EMSWorld.com OCTOBER 2019 | VOL. 48, NO.

10

Charting the Future of Out-of-Hospital Care

SERVICE
ABOVE SELF
Presenting the Winners
of the National EMS
Awards of Excellence
Page 16

SPECIAL ISSUE
EMS WORLD EXPO
Innovation Awards Finalists
Page 60
Research Abstracts from
the International Scientific
EMS Symposium
Page 64

OCTOBER 14–18, 2019 | NEW ORLEANS, LA

#EMSWorldExpo EMSWorldExpo.com
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 CONTENTS
OCTOBER 2019
Vol. 48, No. 10

COVER REPORT
16 Commitment to Excellence
Meet the 2019 National EMS Awards of Excellence Winners
(Cover photo: San Antonio Fire Dept. EMS)

SPOTLIGHT: EMS WORLD EXPO

O C T. 1 4 – 1 8 , 2 0 1 9 , N E W O R L E A N S , L A
60 Meet the Innovation Award Finalists
64 Original Research Abstracts from the
International Scientific EMS Symposium
16
ISSUE FOCUS: EMS EDUCATION

28 Study Abroad Provides a Wider Perspective

A Washington university and Australian service ally for an educational exchange
By Douglas Presta, DPM, NRP, and Scott Devenish, PhD

34 The Fundamentals of Flipping

A ‘flipped classroom’ approach takes work on the front end but pays off on the back
By Ben Tacy

BONUS CONTENT: RESEARCH

42 What Should You Know About

28 Evidence-Based Guidelines?
A broad consortium sets out to bring EBGs to EMS
By Juan March, MD, et al.

FEATURES

48 It’s Complicated: Grief and the First Responder

Understand the process, and you’ll be a more effective patient advocate
By Alexandra Jabr

54 Child Abuse Awareness for the EMS Provider

Know what distinguishes innocent injuries from suspicious ones
By Roger Smith, NRP, Ryan Brown, MD, and Curtis L. Knoles, MD, FAAP

COLUMNS DEPARTMENTS
10 Journal Watch: Uber and EMS 8 Guest Editorial
Responses
By Antonio R. Fernandez, PhD, NRP, FAHA 12 State by State

84 Reader Feedback
48 86 Advertiser Index

6 OCTOBER 2019 | EMSWORLD.com

ONLINE THIS MONTH
WWW.EMSWORLD.COM
OCTOBER WEB SPOTLIGHT: BOOK REVIEW
EDUCATION A Medic’s Mind
Spaced Retrieval to Improve Reviewed by Heather Down
Performance www.emsworld.com/article/1223173/
By Rommie L. Duckworth, LP book-review-medics-mind
www.emsworld.com/article/1223172/
Canadian medic Matthew Heneghan
duckworth-education-spaced-retrieval-
improve-performance delivers an inspiring memoir of resiliency, tenacity
“I can’t wait for this test to be over so I can and hope.
forget everything!” Have you heard this in your class?

PODCASTS WEBINARS
September Article Newly Archived
Readaloud: Selling Small www.emsworld.com/webinars
www.emsworld.com/podcasts EMS and FirstNet: Finding Success
OTEMS Director Kelly Deal discusses in the Field; The Buck Stops Here: A
his system’s move to smaller van- Leader’s Duty to Patient Safety; and
style ambulances. Pulse Oximetry: Putting Your Finger
On It.

CONTACT US EMS World welcomes input from our readers. For editorial submissions, letters to the editor, press releases, permission
questions, and other issues pertaining to the publication or website, please e-mail editor@EMSWorld.com.

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GUEST EDITORIAL

At EMS World Expo and Beyond:

Learn to Teach, Teach to Learn
By Ami Tomaszewski

Taking
In my short time so far with EMS World, I’ve had the opportunity to be
inspired by some pretty passionate educators. I’ve also seen incredibly eager
opportunities
learners: on social media, in print, online, and of course in person at EMS
World Expo. I know I’ll see it again this year in New Orleans, the “Big Easy,”
to teach on a subject
attendees soaking up new knowledge while also preparing to return home can benefit all
and educate their peers.
involved.
Not much about this job could be described as “easy,” though. We are
faced with long hours and tough calls, life and work challenges, all while
myself—learn, retain, teach, retain more—
trying to keep abreast of the latest in evidence-based medicine. It’s impres-
sive how we fit it all in. has helped pull me from the grips of com-
placency in my own practice.
In this month’s guest editorial, flight medic and training officer Ami To- I wrote a blog about something called
maszewski skillfully describes this phenomenon as “the protégé effect,” and I
the protégé effect, which is what I describe
think you’ll find her words fitting for October’s education theme.
above. Knowledge of a subject is better
So, while you’re attending sessions at Expo this year, listening to FOAMed retained when learned with the intent to
on a podcast, or perhaps sitting at your post waiting for the next run, I know teach others. The quote from the Roman
you’ll agree: EMS providers have an obligation to pass on knowledge to the
philosopher Seneca holds true: “While we
next generation. Not just 10- or 15-year-old knowledge, but also the most up-
to-date knowledge you’ve taken the time to research and embrace. teach, we learn.”1
Read below for Ami’s call to action—her message will motivate you to never This effect can change your practice
neglect the new guy. for the better. The more we put ourselves
in these types of teaching situations, the
—Hilary Gates
smaller the complacency black hole gets. If
a situation has a positive outcome because

H
ere is some food for thought:
Educators are the ultimate
learners.
In prehospital medicine it can
be easy to fall into the black hole of compla-
cency. Whether you’re a basic or advanced
provider, whether you fly in a helicopter,
show up in an intercept vehicle, or ride in an
ambulance, you are not immune to this.
Prehospital providers face several regu-
lar challenges: Many work for several dif-
ferent agencies; they log long hours; they
consistently face stressful and dangerous
situations that may wear on them physi-
cally and mentally. This can lead to a loss of
motivation to learn anything new, and with
this there is a failure to maintain mastery of
the craft. Survival mode and going through
the motions often become the norm.
On the flip side, there are new provid-
ers out there who need to be mentored by
motivated individuals who are not down
that black hole already—and we do exist.
Medicine is dynamic, and we all need to learn
constantly to keep up. Tasking a seasoned
provider with teaching the new, young, and
enthusiastic individuals entering the field
is common; it is an expectation of the job.
The seasoned provider must not be the
complacent provider. Years of experience
do not necessarily equate to expertise. If
you don’t take the time to learn the proper
information to pass on to your students,
then who wins? No one. If that individual is
given bad information and produces a poor
outcome, upon whom does this reflect? You,
the teacher who didn’t learn the material!
Relaying the proper information lowers the
risk of preventable errors.
I’ve been in many situations where I was
asked to teach someone. Since I didn’t want
to look dumb, I learned, in depth, the infor-
mation I was going to pass on. In doing so I
realized I was able to retain that information
better than if I were just looking at it for my
own good. This bolstered my motivation to
keep teaching and make sure I had all the
correct information. Creating this cycle for
of something newly learned, we all become
hungry for more, and motivation thrives and
may even be contagious.
Taking opportunities to teach on a sub-
ject can benefit all involved. Educators
grow their expertise, and students receive
the right information to succeed. EMS pro-
viders today have so much opportunity to
be involved in education. With the dawn of
podcasting, blogs, and the FOAMed move-
ment, we have new outlets to put forth and
take in new and exciting content anywhere,
at any time. Because of long hours and mul-
tiple jobs, this is one way to solve the “I have
no time to do extra” conundrum.
The Internet is everywhere. Embrace your
creativity and become the ultimate learner
while enriching minds and influencing others
in the field.
REFERENCE
1. Paul AM. The Protégé Effect. Time, 2011 Nov 30; http://
ideas.time.com/2011/11/30/the-protege-effect/.
Ami Tomaszewski is a flight clinical coordina-
tor for MidAtlantic MedEvac in Burlington, N.J.

8 OCTOBER 2019 | EMSWORLD.com

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JOURNAL WATCH: EXAMINING THE LATEST IN EMS EVIDENCE

UBER AND EMS RESPONSES

Does the ride-share service’s entry into markets reduce ambulance use?
By Antonio R. Fernandez, PhD, NRP, FAHA

B
y now many of you have used
ride-sharing services. They are
popular, convenient, and seem-
ingly everywhere.
There has been some research evaluating
how ride-sharing services impact a commu-
nity. Previous studies have evaluated wheth-
er Uber was associated with reductions in
drunk-driving fatalities (results were mixed)
and how Uber complements other public
transportation. There have even been reports
that cities have investigated how Uber could
be integrated into EMS systems.
Some have speculated that our patients
may be opting to utilize these services rath-
er than call 9-1-1 for transport to hospitals.
However, until now there has not been any
published research specifically addressing
this question.
The authors of this month’s manuscript
sought to estimate the impact of Uber’s
entry into markets on EMS call volume. An
interesting note about this study is that it
was published in an economics journal.
It is nice to see EMS data utilized in other
disciplines!
Compiling Data
The authors employed some interesting
methods to acquire the data they used for
this study. To identify the dates Uber entered
markets, they scoured the Uber Newsroom
blog for Uber launches throughout the coun-
try. They also searched external publications
to identify any additional Uber launches that
were not identified from the blog search. The
study period was from 2012 to 2015. At the
time data was collected, Uber was present
REVIEWED THIS MONTH
Did UberX Reduce Ambulance Volume?
Authors: Moskatel L, Slusky D.
Published in: Health Econ, 2019 Jul; 28(7): 817–29.
Look for research podcasts
based on the topics featured
in this column at
www.emsworld.com/pcrf
in 43 states and Washington, D.C.
Once dates of Uber market entry were
obtained, the authors then worked with the
National EMS Information System (NEMSIS)
to acquire EMS response volumes for the
respective cities. We’ve discussed NEMSIS
many times before; it is a great resource for
national EMS data, and you can find more
information at https://nemsis.org. EMS
response rates were defined here as the
response volume multiplied by 1,000 and
divided by the city population.
Now, one of the more interesting parts of
this study was who the authors worked with
to obtain the NEMSIS data. The agreement
NEMSIS has with the states that submit data
to it does not allow NEMSIS to release infor-
mation that identifies specific states, cities,
or zip codes. Therefore, the authors actually
had to submit the Uber market entry data
to NEMSIS. NEMSIS then calculated EMS
call volume and response rates based on
the authors’ instructions and merged the
data into a deidentifed dataset. Cities like
New York and San Francisco were excluded
because Uber entered these markets so early
these data could be identified simply from
the entry dates.
The authors built a regression model to
estimate the EMS call volume after adjusting
for other important variables such as geog-
raphy and year.
Results
Now let’s talk about what they found. There
were 703 cities included in this analysis;
however, because some crossed state lines,
the authors split them into 723 city-state
groups. As expected, throughout the study
period there was a rapid increase in Uber
availability. The average EMS response rate
was 18 per 1,000 residents per quarter, with
a minimum of less than one and a maximum
of 752 per 1,000 residents.
The authors used this average EMS
response rate to calculate the impact of Uber
entry into a city. Specifically, they found that
when Uber is available in a city, there are at
least 1.2 fewer ambulance trips per 1,000 res-
idents per quarter than before Uber entered
the market. This roughly translates to a 6.7%
drop in EMS call volume.
The authors then tried to determine
whether the reduction in EMS response rate
was in low-severity or high-severity calls. To
do this they used documented lights-and-
sirens transports vs. transports with no lights
and sirens. Documented lights-and-sirens
use during transport may not be the best
proxy for patient severity, and this plays out

10 OCTOBER 2019 | EMSWORLD.com

in their results: The results from the analysis of calls that used lights
and sirens did not reveal a statistically significant difference com-
pared to the no-lights-and-sirens analysis. So the authors were not
able to determine whether Uber availability reduced unnecessary
EMS usage. They also did not see any statistically significant differ-
ences in response times, transport times, lights-and-sirens utilization,
traffic accidents, alcohol-related traffic accidents, patient age, or
patient sex based on Uber’s entry into a market.
As with all research, this study had some limitations. Most nota-
bly we have only discussed Uber, and there are other ride-sharing
services. The authors focused on Uber because adding Lyft would
not have affected the overall ride-share availability, since the study
period was before Lyft was broadly available, Lyft typically enters
cities after Uber, and previous literature focused primarily on Uber.
Nonetheless, this is still a limitation.
Conclusion
It is fantastic to see EMS data published in an economics journal!
The more disciplines that use our data, the more we can learn and
improve our field. This was an interesting study that used national
EMS data coupled with a unique data collection method for obtain-
ing Uber market entry dates. There is also a section discussing
Matthew Ward
Clinical Manager EMS
for Emergency Services at
UK Healthcare
CSU Graduate
When Uber is available in
a city, there are at least 1.2
fewer ambulance trips per
1,000 residents per quarter.
robustness checks that was out of the scope of this review but
is an interesting read into how the authors evaluated threats to
their analytical assumptions, the impact of Uber rollouts, and the
impact of NEMSIS expansion across the nation.
It is encouraging to see that even though NEMSIS must abide by
agreements preventing the release of identifying information, it was
willing and able to work with the authors to help them complete this
study. This should be encouraging to anyone interested in completing
research. NEMSIS is a valuable resource for data, and this manuscript
shows it’s willing to provide assistance.
ABOUT THE AUTHOR
Antonio R. Fernandez, PhD, NRP, FAHA, is research director at the EMS Performance
Improvement Center and an assistant professor in the Department of Emergency
Medicine at the University of North Carolina–Chapel Hill. He is on the board of advisors
of the Prehospital Care Research Forum at UCLA.
Columbia Southern University offers completely
online degrees for EMS professionals interested
in taking the next step in their career.
ColumbiaSouthern.edu/EMS » 877.347.6050
Located in Orange Beach, Alabama. Gainful employment information
available at ColumbiaSouthern.edu/Disclosure.
EMSWORLD.com | OCTOBER 2019 11
 STATE BY STATE: NEWS, UPDATES, AND HAPPENINGS IN EMS

MARYLAND

Court Rules in Favor

of Medics Accused of
Negligence

A Maryland Court of Appeals denied a

family monetary damages in the 2011
death of a Baltimore man, saying that
while medics did not follow protocol
when treating him for a heart attack,
their conduct did not constitute “gross
negligence.” In a 4-3 ruling, the court
wrote that Joseph Stracke and Stepha-
nie Cisneros did not act in a grossly
negligent way when they “inaccurately
diagnosed and treated” Kerry Butler
Jr., 28, who died of a heart attack at
Medstar Harbor Hospital March 2,
2011. Majority judges warned that had
they ruled in the Butler family’s favor, it
“would have a negative impact on not
only the number of individuals who seek
employment as first responders in the
future, but would create a chilling effect
on their conduct.”

PENNSYLVANIA FLORIDA TEXAS

Murdered Scientist’s
Study on Medic Assaults
Published
A federally funded study on assaults
against firefighters and paramedics led
by Drexel University scientist Jasmine
Y. Wright was published Aug. 16 in the
American Journal of Industrial Medicine. In
2015, Wright, 27, was raped and murdered
by a former maintenance worker at her
West Philadelphia apartment complex. It
would be more than a year before her col-
leagues could put aside their grief to finish
Wright’s work. “She was really committed
to the [emergency] service on this issue,”
said Jennifer Taylor, associate professor in
environmental and occupational health,
who helped complete the study.
Search Called Off for FFs
Missing After Fishing Trip
At press time the U.S. Coast Guard had sus-
pended a massive air and water search for
Brian McCluney, 37, an engineer/paramedic
at Jacksonville’s Station 31, and Justin Walk-
er, 33, a master technician at Station 5B in
Franconia, Va. Both disappeared during a
fishing trip that began Aug. 16 at Port Canav-
eral on a 24-foot center-console craft. Over
105,000 square miles of ocean off Florida,
Georgia, and the Carolinas were scoured by
local, state, and federal agencies, as well as
hundreds of volunteers in boats and aircraft.
Study: Majority of Medics Have
Been Assaulted On Duty
About three out of five Austin-Travis
County EMS medics say they have
been physically assaulted more than
once on the job in the past two years,
a new survey by the department says.
Austin-Travis County EMS e-mailed two
surveys to its field medics and commu-
nications staff. The survey found that 22
communications employees had been
verbally assaulted more than once in
the last two years, and 132 field medics
had been physically assaulted more
than once in the last two years. Most as-
saults on medics happened in the backs
of ambulances, while communications
staff were often verbally assaulted by
9-1-1 callers.

12 OCTOBER 2019 | EMSWORLD.com

 Stand ready with
a double defense.
2 antidotes working together.*
• DuoDote delivers atropine + pralidoxime chloride
in 1 injection to treat organophosphorus poisoning1

• DuoDote Auto-Injectors are designed for rapid treatment

using the 2-chambered BinaJect® drug delivery system1

• Meridian holds a federal SAFETY Act designation and certification

from the Department of Homeland Security for DuoDote

*DuoDote contains atropine and pralidoxime chloride in a dual-chamber auto-injector, both of which are used to treat organophosphorus insecticide or chemical nerve agent poisoning.1

INDICATION weakness, dry mouth, emesis, rash, dry skin, hyperventilation,

DuoDote, a combination of atropine, a cholinergic muscarinic
antagonist, and pralidoxime chloride, a cholinesterase reactivator,
is indicated for the treatment of poisoning by organophosphorus
nerve agents as well as organophosphorus insecticides in adults and
pediatric patients weighing more than 41 kg (90 pounds).
IMPORTANT SAFETY INFORMATION
There are no contraindications to the use of DuoDote.
Cardiovascular risks include tachycardia, palpitations, premature
ventricular contractions, flutter, fibrillation, asystole, and myocardial
infarction. Other cardiovascular adverse reactions have also
been reported. Use caution in patients with known CV disease or
conduction problems.
Heat injury may occur. Atropine may inhibit sweating and lead to
hyperthermia. Avoid excessive exercising and heat exposure.
Acute glaucoma may be precipitated in susceptible individuals, and
therefore DuoDote should be administered with caution in patients at
risk for acute glaucoma.
Administer with caution in patients with bladder outflow obstruction
as urinary retention may occur.
DuoDote should be administered with caution in patients with partial
pyloric stenosis because of the risk of complete pyloric obstruction.
Atropine may cause inspiration of bronchial secretions and formation
of dangerous viscid plugs and may exacerbate chronic lung disease.
Monitor respiratory status.
Common adverse reactions of atropine include dryness of the
mouth, blurred vision, dry eyes, photophobia, confusion, headache,
and dizziness, among others. The common adverse reactions of
pralidoxime chloride include changes in vision, dizziness, headache,
drowsiness, nausea, tachycardia, increased blood pressure, muscular
decreased renal function, excitement, manic behavior, and transient
elevation of liver enzymes and creatine phosphokinase.
Muscle tightness and pain may occur at the injection site.
Patients who have received succinylcholine and mivacurium may
exhibit an accelerated reversal of the neuromuscular blocking effects
when treated with DuoDote. Monitor neuromuscular effects with
concomitant administration.
Safety and effectiveness of DuoDote in pediatric patients weighing
less than or equal to 41 kg (90 pounds) have not been established.
Geriatric patients may be more susceptible to the effects of atropine.
Pralidoxime chloride can cause decreased renal function. Patients
with severe renal impairment may require less frequent doses after
the initial dose.
Patients with severe hepatic impairment may require less frequent
doses after the initial dose.
Please see Brief Summary of Prescribing Information
on adjacent pages.
You are encouraged to report negative side effects of prescription
drugs to the US Food and Drug Administration (FDA).
Visit www.fda.gov/medwatch or call 1-800-FDA-1088.
Reference: 1. DuoDote Auto-Injector [package insert]. Columbia, MD:
Meridian Medical Technologies, Inc.; 2017.
Adverse Event or Product Quality Complaints
If you wish to report an adverse event or product quality complaint,
please call: 1-800-438-1985.
Medical Information
If you have a medical question concerning Meridian products, please
call: 1-800-438-1985. US HCPs can visit www.pfizermedinfo.com.

BinaJect, DuoDote, and the DuoDote logo are registered trademarks of Meridian Medical Technologies, Inc., a Pfizer company.
© 2019 Meridian Medical Technologies, Inc., a Pfizer company. All rights reserved. PP-DUO-USA-0028 Printed in USA/February 2019

BRIEF SUMMARY
Consult full Prescribing Information for complete product information
INDICATIONS AND USAGE
DuoDote, a combination of atropine, a cholinergic muscarinic
antagonist, and pralidoxime chloride, a cholinesterase reactivator,
is indicated for the treatment of poisoning by organophosphorus
nerve agents as well as organophosphorus insecticides in adults
and pediatric patients weighing more than 41 kg (90 pounds).
WARNINGS AND PRECAUTIONS
Cardiovascular Risks
Cardiovascular adverse reactions reported in the literature
for atropine include, but are not limited to, sinus tachycardia,
palpitations, premature ventricular contractions, atrial flutter,
atrial fibrillation, ventricular flutter, ventricular fibrillation, cardiac
syncope, asystole, and myocardial infarction. In patients with a
recent myocardial infarction and/or severe coronary artery disease,
there is a possibility that atropine-induced tachycardia may cause
ischemia, extend or initiate myocardial infarcts, and stimulate
ventricular ectopy and fibrillation. DuoDote should be used with
caution in patients with known cardiovascular disease or cardiac
conduction problems.
Heat Injury
Atropine may inhibit sweating which, in a warm environment or with
excessive exercise, can lead to hyperthermia and heat injury. To the
extent feasible, avoid excessive exercise and heat exposure.
Acute Glaucoma
Atropine should be administered with caution in patients at risk for
acute glaucoma.
Urinary Retention
Atropine should be administered with caution in patients with
clinically significant bladder outflow obstruction because of the risk
of urinary retention.
Pyloric Stenosis
Atropine should be administered with caution in patients with partial
pyloric stenosis because of the risk of complete pyloric obstruction.
Exacerbation of Chronic Lung Disease
Atropine may cause inspiration of bronchial secretions and
formation of dangerous viscid plugs in individuals with chronic lung
disease. Respiratory status should be monitored in individuals with
chronic lung disease following administration of DuoDote.
ADVERSE REACTIONS
The following adverse reactions associated with the use of atropine
and pralidoxime chloride were identified in the literature. Because
these reactions are reported voluntarily from a population of
uncertain size, it is not always possible to reliably estimate their
frequency or establish a causal relationship to drug exposure.
Atropine
Because DuoDote contains pralidoxime chloride, which may
potentiate the effect of atropine, signs of atropinization may occur
earlier than might be expected when atropine is used alone.
Common adverse reactions of atropine can be attributed to its
antimuscarinic action. These include dryness of the mouth, blurred
vision, dry eyes, photophobia, confusion, headache, dizziness,
tachycardia, palpitations, flushing, urinary hesitancy or retention,
constipation, abdominal pain, abdominal distention, nausea and
vomiting, loss of libido, and impotence. Anhidrosis may produce
heat intolerance and impairment of temperature regulation in a
hot environment. Dysphagia, paralytic ileus, acute angle closure
glaucoma, maculopapular rash, petechial rash, and scarlatiniform
rash have also been reported. Adverse cardiac reactions, including
arrhythmias and myocardial infarction, have been reported with atropine.
Larger doses of atropine may produce central nervous system
effects such as restlessness, tremor, fatigue, locomotor difficulties,
delirium, and hallucinations.
Hypersensitivity reactions will occasionally occur, are usually seen
as skin rashes, and may progress to exfoliation. Anaphylactic
reaction and laryngospasm are rare.
Pralidoxime Chloride
Pralidoxime can cause blurred vision, diplopia and impaired
accommodation, dizziness, headache, drowsiness, nausea,
tachycardia, increased systolic and diastolic blood pressure,
muscular weakness, dry mouth, emesis, rash, dry skin,
hyperventilation, decreased renal function, and decreased sweating
when given parenterally to normal adult volunteers who have not
been exposed to anticholinesterase poisons.
In several cases of organophosphorus poisoning, excitement and manic
behavior have occurred immediately following recovery of consciousness,
in either the presence or absence of pralidoxime administration.
However, similar behavior has not been reported in subjects given
pralidoxime in the absence of organophosphorus poisoning.
Elevations in AST and/or ALT enzyme levels were observed in
1 of 6 normal adult volunteers given 1200 mg of pralidoxime
intramuscularly, and in 4 of 6 adult volunteers given 1800 mg
intramuscularly. Levels returned to normal in about two weeks.
Transient elevations in creatine kinase were observed in all normal
volunteers given the drug.
Injection Site
Muscle tightness and pain may occur at the injection site.
Inadvertent Injection
In cases where DuoDote is inadvertently administered to people who
are not poisoned with nerve agent or organophosphorus insecticide,
the following effects on their ability to function normally may occur.
Atropine 2 mg IM, roughly the equivalent of one DuoDote
autoinjector, when given to healthy male volunteers, is
associated with minimal effects on visual, motor, and
mental functions, though unsteadiness walking and difficulty
concentrating may occur. Atropine reduces body sweating and
increases body temperature, particularly with exercise and under
hot conditions.
Atropine 4 mg IM, roughly the equivalent of two DuoDote
autoinjectors, when given to healthy male volunteers, is associated
with impaired visual acuity, visual near point accommodation,
logical reasoning, digital recall, learning, and cognitive reaction
time. Ability to read is reduced or lost. Subjects are unsteady and
need to concentrate on walking. These effects begin about 15
minutes to one hour or more post-dose.
Atropine 6 mg IM, roughly the equivalent of three DuoDote
autoinjectors, when given to healthy male volunteers, is associated
with the effects described above plus additional central effects
including poor coordination, poor attention span, and visual
hallucinations (colored flashes) in many subjects. Frank visual
hallucinations, auditory hallucinations, disorientation, and ataxia
occur in some subjects. Skilled and labor-intense tasks are
performed more slowly and less efficiently. Decision making
takes longer and is sometimes impaired.
It is unclear if the above data, obtained from studies of healthy
adult subjects, can be extrapolated to other populations. In the
elderly and patients with co-morbid conditions, the effects of
≥2 mg atropine on the ability to see, walk, and think properly are
unstudied; effects may be greater in susceptible populations.
Patients who are mistakenly injected with DuoDote should avoid
potentially dangerous overheating, avoid vigorous physical activity,
and seek medical attention as soon as feasible.
DRUG INTERACTIONS
Succinylcholine and Mivacurium
Since pralidoxime in DuoDote reactivates cholinesterases and
succinylcholine and mivacurium are metabolized by cholinesterases,
patients with organophosphorus nerve agent or organophosphorus
insecticide poisoning who have received DuoDote may exhibit
accelerated reversal of the neuromuscular blocking effects of
succinylcholine and mivacurium (relative to poisoned patients who
have not received pralidoxime). Monitor for neuromuscular effects
with concomitant administration.
USE IN SPECIFIC POPULATIONS
Pregnancy
Risk Summary
Atropine readily crosses the placental barrier and enters fetal
circulation. There are no adequate data on the developmental risk
associated with the use of atropine, pralidoxime, or the combination
in pregnant women. Adequate animal reproduction studies have not
been conducted with atropine, pralidoxime, or the combination. In
the U.S. general population, the estimated background risk of major
birth defects and miscarriage in clinically recognized pregnancies is
2-4% and 15-20%, respectively.
Lactation
Risk Summary
Atropine has been reported to be excreted in human milk. It is
not known whether pralidoxime is excreted in human milk. There
are no data on the effects of atropine or pralidoxime on the
breastfed infant or the effects of the drugs on milk production.
The developmental and health benefits of breastfeeding should be
considered along with the mother’s clinical need for DuoDote and
any potential adverse effects on the breastfed infant from DuoDote
or from the underlying maternal condition.
Pediatric Use
Safety and effectiveness of atropine in DuoDote in patients
weighing more than 41 kg (90 pounds) is supported by published
literature. Safety and effectiveness of pralidoxime chloride in
DuoDote in patients more than 41 kg (90 pounds) is supported
by data from pharmacokinetic studies in adults and experience in
the pediatric population. Adverse events seen in pediatric patients
treated with atropine are similar to those that occur in adult
patients, although central nervous system complaints are often
seen earlier and at lower doses.
Safety and effectiveness of DuoDote in pediatric patients weighing
less than or equal to 41 kg (90 pounds) have not been established.
Geriatric Use
Geriatric patients may be more susceptible to the effects of
atropine.
Renal Impairment
Pralidoxime chloride can cause decreased renal function. Patients
with severe renal impairment may require less frequent doses after
the initial dose.
Hepatic Impairment
Patients with severe hepatic impairment may require less frequent
doses after the initial dose.
BinaJect, DuoDote, and the DuoDote logo are registered trademarks of Meridian Medical Technologies, Inc., a Pfizer company.
© 2018 Meridian Medical Technologies, Inc., a Pfizer company. All rights reserved. PP-DUO-USA-0030 Printed in USA/December 2018
OVERDOSAGE
Symptoms
Atropine
Manifestations of atropine overdose are dose-related and include
flushing, dry skin and mucous membranes, tachycardia, widely
dilated pupils that are poorly responsive to light, blurred vision, and
fever (which can sometimes be dangerously elevated). Locomotor
difficulties, disorientation, hallucinations, delirium, confusion, agitation,
coma, and central depression can occur and may last 48 hours
or longer. In instances of severe atropine intoxication, respiratory
depression, coma, circulatory collapse, and death may occur.
Pralidoxime
It may be difficult to differentiate adverse events caused by
pralidoxime from those caused by organophosphorus poisoning.
Symptoms of pralidoxime overdose may include dizziness, blurred
vision, diplopia, headache, impaired accommodation, nausea, and
tachycardia. Transient hypertension caused by pralidoxime may last
several hours.
Treatment
For atropine overdose, supportive treatment should be
administered. If respiration is depressed, artificial respiration with
oxygen is necessary. Ice bags, a hypothermia blanket, or other
methods of cooling may be required to reduce atropine-induced
fever, especially in pediatric patients. Catheterization may be
necessary if urinary retention occurs. Since atropine elimination
largely takes place through the kidney, urinary output must be
maintained and increased if possible; intravenous fluids may be
indicated. Because of atropine-induced photophobia, the room
should be darkened.
A benzodiazepine may be needed to control marked excitement
and convulsions. However, large doses for sedation should be
avoided because the central nervous system depressant effect may
coincide with the depressant effect occurring late in severe atropine
poisoning. Barbiturates are potentiated by the anticholinesterases;
therefore, barbiturates should be used cautiously in the treatment of
convulsions. Central nervous system stimulants are not recommended.
PATIENT COUNSELING INFORMATION
Use by Healthcare Providers
DuoDote is intended for use by Healthcare Providers. See the
illustrated Instruction Sheet for Healthcare Providers.
Seek Definitive Medical Care
If feasible and appropriate, advise patients that DuoDote is an
initial emergency treatment, that they need additional care at a
healthcare facility.
Avoid Overheating
If feasible and appropriate, advise the patient to avoid a hot
environment and excessive physical activity since DuoDote can
inhibit sweating which can lead to overheating and heat injury.
For current Prescribing Information and further product information,
please visit https://www.meridianmeds.com/products or call Pfizer
Medical Information toll-free at 1-800-438-1985.
This brief summary is based on DuoDote® Auto-Injector (atropine
and pralidoxime chloride injection) Prescribing Information, Revision
Date: 10/2017.
 SPOTLIGHT:

