blue air vent open to atmosphere.\n8. Attach the tube to continual low suction (approximately 60 mmHg) using onboard\nsuction.\n9. If suction is not readily available, connect the empty 60 ml syringe to the tube\nwhile keeping the blue air vent open to atmosphere.  This will allow the sump\nfunction of the tube to continue working until suction can be applied and will also\nprevent gastric contents from leaking from the tube.\n10. If you cannot place the OG tube quickly (no more than 2 attempts), forego the\nprocedure.  DO NOT DELAY TRANSPORT."
    },
    {
        "document title": "Clinical Procedures",
        "protocol title": "12-Lead ECG Acquisition",
        "overview": "The 12-lead ECG analysis is useful in the diagnosis and treatment of patients with acute myocardial infarction (AMI). 12-lead ECG analysis is also useful in the interpretation and documentation of other transient cardiac arrhythmias that may occur.  When used in the pre-hospital setting, the 12-lead analysis results can be of assistance in diagnosis and treatment decisions once the patient has arrived in the hospital emergency department.",
        "signs and symptoms for 12 lead acquisition": "At a minimum, both ALS and BLS providers should obtain a 12-lead for the following patient complaints:\n- Chest pain/tightness\n- Difficulty Breathing\n- Nausea\n- Stroke/neuro symptoms\n- Altered mental status with no obvious cause\n- General feelings of malaise in diabetic and/or geriatric and/or female patients",
        "protocol for management": "Electrode Placement\n1. Proper skin preparation and use of proper electrodes is essential for good signal quality.   If necessary, prepare the patient\u2019s skin for electrode application by shaving excess hair at electrode site, cleaning oily skin with an alcohol pad, or using benzoine tincture for excessive diaphoresis.\n2. When acquiring a 12-Lead ECG , place the patient in a supine o r semi -fowlers position.  Discuss the need to hold still.  American Heart Associa tion (AHA) recommends placing the electrodes anywhere along the wrists and ankles .  Conversely, w hen it is difficult for the patient to remain motionless due to shivering, muscle tremors, or ambulance movement place limb electrodes on patient\u2019s thorax for better results, per International Electrotechnical Commission (IEC) recommendation.\n3. Placement of the electrodes used to perform a 12-Lead ECG requires proper knowledge of anatomy and precise application for an accurate analysis.  Proper placement is as follows:\nV1: Fourth intercostal space, right sternal margin.\nV2: Fourth intercostal space, left sternal margin.\nV3: Fifth rib, midway between leads V2 and V4.\nV4: Fifth intercostal space, mid-clavicular line.\nV5: Left anterior axillary line, at the horizontal level of V4.\nV6: Left mid-axillary line, at the horizontal level as V4 and V5\nLocating the V1 position (fourth intercostal space) is critically important because it is the reference point for locating the placement of the remaining V-leads.  To locate the V1 position:\n1. Place your finger on top of the jugular notch.\n2. Move your finger slowly downward approximately 1.5 inches (3.8 centimeters) until you feel a slight horizontal ridge or elevation.  This is the \u201cAngle of Louis,\u201d where the manubrium joins the body of the sternum.\n3. Locate the second intercostal space on the patient\u2019s right, lateral to and just below the \u201cAngle of Louis.\u201d\n4. Move your finger down two more intercostal spaces to the fourth intercostal space which is the V1 position.\nWhen placing electrodes on female patients, ALWAYS place leads V3 - V6 under the breast rather than on the breast",
        "normal ecg parameters": "P-R Interval  0.12 - 0.20 sec\nQRS Duration 0.08 - 0.12 sec\nQTc Interval  0.35 - 0.43 sec\n**Anything greater than 0.44 sec is considered prolonged **",
        "considerations for right sided and posterior 12 lead electrode placement": "Right ventricular infarct may complicate up to 40-50% of all inferior AMIs and 13% of all anterior AMIs.  When assessing a patient presenting with AMI it is important to ascertain whether it involves the right ventricle as this may alter your treatment or the receiving facilities treatment upon your arrival.  It is recommended, although not mandatory, that a right-sided and / or posterior 12-Lead ECG be obtained if ST elevation is noted in Leads II, III, AVL, AVF, or V1.  Time is muscle and transport should not be delayed to obtain a right-sided or posterior 12-Lead ECGs.\nTwo ways to obtain a right-sided 12- Lead ECG are noted below, the first being a \u201cquick look\u201d and the second being a full right sided ECG.\nPosterior Lead Placement\nModified Lead V4R\nBasically, this is lead V4 moved to the right side of the chest (mid-clavicular line, fifth inter-costal space).\nWhen Lead V4R shows at least 1 mm of ST segment elevation in the presence of inferior STEMI, it\u2019s a highly sensitive marker for right ventricular  involvement.\nWhen printed out, this ECG should be marked as V4R for clarification.\nRight-Sided and Posterior Lead Definitions:\nV4R \u2013 Fifth inter-costal space at the left right mid-clavicular line (Lead V3).\nV5R \u2013 Right anterior axillary line, horizontal line from V4R (Lead V2).\nV6R \u2013 Right mid-axillary line, horizontal line from V5R (Lead V1).\nV7 \u2013 Left posterior axillary line, horizontal line from V6R (Lead V5).\nV8 \u2013 Left mid-scapular line, horizontal line from V7 (Lead V5).\nV9 \u2013 Left para-spinal line, horizontal line from V8 (Lead V6).",
        "considerations for reviewing 12 lead ecg printout results": "The ECG data can be viewed in three different ways:\nECG Strip  The unit displays a 12 -lead strip with 10 seconds of ECG data, in four staggered 2.5 second segments.\nInterpretation  The unit displays the results of interpretation of the ECG recording by the 12 -lead program.\nMeasurements  The unit displays measurements based on all 12 -leads.\nThe global measurements include heart rate, PR i nterval, QRS duration, QT, and the QTc.\nMeasurement  Description\nHeart Rate  Frequency is shown in beats per minute.  Normal adult range is 60  - 100.\nPR Interval  This time interval is between the beginning of the P wave and the beginning of the QRS complex.  It is sometimes referred to as PQ duration.  Smaller values indicate premature excitation of the ventricles and larger values indicate conduction defects in th e atrioventricular (AV) node.\nQRS Duration  Duration of the QRS complex in milliseconds.  Larger values indicate ventricular conduction defects.\nQT, QTc Duration  Time in milliseconds from the beginning of the QRS complex to the end of T wave.  The QTc value is the QT corrected for heart rate to estimate the value it would have been if the heart rate were 60 beats per minute.   Abnormal values can be due to an electrolyte im balances or drugs.  A short QT may be due to hyperkalemia and long QT due to hypocalcemia, or quinidine -like drugs (procainamide, amiodarone).\nQRS axis  This is the axis of the QRS complex.  Smaller than -30 is called left axis deviation; larger than 90 is a right axis deviation.  Deviations can be due to conduction blocks or hypertrophy"
    },
    {
        "document title": "Clinical Procedures",
        "protocol title": "Pulse Oximetry",
        "overview": "Assessment and maintenance of a patent airway is an important skill required of every \npre-hospital provider.  Pulse Oximetry (Pulse Ox, SpO 2) is a non-invasive method of \nmeasuring the oxygen saturation of arterial blood, thus providing an evaluation of \nventilatory status.  Oxygen saturation is only part of the picture.  The assessment of the \nventilatory status remains one of clinical judgment.   The principle behind pulse oximetry \nis relatively basic.  A probe is applied to the patient and a beam of light is passed \nthrough the tissues to a photo-detector on the other half of the probe.  The photo-\ndetector senses the amount of light absorbed by the oxyhemoglobin molecules in the \narterial blood as it passes through the tissues beneath the probe.  This information is \ntransmitted to the processing unit of the oximeter, and the percentage of oxygen \nsaturation is displayed.",
        "device types and waveform recognition": "Reusable Pulse Oximeter\nPediatric Disposable Pulse Oximeter\nPulse Oximetry Waveforms Recognition\nNormal SpO2 Waveform\nNoise Artifact Waveform\nLow Perfusion Waveform\nMotion Artifact Waveform\nPhoto courtesy of biomedsearch.com\n**Make sure the SPO 2 sensor is correctly positioned to achieve the \noptimum wave form**",
        "pearls": "1. ALWAYS TREAT THE PATIENT NOT THE PULSE OXIMETER .  Never withhold \noxygen from a patient in respiratory distress regardless of the SpO 2 reading.\n2. A SpO 2 reading and corresponding HR on the monitor should be confirmed with \nmanual pulse check and visualization of proper SpO 2 waveform on monitor.\n3. Patients found with possible carbon monoxide poisoning will have an \ninaccurately high SpO 2 reading due to the binding of carbon monoxide with \nhemoglobin.  Carbon monoxide has a binding affinity for hemoglobin 240 times \ngreater than that of oxygen, causing decreased oxygen delivery to the tissue.\n4. Remember that the pulse oximeter only measures arterial oxygen saturation.  It \ndoes not measure the actual PaO 2, nor does it measure the PCO 2 or the pH.  It \nalso does not assess ventilation.  A patient with COPD who has a normal hypoxic \ndrive may have an excellent PaO 2 when given 100% oxygen, but will soon \nhypoventilate and have dangerously high CO 2 levels while maintaining a high \nPO 2.\n5. Pulse oximetry is considered the \u201cfourth vital sign\u201d and should be assessed and \ndocumented when available for use.\n6. The device must sense a pulse to calculate the oxygen saturation.  States of \ndecreased cardiac output, such as :  bradycardia, tachycardia, hypotension, and \ncardiac arrest will greatly limit the probes ability to sense the pulse.  Episodes of \nvasoconstriction, such as shock of hypothermia will also have a similar effect."
