HELLP SYNDROME p. 39
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Medicine, Albany Medical College, NY
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Contents
JUNE 2015
VOL. 44 | ISSUE 6
25
28 Best Practices in CE
How technology is changing the way we deliver continuing education
By the CECBEMS Board of Directors
28
By Mario J. Weber, JD, MPA, NRP, & Michael Gerber, MPH, NRP
COLUMNS
F E AT UR E S
15 CASE REVIEW
Severe Heat Illness
20 GUEST EDITORIAL
Evaluating Patients
Decision-Making Capacity
58 LIFE SUPPORT
Head of the Class
DEPARTMENTS
46
8
12
13
55
56
By Ed Mund
CE A R T ICL E
ON THE COVER
Photo in tablet courtesy of
Richmond Ambulance Authority,
www.raaems.org.
39 HELLP Syndrome
How to recognize and treat this
life-threatening complication of
pregnancy
39
EMS World ISSN 1946-9365 (print) and ISSN 1946-4967 (online) is
published monthly by Cygnus Business Media, 1233 Janesville Ave.,
Fort Atkinson, WI 53538. The publisher reserves the right to reject
nonqualified subscribers. One-year subscriptions for nonqualified
individuals: U.S. $50; Canada and Mexico $70; all other countries
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FE ATURES
Like any business,
every EMS provider
who charges user fees
has some percentage
of customers who are
unable to pay due to
fnancial hardship. Most
just write the unpaid
fees of as bad debts;
Life EMS Ambulance
converts some of these unpaid fees into volunteer assistance at local
nonproft groups. Read more at EMSWorld.com/12072080.
NASHVILLE
www.mountainmedicine.co.uk
PODC A S TS
EMS SQUADCAST: THE FUTURE OF
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Go to EMSWorld.com/awards
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or a colleague in the
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Attending
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By Nancy Perry
Whats
on
the
Horizon?
Theres never been a more exciting time to be in EMS
An investment in knowledge
pays the best interest.
Benjamin Franklin
THIS MONTH I CELEBRATE MY 20TH ANNIVERSARY
working at EMS World. Having spent the past two decades
covering advances in prehospital practice, I dont think
theres been a more exciting time to be in EMS than right
now.
As authors Mario Weber and Michael Gerber report
in this issue, evidence-based practice is gaining traction
throughout EMS, as we transition to the use of high-quality evidencerather than consensus or expert opinion
as the basis for our clinical guidelines (see Why Research
Is Important in EMS on page 32). At the same time, we
are casting a critical eye over every aspect of EMS operations. Read Should Response Time Be a Performance
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NEWS NETWORK
Measles Updates
In the year 2000, measles was declared eliminated in the United
States. Now, unfortunately, in 201415 it is back.
The most recent outbreak to make the news began from
December 28, 2014, to February 13, 2015. This outbreak appears to
have been started by a traveler who acquired the disease overseas
and then visited Disneyland in California, resulting in approximately
114 cases in seven states (California, Colorado, Nebraska, Utah,
Oregon, Washington and Arizona). By February 27 the numbers
had increased to 170 cases in 17 states and the District of Columbia.
About 125 cases are related to exposure at Disneyland. Outbreaks
in Illinois, Nevada and Washington are not related to the Disneyland
outbreak.
14
CASE REVIEW
ABOUT THE
AUTHOR
James J. Augustine,
MD, FACEP, is an
emergency physician
and the director of
clinical operations
at EMP in Canton,
OH. He serves on
the clinical faculty in
the Department of
Emergency Medicine
at Wright State
University; as an EMS
medical director for
fire-based systems in
Atlanta, GA; Naples,
FL; and Dayton, OH;
and on the EMS World
Editorial Advisory
Board. Contact him at
jaugustine@emp.com.
Initial Assessment
A 45-year-old male, confused and warm to
the touch. He was initially reported to be
unresponsive but has been speaking since he
was removed from the training building.
PRIMARY SURVEY
AIRWAY: Open.
BREATHING: Uncompromised.
CIRCULATION: Poor capillary refill.
DISABILITY: Speaking inappropriately, not
oriented to time or place.