COMMITMENT TO
E XCE LLE N CE
Meet the 2019 National
EMS Awards of Excellence
Winners
NAEMT and
EMS World
are pleased to
announce the
recipients of the 2019 National EMS
Awards of Excellence.

The awards will be presented during

the NAEMT’s General Membership
Meeting and during the opening
ceremonies of EMS World Expo
October 14–18 in New Orleans.
We congratulate the following
recipients and recognize their
outstanding contributions to the EMS
profession and the patients they serve.

16 OCTOBER 2019 | EMSWORLD.com

 OCTOBER 14-18, 2019
NEW ORLEANS, LA

EMSWORLD.com | OCTOBER 2019 17

 SPOTLIGHT:
2019 DICK FERNEAU CAREER EMS SERVICE OF THE YEAR
SPONSORED BY FERNO
CAREER
SERVICE San Antonio Fire Department EMS
Doing What’s Right
S P O N S O R E D BY: For the San Antonio Fire Department, excellence
in EMS is more than a simple catchphrase
T
he San Antonio Fire Department’s Division
of Emergency Medical Services is an inno-
vative organization that’s developed and
deployed multiple progressive lifesav-
ing and health-preserving prehospital programs.
These range from deploying whole blood to an entire
metropolitan city to police navigation of behavioral
health patients away from emergency departments
and to more appropriate facilities.
SAFD EMS represents a leading edge not just for EMS
but for all of healthcare, according to deputy medical
director C.J. Winckler, MD. “We have so many smart,
intelligent, and capable EMTs and paramedics, many of
whom have advanced degrees,” says Winckler, who has
been with SAFD for three years. “The culture was already
set up for us to be the best EMS system in the country. All
Dr. Miramontes and I had to do was implement programs
to make that happen.”
David Miramontes, MD, is a firefighter, ICU nurse, and
flight physician who became SAFD’s medical director five
years ago. Winckler is a former field medic with a special-
operations background. Their organization serves about
1.5 million residents of San Antonio, responding to more
than 160,000 annual EMS calls with 400 personnel on
43 dual-paramedic MICU ambulances. There are 10
MIH paramedics that serve the city’s most vulnerable
patients, and multiple other county, regional, and state
missions SAFD EMS serves.
Less than 10 years ago, the department carried fewer
than 10 medications. But leaders and providers alike were
ready to make it something more. “When we got here
the culture was ready to go forward with any cutting-
edge medicine, research, and programs we had in mind,”
Winckler says. “The fuel was there. We just lit the spark
and boom, it took off.”
Some of the department’s programs include:
• Prehospital whole blood transfusion capability citywide:
In October 2018 SAFD EMS became the first metropolitan
EMS system in the world to offer all patients whole blood
as a treatment for hemorrhagic shock;
18 OCTOBER 2019 | EMSWORLD.com
• A prehospital medi-
cal screening tool for
behavioral health
patients that allows
police to transport
those cleared directly
to psychiatric care. To develop the program, SAFD EMS
and UT Health San Antonio’s Office of the Medical Direc-
tor partnered with the Southwest Texas Regional Advi-
sory Council, Southwest Texas Crisis Collaborative, U.S.
Army Medical Command, San Antonio Police Depart-
ment, Bexar County Sheriff’s Office, all 16 of San Anto-
nio’s public and private psychiatric hospitals, and multiple
school and municipal law enforcement agencies;
• A wildland firefighter force-protection team that deploys
advanced-practice paramedics to large wildland fires in
the state;
• A prehospital ECMO CPR activation program for CPR
patients found in shockable rhythms;
• Multiagency tactical law enforcement force protection;
• A prehospital infant safe sleep initiative to recognize,
report, and rectify unsafe sleep environments;
• Mobile integrated healthcare programs that involve
partnerships with hospice agencies to decrease hospice
revocations and unnecessary transports to EDs;
• An active EMS research division that has produced mul-
tiple prehospital articles and award-winning research;
• A paramedic-staffed acute-care station located in the
largest homeless shelter in Texas;
• A unique sepsis triage protocol that identifies patients
at risk for sepsis or in septic shock by use of EtCO2 instead
of temperature;
• A sepsis-alert system to make sure patients have rooms
available and can be treated immediately at hospitals;
• An LVO identification protocol to allow medics to bypass
primary stroke centers and take patients straight to com-
prehensive stroke centers;
• Apps for customized medication references and clini-
cal operating guidelines to decrease errors in treatment
and dosing.

2019 VOLUNTEER EMS SERVICE OF THE YEAR
SPONSORED BY ZOLL
Princess Anne Courthouse Volunteer
Rescue Squad, Virginia Beach, Va.
Extended Family
The Princess Anne Courthouse
Volunteer Rescue Squad stays
strong in the wake of adversity
S
ince 1947 Virginia’s Princess Anne
Courthouse Volunteer Rescue Squad
(PACHVRS) has served the emer-
gency medical needs of the Princess
Anne, General Booth, Redmill, and Salem areas
of Virginia Beach. The city is home to a major
military population along with civilian residents;
these combine for a year-round permanent pop-
ulation of 453,000. PACHVRS is one of 10 volun-
teer rescue squads that provide EMS response
to Virginia Beach.
PACHVRS’ 110 operational/administrative
members provide approximately 50,000 vol-
unteer hours annually to keep Virginia Beach
residents safe. The volunteer EMS unit fields
a fleet of four ALS-equipped ambulances
(though one needs to be replaced after being
stolen and wrecked). The volunteers staff one
ALS-equipped ambulance at each of two sta-
tions each shift. Collectively they answer about
5,000 calls a year. In addition to EMS response,
PACHVRS personnel provide medical assistance
at major public events and local attractions.
In addition to the hours they provide annually
to Virginia Beach, PACHVRS’ volunteer mem-
bers also donate time to connect with the com-
munity. This outreach includes safety/first aid
training at schools and civic organizations, plus
Stop the Bleed education and CPR certification
courses for the public. PACHVRS also stages
two children-oriented holiday events every year
and hosts regular station tours.
Beyond serving the Virginia Beach community,
PACHVRS works hard to support its own people.
“A core concept at PACHVRS is that the squad
should function as an extended family for each
member,” says Trevor M. Kirk, NRP, chair of the
PACHVRS board of directors.
OCTOBER 14-18, 2019
NEW ORLEANS, LA
F
R
O
THE YEA
S P O N S O R E D BY:
A case in
point: Earlier
this year one
new PACH-
VRS member was diagnosed with thyroid cancer
and required time off work that exceeded their
accrued paid vacation time. “PACHVRS mem-
bers saw a family member in need and immedi-
ately stepped up,” says Kirk. “They began selling
#CaitlynStrong bracelets to help the member
offset personal expenses created by income
shortfalls due to time lost at work because of
ongoing treatment appointments and medical
expenses.”
It has been a difficult year for PACHVRS. Two
of its units were first at the scene of the May 31
Virginia Beach active-shooter incident in which
12 people were killed. In a sad twist of fate,
“PACHVRS’ signature blue ambulances soon
became the leading image of local and national
newscasts,” says Kirk.
“On June 2, 30-plus members gathered at
PACHVRS’ home station (the Virginia Beach
Municipal Center fire/EMS station) and took the
short walk to the memorial site to pay respects
as individuals and as a squad. Afterward they
gathered at a local eatery for dinner, for the sake
of spending time together and to appreciate
each other’s company while we had the chance.”
Despite incidents like May’s mass shooting,
PACHVRS’ volunteers remain dedicated to serv-
ing local residents.
“We join the rest of the city of Virginia Beach in
making sure Virginia Beach will not be remem-
bered as a place of violence but as a place of
unwavering support and love for our commu-
nity,” says Kirk. “The horrific events of that Friday
afternoon will not define us.”
EMSWORLD.com | OCTOBER 2019 19
 SPOTLIGHT:

2019 NAEMT/NASCO PARAMEDIC OF THE YEAR

SPONSORED BY NASCO

Debby Carscallen, Moscow (Idaho)

Volunteer Fire Department
F
R
O

THE Y EA

S P O N S O R E D BY: A Champion of Safety and

Well-Being
The year’s top medic is a coach,
leader, teacher, and mentor

D
ebby Carscallen is a paramedic for the
Moscow Volunteer Fire Department
in Idaho. She was nominated by Pam
Rogers, a coworker in Carscallen’s volun-
teer roles as a firefighter, paramedic, police officer,
and now EMS division chief for the city of Moscow.
“[Debby] is an incredible and valuable member of our
community and an outstanding paramedic,” says Rogers.
Carscallen is recognized as a coach, teacher, lead- “Debby is a paramedic whose purpose and focus
er, mentor, and champion of the physical safety and are to serve her community and patients,” says
emotional well-being of crews. She has improved the Nicole Wheaton, RN, of the city’s Gritman Medical
department’s onboarding process, and many volun- Center. She frequently spends evenings helping
teers have advanced to pursue careers in EMS. She EMS agencies in small, rural communities conduct
recruited volunteers to help raise funds to purchase training. She is also working to create a peer support
AEDs for all schools and police vehicles in the com- group to assist and advocate for the mental health
munity. She is an advocate for CPR and Stop the of the first responder community.
Bleed classes and inspires others to become advo-
cates for community education.

20 OCTOBER 2019 | EMSWORLD.com

 OCTOBER 14-18, 2019
NEW ORLEANS, LA

2019 NAEMT/BOUND TREE EMS MEDICAL

DIRECTOR OF THE YEAR
SPONSORED BY BOUND TREE MEDICAL EMS MEDICAL
Michael Dailey, Albany, N.Y. DIRECTOR
F

R
O
TH A
E YE

S P O N S O R E D BY:
A Voice for Clinical Improvement
For the year’s top medical director, every moment counts

M
ichael Dailey, MD, FACEP, FAEMS, is
the regional EMS medical director
for REMO (Regional Emergency
Medical Organization), which
serves a six-county region surrounding Albany,
N.Y., with a population of close to one million
people, and also medical director for a dozen
other EMS agencies. He is a member of multiple
national and state organizations and has been
a strong voice locally, playing an active role in
protocol and systems development.
Nominators Luke Duncan, MD, and Steven Kroll,
MHA, EMT, say Dailey “has been one of the most sig-
nificant and impactful EMS physicians and medical Dailey is devoted, fair, competent, equitable, compas-
directors in New York.” Dailey is credited with helping sionate, and inspiring. He helps others and communi-
agencies advance clinical improvement and excellence ties without pretense, working tirelessly to make things
and mentoring EMS leaders who struggle with sustain- better for our patients and our profession.”
ability and clinical issues. “I am honored and humbled to be recognized as
“Mike uses every precious moment to get something the NAEMT EMS Medical Director of the Year,” says
done,” Duncan and Kroll say. His strength has been in Dailey. “A medical director’s success is determined
motivating groups of interested parties to get involved by the people around them—I work with amazing
and advance important causes, and he leads them to people. I will be accepting the award on behalf of the
tackle challenge after challenge together. members of the REMO medical advisory committee,
As chief of the Division of Prehospital and Opera- New York State Collaborative Protocols Committee,
tional Medicine and professor of emergency medicine and the EMS providers of the Hudson Mohawk Region.
at Albany Medical Center, Dailey educates many young This award really reflects the EMS professionals, both
physicians to become EMS leaders. Jason Cohen, DO, paid and unpaid, who work together every day to make
chief medical officer of Boston MedFlight, says, “Dr. our systems better for our patients.”

EMSWORLD.com | OCTOBER 2019 21

 SPOTLIGHT:

2019 NAEMT/JONES & BARTLETT LEARNING

EMS EDUCATOR OF THE YEAR
SPONSORED BY JONES & BARTLETT LEARNING

Melissa Stuive, Del Mar College,

S P O N S O R E D BY:
Corpus Christi, Tex.
The Skills to Succeed
A perfect paramedic pass rate
is just one of this top educator’s
achievements

M
elissa Stuive is the EMS program direc-
tor at Del Mar College in Corpus Christi,
Tex., sits on the Education Committee
of the Texas Governor’s Emergency
Trauma Advisory Council, and also serves as
Education Committee chair for the Coastal Bend
Regional Advisory Council.
Stuive has served as a question writer for the National
Registry of Emergency Medical Technicians and was able
to significantly improve her college’s paramedic program
pass rates to 100%. student Frank Funke notes, “Melissa sets her students
“Melissa has demonstrated time and again her dedica- up with the knowledge and skills they need to succeed.
tion and commitment to the success of Del Mar’s pub- She has built relationships in our area with her students
lic safety and EMS program, as well as to each student going into the field and clinical work.”
engaged in the program,” says Ricardo Quintero, deputy Stuive continues to work on her own professional
chief of the Corpus Christi Fire Department. development and is completing her EdD. “Her influence
Stuive directed the effort to achieve accreditation to in the lives of practicing EMTs and paramedics cannot be
ensure quality instruction was delivered to every student. emphasized enough,” says Roberto Ruiz, an EMS instruc-
She introduced technology and improvements that gave tor under her supervision.
students the resources to become skilled EMTs. Former

22 OCTOBER 2019 | EMSWORLD.com

 OCTOBER 14-18, 2019
NEW ORLEANS, LA

2019 NAEMT/BRAUN INDUSTRIES EMT OF THE YEAR

SPONSORED BY BRAUN INDUSTRIES

Freya Whalen, CoxHealth,

Springfield, Mo. F

R
O
THE YEA

Passionate About Knowledge S P O N S O R E D BY:

The 2019 EMT of the Year is driven to provide the best

healing experience possible

F
reya Whalen is an EMT for CoxHealth
in Springfield, Mo. She was nominated
by her colleague Aerla McCoy, who
says, “Freya is honest and genuine-
ly compassionate to her patients, making them
feel taken care of. She has a drive to make the
patient experience the best healing experience
possible. She is a shining example of an EMT.”
Whalen is a volunteer fire lieutenant and EMT for a
hospital-based 9-1-1 and transfer service. She previ-
ously received Missouri’s 2018 Kenneth E. Cole Memo-
rial EMT-B of the Year Award. Freya is also an instructor
and trains peers in the fire and EMS services.
Whalen is passionate about passing knowledge
to the next generation of EMTs. She is an EMT field
training officer, providing prehospital training for
newly hired and student EMTs. Her goal, she says, Quoted in a local publication, Whalen says, “In
is to go beyond the textbook and locate needs in the healthcare, we are given a rare opportunity to be
emergency medical service industry. She educates there for someone in their darkest time and help
the community in CPR, bleeding control, AED use, them. Be it big or small, the things we do and say
and injury prevention and safety. She has been an are important.”
advocate for child safety, EMS practitioner safety
and resilience, and patient care.

EMSWORLD.com | OCTOBER 2019 23

 SPOTLIGHT:

2019 NAEMT/NORTH AMERICAN RESCUE

MILITARY MEDIC OF THE YEAR
SPONSORED BY NORTH AMERICAN RESCUE

HM1 Kenneth Russell, Acting Medical Chief,

Company M, 3rd Marine Raider Battalion
S P O N S O R E D BY:

A Top Medical and Tactical Performer

Military medic winner is a leader, trainer, mentor, and
subject matter expert

H
M1 Kenneth Russell is a special operations
independent duty corpsman currently
serving as the acting medical chief and
lead petty officer for Company M, 3rd
Marine Raider Battalion.
Serving the U.S. Navy for the past seven years, Rus-
sell has deployed with 3rd Reconnaissance Battalion in
Okinawa, Japan, as well as serving two overseas tours
to Africa with Marines special operations teams. He is
a successful leader, trainer, mentor and subject matter
expert. “HM1 Russell is a top performer within Marine Spe-
cial Operations Command,” says HMCS Michael J. Mason.
Russell was awarded the prestigious MARSOC Luke
Milam Excellence Award in 2019 for his abilities as both
a medical professional and a tactical leader. He led a
responding joint Department of Defense team of more
than 30 personnel in the care of 21 multisystem trauma earned the highest marks in fitness, and molded a diverse
patients that included prolonged evacuation times of up group of specialists into a team, leading to the best pos-
to six hours. sible outcome in a combat zone for nearly two dozen
In the past year Russell has answered his calling casualties.
as an independent medical provider within a Special “Without reservation, HM1 Russell represents the top
Operations Command. He has sought civilian educa- candidate for nomination by 3rd Marine Raider Battalion,
tion, achieved the height of his technical progression, Marine Special Operations Command,” adds Mason.

About the National EMS Awards of Excellence
Nominees for Service of the Year are scored on advances in
EMS education; innovations in prehospital care and protocol
development; medical community involvement; EMS system/
program upgrades; worker safety and well-being; injury and ill-
ness prevention; and public education sponsorships. Nominees for
Paramedic and EMT of the Year are scored on how the nominee
provides superior patient care; is an advocate for patients and their
families; works with peers to foster a positive work environment;
demonstrates professionalism in interacting with patients, fami-
lies, and medical professionals; and demonstrates a commitment
to continuing education. Nominations for EMS Educator of the Year
are scored on how the nominee demonstrates commitment to pro-
viding high-quality education; serves as an outstanding role model
in the classroom and community; mentors students at all stages
of their development; incorporates innovative approaches that
enhance learning; and participates in the development of educa-
tional content that expands the body of EMS curriculum. Nominees
for Military Medic of the Year are military medics (MOS-qualified
active, reserve, or National Guard U.S. Army medic, Navy corpsman,
or Air Force medic) who demonstrate excellence in military emer-
gency medicine, with their primary role being theater patient care.

24 OCTOBER 2019 | EMSWORLD.com

 OCTOBER 14-18, 2019
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EMSWORLD.com | OCTOBER 2019 27

 STUDY ABROAD
ISSUE FOCUS: EDUCATION

PROVIDES A
W I D E R
PERSPECTIVE
A Washington university and Australian service ally for an
educational exchange
By Douglas Presta, DPM, NRP, and Scott Devenish, PhD
Photos: Douglas Presta

I
t is important for university paramedic
students to realize the learning curve
doesn’t stop at graduation. We stress
to students that graduation is not
the pinnacle of their education but just a
stepping-off point. Local continuing edu-
cation is important, but it’s essential that
students and graduates engage with the
wider national and international para-
medic community through conferences to
expand their education, keep up with the
latest research, and see how their system
compares to those in other places.
Central Washington University (CWU)
took it one step further and started the
university’s first paramedic study-abroad
program in conjunction with the para-
medic program at Queensland University
of Technology (QUT) in Brisbane, Aus-
tralia. This summer we hosted four para-
medic students and their director. During
their time in the U.S., they did ride-alongs
with departments across Washington and
experienced firsthand how the profes-
sion operates in the United States. While a
first for CWU, this program is also a unique
opportunity for EMS in America, as we are
not aware of many other paramedic-specific
university undergraduate study-abroad pro-
grams in the U.S.
Feedback from all parties confirmed
the program was a fantastic success. The
interactions between fire and ambulance
crews and their Australian counterparts
were provocative and informative. As we
looked for differences, we also found

28 OCTOBER 2019 | EMSWORLD.com

similarities and formed numerous friend- to be employed anywhere in the world United States association with the QUT
ships. Students rode with multiple agen- while taking courses. Our study-abroad undergraduate paramedic association
cies, including Seattle’s Medic One, the program is offered only to those fourth- called Student Paramedic Undergradu-
Tacoma Fire Department, Kittitas Valley year students, so they can be out of the ates (SPUs).
Fire and Rescue (KVFR), AMR of Yakima, country for three weeks without affecting We will also partake in other activities,
Ballard Ambulance of Wenatchee, Life- their online courses. Our delegation will such as meeting QAS’ medical direc-
Line Ambulance of Omak, Deer Park Vol- be riding with the Queensland Ambulance tor, Dr. Steve Rashford, and other senior
unteer Ambulance, and Spokane’s city and Service (QAS) high-acuity response units paramedic mangers at state headquar-
county fire departments; and air services (HARUs), interacting with students in the ters. Students will interact with QAS and
that included Life Flight, the University of QUT paramedic program, and starting a Queensland Fire and Rescue (QFRS) staff
Washington’s Airlift Northwest, and Aero
Methow Rescue Service of Twisp. They also
spent time at Kittitas Valley Hospital (KVH)
and Seattle’s famed Harborview Hospital.
We wish to thank these entities for their
support and adding value to the program.
QUT students also gave a presentation to
CWU paramedic students and facilitated
cultural exchange through the sharing of

Proven Leader in Ambulance

a traditional vegemite spread.

