INEVITABLE Change p. 6 MEANINGFUL Metrics p. 16 NECROTIZING Fasciitis p. 20 CREATIVE Thinking p.

24

MARCH 2018

STORIES FROM
THE STORMS
Preplanning & mutual aid key to
navigating last years’ unprecedented
hurricane season, pp. 26–63

www.emstoday.com FEBRUARY 20–22, 2019, NATIONAL HARBOR, MD

1803JEMS_C1 1 2/9/18 3:22 PM

 EMPOWER YOUR
COMMUNITY

A convenient kit to help empower

bystanders to act quickly to treat excessive
bleeding and save lives.

GET PREPARED È www.boundtree.com/stop-the-bleed.asp

STOP THE BLEED is a registered trademark to the

U.S. Department of Defense. All rights reserved.

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 ®

26 PREPARING FOR CATASTROPHE

Houston-area EMS agencies put to the test responding to
Hurricane Harvey’s epic flooding
By Casey B. Patrick, MD; Kevin Schulz, MD, FAEMS, FACEP;
Chivas Guillote, MSN, RN, FNP-C; Robert Dickson, MD,
FAEMS, FACEM, FACEP & Cameron Decker, MD, LP, FACEP

MARCH 2018 VOL. 43 NO. 3

34 ADAPTING TO ADVERSITY
When Hurricane Harvey hit, Galveston EMS was prepared
By Nathan Jung, EMT-P
Contents
44
38 DISASTER DEPLOYMENT
AMR partners with FEMA during an unprecedented hurricane season
By Randy Lauer & Steve Delahousey, RN

44 PREPARING FOR IRMA

Disaster planning facilitates effective hurricane response in Pinellas County, Fla.
By John Peterson, MS, MBA, EMT-P

50 ISLAND AIDN.J. EMS Task Force delivers resources & relief to the hurricane-ravaged U.S.
Virgin Islands
DEPARTMENTS & COLUMNS
4 EMS IN ACTION Scene of the Month
6 FROM THE EDITOR Change on the Horizon
By Richard Huff, NREMT By A.J. Heightman, MPA, EMT-P

56
10 EMS INSIDER News and Winning Strategies for EMS Leaders
ST. CROIX DEPLOYMENT
Special response team from Arkansas provides relief & support to local EMS 15 PRO BONO Unnatural Liability
By Douglas M. Wolfberg, Esq.
crews after Maria’s devastation
By Andrew Ney, BA, NRP 16 MANAGEMENT FOCUS Meaningful Metrics
By Vincent D. Robbins, FACPE, FACHE

18 BACK TO BASICS Cold & Confused

By Dennis Edgerly, MEd, EMT-P

50 56 20 CASE OF THE MONTH Unusual Pain & Swelling

By Renee C. Johnson, MD, MPH

24 STREETSENSE Improvisation
By Kate Dernocouer, NREMT

25 STREET SCIENCE Focus on POCUS

By Keith Wesley, MD, FACEP, FAEMS & Karen Wesley, NREMT-P

59 FIELD PHYSICIANS Troop Support

By Mark E.A. Escott, MD, MPH, FACEP, NRP

60 HANDS ON Product Reviews from Street Crews

By Fran Hildwine, BS, NRP
About the Cover
From Houston to Florida to the U.S. Virgin Islands, EMS agencies nationwide answered the call to 63 AD INDEX
deliver resources and relief as three hurricanes—Harvey, Irma and Maria—ravaged the Southern U.S.
and Caribbean. Read more, pp. 26–63. ap photo/david j. phillip 64 LAST WORD The Ups & Downs of EMS

www.jems.com mARcH 2018 | JEMS 1

1803JEMS_1 1 2/9/18 3:14 PM

 ®

EDITOR-IN-CHIEF – A.J. Heightman, MPA, EMT-P – aheightman@pennwell.com

MANAGING EDITOR – Ryan Kelley, NREMT – rkelley@pennwell.com
SENIOR EDITOR – Sarah Ferguson, MA – sarahf@pennwell.com

MEDICAL EDITOR – Edward T. Dickinson, MD, NRP, FACEP

TECHNICAL EDITOR – Carolyn Gates, EMT-P, FP-C
MOBILE INTEGRATED HEALTH EDITOR – Matt Zavadsky, MS-HSA, EMT
CONTRIBUTING WRITER – Elisse Miller
CONTRIBUTING ILLUSTRATOR – Paul Combs, NREMT
CONTRIBUTING PHOTOGRAPHERS – Vu Banh, Glen Ellman, Craig Jackson, Kevin Link, Courtney
McCain, Tom Page, Rick Roach, Scott Oglesbee, Steve Silverman, Matthew Strauss, Chris Swabb

EDITORIAL GRAPHIC DESIGNER – Kermit Mulkins

PRODUCTION COORDINATOR – Katie Noftsger – katien@pennwell.com
REPRINTS, EPRINTS & LICENSING – Rae Lynn Cooper – 918-831-9143 – raec@pennwell.com
DIGITAL MEDIA CAMPAIGN MANAGER – Erin Huot – erinh@pennwell.com

SUBSCRIPTION DEPARTMENT
(800) 869-6882 – FAX: (866) 658-6156 – JEMS@kmpsgroup.com
SENIOR AUDIENCE DEVELOPMENT MANAGER – Jim Cowart – jimc@pennwell.com
MARKETING MANAGER – Ashley Cope – ashleyc@pennwell.com

SALES & MARKETING SOLUTIONS

WESTERN & CANADA – Mike Shear – 858-638-2623 – mshear@pennwell.com
MIDWEST AND SOUTHEASTERN – Melissa Roberts – 918-831-9727 – melissar@pennwell.com
NORTHEAST AND INTERNATIONAL – Rod Washington – 918-831-9481 – rodw@pennwell.com

WWW.EMSTODAY.COM
SENIOR VICE PRESIDENT/GROUP PUBLISHER – MaryBeth DeWitt
EDUCATION DIRECTOR – A.J. Heightman, MPA, EMT-P
CONFERENCE MANAGER – Debbie Wells (Boyne) – dboyne@pennwell.com
CONFERENCE COORDINATOR – Sara Jones – sjones@pennwell.com
MARKETING MANAGER – Cassie Chitty – cassiec@pennwell.com
SENIOR EVENT OPERATIONS MANAGER – Emily Gotwals-Moreau – emilyg@pennwell.com

FOUNDING PUBLISHER – James O. Page (1936–2004)

CHAIRMAN – Robert F. Biolchini (1939-2017)

VICE CHAIRMAN – Frank T. Lauinger
PRESIDENT AND CHIEF EXECUTIVE OFFICER – Mark C. Wilmoth
EXECUTIVE VICE PRESIDENT, CORPORATE DEVELOPMENT AND STRATEGY – Jayne A. Gilsinger
SENIOR VICE PRESIDENT, FINANCE AND CHIEF FINANCIAL OFFICER – Brian Conway
SENIOR VICE PRESIDENT/GROUP PUBLISHER – MaryBeth DeWitt – marybethd@pennwell.com

For more information, visit JEMS.com/rs and enter 2.

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UNITED STATES
Faizan H. Arshad, MD
EMS Medical Director, Vassar Brothers
Medical Center
William K. Atkinson II, PHD,
MPH, MPA, EMT-P
Health Care Advisor, Raleigh, N.C.
James J. Augustine, MD, FACEP
Chair, National Clinical Governance Board,
U.S. Acute Care Solutions
Paul Banerjee, DO
Medical Director, Polk County (Fla.)
Fire Rescue
Bryan E. Bledsoe, DO, FACEP,
FAAEM
Professor of Emergency Medicine, Director,
EMS Fellowship, Univ. of Nevada
Scotty Bolleter, BS, EMT-P
Chief, Clinical Direction, Bulverde Spring
Branch (Texas) Fire and EMS
Criss Brainard, EMT-P
Fire Chief, San Miguel Fire & Rescue
(Spring Valley, Calif.)
Chad Brocato, JD, DHSc, CFO
Assistant Chief, Pompano Beach (Fla.)
Fire Rescue
Carol A. Cunningham, MD,
FAAEM, FAEMS
State Medical Director, Ohio Dept. of Pub-
lic Safety, Division of EMS
Rommie L. Duckworth, LP
Director, New England Center for Rescue
and Emergency Medicine
EMS Coordinator, Ridgefield Fire Dept.
Mark E.A. Escott, MD, MPH, FACEP
Medical Director, Austin-Travis County EMS
Jay Fitch, PhD
President & Founding Partner, Fitch &
Associates
Ray Fowler, MD, FACEP, FAEMS
Professor and Chief, Division of EMS,
Univ. of Texas Southwestern School
of Medicine
Adam D. Fox, DPM, DO, FACS
Section Chief, Division of Trauma, Rutgers
N.J. Medical School
John M. Gallagher, MD
Medical Director, Wichita/Sedgwick
County (Kan.) EMS System
Ryan Gerecht, MD, CMTE
EMS and Emergency Medicine Physician,
Tacoma, Wash.
Jeffrey M. Goodloe, MD, NRP,
FACEP, FAEMS
Medical Director, EMS System for Metro-
politan Oklahoma City & Tulsa
Keith Griffiths
President, RedFlash Group
Andrew J. Harrell, MD
Associate Professor, Dept. of Emergency
Medicine, Univ. of New Mexico
Joe Holley, MD, FACEP, FAEMS
Medical Director, Memphis Fire Dept.
Christopher N. Kaiser, NRP
Paramedic, Central Wisconsin
Dave Keseg, MD, FACEP
Medical Director, Columbus Fire Dept.
Chetan U. Kharod, MD, MPH,
Colonel, USAF, MC, SFS
Program Director, Dept. of Defense EMS &
Disaster Medicine Fellowship
Keith Lurie, MD
Codirector, Central Minnesota Heart Cen-
ter Resuscitation Center
www.jems.com
1803JEMS_3 3
W. Ann Maggiore, JD, NRP
Clinical Instructor, Univ. of New Mexico,
School of Medicine
Shaughn Maxwell, EMT-P
Deputy Chief, South Snohomish County
(Wash.) Fire & Rescue
Andrew M. McCoy, MD, MS
Assistant Medical Director, Seattle
Fire Dept.
Mike McEvoy, PhD, NRP, RN, CCRN
EMS Coordinator, Saratoga County, N.Y.
John McManus, Col. (Ret.), MD,
MBA, MCR, FACEP, FAAEM
Professor of Emergency Medicine &
EMS Fellowship Director, Georgia
Regents Univ.
Jason McMullan, MD
Associate Director, Division of EMS,
Dept. of Emergency Medicine, Univ.
of Cincinnati
Mark Meredith, MD
Associate Professor of Pediatrics, Le
Bonheur Children’s Hospital (Mem-
phis, Tenn.)
David A. Miramontes, MD,
FACEP, NREMT
Medical Director, San Antonio Fire Dept.
Brent Myers, MD, MPH, FACEP
Senior Medical Consultant, ESO Solutions
President, National Association of EMS
Physicians
Joseph P. Ornato, MD, FACP,
FACC, FACEP
Operational Medical Director, Richmond
Ambulance Authority
Paul E. Pepe, MD, MPH, MACP,
FACEP, FCCM
Professor of Emergency Medicine, Internal
Medicine, Pediatrics, Public Health,
Univ. of Texas Southwestern Med-
ical Center
David E. Persse, MD, FACEP, FAEMS
Physician Director & Public Health Author-
ity, City of Houston EMS
P. Daniel Patterson, PhD,
MPH, MS, NRP
Assistant Professor, Emergency Medicine,
Univ. of Pittsburgh
Mark Piehl, MD
Pediatric Intensivist & Pediatric Critical
Care Transport Advisor, WakeMed
Edward M. Racht, MD
Chief Medical Officer, American Medi-
cal Response
Jeffrey P. Salomone, MD, FACS
Trauma Medical Director, Banner Des-
ert Medical Center/Cardon Children’s
Medical Center
Jullette M. Saussy, MD, FACEP
Emergency Medical Physician
Geoffrey L. Shapiro
Director, EMS & Operational Medicine
Training, School of Medicine and Health
Sciences EHS Program, George Wash-
ington Univ.
Corey M. Slovis, MD, FACP,
FACEP, FAAEM
Medical Director, Metro Nashville Fire Dept.
E. Reed Smith, MD, FACEP
Co-Chairman, Committee for Tactical
Emergency Casualty Care
Walt A. Stoy, PhD, EMT-P
Professor & Director, Emergency Medicine,
Univ. of Pittsburgh
For complete bios of our Editorial Board members, visit jems.com/Editorial-Board.
EDITORIAL BOARD
Peter P. Taillac, MD
Medical Director, Bureau of EMS and Pre-
paredness, Utah Dept. of Health
Jonathan D. Washko,
MBA, NREMT-P, AEMD
Assistant Vice President, North Shore-LIJ
Center for EMS
Keith Wesley, MD, FACEP, FAEMS
Medical Director, HealthEast Medical
Transportation
Katherine H. West, BSN, MSEd
Infection Control Consultant, Infection
Control/Emerging Concepts Inc.
Keith Widmeier, BA, NRP, FP-C
Director of Education, Good Fellowship
Ambulance & EMS Training Institute
Stephen R. Wirth, Esq.
Attorney, Page, Wolfberg & Wirth LLC.
Douglas M. Wolfberg, Esq.
Attorney, Page, Wolfberg & Wirth LLC
Wayne M. Zygowicz, MS,
EFO, EMT-P
Division Chief, Littleton (Colo.) Fire Rescue
MULTI-NATIONAL
Corina Bilger, NREMT-Ret
Director of International Sales, H&H
Medical Corp.
Ahed Al Najjar, BSc, FPHC, FAHA,
MPH, DOHS
Director of Life Support, EMS Faculty &
Researcher, Prince Sultan Bin Abdulaziz
College for EMS – King Saud Univ.
Jerry Overton, MPA
Chair, International Academies of Emer-
gency Dispatch
AUSTRALIA
Colin W. Allen, ASM
Director, Brisbane Operations Center,
Queensland Ambulance Service
Paul Middleton
Chair/Principal Investigator, DREAM (Dis-
tributed Research in Emergency and
Acute Medicine) Collaboration
Peter O’Meara
Professor, Rural & Regional Paramedicine,
La Trobe Univ. (Victoria)
Robyn Smith
Editorial Staff Member, Response
AUSTRIA
Christoph Redelsteiner,
DrPhDr, MSW, MS, EMT-P
Professor, Dept. Social Work & Health,
Univ. of Applied Sciences St. Pölten
CANADA
Randy Mellow
President, Paramedic Chiefs of Canada
Ronald D. Stewart, MD, FACEP
Professor, Emergency Medicine, Dal-
housie Univ.
CZECH REPUBLIC
Jana Šeblová, MD, PhD
Head Physician, EMS Education, Central
Bohemian Region
®
DENMARK JAPAN SAUDI ARABIA
Kjeld Brogaard, EMT-P Hiromichi Naito, MD, PhD Kenneth J. D’Alessandro,
EMS Senior Manager, Falck Denmark Assistant Professor, Dept. of Emergency BS, MS EMS, EMT-P
Freddy Lippert, MD
Medicine, Okayama Univ. Hospital EMS Program Advi er, Saudi Red Cres-
Hideharu Tanaka, MD, PhD cent Authority
CEO, EMS Copenhagen
Professor & Chairman, EMS System, William J. Leggio, EdD, NRP
Heidi Vikke, MSc Graduate School & Research Insitute of Paramedic Program Coordinator, EMS
Head of Research, Falck Denmark
Disaster & EMS, Kokushikan Univ. Education, Creighton Univ.
FINLAND KENYA SCOTLAND
Pertti H. Kiira, RN, EMT-P Elvis Ogweno, MPH, MSc, EMT-P Paul Gowens, FCPara, MSc, AASI,
Consultant of EMS Director, Tactical Search and Rescue PGCert, DipIMC, RCSEd, MCMI
Team, Africa Consultant Paramedic, Scottish Ambu-
FRANCE lance Service
Jean-Clause Deslandes, MD LUXEMBURG
Past Publisher, Urgence Practique Steve Greisch, RNA SINGAPORE
Registered Nurse Anesthetist & Continuing Marcus Ong Eng Hock
Marilyn Franchin, MD
Prehospital Emergency Physician, Fire Bri- Medical Education Instructor, Centre Senior Consultant, Clinician Scientist &
Hospitalier Emile Mayrisch Director of Research, Dept. of Emer-
gade of Paris
gency Medicine, Singapore Gen-
MEXICO eral Hospital
GERMANY
Jan-Thorsten Gräsner, Armando Alvarez, BSBME, SLOVAKIA
MBA, EMT-P, PA
MD, FERC
CEO, Sistemedic Viliam Dobias, MD, PhD
Director, Institute for Emergency Chair of Emergency Medicine, Medical
Medicine, Univ.Medical Center
School of Slovak Medical Univ. Bratislava
Schleswig-Holstein THE NETHERLANDS
Klaus Runggaldier, PhD, EMT-P Ingrid Hoekstra, MSc SLOVENIA
Dean and Professor, Medical School Ham- Ambulance Nurse, RAVU Utrecht Ambu-
Andrej Fink, MSHS , RN, EMT-P
burg, Univ. of Applied Sciences and lance Service, Dept. of Research
Head of Ambulance Service, Univ. Medical
Medical Univ.
Centre Ljubljana
Thomas Semmel, EMT-P NEW ZEALAND
ALS-Instructor, European Resuscita-
Craig Ellis, MD SOUTH AFRICA
tion Council
National Medical Advisor, St. John’s
Ambulance Service Neil Noble, CCP
HUNGARY Director, Paramedics Australasia
Hugo Goodson, MBA, PgCertEd,
Laszlo Gorove, MD BHSc
Senior Lecturer, Paramedicine, Auckland SOUTH KOREA
Managing Director, Hungarian Air Ambu-
Univ. of Technology Sang Do Shin, MD, PhD
lance Nonprofit Ltd.
Professor, Dept. of Emergency Medicine,
Seoul National University College of
ICELAND NIGERIA
Medicine and Seoul National Univer-
Njall Palsson, EMT-P Nnamdi Nwauwa, EMT, sity Hospital
President, Professional Division for CCEMTP, MBBS, MPH, MMSCEM
Founder, Emergency Response Ser-
EMT-Paramedics SWEDEN
vices Group
Styrmir Sigurdarson, EMT-P
Ola Orekunrin, MD Kenneth Kronohage, MSc,
Director of EMS, South Iceland CRNA, BSc, RN
Director, Flying Doctors Service
President, Swedish Ambulance Forum
INDIA
NORWAY
George P. Abraham, MD, FECS, UNITED ARAB EMIRATES
Carl R. Christiansen, EMT-P,
FACS, FWACS, MHA
MPhilEd
Ahmed Alhajeri
Medical Director, Western Alliance Deputy CEO, National Ambulance
Hospital Lecturer, Oslo & Akershus Univ.
EMS System
College of Applied Sciences
G.V. Ramana Rao, MD, DPH, Live Oftedahl, Cand.Philol.
UNITED KINGDOM
PGDGM
Editor-in-Chief, Ambulanseforum Jon Ellis, MBA
Director of Emergency Medicine Learn- Technical Expert, BSI & CEN Committees
ing Center & Research, GVK Emergency Ronald Rolfsen —Ambulance Systems & Patient Han-
Management Research Institute Special Adviser, Division for Prehospi- dling Equipment
tal Medicine, Ambulance Dept., Oslo
Mike Jackson, MSc (Dist), DipIMC,
Univ. Hospital
IRELAND MBA, FCPara
Steinar Olsen, RN, EMT-P Chief Consultant Paramedic & Assistant
Darren Figgis Director, Dept. of EMS, Norwegian Direc-
Advanced Paramedic, Health Service Exec- Clinical Director, North West Ambulance
torate for Health Service NHS Trust
utive National Ambulance Service
POLAND Ian Maconochie, FRCPCH, FECM,
ISRAEL FRCPI, FERC, PhD
Jamie Chebra, EMT-P, CEM,
Consultant, Paediatric Emergency Medi-
Dov Maisel, EMT-P MS, DHAc cine, St. Mary’s Hospital, Imperial Aca-
Senior Vice President of International Opera- EMS Educator & Advisor, Poland EMS demic Health Sciences Centre
tions, United Hatzalah – United Rescue Systems
Fionna Moore, MBE, BSc, FRCS,
Sody Naimer Marek Dabrowski FRCSEd, FRCEM, FIMC FCSEd
Senior Lecturer, Division of Community Lecturer, Poznan Univ. Medical Sciences, Medical Director & Consultant in Prehos-
Health, Ben-Gurion Univ. of the Negev Rescue & Disaster Medicine Dept. and pital Care, South East Coast Ambulance
Sim Center Service NHS Foundation Trust
Oren Wacht, EMT-P, PhD
Lecturer, Ben Gurion University, Dept. of Mateusz Zgoda, MPH, EMT-P Andy Newton, PhD
Emergency Medicine & Health Systems Paramedic, Krakow Rescue Public Ambu- Chief Clinical Officer, South East Coast
Management lance Service Ambulance Service NHS Trust
mARcH 2018 | JEMS 3
2/9/18 3:14 PM
 EMS IN ACTION
SCENE OF THE MONTH

MANHATTAN EXPLOSION

F ire, EMS and law enforcement officials respond to an explosion near New
York’s Times Square on Monday, Dec. 11, 2017. A man with a pipe bomb
strapped to his body set off the crude device prematurely in a passageway
under 42nd Street between Seventh and Eighth Avenues during the Monday
morning commute. The bomber and three others were injured.