EXPOSURE OF OTHER MAJOR PROBLEMS:
Skin blotched, warm to touch on the head, but
extremities cool.
VITAL SIGNS
TIME
HR
BP
RR
PULSE
OX.
1240
130
100/palp.
28
94%
1246
136
104/palp.
28
95%
1253
142
96/palp.
24
92%
AMPLE ASSESSMENT
ALLERGIES: None.
MEDICATIONS: None known.
PAST MEDICAL HISTORY: Negative.
LAST INTAKE: Breakfast at 0700.
EVENT: Altered mental status with likely severe
heat illness.
15
CASE REVIEW
www.naemt.org
16
Case Discussion
The most serious form of heat illness is
often referred to as heatstroke. The most
important symptom that differentiates
severe heat illness is an altered level of
consciousness. The risk factors for severe
heat illness are:
Poor physical fitness/excessive body
weight, and those who have had a previous heat-related illness;
Older age. Persons over 40, even those
in relatively good physical condition, have
an increased potential for heat illness;
Medications or street drugs. Many medications and a large number of illegal drugs
can impact the bodys temperature-regulating systems and hydration level;
Lack of heat acclimatization. This means
severe heat illnesses often happen in the
first few weeks or months after winter
Hospital Course
On arrival at the ED, the patient has a rectal temperature of 105F despite about 30
minutes of prehospital cooling. The cardiac bypass operating room is opened, and
he goes through that process. Hes then
placed in the intensive care unit and recov-
Learning Point
Incident rehabilitation is an important part
of training operations with heavy physical
activity. Altered mental status is the key
symptom for recognizing patients in serious trouble from a heat-related illness.
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CASE REVIEW
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Incident Rehabilitation
NFPA 1584: Standard on the Rehabilitation
Process for Members During Emergency
Operations and Training Exercises was instituted in 2008, and the second revision will
be published shortly. The standard states,
Procedures shall be in place to ensure that
rehabilitation operations commence whenever emergency operations pose the risk of
members exceeding a safe level of physical
or mental endurance.
The standard calls for liberal application of rehabilitation services at working
incidents and training operations. This is
will include screening and surveillance programs to protect candidates and department members taking part in these strenuous activities.
Many fire departments work with support
EMS agencies. These EMS personnel must
be trained and equipped to perform fire
rehabilitation services. Programs should
include training, equipment, methods of
deployment, collection of information,
documentation and integration with other
critical scene responsibilities. If EMS personnel are to establish and maintain the
rehab program, how will that be accomplished at incidents where there are civilian
victims? Who provides rehab if a firefighter
gets injured and needs to be transported to
a hospital? How will rehab crews be utilized
and rotated in prolonged incidents?
Some departments have invested in
equipment useful for personnel cooling.
This may include cooling systems, fans,
shades, drink dispensers, icemakers
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19
GUEST EDITORIAL
20
EMERGENCY
MANAGEMENT
& LEADERSHIP
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21
GUEST EDITORIAL
most EMS systems require the EMT or paramedic to assess the patients capacity to
decline transport and make contact with
medical control. The case at the beginning
is an extreme one, but exploring it can help
frame how to approach such situations.
Evaluating Capacity
While the word competent is often used
when discussing decision-making ability,
such a term is typically reserved for use only
by judges making legal decisions.2 Our discussion concerns medical decision-making
ability (as opposed to the capacity to make
other decisions, such as financial ones). The
physicians question, Is he sober and competent? speaks directly to this. It means,
Are there features about this patient
that impair his ability to make decisions?
including intoxication. Its important that
EMS providers are able to evaluate medical decision-making capacity.
There are several different approaches to
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23
GUEST EDITORIAL
I BELIEVE PATIENTS
HAVE THE RIGHT TO
MAKE INFORMED
DECISIONS I DONT
NECESSARILY AGREE
WITH.
Conclusion
REFERENCES
1. Brock DW. The idea of shared decision making between
physicians and patients. Kennedy Inst Ethics J, 1991; 1(1):
2847.
2. Lo, B. Assessing decision-making capacity. J of Law Med &
Ethics, 1990; 18(3): 193201.
3. Jones RC, Holden T. A guide to assessing decision-making
capacity. Cleve Clin J Med, 2004; 71(12): 9715.