    },
    {
        "document title": "Clinical Procedures",
        "protocol title": "Supraglottic Airway",
        "overview": "Supraglottic airways such as the King LTS- D and LMA Supreme are designed for use as a primary or alternate airway device utilized for airway control in the unconscious patient when oral intubation attempts have failed or are unfeasible. ODEMSA does not advocate for one particular device over another.",
        "king ltd ltsd device name": "King LTD / LTSD",
        "king ltd ltsd indications": "1. Can be used as the primary airway for cardiac arrest.\n2. Any patient requiring intubation when oral ET intubation has failed or insertion of oral ET intubation is unfeasible.",
        "king ltd ltsd contraindications": "1. Patient has an intact gag reflex.\n2. Patient is less than three (3) feet tall.\n3. Patient has a known or suspected underlying esophageal and / or laryngeal disease.\n4. Significant damage to the cricoid cartilage or larynx (fractured larynx) is noted upon exam.\n5. Transection of the patient\u2019s trachea is noted upon exam.\n6. Patient has known or suspected foreign body airway obstruction.\n7. There is significant damage noted to the maxillofacial region.\n8. There is a known ingestion of a caustic substance.",
        "king ltd ltsd sizing": "Size Connector Color Patient Criteria\n2 (Green) 35 - 45 inches 12 - 25 kg\n2.5 (Orange) 41 - 51 inches 25 - 35 kg\n3 (Yellow) 4 - 5 feet N/A\n4 (Red) 5 - 6 feet N/A\n5 (Purple) > 6 feet N/A",
        "king ltd ltsd management protocol": "1. Gently bend the distal portion of the King LTS-D airway to aid in insertion.\n2. Lubricate the distal portion of the tube with a water-based lubricant (KY Jelly) to aid insertion.\n3. Using the thumb and forefinger of your non-dominant hand, grasp the tongue and jaw and gently lift the jaw in an anterior and distal motion, unless contraindicated by C-spine precautions or patient position. Using a lateral approach, introduce the tip into the corner of the mouth.\n4. Insert the tube following the natural curve of the oropharynx until the proximal end of the King LTS-D airway lies flush with the patient\u2019s teeth. DO NOT FORCE THE TUBE INTO PLACE.\n5. Using the large syringe provided, inflate the cuff of the King LTS-D airway with the appropriate volume:\nSize Connector Color Patient Criteria\n2 (Green) 25 - 35 ml\n2.5 (Orange) 30 - 40 ml\n3 (Yellow) 45 - 60 ml\n4 (Red) 60 - 80 ml\n5 (Purple) 70 - 90 ml\n6. Attach the Bag Valve Mask to the King LTS-D airway and evaluate compliance. While bagging patient, gently withdraw the tube until ventilation becomes easy and free-flowing.\n7. Attach capnography sensor, ventilate patient several times, and check monitor for distinct waveform and numerical value. If no waveform is present, check equipment as outlined in Capnography Clinical Procedure. If capnography is working but no waveform is present, remove King LTS-D, oxygenate patient with bag valve mask, and reattempt insertion.\n8. Continue placement confirmation:\n- Observe chest rise upon ventilation\n- Auscultate for bilateral lung sounds\n- Auscultate abdomen for absent epigastric sounds\n- Note condensation in the tube with passive exhalation\n9. If successful tube placement cannot be confirmed, remove the tube and ventilate using basic airway skills.\n10. Secure the King LTS-D airway with a tube holder device and reassess placement.",
        "lma supreme device name": "LMA Supreme",
        "lma supreme indications": "1. Can be used as the primary airway for cardiac arrest.\n2. Any patient requiring intubation when oral ET intubation has failed or insertion of oral ET intubation is unfeasible.",
        "lma supreme contraindications": "1. Patient has an intact gag reflex.\n2. Patients with inadequate mouth opening to permit insertion.\n3. Patient has a known or suspected underlying esophageal and/ or laryngeal disease.\n4. Patients who have ingested caustic substances.\n5. There is a known ingestion of a caustic substance.",
        "lma supreme management protocol": "1. Lubricate the posterior surface of the mask and airway tube just prior to insertion.\n2. Stand behind or besides the patient\u2019s head.\n3. Place the head in the neutral or slight \u201csniffing\u201d position (Sniffing = extension of head & flexion of neck).\n4. Hold the device as shown in the illustration above.\n5. Slide inwards using a slightly diagonal approach (direct the tip away from the midline).\n6. Continue to slide inwards rotating the hand in a circular motion so that the device follows the curvature behind the tongue.\n7. Resistance should be felt when the distal end of the device meets the upper esophageal sphincter. The device is now fully inserted.\n8. Secure the device.\n9. Attach capnography sensor, ventilate patient several times, and check monitor for distinct waveform and numerical value. If no waveform is present, check equipment as outlined in Capnography Clinical Procedure. If capnography is working but no waveform is present, remove LMA Supreme, oxygenate patient with bag valve mask, and reattempt insertion.\n10. Continue placement confirmation:\n- Observe chest rise upon ventilation\n- Auscultate for bilateral lung sounds\n- Auscultate abdomen for absent epigastric sounds\n11. If successful tube placement cannot be confirmed, remove the tube and ventilate using basic airway skills."
    },
    {
        "document title": "Clinical Procedures",
        "protocol title": "Continuous Positive Airway Pressure (CPAP)",
        "overview": "Continuous Positive Airway Pressure (CPAP) has been shown to rapidly improve vital signs and gas exchange, reduce the work of breathing, decrease the sense of dyspnea, and decrease the need for endotracheal intubation in patients who suffer from shortness of breath from asthma, chronic obstructive pulmonary disease (COPD), pulmonary edema, heart failure (HF), and pneumonia. In patients with HF, CPAP improves hemodynamics by reducing left ventricular pre-load and after-load.",
        "indications": "1. Any patient experiencing dyspnea or hypoxemia secondary to asthma, COPD, pulmonary edema, HF, pneumonia, or inhalation injury secondary to CO / CN exposure and:\n  a. Is awake and able to follow commands\n  b. Is > 12 years old and is able to fit the CPAP mask to their face properly\n  c. Has the ability to maintain an open airway\n  d. Has a systolic BP > 90 mmHg\n  e. Exhibits two or more of the following:\n    \uf0b7 Has a spontaneous respiratory rate > 25 breaths per minute\n    \uf0b7 SpO 2 < 94% at any time\n    \uf0b7 Use of accessory muscle usage during respiration",
        "contraindications": "1. Patient < 12 years old.\n2. Patient suspected of having a pneumothorax or has suffered trauma to the chest.\n3. Respiratory or cardiac arrest.\n4. Patient has a tracheostomy.\n5. Patient has agonal respirations.\n6. Patient showing signs of shock associated with cardiac insufficiency.\n7. Unconsciousness.\n8. Persistent nausea / vomiting.\n9. Facial anomalies / stroke / obtundation / facial trauma.\n10. Patient has active vomiting, upper GI bleeding or a history of recent gastric surgery.",
        "protocol for management": "1. Prepare all equipment for CPAP initiation and application:\n  a. Connect CPAP to portable/ ambulance oxygen supply\n  b. Connect CPAP mask to airflow hose and airflow hose to CPAP machine\n  c. Connect capnography sensor to monitor\n  d. Do not delay CPAP application to setup in-line nebulizer attachment\n  e. Assure airflow is present and machine is working properly by placing hand over mask opening and checking pressure\n  f. If not previously initiated, place patient on continuous pulse oximetry and cardiac monitoring (if provider\u2019s certification allows)\n2. Once all equipment is prepared, CPAP should be supplied to patient:\n  a. Explain the procedure to the patient\n  b. Place mask to patient face assuring proper fit and seal over mouth and nose\n  c. Refer to manufacturer\u2019s instructions for set up of your specific device\n  d. Hold mask in place and secure with provided straps. Mask / seal should be tight but not uncomfortable for patient. Check for air leaks, mask / straps may need to be adjusted for proper fit\n  e. If patient present with wheezing, setup nebulizer medications per protocol and apply as inline treatment\n  f. Monitor and document the patient\u2019s respiratory response to treatment\n  g. Check monitor for distinct capnography waveform and numerical value. If no waveform is present, check equipment as outlined in Capnography Clinical Procedure\n  h. Vital signs should be checked and documented every 5 minutes while on CPAP\n  i. All medications per applicable medical treatment protocol should be given in conjunction with CPAP use. CPAP does not replace medication use\n  j. Continue to coach patient as needed to keep mask in place, readjust as needed\n  k. Notify intended receiving hospital as soon as possible of patient status and CPAP application so a CPAP device can be brought to Emergency Department prior to patient arrival\n  l. If respiratory status deteriorates, remove CPAP, assist patient spontaneous respirations with Bag Valve Mask, and prepare for nasal / oral intubation",
        "considerations": "1. CPAP therapy needs to be continuous and should not be removed once applied unless patient cannot tolerate mask, patient respiratory drive declines, or patient begins to vomit.\n2. Upon arrival at hospital, advocate for patient to remain on CPAP and do not remove CPAP until hospital equivalent respiratory therapy is ready to be placed on patient.\n3. Watch patient for gastric distention, which may result in vomiting.\n4. Procedure may be performed on patient with a valid Pre-Hospital Do Not Resuscitate order.\n5. Due to changes in pre-load and after-load of the heart during CPAP therapy, a complete set of vital signs must be obtained every five minutes.\n6. Due to existing high intra-thoracic pressures present with these types of patients it is imperative that the lowest possible pressures be used during treatment to prevent possible development of a pneumothorax from lung over inflation."
    },
    {
        "document title": "Clinical Procedures",
        "protocol title": "Medication Administration Cross-Check",
        "overview": "In line with developing a Culture of Safety, the medication cross-check procedure is a critical component of improving the care we deliver, and keeping our patients safe. As providers, we must appreciate that the measures developed to create barriers, redundancy, and recovery are not attempts to \u201cdumb down\u201d the care we provide, but to address the ubiquitous vulnerabilities of human cognition so that our patients are more than one human error away from harm. The Medication Administration Cross-Check is an attempt to do just that; to insert one more layer of protection for the patient from predictable patterns and frequency of human errors.",
        "indications": "1. Any time a medication is to be administered.",
        "contraindications": "1. None",
        "protocol initiation statement": "The AIC initiates the procedure check by stating \u201cCross -check.\u201d Provider #2 responds that he/she is, \u201cReady.\u201d It is important to avoid using ambiguous responses like, \u201cOkay,\u201d since they may be interpreted many different ways.",
        "two provider procedure details": "The attendant in charge (AIC) obtains intended medication and confirms correct drug.\na. Second Provider verifies and states, \u201cCheck.\u201d\nThe attendant in charge (AIC) confirms expiration date.\nb. Second Provider verifies and states, \u201cCheck.\u201d\nThe attendant in charge (AIC) confirms correct concentration.\nc. Second Provider verifies and states, \u201cCheck.\u201d\nThe attendant in charge (AIC) confirms correct route of administration.\nd. Second Provider verifies and states, \u201cCheck.\u201d\nThe attendant in charge (AIC) confirms correct amount of medication to be given.\ne. Second Provider verifies and states, \u201cCheck.\u201d\nThe attendant in charge (AIC) confirms no allergies or prior reactions to the medication.\nf. Second Provider verifies and states, \u201cCheck.\u201d\nThe attendant in charge (AIC) confirms V/S are appropriate.\ng. Second Provider verifies and states, \u201cCheck.\u201d\nThe attendant in charge (AIC) confirms there are no other contraindications.\nh. Second Provider verifies and states, \u201cCheck.\u201d\nUpon the cross-check procedure being completed, the AIC should then administer the medication.",
        "medication terminology note": "*Terms such as \u201camp\u201d or \u201cvial\u201d should be avoided, as this may lead to an incorrect dosage administration. By providing a specific amount, the false notion that the contents of a vial are a \u201cdose\u201d is avoided and directs the provider\u2019s attention to exactly how much medication they intend to deliver.",
        "two provider summary": "Provider #1 | Provider #2\nCorrect drug name | Check\nExpiration date valid | Check\nConcentration & volume in vial | Check\nRoute of administration | Check\nVolume to be given | Calculate & crosscheck\nNo prior allergy or reaction | Check\nVital signs appropriate | Check\nNo other contraindications | Check\nADMINISTER THE MEDICATION",
        "one provider procedure details": "1. When and AIC must medicate a patient alone (e.g. administering during transport to a hospital), the provider should follow and confirm the medication using a modified version of the established shelf-check procedure on the 1 Provider Medication Administration Cross-Check card.\n2. The AIC must confirm by reading the label that it is the intended medication to administer.\n3. The AIC must confirm by reading the label that the medication is not expired.\n4. The AIC must confirm by reading the label that the concentration by volume in the container.\n5. The AIC must confirm by calculating the amount of medication to be given.\n6. The AIC must repeat each of the above actions to cross-check.\n7. The AIC must verify the patient\u2019s vital signs are appropriate and confirm any drug allergies.\n8. Upon the self-check procedure being completed, the AIC should then administer the medication.",
        "one provider summary": "Action |\nCorrect drug name | Verify\nExpiration date valid | Verify\nConcentration & volume in vial | Verify\nRoute of administration | Verify\nVolume to be given | Calculate\nREPEAT EACH OF THE ABOVE STEPS TO CROSSCHECK\nNo prior allergy or reaction | Verify\nVital signs appropriate | Verify\nNo other contraindications | Verify\nADMINISTER THE MEDICATION",
        "pearls": "1. It is essential that both providers participate in an engaged manner and do not participate passively.\n2. If a discrepancy, disagreement, or a need for clarification is encountered at any step in the process, it must be resolved prior to continuing the cross-check procedure.\n3. The cross-check confirmation has been created to be effective regardless of provider #2\u2019s level of certification and/or knowledge of pharmacology. The drug name, concentration and expiration date can all be verified by visual verification of the information printed on the drug label.",
        "interruption guideline": "IF AT ANY TIME THE PROCESS IS INTERRUPTED DURING A TWO PROVIDER AND ESPECIALLY A ONE PROVIDER CROSS-CHECK, THE PROCESS SHOULD START AGAIN FROM THE BEGINNING."