4 JEMS | MARCH 2018 www.jeMs.CoM

1803JEMS_4 4 2/9/18 3:14 PM

 AP Photo/Andres Kudacki

www.jems.com mARcH 2018 | JEMS 5

1803JEMS_5 5 2/9/18 3:14 PM

 FROM THE EDITOR
PUTTING ISSUES INTO PERSPECTIVE
CHANGE ON THE
HORIZON
EMS agencies must learn to adapt to new challenges
By A.J. Heightman, MPA, EMT-P
M
y job as Editor-in-Chief requires
a lot air travel, where I get to visit
with the individuals that keep
EMS rolling.
People are always proud to tell me what’s
working for their agencies and systems. More
importantly, they often open up to me about
the problems and challenges they face. Some
ask for solutions from those who have faced
similar challenges.
I’m often able to help them, but sometimes I
can’t. Regardless of the challenge, I have plenty
of time in the air to think about and synthe-
size their issues.
As I fly, I often look out the airplane win-
dow at the mountains, rivers, snow and des-
erts below and wonder how the early settlers
in these vastly different landscapes coped with
the challenges ahead of them.
I wonder how the Conestoga wagons, with
their limited water supply, wooden wheels and
no air conditioning, traversed the territory
and allowed them to survive and prosper in
uncharted areas.
The fact is, they did. They learned to adapt,
analyze their problems, and develop innovative
solutions like water towers, telephone systems,
tunnels, railroads and airplanes.
I consider it my job to synthesize what I
observe and learn, and present information
and concepts to you, along with the success
stories, science and references to best describe
it. What you, your colleagues and administra-
tors do with it is beyond my control.
Here are just a few of the challenges I see
on the horizon, as well as information that can
assist you in addressing some common prob-
lems in EMS.
My goal is for these concepts and examples
to challenge you to follow up, read the avail-
able science, pass the information along to
6 JEMS | MARCH 2018
1803JEMS_6 6
those who can make changes—and convince
others to follow suit.
NEW THREATS & DISASTERS
An increasing number of terrorists in vehi-
cles; individuals with automatic weapons in
tall buildings, schools and other soft-target
areas; deadly domestic violence and responder
traps; massive wildfires, mudslides, hurricanes,
floods and the threat of tsunamis and nuclear
attacks, have changed the way we prepare for
major incidents and protect our staff.
As society and situations change, we too
must change. We have to be able to deploy our
personnel faster, and give them the processes,
tools and resources they need to counter each
of these threats.
Body armor and ballistic helmets are no
longer a luxury in many service areas—they’ve
unfortunately become a necessity.
KEEPING UP WITH THE SCIENCE
Medicine is changing rapidly thanks
to research, advances in technology and
improved communications.
Research like we presented in the Decem-
ber issue and its accompanying 36-page
supplement present documented and unde-
niable proof that we can do better in the area
of resuscitation if we change our mindset
and approach.
The Rialto (Calif.) and Lincoln (Neb.) fire
departments, and EMS systems like Alameda
County (Calif.), Minneapolis and King County
(Wash.) are closely aligned and interlinked
with their hospital clinicians for a holistic
approach to cardiac arrest.
They exhibit what can be done if you
rethink your approach to resuscitation, imple-
ment changes outside the norm and convince
hospitals that there can be better outcomes if
the care we start in the field is continued in
the hospital.
These systems have shown that survival rates
can improve by using defined bundles of care,
which include things like technology and citi-
zen alerting systems; mechanical compression
devices; direct-to-cath lab care; extracorporeal
membrane oxygenation (ECMO)-capable EDs
and committing to continuing resuscitation
attempts long after a 20-minute limit that
many systems still adhere to.
Soldiers in Afghanistan are being saved by
resuscitative endovascular balloon occlusion of
the aorta (REBOA), a procedure that tempo-
rarily stems bleeding until they can be treated
in an operating theater. Patients are being resus-
citated after hours on mechanical compression
devices and days of ECMO therapy.
We’ve proven that EMS can detect and
report ST-elevation myocardial infarctions
(STEMIs) and sepsis in the field, and reduce
morbidity and mortality by implementing
direct-to-cath lab and sepsis alert protocols
in conjunction with accepting hospitals.
The problem is that many hospitals keep
their heads buried in the sand. They either
ignore the prehospital assessment, or hold crit-
ically ill or injured patients captive in their
EDs without allowing them to benefit from
essential procedures.
The real elephant in the room is that, despite
proven research and practices, outdated think-
ing and stale protocols in hospitals aren’t offer-
ing the same aggressive care to patients once
we deliver them through the doors of the ED,
or they’re calling resuscitative efforts after the
unsubstantiated 20-minute limit.
This is an area of liability and change that
I promise JEMS and many other associations,
researchers and lawyers will no longer allow to
go unnoticed and unaddressed.
www.jeMs.CoM
2/9/18 3:14 PM
 RETHINKING PATIENT CARE
Thermometers, capnography, impedance
threshold devices and compression devices
are becoming the norm for BLS and ALS
units, allowing them to detect and care for
septic patients, strokes and STEMIs.
Despite resistance from many in the med-
ical community, I predict that improved,
compact, accurate and affordable ultrasound
units (and headsets like the BURL Sonic
Device) will soon be guiding care in the
detection and treatment of codes, strokes and
trauma patients.
I also believe that a new study by Bos-
ton University researchers and
published in Brain, a respected
peer-reviewed journal, will soon
change the way we assess and tri-
age concussions and head injuries.
Their ground-breaking research
has found that it’s the impact to the
head that causes chronic traumatic
encephalopathy (CTE), the neu-
rodegenerative disease that’s been CTE.’ Rather, it’s ‘the hit [to
linked to the type of head trauma
that has been killing football play-
ers, combat veterans and, likely,
many trauma patients.1
The researchers analyzed the brains of
teenagers with head injuries and used mice to
recreate head trauma, and revealed new facts
about the origins of CTE and its relation-
ship to traumatic brain injuries, concussions
and subconcussive head injuries. They found
that brain pathology was “unrelated to signs
of concussion, including altered arousal and
impaired balance.”1
Lee Goldstein, MD, an associate professor
at Boston University’s School of Medicine
and College of Engineering, and author of the
watershed study, has stated that concussion is
“really irrelevant for triggering CTE.” Rather,
it’s “the hit [to the head] that counts.”1
We learned years ago that mechanism of
injury was an important assessment tool for
predicting the seriousness of multisystem
trauma patients.
I believe this new study will change the
way we assess, treat and transport head-
injured patients.
This information will likely lead to protocols
being rewritten to move patients who sustain a
significant impact to their head to a trauma or
neurology center based on the impact—rather
than relying on visible trauma or other signs
of concussion.
www.jems.com
1803JEMS_7 7
DEATH TRAPS REDESIGNED
It took stubborn military leaders and our
government years to accept the fact that flat-
bottomed Humvees were death traps when
they encountered roadside bombs.
Countless soldiers lost their lives until we
invested in mine-resistant armored vehicles
(MRAVs): vehicles with V-shaped, deflective,
heavily armored bottoms and ballistic under-
wear. These innovations have become the stan-
dard of protection for soldiers and vehicles.
It’s taken years, and the loss of countless
emergency personnel, for our industry lead-
ers to accept that reflective chevron striping
A study has shown that
concussion is ‘really
irrelevant for triggering
the head] that counts.’
was needed on the rear of all emergency vehi-
cles and reflective vests needed to be worn by
emergency personnel who park or operate on
fast-moving highways.
In the 80s, we moved from unibody limou-
sine and truck ambulances to “boxes” bolted
on truck frames that frequently cracked open
like eggs when hit from the side or rolled over.
Our industry is now on the right track to
redesigning safer ambulances and safer seats
that keep providers securely in place while able
to reach equipment and patients.
DEADLY FATIGUE & STRESS
On Jan. 22, 2018, an EMT in Miami County,
Indiana, allegedly fell asleep at the wheel of
an ambulance, ran a red light and crashed into
a car. The ambulance rolled on its side and
Mousa Chaban, a 32-year-old paramedic, was
partially ejected and killed.2
Our crews are struggling with stress,
finances, excessively demanding shifts, and
punishment for sleeping on duty and report-
ing medical errors.
These are issues that have been largely
ignored—until now. There’s now significant
evidence, and well-documented cases proving
that sleep deprivation, excessively long shifts
and working back-to-back jobs and overtime,
are resulting in our personnel dying needlessly
or making deadly clinical mistakes.
The research done by JEMS editorial board
member P. Daniel Pattterson, Ph.D., EMT-P,
and his colleagues, reported on in the February
cover story, has, along with many other stud-
ies and reports, now charted a roadmap that
emergency service officials should—and will
probably have to—pay attention to.3–8
Research and deadly incidents, like the one
described previously, have awoken the sleeping
giant of ignorance and placed responsibility—
and liability—on managers and government
officials to make changes.
The military noticed accidents
on aircraft carriers and in cock-
pits, and solved many problems
by adopting the proven process
of crew resource management
(CRM), which carried over to
EMS, fire and law enforcement
agencies. CRM was born out of
tragedies at sea and in the air, and
is now accepted and practiced by
forward-thinking emergency ser-
vice agencies.4
Perhaps the most impact-
ful example of CRM was Captain Chesley
“Sully” Sullenberger’s safe landing of a U.S.
Airways plane in New York’s Hudson River
on Jan. 15, 2009.
On takeoff from LaGuardia Airport, a flock
of geese was sucked into the plane’s engines,
shutting them down in an instant, and forcing
Sullenberger to take quick action in just three
minutes—actions that experts agree wouldn’t
have occurred without CRM knowledge
and training. 9
Many lives have been saved by CRM safety
procedures, which involve use of checklists and
empowering employees to take control of situ-
ations and report risks and near-misses without
fear of reprimand.
The U.S. Navy is finally beginning to rec-
ognize the problems caused by excessive stress,
long shifts, and limited, cyclical sleep and
sleep deprivation.
After several preventable and fatal acci-
dents that that killed sailors and crippled
vessels loaded with accident avoidance tech-
nology, the Navy realized that sleep-deprived
and overworked sailors were the root of
the problem.10
The Navy has now implemented a Circa-
dian Rhythm Watch Program on surface ships
mARcH 2018 | JEMS 7
2/9/18 3:14 PM
 FROM THE EDITOR
to address the problem.10 I believe this will be
adopted by high-demand, high-stress emer-
gency service agencies.
Circadian rhythm is a naturally occurring
24-hour rhythm that drives human processes—
even at the cellular level. Sailors now work on
a routine that allows them to work, eat and
sleep at approximately the same time each day.
Nita Lewis Shattuck, PhD, a professor at the
Naval Postgraduate School, has worked with
the Navy and Marine Corps for more than 14
years, tracking physical, mental and behavioral
changes of sailors who follow a cir-
cadian rhythm watch schedule and
comparing these with sailors on the
typical “five and dime” watch rota- Our crews are struggling
tion (five hours on, ten hours off ), in
which their watch times are different
every day.10
Shattuck says, “People see the 10 excessively demanding
hours off [on a five and dime] and
think it’s better, but the sleep pat-
tern is not as good. The body likes
to sleep at the same time every day,
and the five and dime is a three-day
rotating pattern of sleep.”10 reporting medical errors.
Researchers Michael H. Bon-
net and Donna L. Arand report,
“There is strong evidence that sufficient
shortening or disturbance of the sleep pro-
cess compromises mood, performance and
alertness, and can result in injury or death.
In this light, the most common sense ‘do
no wrong’ medical advice would be to avoid
sleep deprivation.”10
The researchers have shown that the 3/9
(three hours on, nine hours off ) schedule is
better than a 5/10 (five hours on, ten hours
off ), with sailors now working 30% faster
and 40-50% more accurately than those on
the 5/10.10
Shattuck says, “Better sleep is linked to
improved memory, creativity, productivity, con-
centration, happiness, optimism and frustration
tolerance.”10 I believe the research done by the
Navy and Patterson will force EMS agencies to
soon have to rethink and reduce shift lengths,
stop back-to-back deployments and work by
mercenary providers.
Agencies will have to allow staff to take
breaks and naps while on duty and educate
their staff about the deadly hazards of fatigue,
exhaustion, stress and sleep deprivation.
‘PEAK-HOUR’ FIRE ENGINES
Fixing EMS response time gaps has typically
8 JEMS | MARCH 2018
1803JEMS_8 8
involved peak-time deployment of ambulances.
Brian Fennessy, San Diego (Calif.) Fire-Res-
cue’s innovative chief, will soon try deploying
peak-hour engines (PHEs) staffed by a crew
of four paramedics—and not connected to a
station—in an attempt to reduce emergency
response times until additional fire stations
can be built.
The engines will operate from 9 a.m. to 9
p.m. each day—the time when the city’s emer-
gency calls are typically highest—in areas where
response times have been difficult to meet, or
with stress, finances,
shifts & punishment
for sleeping on duty &
where crews aren’t regularly available.11
This trial program will run until additional
fire stations can be built in hard-to-serve
areas, but results may show that fire depart-
ments can benefit by mimicking EMS’ flexible
deployment models, which have been effective
for decades.
City officials have agreed to Fennessy’s plan
to add six PHEs to help achieve a goal to have
EMS arrive on scene within 7.5 minutes at
least 90% of the time.
The city is currently meeting that goal about
80% of the time; this program will determine
if the additional deployment model can sig-
nificantly boost that.11
To fully staff all six engines, the city plans to
hire 48 additional firefighters at a cost of $6.3
million per year. No capital costs are anticipated
because the city has several reserve engines it
can use. 11
CONCLUSION
My wife calls me “the Fly” because I bounce
from topic to topic, project to project and mis-
sion to mission like an insect on steroids.
I accept the nickname because time is
never our friend, and these issues need to
be addressed.
Trust the research from our industry, the
military and other professions, and work to
adopt principles and practices that can pre-
vent needless medical errors, help us avoid
financially devastating lawsuits, and, most
importantly, save our patients and keep our
crews safe. JEMS
REFERENCES
1. Boren C. (Jan. 18, 2018.) A new study shows that hits to the
head, not concussions, cause CTE. Washington Post. Retrieved
Jan. 23, 2018, from www.washingtonpost.com/news/
early-lead/wp/2018/01/18/a-new-study-shows-
that-hits-to-the-head-not-concussions-cause-cte/.
2. LODD: EMT driver falls asleep-technician ejected
& killed in the line of duty. (Jan. 22, 2018.)
Firefighterclosecalls.com. Retrieved Jan. 23, 2018,
from www.firefighterclosecalls.com/lodd-emt-
driver-falls-asleep-technician-ejected-killed-in-
the-line-of-duty.
3. Patterson PD. Dead tired: Evidence-based recom-
mendations for combatting fatigue in EMS. JEMS.
2018;43(2):26–35.
4. Saylors E. (Jan. 6, 2018.) Firefighters are not
machines; they need sleep. Medium. Retrieved
Jan. 23, 2018, from www.medium.com/@esaylors/
firefighters-are-not-machines-they-need-sleep-
9fc33b8cfb3e.
5. Von Thaden TL. (April 1, 2017.) How sleep
affects long-term health. Fire Engineering. Retrieved
Jan. 23, 2018, from www.fireengineering.com/articles/print/
volume-170/issue-4/features/how-sleep-affects-long-term-
health.html.
6. Carvajal J. (October 2011.) Managing firefighter fatigue. NSCA
TSAC Report. Retrieved Jan. 23, 2018, from www.nsca.com/
education/articles/managing-firefighter-fatigue.
7. Do firefighter shift schedules affect sleep quality? (Aug. 17,
2017.) U.S. Fire Administration. Retrieved Jan. 23, 2018, from
www.usfa.fema.gov/current_events/081717.html.
8. Elliot DL, Kuehl KS. (June 2017.) Effects of sleep deprivation
on fire fighters and EMS responders. International Associa-
tion of Fire Chiefs. Retrieved Jan. 23, 2018, from www,aams.
org/toolbox/IAFC%20-%20Effects%20of%20Sleep%
20Deprivation%20Report.pdf.
9. Mulenberg J. (May 11, 2011.) Crew resource management
improves decision making. ASK Magazine. Retrieved Jan. 23,
2018, from www.nasa.gov/pdf/546130main_42i_crew_
resource_management.pdf.
10. LaCrosse L. (Oct. 20, 2017.) Circadian rhythm being imple-
mented on navy surface ships. U.S. Navy. Retrieved Jan. 23, 2018,
from www.public.navy.mil/surfor/Pages/Circadian-Rhythm-
Being-Implemented-on-Navy-Surface-Ships.aspx.
11. Garrick D. (Dec. 30, 2017.) San Diego adding roving fire engines
to shrink response times. Los Angeles Times. Retrieved Jan. 23,
2018, from www.latimes.com/local/lanow/la-me-ln-sd-fire-
response-times-20171230-tory.html.
www.jeMs.CoM
2/9/18 3:14 PM
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 ™
TURNING THE CORNER
New economic models are changing the face of EMS delivery
By Matt Zavadsky, MS-HSA, NREMT, Chris Cebollero, & Jay Moore, MD
I
t’s taken more than 20 years, but it seems
EMS has finally turned the corner on
the vision imagined by the authors of
the preamble for the EMS Agenda for the
Future, written more than 20 years ago.
They predicted a future where EMS is key
to “community-based health management
that is fully integrated with the overall health
care system.”1
Although the authors note that EMS
remains the public’s emergency medical safety
net, EMS agencies would also have the “abil-
ity to identify and modify illness and injury
risks, provide acute illness and injury care
and follow-up, and contribute to the treat-
ment of chronic conditions and community
health monitoring.”1
Thanks to the hard work of innovative
EMS agencies—large and small, public and
private—and key industry associations like
NAEMT, NAEMSP, ACEP and the IAFC,
Anthem believes that if we de-couple payment from transport, it allows EMS personnel to help patients make
informed, patient-centered medical care decisions based on clinical need. Photos courtesy Matt Zavadsky
10 JEMS | MARCH 2018
1803JEMS_10 10
healthcare payers have begun to see the true
value EMS brings to the table.
A representative pivot point to this realiza-
tion occurred on Dec. 13, 2017, when JEMS
hosted the first EMS webcast sponsored by
a commercial payer, Anthem Blue Cross and
Blue Shield.
Not surprisingly, the title was “New Pay-
ment Models for EMS,” and was facilitated by
Jay Moore, MD, from Anthem, Chris Cebol-
lero from Cebollero and Associates, and Matt
Zavadsky, MS-HSA, NREMT, from MedStar
Mobile Healthcare.
The webcast came on the heels of the Octo-
ber 2017 announcement that Anthem would
begin paying EMS agencies for healthcare
common procedure coding system (HCPCS)
code A0998: Ambulance response and treat-
ment, without transport.
This code has existed for years, but because
the 1965 Medicare statute includes ambulance
transportation as a covered benefit, Medicare
and most other payers, generally don’t cover
an ambulance response that doesn’t result in
a transport.
The webcast covered not only the strat-
egy being implemented by Anthem, but the
reasons for the decision, and a discussion on
the regulatory changes that may (or may not)
need to happen to implement this revolution-
ary new EMS payment model.
After 60 minutes of presentation and a
question and answer session, there were sev-
eral questions left unanswered, so the pre-
senters offered to publish the answers to some
of the most commonly asked questions in
EMS Insider.
Why is Anthem doing this?
Jay: For 40 years, payers have incentivized
EMS to use the “you call, we haul” method of
EMS services by only paying for the transport.
Many of the patients assessed and treated by
EMS don’t need care in an ED.
A recent analysis by ACEP revealed that
17% of the patients brought to an ED are
brought there by EMS, and 61% of these
patients are treated and released from the ED.
Many patients can be more appropriately
treated in alternate, more patient-centered set-
tings like urgent care or primary care.
Anthem believes that if we de-couple pay-
ment from transport, it allows EMS personnel
to help patients make informed, patient-
centered medical care decisions based on clin-
ical need—without having to rely on transport
to an ED as the basis for payment.
We believe that you should be paid for the
care you deliver, not whether or not you trans-
port someone to an ED.
How did Anthem determine the
reimbursement rate for A0998?
www.jeMs.CoM
2/9/18 3:15 PM
 Chris: Anthem will reimburse EMS at 75% of
the state average of the allowed payment for
all ambulance trips.2
Let’s use Missouri as an example: The state
average allowed amount for an ambulance trip
is $688—that includes ALS, BLS, emergency
and non-emergency. Seventy-five percent of
$688 is $516.08, the amount allowed for the
A0998 payment.
This basis considers regional variations,
such as the geographic practice cost index that
Centers for Medicare and Medicaid Services
(CMS) uses for the ambulance fee schedule.
It costs more to provide EMS service in Cal-
ifornia vs. Mississippi, and this methodology
accounts for those variations.
Are regulatory changes needed for
an EMS agency to do this?
Matt: As with most transformational things in
EMS, it depends. Generally, patients have the
right to refuse transport to an ED, but EMS is
typically not reimbursed for the refusal against
medical advice (AMA). Under this model, you
can bill A0998 and get paid.
Many EMS agencies have protocols that
don’t allow the EMS provider to initiate the
conversation about alternate destinations for
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a 9-1-1 patient, and some states have regu-
lations about this as well. Historically, this is
because the transport economic model didn’t
encourage EMS agencies, medical directors or
regulators to do anything different.
In this model, we can offer options to
patients who meet clinical eligibility guide-
lines as established by the medical director.
This may require some regulatory and stat-
utory changes.
How will patient safety and
quality be assured?
Jay: EMS agencies should have already estab-
lished patient safety and quality metrics for
patients who are treated and not transported.
For example, if a patient AMAs, do you end
up responding to the same patient within 24
hours for a related complaint? Did the patient
have any other adverse outcome as a result of
the AMA?
In this new payment model, we would
expect the EMS agency and the medical direc-
tor to expand that quality assessment process.
If the patient was referred to an urgent care
or primary care center, did the patient end up
at an ED within six hours? Was there any other
adverse outcome?
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We’re encouraged by the group of EMS
innovators working on national outcome mea-
sures for ambulance transport alternatives, and
we anxiously await the release of the mea-
sures they develop regarding patient safety
and quality.
Can these payment models be
used by other payers?
Chris: Most certainly! Anthem is breaking the
mold for EMS reimbursement by taking this
comprehensive approach across the 14 states
where they operate, but we anticipate other
payers to follow suit.
In fact, more than 10 years ago Medicare
began paying for cardiac arrest patients who
are treated and pronounced dead on scene.
Conventional wisdom tells us this was
adopted by Medicare to avoid the incentive for
EMS transport to an ED—and CMS incur-
ring the ED expense—for a patient who had
no chance of survival.
One of the most innovative payers in the
country, Medicaid, has begun reimbursing for
mobile integrated healthcare (MIH) services in
states such as Minnesota, Nevada and Idaho.
Any payer who recognizes the value of this
type of model can reimburse for it.
2/9/18 3:15 PM
 EMS INSIDER
Are there other economic models
being tested by commercial payers?
Matt: Yes. In addition to the models mentioned
already, MedStar is implementing a model with
another commercial payer, and a managed Med-
icaid payer, to pay a capitated, per member, per
month (PMPM) fixed rate for their members
in our service area. The PMPM covers tradi-
tional ambulance and MIH services.
This allows us to use all our MIH strate-
gies (9-1-1 nurse triage, community paramed-
icine and ambulance transport alternatives) to
help navigate patients to the most appropri-
ate healthcare resource based on their clinical
need—not based on whether or not we trans-
port them to an ED.
Additionally, a managed Medicare payer is
working with us to implement a regional MIH
program to manage high utilizer members in their
network.That model will pay MedStar a monthly
fee for each high utilizer enrolled in the program.
12 JEMS | MARCH 2018
1803JEMS_12 12
How can we learn more about how to
approach payers in our community about
changing the EMS economic model?
Matt: First, keep reading JEMS and EMS
Insider for updates. The National Association
of EMTs has developed numerous resources to
help the EMS transformation.
Their website (www.naemt.org) has an
EMS 3.0 resource section that contains value
statements for discussions with commer-
cial payers, accountable care organizations
(ACOs), hospitals, home health agencies and
other stakeholders. The NAEMT will also be
hosting their next EMS 3.0 Transformation
summit on April 10, 2018, in Washington, D.C.,
as part of the EMS on the Hill Day. JEMS
REFERENCES
1. National Highway Traffic Safety Administration. (1996.) Emer-
gency medical services agenda for the future. National High-
way Traffic Safety Administration. Retrieved Jan. 23, 2018,
from https://one.nhtsa.gov/people/injury/ems/agenda/
emsman.html.
2. Augustine JJ. (Dec. 17, 2014.) Emergency medical services
arrivals, admission rates to the emergency department ana-
lyzed. ACEP Now. Retrieved Feb. 6, 2018, from www.acepnow.
com/article/emergency-medical-services-arrivals-admis-
sion-rates-emergency-department-analyzed/.
Matt Zavadsky, MS-HSA, EMT, is the chief strategic integra-
tion officer at MedStar Mobile Healthcare in Fort Worth, Texas.
He holds a master’s degree in health service administration
and has 30 years of experience in EMS, including volunteer,
fire, public and private sector EMS agencies.
Chris Cebollero is a senior partner at Cebollero and Associ-
ates, a medical consulting firm. He previously held leadership
positions in several EMS organizations throughout the U.S.
Since 2015, he has helped develop and implement a num-
ber of community paramedic programs around the country.
Jay Moore, MD, is the senior clinical officer for Anthem.
Prior to joining Anthem, he was the vice president of medical
affairs and chief medical officer of SSM DePaul Health Center.
www.jeMs.CoM
2/9/18 3:15 PM
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1803JEMS_14 14 2/9/18 3:15 PM