24
STUDENT INTERVIEWS
This article
is the first in
a three-part
series about
interviewing
techniques.
In Part 1,
EMS World
columnist
Mike Rubin
discusses
student
interviews.
25
STUDENT INTERVIEWS
ABOUT THE
AUTHOR
Mike Rubin is a
paramedic in Nashville,
TN, and a member of the
EMS World editorial advisory board. Contact him
at mgr22@prodigy.net.
26
Judgment Day
Interviewers should encourage candidates to ask questions too.
Applicants who see their interviews as conversations rather
than interrogations often learn more about the opportunities
theyre pursuing and presumably make better decisions about
continuing or halting the application process. Thought-provoking questions from subjects can also indicate sincere interest
and good sense.
How candidates dress is another indication of their judgment,
Werfel notes. Most of our applicants look like theyre showing
up at a baseball gamejeans, shorts, tank tops, he says. That
goes to maturity.
Be careful, though; I once interviewed a guy who arrived
in an oil-stained work shirt. I asked him if that was his normal
dress. He said, No, I left work to do this. I really need to get
into this course. I make allowances for that.
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Summary
Student interviews help ensure a match between classroom imperatives and candidates capabilities. Exploring students maturity and
judgment is often more important than confirming their academic
proficiency.
Walking into an interview unprepared can be as damaging
for interviewers as for interviewees. Selecting the right people
and the right process for conducting interviews depends on
planning and practice. A team approach to interviewing can be
particularly effective if team members take the time to discuss
topics and roles before meeting with candidates.
Although imprecise, interviews increase the chances that
instructors and students will achieve mutually satisfying results,
particularly when students play active roles.
Next time well cover patient interviews.
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The product information contained in this document, including the product images and additional product materials, was collected from various supplier sources. All product claims and specifications are those of the product
suppliers, not Moore Medical LLC or its affiliates (Moore) and have not been independently verified by Moore.
Moore is not responsible for errors or omissions in the product information. The properties of a product may
change or be inaccurate following the posting or printing of the product information in the document, either in
the print or online version. Caution should be exercised when using or purchasing any products from Moores
online or print documents by closely examining the product packaging and the labeling prior to use. Due to
product changes, information listed in this document is subject to change without notice. This information is
placed solely for your convenience in ordering and Moore disclaims all responsibility for its completeness and
accuracy, whether or not the inaccuracy or incompleteness is due to fault or error by Moore. All trademarks and
registered trademarks are the property of their respective owners. 2015 Moore Medical LLC. #7144
CONTINUING EDUCATION
Best Practices in CE
28
Evolving Educational
Technologies
In recent months, the CECBEMS Board
of Directors has witnessed a technological
evolution of DL activities available to EMSP.
Some truly innovative DL designs have led
to a shift in consumer/marketplace loyalty
toward the innovation and away from the
more traditional education formats.
INNOVATION IS
DRIVING EVOLUTION
IN CONTINUING
EDUCATION.
Clearly, this new generation of EMS
providers has greater access to technology
that provides instant information at their
fingertips, and they are not as interested in
traditional education. Instead, they yearn
for innovation, for flash and activities they
can accomplish on the go without being
tethered to a teacher or a classroom.1
Accredited providers and CECBEMS
accreditation applicants must commit significant resources to the production and
delivery of the activities listed in their catalogs. High-quality CE activities are not inexpensive to produce regardless of the type
of presentation. As [continuing education
expert Chuck] Karayan stated, the quality
of the presentation must meet or exceed
the investment the student makes to view
and participate in the activity.2 It is in this
light that the CECBEMS Board of Directors
would like to highlight best-practice models
New CE Models
Virtual instructor lead training (VILT)
VILT is a new distributed learning technology that allows an instructor to present information by means of a lecture when
students are only present in a virtual classroom. Students log in to the classroom and
are able to view and hear the presentation.
They interact with the instructor either by
voice and webcam video or by typing questions in a fashion similar to a chat room. All
pieces of the activity occur simultaneously.
Students are typically assigned textbook
chapter reading before the event. At the
end of the session, the students are given
a unique code that grants them access to
a post-test.