    },
    {
        "document title": "Clinical Procedures",
        "protocol title": "Needle Thoracentesis",
        "overview": "A needle decompression is a life saving procedure used to relieve a tension \npneumothorax.  A tension pneumothorax is usually the result of blunt or penetrating \ntrauma to the chest but may also be spontaneous.  A simple pneumothorax develops \ninto a tension pneumothorax as the pressure in the pleural space exceeds the outside \natmospheric pressure.  This increase of pressure within the pleural space further \ncollapses the lung on the involved side and forces the mediastinum to the unaffected \nside decreasing the blood flow to the heart and placing pressure on the unaffected \nlung.",
        "indications": "1. Any patient exhibiting signs/ symptoms of respiratory distress due to blunt \nforce or penetrating chest trauma that also has a complaint of: \na. Increasing respiratory distress and \nb. Decreasing or absent breath sounds unilaterally or bilaterally with \nrespirations and \nc. Decreased SpO 2 despite oxygen therapy and \nd. Increasing tachycardia \n2. Any trauma arrest involving chest trauma that resuscitation is being attempted \nshould have bilateral needle decompression performed as soon as possible to \neliminate hemo / pneumothorax as a cause of traumatic arrest. \n3. Consider in the setting of refractory pulseless electrical activity (PEA).",
        "protocol for management": "1. Prepare all equipment for needle thoracentesis: \na. Over 8 years old: 14g x 3.75\u201d angiocath with 10 ml syringe attached.  \nb. Under 8 years old: 18g x 1.25\u201d angiocath with 10 ml syringe attached.  \nc. \u00bd\u201d silk tape torn into 5\u201d length to use to stabilize catheter.  \n2. Once all equipment is prepared, needle thoracentesis should be performed. \na. Locate proper insertion site, 2nd inter-costal space at the mid-clavicular \nline of the affected side of the chest. \nb. Prep insertion site with betadine using aseptic technique, if available. \nc. Insert angiocath with syringe attached into second inter-costal space \njust over 3rd rib to avoid inter-costal nerves and vessels located on the \ninferior portion of the rib border. \nd. Advance the catheter 1 - 2 inches (3/4 - 1 inch in patients less than 8 \nyears old) through the chest wall while pulling back gently on plunger \nof syringe.  Tension should be felt on the plunger until the needle \nenters the pleural space.  A \u201cpop\u201d or \u201cgive\u201d may also be felt.  Once \nneedle has entered pleural space, do not advance needle any further. \ne. Advance catheter while withdrawing the needle until the catheter is \nflush with the skin. \n3. Listen for a gush or \u201c hiss\u201d of air, which confirms placement and diagnosis.  \nNote:  This may not always be heard due to severity of injury or missed due to \nsurrounding noise. \n4. Dispose of needle properly and never reinsert into the catheter . \n5. Secure catheter by wrapping strip of tape around hub and taping to chest. \n6. Reassess lung sounds and document procedure, whether air or blood was \nexpelled, improvement of vital signs, and success/ failure in PPCR. \n7. Continue to reassess during transport as tension pneumothorax may reoccur.",
        "signs and symptoms": "***PROGRESSIVE SIGNS AND SYMPTOMS OF TENSION PNEUMOTHORAX***  \nEARLY  \n\uf0b7 Unilaterally decreased \nor absent breath \nsounds  \n\uf0b7 Continued increased \ndyspnea and \ntachypnea despite \ntreatment  \n\uf0b7 Increasing heart rate \nwith decreasing SpO 2 \nPROGRESSIVE  \n\uf0b7 Increasing tachypnea \nand dyspnea  \n\uf0b7 Tachycardia and \nsubcutaneous \nemphysema  \n\uf0b7 Increasing difficulty \nventilating an intubated \npatient  \nLATE  \n\uf0b7 Jugular vein distention  \n\uf0b7 Tracheal deviation  \n\uf0b7 Tympany  \n\uf0b7 Signs o f acute hypoxia  \n\uf0b7 Narrowing pulse \npressure",
        "considerations": "PEARLS:  \n1. Catheter may become occluded after initial decompression.  Full procedure \nmay need to be repeated if occlusion occurs.   If additional procedures are \nnecessary, placement of these catheters should be near the original site. \n2. A partially filled syringe of saline (i.e., 5 mL in a 10 mL syringe) may be \napplied to the catheter when available as a visual aide to confirm placement.  \nIf air is present, bubbles will be seen in the syringe."
    },
    {
        "document title": "Clinical Procedures",
        "protocol title": "Oral Intubation",
        "overview": "Advanced airway procedures and competency are the cornerstones of paramedicine. True competency involves knowing not only how to control the airway, but when to control the airway, and selecting the best method to do so.",
        "attempt limit": "Only one (1) attempt at oral intubation should be attempted. If unsuccessful, an alternative airway device should be inserted without delay.",
        "indications absolute": "1. Hypoxia or obtunded patients\n2. Respiratory Arrest\n3. Cardiac Arrest",
        "indications strongly consider with": "1. Any patient with a decreased level of consciousness with compromised ability to manage their airway\n2. Airway burns or edema\n3. HF, acute asthma, COPD, or other respiratory failure\n4. with diminished respiratory drive\n5. Suspected intracranial hemorrhage or closed head injury\n6. Patients who fail to respond to positive pressure ventilation\n7. GCS < 8 without reversible causes",
        "contraindications": "1. An intact gag reflex\n2. Patients that have a tracheostomy or stoma",
        "protocol for management": "1. Patient should be pre-oxygenated with appropriately sized Bag Valve Mask at a rate of 12 - 20 breaths per minute with an appropriately sized oropharyngeal airway in place.  The patient\u2019s SpO 2 should be raised as much as possible with manual ventilations prior to intubation attempt.\n2. Patient airway should be assessed and documented for ability / difficulty of oral intubation via Mallampati classification and prepare for possible use of rescue airway device.  Once visualization of the lower airway has been obtained, assessment of difficulty can again be made using the Cormack & LeHane classification.  The higher the classification, the more difficult the intubation.\n3. Prepare all equipment for intubation:\na. Appropriately sized Macintosh or Miller (provider choice) intubation blade and handle\nb. Appropriately sized ET Tube with stylet and 10 ml syringe attached\nc. Pre-inflate cuff of tube to ensure no leaks, then deflate, leaving syringe attached\nd. Bend tube and stylet into a crescent or \u201chockey stick\u201d shape and ensure that the stylet is at least one (1) centimeter proximal to the end of the tube\ne. Have immediately available a second ET tube, one (1) size smaller for unanticipated smaller trachea\nf. Adult or pediatric tube holder\ng. Capnography sensor connected to monitor\nh. Suction setup turned on and within reach for use with vomited gastric secretions\ni. An alternative airway device should be within reach and ready for use in case of failed intubation\nj. All appropriate BSI / PPE should be worn to include eye protection, mask, and gloves\n4. Once the determination has been made by the provider that the patient has been sufficiently pre- oxygenated, the OPA should be removed and an intubation attempt should be made:\na. Position the patient\u2019s head in the \u201csniffing position\u201d (unless C-spine injury is suspected)\nb. Insert the intubation blade into the mouth, lifting the tongue and sweeping it to the left.  Suction, as necessary, to create a clear field of view of t he lower airway\nc. Insert the laryngoscope blade into the pharynx and visualize the glottic opening and epiglottis by properly seating the blade in the correct position:\n    \uf0b7 Macintosh blade should be inserted until the tip is seated in the vallecula\n    \uf0b7 Miller blade should be inserted until covering the epiglottis\nd. When maneuvering airway with blade, do not use teeth as a fulcrum, as this may cause breakage of teeth, increased intubation difficulty, and / or possible airway obstruction.\ne. Lift the laryngoscope upward and forward, without changing the angle of the blade, to expose the vocal cords.  Do not lift using prying motion.\nf. Once vocal cords are visualized, do not change position of blade.  Insert ET tube into the pharynx and between the vocal cords, anterior to the arytenoid cartilages, until the wide black mark on the distal end of the tube has passed through the vocal cords, approximately 1 inch in the adult and 5 - 10 mm in the child.\ng. Without releasing tube, remove laryngoscope blade.  Inflate ET tube cuff with 5 - 10 cc of air via attached syringe.\nh. Attach capnography sensor, ventilate patient several times, and check monitor for distinct waveform and numerical value.  If no waveform is present, check equipment as outlined in Capnography Clinical Procedure .  If capnography is working but no waveform is present, remove ET tube, and immediately insert an alternative airway device.\ni. If capnography waveform is present, continue placement confirmation:\n    \uf0b7 Observe chest rise upon ventilation\n    \uf0b7 Auscultate for bilateral lung sounds\n    \uf0b7 Auscultate abdomen for absent epigastric sounds\n    \uf0b7 Note condensation in the tube with passive exhalation\n    ***Continually assess the placement of the ET tube***\nj. If breath sounds are not heard equally, deflate cuff and adjust tube for possible left or right main-stem intubation by pulling tube out one (1) centimeter.  Inflate cuff and reassess lung sounds.  In trauma patients, also assess for possible pneumothorax.\nk. Once lung sounds confirmed, document centimeter mark at teeth (depth), and secure ET tube with tube holder and reassess lung sounds and capnography readings.\nl. Reassess the tube placement after all movement of patient or change in capnography readings."
    },
    {
        "document title": "Clinical Procedures",
        "protocol title": "Mechanically-Assisted External Chest Compression Device",
        "overview": "When treating patients in sudden cardiac arrest, consistent, continuous, high-quality chest compressions are critical to survival.  Several devices are now available that provide mechanically-assisted external chest compression, allowing for effective, non-invasive cardiac support during cardiac arrest resuscitation.   ODEMSA does not advocate the use of one device over another.",
        "indications": "Medical origin Cardiac Arrest.",
        "contraindications": "Vary based on the specifics parameters of the device.  Follow the manufacturer\u2019s recommendations for contraindications.",
        "protocol for management": "1. After assessing patient\u2019s condition, begin manual CPR.\n2. Attach defibrillation / pacing pads.\n3. Prepare the mechanically-assisted external chest compression device for deployment.\n4. Apply mechanically-assisted external chest compression device, according to the manufactur er\u2019s recommendations.  WHILE APPLYING DEVICE, ATTEMPT TO LIMIT INTERRUPTIONS IN MANUAL CHEST COMPRESSION TO LESS THAN 10 SECONDS.\n5. As quickly as possible, engage operation of the device.\n6. Ventilate the patient as directed according to manufacturer\u2019s recommendations.\n7. Every effort should be made to not stop compressions unless absolutely necessary.\n8. Positive pressure ventilation can be performed synchronously with any decompression once an advanced airway is in place.\n9. To access the patient, or to pause the device for any reason, press the Stop / Cancel or pause button.\n10. Defibrillate the patient when indicated, according to the manufacturer\u2019s recommendations.\n11. Pause compressions to reassess the patient and check for a pulse.",
        "note": "Any time failure occurs, manual external chest compressions should be  resumed IMMEDIATELY, whilst troubleshooting the device."