UNNATURAL LIABILITY
Plan ahead to avoid liability issues during natural disasters
By Douglas M. Wolfberg, Esq.
W
orrying about legal liability would
seem like the last consideration in
a natural disaster, but EMS agen-
cies should consider a few significant issues
before deploying personnel for a natural disas-
ter-related response, such as last year’s Hurri-
canes Harvey and Maria.
AN OBLIGATION
TO RESPOND
First, clarify whether your agency
has the legal obligation—or the legal
right—to respond to such incidents.
Of course, if you’re the designated to implement temporary
9-1-1 agency for your city or town,
you likely would have legal obliga-
tions to provide care and services.
However, there are often other
EMS agencies in an area that may
not have assigned or designated
9-1-1 territory, but that handle non-
emergency or interfacility transports
as their primary line of business.
It may be that your local EMS plan still
considers those resources to be “fair game” for
activation in a natural disaster, so be sure to
consult your system’s EMS plans and opera-
tional guidelines to determine whether you
may be required to contribute your agen-
cy’s assets. If not, then you should clarify—
in advance—whether your resources can be
offered or utilized in a natural disaster. (Most
local agencies would say yes in a heartbeat, but
never assume!)
INTERSTATE OPERATIONS
If your deployment might cross state lines,
be sure to check that other states’ EMS laws
and regulations to determine if your agency
is permitted to operate there without holding
a license in that state under a disaster excep-
tion of some type.
If not, you may need to work with that
state’s EMS office to determine your options.
Some agencies participate in federal programs
www.jems.com
1803JEMS_15 15
through FEMA, such as a disaster medical
assistance team—which involves entering into
a written contract and a formal activation plan.
You’ll also want to ensure that your indi-
vidual EMS practitioners are permitted to
practice in neighboring states in a disaster or
declared emergency.
Although many states allow for this, not all
More states are moving
practice authorizations
in disaster situations,
which is a good thing.
do, and in some areas, it may be necessary to
hold that state’s certification to practice there.
In a true disaster, we wouldn’t expect to see a
state EMS agency pursue disciplinary action
against an out-of-state practitioner who came
to help, but it’s always best to address this in
advance of a disaster situation.
More states are moving to implement tem-
porary practice authorizations in disaster sit-
uations, which is a good thing.
Furthermore, the Recognition of EMS
Personnel Licensure Interstate Compact
(REPLICA) has now been enacted in about
a dozen states and continues to grow, which
will allow for recognition of EMS personnel
across state lines in a disaster.
ARE YOU COVERED?
Be sure to take a look at your agency’s various
insurance coverages (e.g., auto, professional lia-
bility, workers compensation, etc.) and make
sure you don’t have any restrictions or limita-
tions on coverage when engaging in operations
PRO BONO
EMS LEGAL TIPS & ADVICE
outside of your usual coverage area. Ordinarily
there aren’t limitations or exclusions of that
type, but again, don’t assume.
CLINICAL PROTOCOLS
Finally, be sure to obtain clarification—in
advance of a natural disaster occurring—about
what clinical protocols will be followed in the
jurisdiction in which your person-
nel will be practicing. In some cases,
your providers will still follow their
“home” protocols, but in others, they
may be required to follow the clin-
ical protocols of the jurisdiction in
which care is being provided.
Obtaining clarification in advance
of this important issue can allow for
proper training and preparedness of
your staff, and address potential scope
of practice or liability issues before
they arise.
CONCLUSION
With a bit of planning, the liability and legal
concerns that arise in a natural disaster can
be addressed before a natural disaster occurs.
This will allow your agency and your person-
nel to focus on the things that truly matter:
caring for the sick and injured when disaster
strikes. JEMS
Douglas M. Wolfberg, Esq., is an EMS
attorney and founding partner of Page,
Wolfberg & Wirth, the nation’s leading EMS
industry law firm. In a career of nearly 40
years, Doug has served as an EMS practi-
tioner, a county EMS director, a regional and statewide EMS
administrator and a federal EMS program specialist. He has
authored hundreds of articles and has lectured at EMS con-
ferences across the United States.
Pro Bono is written by the attorneys
at Page, Wolfberg & Wirth, The
National EMS Industry Law Firm.
Visit the firm’s website at www.pwwemslaw.com or find
them on Facebook, Twitter or LinkedIn.
mARcH 2018 | JEMS 15
2/9/18 3:15 PM
 MANAGEMENT FOCUS
STAY ON TOP OF YOUR GAME

MEANINGFUL METRICS
How should we measure what we do?
By Vincent D. Robbins, FACPE, FACHE

3. Use of EWDs increases the stress experi-

O
ur profession has long been plagued This has been an area of great debate over
with the task of proving that what the years, and has been continuously affected enced by patients, adversely affecting their
we do matters. Though very few by a shifting focus on what constitutes equi- vital signs and blood chemistry.5, 7
studies exist that definitively justify the table, scientifically based measurements that 4. Extremely few patients benefit from
expense of our advanced EMS systems around truly identify an EMS agency’s operational a rapid response to their emergency by
the country, two important and comprehen- and financial quality. In recent years, emerg- EMS.7,10–12 In fact, the most important
sive analyses were completed in 2009 and ing research has destroyed many of our old time interval that correlates statistically
2014 that addressed the issue of effectiveness. perceptions about what measures and met- to morbidity and mortality, is the total
The first study made the case that EMS rics are appropriate in assessing our services. time from initial symptoms to definitive
unquestionably improve patient care (i.e., hospital care with phy-
outcomes and health.1 The sec- sician intervention). This includes
ond declared that EMS was dispatch processing, response to
an essential public health ser- In recent years, emerging scene, time on task (i.e., treat-
vice that results in economic ing the patient at the scene—
good for society.2 The reports research has destroyed notably the lengthiest time seg-
were profound, exhaustively ment of them all),13 transport to
researched, and firmly anchored in many of our old perceptions the hospital and turn over to hos-
scientific analysis. pital clinicians (often the second
The first document was pro- about what measures & longest time period).
duced by the National EMS Even with the total time inter-
Advisory Council (NEMSAC), metrics are appropriate val, the number of EMS patients
the nationally designated assem- that are affected by statistically
bly of EMS representatives and in assessing our services. significant morbidity and mor-
consumers, established by Con- tality is less than 10%.5
gress, to provide advice and rec- As the industry has determined
ommendations regarding EMS to the RESPONSE TIME & PRODUCTIVITY the unimportance of response times and the
federal government. Response times have long been a mainstay detrimental effect of using EWDs, prioritized
NEMSAC is comprised of 25 national metric used to determine the quality of an dispatch protocols have been incorporated
experts representing every segment of the EMS operation. For decades, response times into many systems, resulting in dramatically
EMS system. It’s the only advisory body for were used as a fundamental criterion in RFPs fewer cases of EWD response.14, 15 EMS sys-
EMS at the federal level that exists by leg- (requests for proposals) issued by towns to tems around the country are now intention-
islative mandate and is the sole statutory award EMS contracts. Not anymore! ally decreasing the number of 9-1-1 requests
authority organized to provide official advice Several studies in the last ten years (even to which they send units using EWDs.
to the federal government.3 one dating back to 1953!),and a landmark So, what use is measuring response times
The second report was conducted by a NHTSA report, have definitively determined anymore? Continuing to measure and report
study team from the National Academy of four important facts; 3, 4 these to the public reinforces the notion
Public Administration, commissioned by the 1. Use of emergency warning devices that this metric means something. Based
National Highway Traffic Administration (EWDs, such as lights and siren) saves on the science, we should be educating
(NHTSA) Office of EMS.4 minimal time (1.7–3.6 minutes) in both the public toward the opposite conclusion:
Now, we know we matter, and that what we response to the scene and transport to EWDs should be used rarely, and response
do improves our patients’ lives and our society. the hospital.5–7 times aren’t an important measure of an
Our next conundrum has always been how 2. Use of EWDs increases the likelihood of EMS operation.
to measure what we do. What metrics are ambulance/emergency vehicle crashes and What about productivity as a metric? The
important and reveal the quality of the ser- subsequent property damage and injuries efficiency of an EMS operation is certainly
vice an EMS agency provides? to EMS practitioners and the public.5,7–9 important to those paying the bills. This is