Integrated testing
Integrated testing ensures students complete the content requirements by writing
the post-test into the content. In other
words, a student progresses through an
interactive video training program. At key
points in the video the student is given a
question or short series of questions that
must be completed before the student may
progress to the next section. Failure to correctly respond to the questions returns the
student to the relevant section in the video
so the content can be reviewed. The question is then presented again. This is a great
way to ensure student participation.
Accreditation Delivery
CECBEMS, by its charter, maintains
the standards for the delivery of EMS
CE. Those standards include requirements for active medical direction, valid
post-tests, quality infrastructure, sound
educational design including delivery
methodology, marketing, fees, evaluation, student record-keeping and data
reporting.
CECBEMS accreditation exists so that
EMS providers have access to highquality standard-driven continuing education activities and are awarded credit
for participating in such activities. One
of the greatest challenges of delivery
of CECBEMS accreditation is ensuring
that CE providers accurately report the
names, certification numbers, certification state, activity numbers and CEH
hours earned by subscribers (EMS providers). It is of the utmost importance
that CE providers accurately report
data to the CECBEMS data management center so each and every EMS
provider gets credit for the CE they
complete. CECBEMS depends on the
quality of the data it receives. EMTs and
paramedics depend on CECBEMS to
provide accredited programs that are
less likely to be subject to audit by the
National Registry of EMTs or individual
state EMS offices.
Much work is being done to make
the assignment of CEH objective and
29
CONTINUING EDUCATION
30
can be produced by survey of what EMS providers feel they need; review of EMS call data;
review of quality improvement data; review of
patient outcomes; and review of population
demographics. Needs assessments can also
be carried out on an individual level. In these
cases, the criteria listed above are reviewed
taking a short post-test. People are gravitating more toward the higher-end stuff:
the narrative videos, the cell phone applications. Those are the things people want
to seeit has to be interactive and flashy,
but also relevant and current.
Those are the trends now, and its fascinating to watch. Back when I started,
our first monitor was the Lifepak 5, and
there werent a whole lot of functions. It
defibrillated, it read an EKG, and we could
hook it up to a monitor and transmit an
EKG, and that was pretty much it. But as
technological changes happen, continuing education programs have to keep up
with the times.
When CE providers prepare to seek
accreditation for their programs, are
there areas they commonly overlook or
that frequently delay the process? What
trips people up?
I think the things people tend to underestimate when they prepare their applications
are 1) the participation of a system-wide or
service-level medical director whos active,
involved and has EMS experience, and 2)
that theres an active program committee.
We actually like to see some description of
how the medical director interacts with the
program committee and how the workings
of that committee help set their educational agenda.
The needs assessment is built into
that as well. Folks may not to do a good,
careful, detailed needs assessment, and
instead just say, Well, lets just do the
same stuff next year we did last year.
Thats not what EMS providers want. They
want new; they want to see things that
REFERENCES
1. Aran Levasseur. Teaching Innovation Is About More
Than iPads in the Classroom. Media Shift, www.pbs.org/
mediashift/2012/07/teaching-innovation-is-about-morethan-ipads-in-the-classroom198/.
2. Chuck Karayan. The Problem with Continuing
Education. American Surveyor, www.
amerisurv.com/PDF/TheAmericanSurveyor_
KarayanTheProblemWithContinuingEducation_
May2005.pdf.
31
EMS RESEARCH
Why Research Is
Important in EMS
Michael Gerber is a
featured speaker at
EMS World Expo, Sept.
1519 in Las Vegas.
Visit EMSWorldExpo.com.
By Mario J. Weber, JD, MPA, NRP, & Michael Gerber, MPH, NRP
First Do No Harm
One of the guiding maxims for all healthcare providers is to first do no harm. The
sad truth, however, is that several clinical
interventions employed as standard prac-
32
ficult, if not impossible, for EMS researchers to craft an ideal study sample. Frequent
EMS users in particular tend to overrepresent certain segments of the population.16
EMS research also presents ethical barriers not always present in other contexts.