Returning the Favor

The paramedic program at QUT is a three- Seat Belt Technology.
year bachelor’s degree course and also has a
paramedic/nurse dual-degree option, which
is a four-year program. Their paramedic stu- TRUSTED AND TESTED
dents graduate as advanced-care paramed- • Most Accepted Product by EMS
ics (ACPIIs), with fewer skills than paramed-
Providers & Leading Manufacturers
ics in Washington. For example, ACPIIs do
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After graduating and gaining national • Squad Bench & Integrated
registration, Australian paramedics can
Seat Applications
undergo postgraduate studies in criti-
• Colors & Circuited Designs
cal care paramedicine. They can then
become critical care paramedics (CCPs), Available
which have advanced skills to match those
of paramedics in Washington. CCPs can
then complete further training to work on
Ask your
high-acuity response units, where they can
perform open thoracotomies, administer dealer/manufacturer
blood products and transfusions, and per-
about improving safety
form other advanced critical care skills.
This fall CWU will send five paramed- in your vehicle.
ics from Washington and Idaho for a
three-week visit to Australia. Paramedic
program director Doug Presta will accom-
pany them. The group will spend time in
Sydney and then travel to Brisbane.
CWU offers a bachelor’s degree in para-
medicine in our fourth year, with all cours-
es offered online to allow our students
IntertekIndustrial.com

EMSWORLD.com | OCTOBER 2019 29

 ISSUE FOCUS: EDUCATION
Tacoma Fire was one agency with which the visiting Australians spent time.
at the joint ambulance/fire training facil-
ity on Whyte Island in the Port of Brisbane
and tour other facilities to gain an under-
standing of the provision of emergency
care to people living in remote areas.
In addition to paramedicine-related
visits, planned cultural activities include
visiting some of Queensland’s iconic
beaches and tourist attractions and a
visit to Australia Zoo (founded by the
late Steve Irwin) to learn about venom-
30 OCTOBER 2019 | EMSWORLD.com
QUT has set a goal of recruiting outside
locations for exchange programs to provide
experiences for its students.
ous snakes, spiders, jellyfish, crocodiles, academics, and other key stakeholders to
and more. Additionally, we will attend discuss future directions and advanced
professional development and research guidelines for paramedicine in Australia.
events hosted by QAS and Paramedics QUT has set a goal of recruiting out-
Australasia, allowing students to further side locations for exchange programs to
network with Australian paramedics, improve its education and provide expe-
riences for its students. It has exchange
programs in China, Vietnam, Vanuatu,
New Zealand, Canada, the U.K., and
more. Students not only experience great
educational exchanges and ideas, they
return to Brisbane and present on what
they have learned and their experiences
to their cohorts and departments. CWU
is expanding on this concept by promot-
ing study abroad and cultural exchange.
Not only will the school be continuing its
exchange with Brisbane, it’s currently cre-
ating three new study-abroad locations, in
Accra, Ghana, and Milan and Rome, Italy.
Building Bridges
We strongly believe in the concept of the
exchange program. We have seen firsthand
how valuable these programs are to build-
ing networks and lasting friendships, creat-
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ISSUE FOCUS: EDUCATION

The program both shares knowledge and creates lasting friendships. The students from Brisbane finished the last night of their
program in the U.S. at a dinner hosted by the local paramedics
with whom they’d worked over the last three weeks. Several
local medics are now planning on attending the next Paramed-
ics Australasia International Conference.
Furthermore, two of the Australian students are looking into
employment opportunities in Ellensburg, Wash., with Kittitas
Valley Fire and Rescue. We are excited to be part of such edu-
cational opportunities and aim to expand these opportunities
for students at CWU.
If you are interested in one of our exchange programs or a
bachelor’s degree in paramedicine through our advanced stand-
ing program for paramedics looking to get their degree, please
contact Douglas.Presta@cwu.edu.

ABOUT THE AUTHORS

ing new ideas, and sharing experiences and bringing our cultures
closer together.
These programs also provide employment opportunities. QUT
student paramedics have obtained employment in the U.K. and
New Zealand with exchange host organizations—opportunities that
would not have occurred if not for these types of study-abroad
Douglas Presta, DPM, NRP, is paramedic program director at Central Washington
University in Ellensburg, Wash.
Scott Devenish, PhD, is a senior lecturer and course coordinator on the healthcare
faculty in the School of Clinical Sciences at Queensland University of Technology in
Brisbane, Australia.

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ISSUE FOCUS: EDUCATION
THE
FUNDAMENTALS
OF FLIPPING
By Ben Tacy
A ‘flipped classroom’ approach takes work
on the front end but pays off on the back
D
o your students complain about
the time constraints of their train-
ing program? Do they attend
classes scheduled more for the
convenience of instructors than students?
Ever seen one fall asleep in class after com-
ing directly from night shift?
If you’ve not experienced any of these,
you’re more fortunate than most. How-
ever, if you are detecting these signs and
34 OCTOBER 2019 | EMSWORLD.com
symptoms, it could be time to change
your approach. More specifically it may
be time to flip your classroom education.
The flipped-classroom model pres-
ents students with introductory mate-
rial outside the classroom, resulting
in fewer class hours the student must
attend. Technology assumes much of
the educational load, with students intro-
duced to new content by methods such
as interactive lectures, reading assign-
ments, discussions, etc. The material is
then applied within the classroom with
a more in-depth approach.
For example, if a program meets just
three times per week for an hour each
time, the time normally spent introduc-
ing new material essentially can be given
as homework. This will require less face-
to-face time but let it be spent in more
engaging work.
This method can create a more inter-
active learning experience with more
positive outcomes. Educational theorists
speculate that students’ main concerns
regarding courses they take involve times
and delivery methods accommodating
their busy schedules. It goes without say-
ing that emergency services workers are
busy, so why isn’t that taken into consid-
eration? Just reflect on the courses you’ve
had to take. Would you have viewed some
differently if you could’ve only shown up
for the hands-on portion, with less time
on your tush?
Preparing for the Flip
Flipping a classroom is not easy on instruc-
tors. The American Journal of Pharmaceu-
tical Education found implementation of
a flipped classroom required 127% more
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classroom to reduce actual instruction time. Flipping your class ■ Articulation Agreement with
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material is an investment—it requires a significant amount of work 4-Year Universities.

on the front end, but it will ultimately require less work to maintain ■ Currently credentialed state and national
your product. Paramedics earn up to 45 credits toward
Many emergency service educators deliver introductory
their degree just for being certified!
■ Available to residents in all states
material via presentation software programs. Once it’s deliv-
except FL and MA.
ered the material is applied through methods such as scenarios, ■ Designed for demanding EMS work
simulations, etc. The introductory material should be the tip of schedules. Complete the degree
the iceberg. Within the classroom is where the higher level of at your own pace!
learning occurs.
Emergency service personnel are inherently hands-on people, Ranked Fourth in the Nation
and many embrace the motto “train as you fight.” At the least by bestcolleges.com!
you can probably agree you learn best by doing the work. On
the other hand, we routinely see rooms full of our on-duty peers
on their phones and tablets between calls. Imagine combining
both worlds: hands-on and technology!
There is no defined single way to flip your courses, but the
premise is there must be a way for students to access, partici-
pate, and engage academically in the introductory material. One 231 Hwy. 58 South, Kinston, NC
easy method is to record your presentations. No matter which
software you use, there is a means to record. Some, such as (252) 527-6223, ext. 115
PowerPoint, allow recording within the presentation.
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EMSWORLD.com | OCTOBER 2019 35

ISSUE FOCUS: EDUCATION
Here are some basic principles to fol-
low when recording:
• Your presentation should be short
and sweet. Remember, we are a profes-
sion filled with short attention spans!
• Slides within your presentation don’t
need to contain large amounts of text.
More and more research says to only use
pictures as memory joggers. Here’s a test:
What comes to your mind when read-
ing the word dog? Did the letters d-o-g
float in your head, or a picture of a dog?
Imagine trying to describe a hematoma
without a picture.
• Prepare a script apart from your
slides, though. Think through what you
want to say before you say it. Write this
out for each slide so your presentation
has a smooth flow and to reduce record-
ing times.
36 OCTOBER 2019 | EMSWORLD.com
Your presentation doesn't need a
bunch of bells, whistles, and flair;
just the basics.
• Your presentation doesn’t need to be
Hollywood production. It doesn’t need a
bunch of bells, whistles, and flair; just the
basics. Students can become distracted
by too much showmanship.
• Audio quality, however, is very impor-
tant, so invest in a good microphone.
If there is background noise, popping
sounds when you say your Ps, static, etc.,
you will lose your audience. You know
what you do to a radio station when you
hear static.
• Your expensive microphone won’t
make you more entertaining. Put some
emotion into your speech—motivate and
inspire them!
• It’s easiest to record within your pre-
sentation. This lets you have an audio file
per slide. For future updates you can edit
each slide’s audio, rather than an entire
audio clip. Once you’ve completed all
your recordings, you can then save your
entire presentation as a video!
• Preview your work before you assign it!
While preparing your presentation will
take longer than you’d spend delivering
it, consider that you now have that pre-
sentation permanently at your disposal.
It’s been my experience that creating your
own presentation from scratch is about a
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ISSUE FOCUS: EDUCATION

??

A visual depiction of the flipped-classroom approach to education shows the reduced role of the lecture vs. more engaged activities.
—Source: University of Washington Center for Teaching & Learning

4:1 effort: To prepare a 30-minute presentation will take about
two hours of work.
Flipped Delivery
Now that you’ve created a product, it’s time to deliver! Whether the
material is hosted within a learning management system (LMS)
such as Blackboard or Canvas or through an open source such as
YouTube or Vimeo, students will be able to access the material
electronically and at a time convenient for them. They will be par-
ticipating in your lecture just as they would within the classroom,
but asynchronously.
The question many ask is, “How do you make sure the student
watches the lecture?” There are numerous ways. Here are a few:
• Use a third-party website/LMS such as Edpuzzle or Play-
Posit. You can simply track the progress of the video and prevent
skipping by embedding questions within your videos as a means
of informative assessment. This is my favorite method, as it
assesses the student on each topic of discussion.

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ISSUE FOCUS: EDUCATION
Be sure you get feedback
from students on the overall
course and evaluate yourself.
• Create assignments that require students to reflect on
what they’ve learned from the presentation. This can be done by
means of forums, summary papers, collaborative group assign-
ments, and more.
• Use informative assessments at beginning of class. Quiz
your students on the material due for that class. My personal
choice is a learning game like Kahoot (or similar) at the begin-
ning of the session. This allows clarification of any needed
topics and can help refine the day’s lesson plan.
If you are tracking the presentation by some means, I strongly
recommend having it as a grade.
Piecing It All Together
Offering a flipped course is all about creating a logical flow. You will
distribute the online presentation to your students and require it to
be viewed before you meet face to face. At the beginning of class,
conduct a collaborative quiz that will both assess the students and
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create discussion. This creates interaction to allow clarification of
any unclear items. Once that is complete you can begin covering
advanced training through hands-on scenarios and simulation.
Essentially do all the work that can’t be conveyed online
and discover the rest of the iceberg within the classroom.
Once the face-to-face session is complete, the students can
take a summative exam to assess how well they retained the
information and ensure you properly delivered the material.
An often-overlooked component to any course is feedback.
Be sure you get feedback from students on the overall course
and evaluate yourself. Look subjectively at how well the stu-
dent was prepared for the course and formatively evaluate
based on test scores. Following that feedback, correct any
discrepancies you find in your flipped course and prepare it
for the next time!
REFERENCE
1. Rotellar C, Cain J. Research, perspectives, and recommendations on implementing the flipped
classroom. Am J Pharm Educ, 2016 Mar 25; 80(2): 34.
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BONUS CONTENT: RESEARCH
WHAT SHOULD
YOU KNOW ABOUT
EVIDENCE-BASED
GUIDELINES?
A consortium sets out to bring EBGs to EMS
By Juan March, MD; Christian Martin-Gill, MD, MPH;
Mike McEvoy, PhD, NRP, RN; and Joann Freel
A
s healthcare professionals we
want to provide patients the best
possible medical care. Prehospi-
tal care, like the rest of medicine,
is constantly changing, since the research
performed today will shape the medical
care delivered tomorrow.1–4
The strongest type of research study
is a randomized controlled trial (RCT). An
RCT minimizes potential bias by random-
izing the administration of an intervention
to some subjects while others (the control
group) don’t get it. Ideally evidence-based
guidelines in EMS should be based on mul-
tiple RCTs. To properly develop an EBG, a
multistep process (the GRADE methodol-
42 OCTOBER 2019 | EMSWORLD.com
ogy) is required to review research studies
on a specific topic.
In 2015 the National Association of EMS
Physicians (NAEMSP), along with 57 EMS
stakeholder organizations, began the Pre-
hospital Guidelines Consortium (PGC). The
PGC has a mission to assist in the devel-
opment, implementation, and evaluation
of prehospital evidence-based guidelines
(EBGs). Future objectives for the PGC
include promoting development of future
EMS EBGs, promoting grant funding for EMS
EBGs, development of research related to
EMS EBGs, promoting implementation of
EMS EBGs, developing education related
to new EBGs, and promoting standardized
evaluation methods for EMS EBGs.
An Introduction to Evidence-
Based Medicine
Evidence-based medicine (EBM) or evi-
dence-based practice (EBP) is the thought-
ful integration of the best available research
findings with consideration for clinical
expertise and judgment, while also taking
into account the values and preferences of
patients and clinicians. To clarify, EBM is
not based solely on personal experience,
anecdote, or “how we’ve always done it,”
but applies a scientific method to support
(or sometimes refute) these beliefs. 3,5
The goals of EBM include improvement
in the quality of medical care, improvement
in patients’ clinical outcomes, maintaining
clinician/patient satisfaction, and ensuring
consistency of care between clinicians and
across healthcare systems.6–8 Four exam-
ples of EBM include the AHA guidelines for
resuscitation, spinal motion restriction
guidelines, CDC guidelines for field triage,
and evidence-based guideline for pediat-
ric prehospital seizure management using
GRADE methodology.9–12
Many national EMS organizations now
support incorporating EBM into EMS guide-
Table 1: Randomized controlled trials provide the highest quality of scientific evidence.
lines and protocols. In 2012 the National
EMS Advisory Council recommended it.13
In 2013 the Federal Interagency Commit- will receive refresher content on EBM.14 case. A case series is something you did
tee on EMS published a strategic plan several times that seemed to work (or not
that included support for the develop- Different Types of Research work), so you decided to continue doing
ment, implementation, and evaluation of There are many types of research, includ- it (or not doing it) based on those several
evidence-based guidelines.5 ing case studies, case series, case control cases. In contrast, case control studies use
In 2017 research and evidence-based studies, cohort studies, and random- an outcome or intervention and compare
medicine became part of the updated ized controlled trials (see Table 1). A case study groups to control (standardized non-
National Registry’s Core Competency Pro- report or case study is something you did study) groups.
gram (CCP) learning goals. The CCP update that seemed to work (or not work) the one A cohort study retrospectively or pro-
implies that every nationally registered EMS time you tried it, so you decided to continue spectively follows a group of individuals
provider certified at the EMT level or above doing it (or not doing it) based on that one to determine the incidence of a particular

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BONUS CONTENT: RESEARCH
Figure 1: GRADE methodology
—Source: www.cdc.gov/vaccines/acip/recs/grade/downloads/guide-dev-grade.pdf
outcome. Unlike a cohort study, where
the intervention is not controlled by the
investigator, in a randomized controlled
trial the intervention is controlled by the
investigator.
The strongest type of research study
is an RCT. Unfortunately, sometimes an
RCT cannot be performed because it is
not possible or practical to randomize the
intervention. In addition, RCTs are often
very costly, time consuming, require sta-
tistical analysis, and need large numbers of
patients. Furthermore, an RCT may not be
even feasible due to the setting.15 In order
to prevent any local geographic bias, the
best RCTs are multicenter trials held at
several sites.
One quickly realizes that EMS EBGs
should ideally be based on multiple RCTs,
not just one. Developing an EBG is easy
when several RCTs all agree that an inter-
vention provides a benefit (or no benefit).
Unfortunately there are times where RCTs
directly contradict each other. There are
some RCTs that support the prehospital
care delivered to patients, but more com-
monly there are none, and EMS guidelines
are often based on weak research or, even
worse, simply expert consensus.
44 OCTOBER 2019 | EMSWORLD.com
EBGs and GRADE
Methodology
To properly develop an EBG, a multistep
process (the GRADE methodology, for
grading of recommendations assessment,
development, and evaluation) is required
to review several research studies on a
specific topic (see Figure 1).16 This process
begins by identifying an expert multidisci-
plinary panel that develops a focused ques-
tion using what is called a PICO framework
(patient/population, intervention/indicator,
compare/control, outcome, plus time/type
of study or question). This process requires
close collaboration of the entire panel.
The panel then develops and selects
specific patient outcomes important for
decision-making. Outcomes determined
to be critical and important are evaluated
using a systematic review process. Out-
comes rated as not important need not be
considered any further. The novelty of the
GRADE approach is that the outcomes are
evaluated across rather than within studies.
In other words, a different body of evidence
may contribute information to different
outcomes being considered.
When an evaluation of the outcomes
across studies has taken place, evidence
profiles using software such as GRADEpro17
are developed. The presentation of this
information can take place either in typical
evidence profiles or in a summary-of-find-
ings table, where a detailed assessment of
the underlying confidence in an estimate of
effect by outcome is then combined with
an actual analysis.
An expert panel reviews the evidence
and will then “grade” its quality. This is
done for each outcome across four cat-
egories: high, moderate, low, or very low,
on the basis of eight factors that either
increase or decrease the initial quality
(see the upper right-hand corner of Figure
1). Randomization is considered the best
method to protect against bias, and the
evidence from RCTs usually is considered
as higher quality. There are five factors that
can lower the quality (grade) of evidence,
and three that increase it (Figure 1).
Once all critical outcomes for decision-
making have been evaluated, an overall
confidence in the estimate of effect to
support a recommendation or an over-
all GRADE of the quality of evidence is
assigned. The overall GRADE is based on
the outcome with the lowest quality of evi-
dence, given that it is a critical outcome. This
information is provided back to the panel.
The guideline panel needs to formulate
a recommendation by considering four
factors: the quality of evidence, the bal-
ance between benefits and downsides,
values and preferences, and resources
used. The panel will then formulate rec-
ommendations in a clear and unambigu-
ous way using standardized wording, such
as using the term recommend for strong
recommendations and the term suggest
for conditional or weak recommenda-
tions. Other terminology sometimes used
includes should and may. Guideline panels
will express GRADE’s two directions of the
recommendation either for or against an
intervention or diagnostic test or strategy
and the strength of this recommendation
by determining that it is either a strong or a
conditional recommendation. Other users
of GRADE may use the evidence summa-
rized according to the GRADE approach for
health policy decisions.
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BONUS CONTENT: RESEARCH
Prehospital Guidelines
Consortium
In 2007 the Institute of Medicine’s Com-
mittee on the Future of Emergency Care
recommended that a multidisciplinary
panel establish a model for developing
evidence-based protocols for prehospital
care.13 In 2015 NAEMSP, along with 57 EMS
stakeholder organizations, began the Pre-
hospital Guidelines Consortium (PGC). 18
The PGC has a mission to assist in the
development, implementation, and evalu-
ation of prehospital EBGs. The PGC also
identified a need for better education of
the EMS community in regards to EBM. In
an effort to help EMS instructors, the PGC
Education Committee developed an edu-
cational PowerPoint entitled “Research
and Evidence-Based Guidelines in EMS.”
EMS educators/instructors/professionals
can download this slideshow presentation
from the PGC website (http://prehospital-
guidelines.org/) free of charge.
Another helpful resource is the Dalhousie
University website Prehospital Evidenced
Based Practice (https://emspep.cdha.
nshealth.ca/TOC.aspx). This site incorpo-
rates research studies on many different
topics, but unfortunately its reviewers do
not use GRADE methodology. 2
Summary
The ultimate goal of EMS is provide patients
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the best healthcare possible. Yet research
is constantly changing and improving how
prehospital medical care is delivered. For
this reason, EBM and EBGs using GRADE
methodology are a crucial component of
EMS now and in the future. The PGC has
a mission to assist in the development,
implementation, and evaluation of prehos-
pital evidence-based guidelines.
REFERENCES
1. Bledsoe BE. Searching for the evidence behind EMS. Emerg
Med Serv, 2003; 32(1): 63–7.
2. Carter AJE, Jensen JL, Petrie DA, et al. State of the evidence
for emergency medical services (EMS) care: The evolution
and current methodology of the Prehospital Evidence-Based
Practice (PEP) program. Healthcare Policy, 2018; 14(1): 57–70.
3. Treasure T. From anecdote to EBM. J R Soc Med, 2006;
99(5): 267–70.
4. Institute of Medicine. Evidence-Based Medicine and the
Changing Nature of Healthcare: 2007 IOM Annual Meeting
Summary. Washington, D.C.: National Academies Press,
2008.
5. Brown KM, Macias CG, Dayan PS, et al. The Development
of Evidence-based Prehospital Guidelines Using a GRADE-
based Methodology. Prehospital Emerg Care, 2014; 18(sup1):
3–14. 5.
6. Adelgais KM, Sholl JM, Alter R, Gurley KL, Broadwater-
Hollifield C, Taillac P. Challenges in Statewide
Implementation of a Prehospital Evidence-Based Guideline:
An Assessment of Barriers and Enablers in Five States.
Prehosp Emerg Care, 2019 Mar–Apr; 23(2): 167–78.
7. Martin-Gill C, Gaither JB, Bigham BL, Myers JB, Kupas DF,
Spaite DW. National Prehospital Evidence-Based Guidelines
Strategy: A Summary for EMS Stakeholders. Prehosp Emerg
Care, 2016; 20(2): 175–83.
8. Gausche-Hill M, Brown KM, Oliver ZJ, et al. An Evidence-
based Guideline for Prehospital Analgesia in Trauma. Prehosp
Emerg Care, 2014; 18 Suppl 1: 25–34.
9. Sasser SM, Hunt RC, Faul M, et al. Guidelines for field triage
of injured patients: recommendations of the National Expert
Panel on Field Triage, 2011. MMWR, 2012; 61(RR-1): 1–20.
10. Shah MI, MacIas CG, Dayan PS, et al. An evidence-based
guideline for pediatric prehospital seizure management
using grade methodology. Prehosp Emerg Care, 2014; 18
Suppl 1: 15–24.
11. Fischer PE, Perina DG, Delbridge TR, et al. Spinal Motion
Restriction in the Trauma Patient–A Joint Position Statement.
Prehosp Emerg Care, 2018; 22(6): 659–61.
12. Kleinman ME, Perkins GD, Bhanji F, et al. ILCOR
Scientific Knowledge Gaps and Clinical Research Priorities
for Cardiopulmonary Resuscitation and Emergency
Cardiovascular Care: A Consensus Statement. Resuscitation,
2018; 127: 132–46.
13. Lang ES, Spaite DW, Oliver ZJ, et al. A national model for
developing, implementing, and evaluating evidence-based
guidelines for prehospital care. Acad Emerg Med, 2012; 19(2):
201–9.
14. National Registry of Emergency Medical Technicians.
National Continued Compentency Program, https://content.
nremt.org/static/documents/2016_NRP_NCCP_final.
pdf?v=1.
15. West SG, Duan N, Pequegnat W, et al. Alternatives to the
randomized controlled trial. Am J Public Health, 2008; 98(8):
1,359–66.
16. Schunemann H, Ahmed F, Mergan R. Guideline
Development Using GRADE (Online). Department of Clinical
Epidemiology and Biostatistics, McMaster University.
17. Patterson PD, Higgins JS, Weiss PM, Lang E, Martin-Gill C.
Systematic Review Methodology for the Fatigue in Emergency
Medical Services Project. Prehosp Emerg Care, 2018; 22
Suppl 1: 9–16.
18. Prehospital Guidelines Consortium, http://
prehospitalguidelines.org/.
19. Prehospital Guidelines Consortium. Research
and Evidence-Based Guidelines in EMS, http://
prehospitalguidelines.org/wp-content/uploads/2018/11/
EMS-Research-and-EBGs.pdf.
ABOUT THE AUTHORS
Juan March, MD, is professor in the department
of emergency medicinine and chief of the Division
of EMS at East Carolina University. He is cochair of
the Prehospital Guidelines Consortium’s Education
Committee.
Christian Martin-Gill, MD, MPH, is an associate
professor in the Department of Emergency
Medicine at the University of Pittsburgh.
Mike McEvoy, PhD, NRP, RN, is EMS coordinator
for Saratoga County, N.Y., a nurse clinician at
Albany Medical Center, paramedic supervisor and
CME coordinator for Clifton Park and Halfmoon
EMS, and chief medical officer for the West Crescent Fire
Department.
Joann Freel is executive director of the National
Association of EMS Educators (NAEMSE).
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MENTAL HEALTH IN EMS
ITÕS COMPLICATED:
GRIEF AND THE FIRST
RESPONDER
Understand the process, and you’ll be a more effective
patient advocate
By Alexandra Jabr
I
remember the first time I cried over
the death of a patient. It still seems
odd—I didn’t know him before our paths
crossed, and I never expected to hear
about him again after that day. For the
longest time I remembered his name, and
even though enough time has passed that
I can’t anymore, what’s difficult to forget is
everything else that surrounded his death
and the context that framed it.
At the time I was a relatively new EMT,
and I can still remember several details
about that day, such as my partner and
what shift we were working, the fire crew
that responded with us, and which park-
ing lot the patient’s parents called 9-1-1
from. I recall the chief complaint being
generalized illness with a working diag-
nosis of febrile seizures and no history of
epilepsy. The parents said he hadn’t been
feeling well that day, appeared lethargic
at times, and was running a fever.
In hindsight the fact that he would
seize for a couple of seconds and then
return to a normal baseline mental sta-
tus almost immediately was a red flag
that something was seriously wrong. We
eventually discovered that what we wit-
48 OCTOBER 2019 | EMSWORLD.com
nessed were “cardiac seizures,” occur-
ring briefly when his heart would go into
a dysrhythmia, suddenly depriving the
brain of oxygen, then resolve on its own
before we could notice it on the monitor.
I remember dropping him off at the
hospital, alive and in stable condition,
only to get a phone call later that day
from a fellow medic who advised us he’d
crashed and was now being worked up.
We immediately drove back to the ER
to find he was now in the resuscitation
room, intubated and unconscious with a
team running around frantically to sta-
bilize him for transport to a pediatric
specialty center.
It was still daylight when we arrived
back at the hospital, and it was dark by
the time I snuck out to the ambulance
bay, unable to watch any longer, and
broke down in tears. I felt so stupid for
crying. The narrative in my head that
repeated was: Why am I upset over this?
I should know how to handle these types
of calls. I’ve done this before. It isn’t my
kid dying; I I have no right to feel this way.
I remember feeling confused about my
reaction and wanting to shrink up and
disappear so nobody else would see me
like that.
Looking back, this might have been the
moment I began to condition myself into
suppressing the emotions evoked from
experiences like this at work. My MO
became avoiding the family at all costs,
even if it meant depriving them of the
closure only we could offer. I know better
now but was completely unaware for the
better part of my career.
I might have forgotten his name, but it
was nearly impossible to ignore the look
on his mother’s face as she watched her
son’s health decline right before her eyes.
The team worked hard to keep him alive.
The scene stored most vividly in my mind
was seeing the exhausted look of defeat
on the attending physician as she col-
lapsed into a gray chair just outside his
room, tears streaming down her face,
arms crossed over her distended belly.
She was nearly full term with her first
child, and this was her last shift before
going out on maternity leave.
I can’t remember his name anymore,
but I remember that he was only 4 years
old and died on Easter Sunday.
 We are supposed to
be the ones who can
handle the blood, guts,
and death.
Grief: The Healing Process
Several years later I now understand that my response to that call
was quite normal and even predominant in our field, but ironically it’s
something we rarely talk about. To better understand the dynamics
of this experience, we have to start by deconstructing a process we
all go through but sometimes fail to recognize: grief.
Grief is considered a natural response to loss. However, it is
essential to clarify that grief is the healing process, not the injury.
The significant loss (which can range from termination from a job
to death) is the injury, and grief is the process that must take place
for that wound to heal. Many are familiar with the typical grieving
process in which the bereaved make their way through the five
stages of denial, anger, bargaining, depression, and acceptance.
However, these do not occur in any specific order, and we may
experience more than one of these stages at a time over a period
that lasts six months on average.
Complicated grief is when we get stuck in those stages and
are unable to adapt to life following our loss. This type of grief
is especially common with survivors of suicide, homicide, and
unexpected/freak accidents. Part of the grieving process is being
able to find closure in the circumstances that led to the death. In
the case of suicide, the one we mourn is also the one responsible
for the loss. When a homicide occurs it can be months or years
before the perpetrator is caught, if ever. When a freak accident
leads to an unexpected death, we often turn our anger toward
spiritual deities, angry our god would allow this to happen. Many
times the conflict lies with an inability to identify and direct our
blame (i.e., pain). It is not uncommon for complicated grief to be
associated with guilt and for the bereaved to eventually turn that
emotion inward and ultimately blame themselves for the death.
Disenfranchised grief, although considered a type, is closely
related to complicated grief in that one often precedes or follows
the other. This type of grief is the inability to grieve publicly or
acknowledge the loss socially. It is common with women who
suffer the loss of an unborn child or those involved in a relation-
ship that ends in death but must be kept secret (e.g., extramarital
affairs, same-sex relationships in some cases). It is often tied
to suicides and overdoses due to their stigma. Ultimately the
bereaved is either not recognized or unable to open up to others
about the circumstances of their loss. Most of these examples
have two things in common: shame and a lack of communal support.
Community plays a significant role in how we heal. It’s instinc-
tual for us to reach out to others for support when we are in
crisis. Many understand the hormone oxytocin to be the “hug
drug” or “cuddle hormone” because it most notably spikes when
bonding between two individuals occurs, especially just after
birth. However, many would be surprised to learn that oxytocin,
while accurately considered a feel-good hormone, is also a stress