16 JEMS | MARCH 2018 www.jeMs.CoM

1803JEMS_16 16 2/9/18 3:15 PM

 especially true for those agencies that rely
completely on fee-for-service reimbursement
to fund their services, and the public whose
taxes go to supporting EMS.
The industry standard measure of produc-
tivity is the unit hour utilization (UHU). But,
local protocols, regulations and expectations
of both the public and governing bodies, sub-
stantially affect UHU.
For many reasons, including surge capac-
ity and public relations, EMS agencies may
need to operate at a less productive level than
would otherwise be fiscally prudent. Because
of these factors, UHU can’t be equitably used
to compare one EMS system against another.
PROTOCOL COMPLIANCE
& SKILL PERFORMANCE
With response times and productivity off the
table, what should we assess as a meaningful
measure of our services? Compliance with
treatment protocols and successful practi-
tioner skill performance may be an option.
EMS systems around the country have
varying levels of patient treatment protocols,
and the degree to which practitioners comply
with them can be argued to reflect quality of
care. Likewise, the more proficient caregiv-
ers are with their skills, the higher level of
care they provide.
Treatment protocols and scope of practice
are more locally determined than not, and
echo the standards desired by the cognizant
medical community.
Therefore, the more practitioners follow
them, the more the EMS agency is fulfilling
its mission as part of the regional healthcare
system. Additionally, stronger caregiver skills
are better for the patient.
However, compliance with protocols and
expertise with skill performance is almost
always self-reported through the patient
care report.
It’s human nature to minimize one’s inad-
equacies and deviations from protocol. Peo-
ple are reluctant to admit the errors in the
care they render.
If we comparatively measure the quality
of EMS agencies based on protocol adher-
ence and skill performance—especially if this
data is released to the community at large as
part of some “report card”—there will be a
strong incentive to under-report mistakes
and over-report compliance and proficiency.
It will be difficult to design a process that
results in more reliable information.
www.jems.com
1803JEMS_17 17
PATIENT OUTCOMES
Patient outcomes come to mind as another
possible metric.
With outcomes, the only accurate reflec-
tion of the impact EMS practitioners have is
the difference between the patient’s condition
upon our arrival and their status upon transfer
to definitive care.
This is hard to measure empirically,
because we self-report how the patient is
found, and when we transfer them to hospi-
tal personnel, we rely either on self-reporting,
or the information we get from the receiving
nurse or physician.
We can’t depend on discharge diagnosis
or status, since we have no control over the
care the patient receives in the hospital after
we transfer them.
To compare one EMS agency’s quality
of patient care to another, we would have to
somehow level the playing field to adjust for
differences in demographics—some popula-
tions are sicker than others and experience
worse outcomes.
Medicare and state health departments
have accomplished this “equalization” to vary-
ing degrees with hospitals.
We also would need to adjust the outcomes
data for EMS agencies around the country to
compensate for the significantly different base
level of health and environmental conditions
that exist in our various service areas.
Outcomes may still be a reasonable measure
if we can determine reliable mechanisms to
obtain this information along with standard-
ized ways to report on the data.
YOUR THOUGHTS?
What are we to do? It seems, from this short
analysis, that properly adjusted outcomes
data could be a good comparative measure of
EMS systems.
What do you think? Comment on the
web version of this article on jems.com. In
a future issue, I’ll report on your comments
and opinions. JEMS
REFERENCES
1. National EMS Advisory Council. (November. 2009.) EMS
makes a difference: Improved clinical outcomes and down-
stream healthcare savings. National Highway Traffic Safety
Administration Office of EMS. Retrieved Jan. 28, 2018, from
www.ems.gov/pdf/nemsac-dec2009.pdf.
2. Van Milligen M. (May 2014.) An analysis of prehospital
emergency medical services as an essential service and
as a public good in economic theory. National Highway
Traffic Safety Administration Office of EMS. Retrieved Jan.
28, 2018, from www.ems.gov/pdf/advancing-ems-systems/
Reports-and Resources/Prehospital_EMS_Essential_
Service_And_Public_Good.pdf.
3. Hunt RC, Brown LH, Cabinum ES, et al. (1995). Is ambu-
lance transport time with lights and siren faster than that
without? Ann Emerg Med. 1995;25(6):857.
4. Parks LL. Are speeding, open sirens and red light-breaking
by ambulances necessary? Journal of the Florida Medical
Association. 1953;40(1):20–22.
5. Kupas DF. (May 2017.) Lights and siren use by emergency
medical services (EMS): Above all do no harm. National
Highway Traffic Safety Administration Office of EMS. Retrieved
Jan. 28, 2018, from www.ems.gov/pdf/Lights_and_Sirens_
Use_by_EMS_May_2017.pdf.
6. Brown LH, Whitney CL, Hunt RC, et al. Do warning lights
and sirens reduce ambulance response times? Prehosp Emerg
Care. 2000;4(1):70–74.
7. Murray B, Kue R. The use of emergency lights and sirens by
ambulances and their effect on patient outcomes and public
safety: A comprehensive review of the literature. Prehosp
Disaster Med. 2017;32(2):209–216.
8. Saunders CE, Heye CJ. Ambulance collisions in an urban
environment. Prehosp Disaster Med. 1994;9(2):118–124.
9. Ross DW, Caputo LM, Salottolo KM, et al. Lights and siren
transport and the need for hospital intervention in trauma
patients. Prehosp Emerg Care. 2016;20(2):260–265.
10. Marques-Baptista A, Ohman-Strickland P, Baldino KT, et
al. Utilization of warning lights and siren based on hos-
pital time-critical interventions. Prehosp Disaster Med.
2010;25(4):335–339.
11. Kupas DF, Dula DJ, Pino BJ. Patient outcome using medical
protocol to limit “lights and siren” transport. Prehosp Disas-
ter Med. 1994;9(4):226–229.
12. O’Brien DJ, Price TB, Adams P. The effectiveness of lights
and siren use during ambulance transport by paramedics.
Prehosp Emerg Care. 1999;3(2):127–130.
13. Puolakka T, Strbian D, Harve H, et al. Prehospital phase of the
dtroke chain of survival: A prospective observational study.
J Am Heart Assoc. 2016;5(5):e002808.
14. Cone DC, Galante N, MacMillan DS. Can emergency medical
dispatch systems safely reduce first-responder call volume?
Prehosp Emerg Care. 2008;12(4):479–485.
15. Eastwood K, Morgans A, Stoelwinder J, et al. Patient and
case characteristics associated with ‘no paramedic treat-
ment’ for low-acuity cases referred for emergency ambu-
lance dispatch following a secondary telephone triage: A
retrospective cohort study. Scand J Trauma, Resusc Emerg
Med. 2018;26(1):8.
Vincent D. Robbins, FACPE, FACHE, is the
president and CEO of MONOC, New Jersey’s
largest ALS and mobile integrated healthcare
service. He’s also pres- In partnership with
ident of the National
EMS Management Association.
mARcH 2018 | JEMS 17
2/9/18 3:15 PM
 BACK TO BASICS
CASES IN BLS CARE
COLD & CONFUSED
Decreasing body temperature often presents subtly
By Dennis Edgerly, MEd, EMT-P
A
s you arrive at the homeless shel-
ter, a volunteer meets you and your
partner and directs you to the alley
behind the building.
You enter the alley and see a body lying to
the side of a dumpster. Moving closer, you see
it’s a male in his 20s or 30s. He’s wrapped in
blankets and is wearing several layers of clothes
and you can’t see much more than the con-
densation coming from his mouth with each
one of his breaths.
The shelter volunteer tells you the man’s
name is Jeff, that he’s a frequent guest at the
shelter. Last night he didn’t show up, and vol-
unteers found him this morning in the alley.
You call his name loudly and carefully shake
Jeff ’s shoulder with no response other than
a soft moan and a bit of facial grimace. You
carefully conduct a brief assessment to look for
obvious bleeding or possible weapons.
LOSING HEAT
Jeff is breathing eight times a minute with good
tidal volume. He has a weak radial pulse at a rate
of 80. There’s a bag next to him that includes
some socks, partially eaten candy bars, a bag of
chips and two mostly empty bottles of whiskey.
You also find a couple insulin needles, but no
insulin. There’s a prescribed bottle of Effexor
(venlafaxine), which is about empty—the med-
ication is prescribed to Jeff Reagan.
After you and your partner get Jeff moved
to the inside of your ambulance, you conduct
a more thorough assessment. He seems to be
breathing with an adequate minute volume
but he’s unconscious, so you administer oxygen
via nasal cannula. His pulse remains around
80 beats per minute and his blood pressure is
100/82 mmHg.
Your physical exam is unremarkable other
than noting Jeff is cold to the touch. His blood
glucose is 190 mg/dL. You administer 1mg
naloxone via intranasal route with no change
in his breathing or mental status. There are
no signs of traumatic injuries.
18 JEMS | MARCH 2018
1803JEMS_18 18
Jeff ’s vital signs don’t suggest hemor-
rhage or increased intracranial pressure. His
blood glucose is within normal limits and
there was no response from the naloxone.
There’s the probability of alcohol intoxica-
tion, but it appears Jeff may also be profoundly
hypothermic.
Hypothermia occurs when the body loses
the ability to maintain body temperature—the
body loses heat faster than it can generate heat.
The core, or internal temperature of the body
decreases. Mild hypothermia presents with a
sympathetic response meaning heart rate and
breathing increases, and shivering begins in
attempt to generate heat. The patient gets
piloerection (i.e., goose bumps) and typically
seeks to get out of the cold.
When moderate hypothermia is reached,
the patient has difficulty walking and doing
fine motor skills. The patient can become
apathetic, which can sometimes make them
unaware that they’re cold and they may leave
shelter or even remove clothing. They can also
become disoriented not knowing where they
are or where to go.
The person’s heart rate slows down and
insulin starts to become ineffective causing
glucose regulation problems. The patient will
eventually become unconscious. Lethal heart
rhythms such as ventricular fibrillation may
cause cardiac arrest. If the patient continues
to lose heat, they will become less responsive,
reflexes are absent, and the body’s use of oxy-
gen is altered. This state of hypothermia is
commonly lethal.
Populations at risk include the elderly and
children. Alcohol consumption and some anti-
depressants can put people at a higher risk for
heat loss. Jeff had been drinking and he was
out in the cold. It’s difficult to say why he
made it to the back of the homeless shelter
and didn’t make it in, but for whatever reason,
he found himself on the ground.
Being in contact with the ground caused a
conduction heat loss, the wind blowing over
him stole heat through radiation and convec-
tion. Breathing the cold air all night facilitated
a heat loss internally.
WARMING CONSIDERATIONS
The first component of EMS treatment for
hypothermia is to recognize it as a potential
problem and stop the patient from becom-
ing colder.
In early stages of hypothermia, where the
patient is still responsive, active warming is
indicated. This can be accomplished with heat
packs in the axilla, groin and neck. Be cautious
to not cause skin burns. Cover the patient
with blankets and provided warmed oxygen
if it’s available.
In moderate and severe hypothermia, exter-
nal warming may be harmful as it can cause
the blood to move to the arms and legs as the
heat dilates blood vessel, pulling blood from
the internal organs. Patients should be handled
gently, as rough handing can precipitate cardiac
dysrhythmias. Overaggressive stimulation of
the airway can do the same thing, so caution
should be used when placing advanced airways.
The slow pulses and respirations associated
with severe hypothermia makes assessment
difficult. Check for pulses and breathing for
60 seconds. If a patient is in cardiac arrest,
begin CPR and use the AED. Don’t attempt
active warming in the field. The ED will ini-
tiate warming.
Always check for other causes of altered
mental status such as hypoglycemia, opioid
and alcohol intoxication, traumatic injuries
and stroke.
Hypothermia can present subtly, so be sure
to maintain a high index of suspicion and
transport for definitive care. JEMS
Dennis Edgerly, MEd, EMT-P, began
his EMS career in 1987. He’s currently the
EMS academy director for Arapahoe
Community College. He can be reached at
dennis.edgerly@arapahoe.edu.
www.jeMs.CoM
2/9/18 3:15 PM
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 CASE OF THE MONTH
DILEMMAS IN DAY-TO-DAY CARE
UNUSUAL PAIN & SWELLING
Rare skin infection afflicts Hurricane Harvey floodwater rescuer
By Renee C. Johnson, MD, MPH
J
.R. is a young man who worked for a 9-1-1
service immediately after graduation from
high school. He loved his job, and was a
dedicated and arduous worker.
Although J.R. needed to depart from the
EMS world for personal reasons, he maintained
his medical acumen via his current position
within the medical area of a national organiza-
tion. He resides in Missouri City, Texas, with
his wife and children.
On August 25th, 2017, a few hours away
from Missouri City, Hurricane Harvey made
landfall along the Texas coast with anticipated
catastrophic damage. Not only was this hurri-
cane the third Category 4 to ever make landfall
in Texas, but it was also the first since 1961, and
the first in 13 years to hit the U.S.1
In anticipation of Hurricane Harvey, J.R.’s
neighborhood was to be evacuated. However,
there were some neighbors who elected to stay
Redness at the site of the bite quickly increased in size and resulting in significant swelling.
Photos courtesy Renee Johnson
The patient underwent a total of three surgeries for debridement and wound closure.
20 JEMS | MARCH 2018
1803JEMS_20 20
or weren’t able to leave. The flooding that ensued
as a result of the storm was unprecedented and
profound, trapping and isolating Texas residents.
As a part of a neighborhood care team, J.R.
was contacted by a local pharmacy to check on
persons in the neighborhood who were likely in
need of medications. J.R., in collaboration with
his neighbors, used borrowed boats to search his
subdivision for neighbors in need of assistance.
Upon returning home that night, J.R. noticed
what he thought was a red mosquito bite on his
wrist. He described the bite as, “feeling more
painful than usual, maybe like a spider bite.”
The next morning, J.R. noticed that the bite
and redness had increased in size to that of a half
dollar. He described the pain as a burning sensa-
tion that radiated through his hand. Concerned,
J.R. called a physician friend who recommended
that he be evaluated and advised that he obtain
a prescription for antibiotics.
HOSPITAL COURSE
Over the course of the morning, J.R. noticed
the swelling had rapidly increased past his wrist.
Following his friend’s advice, J.R. presented to
an urgent care center later that morning.
When assessed in urgent care, J.R. had a
temperature of 103 degrees F, and was sent to
the ED. In the ED, J.R. noticed that he’d lost
sensation in his pinky finger of the same hand.
Although only in the ED for 45 minutes, his
diagnosis was determined, the surgical team was
consulted, antibiotics were started, and J.R. was
swiftly admitted to the inpatient unit.
Shortly after arriving in the inpatient unit,
J.R. reported “feeling weird.” His blood pressure
was found to be “80s/40,” so IV fluid resuscita-
tion was started without improvement, eventu-
ally requiring the use of vasopressors. J.R. was
subsequently moved to the ICU with concern
for septic shock.
In addition to medical resuscitation, J.R.
underwent a total of three surgeries for
debridement and wound closure. His hospi-
tal course was complicated by development of
compartment syndrome, for which he required
an additional incision from his elbow to his
wrist to treat with drains initially placed, and
eventual closure days later. J.R. also battled
with pneumonia while in the hospital, from
which he recovered.
After a 14-day hospital stay, nine of which
were in the ICU, J.R. was able to return home
with a three-week course of oral antibiotics to
be taken daily. J.R. was required to have multi-
ple follow-up visits with infectious disease doc-
tors including numerous blood draws. However,
J.R. was most anxious to begin rehabilitation to
return to his functional baseline.
Although the duration of occupational and
physical therapy was estimated to take 90 days,
with anticipated cessation of work activities for
3–6 months, J.R. recovered in 2.5 months. J.R.
notes that the most difficult part of the recov-
ery for him is the pain from his scars, but he’s
utilizing specific therapies to assist with this.
www.jeMs.CoM
2/9/18 3:15 PM
 DISCUSSION
Skin and soft tissue infections (SSTIs) are clas-
sified as simple or complicated, and can involve
the epidermis, dermis, subcutaneous fat, fascia
or muscle. Cellulitis, erysipelas, impetigo, fol-
liculitis, and an abscess are examples of simple
SSTIs. Necrotizing fasciitis is an example of a
complicated SSTI, one that reaches the level
of the fascia and continues to spread.2
Since 2010, necrotizing fasciitis has an
incidence of 600–1,200 cases per year in the
United States, and the incidence appears to
be increasing.3,4 Although rare, it’s associated
with high mortality, bearing mortality rates
that exceed 30%.5
The incidence of necrotizing fasciitis inpa-
tient admissions in Texas varied between 59
cases per 1,000,000 person between 2001
and 2002, and 76 cases per 1,000,000 person
between 2009–2010, with a reported overall
in-hospital mortality rate of 9.4%.6 Thus, early
diagnosis is imperative with necrotizing fasciitis
as appropriate intervention can reduce mor-
tality rates.7 However, this is often difficult to
accomplish without a high index of suspicion by
For more information, visit JEMS.com/rs and enter 8.
www.jems.com
1803JEMS_21 21
medical providers given the rarity of the disease.
Necrotizing fasciitis can occur in any area
of the body, but is most commonly seen in
the extremities, perineum and genitalia; the
extremities are the most common site. The
pathogen is often introduced into the sub-
cutaneous tissue. Instances of trauma, injec-
tions, bites and surgical complications are a
few examples of mediums through which the
pathogens may enter the skin.
Various pathogens may cause necrotizing
fasciitis, and the specific etiologic agent forms
the basis for classification of necrotizing fas-
ciitis. Type 1 infections are classically poly- An incision from the patient’s elbow to his wrist was
microbial, including clostridium infections; required in order to place drains after the patient
these infections typically have foul-smelling, developed compartment syndrome.
serosanguinous fluid with associated crepitus
gas. Type 2 infections characteristically involve the degree of destruction in the deeper tissue
group A beta hemolytic streptococci (GAS) layers.6 Thus, being able to recognize necro-
and/or staphylococcal species. Type 3 infections tizing fasciitis, let alone differentiate the type
are usually caused by gram-negative marine can be an arduous task.
organisms, most commonly Vibrio vulnificus.3 Early signs and symptoms of necrotizing
The release of bacterial toxins causes the fasciitis can be similar to those seen with sim-
infection to rapidly spread along fascial planes, ple SSTIs. Erythema, pain and swelling are the
while the overlying skin doesn’t often reflect most common physical exam findings. One of
MRSA
C. Difficile
Norovirus
Hepatitis
SARS
Flu
TB
First-Responder.com
Patent # US 9,623, 140 B2
mARcH 2018 | JEMS 21
2/9/18 3:15 PM
 CASE OF THE MONTH
the most consistent features of necrotizing fasciitis is pain that’s out of
proportion to the swelling or erythema. Blisters and skin necrosis are
later findings with necrotizing fasciitis. Fever may or may not be pres-
ent, and the absence of a fever should not rule out necrotizing fasciitis.7,8
Additional “red flags” for necrotizing fasciitis include surgery at the
site of infection in preceding 90 days, altered mental status, skin fluc-
tuance, hemorrhagic bullae or hypotension.5
Laboratory markers are often utilized to aid in the diagnosis of nec-
rotizing fasciitis, however blood cultures are positive in only 60% of
cases with GAS. Imaging studies such as XR, MRI, CT and Doppler
studies are often utilized to define infection progression.9 Necrotizing
fasciitis is a rapidly progressive disease, and patients quickly develop
sepsis. Necrotizing fasciitis is life and/or limb threatening, and a sur-
gical emergency.
The Infectious Diseases Society of America (IDSA) guidelines
indicate early and aggressive surgical excision of the infected tissue in
addition to adequate antibiotic therapy.10 Surgical intervention often
consists of radical, widespread debridement to remove infected and
necrotic tissue, sometimes requiring amputation.3 Multiple surgeries
(3–4 on average) are often required, and in some instances reconstruc-
tive surgery is necessary to cover the soft tissue defects. Aggressive care
has been successful in lowering case fatality over the last two decades by
16–34%.11 Early recognition, and thus early intervention, will decrease
mortality and amputation rates.
Not only does necrotizing fasciitis require early recognition, initial
TM
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22 JEMS | MARCH 2018
1803JEMS_22 22
resuscitation and debridement, but it also necessitates extensive wound
management and rehabilitation. Thirty percent of necrotizing soft tissue
infection survivors have been found to have mild to severe functional
limitation at the time of discharge.3
A survivor of necrotizing fasciitis has to endure months of contin-
ued physical therapy to regain functional independence. Rehabilitation
is aimed at improving functional outcomes, developing psychological
well-being and fostering reintegration into society.6 A survivor’s quality
of life is significantly impacted by their physical function and ongoing
pain, and many often also focus on the effect their experience has had
on their family and other relationships.10 Early diagnosis and early, com-
plete surgical intervention have continually shown to improve outcomes
in the multi-dimensional nature of this disease and its recovery process.
TEACHING POINTS
>>Maintain a high index of suspicion for necrotizing fasciitis in patients
with cellulitis in setting of trauma;
>>Remember the “red flag” triad of pain, swelling and erythema—and
the classical finding of pain out of proportion, rapid worsening of
lesion and spread of swelling and/or erythema;
>>Keep draining or open wounds covered with clean and dry bandages;
>>Wash hands often with soap and water or use an alcohol-based
hand rub if washing is not possible;
>>Wear gloves if working in environment with potential for con-
tamination; and
>>Generally, a person with necrotizing fasciitis does not spread the
infection to other people. JEMS
REFERENCES
1. Historic Hurricane Harvey’s recap. (Sept. 2, 2017.) The Weather Channel. Retrieved Jan. 31, 2018, from
www.weather.com/storms/hurricane/news/tropical-storm-harvey-forecast-texas-louisiana-arkansas.
2. Ramakrishnan K, Salinas RC, Agudelo Higuita NI. Skin and soft tissue infections. Am Fam Physician.
2015;92(6):474–483.
3. Hakkarainen TW, Kopari NM, Pham TN, et al. Necrotizing soft tissue infections: Review and current
concepts in treatment, systems of care, and outcomes. Curr Probl Surg. 2014;51(8):344–362.
4. Necrotizing fasciitis. (July 3, 2017.) Centers for Disease Control and Infection. Retrieved Jan. 31, 2018,
from www.cdc.gov/features/necrotizingfasciitis.
5. Alayed KA, Tan C, Daneman N. Red flags for necrotizing fasciitis: A case control study. Int J Infect Dis.
2015;36:15–20.
6. Arif N, Yousfi S, Vinnard C. Deaths from necrotizing fasciitis in the United States, 2003–2013. Epide-
miol Infect. 2016;144(6):1338–1344.
7. Goh T, Goh LG, Ang CH, et al. Early diagnosis of necrotizing fasciitis. Br J Surg. 2014;101(1):e119–125.
8. Wang JM, Lim HK. Necrotizing fasciitis: Eight-year experience and literature review. Braz J Infect Dis.
2014;18(2):137–143.
9. Sabre A, Robles CG, Krisar-White P, et al. Soft tissue injury of the lower extremity complicated by type
II necrotising fasciitis highlighting the need for astute clinical practices and proper treatment. BMJ
Case Rep. 2014:bcr2014204720.
10. Faraklas I, Yang D, Eggerstedt M, et al. A multi-center review of care patterns and outcomes in nec-
rotizing soft tissue infections. Surg Infect (Larchmt). 2016;17(6):773–778.
11. Hakkarainen TW, Burkette Ikebata N2 Bulger E, et al. Moving beyond survival as a measure of
success: understanding the patient experience of necrotizing soft-tissue infections. J Surg Res.
2014;192(1):143–149.
Renee C. Johnson, MD, MPH, is an emergency medicine physician practicing and residing in
Texas. She’s the assistant medical director for the Houston Fire Department (HFD) through an
EMS fellowship with the HFD and University of Texas Health Science Center.
www.jeMs.CoM
2/9/18 3:15 PM
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For more information, visit JEMS.com/rs and enter 10.