For example, obtaining informed consent
from patients in the prehospital setting
may not be possible. Consequentlyand
despite the lack of evidence for much of
the EMS standard of caredeviating from
accepted interventions under an exception
from informed consent can present a difficult ethical quandary.17 In the past year,
media attention surrounding a clinical trial
to examine the efficacy of epinephrine in
cardiac arrest has questioned whether withholding the medication (obviously without
a patients permission) would cause harm.18
A recent study, however, found that patients
themselves may be highly accepting of
exceptions from informed consent.19 The
same cannot be said for prehospital providers, as only 30% in one survey agreed with
enrolling patients in a study without their
informed consent.20
33
EMS RESEARCH
isolated, the severity of each patients condition may also vary greatly. This is particularly problematic when studying the relative
efficacy of interventions that are generally
reserved for more critical patients, e.g., endotracheal intubation.
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34
Existing Data
Many EMS systems already collect a large
volume of information during their daily
operations. These data include information regarding incidents (type of call and
location), patients (identifying information
and medical history), clinical presentations
(symptoms and vital signs) and interven-
tions provided by EMS. In most jurisdictions these data are reported to national and
state databases such as the National EMS
Information System (NEMSIS).
For the most part, however, EMS systems have not yet been able to translate this
wealth of information into actionable clinical research.26 Part of the reason is that the
data they collect is often unreliable or incomplete. EMS providers are inconsistent when it
comes to information-gathering. Even when
EMS1504S
35
EMS RESEARCH
Steve Berry
36
Conclusion
If EMS is to continue its professional evolution and become a respected member of
the healthcare community, it is critical that
prehospital clinical decisions be made on
the basis of good research. The next step
will require that more EMS providers
become actively engaged in conducting
EMS researchin order to supplement the
small cadre of academic EMS researchers
and also bolster the credibility of EMS as a
stand-alone profession that can contribute
to its own clinical development.
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For More Information Circle 27 on Reader Service Card
REFERENCES
1. Institute of Medicine. Committee on the Future of
Emergency Care in the United States Health System.
Emergency Medical Services: At the Crossroads. Washington,
DC: National Academies Press, 2006.
2. Gausche-Hill M, et al. An evidence-based guideline for
prehospital analgesia in trauma. Preh Emerg Care, 2014;
18(s1): 2534.
3. Shah MI, et al. An evidence-based guideline for pediatric
prehospital seizure management using GRADE methodology.
Preh Emerg Care, 2014; 18(s1): 1524.
4. Bulger EM, et al. An evidence-based prehospital guideline
for external hemorrhage control: American College of
Surgeons Committee on Trauma. Preh Emerg Care, 2014;
18(2): 16373.
5. Lang ES, et al. A national model for developing,
implementing, and evaluating evidence-based guidelines for
prehospital care. Acad Emerg Med, 2012; 19(2): 2019.
6. Bledsoe BE. EMS Myth #1: Medical Anti-Shock Trousers
(MAST) autotransfuse a signifcant amount of blood and save
lives. EMS World, www.emsworld.com/10325078.
7. Wang HE, Yealy DM. Out-of-hospital endotracheal
intubationits time to stop pretending that problems dont
exist. Acad Emerg Med, 2005; 12(12): 1,245.
P r o te c t y o u r D e Pa rtM en t, Sta ff a n D I nV en t o ry
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EMS RESEARCH
online.uwosh.edu/ferm
38
CONTINUING EDUCATION
To take the CE test that accompanies this article and receive 1 hour of CE credit
accredited by CECBEMS, go to rapidce.com. Test costs $6.95. Questions?
E-mail editor@EMSWorld.com.
HELLP Syndrome
How to recognize and treat this life-threatening
complication of pregnancy
By Scott R. Snyder, BS, NREMT-P, Sean M. Kivlehan, MD, MPH, NREMT-P, Kevin T. Collopy, BA, FP-C, CCEMT-P, NREMT-P, WEMT
CONTINUING
EDUCATION
This CE activity is approved by
EMS World, an organization
accredited by the Continuing
Education Coordinating
Board for Emergency Medical
Services (CECBEMS), for 1 CEU.
OBJECTIVES
Define HELLP syndrome.
Discuss the pathophysiology
of HELLP syndrome.
Differentiate HELLP syndrome
from the other liver disorders
of pregnancy.
Identify the signs and
symptoms of HELLP
syndrome.