EMSWORLD.com | OCTOBER 2019 49

MENTAL HEALTH IN EMS
hormone. Just like cortisol, oxytocin increases when we are
in crisis. The purpose of this is to encourage us to reach out
to others when we go through something traumatic because
we are not intended to go through these experiences alone.
It is in our biology, and it’s instinct, so you can imagine how
conflicting this might feel when we isolate ourselves through
the grieving process.
The Weight of Expectation
Now, here’s why all the above is important: Disenfranchised and
complicated grief has been linked to mental stressors, occupational
burnout, and compassion fatigue in physicians, nurses, and, yes,
even first responders. Why? Because the persona and uniform
we wear carry the weight of expectation. We are supposed to be
more capable than the average person and expected to remain
unscathed by the chaotic environments of 9-1-1 calls. We are sup-
posed to be the ones who can handle the blood, guts, and death.
We are the ones who can transport a traumatic cardiac arrest
to the hospital, spend an hour deconning the back of a bloody
ambulance, and still have enough of an appetite to ask, “What’s
for dinner?” So you can understand how unnatural it feels on those
occasions when our emotions escape the containers in which we’ve
strategically placed them and suddenly we, too, are grieving the
death of someone we don’t even know.
One discernable link that seems to increase the likelihood
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of a call getting to you is when we can identify with the patient
and/or family in some way. The most straightforward example is
kids. I’ve asked a classroom full of first responders and nurses,
“What changed for you when responding to and treating chil-
dren after you became a parent?” The answer is always the
same: “Everything!”
Everything changes because there’s an instinct within us
all that remains dormant until we become parents. Suddenly
that toddler in cardiac arrest approaching his second birth-
day is your little guy at home, and you can’t help but imagine
what it would be like for a freak accident like this to impact
your family, your spouse, and their siblings. You put yourself
in the mom’s or dad’s shoes, and you can’t seem to stop the
thought process that unfolds. Now you’re the one holding back
tears because you can’t help but empathize with the emotional
response of his parents.
Coping Mechanisms
But why does the same call manage to affect us all differently?
Imagine responding with your crew to that scene where the toddler
in cardiac arrest was worked up and ultimately pronounced in the
ER—and afterward you feel like you’re the only one who’s feeling
a strong emotional reaction, whereas everyone else appears to
have compensated without any issues.
This is an all-too-familiar scenario, and it’s difficult to pin-
point precisely why. We all have different backgrounds, risk
factors, levels of resilience, and adverse experiences in our lives
that subconsciously accompany us on every 9-1-1 call. What
significantly impacts one person will roll off the back of their
partner. This is because it’s the call plus everything else: That
tough call plus a nasty divorce, a career-compromising injury,
a parent’s declining health, a bankruptcy or substance abuse.
Often it’s the call that is simply the trigger to the underlying
risk factors we carry with us on any given day.
How do we respond to those daily adversities we all experi-
JSA-365 ence on top of the anticipated stressors of the job? We compen-
sate by coping. Coping is a natural way that all people respond
to stressful events, and most of us don’t realize we’re doing
it, much less the difference between healthy and unhealthy
mechanisms. The most natural and subconscious way first
responders cope is by compartmentalizing. Simply put, com-
72" L x 16" W
partmentalizing is how we manage to go on a scavenger hunt
for missing body parts without triggering our gag reflex, or
Bright Yellow how we function on that cardiac arrest in the living room on
Christmas morning. It’s how we manage to help stabilize mul-
tiple shooting victims while the gunman is still unidentified: We
shift our focus to the task in front of us and repress any natural
emotions that might divert us from completing it.
Researchers have found first responders are exceptionally
good at this. That’s great—until those containers into which
we separated and organized these emotional responses ulti-
mately spill over. The reason is simply that we all potentially
compensate until we can’t. The tricky part is not being able
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 MENTAL HEALTH IN EMS
We all potentially compensate until we can't.
The tricky part is not being able to predict or
recognize when that happens for each person.
to predict and recognize when that happens for each person
because it is all relative to his or her own life experiences and
compensatory abilities.
Other ways we cope include using substances like alcohol
to numb the feelings these stressors evoke. I’m not going to
tell you not to drink—you know the effects already, and I’d be
lying if I said I’d never made the same choice. Mind-numbing
substances are, in fact, effective at helping us circumvent the
painful emotions we experience. But what I wish I understood
earlier in my life is that when we numb out the sadness, we
inadvertently numb out the joy. When we numb out the grief,
we numb out the hope. When we numb out the depression,
we numb out our ability to feel happy. We can’t select what
we repress, and the negative emotions are just as normal and
a part of life as are the positive ones. So while I won’t tell you
it’s a bad idea to call a friend and ask them to meet you for
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52 OCTOBER 2019 | EMSWORLD.com
a beer after your latest rough call, I will at least ask that you
be mindful of all the positive things our vices block us from
experiencing when we overdo them.
Closing the Loop
Positive coping mechanisms include working out and finding ways
to discharge the stress that gets built up over time. The simplest
but sometimes most challenging is opening up to someone you
trust to hear your story. This is the fundamental purpose of peer
support programs within organizations: to simply give one another
a safe and familiar place to be heard and understood. This is also
why it is important to have strong support systems off duty.
An often-overlooked but effective way to cope is by seeking
out closure and requesting a follow-up on a patient’s hospital
outcome. After my department experienced a rash of pediatric
drownings, two colleagues and I developed a process called
an “integrated conclusion of care” to provide a timeline of
calls in their entirety. This includes objective notes from the
dispatcher’s engagement with the reporting party, the events
that occurred on scene, and detailed information as to what
occurred after the patient was transported to the hospital.
This report is sent to every person who responded, as well as
the dispatcher who took the call. Nothing about it is clinical,
punitive, or developed for any purpose other than the mental
well-being of the providers. While this is a new idea for us, it
has already been welcomed with positive reviews from our
field personnel, and we encourage other agencies to adopt it.
Conclusion
To say our mental health in EMS is in crisis would be a significant
understatement. We now belong to a profession where more of us
die by our own hands than by the hazards of the job. While I believe
the way we grieve is a contributing factor, it is just one piece of what
sometimes feels like an endless puzzle we’re still trying to decipher.
What I do know is that it is beneficial to understand how the
survivors of the patients we cannot save respond with grief,
because it allows us to be better patient advocates when there’s
nothing more that can be done for the patient. As a result it
helps us recognize this response in ourselves when it’s our turn
to do the healing. Because at the end of our shift, there is still
an ordinary person under the uniform, and we are not hardwired
to go through these hard times alone.
ABOUT THE AUTHOR
Alexandra Jabr holds a master’s in mental health, specializing in death, grief, and
bereavement. She works for Riverside County (Calif.) Fire Department as a paramedic/EMS
specialist and is an adjunct faculty member at the Victor Valley College Paramedic Academy.
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EMSWORLD.com | OCTOBER 2019 53
CHILD ABUSE
PEDIATRICS

AWARENESS
FOR THE EMS
PROVIDER
Know what distinguishes innocent injuries from
suspicious ones
By Roger Smith, NRP; Ryan Brown, MD; and Curtis L. Knoles, MD, FAAP

W
e’ve all had that call that makes the hair on our necks
stand up or gives us that twinge in our gut that tells us
the “facts” parents or caregivers are giving us do not
add up. People are not supposed to hurt children, but
they do, and all too often they are the parents, family members,
and caregivers upon whom those children depend so profoundly
to protect them. Beyond the physical damage, the long-term psy-
chological abuse that accompanies child abuse can create invis-
ible wounds that last decades after the bruises and bones heal.
What is the role of the EMS provider in child abuse cases?
Prehospital providers are the first to see the scenes, smell the
smells, and hear the stories. In regards to child abuse, EMS
providers may be the first investigators of potential crimes. It
is imperative to have at least a basic understanding of child
abuse statistics, signs, symptoms, and reporting.

Barriers and Blind Spots

Rarely will EMS be dispatched on a call where child abuse is the
complaint. We’re not likely to hear, “My boyfriend just shook my
baby until he had a seizure!” More likely EMS will be dispatched to
#SurviveStroke a “new-onset seizure” or “accidental fall.” When arriving at a call
like this, It is imperative to have a high level of suspicion.

Stroke Scales Why is it essential for emergency medical service personnel

to know, understand, and recognize abuse? The overwhelm-

FOR EMS
When lives are on the line, you need to
make decisions quickly. Stroke Scales for
EMS is a free app that helps first responders
assess stroke severity so you can triage
and transport patients quickly to facilities
that can save their lives.
Available for download on the iOS
App Store and Google Play.
ing majority of pediatric patients transported to emergency
departments are taken to a general or adult ED as opposed
to a pediatric ED associated with a dedicated pediatric hos-
pital.1 Even when a child presents to a pediatric emergency
department, there can be variability in pediatric training and
experience among its physicians and nurses. 2
Barriers to recognizing child abuse can come from the
discomfort of not being used to treating pediatric patients,
being unprepared to distinguish between accidental and inten-
tional injuries, and believing parental stories of how an injury
occurred. 3 It is in our nature to want to believe parents are tell-
ing us the truth about the accident. They may be upstanding
members of our community. But we don’t know what happens
behind closed doors or what stressors may shape their world.
Abusers don’t always fit a stereotype.

54 OCTOBER 2019 | EMSWORLD.com

Incidence and Types developed by Mary Clyde Pierce, MD, and Unfortunately, the worst victims of
What is abuse, and how often does it occur? colleagues to help distinguish injuries that abuse tend to be the youngest. Infants
Every year in the United States, child pro- suggested a greater chance of abuse. The less than 12 months of age have a vic-
tection services receive nearly 3.5 million T stands for torso, E for ears, N for neck. timization rate of 24.2 per 1,000 chil-
referrals of suspected child maltreatment. The 4 is for four months of age or younger. dren—more than double that of any
These referrals encompass about seven When any bruising is noted on the torso, other age group. Of child deaths, nearly
million children. After investigation, almost ears, or neck of a child four months of three-quarters are under three. In 2015
three-quarters of a million cases of child age or younger, be concerned for abuse. 8 about 1,670 pediatric deaths were abuse-
abuse are substantiated.4
Child abuse is defined by the Child
Abuse Prevention and Treatment Act as
“Any recent act or failure to act on the
part of a parent or caretaker which results
in death, serious physical or emotional
harm, sexual abuse, or exploitation; or an
act or failure to act which presents an
imminent risk of serious harm.” 5
Victims can suffer from different types
of abuse. Child neglect is the most com-
mon form, accounting for about 75% of
reported cases. Neglect is followed by
physical abuse (17.2%), sexual abuse
(8.4%), psychological maltreatment
(6.2%), and medical neglect (2.2%).4
To discuss all the forms of abuse ade-
quately would require a textbook. There-
fore, we’ll limit our focus to physical abuse
and sudden unexplained infant deaths.
Physical abuse often has the most
common visual sign of abuse: bruising.
But while bruising is a common mani-
festation of physical abuse, it is also the
most common physical manifestation of
childhood itself. The key to knowing the
difference is in the history, location, and
age of the victim.
Common sites of bruises from acciden-
tal trauma are on bony prominences. Abu-
sive injuries can occur in the same areas,
but also in areas where the body has more
natural cushion, like the backs of the legs,
the cheeks, and the buttocks.6
Another factor in bruising is the victim.
Age plays a significant role in the deter-
mination of abuse. Bruising rarely occurs
in nonmobile infants. In one study only
two (0.6%) of 366 children less than six
months were noted to have any bruises.
Only eight (1.7%) of 473 children less than
nine months were noted to have any.
A great resource in the evaluation of
child abuse is the TEN-4 rule. This was

EMSWORLD.com | OCTOBER 2019 55

PEDIATRICS

sudden and unexplained death

of an infant under one year of
age, occurring during sleep and
unexplained after a thorough
investigation that includes a
complete autopsy and review
of the circumstances of death.
Therefore, a child older than 12
months who is found down is not
a SIDS case.
SIDS is suspected when a pre-
viously healthy infant, usually
younger than six months, appar-
Injuries tend to bruise bony prominences. —Source: Maguire S, Mann M. Systematic Reviews of Bruising in Relation to Child Abuse—
What Have We Learnt? An Overview of Review Updates. Evid Based Child Health, 2013 Mar 7; 8(2): 255–63 ently dies during sleep, prompting
an urgent call for assistance. Often
related—about 4.6 children a day.4 Again, the most common the infant fed normally just before being placed in bed, and
form of abuse is neglect. no outcry is ever heard. The parents then find the infant in the
position in which they left them.
SIDS and SUID Telecommunicators will instruct the parents in basic CPR
The most common age group affected by child abuse deaths is less until EMS arrives. EMS will continue CPR without apparent ben-
than 12 months. However, this group shares a common denomina- efit en route to the hospital, where the infant is finally declared
tor with another group of an inflicted child with a life-threatening dead. Evidence of terminal motor activity, such as clenched
condition: SIDS. fists, may be seen. There may be serosanguineous, watery,
SIDS, or sudden infant death syndrome, is defined as the blood-tinged, frothy, or mucoid discharge from the nose or
mouth. Skin mottling and postmortem lividity in dependent
portions of the infant’s body are commonly found.
After review of the medical history, scene investigation, radio-
graphs, and autopsy, the “triple risk” hypothesis emerges: 1) a
®
The Infinium ClearVue vulnerable infant; 2) a critical developmental period in homeo-

Video Laryngoscope static control; and 3) an exogenous stressor(s). An infant will

die of SIDS only if he/she possesses all three factors. This
hypothesis proposes that SIDS, or a subset of SIDS, is due to
a developmental abnormality that results in a failure of pro-
tective responses to life-threatening stressors (e.g., asphyxia,
3.5 inch screen hypoxia, and hypercapnia) during sleep as the infant passes
2.0 Megapixel camera through a critical period in homeostatic control.
Rigid steel construction Recently medical examiners and forensic pathologists have
Blade sizes 1,2,3,4 and 5 been separating cases of death in infants less than 12 months

Low cost blades of age. Sudden unexplained infant death (SUID) is the more
commonly used verbiage in infants where foul play may not be
1 year Warranty
obvious. After an in-depth investigation by law enforcement
and autopsy, the medical examiner may find the child died as a
result of an unsafe sleeping environment—for instance, sleep-
ing with a parent, sleeping on a couch or chair, or sleeping in a
bouncy or car seat. This is often the finding if a child dies of a
SIDS-type condition but is not found in their crib or bassinet.

Reporting to CPS
The final step in a child abuse case is reporting to child protective
services. Every state in the United States has laws defining man-
dated reporters, and emergency medical service personnel are
Visit: www.infiniummedical.com
mandatory reporters in all states. Many EMS personnel have good
E-mail: sales@infiniummedical.com
Call: 727-455-8160

56 OCTOBER 2019 | EMSWORLD.com


relationships with the medical staff at the
facilities to which they transport patients.
If the medical staff makes a referral to CPS,
then EMS will not have to, although it is
always a best practice.
Reluctance by the hospital team should
not deter reporting by the EMS team if
the groups are not in agreement. Medi-
cal staff from nonpediatric facilities may
be hesitant to report either because they
are uncomfortable or unsure if a case is
abuse or neglect. It is always best to advo-
cate for the safety and well-being of a
child who may be unable or too fearful to
advocate for themselves. If the EMS staff
feels child maltreatment has occurred,
they should report to CPS regardless of
the opinion of the hospital staff.
Conclusion
Child abuse cases may be easy to assess
and diagnose, or they may slip through the
cracks. However, the more we educate
ourselves on abuse and neglect, the more
empowered we will become to advocate
for these victims. Dealing with children who
have suffered abuse or neglect strengthens
our ability to advocate for them.3 We should
focus on training and education that pro-
vides us with a stronger ability to detect and
report in real time cases of potential child
abuse and neglect.
The U.S. Department of Health and
Human Services lists state child abuse
repor ting numbers and of fers other
resources at w w w.childwelfare.gov/
organizations.
REFERENCES
1. McDermott KW, Stocks C, Freeman WJ. Overview of Pediatric
Emergency Department Visits, 2015. Healthcare Cost & Utilization
Project, Statistical Brief #242.
2. Maldonado T, Avner JR. Triage of the Pediatric Patient in the
Emergency Department. Pediatrics, 2004 Aug; 114(2): 356–60.
3. Tiyyagura GK, Gawel M, Alphonso A, Koziel J, Bilodeau K, Bechtel K.
Barriers and facilitators to recognition and reporting of child abuse by
prehospital providers. Prehosp Emerg Care, 2017; 21(1): 46–53.
4. Department of Health and Human Services. Child Maltreatment
2015, www.acf.hhs.gov/sites/default/files/cb/cm2015.pdf.
5. Child Welfare Information Gateway. Definitions of Child Abuse and
Neglect, www.childwelfare.gov/pubPDFs/define.pdf.
6. Carpenter RF. The prevalence and distribution of bruising in babies.
Arch Dis Child, 1999 Apr; 80(4): 363–6.
7. Sugar NF, Taylor JA, Feldman KW; Puget Sound Pediatric Research
Network. Bruises in infants and toddlers: those who don’t cruise rarely
bruise. Arch Pediatr Adolesc Med, 1999 Apr; 153(4): 399–403.
8. Pierce MC, Kaczor K, Aldridge S, O’Flynn J, Lorenz DJ. Bruising
characteristics discriminating physical child abuse from accidental
trauma. Pediatrics, 2010 Jan; 125(1): 67–74.
ABOUT THE AUTHORS
Roger Smith, NRP, is pediatric EMS coordinator at
Children’s Hospital in Oklahoma Cit y and adjunct faculty
for the OSU-OKC paramedicine program.
Ryan Brown, MD, is a clinical associate professor in the
Deparment of Pediatrics at the University of Oklahoma
College of Medicine and an attending physician in the ED
at the Children's Hospital at OU Medical Center.
Curtis L. Knoles, MD, FAAP, is a clinical associate
professor in the Deparment of Pediatrics at the University
of Oklahoma College of Medicine and assistant medical
director for the Medical Control Board that oversees the EMS systems
in Oklahoma City and Tulsa.
EMSWORLD.com | OCTOBER 2019 57
OCTOBER 14–18, 2019
NEW ORLEANS, LA

EMS World Expo is taking you places.

From reviving a patient in cardiac arrest, to treating an entrapped patient in a
motor vehicle crash, to helping a patient manage their chronic disease, EMS
World Expo will take you every step of the way throughout your EMS career.

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 SPOTLIGHT:

2019
MEET THE FINALISTS
EMS World’s Innovation Awards showcase the
most noteworthy advances in EMS products
and technologies this year
EMS World is proud to present the finalists for the 2019 EMS World Innovation Awards. The
Innovation Awards program recognizes the industry’s most pioneering products of the year that
have the potential to transform EMS care.
An independent panel of judges consisting of EMS World editorial advisory board members evaluated each entry on its
innovation, features, and applicability to EMS care. Products must be new or have undergone significant design changes since
August 2018.
From this pool of 30 finalists, judges will meet one-on-one with company representatives at EMS World Expo to demo each
product, learn about its application, and determine whether it is worthy of this esteemed honor. The 20 top-scoring products will
be named 2019 Innovation Award winners and profiled in the December 2019 issue of EMS World.
If you’re attending EMS World Expo in New Orleans Oct. 14–18, visit the following exhibitors to see how their products,
technologies, and services will transform the delivery of prehospital care.
Here are the finalists for 2019, listed in alphabetical order. EMS World congratulates the finalists for this accomplishment.

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60 OCTOBER 2019 | EMSWORLD.com


American Red Cross
First Aid for Opioid Overdoses
BOOTH 568
Straightforward 45-minute online session
informs the public how to identify signs of
a suspected overdose as well as appropri-
ate care based on patient presentations.
www.emsworld.com/node/1223161
American Red Cross
Resuscitation Suite Program
BOOTH 568
Blended BLS, ALS, and PALS course deliv-
ers flexibility on any device and challenges
critical decision-making with the latest
science in a shorter overall course time.
www.emsworld.com/node/1223162
Armor Express
Triton Steel Plate With Spall Guard
Technology
BOOTH 1152
Multi-shot rated, polyurea-coated, 2018
DEA-certified plate is certified to level III
with a III+ rating and fits into the rifle plate
pocket of your plate carrier or body armor
carrier.
www.emsworld.com/node/1223163
Biomedix
Pressure Extension Set
BOOTH 537
Neutral, needleless pressure extension
set measures 8 inches, tolerates high
pressures, and features neutral needle-
less connector, slide clamp, and Luer lock.
www.emsworld.com/node/1223164
CAE Healthcare
AresAR for Microsoft HoloLens
BOOTH 1720
Integrates augmented-reality scenarios to
establish the crucial link between inter-
ventions and vital signs using holographic
signs and physiology.
www.emsworld.com/node/1223165
OCTOBER 14-18, 2019
NEW ORLEANS, LA
Cambridge Sensors USA
Microdot Carbon Monoxide Breath
Analyzer
BOOTH 952
A simple breath test establishes carbon
monoxide levels in a subject’s blood. Can
be used on multiple patients with minimal
effort.
www.emsworld.com/node/1223166
Canada Rope and Twine Ltd.
Night Saver Rescue Rope
BOOTH 469
Features include an illuminating cover with
bright reflective filaments and an optional
polypropylene core for buoyancy during
water rescues.
www.emsworld.com/node/1223185
CompX Security Products
NARC iD Inventory Control System
BOOTH 529
Automatic enrolling and inventory control
of narcotics in a mobile or fixed environ-
ment. Audit trail shows door openings and
closings, who accessed it, expiration dates,
and much more.
www.emsworld.com/node/1223167
EM Innovations Inc.
SEADUC—Suction Easy with SSCOR
DuCanto Catheter
BOOTH 639
Pairs the Suction Easy disposable emer-
gency suction unit with the SSCOR DuCan-
to catheter to enable the SALAD airway
clearing technique without batteries or
electricity.
www.emsworld.com/node/1223168
Ferno
KangooFix Neonatal Restraint System
BOOTH 561
Safely envelops a newborn during noncriti-
cal ambulance transport, allowing parents
to travel with infants up to 11.1 pounds.
www.emsworld.com/node/1223169
EMSWORLD.com | OCTOBER 2019 61
 SPOTLIGHT:
Fire Armor LLC
First Responder Ballistic Vest
BOOTH 1639
One-size-fits-all system is worn over the
uniform and provides maximum protec-
tion in front, back, and side coverage, uti-
lizing III-A soft armor with optional added
rifle plates.
www.emsworld.com/node/1223187
GD
E-Bridge Interpreter
BOOTH 552
Fast, HIPAA-secure, FirstNet-listed video
connection to accredited interpreters elimi-
nates the language barrier between provid-
ers and patients.
www.emsworld.com/node/1223170
GE Healthcare
Vscan Extend R2 with Dual Probe
BOOTH 238
Handheld point-of-care ultrasound system
fits easily in a jump bag pocket, and built-in
protocols efficiently capture clear images
when time counts.
www.emsworld.com/node/1223188
Henry Schein
MedPod MobileDoc
BOOTH 327
Portable diagnostic cart folds into a 21-inch
suitcase and meets all requirements for
CMS parity and Medicare ET3 needs.
www.emsworld.com/node/1223171
I.M. Lab
CPR Add-on Kit
BOOTH 641
An efficient and immersive CPR training
experience with real-time CPR feedback is
controlled via an app and can be retroffited
to multiple brands of manikins.
www.emsworld.com/node/1223174
62 OCTOBER 2019 | EMSWORLD.com
IMMI
Per4Max
BOOTH 1436
Game-changing four-point restraint system
allows crew members to reach, stretch, and
even stand up if necessary. Includes exclu-
sive controlled deceleration technology.
www.emsworld.com/node/1223175
iSimulate
REALITi 360 CPR
BOOTH 909
CPR module provides detailed, real-time
visual feedback on CPR quality. Reports
can be generated, saved, printed, or
e-mailed.
www.emsworld.com/node/1223176
Life Giving Warmth
Kodiak Battery-Powered Heating
Blanket
BOOTH 761
Patented 5-by-6-foot portable battery-
operated heating blanket delivers 6 hours
of steady, continual heat.
www.emsworld.com/node/1223186
LogRx
Medication Tracking & Inventory
Management
BOOTH 446
Real-time medication tracking via smart-
phone or tablet, leveraging secure capabili-
ties such as geolocating, user verifications,
time stamping, and detailed analytics.
www.emsworld.com/node/1223177
Mobile Power
Power Management Interface
PMI Option
BOOTH 1751
Adding the PMI to Mobile Power’s idle-
reducing technology automatically man-
ages your vehicle’s 120V load by using
engine power to recharge its batteries
while driving.
www.emsworld.com/node/1223189