    },
    {
        "document title": "Clinical Procedures",
        "protocol title": "Intraosseous Access",
        "overview": "Intraosseous vascular infusion is a method of gaining access to the circulatory system by using a specialized trocar that is placed into the cavity of a long bone. Within the bone marrow, is a network of venous sinusoids that drain into the venous system, thereby accepting fluids or medications infused through an intraosseous access site. Although an IO can be used to infuse any fluid or medication, a drawback to its use may include slower than normal infusion rates due to anatomy of the IO space. To improve the infusion flow, a pressure bag should be used with all fluids administered via IO. Proper BSI precautions and aseptic technique should be used at all times.",
        "indications": "1. Intravenous fluids or medications are needed and a peripheral IV cannot be established in one (1) attempt or ninety (90) seconds AND the patient exhibits one or more of the following:\n    a. An altered mental status (GCS of 8 or less)\n    b. Respiratory compromise (SpO2 80% after appropriate therapy, respiratory rate < 10 or > 40 per minute)\n    c. Hemodynamic instability (Systolic BP of < 90 mmHg)\n2. Intraosseous access may be considered PRIOR to peripheral IV attempts in the following situations:\n    a. Cardiac arrest (medical or trauma)\n    b. Profound hypovolemia with altered mental status\n    c. Patient in extremis, with immediate need for delivery of medications, and / or fluids.",
        "contraindications": "1. Suspected narcotic overdose and / or hypoglycemia.\n2. Fracture of the bone selected for IO insertion.\n3. Excessive tissue at insertion site or inability to locate anatomical landmarks.\n4. Previous significant orthopedic procedures in area selected for IO insertion (IO within 24 hours, knee replacement, and surgically implanted hardware). Look for scars.\n5. Signs of infection in area selected for IO insertion (redness, skin lesions).\n6. Osteogenesis imperfecta (severe congenital bone degenerative disorders if known).",
        "protocol for management": "1. Assemble and prepare all equipment:\n    a. IO device\n    b. Cleansing agent\n    c. Syringe for aspiration and flushing\n    d. Fluid and administration tubing\n    e. Materials to secure site\n2. Prepare and position the patient.\n3. Select a site for insertion of the intraosseous access device. The site should be readily accessible and should be a site approved for use by the device manufacturer and agency operational medical director.\n4. Once the proper area of insertion has been located, clean the site and the immediate surrounding area with betadine, or other acceptable cleansing agent, allowing a large sterile field to work in.\n5. Stabilize the site with non-dominant hand, making sure hands and fingers are out of the path of the insertion.\n6. Insert the device, according to manufacturer\u2019s instructions for use.\n7. Aspirate the site with a syringe, as directed by the device manufacturer, to ensure accurate placement. Upon aspiration, a small volume of blood or marrow indicated correct medullary placement of the trocar.\n8. Flush the site with a small volume of saline (10 \u2013 20 mL). If the patient is alert, you may administer 0.5 mg / kg to a max dosage of 20 - 40mg of lidocaine (or as otherwise approved by the agency medical director) through the IO site for control of pain associated with infusion pressure within the bone cavity.\n9. Secure site according to device manufacturer\u2019s recommendations.\n10. Infuse fluid at the appropriate rate. A pressure bag may be necessary to obtain an adequate flow rate."
    },
    {
        "document title": "Clinical Procedures",
        "protocol title": "Tourniquet",
        "overview": "If external bleeding from an extremity cannot be controlled by pressure, application of a\ntourniquet is the next step in hemorrhage control.  Tourniquets that are narrow and\nband-like are more likely to result in damage to arteries and superficial nerves and\nshould be avoided.  Wider tourniquets are more effective at controlling bleeding, and\nthey control hemorrhage at a lower pressure.  A tourniquet should be applied just\nproximal to the hemorrhage, regardless of location on extremity.   Other devices are\navailable, including commercial devices for use in place of the manual tourniquet.   \n\n***The application of a tourniquet increases the risk of loss of limb* **",
        "indications": "Extremity hemorrhage that cannot be controlled with basic or pressure bandaging",
        "contraindications": "1. Any hemorrhage that can be controlled by a basic or pressure bandage.",
        "protocol for management": "The technique for application of a manual tourniquet is as follows:\n\n1. Fold a cravat into a\nwidth of about four (4)\ninches (10 cm) and\nwrap cravat twice\naround the affected\nextremity.\n\n2. Tighten the bandage\nmanually and tie a knot\nsecuring it in place.\n\n3. Place a metal or plastic\nrod on top of the knot,\nand tie a second knot\nsecuring the rod in\nplace.\n\n4. Twist the rod until\nbleeding has stopped\nand the distal pulse is\neliminated.\n\n5. Tie the ends of the rod\nin place and reassess\nfor pulse and bleeding.\n\n6. Place a piece of 2\u201d\ntape above the\ntourniquet and record\nthe time of application\non the tape.",
        "pearls": "1. The tourniquet should be placed around a solid piece of bone, if possible,\nproximal to the uncontrolled hemorrhage.  Placing the tourniquet over a solid\npiece of bones will aid in the tourniquet\u2019s ability to tamponade the hemorrhage.\n2. The tourniquet should be placed as close proximally to the wound as possible to\nminimize further extremity damage.\n3. The tourniquet must be marked with the time of application.  Do not write on the\nactual tourniquet.\n4. Consider Pain Management Protocol in conjunction with the application of a\ntourniquet.   Be vigilant of the patient\u2019s hemodynamic status."
    },
    {
        "document title": "Administration",
        "protocol title": "Infection Control - Exposure",
        "overview": "Each agency is responsible for identifying a designated infection control officer.  This person shall have been formally trained for this position and shall be knowledgeable in proper procedures and current regulations and laws regarding governing disease transmission.\n\nIn 1990, the Ryan White Comprehensive AIDS Resources Emergency Act, Public Law 101 - 381, was enacted into law.  Although this law deals primarily with funding for HIV / AIDS programs throughout the country, Subpart B contains key provisions for fire / EMS personnel regarding notification of possible exposure to communicable diseases.  This portion of the law, often referred to as the Ryan White Notification Law, requires every emergency response entity in the country to have a designated infection control officer (DICO) to serve as the liaison between emergency responders involved in exposure incidents and medical facilities to which the source patients in the exposures are transported.  This covers emergency responders including firefighters, EMTs, paramedics, police officers, and volunteers.  The law also outlines the role and responsibilities for this individual, which are extensive and comprehensive.  Since this individual is charged with the post-exposure follow-up and deals with infection control issues, the DICO title seemed appropriate.\n\nThe law requires medical facilities to provide the disease status of source patients as soon as possible and no later than 48 hours after an exposure has been reported to the facilities by the DICO of the responder involved in the exposure.  The law also requires that medical facilities contact the DICO of the transporting entity that delivered a patient suspected for or diagnosed with pulmonary tuberculosis.  The law also affords coverage to fire / EMS agencies that were not covered under the Occupational Safety and Health Administration's (OSHA's) Bloodborne Pathogen Standard ( 29 CFR 1910.1030 ).1",
        "blood borne pathogens": "Includes but are not limited to: \n1. HIV \n2. Hepatitis B \n3. Hepatitis C \n4. Syphilis",
        "airborne pathogens": "Include but are not limited to: \n1. Tuberculosis \n2. Measles (Rubeola) \n3. Varicella",
        "other less common pathogens": "Include but are not limited to: \n1. Malaria \n2. Rabies \n3. Neisseria Meningitis \n4. Plague \n5. Hemorrhagic fevers \n6. Diphtheria \n7. Rubella \n8. SARS",
        "management protocol": "1. Determine if exposure has occurred.  Body fluids should have visible blood before exposure should be considered.  Routes of exposure include direct injection (needle stick), through non intact skin (cuts and abrasions), and through mucous membranes (eyes and mouth).  If the exposure is a sharps injury, let the area bleed freely and wash the area with soap and water or the waterless hand wash solution.  If the exposure was a splash to eye, nose, or mouth, flush the area for 10 minutes with water. \n2. Consult with / notify your designated infection control officer (DICO) with any exposure or infection control questions. \n3. The DICO shall contact the facility to initiate testing required by federal and state rules and regulations. \n4. The facility shall notify the DICO or designee with results as required by federal and state rules and regulations. \n5. The DICO shall arrange follow up and prophylaxis based on the results as guided by the most recent CDC recommendations. \n\nEach agency must develop a comprehensive infection control plan and designate an infection control officer.",
        "ems provider initial actions for exposure": "Initial Action for EMS Provider in Event of Potential Exposure:\n\nQuestion: Did an EMS Exposure Occur?\n\nIf Exposure was Airborne:\n- Notify hospital staff of possible exposure.\n- Notify the Designated Infection Control Officer.\n- Designated Infection Control Officer to arrange for follow-up as needed.\n\nIf Exposure was Percutaneous (through the skin):\n- Let area bleed freely.\n- Notify hospital staff of possible exposure.\n- Notify the Designated Infection Control Officer.\n- Designated Infection Control Officer to arrange for follow-up as needed.\n\nIf Exposure was to eyes, nose or mouth:\n- Flush affected area w/flowing water for at least 10 minutes.\n- Notify hospital staff of possible exposure.\n- Notify the Designated Infection Control Officer.\n- Designated Infection Control Officer to arrange for follow-up as needed.\n\nIf Exposure was to non-intact skin:\n- Remove any contaminated clothing.\n- Notify hospital staff of possible exposure.\n- Notify the Designated Infection Control Officer.\n- Designated Infection Control Officer to arrange for follow-up as needed.\n\nFor all other exposure determinations or questions contact Designated Infection Control Officer Immediately."
    },
    {
        "document title": "Administration",
        "protocol title": "Traumatic Cease Resuscitation",
        "overview": "The primary purpose of a traumatic cease resuscitation protocol is to reduce the likelihood of injuring pre-hospital providers and to prevent injury to the public whom we serve while transporting non-viable patients to receiving facilities.",
        "considerations": "If a trauma patient presents with one or more of the following conditions, then the pre-hospital provider should consider termination of treatment or do not resuscitate. In cases of hypothermia or submersion, follow the appropriate protocol.",
        "signs and symptoms": "The conditions are:\n\uf0b7 Decapitation.\n\uf0b7 100% full thickness burns without signs / symptoms of life.\n\uf0b7 Obvious mortal wounds (i.e., crushing injuries to the head or chest, gunshot wounds to the head o r chest with massive tissue destruction or loss) without signs / symptoms of life.\n\uf0b7 Blunt or penetrating trauma with no signs of life when first responders arrive.\n\uf0b7 Greater than 30 minute transport time to any receiving facility with a pediatric cardiac arrest.",
        "protocol for management adult": "1. WHEN IN DOUBT, RESUSCITATE!\n2. The responding pre-hospital provider should perform a routine patient assessment.\n3. Once the provider determines that the patient is without life (no pulse, no respirations), the provider will verify the patient\u2019s condition with another pre-hospital provider.\n4. If both providers agree, they will note the time of death and follow local protocols concerning notification of law enforcement or the medical examiner.\n5. At the provider\u2019s discretion, the cardiac monitor may be attached for the purpose of printing a rhythm strip to document a non-perfusing rhythm. At no time during the assessment phase should other ALS procedures / treatments be started. DO NOT initiate IV lines, intubate, etc. ALS procedures indicate that a patient needs to be transported to the closest appropriate hospital.",
        "protocol for management pediatric": "1. WHEN IN DOUBT, RESUSCITATE!\n2. Almost all pediatric cardiac arrest patients should have the benefit of full resuscitative efforts, including transport.\n3. If the pediatric patient presents with any of the indications for Traumatic Cease Resuscitation and the pediatric patient remains in cardiac arrest after initial BLS resuscitative efforts, contact the receiving facility and establish on-line medical control for orders to cease resuscitation.\n4. Note the time of death and request law enforcement response.",
        "special circumstances": "1. Remember there are several special circumstances (hypothermia, electrocution, etc.) that warrant patient transport. Any patient, who may benefit from advanced life support, should receive such."