Visit JEMS CE at http://jems.com/jems-ce

to learn more today!

1803JEMS_23 23 2/9/18 3:15 PM

 STREETSENSE
ESSENTIAL NON-MEDICAL FIELD SKILLS
IMPROVISATION
It might be all you have
By Kate Dernocoeur, NREMT
A
n eight-foot wave at an Acapulco beach
proved too much for a middle-aged
body-surfing American tourist.
After the pummeling, he lay in the shallows,
his distal tib-fib a mushy mess of crepitus.
Hearing the cries for help and seeing none on
the nearly deserted beach, I went into action,
an earnest advanced first aider with little direct
experience with an actual injury.
This being the mid-70s, there was
no 9-1-1, no Mexican emergency
response. I headed over to him, intro-
duced myself and offered to help.
The physical exam proved the leg
fracture to be an isolated injury.
Time to splint. The beach was
all sand and seashells. Scanning for
possibilities, I saw a small wooden
sign pounded into the beach nearby.
A couple of willing assistants sepa-
rated the crosspiece from the stake, and I bor-
rowed some towels for padding, then used a
couple of belts to hold it all in place.
Someone brought a lounge chair over and
a group of volunteers helped haul the man to
a waiting cab. Off he went with his friends
to the hospital.
It wasn’t textbook, but it worked (and
worked well, he reported, when we saw him
at the airport in a cast a few days later).
BEYOND THE USUAL
What I love about wilderness medicine is the
need for improvisation. And as the example
from Acapulco shows, “wilderness” might be
as close as your next tornado, hurricane, or
other disaster.
A knack for improvisation relies on two
things: 1) attention to the principles of care
while employing flexibility; and 2) creativity
in their application. There might not always
be a well-stocked ambulance at hand or an ED
20 minutes away. Improvisation means taking
the knowledge in your head and using what-
ever you can scrounge up from your backpack
24 JEMS | MARCH 2018
1803JEMS_24 24
or from other nearby sources.
At the time of the Acapulco rescue, my
only EMS experience consisted of a year with
a volunteer mountain rescue team in Colo-
rado, a couple of years as an assistant instruc-
tor for a wilderness-oriented first aid course
in New England, and a winter mountaineer-
ing course at the National Outdoor Leader-
Improvisation demands
that you be emotionally
& logistically prepared to
think beyond the usual.
ship School (NOLS). Unconventional, true,
but these experiences left me adept in the art
of improvisation.
It’s a worthy skill. Knowing various alter-
native ways to provide emergency care using
limited tools will help anyone cope with abrupt
changes to the EMS landscape, even right
at home.
Improvisation demands that you be emo-
tionally and logistically prepared to think
beyond the usual. It’s one reason I always wear
a webbed belt in the backcountry and carry a
cotton bandana, usually tied around my neck.
Each has multiple possible uses, such as a rapid
dressing, bandage wrap, splint tie and even a
tourniquet. Everything I carry–extra clothing,
a ground pad, walking sticks—can serve in
various ways. What’s in your pack?
Natural materials can also be handy. Many
a stick has been padded and pressed into ser-
vice as a splint. Soft grasses make excellent
padding. Streams are great for cold soaks on
sprains, and for cooling burns. Snow packed
into a bandana works well as a cool compress.
In less remote settings, use a magazine to cup
a forearm fracture. At a crash demanding rapid
extrication, I quickly devised a pillow splint
for a nasty lower leg injury, and we got the job
done fluidly while preserving the principles of
fracture management.
You can even use your own body. A (gloved)
hand against a bad bleed is better than nothing
while others scramble for a proper bandage.
Your arms can serve as temporary
splints: envision a motorcycle crash
victim face down, his mid-shaft
femur fracture draped over the top
of a small berm. It worked well to
stabilize both sides of the femur
with my arms when he was turned
(another person rotating the lower
leg in synch) and moved fluidly to
the backboard. Then I slid my arms
into proper position to pull traction
and was greeted with that classic
“ahhh!” of relief as his muscle spasms relaxed.
CONCLUSION
Improvising doesn’t give you permission to be
slack with standards of care. Joints above and
below fractures need to be immobile. Cardiac
patients shouldn’t be walking. Distal pulses and
sensation need to be accessible for rechecking.
But as long as you are flexible and creative,
it can be a great skill to add to your toolbox.
After all, you never know when you’ll need
to think on your feet and find an improvised
solution. JEMS
Kate Dernocoeur, NREMT, has written
numerous books, articles and columns for
EMS readers. Her involvement with emer-
gency care began in 1976, and she served
with Denver’s famous Paramedic Division
from 1979 to 1986. She’s now an EMT-firefighter with the
Ada (Mich.) Fire Department and a SARTECH-II with Kent
County Search and Rescue’s K-9 unit. The fourth edition of
her seminal book, Streetsense: Communication, Safety and
Control, is scheduled for release in 2019 by JEMS Books
and Videos.
www.jeMs.CoM
2/9/18 3:15 PM

FOCUS ON POCUS
Does point-of-care ultrasound have an effect on chest
compression interruptions?
By Keith Wesley, MD, FACEP, FAEMS & Karen Wesley, NREMT-P
THE RESEARCH
Clattenburg EJ, Wroe P, Brown S, et al. Point-
of-care ultrasound use in patients with cardiac
arrest is associated with prolonged cardiopul-
monary resuscitation pauses: A prospective
cohort study. Resuscitation. 2018;122:65–68.
THE SCIENCE
This study reports the length of chest com-
pression interruptions that occurred when
point-of-care-ultrasound (POCUS) was per-
formed to detect cardiac motion during cardiac
arrest resuscitation.
Over a period of six months, 24 of the
84 arrests resuscitated in the ED were video
recorded. The length of compression inter-
ruptions was compared when POCUS was or
wasn’t performed. The average interruption was
17 seconds when POCUS was performed, vs.
11 seconds when it wasn’t. POCUS performed
by a fellow trained in ultrasound resulted in
compression interruptions that were, on aver-
age, 4.1 seconds shorter than those performed
by non-trained fellows. Interruptions were 6.1
seconds longer when POCUS was performed
by the physician leading the resuscitation.
MEDIC WESLEY COMMENTS
Ultrasound during cardiac arrest sounds like a
great idea in a controlled hospital setting with
personnel specifically trained to provide the
procedure.POCUS has also become a valu-
able tool in the trauma setting. Certainly, it
can help to locate critical injuries requiring
immediate attention.
However, the idea that it could or might be
added to the prehospital protocol for patients
in pulseless electrical activity (PEA) just isn’t
plausible with current staffing, training and
equipment budgets. Would the results actually
be timely enough to limit compression pauses
to acceptable gaps? I don’t think so.
Although it would likely be more valuable
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1803JEMS_25 25
CONVERSATIONS ABOUT EMS RESEARCH
in trauma patients, it’s sometimes best to do
what we can in the field to stabilize and trans-
port in a timely fashion.
Further, as with any skill, this would require
frequent in-hospital training and clinical time
that just isn’t available to prehospital providers.
Let’s add the cost of equipment to the whole
equation. It’s simply not in the budget for the
majority of services.
Make no mistake; I’m all about new skills
and education. The lessons learned from this
study are valuable to the providers in the street
when dealing with PEA cardiac arrest.
However, I don’t see the training oppor-
tunities, reimbursement, or staffing changes
allowing for prehospital POCUS in the
near future.
DOC WESLEY COMMENTS
Interruptions in chest compression greater than
10 seconds are associated with lower rates of
successful resuscitation. That’s why the Amer-
ican Heart Association strongly recommends
limiting compression interruptions to less
than that.1
Ultrasound, especially for trauma, is one of
the most impactful procedures an emergency
medicine physician can perform. It can rap-
idly detect the presence of injury to the thorax
or abdomen—but it’s usually performed on a
patient with a pulse.
As it relates to this study, PEA is the result
of a large variety of causes which, in most cases,
creates severe shock, which is noted by the
presence of heart contractions in the absence
of a pulse.
Ultrasound in PEA cardiac arrest is used to
detect clinically significant contraction of the
heart thus guiding treatment.
This study documents that it takes a signif-
icant length of time to use ultrasound while
performing CPR. Additionally, the level of
training in the procedure correlates with the
STREET SCIENCE
length of chest compression interruptions. It
raises questions about the viability of extend-
ing this technology to the prehospital arena.
Perhaps it’s possible to train EMS provid-
ers to use ultrasound for trauma, but can we
train them to the level of emergency medicine
fellows? I have serious reservations.
Perhaps it would be more appropriate to
place the PEA arrest victim on mechanical
CPR, secure the airway, administer epineph-
rine every 5 minutes and transport them to the
ED where a larger team can continue resus-
citation and use ultrasound in the most effi-
cient manner.
However, if a service decides to implement
POCUS, they should appreciate the fact that
these authors noted that compression inter-
ruptions were longer when the physician
leading the resuscitation also performed the
ultrasound procedure.
Therefore, it may be more effective to train
a small group of providers to their best abil-
ity and then deploy them to the cardiac arrest
scene, so that performance of POCUS is done
as efficiently as possible. JEMS
REFERENCE
1. Kleinman ME, Goldberger ZD, Swor RA, et al. Part 5: Adult basic
life support and cardiopulmonary resuscitation quality: 2015
American Heart Association guidelines update for cardiopul-
monary resuscitation and emergency cardiovascular care. Cir-
culation. 2015;132(18 Suppl 2):S414–S435.
Keith Wesley, MD, FACEP, FAEMS is the med-
ical director for HealthEast Medical Transpor-
tation in St. Paul, Minn., and United EMS in
Wisconsin Rapids, Wis. He can be reached at
drwesley@charter.net.
Karen Wesley, NREMT-P, is a paramedic and
educator for Mayo Clinic Medical Transport
and is the medic team leader for the Eau Claire
County (Wis.) Regional SWAT team. She can
be reached at admkaren22@hotmail.com.
mARcH 2018 | JEMS 25
2/9/18 3:15 PM
 26 JEMS | MACH 2018

1803JEMS_26 26 2/9/18 3:19 PM

 Houston-area EMS agencies put to the test
responding to Hurricane Harvey’s epic flooding
By Casey B. Patrick, MD; Kevin Schulz, MD, FAEMS, FACEP; Chivas Guillote, MSN, RN, FNP-C;

Robert Dickson, MD, FAEMS, FACEM, FACEP & Cameron Decker, MD, LP, FACEP

Rescue boats fill Tidwell Road as they help flood victims evacuate as floodwaters from Tropical
Storm Harvey rise Monday, Aug. 28, in Houston. AP Photo/David J. Phillip

www.jems.com MARCH 2018 | JEMS 27

1803JEMS_27 27 2/9/18 3:19 PM

 PREPARING FOR CATASTROPHE
Citizen volunteer rescuers evacuated numerous patients from flooded areas, and there was initial confusion
when these patients turned up at shelters throughout the county. AP Photo/David J. Phillip
H
urricane Harvey made landfall
on Friday, August 25, at 11p.m.,
between Port Aransas and Port
O’Connor, Texas. A Category 4 hurricane,
it was the strongest to hit Texas since 1961.
Estimated economic losses from the dev-
astation caused by Harvey will be in the
$150–200 billion range, making it the costli-
est hurricane in history. (The previous record
was held by Katrina in 2005 with estimated
$120 billion in losses.)
After a devastating landfall, Harvey quickly
weakened to a tropical storm and stalled over
the Southeast Texas region for the next five
days, causing catastrophic flooding.
The destruction caused by this epic storm
prompted disaster declarations in 50 Texas
counties and stressed EMS systems and first
responders in a manner not previously expe-
rienced since Katrina.
The Houston metropolitan area is made
up of nine counties and has an estimated
28 JEMS | MARCH 2018
1803JEMS_28 28
population of 6.5 million residents, making it
the fifth largest metro area in the United States.
This article outlines the preparations, expec-
tations, actual operational specifics and lessons
learned from three of the agencies responding
to the disaster: Montgomery County Hospi-
tal District (MCHD) EMS, Houston Fire
Department (HFD) EMS, and Harris County
Emergency Corp (HCEC) EMS.
MONTGOMERY COUNTY HOSPITAL
DISTRICT (MCHD) EMS
MCHD EMS is a non-fire-based ALS sys-
tem covering a 1,100-square mile area in the
north Houston metropolitan area, with a pop-
ulation of 600,000 residents. MCHD’s 9-1-1
transport service is supported by approximately
900 EMT-B first responders representing 13
fire departments in the county. Montgomery
County is the farthest inland of all the agen-
cies included in this article, and several areas
of the county suffered major flooding. This
cut off access to many patients in southeast
Montgomery County and made safe response
a challenge.
MCHD: Storm Preparation
MCHD EMS expected significant storm
damage resulting in surges of requests for
services and patients. All available personnel
were brought to their stations and provided
cots and food.
Anticipating that flooding or damage might
prevent access to stations, MCHD also hired
back staff and prepositioned personnel.
Trucks and equipment were strategically
placed. To mitigate the effects of possible
widespread power outages, diesel generators
were installed at all stations. Each station was
also equipped with extra supplies and emer-
gency fuel.
In anticipation of the storm making it dif-
ficult to access and egress hospital facilities,
Medical Command (MedCom) was brought
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2/9/18 3:19 PM
 online in the alarm office to provide direct difficulty in identifying shelter contacts with for displaced chronically ill patients (agree-
medical oversight for transport refusals and correct information, made it imperative to ments with local pharmacy for prescrip-
phone consultations with patients that pro- have MCHD crews and supervisors on the tions, processes for the medical directors to
viders wouldn’t be able to access. ground to make assessments and communi- write emergency prescriptions, and access
For difficulties accessing patients, boat and cate needs to MedCom. to hemodialysis services); and
air resources were secured and coordinated A command staff update meeting, which >>Improve MCHD’s system to identify access
through MedCom to assist first responders. included representatives from all departments and egress routes so that it can be updated
(EMS, Alarm, MedCom, Communications, in real time.
MCHD: Storm Response Facilities, Fleet and Public Health), was held
There was a minimal amount of patient surge twice daily in conjunction with the county HOUSTON FIRE DEPARTMENT (HFD)
just after the storm, but safely The HFD is a fire-based tiered
navigating routes to access ALS/BLS EMS system cover-
patients and hospitals posed ing the city of Houston, which
a unique challenge, including The information on road consists of approximately 650
terminating CPR efforts via square miles and is home to a
phone in patients that couldn’t closure was inconsistent & population of more than 2 mil-
be accessed. lion, with millions more from the
The information on road dynamic, requiring intermittent surrounding area coming into
closure was inconsistent and the city for work and recreation.
dynamic, requiring intermittent survey by command staff & HFD’s staff of nearly 4,000
survey by command staff and members use both transport
constant updating by field crews. updating by field crews. units as well as ALS and BLS
Phone consultations with first responder units, including
medical command staff in the SUVs and fire apparatus.
alarm office contributed direct medical over- emergency operations center (EOC). These Several major bayous cut through Houston.
sight to patients that the crews couldn’t reach. meetings provided an excellent situational They not only drain rainwater in the city, but
These contacts were recorded and the medi- update from all involved parties and the EOC. also carry water from north and west of the
cal directors followed up with each patient to city to empty into the Houston Ship Channel.
assess progression of their symptoms in order MCHD: Lessons Learned Houston has had several major flood events in
to assist in triaging their rescues. >>Early work in the county to identify all recent years from heavy rainstorms, and cer-
Citizen rescuers evacuated numerous shelters, including their capabilities and tain areas of the city are known to be prone
patients from flooded areas, and there was contacts, is important in the aftermath of to flooding in major storms.
initial confusion when these patients turned up sorting through the displaced with medi- The Texas Medical Center, the largest med-
at both known Red Cross shelters and pop-up cal needs is vital; ical complex in the world—home to more than
shelters throughout the county. >>Utilization of community paramedics to 50 major hospitals, medical schools, and other
Misinformation on medical and care capa- coordinate shelter and patients’ needs; medical institutions—is located not far from
bilities from multiple shelters, along with >>Early identification of community resources one of the major bayous, creating the potential