North American Rescue
Quantum Blood & Fluid Warming
System
BOOTH 619
Whole-blood delivery system consists of
thermal administration sets, adjustable
power, and sensing elements to ensure
consistent normothermic fluid delivery.
www.emsworld.com/node/1223178
PerSys Medical
Flexible Tip Bougie
BOOTH 752
Universal, disposable, articulating bou-
gie for use with adult oral endotracheal
tube features one-handed operation with
maneuverable tip.
www.emsworld.com/node/1223179
Philips
Lumify with Integrated Tele-
Ultrasound
BOOTH 1601
Durable app-based mobile ultrasound
takes communications and high-quality
portable ultrasound to a new level with
live streaming and video call capabilities.
www.emsworld.com/node/1223180
Prodigy EMS
Prodigy EMS Learning Management
System
BOOTH 1452
Advanced tracking makes recertification
easier, and engaging content with multi-
camera video format supplements simu-
lations and case discussions for a true CE
experience.
www.emsworld.com/node/1223190
Pulsara
EMS-to-EMS Handoff
BOOTH 1434
Popular mobile technology platform now
extends to other critical team members,
allowing exchange of images, audio, stroke
scores, scene information, and more.
www.emsworld.com/node/1223181
OCTOBER 14-18, 2019
NEW ORLEANS, LA
REX Rapid Extraction
RexOne
BOOTH 465
Reengineered mobile stretcher features
updated ergonomic positioning, 20-inch
all-terrain airless wheels, solid steel tele-
scoping handle, multi-angle IV pole, inte-
grated descent control system, and more.
www.emsworld.com/node/1223191
SafeBVM
SIP Safety Accessory
BOOTH 250
The SIP Safety Accessory prevents gastric
insufflation during manual ventilation by
ensuring optimal pressure and air flow.
www.emsworld.com/node/1223182
Simulator Solutions LLC
Rollover Simulator
BOOTH 1561
Durable welded steel construction with
gear box and brake design allows realistic
and practical experience in vehicle rescue
scenarios.
www.emsworld.com/node/1223183
Technimount System
Cardiatek
BOOTH 721
Universal high-density aluminum mounting
system complies with highest safety stan-
dards and mounts to the Automatic Impella
Controller from Abiomed on surface, floor,
cot/stretcher, and wall systems.
www.emsworld.com/node/1223184
ZeroRPM
Ambulance Idle Mitigation System
BOOTH 1301
Produced in partnership with the REV
Ambulance Group, the IMS automatically
shuts down the vehicle’s engine while in
park, yet provides continual use of all con-
trols via auto-charged batteries.
www.emsworld.com/node/1223192
EMSWORLD.com | OCTOBER 2019 63
SPOTLIGHT:
PCRF RESEARCH ABSTRACTS
Again this year EMS World presents new information
from the Prehospital Care Research Forum
at the UCLA Center for Prehospital Care
E
stablished in 1992, the Prehospital Care
Research Forum (PCRF) is dedicated to
the promotion, creation, and dissemina-
tion of prehospital research. In this, our
third year of partnership with EMS World, we
are proud to feature selected abstracts from the International
Scientific Symposium, to be held during EMS World Expo, Oct.
14–18 in New Orleans, as well as proceedings from the 24th
annual National Association of EMS Educators Symposium,
which occurred in August.
The PCRF is proud to highlight the work of EMS providers
who advance the profession with science. We believe it is the
responsibility of emergency medical professionals world-
wide to practice evidence-based medicine and develop a
body of evidence that examines prehospital emergency care.
Each year we make research more accessible and under-
standable through the publication of these abstracts. We
hope you will join us in creating a culture of science in EMS
by participating in our symposia, workshops, and monthly
journal clubs.
On the second Monday of every month at 1 p.m. Eastern,
podcasts focus on the content of Dr. Tony Fernandez’s “PCRF
Journal Club” (Journal Watch) column in EMS World Maga-
zine. On the fourth Friday of every month, we host a joint
podcast with the National Association of EMS Educators
during which Dr. Megan Corry focuses on the “PCRF Research
PCRF SALUTES OUR SUPPORTING ORGANIZATIONS:
64 OCTOBER 2019 | EMSWORLD.com
Alert” articles she authors for EMSWorld.com. Register for
all podcasts at www.prehospitalcare.org.
We would like to thank our volunteer board of advisors and
33 associates. Without the dedication of these volunteers,
none of this would be possible. In addition to the hard work
of many people, much of our success can be attributed to
the commitment of organizations dedicated to research in
prehospital care. I would like to acknowledge our strategic
partner, EMS World; education partner, the National Associa-
tion of EMS Educators; founder, iSimulate; benefactor, ESO
Solutions; partners, FirstWatch, Limmer Creative, and Jones
& Bartlett Learning; and friends, Fisdap and Weber State
University. The generous support of these fine organizations
and our affiliation with the National Association of EMTs and
the International Academies of Emergency Dispatch are what
enable the PCRF to fulfill our mission.
The future of EMS depends on the quality and quantity of
research we produce. We invite you to take a stand, conduct
research in your community, and submit it in 2020 for the
greater benefit of EMS. Our PCRF mentors are standing by
to assist you.
Sincerely,
David Page, MS, NRP
Director, Prehospital Care Research Forum at UCLA

CLINICAL ABSTRACTS
Disparate Treatment of the Pediatric Diabetic
Patient in the Prehospital Setting
Author: Ginny K. Renkiewicz, PhD(c), MHS, Paramedic
Associate Authors: Lee VanVleet, MHS, NRP; Bradley Baggett, BS, NRP,
FP-C; April Elmore, NRP; Michael Ross, BS, NRP, CCEMT-P; Melisa Martin,
EdD(c), Paramedic
Introduction: Current research indicates the adult population dem-
onstrates higher tendencies in poor glycemic control based on race,
ethnicity, and socioeconomic status. Assuming a similar tendency in
the pediatric population, it is important to identify any disparities in
prehospital treatment.
Objective: To identify disparities in the prehospital treatment of
pediatric diabetic emergencies.
Methods: A retrospective observational study of pediatric diabetic
emergencies was conducted using national ESO reporting data from
January 1, 2017–December 31, 2017. The database contains prehos-
pital patient care records for over five million EMS responses from
more than 900 agencies across the United States and encompasses
a broad range of practice settings from urban to rural. Inclusionary
criteria consisted of patients whose lowest blood glucose level (BGL)
was less than 70 mg/dL, had a total Glasgow Coma Score of 14 or
less, and had a primary impression that suggested a potential BGL
abnormality. A multivariate logistic regression was used to calculate
the odds ratio for hypoglycemic treatment (D10, D25, D50, Glucagon,
and/or oral glucose) while controlling for age, weight, gender, minor-
ity status, and primary impression.
Results: A total of 251 patients met our inclusionary criteria,
of whom 58.2% were Caucasian and 51.8% were male. A total of
36.7% patients received an included treatment modality, and 63.3%
patients were not treated. A primary impression of altered level of
consciousness was statistically significant (OR 8.05, p=0.029)
regarding the treatment of prehospital pediatric hypoglycemia.
Age, weight, gender, and minority status revealed no statistically
significant influence on treatment.
Conclusions: The study identified no discernable disparity in the
treatment of prehospital pediatric diabetic patients filtered by age
in years, weight, gender, or minority status. Further study is indicated
to identify the rationale for whether a patient is treated when altered
mental status is identified as a primary impression.
Pediatric Cardiac Arrest Resuscitation by EMS
(CARE)
Author: Ginny K. Renkiewicz, PhD(c), MHS, Paramedic
Associate Authors: Bradley Dean, MA, NRP; Sara Houston, MHS, NRP;
Stephen Taylor, MHS, Paramedic; Steven Howell, BS, NRP; Cody Corne-
lius, Paramedic
Introduction: Epidemiology of pediatric out-of-hospital cardiac
arrest (pOHCA) and return of spontaneous circulation (ROSC) rates
OCTOBER 14-18, 2019
NEW ORLEANS, LA
varies greatly. A paucity of literature exists concerning pOHCA and
the factors that affect field ROSC and thus potential survivability.
Objective: To examine factors influencing the likelihood of achiev-
ing field ROSC in pOHCA.
Methods: We conducted a retrospective analysis of field ROSC
using electronic patient care records from the 2017 ESO research
database. The database contains prehospital patient care records
for over five million EMS responses from more than 900 agencies
across the United States and encompasses a broad range of practice
settings from urban to rural. Inclusion criteria consisted of pOHCA
patients aged 18 years or less for whom resuscitation was attempted.
Patients with traumatic or “other” OHCA etiologies were excluded.
Data were analyzed using univariate tests and logistic regression
with p≤0.05 indicating significance. Patients were stratified by age
(newborn: 0–1 year and child: 2–18 years) for analysis.
Results: A total of 656 pOHCA patients met inclusion criteria. The
mean (+SD) age was 4.8 (+6.5) years, of which most were 1 year of
age or less (59.5%); 55.9% were Caucasian, 59.5% were male, and
24.7% attained ROSC. Compared to unwitnessed arrests, patients
were more likely to achieve ROSC when arrests were witnessed
by a healthcare provider (OR 6.53, p=0.003), bystander (OR 2.94,
p=0.001), or family member (OR 2.77, p=0.016). Field ROSC was also
associated with Caucasian race (OR 2.39, p=0.004), use of CPR feed-
back device (OR 2.21, p=0.007), and quicker epinephrine administra-
tion (OR 0.98, p=0.042 per minute from 9-1-1 call received time to
first epinephrine administration). The child age group (2–18 years)
also exhibited improved odds of ROSC (OR 2.11, p=0.008). Factors
that did not influence the likelihood of ROSC included gender, shock-
able presenting rhythm, and layperson CPR.
Conclusions: In this retrospective analysis of pOHCA, witnessed
arrests and those receiving CPR feedback-guided resuscitations were
more likely to achieve ROSC. Caucasian pOHCA and early epinephrine
administration also increased the likelihood of ROSC. Additional pro-
spective investigation is needed to elucidate determinants of ROSC
in pOHCA.
Impact of Delayed Epinephrine Administration
on Return of Spontaneous Circulation During
Pediatric Out-of-Hospital Cardiac Arrest
Author: Emily A. Burchette, BS, NRP
Associate Authors: Michael W. Hubble, PhD, MBA, NRP; Ginny K. Ren-
kiewicz, PhD(c), MHS, Paramedic; David Stallings, MHS, NRP; Helen
Tripp, LPCA, MA, NRP
Introduction: Epinephrine is the only vasopressor associated with
return of spontaneous circulation (ROSC). While current guidelines
recommend rapid and frequent vasopressor administration during
cardiac arrest, delays in administration in out-of-hospital cardiac
arrest (OHCA) remain a concern. Consequently, this study evalu-
EMSWORLD.com | OCTOBER 2019 65
SPOTLIGHT:
ated the effect of vasopressor administration delay on field ROSC
in pediatric OHCA.
Methods: This was a retrospective analysis of electronic patient
care records from the 2017 ESO research database. The 2017 research
database contains patient care records for over five million EMS
responses from more than 900 agencies across the United States
and encompasses a broad range of practice settings from urban to
rural. All patients aged less than 18 years who suffered a nontrau-
matic OHCA prior to EMS arrival and for whom resuscitation was
attempted were included. Data were analyzed using univariate tests
and logistic regression with p≤0.05 indicating significance.
Results: A total of 412 patients met inclusion criteria with a mean
age of 5.0 (±6.5) years. Mean EMS response time was 9.1 (±6.1) min-
utes, 28.4% were witnessed arrests, 42.5% received bystander CPR,
8.3% had shockable initial rhythms, and 22.6% experienced ROSC.
The mean and 90th-percentile call-receipt-to-pressor intervals were
31.0 and 51 minutes, respectively. Patients receiving advanced airway
control prior to epinephrine administration had longer scene-arrival-
to-pressor intervals (24.9 vs. 19.3 minutes, p<0.01). Significant adjust-
ed odds ratios for ROSC included call-receipt-to-pressor interval
(per minute; OR 0.97, p<0.01); patient age (per year; OR 1.06,p<0.01);
non-Caucasian race (OR 0.43, p=0.01); and witnessed arrests (OR
2.88, p<0.01). In addition, compared to arrests of cardiac etiology,
arrests of respiratory (OR 2.42, p=0.01) and other etiologies (OR 2.12,
p=0.04) were more likely to attain ROSC. An increased likelihood of
ROSC was associated with an initial ECG of VF/VT or shockable AED
rhythm (OR 3.06, p<0.01), PEA (OR 5.97, p<0.01), and unknown AED
nonshockable rhythm (OR 8.42, p=0.03) when compared to asystole.
Conclusion: The odds of ROSC decrease 3% per minute of call-
receipt-to-drug-administration delay. Airway control procedures
account for a substantial portion of the delay in epinephrine admin-
istration and reduce the likelihood of ROSC.
Descriptives and Effectiveness of Opioid-Based
Analgesics for Managing Pain for Wyoming EMS
Incidents: Fentanyl and Morphine
Author: Morgan Anderson, MPH
Associate Authors: Douglas Butler, Jr., Clinical Specialist; Jay Ostby,
Reporting Data Analyst
Purpose: To describe the patient characteristics for use of fentanyl
compared to morphine for pain management and identify factors
associated with effective pain management (EPM) using fentanyl
and morphine in Wyoming.
Methods: EMS treated and transported patient records were
analyzed from the state of Wyoming from January 2016 through
May 2019. All patients aged 12 years or older who had self-assessed
pain scores were included in the analyses. EPM was determined
for patients experiencing pain scores of 4 or more where their final
66 OCTOBER 2019 | EMSWORLD.com
pain score was reduced by at least 2 points. A logistic regression
(adjusted) model was performed looking at the odds of effective
pain intervention by fentanyl and morphine.
Results: From Jan 2016 to May 2019, 5,394 patients over the age
of 12 years received fentanyl (82%), 1,059 (16%) received morphine,
and 177 (2%) patients received both fentanyl and morphine inde-
pendently during EMS care. Initial pain scores were missing for 1,130
(14%) patients. Multivariate analyses found strong evidence to sug-
gest morphine had less EPM compared to fentanyl (OR 0.78, 95% CI,
0.68–0.90). There was less EPM in older age groups (50–69 years:
OR 0.69, 95% CI, 0.60–0.79; 70 years or more: OR 0.82, 95% CI,
0.72–0.93) compared 12–29-year-olds, and for those experiencing
abdominal/GI pain (OR 0.85, 95% CI, 0.73–0.99) compared to trau-
matic injuries. There was increased EPM for those where transpor-
tation time was greater (8–10 minutes: OR 1.26, 95% CI, 1.10–1.46;
11–21 minutes: OR 1.56, 95% CI, 1.35–1.78; 22 minutes or more: OR
2.03, 95% CI, 1.76–2.34) compared to 7 minutes or less and those
experiencing back pain (OR 1.30, 95% CI, 1.03–1.64) compared to
traumatic injuries.
Conclusion: Within this study only 51% of the population had EPM
during their EMS treatment and transport. Based on this study’s
results, fentanyl was a more EPM medication, and older age groups
had less EPM, specific conditions such as abdominal/gastrointes-
tinal pain/issues experienced less EPM, and longer transport times
showed a trend in increased EPM. Although not analyzed within this
study, results suggest analgesic dosage protocols may be an area
to reevaluate due to only about half the population experiencing
effective pain management.
Air Medical Pediatric Rapid Sequence Intubation
Author: David Olvera, NRP, FP-C, CMTE
Associate Author: Daniel Davis, MD
Background: Advanced airway management, including the use
of rapid sequence intubation (RSI), is a fundamental skill in resus-
citation. However, the reported experience with pediatric patients
is limited as most institutions do not accumulate a large number of
emergency RSI procedures in children.
Objective: To document the experience with pediatric RSI in a
large air medical database.
Methods: Air Methods Corporation includes more than 150 bases
throughout the United States. Air medical crews, including a flight
nurse and flight paramedic, respond to both scene calls and inter-
facility transports. The RSI procedure includes either etomidate or
ketamine for induction followed by paralysis with either succinyl-
choline or rocuronium. Video or direct laryngoscopy are available,
including smaller blades for pediatric patients. Air medical crews
document up to 150 data elements regarding the airway manage-
ment procedure in a protected performance improvement database.

All pediatric patients (age less than 18 years) were included in this
analysis; patients were divided into three subgroups based on age
(0–2 years, 3–8 years, 9–17 years). The primary variables of interest
reflected intubation success: overall successful intubation (Overall),
first attempt intubation success (FAS), and first attempt intubation
success without desaturation (FASWD).
Results: Over a three-year period, a total of 1,149 pediatric patients
were identified. Intubation success for all patients and for each sub-
group are included in the following table:
Age Group n Overall (%) FAS (%) FASWD (%)
0–2 269 96 87* 82*
3–8 263 97 92 89
9–17 617 98 93 90
ALL 1,149 97 91 88
*p<0.05 vs. 3–8 years and 9–17 years
Discussion: Overall pediatric RSI success rates were high despite
less-than-optimal intubation conditions in the air medical environ-
ment. Rates for FAS and FASWD were lower for the youngest patients;
this may represent an opportunity for education and training.
Evaluating the Current EMS Workforce in South
Carolina
Author: Arnold Alier, EdD, NRP
Associate Authors: Sean P. Kaye, BS, EMT-P; Remle P. Crowe, PhD,
NREMT; Robert A. Wronski, MBA, CPM, CEMSO, NRP; Jennifer K. Wilson,
BS, EMT-B; J. Brent Myers, MD, MPH, FACEP
Introduction: Evaluating the current EMS workforce is important
for planning routine field operations and preparing for disasters.
Objective: Describe the current EMS workforce in South Carolina
with respect to patient contacts, number of agency rosters on which
they appear, roles, and years of experience.
Methods: This cross-sectional evaluation included all certified
South Carolina EMS professionals in 2019. Data were extracted from
the South Carolina EMS data system and included number of patient
contacts (patient care reports listing the individual as a patient care
provider in the last 12 months), number of agency rosters, total years
of experience (time from initial EMS certification to current certifica-
tion expiration date), and roles (field provider, management/opera-
tions, leadership/administration, and educator). Roles were catego-
rized in collaboration with the state EMS office to accurately reflect
duties based on current jobs recorded in the South Carolina EMS
data system. Roles were not mutually exclusive. Descriptive statistics
were calculated.
Results: There were 11,197 South Carolina EMS-certified individuals
in 2019. Of those, 3,138 (27.9%) were not listed on any agency rosters.
There were 8,069 (72.1%) who appeared on at least 1 agency roster.
Number of rosters ranged from 1 to 20 with a median of 1 (interquartile
OCTOBER 14-18, 2019
NEW ORLEANS, LA
range [IQR] 1–2). There were 1,757 (21.8%) individuals who appeared
on a roster but had no patient contact within the last 12 months.
There were 7,823 field providers. Experience ranged from less than
1 to 47.1 years with a median of 5.2 (IQR 2.4–11.3). There were 545 in
management/operations. Experience ranged from less than 1 to 47
years with a median of 14.1 (IQR 6.3–24.6). There were 360 in leader-
ship/administration. Experience ranged from less than 1 to 47 with a
median of 17.0 (IQR 7.3–26.5). There were 29 educators. Experience
ranged from 3.7 to 46.8 years with a median of 16.0 (IQR 8.9–27.2).
Conclusion: Over one-quarter of EMS-certified individuals in South
Carolina did not appear on an agency roster. Over one fifth of those
on at least one roster have not had any patient contact in the last 12
months. Field providers had fewer years of experience compared to
those in leadership, management, or educator roles.
What Do We Truly Know About Situational
Awareness in Paramedicine?
Author: Justin Hunter, PhD(c), MPA, NRP, FP-C
Background: Paramedics, crews, patients, and the public may
be at risk for injury or medical error without situational awareness
(SA). Currently SA has received very little attention in the setting of
paramedicine.
Objective: Review and identify the current literature related to SA
and paramedicine
Methods: Extensive searches of electronic databases (5) were
conducted to identify papers published related to paramedicine and SA.
A narrative approach was then used to synthesize and map the literature.
Results: Utilizing the two concepts of paramedicine and SA, 1,125
papers were initially identified. After screening, 20 papers were then
included for qualitative synthesis. It was identified that there is very
little empirical understanding of paramedicine in the context of SA.
Conclusions: Industries such as commercial aviation, offshore oil
drilling, and nuclear energy have all been shown to experience few
errors and a reduction in accidents when each professional possesses
SA. However, SA has not been researched in paramedicine to the
same degree as these other industries. Further research is needed in
order to identify the potential effects of possessing or not possessing
SA in the setting of paramedicine.
Monitoring for Carboxyhemoglobinemia During
Fire Rehab With the Nonin CO-Met Noninvasive
Oximetry System Is More Reliable and Faster Than
the Rad-57
Author: Adam Valine, BS, NREMT
Associate Authors: Allen Wesley, MD; Marcus Kramer
Background: The National Fire Protection Association suggests
assessment of firefighters for CO poisoning after potential exposure.
EMSWORLD.com | OCTOBER 2019 67
SPOTLIGHT:
As such, many EMS services have adopted the Rad-57 pulse oximetry
system for monitoring COHb as a part of their standard fire rehabilita-
tion. However, multiple studies have indicated varying reliability and
accuracy of the Rad-57 for CO monitoring. Nonin Medical recently
developed an oximetry system capable of measuring dyshemoglo-
bins with clinical accuracy during hypoxia. This study was conducted
to evaluate the reliability of the COHb measurements from the Nonin
versus the Rad-57 device.
Methods: Firefighters undergoing standard fire rehabilitation were
enrolled and had a DCI sensor (no light shield) with Rad-57 Pulse
CO-Oximeter utilized in keeping with standard use of the product.
On the opposite hand a Nonin 8330AA CO-Met fingertip sensor with
prototype handheld oximeter was applied to the index, middle, or
ring finger. Subject demographics were collected along with the
COHb, peripheral oxygen saturation, and pulse rate values from the
oximeters. Observations from the EMS personnel operating the two
systems were also collected.
Results and Discussion: 114 measurements on 43 firefighters (42
male, age 36 ± 10 years, one smoker). Longer fire events resulted in
multiple rehabilitations and measurements for a single firefighter.
The Nonin CO-Met system reported readings for COHb on 97% of
attempted measurements compared to 88% for the Rad-57. EMS
personnel noted that the Nonin device displayed readings faster
than the Rad-57, with a majority of blank readings on the Rad-57
occurring during a nighttime fire with an ambient temp of 18°F. The
Rad-57 manual notes that ambient light can interfere with its COHb
readings. Light shields were not used with the Rad-57 device, which
may have contributed to the reading errors during daytime events.
Per the manufacturer, the Nonin device did not require a light shield.
Conclusion: These results suggest the Nonin CO-Met noninvasive
oximetry system delivers reliability in a fire rehabilitation environ-
ment. The ongoing study will continue to expand on these results,
adding subjects and observers. Further work is still needed to verify
the accuracy of the new Nonin device in clinical use.
Likelihood of Bystander CPR in Pediatric Cardiac Arrest
Author: Lee Van Vleet, MHS, NRP
Associate Authors: Bradley Baggett, BS, NRP, FP-C; April Elmore, NRP;
Michael Ross, BS, NRP, CCEMTP; Melisa Martin, EdD(c), Paramedic
Introduction: From 2014 to 2015, over 7,000 pediatric patients
experienced out-of-hospital cardiac arrest (OHCA). However, only
10.7% of these children survived to hospital discharge. Layperson
cardiopulmonary resuscitation (CPR) has been shown to markedly
improve out-of-hospital cardiac arrest outcomes in the adult popu-
lation. Bystanders are not, however, always willing to perform CPR on
adults before trained responders arrive, especially in impoverished areas
and among minority populations. There is a lack of such data regarding
the likelihood of bystanders to perform CPR on pediatric patients.
68 OCTOBER 2019 | EMSWORLD.com
Objective: To determine the incidence of layperson CPR in wit-
nessed pediatric cardiac arrest and demographic factors that may
impact the likelihood of layperson efforts.
Method: We conducted a retrospective observational study of
pediatric patients less than 18 years of age who experienced wit-
nessed OHCA from January 1, 2017–December 31, 2017. Inclusionary
criteria consisted of patients identified as experiencing witnessed
cardiac arrest prior to the arrival of emergency medical services per-
sonnel. Descriptive statistics and multivariate logistic regression were
used to analyze the incidence of and influence upon performance
of layperson CPR.
Results: A total of 269 patients met inclusionary criteria, of whom
69.5% (160) were Caucasian, 39.4% (163) were male, and 42.8%
(115) received layperson CPR. Of the patients receiving layperson
CPR, 54.8% (63) were male and 45.2% (52) were female. Compared
to males, female OHCA victims were more likely to receive layperson
CPR (OR 2.05, p=0.04). Gender was the only factor that showed
a statistically significant (p=0.048) difference in the likelihood of
bystanders to perform CPR, with females 2.05 times more likely than
males to receive layperson CPR. There was no difference in age,
weight, race, and cardiac arrest etiology regarding performance of
layperson CPR.
Conclusion: The percentage of pediatric OHCA patients receiv-
ing bystander CPR is unacceptably low, and bystanders appear to
exhibit a bias toward providing CPR to pediatric females. Further pub-
lic initiatives are needed to increase bystander CPR and to decrease
bystander bias.
Paramedic Team Emotional Intelligence and
Its Impact on Performance During Simulation
Training
Author: Hannah McGowan, BS
Associate Authors: Yasmin Graham, BS; Gary B. Williams, Jr., BS, NRP; J.
Lee Jenkins, MD, MS, FACEP; Helena Mentis, PhD; Andrea Kleinsmith, PhD
Introduction: Emotional intelligence (EI) has been shown to play
an important role in team functioning and can impact performance.
While much of the research has focused on team EI in an office set-
ting or a lab setting with an experimentally defined task, less work
has considered EI in a more complex real-world context, such as
paramedic simulation training.
Objective: To evaluate the EI of paramedic trainee teams dur-
ing simulation training and the impact EI may have on simulation
performance.
Methods: Paramedic trainees in their fourth year of the paramedic
track at University of Maryland, Baltimore County were participants.
Data was collected during the emergency response simulations car-
ried out in the Field and Clinical Experience course as part of the
curriculum. Each simulation day comprised 6–8 simulations car-