    },
    {
        "document title": "Administration",
        "protocol title": "Interfacility Transfers",
        "indications": "An interfacility transfer is defined as \u201cthe movement of a patient, directed by p hysician orders, from one facility to another , for the purpose of specialty care ; after initial and / or stabilizing care has been provided by the transferring facility.",
        "protocol for management": "1. The interfacility transport should be performed by an appropriately equipped and appropriately staffed ambulance / aircraft.\n2. The transferring physician/institution (or designee) will provide the EMS agency, prior to dispatch, a patient report that includes the patient\u2019s condition and any special treatment the patient is receiving.\n3. The clinical level of care should be maintained throughout transport. Additional staff (RN, Respiratory Therapist, MD, etc.) may be required.\n4. The Attendant in Charge (AIC) should request a brief patient report from the health care personnel on scene, and should obtain the pertinent records to go with the patient (i.e., face sheet, transport sheet, lab work, x-rays, etc.)\n5. If the patient has a valid Do Not Resuscitate order, a written order (including a Prehospital DNR order) must accompany the patient.\n6. Assessment by the AIC should be kept to a minimum and should not delay transport. Also, the AIC will have access to information necessary to provide appropriate care during transport.\n7. If the ambulance / aircraft crew arrives and the patient\u2018s condition has deteriorated to a life-threatening situation where immediate intervention is necessary, stabilizing effort should be initiated by the transferring hospital staff. EMS should not initiate transfer of a patient who is unstable.\n8. An ALS provider may monitor and administer nonstandard medications prescribed by the patient\u2019s tra nsferring physician with on-line Medical Control as needed during transfer.\n9. The administration of any medications not covered by protocol will be recorded on the Prehospital Patient Care Report, noting the name of the transferring physician, time that Medical Control was contacted, and dosage of the medication and route administered."
    },
    {
        "document title": "Administration",
        "protocol title": "Management",
        "overview": "An orderly management of the emergency scene will improve any level of pre-hospital patient care.  Although questions concerning authority (i.e., on-scene physician and response by more than one EMS agency) can arise, they should be settled quickly and quietly.",
        "protocol for management": "1. Upon arrival at the scene, NIMS (National Incident Management System) shall be used and the Incident Commander (or designee) shall have authority for patient care and management at the scene of an emergency.\n2. Authority for management of the emergency scene, exclusive of medical control over the patient, will rest with the appropriate on-scene public safety officials (i.e., police, fire, and rescue).  It is recommended that scene management be negotiated in advance of emergencies by local agreements and written protocols.\n3. If other medical professionals are at the emergency scene offer or provide assistance in patient care, the following will apply:\n  a. Medical professionals who offer their assistance at the scene should be asked to identify themselves and their level of training.  The pre-hospital provider should request that the medical professional provide proof of her / his identity if that person wants to continue to assist with patient care after the ambulance has arrived.\n  b. Physicians are the only medical professional who may assume control of the patient\u2019s care.  Pre -hospital providers should recognize the knowledge and expertise of other medical professionals and use them, if needed, for the best patient care possible.  Any bystander claiming to be a physician must show credentials to EMS on scene prior to being allowed to provide patient care.  All medical professionals who assist or offer assistance should be treated with courtesy and respect.\n  c. The authority of the pre- hospital provider\u2019s procedures rests in these pre -hospital Patient Care Protocols adopted by the EMS agency and the agency Operational Medical Director (OMD).\n  d. A physician at the scene who renders care to the patient prior to arrival of an EMS unit may retain medical authority for the patient if the physician desires.  The pre-hospital provider shall advise the physician who wants to supervise o r to direct patient care that, in order to so, the physician MUST accompany the patient to the receiving hospital to maintain continuity of patient care.  Documentation of these events will be complete and will include the physician\u2019s name.\n  e. If there is a conflict about patient care or treatment protocols, the pre-hospital provider will contact on-line medical control or, if practical, the agency OMD for further instructions.  Under no circumstances should this conflict interfere with prudent patient care.\n4. The levels of pre-hospital EMS certification currently recognized by the Commonwealth of Virginia are:\n\nCore Certifications\n  a. First Responder  / EMR\n  b. Emergency Medical Technician -Basic  / EMT\n  c. Emergency Medical Technician \u2013Enhanced  / Advanced  EMT\n  d. Emergency Medical Technician  \u2013Intermediate\n  e. Emergency Medical Technician -Paramedic  / Paramedic\n\nSpecialty Certifications\n  a. Pediatric Neonatal Critical Care Transport Paramedic\n  b. Critical Care Emergency Medical Technician \u2013 Paramedic\n  c. Certified Flight Paramedic"
    },
    {
        "document title": "Administration",
        "protocol title": "Infection Control - PPE",
        "overview": "In order to protect patients, healthcare providers, and their families, pre-hospital providers must be familiar with, and act in accordance with, effective infection control measures for airborne and bloodborne pathogens.  Infection control is the responsibility of all members of the EMS system.  The ultimate goal is a safe environment for patients and everyone else involved in the healthcare system.\n\nEach agency is responsible for identifying a designated infection control officer.  This person shall have been formally trained for this position and shall be knowledgeable in current regulations and laws governing infection control practices.",
        "standard precautions": "1. Standard precautions should be observed with every patient.  This includes, but is not limited to, starting IVs, intubation, suctioning, caring for trauma patients, nebulizer treatments, OB emergencies.\n2. Body fluids include: blood, saliva, sputum, vomitus or other gastric secretions, urine, feces, cerebrospinal fluids, breast milk, serosanguinous fluid, semen and / or bodily drainage.",
        "protocol for management": "1. Wear appropriate protective gloves on every patient.  Change gloves between patients or if gloves become contaminated or torn.\n2. Wash hands after any patient contact, even when gloves have been us ed.\n3. Wear gown if soiling of clothing or of exposed skin with blood or body fluids is likely. Gowns must be impervious to fluids.\n4. Wear appropriate mask and eye protection if aerosolization or spattering of body fluids is likely to occur, (e.g., during suctioning, nebulizer treatments, insertion of endotracheal tubes and other invasive procedures ); or when a patient displays signs and symptoms suggestive of an infection with an airborne or respiratory route of transmission; or if the provider has been told the patient has an infection with a respiratory component.\n5. Use airway adjuncts whenever respiratory assistance is indicated.  Adjuncts include pocket masks with one-way valves, shields and Bag-Valve Masks (BVM).  BVMs should be the first choice when ventilating a patient.\n6. Contaminated equipment:\n   a. Place contaminated disposable equipment in an appropriately marked biohazard bag.  Dispose in a location approved for biohazard waste or served by an agency licensed to haul biohazard waste.\n   b. Render non- disposable equipment safe for handling before putting it back in service.  Follow manufacturers' recommendations for proper cleaning and decontamination procedures.  CDC may also provide information on current decontamination of equipment.\n   c. Use a high-level disinfecting solution on non-disposable equipment, (i.e., laryngoscope blades), before re-using the items.\n7. In the field, place linens soiled with body fluids in appropriately marked biohazard bags.  In the hospital, ask and determine the appropriate container and place soiled linens in it.  Remove linen from biohazard bag before placing in linen container.  Always wear appropriate protective gloves when handling soiled linens.\n8. Dispose of needles, syringes and sharp items in a rigid, puncture-resistant container, red in color or bearing the universal biohazard symbol.  Do not bend or shear needles.  Recapping contaminated needles is only permitted by a single-handed method and is NOT  recommended.\n9. Do not leave sharps or any contaminated items in any Drug Box.\n10. Place any specimen to be left at the hospital in double-bagged, zip-lock-type bags with the universal biohazard label attached to the outer bag. Attach a specimen label to the outer bag.  When in doubt, check with the Charge Nurse.\n11. Wipe up body fluid spills promptly.  Wear gloves when cleaning up spills.  Decontaminate with a disinfectant approved by the Environmental Protection Agency (EPA) and CDC.  Dispose of gloves and cleaning items in an appropriately marked biohazard bag.\n12. Regularly clean and disinfect the interior of emergency vehicles and any on-board equipment.  Follow agency procedures for cleaning and disinfecting solutions in accordance with manufacturers' guidelines and Center for Disease Control (CDC) recommendations.\n13. Discard unused articles, medications and equipment only when those items have been opened or in some way have been contaminated with blood and / or body fluids.\n14. Consult with your designated infection control officer with any actual or potential exposure or any infection control questions"
    },
    {
        "document title": "Administration",
        "protocol title": "DNR",
        "overview": "Pre-hospital providers may, at times, withhold cardiopulmonary resuscitation (CPR) and\nadvanced cardiac life support (ACLS) due to a patient\u2019s pre -determined wishes.  For\nresuscitative efforts to be withheld, a valid state of Virginia Durable Do Not Resuscitate\n(DDNR) order must be present.",
        "protocol for management": "1. The responsible pre-hospital\nprovider should perform routine\npatient assessment, resuscitation\nand / or intervention efforts until the\nDDNR or other alternate form of\nDNR status is confirmed.  Alternate\nforms of DNR orders include:\na. EMS-DNR order (old format)\nwritten after July 1, 1999.\nb. DNR order written for a patient\ncurrently admitted to a licensed\nhealth care facility.  EMS\npersonnel may recognize these\norders only while the patient is in\nthe facility.  The DNR may\nappear in different forms\nincluding prescription forms,\nfacility DNR forms, and patient\nrecords.  All DNR formats must\ncontain: Patient name, physician\nname, DNR determination, and\ndate of issue.\nc. DNR order written for the purpose of transfer.  EMS personnel may recognize\nthese orders during transport.  DNR may appear in different forms including :\nprescription forms, facility DNR forms, and patient records.  All DNR formats\nmust contain: Patient name, physician name, DNR determination, and date of\nissue.\nNOTE:  Many times pre-hospital providers are presented with a Living Will.  Living Wills\nare NOT recognized in the pre-hospital setting due to the fact that it is not a\nphysician ordered DNR and therefore does not fit into the accepted \u201calternate DNR\norder. \u201d\n2. Request the original DDNR form.\n3. Determine that the DDNR order is intact and not defaced.\n4. The provider should verify the identity of the DDNR patient through the family\nmembers or friends at the scene, or with appropriate photo identification (e.g.,\ndriver\u2019s license).\n5. Once validity is verified, resuscitation efforts may be ceased or withheld.\nDocument all pertinent information on ePCR form including:\na. DDNR form number\nb. Patient name\nc. Physician name\nd. Date of issue\ne. Method of identification",
        "prohibited resuscitation measures with ddnr": "1. Cardiopulmonary Resuscitation (CPR).\n2. Endotracheal intubation or other advanced airway management.  This does\nNOT include CPAP.\n3. Artificial ventilation.\n4. Defibrillation.\n5. Cardiac resuscitation medications.",
        "encouraged comfort measures": "1. Airway (excluding intubation or advanced airway management).\n2. Suction.\n3. Supplemental oxygen delivery devices including CPAP.\n4. Pain medications or intravenous fluids.\n5. Bleeding control.\n6. Patient positioning.\n7. Other therapies deemed necessary to provide comfort care or to alleviate pain.",
        "ddnr orders may be revoked by": "1. The patient, by destroying the EMS-DDNR form or alternate DNR form or by\nverbally withdrawing consent to the order.\n2. The authorized decision-maker for the patient.",
        "revisions in the virginia ddnr vs ems dnr": "1. DDNR program, adopted by the Virginia State Board of Health, became\neffective on January 3, 2000. Once issued, the DDNR orders do not expire.\n2. DDNR forms may be honored in any facility, program or organization operated\nor licensed by the State Board of Health or by the Department of Mental Health,\nMental Retardation and Substance Abuse Services, or operated, licensed or\nowned by another state agency.\n3. DDNR orders can now be written for anyone, regardless of health condition or\nage.  Inclusion of minors is a significant change in the emergency DDNR order.",
        "alternate forms of ddnr identification": "1. DDNR bracelets and necklaces are available and can be honored in place of the\nVirginia Durable DNR Order form by emergency medical services providers.\nOnly approved necklaces or bracelets can be honored.  These alternative forms\nof identification must have the following information:\na. Patient\u2019s full legal name.\nb. Durable DNR number from the Virginia DDNR form or a unique to the\npatient number that the vendor has assigned.\nc. The words \u201cVirginia Durable Do Not Resuscitate\u201d.\nd. The vendor\u2019s 24 hour phone number.\ne. The phys ician\u2019s name and phone number.\n2. MOLST ( Medical Orders for Life-Sustaining Treatment) and POLST\n(Physician Orders for Life-Sustaining Treatment) forms can be honored in\nplace of the Virginia Durable DNR Order form by emergency medical services\nproviders."