Phone consultations with Montgomery County Hos-

pital District medical command staff in the alarm
office contributed direct medical oversight. In Montgomery County, safe navigating routes to access patients and hospitals posed a unique challenge,
Photo courtesy Robert Dickson despite a minimal amount of patient surge just after the storm. Photo courtesy Robert Dickson

www.jems.com mARcH 2018 | JEMS 29

1803JEMS_29 29 2/9/18 3:19 PM

 PREPARING FOR CATASTROPHE
for significant healthcare system delays, should Center, typically the large-scale shelter in pre- high-water rescue vehicles. Stressed water res-
it become inaccessible. vious city of Houston weather events. cue resources required major assistance from
the Houston Police Department, the Public
HFD: Storm Preparation HFD: Storm Response Works Department, the U.S. Coast Guard, the
HFD prepositioned certain assets, including Calls for service during the storm exceeded Texas Guard, mutual aid agencies and civilian
rescue resources and evacuation boats, near expectations: At one point, the Houston pub- volunteers to assist with rescues.
areas historically known for flooding. Fire sta- lic safety answering point had received 56,000 The George R. Brown Convention Cen-
tions in known flooding areas were evacuated calls for service in 15 hours (there’s typically ter opened as a major shelter, and required
ahead of the storm, with their units heavy HFD EMS involvement
and personnel being relocated to to run effective medical care for
other stations. more than 10,000 evacuees. HFD
Anticipating heavy flooding Anticipating heavy flooding EMS medical directors staffed the
and rescue of civilians, preparations facility 24/7 in the first two weeks
were made to staff dump trucks requiring rescue of civilians, to provide overall medical con-
from the Public Works Depart- trol, and HFD EMS supervisors
ment as high-water rescue vehi- preparations were made to maintained the role of transport
cles. Other agencies and resources officer. This local EMS involve-
would be called upon should addi- staff dump trucks from the ment helped protect the hospital
tional support be needed. system and the limited transport
In case of difficulty with access Public Works Department as resources available.
and egress from our hospital facil- Chronic care patients (e.g.,
ities, medical direction staff stood high-water rescue vehicles. hemodialysis, chronic O2, behav-
by to assist crews with patient ioral health, nursing care, etc.) were
transport decisions, protocol devi- a major concern in the shelter, as
ations and other non-standard medical issues. around 8,000 in that timeframe). access to resources needed to care for these
Medical facilities would also be established Areas of the city that had never flooded patients were limited.
at the largest shelters to relieve stress on the before were inundated, and floodwaters Systems were established at the convention
hospital system and prevent transports. remained high for days, limiting access to center shelter to accommodate these patients
HFD personnel and medical directors pre- patients and evacuees, and preventing fire and without stressing the hospital systems and
pared to open medical areas in major shelters EMS crews from relieving the ride-out crews EMS transportation resources.
as they opened around the city, with an eye at the fire stations. Coordination between multiple agencies
towards the George R. Brown Convention There was a drastic shortage of available was challenging. One of the primary difficul-
ties was communication.

HFD: Lessons Learned

>>More high-water rescue vehicles were
needed; although it was recognized that
improvisation, such as the use of dump
trucks, was key to the continued operations;
>>Areas that had never flooded before did,
causing a potential re-examination of the
way resources were staged;
>>Coordination with multiple agencies
involved in the rescue efforts could have
been more effective early in the response,
but were rapidly improved by embedding
liaison personnel and bringing representa-
tives to the Houston EOC;
>>Despite it being a nontraditional role, the
heavy involvement of HFD EMS in the
medical care during shelter operations at
George R. Brown helped protect the hos-
pital system and maintain the limited EMS
transport resources for patients who truly
Calls for service during the storm exceeded expectations in Houston, and at one point the Houston Emergency needed them;
Center received 56,000 calls for service in 15 hours. AP Photo/Matt Sedensky >>Improvisation and critical thinking, from

30 JEMS | MARCH 2018 www.jeMs.CoM

1803JEMS_30 30 2/9/18 3:19 PM

 the command level to the individual fire-
fighter and paramedic, ensured the smooth-
est possible HFD operations and certainly
saved lives during a catastrophic disaster
that no city could have been completely
prepared for.
HARRIS COUNTY
EMERGENCY CORPS (HCEC)
HCEC is a non-profit EMS system encom-
passing 130 square miles in an unincor-
porated area of Harris County, which is
north of downtown Houston. HCEC
provides vital 9-1-1 and community
healthcare to a medically underserved
population of more than 400,000 citizens.
Patient care is augmented by six local
fire department first responders, most
of which are under the HCEC medical
control system.
HCEC’s service area contains com-
munities with limited public works infra-
structure located in a watershed zone with
numerous small creeks and bayous. High-den-
sity development in the watershed’s floodplain
has previously led to major damage to homes,
businesses and vehicles during frequent flood-
ing events over the past several decades.
During significant weather events such as
hurricanes, street flooding has significantly
limited the ability to access patients in need.
HCEC: Storm Preparation
HCEC has a centrally located administrative
headquarters and a number of satellite sta-
tions in the area. Many of the satellite stations
are designed to accommodate flex staffing.
The typical deployment plan is a mix of
static and dynamic deployments, depending
on call volume and geographic coverage needs.
For Hurricane Harvey, additional units were
scheduled in anticipation of high call volume
and the likelihood of delayed response due to
high water road conditions.
The administrative headquarters and each
satellite station were checked for operational
readiness. All generators were verified to be
in proper working order. Reserve ambulances
were prepared for deployment to augment the
frontline fleet. Unleaded and diesel fuel storage
tanks were filled at the administration building.
Liquid oxygen supply was topped off to
ensure the system had enough oxygen to oper-
ate during extended periods of isolation. The
logistics team ensured supplies were distrib-
uted to all stations for restocking. Hot meals
www.jems.com
1803JEMS_31 31
were prepared and rotated to each crew on
a daily basis. Additionally, non-perishable
foods were distributed, as each station has
cooking facilities.
Most of HCEC’s staff live outside of the
jurisdictional boundaries of the 9-1-1 response
area. As such, it was important to identify
ways to ensure staff members could make it
to work as well as have a safe place to rest
while off-duty. Hotel rooms were reserved and
Making sure family
members of personnel
would be safe was
a top priority.
made available to staff concerned about driv-
ing home. This strategy proved invaluable as
flooding blocked access to many staff member’s
homes. Those who were able to make it to their
shifts worked extended hours. Crewmembers
were encouraged to bring their issued raingear
as well as extra socks, boots and uniforms.
Making sure family members of personnel
(even four-legged ones!) would be safe was a
top priority; a local pet boarding facility was
opened to the staff so communicators and
medics could be deployed for extended hours
without having to worry.
Unfortunately, Hurricane Harvey fell on a
pay week. Anticipating widespread internet
failures and bank closures, many redundant
Anticipating heavy flooding requiring rescue of civilians, dump trucks from Houston’s Public Works Depart-
ment were used as high-water rescue vehicles. AP Photo/David J. Phillip
systems had been established in advance to
guarantee payroll would be issued on time.
Manual checks were ordered in case direct
deposit became unavailable. Forms that were
usually electronic and deemed essential for
daily operations were printed in hardcopy
in case of power failure. Cash reserves were
increased in the event additional supplies
needed to be purchased without credit cards.
Administrative staff members who weren’t
required to be on site were able to log in
via remote access and worked from home.
Recognizing medics may encounter
unique patient care scenarios includ-
ing the inability to access hospitals or
lack of supervisor support, HCEC pro-
vided a secure, HIPAA-compliant video
conferencing solution that crews could
use for live discussions with HCEC’s
medical consult team which includes
the medical director and a nurse prac-
titioner. As a redundancy measure, in
addition to the cellular network, a backup
800 MHz channel was made available for
medical consults.
The IT team made ready spare radios, lap-
tops and mobile phones. They confirmed the
Governmental Emergency Telecommuni-
cations Service for all essential personnel’s
mobile devices. They also ensured redundant
power sources were functional, and that the
company’s remote servers and backups were
working properly.
Several generator tests were completed prior
to the arrival of the storm. HCEC has a redun-
dant communications center located at one of
its satellite stations, which was also checked
for operational readiness.
mARcH 2018 | JEMS 31
2/9/18 3:19 PM
 PREPARING FOR CATASTROPHE
Houston Fire Department EMS personnel were heavily involved in the medical care during shelter operations at the city’s George R. Brown Convention Center,
helping to maintain the limited EMS transport resources for patients who truly needed them. AP Photos/LM Otero
HCEC: Storm Response
Despite closely following weather predictions,
HCEC’s service area received significantly
more rain than was originally anticipated. Fur-
ther, the event lasted several days longer than
had been planned. As a result, HCEC’s per-
sonnel staffing plan was lean at times. Some
of the more notable events experienced during
the storm included:
>>Medical control authorized alternate care
transportation methods for patients, starting
with a mother who had delivered a healthy
child but was surrounded by floodwaters;
>>In an effort to improve communications
with law enforcement partners, HCEC
housed Harris County Sheriff ’s Office dis-
patchers in their communications center;
>>Twice daily EOC conferences were held
with all major stakeholders to increase sit-
uational awareness;
>>Twice daily email reports and a website
were established to notify both incoming
and on-duty crew members of road closures
and important updates;
>>Multiple HCEC crews deployed with the
state’s disaster response team, Emergency
Medical Task Force 6;
>>Several stations became isolated due to
flooding, but crews were able to evacuate
with their apparatus to alternate deploy-
ment points;
>>After a short power interruption and a
faulty breaker on the recently replaced
32 JEMS | MARCH 2018
1803JEMS_32 32
high-power generator, HCEC experienced
extended natural gas generator usage at the
administrative headquarters;
>>Due to the inaccessibility of typical food
vendors, Walmart generously donated food
and supplies to HCEC personnel; and
>>Crews were stationed at several shelters that
opened in the HCEC primary service area
to help oversee medical care until formal
shelter medical operations were established.
HCEC: Lessons Learned
>>Develop relationships with local hotels for
preferred room reservations during times
of crisis, as many employees were unable to
get home, and a hotel rest opportunity was
identified as critical “disconnect” time for
the heavily worked crew members;
>>Purchase high-water vehicles with the
intent of transporting staff to/from stations;
>>Develop improved flexible sleeping quar-
ters at the administration building and key
stations;
>>Deploy locked, deep freezers filled with
frozen foods to all stations at the beginning
of hurricane season to make available for
emergency use;
>>Reduce work hour duration of commu-
nications staff and increase break cycles;
>>Increase communicator shift overlap so that
a better hand-off and briefing is achieved;
>>Install fuel storage tanks at each station
to avoid reliance on external fuel supply;
>>Integrate a medical provider into communi-
cations who can help dictate preferred hos-
pital destinations based off of known bed
availability and road closures; and
>>Practice using secure video conferenc-
ing consultation as well as digital disas-
ter patient tracking software throughout
the year. JEMS
Casey B. Patrick, MD, is assistant medical director at Mont-
gomery County Hospital District and works in community emer-
gency medicine in the Houston area.
Kevin Schulz, MD, FAEMS, FACEP, is an emergency physician and
assistant EMS medical director for the Houston Fire Department.
He’s also assistant clinical professor of emergency medicine and
EMS fellowship director at McGovern Medical School at UTHealth.
Chivas Guillote, MSN, RN, FNP-C, is the vice president of clin-
ical services at Harris County Emergency Corps. He’s also an ED
nurse practitioner at Tomball Regional Medical Center and has
more than 25 years of experience in EMS and air medical services.
Robert Dickson, MD, FAEMS, FACEM, FACEP, is the medical direc-
tor for Montgomery County Hospital District EMS and assistant
professor of emergency medicine at Baylor College of Medicine
in Houston. He has a background in law enforcement and is a
former firefighter/paramedic for the city of Dallas.
Cameron Decker, MD, LP, FACEP, is medical director of Harris
County Emergency Corps, Rice University EMS, Aldine Fire Rescue,
Eastex Fire Department, Northwest Fire Rescue, Westfield Fire
Department and Emergency Medical Task Force 6. He’s board
certified in both emergency medicine and EMS medicine, an
assistant professor of emergency medicine at Baylor College
of Medicine, and faculty at Ben Taub General Hospital, one of
the busiest Level 1 trauma centers in the country.
www.jeMs.CoM
2/9/18 3:20 PM
 Table 1: Hurricane Harvey storm chronology and operational timelines
Storm Chronology
• By 2 p.m., Harvey is upgraded to
a Category 3 hurricane, with sus-
Friday, August 25
tained maximum winds of 120 mph
(195 kph)
• By 6 p.m., Harvey is upgraded to Cat-
egory 4, with maximum sustained
winds of 130 mph (215 kph)
• At 10 p.m., Harvey makes landfall
as a Category 4 hurricane when the
eye of the storm comes ashore near
Rockport, Texas
• By 2 a.m., Harvey is downgraded to
a Category 3, with maximum sus-
Saturday, August 26
tained winds of 115 mph (185 kph).
• Two hours later, it’s downgraded fur-
ther to a Category 2, but remains
stalled over Southeast Texas.
• Over the next several days, Harvey
will change direction several times,
bounce back out into the Gulf of
Mexico, and make landfall again,
continuing to dump rain on the
entire region.
Sunday, August 27
• Harvey begins moving slowly south-
east toward Houston area
• Flooding emergencies occur
throughout southeastern Texas coast
Monday, August 28
• Harvey finally moves east of Mont-
gomery County, and heavy rain ends
• Rivers and waterways continue to
flood areas of Montgomery County
Tuesday, August 29
• Harvey is downgraded to a Category
1 storm, with maximum sustained
winds of 90 mph (150 kph)
• Harvey causes catastrophic flooding
for Southeast Texas region
Wednesday, August 30
• Harvey makes its third landfall, just
west of Cameron, Louisiana
• Harvey continues through south-
western and central Louisiana
• Harvey weakens to tropical
depression
www.jems.com
1803JEMS_33 33
MCHD EMS Operational Timeline
• Perishable food delivered to stations
• Emergency operations began at 7:00 p.m.
• Staffing ramped up for EMS, public health and
facilities
• Medical directors Dickson and Patrick arrive at
Medical Command (MedCom) and begin prep
work
• County emergency operations center (EOC)
fully activated
• Four ambulances and a strike team leader are
deployed with EMTF-6
• Shelters begin opening overnight as floodwa-
ters began to rise
• Medical reserve corps volunteers contacted to
help staff official shelters
• Epidemiology starts shelter surveillance
contacts
• Station 42 isolated by rising floodwaters
• Shelters begin requesting more medical volun-
teers, equipment, and supplies to support med-
ically fragile residents
• MedCom activated to assist with consults and
transport decisions, initating EMS treat and
release along with EMS refusal to transport
protocols
• Inaccessibility to patients become an issue,
MedCom queues calls to check back with these
patients until rescue
• Medical directors initiate an active CPR/cardiac
arrest situation from MedCom radio due to lack
of access
• Administration building loses power and begins
running on generator power
• Oxygen at regional stations is stocked
• Posting is suspended and ambulances are
moved back to their home stations as quickly
as possible after calls
• National Guard helicopters arrive at Station 30
to assist with evacuations
• Materials management delivers water, blankets,
oxygen and other supplies to stations
• All queued patients from MedCom are
accessed/transported
• Multiple patient transport situation are diverted
with medical director field evaluation.
• Community Paramedicine staff are deployed to
assist at shelters and bring supplies to affected
people
• Oxygen distribution and dialysis access is one
of the biggest challenges
• Nursing home from Orange County arrives at
Lone Star Airport via helicopters; EMS staff
assist on site until EMTF arrives to transport
them to Lufkin-area facilities
• MedCom discontinued at 7:00 p.m.
HFD Operational Timeline
• Daily briefings begin at the Houston Emergency Opera-
tions Center with a 24/7 presence by HFD command-level
personnel
• Three community shelters are identified for potential
evacuees
• HFD assists with the evacuation of East Houston Regional
Hospital ahead of the storm
• Units in stations in flood-prone areas are relocated, and
rescue and evacuation boats are staged near areas known
to have flooded in previous storms
• Braes Bayou crests in southwest Houston, beginning cata-
strophic neighborhood flooding overnight
• HFD and police high-water rescue vehicles and boats
are staged throughout the city, as well as dump trucks
and other improvised high-water vehicles from other
departments
• George R. Brown (GRB) Convention Center opens as evac-
uee shelter with capacity around 4,500 people
• Multiple HFD and HPD stations and vehicles damaged or
lost to rising flood waters
• HFD call volume up by more than 450%, with over 4000
water rescue calls
• Rescue efforts begin in earnest, as there is catastrophic
flooding throughout the city
• Houston Airport System shuts down airports for all com-
mercial flights, open only for relief flights
• GRB shelter nearly hits its 4,500-person capacity, with
evacuees still arriving
• HFD personnel take a leading role in coordinating medical
care and transports at GRB
• Disaster Medical Assistance Teams enroute to GRB to pro-
vide shelter medical support
• Army Corps of Engineers begins controlled releases from
Addicks and Barker Reservoir dams, increasing flooding
downstream
• Multiple hospitals, including some of the city’s high-
est-volume EDs, go on internal disaster status, mostly due
to access issues from high water
• Rescue operations ongoing, with over 20 helicopters,
innumerable boats, and other local, regional, state and
federal assets
• GRB shelter approaches 10,000 people (more than double
its initial stated capacity)
• HFD continues to respond to rescue calls around the city
with the help of police, the U.S. Coast Guard, the Depart-
ment of Public Safety, the Texas Guard and volunteers.
• Federal DMAT teams take over medical care inside the
GRB shelter, but HFD medical direction and EMS super-
visors maintain overall medical control and transport
decision-making
• HFD call volumes begin approaching normal levels
• Ongoing rescue operations continue
• Federal teams manage GRB medical care with HFD medi-
cal direction and transportation officers
mARcH 2018 | JEMS 33
2/9/18 3:20 PM