ried out by one team that consisted of four trainees (n=10 teams).
Trainees alternated between the roles of team lead, partner, and
support crew. At the end of each simulation day, trainees completed
the Work Group Emotional Intelligence Profile (short version) which
measures EI in terms of awareness and management of one’s own
and others’ emotions, yielding four subscales. Team performance
was evaluated by course instructors as bad, moderate, good, and
excellent for the categories: patient care, crew interaction, and tim-
ing throughout the call.
Results: A Kruskal-Wallis H test did not reveal significant dif-
ferences in EI between teams (p=0.113). Wilcoxon signed ranks
analysis of EI within teams demonstrated that teams were better
at managing their own emotions than managing teammates’ emo-
tions (p=0.0049), as well as being aware of their own emotions
(p=0.0005) and being aware of teammates’ emotions (p=0.001).
Linear regression was employed to assess the relationship between
EI and performance. Results indicated team EI was moderately cor-
related with crew interaction (r=0.468) and patient care (r=0.404).
Conclusion: In the complex context of simulation training, EI within
paramedic trainee teams had a moderate impact on team perfor-
mance with respect to patient care and crew interaction. However,
further analysis is necessary to draw more concrete conclusions.
As a next step, the electrodermal activity of each participant—also
recorded during each simulation—will be examined.
An Epidemiology of Pediatric Suicide Attempts
Author: Ginny K. Renkiewicz, PhD(c), MHS, Paramedic
Associate Authors: Helen E. Tripp, MA, LPCA, Paramedic; Emily A.
Burchette, BS, NRP; David A. Stallings, MHS, NRP; Michael W. Hubble,
PhD, MBA, NRP
Introduction: Suicide is the second-leading cause of death for
individuals between the ages of 10–24, and it is estimated that 2
million adolescents attempt suicide each year. While there is litera-
ture describing epidemiological factors associated with pediatric
suicidality, little is known about the presentation of this population
in a prehospital setting.
Objective: To describe epidemiological and patient-related factors
of a nationwide population of prehospital pediatric suicide attempts.
Methods: This was a retrospective epidemiological study per-
formed using nationwide data from ESO Solutions from January 1,
2017–December 31, 2017. The database contains prehospital patient
care records for over five million EMS responses from more than 900
agencies across the U.S. and encompasses a broad range of practice
settings from urban to rural. All patients who had an EMS provider
primary impression of suicide attempt were included, and descriptive
statistics were utilized to describe the sample. A licensed profes-
sional counselor associate (LPCA) categorized chief complaints into
26 subgroupings.
OCTOBER 14-18, 2019
NEW ORLEANS, LA
Results: A total of 2,698 patients met inclusionary criteria, of
whom 65.2% (n=1,759) were female and 26% (n=702) were minori-
ties. Suicide attempts accounted for approximately 1% of the overall
sample from the data set. Mean age was 15.5 ± .05 years with a range
of 6–18. Patients identified as prepubescent (<13 years) accounted
for 15.3% (n=413) of the sample. Average EMS response time was
11.75 ±33.36 minutes, and 457 (16.9%) attempts had a traumatic
component. Suicidal ideations without actual attempt were the high-
est subgrouping (n=990; 36.7%), followed by nonspecific suicide
attempt (n=414; 15.3%), overdose (n=390; 14.5%), lacerations (n=172;
6.4%), and depressive symptoms (n=101; 3.75%). Upon EMS arrival,
5 patients were observed to be in cardiac arrest. Of these, resusci-
tation was attempted on 2, and 1 achieved ROSC. Twelve patients
were intubated.
Conclusions: Pediatric suicide is a significant cause of prema-
ture death, especially among adolescents. Our study shows the
prepubescent population is at risk. EMS data does not accurately
describe the methods used to attempt or complete suicide and
more research is needed to further define suicidality in EMS pedi-
atric patient cohorts.
Validation of Proposed Criteria for Withholding
Resuscitative Efforts in Out-of-Hospital Cardiac Arrest
Author: Sabrina Vlk, MS, LP, CCRC
Associate Authors: Veer Vithalani, MD, FACEP, FAEMS; Dwayne How-
erton, RN, LP
Background: In 2018 Shibahashi, Sugiyama, and Hamabe pro-
posed a new set of criteria for withholding resuscitative efforts for
patients in out-of-hospital cardiac arrest (OHCA). Using their all-
Japan registry, they found that patients who were 73 years of age or
older and suffered an unwitnessed, unshockable OHCA were sig-
nificantly likely to have an unfavorable neurologic outcome, includ-
ing death. This study aims to validate the proposed criteria using
previously collected data on OHCA in a large, urban-suburban EMS
system in the United States.
Methods: A retrospective review was performed on all completed
cardiac arrest data for this system within the Cardiac Arrest Registry
to Enhance Survival (CARES) from 2013 through 2018. The data was
analyzed using the proposed criteria: age 73 years or more, unwit-
nessed, and unshockable initial rhythm. Neurologic outcome was
quantified through Cerebral Performance Category (CPC) scores;
unfavorable neurologic outcome was qualified as a CPC of 3, 4, or 5.
Results: There were a total of 4,532 cardiac arrests in the inclusion
period. Of these, 863 (19%) met the proposed criteria. Eleven (1.3%)
survived to discharge, with only 2 (0.2%) of those patients having a
favorable neurologic outcome. This represents a PPV of 99.8% (99%
CI, 99.3%–100%), specificity of 99.3% (99% CI, 98.0%–100%), PLR
of 29.4 (99% CI, 4.8–181), and OR of 36.7.
EMSWORLD.com | OCTOBER 2019 69
SPOTLIGHT:
Conclusions: When tested using an unrelated population set, this
study validated the proposed criteria’s ability to accurately iden-
tify OHCA patients likely to suffer neurologic devastation or death.
Though differences in system design between Japan and the United
States warrant further large-scale derivation/validation studies,
this study highlights a significant opportunity to risk-stratify OHCA
patients while maximizing resources on those who may benefit.
Reference: Shibahashi K, Sugiyama K, Hamabe Y. A potential
termination of resuscitation rule for EMS to implement in the field
for out-of-hospital cardiac arrest: An observational cohort study.
Resuscitation, 2018; 130: 28–32.
The Doctor Is In? Patient Acuity and Its Influence
on Paramedic Utilization in the Emergency
Department
Author: Jackson Deziel, PhD, MPA, NRP
Associate Authors: Eryn Dixon, EMT; Joshua Guthrie, EMT; Madison
Benton, EMT
Introduction: In recent decades hospital emergency depart-
ments have increasingly diverged from the traditional medical pro-
vider model. Once the sole province of physicians, patients are now
attended to by physician assistants, nurse practitioners, and even
EMT/paramedics. Given their unique skill set, EMT/paramedics have
the capacity to make significant contributions to patient care in the
emergency department setting. However, the question remains:
Which patients are these providers treating?
Objective: To explore provider assignments in the emergency
department given differing patient acuities.
Methods: The analysis examined a nationally representative sam-
ple of deidentified emergency department patient encounters from
2011 through 2016, gathered from the National Hospital Ambulatory
Medical Care Survey (NHAMCS). Triage (acuity) levels followed the
standard five-point Emergency Severity Index scale. Multivariate
logistic regression analyses were adjusted for the weighted data
set and controlled for potential confounders. Likelihoods of medical
practitioner consultation were analyzed by presenting acuity level.
Results: Drawing from the NHAMCS data set, 69,820 emergency
department records were analyzed, weighted to represent 350.7
million estimated patient encounters. Patients triaged as “immedi-
ate” were 14 times more likely to be cared for by an EMT/paramedic
(OR 14.63, p<0.000). Patients triaged as “emergent” were nearly
five times more likely to be cared for by an EMT/paramedic (OR
4.80, p<0.000). Patients triaged as “urgent” were also more likely
to be cared for by an EMT/paramedic (OR 2.59, p<0.000). Patients
attended to by an EMT/paramedic spent more time in the emergency
department (B=24.28, p<0.000) and received more total diagnostic
services (B=1.55, p<0.000). Findings show that higher-acuity patients
were increasingly more likely to see a physician (attending, consul-
tant, or resident) and less likely to see a nurse practitioner or physi-
70 OCTOBER 2019 | EMSWORLD.com
cian assistant.
Conclusion: In the emergency department, hospitals appear to be
utilizing EMT/paramedics for higher-acuity patients. This application
of provider expertise profits from the EMT/paramedic’s training and
general comfort in a fast-paced emergent setting. With the relatively
recent addition of EMT/paramedics into emergency departments,
there has been a broad fear of relegation to “minor care” or “fast-
track” areas (i.e., low-acuity patient populations). This study, how-
ever, suggests the opposite: EMT/paramedics are being reserved for
the sickest of patients.
New Documentation Mnemonic and Rubric
Substantially Improved Documentation
Performance
Author: Douglas Randell, BS, NRP
Associate Author: Michelle Mayer, BA, NRP
Background: Emergency medical services (EMS) documentation
is essential for recording patient care, billing, and quality improve-
ment and patient outcomes. Documentation techniques vary, and
few tools exist to provide feedback to EMS professionals regarding
their documentation processes and performance.
Objective: The objective was to evaluate the performance of a
newly developed mnemonic for documentation, an accompanying
evaluation rubric, and to improve compliance with documentation
of patient care report elements.
Methods: A descriptive method was used based on the devel-
opment of a mnemonic as a method for improving the process of
recording patient care. An evaluation rubric was developed in con-
junction with the mnemonic to assess documentation performance.
Scores greater than 80% were deemed ‘passing’ and scores greater
than or equal to 95% were classified as ‘high achievers’ out of 100%.
Training was conducted at a fire-based EMS agency in the fall of 2017.
Beginning January 1, 2018, a team of quality improvement person-
nel randomly reviewed one run report per employee per shift. The
analysis was from January 1 to December 31, 2018.
Definition: DOCUMENT
• Dispatch/demographics/distance
• On-scene assessment
• Chief complaint
• You (U) say what?
• My eyes
• Examination
• And (N) the verdict is…
• Treatment and transport and decisions
Results: In October 2016 a retrospective analysis was conducted
using the rubric (instrument). The review was conducted prior to the
implementation of the instrument, training, or evaluation. Forty-three
percent of patient care reports were reviewed in October 2016 (n=122)
using the rubric. Reports above the passing score (greater than or

equal to 80% compliance) were 48%. Reports in the ‘high achiev-
ers’ category (greater than or equal to 95% compliance) was 0%.
After implementation of the instrument, 37% (n=1,482) of patient
care reports were reviewed. The reports with a passing score ranged
from 85% in January 2018 to 98% in December 2018. Reports in the
‘high achievers’ category ranged from 16% in January 2018 to 71%
in December 2018.
Conclusion: Substantial improvement in the documentation of
key patient care record elements was noted following implementa-
tion of the newly developed mnemonic DOCUMENT and associated
objective evaluation rubric. Future work is needed to assess the gen-
eralizability of these findings at other EMS agencies.
The Kids Are All Right: A Multiyear Statewide
Analysis of Pediatric Nontransport
Author: Eryn Dixon, EMT
Associate Authors: Joshua Guthrie, EMT; Madison Benton, EMT; Jackson
Deziel, PhD, MPA, NRP; Evelyn Wilson, EdD, MHS, NRP
Introduction: In the world of emergency medical services, refusals
of care and/or transport are relatively common. For those aged 18
years or greater, it is his/her right to refuse treatment and/or trans-
port. Minors, however, are not allowed this autonomous decision.
In situations such as these, a responsible adult is charged with the
choice to continue or stop medical care.
Objective: This study explores differences in nontransport among
pediatric age ranges.
Methods: This retrospective study captured all 9-1-1 ambulance
requests in the state of Virginia for the years 2009 through 2013.
Pediatric patients were isolated and then classified into Infant (0–1
years), toddler (2–5 years), child (6–10 years), tween (11–12 years),
teen (13–16 years), and pre-adult (>16 years). Multivariate logistic
regressions with time-fixed effects were utilized. Control variables
included patient sex, race, EMS organizational ownership type, and
EMS employment structure (paid, volunteer, or mixed).
Results: Of all 9-1-1 requests during this time period, 288,120
pediatric patients were analyzed. Overall, 19.9% of all pediatric calls
resulted in a refusal, and 3.2% resulted in a determination of “no
treatment required.” Compared to refusal and no-treatment rates
in adults (11% and 1.7%, respectively), pediatric patients were more
likely to have a refusal issued (OR 1.98, p<0.000) and were more likely
to be classified as “no treatment required” (OR 2.06, p<0.000). Logis-
tic regression analyses showed increased patient age was positively
associated with patient refusal (OR 1.058, p<0.000) and negatively
associated with “no treatment required” (OR 0.883, p<0.000). When
analyzed by age group, infants were 33% less likely to have a refusal
issued (OR 0.667, p<0.000), but three times more likely to be classi-
fied as “no treatment required” (OR 3.136, p<0.000).
Conclusion: Younger patients were more likely to receive no treat-
ment, while older pediatric patients were more likely to have a refusal
issued. Several factors may be in play, but the “scared new parent”
OCTOBER 14-18, 2019
NEW ORLEANS, LA
may account for the higher likelihood of no-treatment 9-1-1 calls,
while older teenagers might be allowed a bit more autonomy and
input regarding their medical care. Previous research also highlights
that providers are generally uncomfortable with pediatric patients
and may influence the decisions of guardians.
The Effects of a Recent Emergency Department
Visit on Acuity Classification and Diagnostic
Service Provision
Author: Joshua Guthrie, EMT
Associate Authors: Eryn Dixon, EMT; Madison Benton, EMT; Jackson
Deziel, PhD, MPA, NRP; Susan Braithwaite, EdD, NRP
Introduction: Return visits to the emergency department are a
significant problem in the field of emergency medicine. Some stud-
ies suggest that patients often feel as if their original diagnosis was
not correct or ineffective, and many times these patients are right.
Additionally, a large number of return visits can be attributed to poor
discharge instructions or a lack of understanding by the patient about
their condition and treatment. The perceived ideas of convenience
and speed also play a role in patient’s choosing to return to the emer-
gency department versus a primary care provider. Yet little research
has explored the effects of a recent visit on the services rendered.
Methods: The analysis examined a nationally representative
sample of deidentified emergency department patient encoun-
ters from 2011 through 2016, gathered from the National Hospital
Ambulatory Medical Care Survey (NHAMCS). Multivariate linear and
logistic regression analyses were adjusted for this weighted data
set and controlled for potential confounders. The provision of diag-
nostic services, length of visit, and patient acuity were explored for
patients presenting to the emergency department within 72 hours
of a previous visit.
Results: Drawing from the NHAMCS data set, 62,699 emer-
gency department records were analyzed, weighted to represent
313.9 million estimated emergency department patient encounters.
Findings suggest that patients who had been seen in the emergency
department in the prior 72 hours were less likely to be classified as
“emergent” (OR 0.864, p=0.006) and more likely to be classified as
“nonurgent” (OR 1.139, p<0.000). Additionally, these patients received
fewer total diagnostic services (B=[-0.462], p<0.000). There was no
significant difference in length of visit.
Conclusions: Patients who present to the emergency department
within 72 hours of their previous visit are much more likely to be tri-
aged as low-acuity and subsequently receive fewer diagnostic tests.
These patients, however, do not appear to be expedited through the
department. Many reasons contribute to return visits, among them
inadequate discharge education and lack of primary care access.
This study highlights that return visits are largely low-acuity and do
not require extensive diagnostic testing.
EMSWORLD.com | OCTOBER 2019 71
SPOTLIGHT:
Current and Potential Community Paramedic Call
Volume in the NEMSIS Database
Author: Avery Dorgan, MPH, NREMT
Associate Author: Joyce A. O’Connor, DrPH, MA, RD
Introduction: Though overall use of emergency departments has
increased in recent years, there are interventions that could curb the
currently observed overcrowding. One promising intervention is the
implementation and scale-up of community paramedicine.
Methods: Using data from the National EMS Information Sys-
tem database, 2017 emergency calls with a community paramedic
response were analyzed for call, patient, and payment characteris-
tics. The most frequent dispatch categories were then used to assess
the total number of calls in the data set that could potentially be
averted through the scale-up of community paramedicine.
Results: Table 1 shows the distribution and demographics of cur-
rent and potential community paramedicine calls. Analysis of the
3,862 calls with a community paramedic response showed the most
frequent dispatch categories were “no other appropriate choice”
(23%), “sick person” (12.4%), and “well-person check” (11.5%). Of
the total 8.9 million calls in 2017, 1.9 million fit those categories and
could potentially be averted.
Table 1. Comparative demographic results between community paramedic
subpopulation and all calls that could be handled by community paramedics
Discussion: Though the National Registry of EMTs does not recog-
nize community paramedic as a level of care, providers are operating
at that care level. As paramedics currently respond to most commu-
nity paramedicine-eligible calls, paramedics may be able to address
these calls before they elevate to the emergent level and help triage
services, lowering the current EMS system call volume and allowing
the system to better prepare for more urgent calls.
Conclusion: By formalizing the community paramedic role through
uniform policies, procedures, standards, and training programs to
ensure level of care, nearly 2 million calls could be handled in the
community.
72 OCTOBER 2019 | EMSWORLD.com
A Pediatric Medication Dosing Support Tool
Increases Rates and Safety of Medication
Delivery
Author: David Miramontes, MD, FACEP, FAEMS, NREMT
Associate Authors: Bailey Devereaux, MPH; Michael Stringfellow, EMT-
P; David A. Wampler, PhD, LP, FAEMS
Background: Pediatric patients represent 13% of all EMS trans-
ports, and only approximately 10% of pediatric patients transported
are critically ill or injured requiring parenteral medication adminis-
tration. This low exposure rate of critically ill children increases the
risk of medication administration errors. Medication administration
is further complicated by a weight-based schema. Technology sup-
port that addresses medication-dosing errors in pediatric care holds
the potential to significantly increase pediatric patient safety. The
goal of this study was to evaluate the medication dosing error rates
before and after deployment of the Handtevy age-based system in
a large metropolitan fire-based EMS system.
Methods: This was an interrupted time series comparing three
months (Q1 2016) prior to the deployment of a pediatric dosing sup-
port tool (period 1) with the three months (Q1 2018) following full
implementation (period 2). Criteria: All pediatric patients (≤13 years
old) treated for pain or seizure. Medication dosing errors were defined
as greater than 10% medication deviation from the correct mg/kg
dose. Descriptive statistics and chi square were used to compare
periods 1 and 2.
Results: A total of 133 pediatric patients were enrolled in this study,
51 in period 1 and 82 in period 2. Mean age was 8 ± 3 years for period 1
and 6 ± 4 in period 2 (p=0.003). The observed error rate was greater
than expected, 72% and 82% for fentanyl and midazolam, respec-
tively for period 1. Ninety percent of the errors were by underdosing
patients. Error rates for period two were 41% and 36% for fentanyl
and midazolam, respectively, with 69% being underdosing (p<0.001).
Conclusions: Post deployment of the Handtevy pediatric drug
dosing support application was correlated with a younger cohort and
61% increase in the overall rate of pediatric patients receiving pain or
antiepileptic medications. Using a very conservative definition of a
doing error (10% over or under ideal dosage per kg), the intervention
resulted in a 42% reduction in overall dosing error.
Evaluating the Utility of Initial Prehospital Shock
Index and Modified Shock Index to Predict
Hospital Sepsis and Septic Shock Diagnosis
Author: Antonio Fernandez, PhD, NRP, FAHA
Associate Authors: Ryan Schroeder; Remle P. Crowe, PhD, NREMT; J.
Brent Myers, MD, MPH; Scott Bourn, PhD, RN
Introduction: Early recognition and initiation of treatment for sus-
pected sepsis patients is important to reduce morbidity and mortal-
ity. Shock index (SI) and modified shock index (MSI) can be readily
obtained in the prehospital setting and may be useful predictors of

sepsis; however, their predictive value for sepsis and septic shock
has not been tested for use by EMS.
Objective: To evaluate SI and MSI in the prehospital setting as
predictors of hospital sepsis diagnosis.
Methods: This retrospective analysis used linked prehospital and
hospital patient care records for January 1, 2018–December 31, 2018
from the large national health data exchange research database
maintained by ESO. All medical emergency EMS responses with
linked hospital data were included. Patients under 18 and those with
traumatic injuries were excluded. Any sepsis diagnosis was defined
by hospital ICD-10 codes A40, A41, R65.20, and R65.21, and septic
shock was restricted to R65.21 only. SI was calculated by dividing
initial heart rate by systolic blood pressure. MSI was calculated by
dividing initial heart rate by mean arterial pressure. Based on previous
research, elevated SI was defined as greater than 1.0, and elevated
MSI was greater than 1.3. Four multivariable logistic regression mod-
els were created to separately evaluate SI and MSI as predictors of
sepsis and septic shock, controlling for patient age, gender, race/
ethnicity, community size, and census region.
Results: This analysis included 325,558 patients. The median
age was 60 (IQR 43–75), 53% were female, 69% were white (non-
Hispanic), and 94% were in urban communities. Five percent (16,881)
were diagnosed with sepsis. Of these, 19% had septic shock (3,144).
Over a fivefold increase in odds of any sepsis diagnosis was noted for
patients with an elevated initial SI (AOR 5.30, 95% CI, 5.08–5.52) or
MSI (AOR 5.42, 95% CI, 5.21–5.64). Approximately a ninefold increase
in odds of septic shock was observed for patients with an elevated SI
(AOR 9.05, 95% CI, 8.32–9.85) or MSI (AOR 8.61, 95% CI, 7.92–9.36).
Conclusion: Our findings suggest elevated initial prehospital SI
and MSI are both strong predictors of hospital sepsis diagnosis and
stronger predictors of septic shock.
Effects of Paramedic Tenure on the Accuracy of
Prehospital Stroke Identification
Author: Justin Brines, BS, NRP
Associate Author: Jackson Deziel, PhD, MPA, NRP
Introduction: Stroke is the fifth-leading cause of death in the Unit-
ed States and the No. 1 cause of disability, affecting approximately
795,000 people per year. Reliable identification of stroke in the field
by prehospital personnel expedites delivery of acute stroke therapy.
While the National Institutes of Health (NIH) scale is comprehensive,
it is difficult to perform in the prehospital environment, and abbrevi-
ated scales are much more common. Provider experience, however,
may factor into the correct identification of stroke.
Objective: To determine if years of prehospital experience affect
the accuracy of stroke identification.
Methods: A systematic review was conducted of data from a sub-
urban EMS agency answering approximately 34,000 calls per year
with access to a Level 1 trauma center and a certified stroke center.
OCTOBER 14-18, 2019
NEW ORLEANS, LA
All patients determined to be having a stroke by paramedics between
January 1, 2013 and December 31, 2017 were included in the analysis.
There were no exclusions based on age, sex, race, or comorbidities.
ICD-10 diagnostic codes were collected for each patient. Multivariate
logistic regression with robust standard errors was utilized.
Results: A total of 621 patients were included in the data analysis.
Of the patients identified by the paramedic as having a stroke, 51%
were subsequently admitted to the hospital for stroke, while 49%
were not determined to be suffering from an acute stroke. For each
additional year of experience, the paramedic was 6.5% more likely
to correctly identify stroke (OR 1.065, p=0.112). It was also found that
paramedics were more likely to correctly diagnose stroke in male
patients (OR 1.020, p=0.045) and less likely to correctly diagnose
stroke in female patients for each additional year of experience (OR
0.982, p=0.046).
Conclusions: This study may suggest that paramedics with more
tenure are more accurate at recognizing stroke in the prehospital
setting. Additionally, a disparity appears to exist between male
and female patients. Patients included in this study appear to have
been overtriaged by paramedics. While there is an acceptable level
of overtriage related to stroke, it should be noted that this may lead
to alarm fatigue and overuse of scarce resources.
Attitudes of EMS Stakeholders in Barbados: A
Convergent Parallel Mixed-Methods Study
Author: Hezedean Smith, DM(c), CFO, CEMSO, FACPE, CPM, EF/ESO,
MIFireE, CHSE, PMD
Objective: To examine the attitudes of accident and emergency
(A&E) doctors, prehospital EMS providers, and A&E nurses based
on the tripartite model of attitudes theory. How do the attitudes of
EMS stakeholders in Barbados align with the attributes of the EMS
Agenda for the Future?
Design and Methods: A convergent parallel mixed-methods
design was used. Beliefs, affect, and behavior measures were used
as dependent and independent variables. Stakeholders were exam-
ined collectively and separately. Sampling was purposeful (n=105).
Semi-structured interviews and a four-part survey were used to
answer eight research questions. Inferential statistical methods
were applied using SPSS. NVivo was used to code qualitative infor-
mation collected.
Results: A confidence interval of 0.95 was used to report findings.
A significant regression model based on beliefs and behaviors was
identified for prehospital EMS providers (F[1,63]=9.278, p=0.003),
with an R2 of .130. A significant regression model based on affect and
beliefs was identified for A&E doctors (F[1,27]=5.896, p=0.022), with
an R2 of 0.179; prehospital EMS providers (F[1, 62]=10.931, p=0.002),
with an R2 of 0.150; and A&E nurses (F[1, 9]=7.318, p=0.024), with an
R2 of 0.448. Eight themes emerged from the research.
Conclusions: EMS legislation, regulation, and medical direction
EMSWORLD.com | OCTOBER 2019 73
SPOTLIGHT:
are important in the English-speaking Caribbean, as they address a
strategic priority of the Caribbean community. A 2050 EMS Agenda
for the Caribbean is suggested to strengthen prehospital EMS and
serve as a future model for out-of-hospital care in the region.
Road Traffic Accident Related Fatalities in Addis
Ababa City, Ethiopia: An Analysis of Police
Reports 2013–2014
Author: Anteneh Kebede Sebsbie, BSN, MSN
Associate Authors: Temesgen Beyene, MD, Assistant Professor;
Haimanot Geremew, Assistant Professor
Background: The increase in access and number of transporta-
tions pose a great challenge in the individual’s daily activity ranging
from minor injuries to death. The nation also suffers from loss of
productive citizens.
Objectives: To assess the magnitude and factors contributing to
the mortality related to road traffic accidents in Addis Ababa, Ethiopia.
Methodology: Data from the Addis Ababa Police Commission,
Traffic Police Department was collected from the checklist of infor-
mation by the police officer at the scene. Data were entered to SPSS
version 16.00. Results were generated from the SPSS and presented
to the department of emergency medicine. The results were made
available to concerned bodies (Addis Ababa Traffic Police Department,
Federal Ministry of Health Ethiopia, and Federal Ministry of Transport).
Results: Overall there were 2,372 recorded road traffic accidents
in Addis Ababa during the study period. Of these, 382 (16.1%) were
fatal. Among all fatalities the majority were male 279 (73.03%),
the ratio of male/female was 3:1, and pedestrians accounted for
321 deaths (84.0%). Fatal accidents were more prevalent on isled
roads 262 (60.7%) and involved especially commercial cars. More
than half of fatalities (205, 53.8%) occurred due to failure to give
the right of way for pedestrians.
Conclusion: The majority of affected victims were vulnerable road
users and pedestrians. Many victims died at the scene instantaneously.
These findings can serve as a basis for healthcare professionals and
policymakers to create preventive measures for traffic accidents.
Impact of Pediatric Age Groups on Prehospital
Intubation Success
Author: Ginny K. Renkiewicz, PhD(c), MHS, Paramedic
Associate Authors: A. Watkins, BS, EMT; K. Collopy, BA, NRP, FP-C,
CMTE; J. Hoover, EMT; J. Tuttle, MHS, NRP
Introduction: Current studies indicate that first-pass success
rates for endotracheal intubation (ETI) range from 66% to 91%.
Additional studies suggest that basic airway management with a
bag-valve mask produces better outcomes in out-of-hospital car-
diac arrest (OHCA) than advanced airway management with ETI.
Additional data demonstrates decreased success with repetitive
74 OCTOBER 2019 | EMSWORLD.com
prehospital intubation attempts. However, there are limited data
evaluating intubation success among pediatric age groups.
Objective: This study sought to evaluate whether prehospital
overall ETI success varied based on patient age.
Methods: This is an IRB-approved retrospective analysis of pedi-
atric ETI from January 1, 2017–December 31, 2017. Data were col-
lected from all pediatric records in the ESO database. All patients
aged less than 18 years with an ETI attempt were included. Patients
were divided into 6 age groups: neonate (age 0–30 days), infant
(31–364 days), toddler (1–3 years), preschool (4–6 years), school-
age (7–12 years), and adolescent (13–17 years). A logistic regression
was performed to evaluate the influence of patient age on overall
ETI success while controlling for patient age, sex, minority status,
and receipt of paralytic agents.
Results: A total of 553 patients were included in the analysis,
of which most were male (n=331; 59.9%) and Caucasian (n=384;
69.4%). Adolescents were the most commonly intubated age
group (n=164; 29.66%), followed by infants (n=160; 28.93%), tod-
dlers (n=82; 14.82%), school-aged children (n=60; 10.84%), pre-
schoolers (n=45; 8.13%), and neonates (n=42; 7.59%). Compared
to adolescents, neonates (OR 0.404; p=0.014) and those patients
not receiving paralytics were less likely to obtain overall ETI success
(OR 0.404; p=0.049). Neither sex nor minority status were statisti-
cally significant predictors of ETI success.
Conclusions: Compared with adolescents, prehospital profes-
sionals are 60% less likely to successfully intubate neonates. In
addition, patients are 60% less likely to be successfully intubated
when paralytic agents are not used. Further research is necessary
to evaluate if provider experience and training influence pediatric
patient intubation success rates.
Treatment Equity Among Pediatric Diabetic
Patients in the Prehospital Setting
Author: Lee Van Vleet, MHS, NRP
Associate Authors: Bradley Baggett, BS, NRP; April Elmore, NRP;
Michael Ross, BS, NRP; Melisa McNeil, EdD(c), EMT-P
Introduction: Current research indicates the adult population
demonstrates higher tendencies of poor glycemic control based
on race, ethnicity, and socioeconomic status. Assuming a similar
tendency in the pediatric population, it is important to identify any
disparities in the prehospital treatment of this underexamined
population.
Objective: To identify disparity in prehospital treatment of pedi-
atric diabetic emergencies.
Method: A retrospective observational study of pediatric diabetic
emergencies was conducted using national ESO reporting data from
January 1, 2017–December 31, 2017. Inclusionary criteria consisted
of patients whose lowest blood glucose level (BGL) was less than
70 mg/dL and had a total Glasgow coma score of 14 or less and a