Discuss prehospital
management of the patient
with HELLP syndrome.
AndreyPopov /iStock/Thinkstock
39
CONTINUING EDUCATION
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CONTINUING EDUCATION
Management
Before discussing prehospital management
of the patient with HELLP syndrome, it
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43
CONTINUING EDUCATION
44
Conclusion
The patient is placed on the gurney in a
semi-Fowlers position and administered
oxygen via nonrebreather mask at 15 lpm.
The crew considers CPAP but rules it out
due to the patients decreased level of consciousness and mental status. A 16-gauge
IV catheter is placed and a 1,000-mL bag of
normal saline with a macro drip set attached
is administered KVO.
Upon arrival at the ED, the patient is
intubated, the 12-lead ECG repeated and
a Foley catheter placed. A chest radiograph reveals bilateral pulmonary edema.
Laboratory findings include increased
serum creatinine and aminotransferases,
thrombocytopenia, decreased platelets,
increased serum bilirubin and hemolysis.
The patient is determined to be suffering
from postpartum HELLP syndrome complicated by DIC and is administered fresh
frozen plasma, packed red blood cells and
REFERENCES
1. Stone JH. HELLP syndrome: hemolysis, elevated liver
enzymes, and low platelets. JAMA, 1998; 280: 559.
2. Sibai BM. HELLP syndrome. UpToDate.com, www.uptodate.
com/contents/hellp-syndrome.
3. van Oostwaard MF, Langenveld J. Recurrence of
hypertensive disorders of pregnancy: an individual patient
data metaanalysis. Am J Obstet Gynecol, 2015; 215(5):
624e1624e17.
4. Lachmeijer AM, Arngrímsson R, et al. A genomewide scan for preeclampsia in the Netherlands. Eur J Hum
Genet, 2001; 9(10): 758.
5. Sibai BM, Ramadan MK, et al. Maternal morbidity and
mortality in 442 pregnancies with hemolysis, elevated liver
enzymes, and low platelets (HELLP syndrome). Am J Obstet
Gynecol, 1993; 169(4): 1,000.
6. Hepburn IS, Schade RR. Pregnancy-associated liver
disorders. Dig Dis Sci, 2008 Sep; 53(9): 2,33458.
7. Kondrackiene J, Kupcinskas L. Liver diseases unique to
pregnancy. Medicina (Kaunas), 2008; 44(5): 33745.
8. Lee NM, Brady CW. Liver disease in pregnancy. WJG, 2009;
15(8): 897906.
9. Sibai BM. The HELLP syndrome (hemolysis, elevated liver
enzymes, and low platelets): much ado about nothing? Am J
Obstet Gynecol, 1990; 162: 311.
10. Simhan HN, Himes KP. Neuroprotective effects of in
utero exposure to magnesium sulfate. UpToDate.com, www.
uptodate.com/contents/neuroprotective-effects-of-in-uteroexposure-to-magnesium-sulfate.
11. Echevarria MA, Kuhn GJ. Chapter 104: Emergencies
After 20 Weeks of Pregnancy and the Postpartum Period. In:
Tintinalli JE, et al., eds. Tintinallis Emergency Medicine: A
Comprehensive Study Guide, 7th ed. New York, NY: McGrawHill, 2011.
12. Sibai BM. Diagnosis, controversies, and management of
the syndrome of hemolysis, elevated liver enzymes, and low
platelet count. Obstet Gynecol, 2004; 103: 981.
13. August P. Management of hypertension in pregnant and
postpartum women. UpToDate.com, www.uptodate.com/
contents/management-of-hypertension-in-pregnant-andpostpartum-women.
14. Duley L, Meher S, Jones L. Drugs for treatment of very high
blood pressure during pregnancy. Cochrane Database Syst
Rev, 2013; 7: CD001449.
15. American College of Obstetricians and Gynecologists,
Task Force on Hypertension in Pregnancy. Hypertension in
pregnancy. Report of the American College of Obstetricians
and Gynecologists Task Force on Hypertension in Pregnancy.
Obstet Gynecol, 2013; 122(5): 1,122.
16. Lacasse A, Rey E, et al. Nausea and vomiting of pregnancy:
what about quality of life? BJOG, 2008; 115(12): 1,484.