    },
    {
        "document title": "Administration",
        "protocol title": "Minors",
        "overview": "Pre-hospital providers are called to treat young patients and occasionally, there is no parent or other person responsible for the minor.   Minors, in the eyes of the law, are generally considered to be incapable of self-determination; and therefore require parental or guardian consent for treatment / transport.  That being said, generally one of three situations present: (1) Emancipated Minor ( Very rare), (2) A concept of Mature Minor emerges, or (3) the patient is a bona fide Minor.",
        "guideline": "Whenever delay in providing medical or surgical treatment to a minor may adversely affect such minor\u2019s recovery and no person authorized in this section to consent to such treatment for such minor is available within a reasonable time under the circumstances, no liability shall be imposed upon qualified emergency medical services personnel as defined in \u00a7 32.1-111.1  at the scene of an accident, fire or other emergency, a licensed health professional, or a licensed hospital by reason of lack of consent to such medical or surgical treatment.  However, in the case of a minor 14 years of age or older that is physically capable of giving consent, such consent shall be obtained first.1\n\nA pregnant minor shall be deemed an adult  for the sole purpose of giving consent for herself and her child to surgical and medical treatment relating to the delivery of her child when such surgical or medical treatment is provided during the delivery of the child or the duration of the hospital admission for such delivery; thereafter, the minor mother of such child shall also be deemed an adult for the purpose of giving consent to surgical and medical treatment for her child.1\n\nAuthority of Parents, Guardians or Others : Parents have the authority to direct or refuse to allow treatment of their children.  A court appointed guardian, and any adult person standing in loco parentis , also has the same authority.  \u201cIn loco parentis\u201d is defined as \u201c[I]n the place of a parent; instead of a parent; charged, fictitiously, with a parent\u2019s rights, duties, and responsibilities.\u201d Black\u2019s Law Dictionary, 708 ( 5th ed. 1979). 1987 - 88 Va. Op. Atty. Gen. 617 \u201cFurthermore, I would point out that \u00a754 -325.2(6) allows any person standing \u201cin  locos parentis\u201d to consent to medical treatment for a minor child. This signifies, in my judgment, an intent to allow any responsible adult person, who acts in the place of a parent, to consent to the treatment of a minor child, particularly in emergency situations.\u201d 1983 -84 VA. Op. Atty. Gen. 219 .  Such a person may be a  relative, schoolteacher or principle, school bus driver, baby-sitter, neighbor, or other adult person in whose care of the child has been entrusted.2\n\nIn situations where parental involvement is impractical or problematic, OR the patient is unconscious and/or lacks mental capacity to consent to care, the pre -hospital provider may treat  and/or transport.",
        "persons subject to policy under age 14": "A person that is under the age of 14 shall be treated and transported unless a parent or guardian or person in locos parentis advises otherwise.  Do not delay treatment or transport for extended periods simply trying to contact a parent or guardian.  If you believe that treatment is necessary, but the parent or guardian or person in locos parentis refuses to allow treatment, medical control should be consulted. 2",
        "persons subject to policy aged 14 to 18": "A person between the ages of 14 and 18 may refuse treatment and transport, unless a parent or guardian or person in locos parentis advises otherwise.  If you believe that treatment is necessary, but the person refuses, an attempt should be made to contact a parent or guardian, and medical control should be consulted.  If you believe that treatment is necessary, but the parent or guardian or person in locos parentis refuses to allow treatment, medical control should be consulted.2",
        "emancipation": "Emancipation is a court ordered decree.  The circumstances under which a minor may petition for emancipation are as follows:  A minor who has reached his / her sixteenth birthday and is residing in this Commonwealth, AND (i) the minor has entered into a valid marriage, whether or not that marriage has been terminated by dissolution; or (ii) the minor is on active duty with any of the armed forces of the United States of America; or (iii) the minor willingly lives separate and apart from his parents or guardian, with the consent or acquiescence of the parents or guardian, and that the minor is or is capable of supporting himself and competently managing his own financial affairs.   If the courts determine that an emancipation order is appropriate and subsequently issues such order, the emancipated minor is legally able to consent to medical, dental, or psychiatric care, without parental consent, knowledge, or liability.   Once emancipation has been granted by the courts, DMV issues identification indicating the emancipation degree, that identification should be readily available for your review.",
        "consent mental capacity requirements": "In situations where the parent / guardian or emancipated minor possess sufficient mental capacity to formulate decisions regarding medical care / treatment, consent shall be obtained prior to initiating care.   Mental capacity means that the individual rendering the consent, is informed and possesses sufficient ability to be able to understand: \n\u2022 The general nature of the injury / illness \n\u2022 Nature and purpose of proposed treatment \n\u2022 Risks and consequences of proposed treatment \n\u2022 Probability that treatment will be successful \n\u2022 Feasible treatment alternatives and have the ability to make a voluntary choice among the alternatives \n\u2022 Prognosis if treatment is not given",
        "handling refusal of care": "In situations where the parent / guardian or emancipated min or demonstrates sufficient mental capacity to formulate decisions and subsequently refuses the offer of care; yet in the provider\u2018s judgment  is in need of medical attention, the provider should first attempt to discern the reasons for the patients\u2019 refusal  of consent.  Often it is something so inconsequential, that reason and common sense often prevail and once you have provided assistance with whatever is the basis of concern (i.e., patient needs to call someone to look after a pet, etc) the patient often consents to treatment / transport.  If unable to influence the parent / guardian or patient, contact on-line Medical Control for additional guidance.",
        "pearls": "1. Always act in the best interest of the patient  - EMS providers must strike a balance between abandoning the patient and forcing care.\n2. All states allow parental consent for treatment of a minor to be waived in the event of a medical emergency. The circumstances that should be present in order for such an emergency include the patient being incapacitated to the point of being unable to give an informed choice, the circumstances are life-threatening or serious enough that immediate treatment is required, and it would be impossible or imprudent to try to get consent from someone regarding the patient. In these cases, consent of the parent is presumed, since otherwise the minor would suffer avoidable injury.\n3. If a minor is injured or ill and no parent contact is possible, the provider should contact on-line Medical Control for additional instructions.  \n4. Refer to the appropriate Pediatric Protocol sections and consider the following in regard to transport: \na. Transport conscious children with a parent unless it interferes with proper patient care. \nb. In cases of major trauma or cardiopulmonary arrest, exercise judgment in allowing parents to accompany the child in the ambulance .\nc. Allow the parent to hold and / or touch the child whenever possible and safe to do so. \nd. Both parent and child will respond best to open and honest dialogue."
    },
    {
        "document title": "Administration",
        "protocol title": "Patient Destination",
        "purpose": "To provide for a defined, consistent policy for the destination of ambulance patients consistent with quality patient care and regional medical protocols within the ODEMSA region this includes Planning Districts 13, 14, 15 and 19.",
        "policy elements": "1. Stable patients should be transported to the patient\u2019s destination of choice if allowed by local EMS agency policies and by available       resources .\n\n2. All unstable ambulance patients (resulting from requests for emergency assistance which result in transport) normally will be transported to the closest appropriate hospital emergency department unless otherwise directed by the on-line medical control physician and/ or by medical control during a declared diversion.  The closest appropriate hospital is defined as the hospital closest to the location of the patient that can provide the level of care needed by the patient .  The medical control physician is defined as the attending emergency department physician at the hospital contacted by the ambulance Attendant -in-Charge (AIC) or a person designated by the AIC.  Medical C ontrol Hospital is defined as that hospital designated to direct ambulance movements in line with ODEMSA\u2019s Hospital Diversion Policy as most recently revised.  \n\n3. Patients who meet certain criteria as severe trauma patients, as defined in the Old Dominion EMS Alliance Trauma Care System Plan, usually will be transported directly to a T rauma Center unless redirected by the M edical Control Physician in accordance with the Trauma Care System Plan.\n\n4. Individual EMS agencies and/or EMS systems are responsible for determining operational policies related to the most effective ambulance deployment and utilization patterns.  This may include policies allowing transport of stable patients to hospitals of the patient\u2019s choice.  \n\n5. In mass casualty incident (MCI) situations, the current Central Virginia Mass Casualty Incident Plan and its EMS Mutual Aid Response Guide, as most recently revised, will govern patient transportation and hospital destination(s).  \n\n6. Other policies and protocols related to patient transport and ambulance- to-hospital communications are defined in the ODEMSA Pre- hospital Patient Care Protocols and the Hospital Diversion Policy as most recently revised."
    },
    {
        "document title": "Administration",
        "protocol title": "Cease Resuscitation",
        "overview": "Prehospital termination of resuscitation guidelines have been developed by the Ontario Prehospital Life Support (OPALS) study group. In their BLS prediction rule, EMT with defibrillation capabilities could consider patients with the following for termination of resuscitation: 1. No return of spontaneous circulation prior to transport 2. No shock was given 3. The arrest was not witnessed by EMS personnel. In applying the BLS rule 37.4% of the cardiac arrest cases would have been transported. There were a very small number of cases of survival to hospital discharge in patients who the BLS rule would have recommended termination of resuscitation. The OPALS group developed a more conservative ALS prediction rule in which providers could consider patients with the following for termination of resuscitation: 1. No return of spontaneous circulation prior to transport 2. No shock was given 3. The arrest was not witnessed by EMS personnel 4. The arrest was not witnessed by bystander 5. No bystander CPR. If CPR has been initiated and circumstances arise where the pre-hospital provider believes resuscitative efforts may not be indicated, cease resuscitation orders may be requested via on-line medical control.",
        "indications for not initiating cpr": "Under existing Virginia EMS practice standards, prehospital providers should initiate cardiopulmonary resuscitation (CPR) on all patients without vital signs UNLESS the patient presents with one or more of the following conditions: a. Decapitation b. 100% full thickness burn (incineration) c. Putrefied, decayed, or decomposed body d. Advanced lividity e. Rigor mortis f. Obvious mortal wounds, i.e. crushing injuries to head and/or chest g. A valid state of Virginia EMS_DDNR approved order h. Asystole as a presenting rhythm in an unwitnessed arrest.",
        "criteria for requesting cease resuscitation orders after cpr initiated": "The provider should confirm that the patient is pulseless and apneic. Prior to contacting medical control, the following criteria should be met: a. No return of spontaneous circulation prior to transport b. No shock was given or indicated c. The arrest was not witnessed by EMS personnel d. The arrest was not witnessed by bystander e. No bystander CPR f. 15 minutes of CPR g. ETCO 2 is less than 10.",
        "special considerations": "Patients who are hypothermic or who are victims of cold water drownings should receive appropriate resuscitative efforts. Patients with electrical injuries, including those struck by lightning, may initially be tetanic, or stiff, and should receive appropriate resuscitative efforts.",
        "procedure for ceasing resuscitation": "1. Once all prerequisites have been met, the provider should then contact Medical Control so that the on-line physician can decide to continue or stop resuscitative efforts. Providers should begin contact with Medical Control with the statement: \"This is a potential cease- resuscitation call.\u201d The provider should review why resuscitative efforts may not be indicated (i.e., end-stage cancer). The provider then should report interventions and, if directed by on-line Medical Control, stop resuscitative efforts. 2. If a patient is determined to be dead on the scene (DOA) or if the cessation of resuscitative efforts is authorized by on-line Medical Control, law enforcement authorities should be requested to respond if indicated. 3. Document specific findings, such as signs of death, on the ePCR form. Include name of physician who ordered resuscitation efforts ended and log the time of the order. 4. Be attentive to the emotional needs of the patient's survivors when dealing with them. If possible, leave survivors in the care of family and / or friends."