primary impression that may have been related to BGL abnormalities.
A multivariate logistic regression was used to calculate the odds ratio
for hypoglycemic treatment (D10, D25, D50, glucagon, and/or oral
glucose) while controlling for age, weight, gender, minority status,
and primary impression.
Results: A total of 251 patients met our inclusionary criteria, of
whom 58.2% (146) were Caucasian and 51.8% (130) were male. A
total of 36.7% (92) patients received an included treatment modal-
ity, and 63.3% (159) patients were not treated. A primary impres-
sion of altered level of consciousness was statistically significant
(OR 8.05, p=0.029) regarding the treatment of prehospital pediatric
hypoglycemia. Age, weight, gender, and minority status revealed no
statistically significant influence on treatment.
Conclusion: This study identified no discernable disparity in treat-
ment of prehospital pediatric diabetic patients when examined by
age in years, weight, gender, or minority status. Further study is indicated
to identify factors affecting the likelihood for treatment in the primary
impression of altered mental status in pediatric prehospital patients.
Lifesaving Policy Solutions for EMS
Motor Vehicle Collisions
Author: Jeffrey Rollman MPH, NRP
Associate Author: Michael Kaduce, MPS, NRP
Background: Emergency medical services (EMS) providers are
first responders to motor vehicle collisions and other emergencies,
transporting these patients to definitive care. Despite their critical
role in society, transportation-related injuries and fatalities among
EMS providers range from two to five times the general worker popu-
lation. The majority of these fatal collisions involve the use of lights
and sirens.
Objectives: The primary objective is to better understand the
incidence and severity of EMS motor vehicle collisions. A second-
ary objective is to analyze potential policy interventions that address
the problem of motor vehicle collisions.
Methods: First, a literature review was conducted in order to
synthesize current knowledge surrounding the statistics and epi-
demiology of this issue. Then policy solutions were explored that
can address the problem of motor vehicle collisions in EMS. Finally
a recommendation was proposed that incorporates regulatory and
fiscal realities.
Results: Lights and sirens usage quadruples the risk of motor
vehicle fatality and injury. Research demonstrates that lights and
sirens are almost always unnecessary and generally do not improve
patient outcomes. EMS provider fatalities are on par with or higher
than police, firefighters, and other public safety personnel. Fatal
ambulance crashes disproportionately occur on rural roads and
among volunteer EMS providers. Engineering controls are necessary
given the lack of any federal ambulance safety equipment or chassis
mandates. Administrative controls, through improved training and
driving policies, may enhance EMS driving behavior. Safety culture
OCTOBER 14-18, 2019
NEW ORLEANS, LA
is also an important mediator to address, as research demonstrates
that EMS agencies with strong safety cultures have much lower injury
and fatality rates. Personal accountability for seat belt usage and
distracted driving may lead to a decrease in collisions without regu-
latory control.
Conclusions: Sufficient evidence is available to suggest that sig-
nificant reductions in lights and sirens usage can lead to dramatic
reductions in EMS motor vehicle collisions without negatively impact-
ing health outcomes, yet this risky practice largely continues. Ambu-
lance collisions are also underreported, which means the incidence
is likely even higher. Simple regulatory changes to address lights and
sirens utilization could yield positive benefits without any apparent
unintended consequences.
Exhaustion and Disengagement in Emergency
Responders: Measuring Burnout Using the
Oldenburg Burnout Inventory Tool
Author: Morgan Anderson, MPH
Intro/Background: Employee burnout, which ultimately can lead
to staff turnovers, is a commonly heard problem within the emer-
gency responder industry. There are few tools available to measure
the extent of the issue and gain insight into specific themes related
to exhaustion, disengagement, and burnout. There has been minimal
research done on burnout within this population.
Purpose: To evaluate burnout in an emergency responder popula-
tion utilizing the Oldenburg Burnout Inventory (OLBI) tool and identify
what portion of the population have scores indicative of burnout.
Methods: This retrospective study gathered data from the Crew-
Care mobile app, an anonymous mental health app for first respond-
ers. Respondents were located in the United States and were indi-
viduals working in emergency medical services, fire, and law enforce-
ment. Self-reported respondent data was acquired from February
2018 to May 2019. The OLBI questions were analyzed and scored.
Each question received a score between 1 and 4 points depending
on the answer. Exhaustion and disengagement scores were indica-
tive of burnout based on a study by Peterson, et al. (2008). In order
to receive a burnout score, respondents had to have answered all
16 questions. Points were totaled and divided by 8 in each section
(Exhaustion and Disengagement). Burnout was indicated by a score
of 2.25 or more for exhaustion and 2.10 or more for disengagement.
Results: There were 1,254 respondents that participated in the
OLBI tool, and 1,195 (95%) answered all 16 questions. The average
exhaustion score was 2.60 ± 0.49, and the mean disengagement
score was 2.42 ± 0.4. Of those that answered all 16 questions, mean
scores for exhaustion were 2.81 ± 0.35 and disengagement was 2.62
± 0.37. Almost three-quarters (72%) of the study population had
scores indicative of burnout.
Conclusion: This study confirms there is an epidemic of exhaustion,
disengagement, and burnout within the emergency response industry.
Efforts should continue to focus on providing support and wellness
programs to combat burnout, which can lead to high staff turnover.
EMSWORLD.com | OCTOBER 2019 75
SPOTLIGHT:
A Randomized Control Equivalence Study of
Emergency Medical Services Use of Inhaled
Isopropyl Alcohol Versus Ondansetron for
Treatment of Prehospital Nausea
Author: David Miramontes, MD, FACEP, FAEMS, NREMT
Associate Authors: Michael Stringfellow, EMT-P; Jacob Watson, MD(c);
David A. Wampler, PhD, LP, FAEMS
Background: Nausea is a common symptom encountered in the
emergency medical services (EMS) environment that is often treated
with oral or intravenous antiemetic medications, most commonly
ondansetron or promethazine. Intravenous medications are beyond the
scope of most basic life support (BLS) EMS providers. Isopropyl alco-
hol (IPA) has long been used to relieve postoperative nausea and was
recently shown to be effective in the emergency department. Isopropyl-
saturated pads are ubiquitous in ambulances, even at the BLS level.
Purpose: This study compared standard practice intravascular
ondansetron (OND) with inhaled IPA for the relief of prehospital nausea.
Methods: This was a prospective open-label randomized con-
trolled equivalence trial comparing 4.0 mg ondansetron given IV with
inhaled IPA. Inclusion: Adult EMS patients complaining of nausea
rating scale of 5 or greater, with the cognitive ability to consent. Exclu-
sion: minors, prisoners, pregnancy, impaired mental status, or significant
upper respiratory infection. After consent, a sealed black box is opened;
contents include either three large 70% IPA pads or 4.0 mg of ondan-
setron and syringe. Ondansetron is administered by standard-practice
IV, IPA pads are opened and handed to the patient to self-administer as
needed by sniffing through the nares. Nausea rating is monitored before
and every 2 minutes after administration up to 10 minutes. Time was
stopped at 10 minutes or arrival to the hospital.
Results: Over an 18-month trial, 51 subjects were recruited. Their
initial nausea mean rating was 7.5 (95% CI, 6.7–8.2; n=28) and 7.9
(95% CI, 7.3–8.4; n=23) for the IPA and ondansetron groups (p=0.4),
respectively. There was no difference in the percent of subjects who
reported at least some relief of nausea: 86% in the IPA group versus
91% in the ondansetron group (p=0.08). Final nausea mean rating
was IPA 4.3 (95% CI, 3.1–5.5) and ondansetron 3.5 (95% CI, 2.3–4.8;
p=0.4). There were also no differences between groups at each of
the two-minute intervals.
Conclusion: Inhaled IPA was similarly effective at relieving nausea
as the standard-practice intravascular ondansetron in the undiffer-
entiated EMS nausea patient. Additional research needs to be done
to validate use of IPA by BLS personnel in the critically ill patient.
Death and Disability Meetings at the London’s Air
Ambulance: Debrief, Case Review, and Beyond
Author: Tsz Lun Ernest Wong, Medical Student
Associate Author: Danë Goodsman, PhD
Introduction: London’s Air Ambulance (LAA) is an advanced
emergency medicine service operating for the population of Lon-
76 OCTOBER 2019 | EMSWORLD.com
don. The team offers highly specialized trauma care to seriously ill
patients in the prehospital environment. Alongside their innovative
medical practices, the team has developed a variety of manage-
ment processes to support their work. One such is the “death and
disability” meetings (D&D) introduced to foster individual and team
learning through discussions of patient cases. D&D in this form does
not have much presence in the literature; therefore this study serves
to describe D&D and its functions as used by the LAA and prehos-
pital medicine.
Methods: The study used an ethnographic approach and observed
a total of eight D&Ds, followed up with four interviews with LAA cli-
nicians (doctors and paramedics). These were conducted between
April and June 2019. The collected data was analyzed using a ground-
ed theory approach with the aid of Nvivo 12 software.
Results: D&Ds are regular consultant-led meetings, attended by
LAA clinicians and various other professionals and medical students.
Selected cases are reviewed and chosen generally in relation to both
specific interest and who is present. The process of discussion fol-
lows a similar structure for each: i.e., everyone introduces themselves,
including role and background; the case is then outlined from the
paperwork on file, and the clinicians who attended the case give a
moment-by-moment account of their involvement. The consultant-
chair facilitates discussion and draws out, if needed, specific areas
of interest. For each case key learning points and action points are
identified and documented.
The key functions of D&D include debriefing, case-based learning,
review of clinical decisions made by the attending team, review of
the diagnostic tool or intervention, review of clinical documentation,
and support of staff welfare.
Conclusion: Death and disability meetings provide an open and
nonjudgmental environment for clinicians to reflect and discuss their
cases. These meetings serve an important role in education, clinical
governance, and supporting staff welfare in the LAA. From the obser-
vations it was demonstrated that D&D is integral to LAA’s processes
to improve and deliver care of the highest possible standard.
Influence of Intercompression Cycle Rest Period
Duration on CPR Quality
Author: Daniel Wesley, MHS, NRP
Associate Authors: Jackson D. Déziel, PhD, NRP; Michael W. Hubble,
PhD, NRP
Introduction: Cardiopulmonary resuscitation (CPR) has been the
keystone of cardiac arrest care since its creation in the early 1900s.
CPR quality, however, decreases drastically, in some cases over 60%,
in just a few minutes. Limited research has investigated rest periods
that providers may need in order to provide another full and effective
two minutes of CPR following their previous cycle.
Objective: To explore whether rest periods of varying durations
influence provider fatigue and CPR compression quality.

Methods: Participants volunteered their time, were active pre-
hospital providers, and were tasked with performing four continuous
two-minute cycles of CPR compressions. Participants were randomly
assigned to one of four groups. Each group had a specified rest period
between cycles: two, four, six, or eight minutes. Chest compression
rate, depth, hand placement, and recoil were recorded by propri-
etary CPR manikins. Following each CPR cycle, the participant also
self-reported his/her fatigue level on a 0–10 scale. Linear regression
models utilizing robust standard errors were estimated and con-
trolled for the participant’s age, sex, years of EMS experience, level
of EMS certification, and BMI.
Results: Sixty-two volunteers participated and were equally
split among the four rest duration groups. Using the two-minute
rest duration group as the referent, there were no statistically sig-
nificant differences in compression rate, depth, hand placement, or
recoil among groups. There was, however, a statistically significant
difference in self-reported fatigue among the groups. Following the
fourth compression cycle, participants in the eight-minute rest group
reported a fatigue level nearly three points lower than the two-min-
ute rest group (β=[-2.94], p<0.000). The six-minute (β=[-1.75], p=0.013)
and four-minute (β=[-1.48], p=0.037) rest groups also reported lower
fatigue after four cycles.
Conclusions: Previous research has shown that compressor rota-
tion is an important contributor to CPR quality. Although a two-min-
ute cycle is now the standard, there are no recommendations on the
length of rest between cycles for each provider. Using rest duration
as a proxy for the number of available providers, this study may sug-
gest that increasing the number of responders decreases fatigue but
does not improve the quality of CPR compressions.
A Descriptive Assessment of EMS Encounters
for Patients Experiencing Behavioral Health
Emergencies
Author: Lee Van Vleet, MHS, NRP
Associate Authors: Brooke Burton, NRP, FACPE; Remle Crowe, PhD,
NREMT; David Page, PhD(c); Henry Wang, MD, MS
Introduction: Behavioral health emergencies (BHE) comprise a
considerable proportion of patients receiving care by emergency
medical services (EMS). However, only limited data describe the
characteristics and outcomes of this population.
Objective: To describe characteristics of EMS patients experiencing BHE.
Method: This retrospective observational study of patients expe-
riencing BHE was conducted using a large national EMS research
data set maintained by ESO. A subset of encounters in this data-
base participate in the ESO health data exchange, linking hospital
outcome data to the prehospital record. The study period spanned
January 1 through December 31, 2018. Inclusion criteria consisted of
9-1-1 responses for adult patients (older than 18 years) with a docu-
mented EMS provider primary or secondary impression of a behav-
OCTOBER 14-18, 2019
NEW ORLEANS, LA
ioral or psychiatric etiology transported to the ED. Substance abuse
and overdose were specifically excluded. We analyzed the data using
descriptive statistics.
Results: The data set included 7,574,879 responses from 1,289
EMS agencies, of which 5,970,280 (79%) were 9-1-1 responses. BHE
was present in 213,410 (4%). We excluded 21,901 (10%) with patient
age less than 18. Of the remaining 191,509 encounters, there were
146,124 (76%) transports by EMS. Median age was 41 (IQR 29–56),
51% were male, 69% were white (non-Hispanic) and 25% were black
(non-Hispanic). Hospital outcome data was available for 15,500
encounters (11%). Of these, 51% (7,948) were discharged home in
24 hours or less.
Conclusion: The majority of adult patients with a BHE encountered
by EMS were transported to the hospital. More than half of patients
transported to the ED for BHE were discharged home within 24 hours.
Further study may identify opportunities for the alternative care of
BHE patients. Limitations to this study include a lack of universal
definition for BHE and the inability to track the same patient over
separate EMS encounters.
The Epidemiology of EMS-Witnessed Cardiac
Arrest in a U.S. Patient Cohort
Author: David Wampler, PhD, LP, FAEMS
Associate Authors: Roland Tenley, EMT-P; Remle Crowe, PhD, NREMT;
Jeffrey Jarvis, MD, MS, EMT-P
Introduction: Out-of-hospital cardiac arrest is fatal without imme-
diate aggressive intervention. Arrests witnessed by EMS personnel
are associated with more favorable neurological outcomes, likely
because of earlier resuscitation. It is also possible that, if signs of
impending arrest are recognized early, some arrests may be avoided.
The goal of this study was to describe the epidemiology of EMS-
witnessed cardiac arrests.
Methods: This retrospective analysis was conducted using deiden-
tified patient care records from a large national research database
maintained by ESO. All adult (18 years and older) arrests from 2018
were included. Descriptive statistics were calculated to describe
patient demographics, arrest characteristics, and presence of return
of spontaneous circulation (ROSC).
Results: The data set included 7,574,879 responses from 1,289
distinct agencies. There were 70,746 (<1%) records with document-
ed cardiac arrest. Of these, 62,750 (89%) records were from 9-1-1
responses. Records for 2,207 (4%) patients under 18 were excluded,
leaving 60,543 in the analysis population. Of the emergency responses
for documented cardiac arrests among adult patients, EMS witnessed
8,014 (13%). Among EMS-witnessed cardiac arrest patients, median age
was 65 (IQR 53–76), 71% were white (non-Hispanic), and 60% were
male. Presumed etiology of EMS-witnessed arrests included cardiac
(54%), followed by respiratory (25%), trauma (12%), and drug overdose
(2%). Initial arrest rhythm was shockable in 21% of witnessed arrests,
EMSWORLD.com | OCTOBER 2019 77
SPOTLIGHT:
while PEA or asystole was documented in 73% of cases. Common
locations where EMS-witnessed cardiac arrests occurred included resi-
dences (70%), streets/highways (10%), and nursing homes/assisted
living centers (8%). Circulation was restored in 43% of cases.
Conclusion: In this large national EMS registry data set, EMS wit-
nessed less than 15% of documented cardiac arrests during emergency
responses. Most of these EMS-witnessed arrests occurred at a resi-
dence, and half of EMS-witnessed arrests occurred in patients younger
than 65. About one-fifth presented with an initial shockable rhythm.
For all EMS-witnessed cardiac arrests, less than one-half experienced
restored circulation.
The Impact of Race and Ethnicity on Prehospital
Pain Management: Examining Disparities in a
Hispanic Majority State
Author: Madison Schaeffer, MS, MPH
Associate Authors: Sahaj S. Khalsa, BS, NRP, NM I/C; Charles Becvarik,
EMT-P, EMD; Edward T. Oliphant, BA, NRP
Introduction: Previous research has found significant differences
in patient care associated with race/ethnicity. However, little research
has been conducted in the prehospital environment. We examined
prehospital patient care records in New Mexico, a state where His-
panic individuals represent more than half of the population and
where provider demographics match the general population. Addi-
tionally this research compares care provided to patients with more
objective indications for treatment (respiratory distress and hypo-
glycemia) versus more subjective indications for treatment (pain).
Methods: We performed a retrospective cohort study using New
Mexico EMS Tracking and Reporting System data from the New
Mexico Department of Health Epidemiology and Response Divi-
sion Emergency Medical Systems Bureau for patient care records
entered between January 1, 2015 and December 31, 2017. We identified
patients presenting with indicators of respiratory distress (n=2,722)
(hypoxia, tachycardia and tachypnea), hypoglycemia (low blood glu -
cose level, n=905), and (primary or secondary complaint of pain,
n=52,220). We assessed whether patients had received appropriate
treatment for those conditions based on state treatment guidelines.
We then analyzed cases for all three complaints to identify differ-
ences in the rate of appropriate treatment associated with patient
race/ethnicity.
Results: We found no significant difference in treatment rates
for respiratory distress and hypoglycemia across races and ethnici-
ties in this study population. In contrast, we found the rate of pain
medication administration was significantly less in American Indian
and black populations. White patients were 1.07 times more likely
to receive pain medication compared to Hispanic patients (95% CI,
1.01–1.12), 1.28 times more likely than American Indian patients (95%
CI, 1.20–1.38), and 1.66 times more likely than black patients (95%
CI, 1.41–1.97).
78 OCTOBER 2019 | EMSWORLD.com
Conclusion: This research suggests minority patients are less likely
to receive prehospital pain medication compared to white patients.
Additionally, we found disparities are reduced in Hispanic populations
in the majority Hispanic state of New Mexico compared to Hispanics
in the national population. This shows a need for services to sys-
temically examine their patient care for such disparities and improve
provider education.
Evaluation of a Novel Point-of-Care
Neuromonitoring Device (AlphaStroke) to Detect
Large Vessel Occlusion in Suspected Acute Stroke
Patients
Author: Matthew Kesinger, MS
Associate Authors: Madeleine Wilcox, PhD; Liam Berti, BS; Andrew
Maza, BS; Frank Peacock, MD
Study Objectives: Several prehospital stroke scales have been
developed to provide quick and accurate triage to facilitate timely
treatment. This study evaluated a portable, experimental electroen-
cephalogram (EEG) device (AlphaStroke, Forest Devices, Pittsburgh,
Penn.) using artificial intelligence (AI) as a potential tool for detection
of acute stroke and large vessel occlusion (LVO) among patients with
neurological deficits. Both device performance and feasibility in the
emergent setting were assessed.
Methods: This observational study enrolled a convenience sample
of emergency department (ED) patients evaluated for suspected
stroke within 24 hours of symptom onset. LVO status was determined
by local neuroradiologists blinded to AlphaStroke’s output. LVO was
defined as an acute occlusion of the any of the following arteries:
ICA/MCA (M1 or M2)/vertebral/ basilar. Controls were neurologically
normal subjects (NIHSS=0).
Results: From May 2018 to June 2019, eight urban US stroke cen-
ters enrolled 100 subjects being evaluated for stroke. The study also
enrolled 113 controls. In subjects with acute neurologic deficits, 26
had LVOs (26%). Device performance for detecting stroke and LVO
is shown in Table 1. There were no severe adverse events related to
use of the device.
Table 1: AlphaStroke Performance for Identification of LVO
Predicted:
• True positives, 52; false positives, 17
• False negatives, 6; true negatives, 113
Sensitivity=92%, positive predictive value=46%, positive likelihood ratio, 6.17
Specificity=85%, negative predictive value=99%, negative likeli-
hood ratio, 0.09
Conclusion: The AlphaStroke device performed well in identify-
ing LVO in patients presenting with suspected stroke. The perfor-
mance of the AlphaStroke device in the acute setting indicates it
may be able to support prehospital decision-making when triaging
suspected stroke subjects. Additional studies with larger sample
sizes are needed to validate this study’s findings.