When Hurricane Harvey hit, Galveston
EMS was prepared
By Nathan Jung, EMT-P
E
very year, EMS, fire, police and emer-
gency managers from across the Gulf
Coast review their hurricane plans,
conduct drills and make updates as needed.
November, the end of hurricane season, slips
quietly by for most—but not for those charged
with managing the disaster that ensues with
a hurricane. For these people, the passing of
hurricane season only offers a short reprieve
from wondering when the next storm is going
to come.
Developing a plan for a disaster is a very
complex process, and it’s a plan you hope you
never have to use. With hurricanes, how-
ever, it’s not matter of if, it’s simply a matter
of when.
Hurricane Harvey was unlike any other
storm we’ve faced in recent history, and it
34 JEMS | MARCH 2018
1803JEMS_34 34
demonstrated how important it is to drill and
understand a plan—and quickly adapt when
the storm doesn’t care about that plan.
PREPARATION BEGINS
Although landfall was forecast south of the
Houston/Galveston region, it became clear on
August 23, that Hurricane Harvey was going
to impact our area beyond a few feeder bands
of rain.
Our entire management team was called
together to start preparing for potential evacu-
ations and to activate crews who could poten-
tially be deployed to assist other communities,
in the event our own area wasn’t significantly
impacted. Preparing for a major rain event also
started, including identifying areas where our
hurricane plan didn’t fit.
Patients are evacuated from a nursing home in
Wharton, Texas. Photo courtesy Nathan Jung
The National Weather Service started to
forecast the potential for historic, heavy rains
that would lead to catastrophic flooding. Fore-
cast models were showing the storm turning
back toward the Gulf of Mexico and then north
along the Texas coast. With most state assets
already committed to the communities south
of us, the ability to conduct wide-scale evac-
uations was unlikely. In addition, the analysis
we conducted was shifting from facility failure
caused by wind, to infrastructure capability to
provide care to medical patients.
Over the past few years, the city of Hous-
ton has flooded a number of times, and it had
become clear that a significant rain event could
impact our ability to move patients between
Galveston and Houston. It would also have an
impact on deliveries of critical items, including
oxygen, pharmaceuticals, medical supplies and
other necessary items.
We knew we needed to work with the nurs-
ing homes, assisted living centers and high-risk
patients (e.g., those on ventilators, ventricular
assist devices, etc.) to encourage them to heed
voluntary evacuation orders. This proactive step
www.jeMs.CoM
2/9/18 3:20 PM
 was key as the storm progressed.
Galveston EMS and many other agencies in
Texas participate in the Texas Emergency Med-
ical Task Force (EMTF) program. After Hur-
ricane Ike, the task force developed a plan to
create a safety net—a sort of “9-1-1 for 9-1-1,”
that would bring assets from across the state
to help a local agency during a time of crisis.
On the morning of August 25, one of the
nursing homes in our service area, Gulf Health-
care Center, decided it was best to evacuate, as
they were situated only a few blocks off of the
seawall on Galveston Island.
Several high-risk patients who reside at
home also decided to evacuate due to the
potential of limited supplies, loss of power Galveston EMS evacuated patients on C-130s from Scholes International Airport. Photo courtesy Kory Dominy
and inability to travel.
Prior to Hurricane Harvey, the Gulf Health- adjectives our staff had never before heard crews found themselves triaging and manag-
care Center would have been evacuated with used in weather briefings. In fact, two new ing patients until transport to definitive care
about 15–20 ambulances and two charter buses. color categories for rainfall severity had to be could be arranged.
The EMTF program had already been acti- created on the weather maps because of Hur- Flooding continued, and at daybreak, the
vated and was working hard south of us in the ricane Harvey. overwhelming extent of the flooding was
Corpus Christi area. We were able to secure an The heavy rain came at night, and so did revealed. Help wasn’t coming unless it was by
ambulance bus from Atascocita (Texas) Vol- the floodwaters, which made rescue work dan- aircraft, and the entire region was devastated.
unteer Fire Department, which allowed us to gerous. The water rose quickly overnight, and To make matters worse, Hurricane Harvey
move all bed-bound patients at once. caught many people off guard. Thousands wasn’t finished with Texas.
Within a few hours of the decision being woke up to find water quickly rising in their Our county was full of residents, many dis-
made, Gulf Healthcare Center was closed. homes. Soon, Galveston County would be cut placed and without transportation. Obtaining
Just a few days later, after some minor repairs off from neighboring counties by flooded roads. supplies from the American Red Cross wasn’t
and cleanup, the facility would serve as a place Flooding was so intense that it even cut off our possible, since the Houston warehouse had
of refuge for another nursing home that was own operations on the mainland portion of been flooded.
evacuated after it flooded. the county. For the most part, Harvey didn’t impact
In our hurricane plan, we prepare to evac- As EMS personnel, firefighters, police offi- Galveston Island, and many who were rescued
uate, secure our facilities and equipment and cers and volunteers within the community were brought there because there were no pass-
then shelter in place until operations can worked to rescue those trapped by floodwaters, able routes north to one of the large shelters in
resume. As part of the plan, once operations we learned that the hospitals had become inac- Houston. The hurricane was still lurking in the
resume, we provide EMS to a much smaller cessible by ambulances due to the flooded road- Gulf of Mexico, so a large-scale evacuation by
population of residents who didn’t evacuate. ways. Temporary shelters were set up wherever air was organized using Air National Guard
During Hurricane Harvey, however, very it was safe, and many of our extra ambulance C-130 airplanes.
few people evacuated, and it became clear early
on that the normal plan for a hurricane wasn’t
going to fit. We were going to be operating
an EMS agency in a coastal area that was still
heavily populated and isolated because of cat-
astrophic flooding.

THE STORM HITS

Hurricane Harvey’s arrival brought heavy rain,
but the winds weren’t overwhelming and the
flooding wasn’t immediate. Many believed that
our region had been spared, and that our neigh-
bors down in Rockport had seen not only the
worst of it, but also the extent of it.
The National Weather Service insisted that
more rain was to come, and maintained it Neonatal ICU transports from Baptist Hospital in Beaumont arrive at Scholes International Airport in Galveston.
would be “catastrophic,” “biblical” and other Photo courtesy Nathan Jung

www.jems.com mARcH 2018 | JEMS 35

1803JEMS_35 35 2/9/18 3:20 PM

 ADAPTING TO ADVERSITY
Galveston EMS secured an ambulance bus from Atascocita (Texas) Volunteer Fire Department, allowing the two
agencies to evacuate bed-bound patients at Gulf Healthcare Center prior to the arrival of Hurricane Harvey.
Photo courtesy Tommy Leigh
PATIENT CARE & MORE
Despite evacuation efforts, routine 9-1-1 calls
were still coming in. Calls included chest pain,
respiratory distress, cardiac arrest and even a
few shootings. It was like a normal day—except
there was water everywhere.
Prior to the start of hurricane season, Gal-
veston EMS increases the amount of on-hand
medical supplies and pharmaceuticals to ensure
the ability to operate for an extended period.
What wasn’t factored in during Harvey,
however, was that patients who received sup-
plies from home health providers would remain,
In the face of Harvey’s unpassable floodwaters, Galveston EMS set up a mobile station at a county shelter—a concept only briefly sketched out before the storm.
Photos courtesy Nathan Jung
36 JEMS | MARCH 2018
1803JEMS_36 36
exhausting their medical supply cache and in
need of assistance with everything from basic
suctioning supplies to breathing treatments.
Hospitals were becoming more accessible
and mobility in the county was improving with
each day, but new issues were mounting. One
municipal service was low on supplies, several
were low on oxygen, availability of diabetic sup-
plies was becoming an issue, prescription med-
ications were in need of refills, and every EMS
agency and hospital was faced with the ever-in-
creasing need of finding a solution to provid-
ing dialysis. Within a few days not receiving
treatment, the number of calls related to dial-
ysis patients started to rise sharply. Dialysis
patients became the largest patient population
impacted by the storm.
As a result of Harvey, Galveston County
Health District and the University of Texas
Medical Branch are now working on a better
way to manage dialysis patients in a disaster,
along with ways to get dialysis treatment cen-
ters open more quickly.
There was still no passable route between
Galveston and the Texas Medical Center in
Houston. A few of the nursing homes through-
out Galveston County had to be evacuated
because of flooding, and their patients were
being housed in temporary shelters. Hospi-
tals were holding patients because there was
nowhere to be discharged, medical shelters
were unreachable and home health services
couldn’t deliver supplies to all their patients.
EMS was quickly filling a new role, which
included setting up a mobile station at a county
shelter to augment our mobile clinic’s capabil-
ities—a concept we had only briefly sketched
out on paper before the storm.
Hurricane Harvey took aim at Texas for the
final time, and set a course for the Golden Tri-
angle (an area of Southeast Texas between the
cities of Beaumont, Port Arthur, and Orange).
Galveston Island once again found itself receiv-
ing medical evacuees.
First, it was a nursing home that had be
evacuated due to rising water. After several
hours on the road, two charter buses and more
than 10 ambulances were unloaded at Gulf
Healthcare Center in Galveston. This incred-
ible feat took less than 53 minutes.
The next day we received several neonatal
www.jeMs.CoM
2/9/18 3:20 PM
 ICU patients from Beaumont and facilitated
a large move from Scholes Airport to the Uni-
versity of Texas Medical Branch (UTMB) with
the assistance of the Galveston Fire Depart-
ment and Galveston Police Department.
CHALLENGES & LESSONS LEARNED
Hurricane Harvey was a worst-case scenario,
using nearly every ambulance in Texas and
requiring the assistance of neighboring states.
It impacted almost the entire Texas coast, par-
alyzed one of the nation’s largest metropolitan
areas, and will be recorded as one of the cost-
liest natural disasters in U.S. history.
The storm didn’t follow our plan, but we
adapted, overcame and achieved so much
during this storm and the days that followed.
Since ambulances aren’t equipped for high
water, it was difficult to transport patients in the
traditional manner following rescue. Our per-
sonnel frequently work on boats, in the water,
and in isolation for extended periods of time,
but it was still difficult. The cardiac monitor,
the jump bags, and just about everything else
we use isn’t supposed to get wet.
Additionally, the water wasn’t clean, we
couldn’t see where we were walking, and mod-
ern stretchers are equipped with electronics
that are easily damaged by the brackish water.
Our hurricane plan calls for the removal
and relocation of most of our physical assets.
During Harvey, that wasn’t done, and staffing
wasn’t reduced. Assets were left in place to con-
tinue running a fully functioning 9-1-1 service
with additional units to support rescue opera-
tions, shelter operations and flight operations.
This was stressful and exhausting for every-
one. Some staff were unable to get back into
the region to provide relief, while others were
stuck in their homes. Mandatory downtime
for crew rest in a shelter simply isn’t the same
as being able to rest at home.
Though none of our ambulances were a total
loss, nearly all of them had been through high,
brackish water, often operating for hours par-
tially submerged in floodwaters. As the days
went by, electrical issues started to occur and
sometimes led to mechanical failures. It wasn’t
until December that we were finally able to
complete repairs on our entire fleet.
Although Galveston County was isolated
by flooding, the power grid remained intact,
as did the ability to communicate by radio and
cellphone. This made a significant impact, but
the biggest difference between Harvey and past
storms was that social media played an integral
role in disseminating information.
With a few clicks, someone could let their
family know they were safe, see which road-
ways were passable, and learn which grocery
stores were open.
When the need for more diabetic supplies
arose, we were able to quickly locate a phar-
macist as well as medical volunteers looking
to help.
For years, Galveston EMS has worked with
the Galveston County Office of Emergency
Management on disaster preparation. It’s rare
that EMS gets involved at this level, but we’ve
done this to prepare our agency to respond. It’s
important to understand the role that EMS can
provide, the role we’re expected to provide, and
the limitations that come with this.
Hurricane Harvey showed us that plans
are good to have; however, having the abil-
ity to adapt to the changes is also important.
Proper preparation and training is paramount,
and ensuring that the knowledge is communi-
cated throughout the organization is a must.
A disaster doesn’t mean that patient care
needs to suffer, but it certainly makes it more
difficult. Hurricane Harvey presented chal-
lenges that were unique, but ultimately man-
ageable. JEMS
Nathan Jung, EMT-P, is the director of EMS for Galveston
County Health District in Galveston, Texas.

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1803JEMS_37 37 2/9/18 3:20 PM

 AMR partners with FEMA during an
unprecedented hurricane season
By Randy Lauer & Steve Delahousey, RN
T
he year 2017 will undoubtedly go
down as having one of the worst hur-
ricane seasons to affect the United
States. In the months from August through
December, American Medical Response
(AMR), along with other EMS agencies,
responded to the call for help for back-to-
back Hurricanes Harvey, Irma and Maria.
AMR was activated for Hurricane Harvey
on August 25, and was eventually demobilized
from Hurricane Maria on Dec. 31, 2017. These
federal EMS deployments yielded 128 con-
secutive days of providing medical resources
across the three major hurricanes. This is the
longest consecutive EMS disaster deployment
in U.S. history.
AMR is the prime contractor with FEMA
to provide ground ambulance, air ambulance,
paratransit services and non-ambulance EMS
38 JEMS | MARCH 2018
1803JEMS_38 38
personnel to supplement the federal and mil-
itary response to a disaster.
Federal initiatives launched in the aftermath
of Hurricane Katrina in 2005 led, in part, to
development of a National Medical Trans-
port and Support Services Contract through
FEMA. AMR was awarded the contract and
assembled an internal Office of Emergency
Management (OEM) to operationalize the
contract, along with a large network of ambu-
lance providers who partner with AMR to
carry out successful deployments.
PREPAREDNESS PAYS OFF
The unpredicted and sudden intensification of
Hurricane Harvey just two days before land-
fall marked the beginning of one of the most
active years for FEMA deployment, both in
geographic scope and duration. AMR was
EMS command center in Houston, Texas.
Photos courtesy American Medical Response
deployed by FEMA on August 25 to support
the state of Texas. The response included 200
ground ambulances, 115 operations support
and incident management team members,
12 communications specialists, 25 helicopter
air ambulances and 29 fixed wing air ambu-
lances. In anticipation of this disaster deploy-
ment, AMR stood up its National Command
Center (NATCOM) in Dallas, and deployed a
forward operating base (FOB) incident man-
agement team (IMT) to San Antonio.
AMR’s OEM works year-round to develop
and maintain a strong network of partners,
does ongoing accounting of the number and
location of available resources, maintains a reg-
istry and pre-alert system, and has a process to
activate resources when a FEMA deployment
order is received.
AMR’s online Rapid Electronic Deploy-
ment System allows all registered operations,
both AMR and network partners, to update
their list of available personnel and response
www.jeMs.CoM
2/9/18 3:20 PM
 resources, and issues a notice to proceed when can continue working using approved pro- drop torrential rains, with the greater Houston
activated. Every resource is assigned a unique tocols and medical direction during the area receiving more than 50 inches of rain in
numbered placard used only for federal EMS disaster deployment. five days. Devastating flooding wreaked havoc
responders. These placards are displayed on Many of the ground and air resources were on many communities as the storm progressed
the front and rear windows of each vehicle. assigned to Texas immediately upon check-in through Houston, Beaumont and into Loui-
AMR OEM also maintains credentials for and deployed forward to conduct patient evac- siana, causing death and destruction and iso-
all responders as well as the incident command uations—the first step during federal deploy- lating populated areas so that they essentially
system (ICS) and related forms to push for- ment for an event with advance notice, such became islands surrounded by floodwaters.
ward when needed. NATCOM’s role includes as a hurricane. On August 31, with most rescue and recov-
deploying and tracking inbound resources to ery activity occurring in the Houston and
the FOB, liaising with federal agencies, send- UNPREDICTABLE HURRICANE Beaumont areas, but with some remaining
ing logistics packages to the FOB, aggregat- Harvey defied predictions to remain a tropical need around San Antonio, the FOB IMT
ing documentation, and providing leadership storm and made landfall on August 26 as a was split and a second base was set up on the
and support. Category 2 hurricane north of Corpus Christi. grounds of NRG Stadium in Houston, join-
The FOB IMT checks in arriving resources, From there, it again ignored projections to ing the state EMS IMT to coordinate fed-
assembles them into strike teams of five ambu- move inland and dissipate, instead hovering eral resources along with state EMAC assets
lances with a strike team leader, deploys logis- inland for two days before returning into the deployed there.
tics and stages the resources. All of this occurs Gulf of Mexico, where it would make several The vast flooding along hundreds of miles
within 24 hours of the task order receipt. more landfalls as it moved northeast along posed significant challenges to rescuers. AMR
The FOB IMT’s first order of business is the Texas coast. and partner crews were assigned missions to
to contact state and local leadership and set Between landfalls, it tended to hover and large and small communities to evacuate
up a staging base. This process typically takes
24–48 hours, and is replicated each time the
deployment moves and a new base is required.
During this deployment, AMR moved six
times and set up seven staging bases, add-
ing a layer of complexity not experienced in
prior deployments.
To avoid any concerns about depleting local
or state EMS resources when responding to
federal disasters, AMR refrains from using
EMS resources from areas that have been
declared major disasters. AMR will also not
utilize resources that are part of an emergency
management assistance compact (EMAC)
agreement and will not jeopardize the standard
of care in the local communities by diverting
resources to federal disasters or events.
The EMS needs of local communities are
primary—participating in the AMR disaster
response network is subject to availability and
must not conflict with other local obligations.
AMR and its subcontracted network provid-
ers are robust enough to respond to federal
disasters without compromising local EMS.
All EMS providers responding to the
AMR/FEMA federal EMS contract are
licensed or certified in their state of origin.
Nationally recognized curricula and scope of
practice guidelines are used to establish mini-
mum competency for state licensure and prac-
tice. The states generally grant reciprocity to
EMS providers responding to the contract.
The state disaster declaration typically
includes a reciprocity component, so EMS
personnel responding from numerous states Driving on flooded roads from Houston to Port Arthur.