17. Lee NM, Saha S. Nausea and vomiting of pregnancy.
Gastroenterol Clin North Am, 2011; 40(2): 309.
18. Matthews A, Haas DM, et al. Interventions for nausea and
vomiting in early pregnancy. Cochrane Database Syst Rev,
2014; 3: CD007575.
19. Bailit JL. Hyperemesis gravidarium: Epidemiologic
fndings from a large cohort. Am J Obstet Gynecol, 2005;
193(3 Pt 1): 811.
20. Laifer SA, Stiller RJ, et al. Ursodeoxycholic acid for the
treatment of intrahepatic cholestasis of pregnancy. J Matern
Fetal Med, 2001; 10(2): 131.
21. Lee RH, Goodwin TM, et al. The prevalence of intrahepatic
cholestasis of pregnancy in a primarily Latina Los Angeles
population. J Perinatol, 2006; 26(9): 527.
22. Sibai B, Dekker G, Kupferminc M. Pre-eclampsia. Lancet,
2005 Feb 26; 365(9,461): 78599.
23. Mjahed K, Charra B, et al. Acute fatty liver of pregnancy.
Arch Gynecol Obstet, 2006; 274(6): 34953.
24. Castro MA, Fassett MJ, et al. Reversible peripartum
liver failure: a new perspective on the diagnosis, treatment,
and cause of acute fatty liver of pregnancy, based on 28
consecutive cases. Am J Obstet Gynecol, 1999; 181(2):
38995.
45
PERFORMANCE MEASURES
46
a Performance Indicator?
Brian LaCroix, President, Allina Health EMS
o. But ignore them at your peril.
If EMS is the practice of medicine, measuring
the value of a system based on how fast you drive
seems archaic and overly simplistic. However, it
wasnt all that long ago when all most ambulance
agencies had to offer was a quick response.
Prior to the 1960s, most well-intended ambulance
drivers had two skills: comfort around chaos and
driving fast. This rapid-response model was rooted
in the experience of our of police and fire colleagues.
Driving fast
is not a key
indicator of
quality.
Brian LaCroix
Greater
emphasis on
developing
evidencebased
measures of
clinical quality
is required.
Steve Knight, PhD
Time is easy
to measure
response times
are not.
Bruce Moeller,
PhD
47
PERFORMANCE MEASURES
2015 Pinnacle
EMS Leadership
Forum
The Pinnacle EMS
Leadership Forum is
the premier event for
EMS leaders from all
service models, for
every size of service.
Sponsored by Fitch &
Associates, it is now in
its 10th year. Pinnacle
2015 will be held at the
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Plantation Resort, near
Jacksonville, FL, August
3-7, 2015. For more see
pinnacle-ems.com.
We have done
a very good
job of training
our customers
to expect us to
arrive at their
emergency
within an
average of six
minutes.
Norman Seals
48
EMS agencies
need to stop
designing
systems around
response-time
goals.
Scott Matin, MBA
stroke, airway obstruction and severe trauma, the
majority of calls to which EMS is dispatched arent as
time-sensitive and dont show better outcomes with
a more rapid response. Additionally, emphasis on
response time may have unintended consequences
such as more motor vehicle crashes and skill degradation when increasing the number of paramedics
answering a finite number of calls.
EMS agencies need to stop designing systems
around response-time goals. While EMS systems
need to meet public expectations, these expectations
should be weighed against available resources and the
ultimate good of the community. For EMS agencies
to effectively convey the message that faster doesnt
always mean better, they must open an ongoing dialogue with their communities. Agencies need to communicate what quality is in EMS and how it can be
obtained. Programs that can lead to better outcomes
include a robust first responder system utilizing current police and fire resources; public education on
how to identify strokes and heart attacks and when to
call 9-1-1; and community-wide education and buy-in
to develop a public-access CPR and AED program.
EMS should
continue to build
systems to ensure
timely lifesaving
care.
Greg Mears, MD
For at least
some calls,
fast response
times really
do matter
clinically.
Todd Stout
Measuring an
EMS systems
performance
requires far
more than
a single
performance
measure.
Skip Kirkwood,
MS, JD
The clock is
always going to
be a factor in
the EMS field.