    },
    {
        "document title": "Administration",
        "protocol title": "Patient Refusal",
        "overview": "If a patient (or the person responsible for a minor patient) refuses secondary care and / or ambulance transport to a hospital after pre-hospital providers have been called to the scene, the following procedures should be completed:",
        "definition adult": "A person at least eighteen (18) years of age.",
        "definition minor": "A person less than eighteen (18) years of age.",
        "definition emancipated minor": "A person under the age of eighteen (18) is emancipated if any of the following conditions met:\na. Married or previously married\nb. On active military duty\nc. Has received a declaration of emancipation from the Commonwealth of Virginia",
        "definition mental capacity": "A person who is alert, oriented, and has the capacity to understand the circumstances surrounding their illness or impairment, and the possible risks associated with refusing treatment and / or transport. The patient\u2019s judgment is also not significantly impaired by illness, injury or drugs / alcohol intoxication. Patients who have attempted suicide, verbalized suicidal intent, or if other factors lead pre-hospital care personnel to suspect suicidal intent, should not be regarded as having capacity and may not decline transport to a medical facility.",
        "protocol for management": "1. Complete an initial assessment and complete set of vital signs of the patient, with particular attention to the patient\u2019s neurological status.\n2. Determine the patient\u2019s capacity to make a valid judgment concerning the extent of their illness or injury. If the provider has doubts about whether the patient is competent to refuse, the provider should contact on-line medical control.\n3. Clearly explain to the patient and all responsible parties the possible risks and / or overall concerns with regards to refusing care.\n4. Perform appropriate medical care with the consent of the patient.\n5. Complete an ePCR form, clearly documenting the initial assessment findings and the discussions with all involved persons regarding the possible consequences of refusing additional pre-hospital care and/or transportation. A third party should witness the form and discussion. If no such party is available then a second EMS provider should witness this.\n6. After the form has been completed, have the patient or the person responsible for a minor patient sign the refusal form provided on the ePCR form. This procedure should be witnessed by at least one other individual.\n7. Any person who calls for any type of assistance should have a refusal form completed unless, upon evaluation, the caller denies any injury or illness and none is suspected. This includes motor vehicle accidents. Furthermore, a refusal should always be completed if the original caller was the complainant (1st party), as a complaint originally existed prior to EMS arrival.",
        "pearls": "1. An adult or emancipated minor, who has demonstrated possessing sufficient \u201cmental capacity\u201d for making decisions, has the right to determine the course of their medical care, including the refusal of care. These patients must be advised of the risks and consequences resulting from refusal of medical care.\n2. All patients, under the age of 14 years, must have a parent or legal representative to refuse evaluation, treatment, and / or transport for an emergency condition. In Virginia, patients 14 years of age or older can refuse treatment and transport (see protocol for Minors).\n3. A patient determined by EMS personnel or On-line Medical Control to lack \u201cmental capacity\u201d may not refuse care against medical advice or be released at scene. Mental illness, drugs, alcohol intoxication, or physical/mental impairment may significantly impair a patient\u2019s capacity. Patients who have attempted suicide, verbalized suicidal intent, or if other factors lead EMS personnel to suspect suicidal intent, should generally, not be regarded as having demonstrated sufficient \u201cmental capacity.\n4. At no time, should EMS personnel put themselves in danger by attempting to treat and / or transport a patient who refuses care.",
        "source organization": "Created, Developed, and Produced by the Old Dominion EMS Alliance"
    },
    {
        "document title": "Administration",
        "protocol title": "Documentation",
        "overview": "Under existing Virginia law, all licensed emergency medical services agencies are\nrequired to \u201cparticipate in the pre-hospital patient care reporting procedures by making\navailable \u2026 the minimum data set on forms .\u201d Licensed EMS agencies, pre -hospital\nproviders and the Commonwealth of Virginia are required to keep patient information\nconfidential.",
        "protocol for management": "1. An electronic patient care report (ePCR) will be completed for each patient\n   encounter. The report must be completed and sent to the appropriate facility\n   within the following 12 hours. ODEMSA, at the request of the region, has\n   developed a MIVT report for documenting patient care to assist the hospital\n   between the time when the patient is delivered to the ED and when the patient\n   care report is received. A copy of the MIVT is included in these protocols.\n2. Each ePCR will include documentation of:\n   a. The evaluation and care of the patient during pre-hospital care.\n   b. The patient\u2019s refusal of the evaluation. \n   c. The patient\u2019s encounter to protect the local EMS system and its personnel\n      from undue risk and liability.\n3. A patient is defined as any individual that requests evaluation by EMS. If an\n   individual is not legally competent due to age, injury, chronic illness, intoxication,\n   etc., always err on the side of patient safety and assume an implied request for\n   evaluation.\n4. All patient encounters, which result in some component of an evaluation, must\n   have an ePCR completed.\n5. All patients who refuse any component of the evaluation or treatment, should\n   have a refusal signed and documentation of the refusal noted in the narrative.\n6. All patients who are not transported by EMS should have a refusal completed.\n7. When utilized effectively, the ePCR allows great detail in documentation by using\n   the pre-loaded information coupled with notes. However, this does not eliminate\n   the need for a narrative to be completed. No ePCR will be considered complete\n   without a written narrative that \u201cpaints\u201d an accurate picture of the scene, patient\n   presentation, and all occurrences during the interaction with that patient.\n8. When a patient is transported, a copy of the MIVT report should be left at the\n   receiving hospital. Also, some facilities have printing capability and providers\n   can print ePCRs before leaving the facility. It is imperative that reports are\n   completed and uploaded in a timely manner as these reports may influence the\n   patient\u2019s care at the receiving facility and will be placed in the patient\u2019s\n   permanent medical record once received."
    },
    {
        "document title": "Administration",
        "protocol title": "Diversion",
        "contraindications": "Patients with STEMI, Acute Stroke, Airway Obstruction, Uncontrolled Airway, \nUncontrolled Bleeding, who are in Extremis or with CPR in progress, should be taken \nimmediately to the closest appropriate hospital , without regard to the hospital\u2019s diversion \nstatus.",
        "diversion override decisions": "Prehospital EMS providers may overrule diversion if a patient is in extremis, or for \nsignificant weather / traffic delays, mechanical problems, etc.  An EMS provider who \nbelieves an acute decompensation is likely to occur if the patient is diverted to a more \ndistant hospital ALWAYS has the option to take that patient to the closest Emergency \nDepartment regardless of the diversion status.",
        "note ems communication and patient care": "Early c ontact and notification by the EMS ambulance crew to the \nreceiving facility is essential for optimal patient care. It is highly \nrecommended that the ambulance Attendant in Charge (AIC) use the regional \nMIVT Report format when providing the receiving facili ty with pre -arrival \ninformation on the patient. Once an EMS unit has marked enroute and a \nreport has been given to the receiving facility, any later change in diversion \nstatus of the receiving facility will not affect that ambulance.  \n\nThe Attendan t-in-Charge also has the option to ask via radio or \nphone to speak directly to an Emergency Department physician. \nGood clinical sense and optimal patient care are the ultimate \nconsiderations.",
        "categories of hospital status": "A. OPEN - When a hospital has full capacity for receiving its usual patient \nload. \n\nB. DIVERSION  \u2013 When a hospital is unable to handle certain types of patients.  \nSubcategories are listed below. \n\n1. Adult Medical / Surgical \u2013 includes Minor Trauma .  \n2. Major Trauma \u2013 means the operating rooms and surgeons are \ncompletely full.   Reference: Trauma Triage Schematic \u2013 Appendix E. \n3. Labor & Delivery (L & D) \u2013 Pre-Term is defined as active labor \nbefore 36 weeks. \n4. Psychiatric \u2013 divided into three areas:  \na) Child & Adolescent Psych  \u2013 age infant < 18 \nb) Adult Psych  \u2013 age 18 to 64 \nc) Geriatric Psych  \u2013 age 65 and over \n5. Pediatric \u2013 For the purposes of this Hospital Diversion Policy , \npediatric is defined as under the age of 18. \n\nC. OUT OF SERVICE - Critical or catastrophic circumstances result in \noperational shutdown.  Hospital cannot receive any new patients by EMS \nor any other means.",
        "medical control hospital details": "The primary Medical Control Hospital will be the Virginia \nCommonwealth University Medical Center, or an identified \nalternate facility, as specified in the Central Virginia MCI \nPlan.  If  VCU cannot handle Medical Control, the identified \nalternate facilities, in order, are :  (1) Chippenham Medical \nCenter and (2) Southside Regional Medical Center."