EDUCATIONAL ABSTRACTS
In partnership with the National Associa-
tion of EMS Educators, these are the
educational abstracts presented at
NAEMSE Educator Symposium in Ft.
Worth on July 31–August 5, 2019.
Paramedic Student Performance on the
Paramedic Readiness Exam 4 (PRE4) Improves
With Exposure to Higher-Acuity Patients
Author: Dale Edwards, EdD
Associate Authors: Hezedean Smith; Lindsay Eakes; Charles Foat; C.E.
Casey; Katie Grondahl; Jackson Déziel; Ron Lawler
Introduction: Paramedic program directors struggle with balanc-
ing limited time available in clinical and field learning experiences
with accomplishing required objectives and allowing for a broad
exposure to differing patient types. The purpose of this study was
to examine how the students’ exposure to perceived high-acuity
patients relates to cognitive performance.
Methods: A retrospective review of 554,546 student records
from Fisdap was conducted from 2014 to 2018. Participants were
included in this analysis if they completed a first attempt at the PRE4
and had completed clinical and field patient contacts prior to their
exam attempt. The outcome variable was pass/fail on the PRE4. The
dichotomized pass/fail was determined by Angoff standard-setting.
The cut score for the PRE4 is 73%, with a 97% positive predictive
value for passing the NREMT paramedic examination. The primary
independent variable was exposure to patients by perceived critical-
ity as a proxy for patient acuity.
Results: A logistic regression model estimated the likelihood of
passing the PRE4 was 1.07 (95% CI, 1.02–1.12, p=0.003) for perceived
red criticality when compared to all other levels of criticality. Further
analysis explored the differences observed between this associa-
tion in the clinical and field settings. The likelihood of passing the
PRE4 was 1.18 (95% CI, 1.17–1.19, p=0.000) for perceived red criticality
patients in the field setting, and the likelihood of passing the PRE4
was 0.84 (95% CI, 0.83–0.85, p=0.000) for perceived red criticality
patients in the clinical setting.
Conclusions: This study suggests there is a positive correlation
between exposure to high-acuity patients in field placements and
performance on the PRE4. Conversely, this study suggests a nega-
tive correlation between exposure to high-acuity patients in clinical
placements and performance on the PRE4. These findings suggest
paramedic programs should place greater emphasis on field place-
ments with reduced emphasis on clinical placements for paramedic
students.
OCTOBER 14-18, 2019
NEW ORLEANS, LA
Effective EMT Education: Brick or Click
Author: Michael Kaduce, MPS, NRP
Associate Author: Jeffery Rollman, MPH, NRP
Introduction: The advent of online education has opened the door
to novel training options. However, it is unclear if online programs can
match the success of their traditional counterparts. Though many
online/hybrid emergency medical technician (EMT) and paramedic
courses exist nationwide, little empirical data exists to support pro-
gram effectiveness.
Objective: Evaluate whether online/hybrid EMT education is as
effective as traditional in-class EMT education.
Methods: A 12-month retrospective review of both online/hybrid
and traditional EMT education began in August 2017. Both classes
totaled 182 hours of training, including 24 hours of ambulance ride-
along and the same textbook, based on the U.S. Department of
Transportation EMT curriculum, grading policy, exams, and policy
manual. All the traditional students’ hours were in person, while
hybrid students completed didactic education (54 hours) in an
online synchronous format with 52 hours of in-person skills labs.
Both courses were evaluated for completion and NREMT certification
exam passage rates. Course completion was defined as students
who completed all course requirements among those who took the
first exam. Pearson’s chi-square tests of proportions were performed
to quantify differences in outcomes between the two independent
samples of EMT course types.
Results: In total 1,062 students enrolled in the EMT courses (521
hybrid, 541 traditional), and 991 students took the first course exam
(473 hybrid, 518 traditional). Among those who took the first exam, no
significant difference was found in course completion rates (71.9%
hybrid, 76.8% traditional, p=0.077). No significant differences were
found in first-attempt NREMT passage rates (98.2% hybrid, 98.8%
traditional, p=0.54) or within 3 attempts (98.5% hybrid, 98.8% tra-
ditional, p=0.75). Student demographics were unavailable so data
could not be adjusted for student-level characteristics.
Conclusions: Similar outcomes in completion and NREMT passage
rates suggest the hybrid course prepares students for the NREMT
exam as well as the traditional course. Further research is necessary
to understand which student-level factors are associated with attri-
tion, retention, and success in hybrid online EMT education.
Does Your Address Make the Grade?
Author: Lydia Hamel, BS
Associate Authors: Justin Hunter, MPA, PhD(c), NRP, FP-C; Christopher
Goenner, MHS, NRP, NCEE; Kathleen O’Connor, MPP, NRP; Tom Fentress,
MBA, NRP, PI, CFI; Adisack Nhouyvanisvong, PhD; Ashley Procum, BA;
Sahaj Khalsa, BS, NRP, NM I/C; Alan Batt, MSc, PhD(c), CCP
Introduction: There are several factors that can affect a student’s
academic performance. These include family and peer support, pre-
vious education, and socioeconomic status (SES). Research indicates
that students of lower SES are educationally disadvantaged. This
EMSWORLD.com | OCTOBER 2019 79
SPOTLIGHT:
study sought to examine the relationship between paramedic student
academic performance and county-level SES indicators.
Methods: Student academic performance data from Fisdap was
combined with data from the Robert Wood Johnson Foundation
County Health Rankings for 2017 and U.S. Census data for counties
in California, Mississippi, Louisiana, Texas, and Virginia. Multiple linear
regression modeling was performed to determine the relationship
between income, high school graduation rate, poverty, and food inse-
curity with first-attempt scores on the Fisdap Paramedic Readiness
Exam (PRE), versions 3 and 4. Counties with less than five reported
PRE3 or PRE4 scores were excluded. One-way analysis of variance
was performed between entrance exam (EE) score and parent edu-
cation level.
Results: There were 3,697 records across 151 counties (PRE3), 1,293
records across 60 counties (PRE4), and 3,607 records (EE). Results
of the multiple linear regression models indicated there was a signifi-
cant collective effect between income, poverty, graduation rate, food
insecurity, and both PRE3 scores (F[4,143]=10.66, p<0.001, R2=0.23)
and PRE4 scores (F[4,54]=4.72, p <0.01, R2=0.26). Income, gradu-
ation rate, and poverty were significant individual predictors in the
PRE3 model, but only income was a significant predictor in the PRE4
model. ANOVA was statistically significant (p<0.001) for EE score
and parental education. Students whose parents had a high school
diploma or less had the lowest EE scores (mean 77.42, SD 9.21), while
students whose parents had a graduate degree had the highest EE
scores (mean 81.55, SD 8.22).
Conclusions: This study demonstrated an association between
the county-level SES indicators mentioned above and paramedic
student academic performance. Parental education level appears
to be related to entrance exam scores. Since data were analyzed
only at the county level, it remains unclear what type of relationship
exists between individual SES and academic performance of para-
medic students. These findings support future collection of individual
student-level SES data to further explore the relationship between
SES and academic performance.
Do Paramedic Students Possess Situational
Awareness?
Author: Justin Hunter, MPA, PhD(c), NRP, FP-C
Background: For paramedic students to be situationally aware,
they must identify a situation, interpret the situation, and then be able
to predict how that information will affect future events. No empiri-
cal research has been completed that identifies whether paramedic
students possess situational awareness.
Objective: To identify if paramedic students possess situational
awareness.
Method: Students wore a point-of-view camera during a simulated
prehospital emergency call. Descriptive statistics and thematic analy-
ses of interviews were utilized to interpret the data derived from 12
80 OCTOBER 2019 | EMSWORLD.com
paramedic students in the simulated prehospital environment. Sta-
tistics were derived from debriefing interviews, surveys, as well as the
point-of-view cameras. The situational awareness global assessment
technique (SAGAT) was used during all debriefings to help determine
if students were situationally aware.
Conclusions: The data show paramedics students do not possess
full situational awareness. While the students may have been suc-
cessful in these simulations with other assessment tools, they failed
to recognize too many pertinent events, and of the events they did rec-
ognize, they struggled to properly interpret what those events meant
or how they may affect future events. Students were not performing
thorough enough assessments, which might have led to the failure to be
situationally aware. Further research is needed to determine improved
best practices in paramedic situational awareness education.
Evaluating the Impact of Individual Student Exam
Performance on Overall Cohort Exam Performance
Author: Michael Kaduce, MPS, NRP
Associate Authors: Edward Oliphant, BA, NRP; Maritza Steele, BA; Tashi
Wangmo, BA; James Dinsch, MS, NRP, CCEMT-P; Andrea Lalumia, BS,
NRP; Robert Gurliacci, BPS, EMT-P
Introduction: Student performance has been documented to be
dependent on size, socioeconomic status, and attendance, yet not
on other classmates’ performance. This study seeks to determine
if the class performance affects individual academic achievement.
Methods: A retrospective review of EMT student data in Fisdap
analyzed EMT Entrance Assessment (EMTEA) and EMT Readiness
Exam (ERE2 or ERE4) results to classify students based on exam
performance. Scores from 164 students from December 2017 to Sep-
tember 2018 were analyzed from 13 student cohorts ranging from 4
to 57 students. To determine the “cohort effect,” the student’s ability
(EMTEA score) and the cohort’s ability (mean cohort score) were mea-
sured. Student performance was divided into four student-groups.
Cohort performance was divided into three cohort-groups. ANOVA
was calculated with the dependent variable of difference score and
two factors: student-group and cohort-group.
Results: The main effect of cohort-group wasn’t statistically sig-
nificant (F[3,145]=2.5, p=0.088). The ability of the cohort didn’t have
a significant effect on ERE scores. The main effect of student-group
was statistically significant (F[3,145]=53, p<0.001). Most interesting
is the lack of an interaction effect (F[5,145]=0.9, p=0.47). Students
in a given student-group did not have a significant difference in per-
formance based on cohort-group.
Conclusions: There was no significant difference in students’ per-
formance when compared to classmates’ performance. Students who
scored lowest initially showed the most improvement, independent
of the cohort. Students who scored highest initially showed the least
improvement, again independent of cohort.

Does Patient Age Affect a Student’s Opportunity
to Be a Team Leader?
Author: John Thomas Meyer, BS, PGDip Education, CCP
Associate Authors: Adam Alford, BS, NRP; Elizabeth Todak, MS, PM;
Kyra Wicklund, MPH; Kevin Loughlin; William Camarda, MS, NRP; Marilee
Rosensweig, MEd, NRP; William Robertson, DHSc, NRP
Introduction: Students must act as team leads in the field to
successfully graduate from their paramedic program. The team
leads allow the student to develop technical skills, scene manage-
ment skills, and nonclinical skills. However, there are times when
the student as a team lead has the leadership role taken over by
the preceptor. In previous research it was shown there was a cor-
relation between the acuity of the patient and preceptors taking
control of the call.
Objectives: To determine if the age of the pediatric patient affected
the student’s ability to complete team leads; to determine if the critical-
ity of the pediatric patient affected the student’s ability to complete
team leads; to determine if the criticality and the age of the pediatric
patient affected the student’s ability to complete team leads.
Methods: The methodology for this research includes data from
student field time from January 2010 to December 2018 from para-
medic students with accounts in Fisdap, an Internet-based admin-
istrative database. SPSS was used to conduct a descriptive analysis
and represented as chart and tables.
Results: Paramedic students were team leaders for 68% of all
patient interactions. For pediatric patients the rate of the student
as the team leader dropped to 38% (p<0.00). The likelihood of the
paramedic student functioning as the team leader was lower as the
patient’s age decreased. When patient acuity was factored in, all age
groups had the same rate of team leads by the paramedic student
when the patient was deemed a “green.” However, paramedic stu-
dents had almost no opportunities to function as the team leader
for pediatric patients with higher acuities.
Conclusions: We hypothesized that the age of the patient would
also affect the likelihood of students being team leaders. Paramedic
students had fewer opportunities to function as team leaders on
pediatric patients, particularly in the younger age groups (infant, tod-
dler). The results suggest paramedic students do not get opportuni-
ties to function as team leaders for pediatric patients, and even less
so on high-acuity pediatric patients.
Are We Dense? Effects of Paramedic Program
Length and Nondidactic Course Density on
Student Summative Exam Scores
Author: Daniel Armstrong
Associate Authors: Jackson Deziel; Sarah Glass; Glen Keating; Lisa
Clegg; Christopher Metsgar
Introduction: A lack of standardization among paramedic programs
has long been identified as one of the most significant problems in
prehospital education. One example of this lack of standardization
OCTOBER 14-18, 2019
NEW ORLEANS, LA
is variance in program length and density. According to the National
Emergency Medical Services Standard Curriculum, a paramedic pro-
gram is estimated to take 1,000–1,200 hours to complete. These hours
may be delivered over months or years, affecting program density. This
study was designed to determine whether paramedic program length
and density have an effect on paramedic student success.
Methods: A retrospective analysis of Fisdap educational data
was conducted. A total of 3,268 paramedic student records from
October 2012 to January 2019 were examined. This study used stu-
dent performance on the summative Fisdap Paramedic Readiness
Exam version 3 (PRE3) as the measure of student success. Elasticity
functions were estimated to determine whether course length (in
months) and/or course density (field and clinical hours per month)
was related to performance on the PRE3 summative exam.
Results: Course length (ß=0.027, p=0.001) and course density
(ß=0.032, p<0.000) were both statistically significant contributors
to paramedic student success on the PRE3. Course density had a
greater positive effect on student success than course length. For a
10% increase in course density, student scores on the PRE3 increased
by 0.32%. Similarly, for a 10% increase in course length, student
scores on the PRE3 increased by 0.27%.
Conclusion: A positive correlation exists between the length
and the density of a paramedic program and scores on a summa-
tive paramedic exam. This study highlights the importance of length
and concentration of a paramedic student’s educational experience.
Can a Short Survey Predict Outcomes on the
NREMT Exam?
Author: Daniel Limmer, AS, LP
Associate Authors: Sandra L. Turner, RN; Robert Preshong, NRP
Hypothesis: A short survey of clinical questions and student per-
ceptions can be used to identify student outcomes on the NREMT
cognitive EMT exam.
Methods: The National Registry of Emergency Medical Techni-
cian Readiness Assessment Test (NREMT-RAT) containing two parts,
perceptions of preparation and core clinical concepts, was adminis-
tered to EMT students at the U.S. Army EMT training program. Clinical
components of the NREMT-RAT contained multiple-choice items
relating to core EMT knowledge points, including pathophysiology,
airway, cardiology and resuscitation, medical emergencies, obstet-
rics, and trauma. Three questions in the perception of preparation
and readiness section asked about the student’s EMT class, study
efforts, and ability to focus. Surveys were evaluated in an attempt to
identify differentiating characteristics between students who passed
and failed the NREMT.
Results: The 752 students in two cohorts completed the NREMT-
RAT. The NREMT pass rate for the combined cohorts was 78% (586
students). Of the students who failed the NREMT (166), 86.7% scored
7 or fewer correct. 3.8% (22) of the students who failed the NREMT
scored 8 or more correct. Also, 66% (389) of the students who
EMSWORLD.com | OCTOBER 2019 81
SPOTLIGHT:
scored 7 or fewer correct passed the NREMT. The student’s percep-
tion of preparation varied widely from their actual NREMT results.
Of those who failed the NREMT cognitive examination, 89% (147)
believed they were prepared well by their EMT class, and 55% (91)
thought their study was effective. In addition, 40% (66) of those
who failed reported feeling able to focus during study, compared to
52% (303) of successful students.
Conclusions: The NREMT-RAT identified students who were likely
to be unsuccessful on the NREMT cognitive examination but was
not a predictor of exam success. This will be helpful in identifying
students in need of remediation before testing as well as highlight-
ing foundational educational concepts to be highlighted in the EMT
classroom. Students’ perceptions of preparation did not correspond
to actual performance on the examination.
Evaluating the Impact of Individual Student
Exam Performance on Overall Cohort Exam
Performance
Author: Michael Kaduce, MPS, NRP
Associate Authors: Edward Oliphant, BA, NRP; Maritza Steele, BA;
Adisack Nhouyvanisvong, PhD; Andrea Lalumia, BS, NRP; Robert Gurli-
acci, BPS, EMT-P; James Dinsch, MS, NRP, CCEMT-P; Kenneth Kirkland,
MSN, RN, NRP
Introduction: Socioeconomic status, class size, and attendance
are known to affect student performance, but it is not yet known if
the performance of the class as a whole affects learner success. This
study seeks to determine if the class performance affects individual
academic achievement.
Methods: A retrospective review of EMT student data in Fisdap
analyzed EMT Entrance Assessment (EMTEA) and EMT Readiness
Exam (ERE2 or ERE4) scores to evaluate changes from EMTEA to
ERE when compared to classmates’ performance. Scores from 164
students from December 2017 to September 2018 were analyzed
from 13 student cohorts ranging from 4 to 57 students. To determine
the “cohort effect,” the student’s ability as measured by the EMTEA
score and the cohort’s ability (mean cohort score) were measured.
ANOVA was calculated with the dependent variable of difference
score for both student and cohort groups.
Results: The ability level of the cohort did not have a statisti-
cally significant effect on the individual ERE scores (F[3,145]=2.5,
p=0.088). Students who were low-performing did not get a boost by
being in the high-performing cohort (F[5,145]=0.9, p=0.47).
Conclusion: There is no significant difference in EMT students’
performance when compared to classmates’ performance. Students
who scored lowest initially showed the most improvement, indepen-
dent of the cohort. Students who scored highest initially showed the
least improvement, again independent of cohort.
82 OCTOBER 2019 | EMSWORLD.com
Flipping Toward Success
Author: Leah Tilden, MA, AEMT
Associate Authors: Sara Walker, MS, EMT-P; Felix Marquez, BA, NRP;
Mark Malonzo, EdD(c), NRP; Kelly Kohler, BA, NRP; Justin Allen, BA, EMT-
P; Marissa Peterson, BA; Kevin Loughlin, PhD(c); Nancy Hoffmann, MSW
Introduction: The flipped classroom methodology is based on
students gaining first exposure to new material outside of class,
followed by the assimilation of that knowledge through in-class
activities and discussion. Flipped classrooms are thought to enhance
learning through interactive activities among instructors and peers
that lead to improved outcomes. Results from a 2018 study found
EMT students have higher cognitive competency in a flipped class-
room setting.
Hypothesis: 1) Increasing the amount of flipped classroom meth-
odology in an EMT classroom will increase first-time NREMT pass
rates; 2) EMT students in a flipped classroom will have higher NREMT
first-time pass rates versus hybrid or traditional classrooms.
Methods: Surveys were distributed to about 1,600 EMS programs
across the United States that are current Fisdap users. Each indi-
vidual program was asked a universal set of questions to determine
if their EMT classes utilize a traditional, hybrid, or flipped classroom
model. Programs were also asked to share first-time NREMT pass
rates for 2017 and 2018.
Results: The survey yielded 224 responses. One hundred and
seventy-eight respondents had complete data and were included
in the final data set. Thirty-two states were represented in the data.
Sixty-seven percent of respondents self-identified as nonflipped
(hybrid and/or traditional), and 33% identified as flipped. There was
a positive correlation between increased flipped methodology in an
EMT classroom and first-time EMT class pass rates. EMT students in
classes with flipped methodology have higher NREMT first-time pass
rates than students not exposed to flipped methodology.
Conclusions: The study revealed a positive correlation between
flipped classrooms and NREMT scores. Also it was determined there is a
thin line distinguishing the flipped from the hybrid classroom methodol-
ogy. The sample size played an intricate role in determining statistical
significance. In the future the survey will be sent again to programs to
achieve a higher response rate, and then data reanalyzed.
Lab Knows Best: Effects of Experiential Course
Setting on EMT Student Success
Author: Daniel Armstrong
Associate Authors: Jackson Deziel; Christopher Metsgar; Lisa Clegg;
Glen Keating; Sarah Glass
Introduction: According to the National Emergency Medical Ser-
vices Education Standards the length of an initial Emergency Medical
Technician (EMT) course is estimated to take about 150–190 hours.
These hours include the four integrated phases of EMT education:
didactic, laboratory, clinical, and field. The didactic phase is the most

uniform, while the number of hours spent in the laboratory, clinical,
and field settings shows more variability among programs. This project
was designed to determine whether the number of hours spent in the
laboratory, clinical, and field settings are related to EMT student suc-
cess on a summative exam. Evidence from this study could be used
by educators to determine the most effective training venues for a
more valuable educational experience.
Methods: A retrospective analysis of Fisdap educational data was
conducted. A total of 2,125 EMT student records from October 2012 to
January 2019 were examined. This study used student performance
on the summative Fisdap EMT Readiness Exam version 2 (ERE2) as
the measure of student success. Student data were analyzed with
linear regression and elasticity models to determine if the number of
hours students spent in the laboratory, clinical, and field settings was
related to performance on the ERE2 summative exam.
Results: Linear modeling revealed that laboratory (ß=0.027,
p<0.000) and clinical (ß=0.016, p=0.024) hours had a statistically sig-
nificant impact on exam performance, while the number of field hours
was not statistically significant to test scores (ß=[-0.008], p=0.214).
The elasticity function isolated laboratory hours as the most impor-
tant contributor to EMT student success. For each 10% increase in
lab hours, student scores on the summative exam increased by 0.15%
(ß=0.015, p<0.000).
Conclusions: The number of hours spent in the laboratory had
a statistically significant positive impact on student success and
appears to be the most significant influence on EMT student success
outside of the traditional didactic phase. This study highlights that
assessment and skills practice in the lab may be the most beneficial
for initial EMT students.
Beyond the Lecture: Effects of Nondidactic Hours
on Paramedic Student Success
Author: Daniel Armstrong
Associate Authors: Jackson Deziel; Sarah Glass; Angela Finney; Lisa
Clegg; Christopher Metsgar
Introduction: According to the National Emergency Medical Ser-
vices Standard Curriculum, the length for an initial paramedic course
is estimated to take about 1,000–1,200 hours. The hours spent in a
paramedic program span didactic, lab, clinical, and field settings. The
hours spent in each of these components also varies among programs.
Accreditation guidelines do not offer specific information regarding
in which setting the students should concentrate their time. Despite
widespread agreement on the importance of nondidactic experiences,
the number of hours for each phase remains unclear and inconsistent
across programs. This study was designed to explore which nondidac-
tic setting is the most valuable for paramedic students.
Methods: A retrospective analysis of Fisdap educational data was
conducted. A total of 3,268 paramedic student records from October
2012 to January 2019 were examined. This study used student perfor-
mance on the summative Fisdap Paramedic Readiness Exam version
OCTOBER 14-18, 2019
NEW ORLEANS, LA
3 (PRE3) as the measure of student success. Student data were ana-
lyzed with linear regression and elasticity models to determine if the
number of hours students spent in the laboratory, clinical, and field
settings were related to performance on the PRE3 summative exam.
Results: Students who took the PRE3 summative exam increased
their scores when they had more field (ß=0.011, p<0.000) and lab hours
(ß=0.001, p=0.040), while increased clinical times appeared to have a
negative impact on PRE3 scores (ß=-0.004, p=0.025). The elasticity
function isolated field and laboratory hours as the most important
contributor to paramedic student success. For each 10% increase
in field hours, student scores on the summative exam increased by
0.33% (ß=0.033, p<0.000). Additionally, a 10% increase in lab hours
yielded a PRE3 score increase of 0.08% (ß=0.008, p<0.000). Clinical
hours remained negative correlated to student success (ß=[-0.011],
p=0.081).
Conclusions: The number of hours spent in laboratory and the field
experiences had a statistically significant positive impact on student
success on a summative paramedic exam. This study highlights that
assessment and skills practice in the lab and internship may be the
most beneficial for initial paramedic students.
Do Team Lead Experiences of Paramedic Students
Influence Critical Thinking?
Author: Kim McKenna, PhD, RN, EMT-P
Associate Authors: Patricia Tritt, MA, RN; Steven Jenison, MD, NRP;
Elizabeth Robinson, MD; Jose Palma, PhD; Megan Corry, EdD, NREMT-P
Introduction: Since 2013 EMS education has had substantial
changes in laboratory and team lead requirements. Previous research
demonstrated a positive correlation between the number of patient
contacts and critical-thinking scores (CTS) on summative and certi-
fication exams. We investigated the relationship between team leads
in the lab and CTS and the number of team leads in the field and CTS.
Methods: This study used retrospective data from Fisdap between
2014 and 2019. Data points included the number of field and lab
patients and team leads. Students’ logit scores were correlated to
total team leads and total patient encounters.
Results: A sample of 2,623 students from the 2014–2019 PRE4
administrations were evaluated. The average PRE4 CTS was 0.65
(SD=10). There was a positive correlation between field team leads
and CTS (r=0.08, p<0.01) and lab team leads and CTS (r=0.09, p<0.01).
Limitations include the timing of PRE4 exam and definition of “team
leads” varying by program.
Setting Total patient (average) Team lead (average)
Field 13 (SD=30) 7 (SD=15)
Lab 92 (SD=47.7) 73 (SD=43.4)
Conclusions: These results confirm previous findings that correlate
team leads to improved critical thinking performance.
EMSWORLD.com | OCTOBER 2019 83
 READER FEEDBACK: YOUR COMMENTS, POSTS, E-MAILS, AND REACTIONS
WELCOMES YOUR FEEDBACK
The Benefit of Lights and Sirens
In reference to the April 2019 Journal Watch column on use of lights
and sirens [“Lights, Sirens, and Ambulance Crash Risk,” www.
emsworld.com/article/1222428/journal-watch-lights-sirens-and-
ambulance-crash-risk]: It seems the latest trend is to debunk the
general efficacy of L&S. This is progressive and welcomed, but as
we use these studies to make policy changes, I’d like to warn us
not to apply findings too universally.
Case in point: I used to work in a region where a certain two-block
span and major thoroughfare would take 15–20 minutes to navigate. It
was the only way to reach the local everything (trauma, STEMI, stroke)
center. Simple L&S would reduce the time to 2–4 minutes. Additionally, the
drive from our service area to this specialty center was 40-plus minutes
in rush hour, but under 15 with L&S. Our response times themselves were
5–8 L&S, reduced from 10–15 minutes without.
Keep in mind that in the most congested areas, running L&S does not
mean driving at breakneck speeds. It usually means slowly weaving around
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stopped traffic at 10–25 mph. While studies provide data on urban ver-
sus rural, it is then up to us to use further critical thinking and realistic
analysis that accounts for our various local systems prior to implementing
any policy changes that may impact time to definitive care for patients in
critical conditions.
—Anthony G. Mendoza, paramedic and EMS educator,
Los Angeles/Ventura County, Calif.
Extubation: Leave Well Enough Alone
I read with great interest the CE article on unplanned extubation in
the July 2019 edition [Unplanned Extubation: An Underrecognized
Complication, www.emsworld.com/article/1222047/unplanned-
extubation-underrecognized-complication]. While this was a good
review, it leads to several observations.
First, you have a patient who had been hypoxemic with bradypnea,
with otherwise normal vital signs. Manual ventilation and intubation
returned all vitals to normal; the patient was packaged and placed in
a transport vehicle. In all honesty that should have ended the exercise.
Unfortunately, a completely preventable chain of events then ensued.
The patient became a suspected opiate intoxication, with a secure air-
way and normal vital signs, who was then given nalaxone during the
transport to the hospital. The patient completed a transport to the
hospital with an unrecognized extubation, which was only diagnosed
by chest x-ray. This points out several errors in both judgement and
assessment.
A patient who is otherwise stable should not be reversed while in
transit, when supplies, equipment, and personnel may be suboptimal
to control sudden arousal. Waveform capnography may not demon-
strate intubation or extubation if the endotracheal tube is in the airway
(either upper or lower) if exhaled airflow is going past the CO2 cuvette/
sampling line.
Tube location was not mentioned. It is difficult to monitor if one never
pays attention. That being said, one of the problems with securing an
endotracheal tube is that it is secured on a pivot point, which will allow
a tube to stay secure at the lip, but may bend upward into the posterior
oropharynx and become dislodged.
Finally, ventilating a patient with “the tip of the tube in the posterior
pharynx” will not have the same amount of back pressure that will be
noticed when a tube is correctly placed. There will be a large air leak
noticed during manual inspiration, and breath sounds will not be in
heard coordination with mandatory breaths.
The take-home message is actually two things. Don’t invite prob-
lems by attempting to make a good situation better, and confirm and
reconfirm the status of invasive airways after all patient movement,
whether performed by the caregivers or the patient.
—Nick Widder, RRT-NPS, ACCS, C-NPT, NRP
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