Chris Cebollero, MS
49
PERFORMANCE MEASURES
In todays
instant
society, a
long wait at
any point in
the service
cycle will be
perceived
negatively.
Jay Fitch, PhD
managed to balance the risk to the patient, the caregiver and the community. Not every 9-1-1 request
merits a hot response from the system.
That said, customer satisfaction is part of one of the
three elements of the Triple Aim. Patients and families want their EMS system, including the transport
component, to flow smoothly and quickly. In todays
instant society, a long wait at any point in the service
cycle will be perceived negatively. Some communities
have been willing to pay the additional costs of having short response times but now feel compelled to
reassess the implications of those decisions in light
of other financial priorities. Stakeholders must be
educated that sending the correct type of help, which
is able to manage the patients needs within a reasonable time frame, may be more important than
considering response times as the primary measure
of performance.
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Payer
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52
ABOUT THE
AUTHOR
EMS STATE OF THE SCIENCES CONFERENCE: REPORT FROM THE GATHERING OF EAGLES
The 17th annual EMS State of the Sciences Conferencemore commonly referred to as
the Gathering of Eaglesconvened in Dallas, TX, on February 20 and 21, 2015.
This event is famous for its 10-minute bullet plenary presentations, lightning rounds
and other innovative educational advances, delivering 60+ presentations over two days,
which, according to conference evaluations, change nationwide medical practices almost
overnight. Comprised of the jurisdictional EMS medical directors from the nations largest
municipalities and their counterparts in pivotal federal agencies, the faculty is responsible
for the care of nearly 100 million citizens and is influential in shaping future EMS practice
trends worldwide.
Over the next few months, we will share highlights from the conference, which presents
cutting-edge information and advances in EMS patient care, clinical research and systems
management.
This month we write about two presentations that looked at expanding the use of ultrasound technologies into the prehospital arena for patients in cardiac arrest.
Parasternal Long
53
EMS STATE OF THE SCIENCES CONFERENCE: REPORT FROM THE GATHERING OF EAGLES
tions were examined by paramedics during transport, after all other emergency
care was provided. Follow-up reading by
physicians agreed with 100% of the medics exam interpretations. Most important,
according to Harrell, was that pericardial
fluid was found in 7% of the exams, potentially leading to altering patient care.
That study shows there certainly is an
opportunity. The results speak volumes to
the fact that its technically doable in the
field and trainable for field use, Harrell
said.
A 2014 survey of National Association
of EMS Physicians EMS medical directors
showed 22% of respondents considering
using ultrasound in the prehospital setting.
Harrell said the devices are becoming more
Transesophageal Echocardiography
By Ed Mund
54
Youngquist cited a study where TEE correctly identified the arrest cause in 65% of
patients. For 31%, this changed how they
were managed. Youngquist said TEE can
reveal signs of pulmonary embolism, cardiac tamponade, aortic rupture, aortic dissection, papillary muscle rupture and hypovolemia. Wall motion during compressions
can identify tissue damaged by myocardial
infarction.
Youngquist said field use of TEE is not
right around the corner. Key research yet to
be done includes gathering more observational data on the epidemiology of PEA.
ADVERTISER INDEX
COMPANY
PAGE
INQ #
Ambu, Inc.
60
38
21
20
Biomedix Inc
44
PAGE
INQ #
43
35
Mangar International
12
13
36
18
18
12
MedaPoint
13
14
24
23
14
15
19
19
27
24
34
25
NAEMT
16
16
Nasco
23
22
Plano Molding
10-11
27
COMPANY
Everglades University
37
Firehouse/EMS Store
50
GKR Industries
42
34
Prestan Products
17
17
42
33
Rosco Inc
41
32
10
22
21
Simulaids Inc
35
26
40
30
Stryker EMS
59
37
Knox Company
37
28
38
29
11
Limmer Creative
40
31
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EMSWORLD.com | JUNE 2015
57
LIFE SUPPORT
By Mike Rubin
ABOUT THE
AUTHOR
Mike Rubin is a
paramedic in
Nashville, TN,
and a member
of the EMS
World editorial
advisory board.
Contact him at
mgr22@prodigy.
net.
58