    },
    {
        "document title": "Administration",
        "protocol title": "Mass Gathering",
        "scope": "This policy and its related protocol are intended for use only in gatherings of\nlarge numbers of persons such as races, concerts and rallies, and in those\ncircumstances / situations approved by the EMS Agency\u2019s operational medical\ndirector (OMD). It is designed to give clear patient care guidelines to EMS\nproviders in the ODEMSA region, and allow them the option of treating patients\nwith minor injuries and / or medical complaints without transporting patients to a\nmedical facility. The OMD must approve the use of this policy for each event\nbefore it is implemented.\n\nIt is intended for use only when the number of anticipated patients could quickly\noverwhelm existing EMS or hospital resources to provide appropriate patient\ncare. This policy will apply to any patient that meets the patient profile (below)\nthat requires basic first aid only.\n\nEMS providers are expected to use good clinical judgment and complete\ndocumentation. Providers may transport any patient to a medical facility\nregardless of the patient\u2019s chief complaint, presenting symptoms, or clinical\nassessment according to ODEMSA Prehospital Patient Care Protocols.\n\nAny patient, who asks to be transported to a medical facility, even if the EMS\nprovider feels that the patient could be treated and released under this policy, will\nbe transported.\n\nAny patient, for whom the E911 System has been appropriately activated, may\nbe transported to the hospital for further evaluation.",
        "patient profile (those patients who may be treated with this protocol)": "A. Patient history and examination will be reliable:\n1. Alert and oriented x 3\n2. No suggestion of drug, alcohol or other substance\nusage/abuse\n3. No suggestion of psychological/psychiatric problems\n4. No head injury (including loss of consciousness or\naltered mental status)\n5. Patient is able to communicate adequately and to\nunderstand what is being communicated to him/her\nB. Injuries sustained where mechanism of injury is very low risk for\nsignificant injury.\nC. Patient has no spinal injury, pain, tenderness or deformity on\nexam, and has a normal sensory/motor exam.\nD. Patient does not exhibit signs of chest pains or shortness of\nbreath.\nE. Patient will have vital signs within age specific normal limits.",
        "general exclusion criteria": "A. Any patient with a pain scale assessment higher than a \u201c5\u201d on a 1 to 10 scale\nB. Any patient who does not meet all requirements in the Patient Profile section\nC. Any patient who requests transportation to a medical facility\nD. Any patient for whom the E911 System has been appropriately activated",
        "indications and treatments": "Minor complaints / injuries may include the following, but are not limited to:\n\n12 - 12A: Minor Wounds\nIndications:\nAny minor injury requiring simple wound disinfection and bandage application:\nContraindications:\na. Any signs or symptoms of infection (redness, swelling, fever, drainage)\nb. Any wound to facial area, unless it is a simple abrasion\nc. Any deep, jagged or gaping wound\nd. Any uncontrolled bleeding from the wound\ne. Any wound exposing subcutaneous tissue / structure\nA. Any patient with a pain scale assessment higher than a \u201c5\u201d on a 1 to 10 scale\nB. Any patient who does not meet all requirements in the Patient Profile section\nC. Any patient who requests transportation to a medical facility\nD. Any patient for whom the E911 System has been appropriately activated\n1. Perform a general assessment.\n2. Clean abrasions, simple avulsions and small lacerations\nnot requiring suturing with normal saline.\n***Note: ensure that the patient has had Tetanus Toxoid immunization within the last\nfive (5) years. If not current, the patient must be referred within 72 hours from the\nincident to his/her own physician. ***\n\n12 - 12B: Request for over the counter medications for c/o headache or\nsimple muscle type pain\nIndications:\nRequest for over the counter medications for c/o headache, or simple muscle\ntype pain\nContraindications:\na. Any neurological deficits with headache\nb. Any history of allergies to approved medications\nc. Any request for ASA for complaint of chest pain (These patients must\nbe referred to the hospital for further evaluation. ASA may be given\nunder the ALS protocol for chest pain)\nd. Any patient requesting ASA or Ibuprofen with a history of asthma\n1. Perform a general patient assessment.\n2. Assess patient for allergies.\n3. Administer Tylenol, Ibuprofen, or ASA as requested by\nthe patient per manufacturer dosage recommendation.\n\n12 - 12C: Soft Tissue Injury without signs or symptoms of a fracture\nIndications:\nSoft tissue injury without signs or symptoms of a fracture\nContraindications:\na. Any signs or symptoms of a fracture (deformity, excessive swelling,\ndiscoloration, any open wounds over the site, or decreased range of\nmotion)\nb. Any neurological deficits (numbness or tingling distally, delayed\ncapillary refill, or decreased pulses distally)\nc. Any severe pain or swelling requiring splinting\nd. Any injury associated with vascular deficits distal to the injury\n1. Perform a general assessment.\n2. Elevate the affected area and apply a cold / ice pack.\n3. Provide education on removal of cold pack within 20\nminutes of placement.\n\n12 - 12D: Insect Stings\nIndications:\nAny patient with an insect sting\nContraindications:\na. Any patient with a history of allergies to insect stings\nb. Any insect sting on the face or neck\nc. Any patient that exhibits signs of respiratory distress, tightness in throat\nor chest, dizziness, rash, fainting, nausea / vomiting, or difficulty\nswallowing\nd. Any swelling of the face, lips or eyelids\ne. Hypotension\nf. Presence of hives or other obvious symptoms of a more generalized\nallergic reaction\n1. Perform a general assessment.\n2. Assess patient for previous allergies to bee stings.\n3. Remove the stinger by scraping with a blunt edged\nobject. Do not remove with tweezers as squeezing may\nrelease more of the poison into the surrounding tissue.\n4. Wash the area thoroughly with soap and water.\n5. Monitor airway for allergic reaction / swelling.\nNOTE: Stingers NOT removed will continue to release venom into the tissue for a long\nas 20 minutes.\n\n12 - 12E: Tick Bites\nIndications:\nAny patient with a tick bite\nContraindications:\na. Any tick that appears to have been embedded for longer than 24 hours\nb. Any signs or symptoms of infection present\nc. If the tick does not appear to have been removed whole and the head\nremains embedded in the skin, the patient must be sent to a physician\nor medical facility that day\n1. Perform a general assessment.\n2. Remove the tick gently by using tweezers to grasp the\ntick firmly at its head, next to the patient\u2019s skin. Pull\nfirmly and steadily on the tick until it lets go.\n3. Swab the bite with alcohol.\n4. Inspect the tick to ensure that the head has been\nremoved successfully.\n5. Educate patient on signs / symptoms of Lyme Disease\n(bull\u2019s eye rash, fever, headache, joint pain) and Rocky\nMountain Spotted Fever (purple to red rash on trunk and\nextremities, fever and headache).\n\n12 - 12F: Minor Animal Bite\nIndications: Minor Animal Bites\nAny patient with a minor animal bite\nContraindications:\na. Any facial involvement\nb. Any wound that will not stop bleeding after 15 minutes of direct pressure\nc. The attacking animal was wild or behaving strangely\nd. Animal immunization status is unknown, or the animal cannot be found\n1. Perform a general assessment.\n2. Wash the area of the bite carefully with soap and water.\n3. Apply antibiotic cream and a sterile dressing.\n4. Ensure that the patient has had Tetanus Toxoid\nimmunization within the last five (5) years.\n***NOTE: If not current with Tetanus immunization, the patient must be referred within\n72 hours from the incident to his / her own physician.***\n5. Report bite (as required under State and local laws) to\neither local animal control or the local health department.\nIf possible to do so without endangering anyone, detain\nor take steps to identify the biting animal. If the animal is\ndeceased, the carcass should be immediately turned\nover to animal control.\n6. Refer the patient to their primary care physician for\nfollow up treatment because the risk of infection needs\nto be closely monitored.\n\n12 - 12G: Non-traumatic Nose Bleeds\nIndications:\nNon-traumatic nose bleeds\nContraindications:\na. Any medical causes ( i.e., hypertension, history of hemophilia )\nb. Currently on blood thinner medication\nc. Bleeding uncontrolled for longer than 10 minutes after treatment\nd. Any nosebleed caused by a direct traumatic injury\n1. Perform a general assessment (rule out any medical\ncauses).\n2. Lean the patient slightly forward to avoid swallowing\nblood.\n3. Apply firm pressure below the bony part of the nose for\n10 minutes.\n4. Reassess. If bleeding continues, transport to a medical\nfacility.\n\n12 - 12H: 1st Degree Burns\nIndications:\n1st degree burns\nContraindications:\na. Any 2nd or 3rd degree burns\nb. Any burns to the face, eyes, mouth, hands, or genital areas\nc. Any burn too large to cover with a bandage\nd. Any burn caused by electricity or an explosion\n1. Perform a general assessment.\n2. Run cool water over the burned area or hold a cold\ncompress on the burn. Do NOT use ice.\n3. Cover loosely with a sterile bandage.\n4. Offer extra fluids.\n\n12 - 12I: Eye Irritation / FB on the surface of the eye\nIndications:\nEye irritations\nContraindications:\na. Any embedded foreign body\nb. Any eye irritation due to chemical exposure\nc. Any eye irritation due to trauma\n1. Perform a general assessment.\n2. Flush the affected eye with sterile saline solution. Flush\nfor up to 15 minutes, checking the eye every five (5)\nminutes to see if the foreign body has been flushed out.\n3. Encourage the patient not to touch or rub the affected\neye.\n4. If the foreign material cannot be removed by flushing, or\nthe eye remains irritated after flushing, transport to a\nmedical facility.\n\n12 - 12J: Splinter Removal\nIndications:\nSplinter Removal\nContraindications:\na. If the splinter is too large or went deeply into the skin\nb. Any signs of infection\nc. If the splinter is unable to be removed\n1. Perform a general assessment.\n2. Remove the splinter from the skin by pulling at the same\nangle that it entered with a pair of tweezers.\n3. Wash with soap and water.\n4. Apply antibiotic ointment and a sterile dressing.\n5. If a splinter is not easily removed, refer the patient to a\nphysician for removal.\n\n12 - 12K: Heat Exhaustion / Heat Cramps (heat related illness)\nIndications:\nHeat exhaustion / cramps (heat related illness)\nContraindications:\na. Heat stroke (a life threatening condition where the body loses the\nability to regulate its own temperature). Signs and symptoms\ninclude:\ni. Hot, red, dry skin, but NOT sweaty\nii. Confusion, delirium, hallucinations\niii. Seizures\niv. Syncopal episode\nv. Frequent uncontrolled vomiting\nvi. Difficulty breathing\nvii. Elevated internal body temperature (>103\u00b0)\nb. Patients experiencing the above symptoms should be rapidly\ncooled, an IV of NS established, and transported immediately to\nthe closest emergency department (See ODEMSA protocol\nHyperthermia / Heat Stroke )\nc. Any patient with complaint of chest pains or dyspnea\nd. Any patient with a BP < 90mmHg systolic\ne. Any patient over the age of 70, or under the age of 13\n1. Perform a general assessment.\n2. Place patient in a cool area to rest.\n3. Exam Remove any excess clothing.\n4. Sponge the patient\u2019s skin with cool water. Consider the\nuse of fans, if available, to aid in the cooling process.\n5. Apply cold packs to the forehead and / or back of neck.\nConsider the application of these packs to the axillae\nand groin to further enhance the cooling effects in\nseverely symptomatic patients.\n6. Provide cold water for drinking.\n7. Initiate IV fluid bolus for patients with persistent\nsymptoms, despite above cooling efforts Bolus with 250\n- 500 cc over 10 - 20 minutes.\n8. Reevaluate symptoms. Repeat once as needed.\n9. Appropriately document findings. Patients who show\nsignificant improvement with cessation of symptoms may\nbe released.\n10. Provide the patient with education related to prevention\nof future heat related illness and / or symptoms.\n11. Patients will be transported to a medical facility\nimmediately for symptoms that persist after a total of one\n(1) liter of normal saline.\n12. Patients will be transported to a medical facility\nimmediately for symptoms which persist for more than\none (1) hour despite treatment.",
        "patient assessment and documentation": "A. Documentation is required for each patient and should be done on\na PPCR, ODEMSA Treat and Release for Minor Injuries form, or\nother locally developed form. This form, when complete, will\ninclude:\n1. Chief complaint\n2. Vital signs (including pain scale)\n3. Primary assessment with particular attention to the\npatient\u2019s neurological status\n4. Clinical assessment\n5. Treatment rendered\n6. Education of follow up care\nB. Providers\u2019 assessment skills should be renewed and reviewed on\na regular basis.",
        "patient referrals": "In all cases where patients are treated and released under this policy and\nprotocol, there will be clear documentation and explanation to the patient or\nresponsible party of the absolute need for the patient to be reevaluated by the\npatient\u2019s own physical or medical facility of choice for definitive medical care.\n\nThis policy and protocol is not intended to provide definitive care to any patient.\nRather, it is intended to provide a mechanism by which basic first aid may be\nadministered acutely, with physician follow up at the patient\u2019s earliest\nconvenience.",
        "performance improvement": "It is recommended that participating agency\u2019s quality assurance / performance\nimprovement policy stipulate that both during and upon completion of each event\nwhere the use of the Treat and Release Patient Care Policy and Protocol has\nbeen authorized, the OMD conduct a random review of the charts generated for\nthe appropriateness of documentation, treatment and disposition of the patient.\nThe sample size should be large enough to assure that appropriate care by all\nproviders is being rendered.",
        "reporting": "It is recommended that clinical / performance improvement or administrative\nissues regarding the mass gathering guideline be reported back to the ODEMSA\nMedical Control Committee for quality assurance and performance improvement\npurposes."
    }
]