www.jems.com mARcH 2018 | JEMS 39

1803JEMS_39 39 2/9/18 3:20 PM

 DISASTER DEPLOYMENT
FEMA staging in San Antonio, Texas.
people who were ill, injured or isolated with-
out the basic resources to survive. EMS crews
were taken into these areas by boat, aircraft
and, in many cases, navigated through flooded
roads to reach patients.
As the hurricane progressed northeast, bases
were established at Ford Field and Jack Brooks
Regional Airport, joining an army of state and
federal resources all working together to help
Texans in need.
Ground and air ambulances transported
patients to the airport, where they were
flown out on fixed-wing aircraft. In many
cases, ambulance crews that had reached small
communities cut off by floodwaters became
their primary source of EMS and these crews
worked with local, largely volunteer services
to care for their communities.
SUPPORTING RESPONDERS
At this point, deployments and IMTs were
FEMA shelter at Florida A&M University.
40 JEMS | MARCH 2018
1803JEMS_40 40
spread over nearly 300 miles from San Anto-
nio to Houston to Beaumont. With the major-
ity of resources deployed in Texas, the FOB
IMT began working with leaders to ensure
that the crews were supported. In some cases,
the forward local areas were devastated and
didn’t have the capacity to support our crews.
In those instances, the FOB IMT pushed
out supplies and support, or rotated strike
teams back the staging base for rest and rehab.
The crews also held twice daily briefings with
strike team leaders following each 12-hour
operational period.
Local, state and federal resources relied on
each other to maximize rescue and support
over this long area of devastation, and did
so effectively with the common recognition
that all were there to help the same people.
EMS is often referred to as a “community,”
and disaster circumstances bring home what
that really means. There’s no “us vs. them” in
this environment. Rather, there are people who
come together from across the country with a
singular focus: to help others without regard
to turf, role or responsibility.
By Sept. 4, the immediate rescue and
recovery efforts were wrapping up in San
Antonio and beginning to wind down in
Houston and Beaumont. The last federal EMS
assets deployed for Hurricane Harvey were
demobilized on Sept. 8, making this a 15-
day deployment.
Even before resources were completely
demobilized from Harvey, additional EMS
resources were deployed for Irma, which was
approaching Florida with an uncertain, but
powerful path.
HURRICANE IRMA STRENGTHENS
As focus moved to Hurricane Irma, FEMA
issued forward-leaning deployment orders on
Sept. 6 to stage federal EMS resources in Flor-
ida, the U.S. Virgin Islands and Puerto Rico.
This was a first on several levels for FEMA
and AMR:
>>It was the first time the federal EMS con-
tract was activated for Florida;
>>The first time fixed-site (non-ambulance)
EMTs and paramedics were deployed to
staff medical shelters;
>>The first time FEMA-contracted EMS
resources were deployed jointly and in
coordination with the Department of
Defense U.S. Transportation Command
(USTRANSCOM) at Scott Air Force
Base; and
>>The first time federal EMS resources were
deployed beyond the continental U.S. to
a U.S. territory. (AMR’s contract with
FEMA requires response to the 48 con-
tiguous states. Response to a U.S. territory
is “best effort.” This wouldn’t be the last
time that AMR was called upon to make
this extraordinary effort.)
These decisions would prove to be very
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2/9/18 3:20 PM
 AMR Response By the Numbers
The National Medical Transport and Support Services Contract >>6 fixed-site medics
through FEMA, developed in the aftermath of Hurricane Katrina
in 2005, has been activated 12 times to date: Federal EMS assets deployed to Florida for Irma:
>>2007, Hurricane Dean (Texas) >>300 ground ambulances
>>2008, Hurricane Gustav (Louisiana) >>144 paratransit vehicles
>>2008, Hurricane Ike (Texas) >>100 operations support team members
>>2009, Presidential Inauguration >>20 communications support team members
>>2011, Hurricane Irene (New York and New Jersey) >>2 interoperable communications infrastructure packages
>>2012, Hurricane Isaac (Louisiana) >>1,200 mobile communications devices
>>2012, Superstorm Sandy (New York and New Jersey) >>10 critical care fixed-wing air ambulances
>>2016, Hurricane Matthew (Georgia) >>15 critical care helicopter air ambulances
>>2017, Hurricane Harvey (Texas) >>1 physician medical director
>>2017, Hurricane Irma (Florida, U.S. Virgin Islands and Puerto Rico)
>>2017, Hurricane Maria (Florida, U.S. Virgin Islands and Puerto Federal EMS assets deployed to U.S. Virgin Islands and
Rico) Puerto Rico for Irma:
>>2017, California Wildfires (Travis Air Force Base) >>38 operations support team members
>>4 communications support team members
Federal EMS assets deployed to Texas for Harvey: >>7 critical care fixed-wing air ambulances
>>200 ground ambulances >>1 neonatal critical care fixed wing air ambulance
>>115 operations support and incident management team members >>4 neonatal clinician specialists
>>12 communications specialists >>4 EMTs to staff medical shelter
>>25 helicopter air ambulances >>2 paramedics to staff medical shelter
>>29 fixed-wing air ambulances >>1 medical shelter package (with enough equipment and supplies
to treat 100 ALS patients)
Federal EMS assets deployed for Maria: >>1 general population shelter package (with enough equipment and
>>90 ground ambulances supplies to treat 75 BLS patients)
>>11 critical care fixed-wing air ambulances >>1 physician medical director

intelligent foresight by FEMA leadership. All
federal EMS assets deployed for Hurricane
Irma were finally demobilized on Sept. 25,
making it a 19-day deployment.
On Sept. 12, when the scope of need was
better understood, air and ground ambulances
were partially demobilized.
On Sept. 14, remaining resources were relo-
cated to the fire training and support center
in Boca Raton, Florida. It was the sixth base
throughout the deployment, and under the
leadership of Chief Tom Wood and Assis-
tant Chief Mike LaSalle, the Boca Raton Fire
Department was welcoming and accommo-
dating with open arms.
MARIA MAKES LANDFALL
FEMA deployed AMR assets to support vic-
tims of Hurricane Maria on Sept. 20.
Most of the dialysis facilities on the U.S.
Virgin Islands and Puerto Rico were inoper-
able following Hurricanes Irma and Maria.
This resulted in dialysis patients being relo-
cated to Miami and Atlanta. To transport
patients to and from dialysis centers, AMR
sent six ground ambulances and 32 paratransit
vehicles to Miami and 23 paratransit vehicles
to Atlanta.
By Sept. 20, in Florida, 30 ambulances had
been deployed to Lee County, 25 to Collier
County, 20 to Monroe County and 35 at the
staging area in Boca Raton. Primary missions
were 9-1-1 and hospital support until regular
providers could return and resume full activity.
In each location, AMR was embedded with
local EMS to provide relief for their personnel
and augment capacity to respond to increased
call volume.
On Sept. 22, following additional partial
demobilizations, personnel and resources were
moved to a seventh staging base in Miami to
support two strike teams remaining in Key
West and paratransit resources supporting
the dialysis patients in Miami.
Finally, on Sept. 24, the remaining IMT
was demobilized, leaving a paratransit IMT
in south Florida for a few more days.
Ongoing air support was focused in Puerto
Rico and the U.S. Virgin Islands, which had
increased to 11 critical care fixed-wing air-
craft and six fixed-site paramedics to support
shelters. Operations support teams, commu-
nications support teams and neonatal clinical
specialists were also provided.
Critical care air ambulances remained in U.S.
Virgin Islands and Puerto Rico until Dec. 31,
when they were demobilized.
AIR MEDICAL TRANSPORTATION
Air medical transportation was a major com-
ponent for all the 2017 hurricane deployments.
A combined total of 98 private air ambulances
were used.
Most of the 68 hospitals in the U.S. Vir-
gin Islands and Puerto Rico were signifi-
cantly damaged. AMR/FEMA-contracted
fixed wing air ambulances were used to trans-
port patients daily from the islands back to
the U.S. mainland. While in the islands, pri-
vate fixed-wing aircraft provided most of the
individual critical care and neonatal transports,
while the larger aircraft provided en masse

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1803JEMS_41 41 2/9/18 3:20 PM

 DISASTER DEPLOYMENT
transportation, especially for dialysis patients.
The clinical skills of the air crews in crit-
ical care and neonatal care is unsurpassed.
In addition to providing clinical expertise,
AMR’s air transportation partners also pro-
vided IMT for the Air Medical Branch at
FOB and NATCOM.
They also provided air medical liaison offi-
cers to the USTRANSCOM at Scott Air
Force Base. Although AMR contributed to
this effort, special recognition goes to Air
Medical Group Holdings (AMGH), who
coordinated and managed most of the air
operations.
USTRANSCOM is the single manager
of the country’s global defense transportation
system. USTRANSCOM is tasked with the
coordination of people and transportation
assets to allow the country to project and sus-
tain forces, whenever, wherever, and for as long
as they are needed.
For the first time in history, FEMA assigned
AMR liaison officers to USTRANSCOM.
Together they worked tirelessly to manage
the air medical evacuations for these disasters.
Evidence-based EMS Education
From the Trusted Brand for Quality
Access courses when you need them and how you want them –
in the classroom, online, in print or digital.
NAEMT.ORG/EDUCATION /NAEMTFriends
42 JEMS | MARCH 2018
1803JEMS_42 42
TEAMWORK & COMMITMENT
Checking in resources, mission deployment,
logistics management, crew support, tracking
mission types and patient contacts, federal/
state/local interface and demobilization—are
all normal parts of a deployment.
What made this year particularly challeng-
ing was moving six times and setting up seven
bases over a path covering nearly 1,400 miles,
from San Antonio to Miami. Each base set-up
is normally an all-hands process that includes
24–48 sleepless hours.
But, with talented and motivated peo-
ple working together, nearly anything can
be accomplished.
Many crews and IMT members have
deployed multiple times, and thus a deploy-
ment is a reunion of sorts. They’re all problem
solvers. It doesn’t matter which agency they
work for—on a deployment, everyone is logo-
blind and part of the same team, committed
to helping people devastated by a disaster.
Everyone who deployed did so voluntarily
to join local responders—many of whom were
victims themselves—to help others in need.
/NAEMT_
For more information, visit JEMS.com/rs and enter 12.
They deployed knowing conditions would be
austere, often sleeping in their ambulances,
eating ready-to-eat rations and foregoing
showers and other normal daily amenities for
extended periods. JEMS
Randy Lauer has deployed as the forward incident com-
mander on 10 hurricanes, beginning with Katrina in 2005,
and as the federal ambulance deployment for the 2017 Cali-
fornia wildfires. He’s based in Portland, Ore., and leads AMR’s
operations in Oregon and South Dakota.
Steve Delahousey, RN, is the AMR vice president of emer-
gency management, where he also serves as the FEMA federal
liaison officer. As a registered nurse and former paramedic, his
career in EMS dates to Hurricane Camille in 1969. He’s based
in Gulfport, Miss., where he also serves as chairman of the
Harrison County 9-1-1 Commission.
Acknowledgment: AMR wishes to acknowledge the federal
partners who worked side-by-side with us during the 2017
disasters. They include the U.S. Department of Homeland Secu-
rity (DHS), Federal Emergency Management Agency (FEMA),
U.S. Department of Health and Human Services (HHS), Assistant
Secretary for Preparedness and Response, U.S. Department
of Defense (DoD), Scott Air Force Base and the Department
of Defense U.S. Transportation Command (USTRANSCOM).
1-800-34-NAEMT
www.jeMs.CoM
2/9/18 3:20 PM
 For more information, visit JEMS.com/rs and enter 13.

1803JEMS_43 43 2/9/18 3:20 PM

 Disaster planning facilitates effective
hurricane response in Pinellas County, Fla.
By John Peterson, MS, MBA, EMT-P
I
n September, Hurricane Irma was projected
to hit Florida as a Category 5 storm with
significant impacts on most of Florida.
Irma was expected to be a record storm as
one of the largest and strongest hurricanes to hit
the East Coast. At one point, the forecast pre-
dicted that Hurricane Irma would directly hit
the city of St. Petersburg and Pinellas County.
Pinellas County lies on the west coast of
Florida, and is surrounded by water on three
sides. Its low-lying lands make it extremely
vulnerable to even a few inches of rain, and a
high-category hurricane could have a devas-
tating impact on the county and its residents.
Hurricane Irma would prove to be a new and
challenging test for Sunstar Paramedics, the
9-1-1 ambulance provider for Pinellas County,
to provide EMS before, during and after a nat-
ural disaster.
44 JEMS | MARCH 2018
1803JEMS_44 44
PRE-STORM PREPARATIONS
Sunstar Paramedics has had hurricane plans
in place since the highly active 2004 hurri-
cane season. The management team revises
the plan annually and felt confident that they
were prepared for Hurricane Irma.
When Pinellas County declared a local
state of emergency on Sept. 8, Sunstar Para-
medics requested that all employees report
to headquarters or other strategic locations
in the county.
The all-call was broadcasted through the
agency’s employee communications channels,
including the internal Facebook page, and the
company began preparing employees for long
shifts in which they might not be able to return
home for several days.
Managers sent out checklists with recom-
mended supplies for employees to bring with
Strike team ambulances line up in preparation to
evacuate patients in hospitals and skilled nursing
facilities in Pinellas County, Fla.
Photos courtesy Sunstar Paramedics
them, such as air mattresses to sleep at head-
quarters or the shelters, changes of clothes, and
more. Employees were also advised to prepare
their own homes and make accommodations
for their families and pets.
The first rounds of ordered evacuations in
Pinellas County occurred on Sept. 8, start-
ing with coastal, low-lying areas and mobile
homes (Evacuation Level A), which affected
about 160,000 residents.
By the next day, mandatory evacuations
expanded to all residents and businesses in
Evacuation Level B—accounting for a total of
260,000 people—including completely evacu-
ating 10 cities on the Gulf of Mexico. In total,
these evacuations were more than one quar-
ter of Pinellas County’s population of over 1
million residents and visitors.
Sunstar Paramedics began evacuating four
local hospitals. The 18 local fire rescue agencies
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2/9/18 3:20 PM
 coordinated the evacuation of special needs advanced life support (ALS) gear in case of take care of our employees’ needs, so employ-
residents and 50 skilled nursing facilities an emergency. The Pinellas County Depart- ees could work through 12-hour shifts with a
that were located in Levels A and B through ment of Health also had medical staff at each clear mind and provide the best care possible.”
Sunstar Paramedics’ operations subcenter. All shelter for basic medical needs. Cobb and the team stocked up on food
patients needed to be moved to other hospi- While EMTs and paramedics were evac- from several grocery stores, brought in catered
tals and facilities on higher ground and certain uating hospitals and stocking shelters, the meals, and ordered in pizza before the storm
patients, such as those who were dependent management teams were preparing to feed was supposed to hit.
on ventilators, were transported by ambulance. and house more than 600 employees. Sunstar The detailed hurricane preparedness plan
In addition to the evacuations, EMTs and Paramedics had partnerships in place with was effective in navigating Sunstar Paramed-
paramedics were still transporting ics through the pre-storm phase,
patients who were discharged ahead although there were still some les-
of the storm. sons learned:
Sunstar Paramedics put out a call Even though Irma wasn’t Communicate more efficiently:
for three FEMA strike teams who Though the internal Facebook group
came from multiple states with 15 as strong as expected, is well-used during normal oper-
ambulances to assist with transports ations, it wasn’t the most efficient
before the storm arrived. the high winds, rain, form of communication in an emer-
As people were evacuating, shel- gency situation. Sunstar Paramed-
ters had to be opened to accommo- flooding, evacuations, & ics is now able to send texts to all
date residents who had nowhere employees with important infor-
else to go. Sunstar Paramedics was downed trees & powerlines mation through Pinellas County’s
responsible for stocking and deliv- alert system.
ering medical supplies to three spe- still put pressure on Distributing staff time and work-
cial needs shelters throughout the load: The special needs shelters were
county. This was included in Sun- the EMS system. much busier than expected. Manage-
star Paramedics’ hurricane prepared- ment recognized the need to have
ness plan, so the supplies were kept more than one EMT and paramedic
packaged, quality assured and ready to go all seven hotels across the county and a church on-hand at the shelters, or rotate shifts more
year long. across the street from its headquarters to pro- frequently.
The management team made the decision vide shelter for some of its employees. Addressing family concerns: Many
early on to rent a second truck to assist with Community outreach coordinator Char- employees were unsure where family mem-
deliveries. This decision enabled employees to lene Cobb began the mission of buying food bers and animals could shelter while they were
deliver all supplies and equipment in a single to feed hungry and hard-working employees. working long shifts or required to remain at
day, instead of two days, which allowed staff to “While providing a safe work environment one of the designated employee shelter loca-
focus their time on other preparations. and places to sleep were certainly import- tions. Sunstar Paramedics had space reserved
In addition to delivering materials, Sunstar ant, feeding our employees three meals a day at several hotels and a church that was serving
Paramedics assigned one paramedic and one seemed to have one of the largest impacts,” as a shelter, with room to board some employ-
EMT to each special needs shelter with full said Cobb. “Our management team wanted to ees’ pets too, but still received an influx of

A total of 120 calls were on hold in the dispatch

queue as Hurricane Irma battered Pinellas County Providing family style meals made a big difference to employees of Sunstar Paramedics during their all-call
and EMS operations were down for eight hours. response to Hurricane Irma.

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 PREPARING FOR IRMA
Table 1: Hurricane Irma transports in Pinellas County, Fla. However, the call volume didn’t decrease
with the wind speeds. The Pinellas County
Critical care Fire rescue Strike team
Date Ambulances Total EMS call volume rose to 48% above normal
transport agencies ambulances
and lasted two days after the storm.
Sept. 8 599 1 0 0 600 A second request for FEMA strike teams
was made, resulting in an additional 25 ambu-
lances being sent to Pinellas County to assist
Sept. 9 605 19 0 22 646 with patient transports.
Sunstar Paramedics, local fire departments
Sept. 10 330 0 10 0 340 and the strike teams completed a total of 5,321
transports during the week of Hurricane Irma.
(See Table 1.)
Sept. 11 483 1 6 0 490 To address the higher call volume, Sunstar
Paramedics had its fleet of 85 ambulances on
Sept. 12 620 20 42 59 741 the road and responding to calls, and support
staff, such as ambulance mechanics and vehicle
supply technicians, were needed 24/7 to repair
Sept. 13 597 5 61 62 725 and restock the ambulances for the next shift.
“We anticipated an influx of 9-1-1 calls
during and after the storm, but having 85
Sept. 14 560 5 0 55 620
ambulances available and on the road is a
large undertaking,” said Nick Berry, Sunstar
Sept. 15 576 6 4 57 643 Paramedics’ logistics manager who oversees
materials and fleet. “We utilized the staff we
had available, and we’re grateful for their hard
Sept. 16 512 4 0 0 516
work in making sure all ambulances were fully
functional and materials were properly stocked
Total 4,882 61 123 255 5,321 throughout the storm.”
In addition, the emergency operations cen-
ter (EOC) desk needed to be fully staffed to
last-minute requests. Management is now Once cleared by officials at 6 a.m., Sun- manage the influx of calls during and after the
looking into the possibility of securing an star Paramedics began responding to the 120 storm. Sunstar Paramedics employees are spe-
entire shelter for Sunstar Paramedics’ employ- calls that were on hold in the dispatch queue cially trained to work in the EOC.
ees and their families, and working out a con- due to the wind restriction. The initial strike After the high call volume subsided, Sun-
tract with a local animal shelter to reserve more teams that helped with evacuations before the star Paramedics had to reverse some measures
space for pets. storm had gone to Georgia and Alabama to taken before the storm, including transport-
Setting expectations for employees: The avoid storm damage. As a result, only Pinel- ing back all patients that were evacuated from
management team sent out checklists for las County assets were available to respond the hospitals and skilled nursing facilities. The
employees to bring certain supplies before the during the storm and immediately after. Sun- strike teams were essential in supplementing
all-call and distributed reminders, but many star Paramedics and the local fire departments the EMS system, coming down from neigh-
employees didn’t have all of the needed sup- worked cohesively to provide the highest level boring states and completing 255 transports.
plies. Sunstar Paramedics is planning to add of response and quality patient care. During the storm, Sunstar Paramedics also
training on employees’ responsibilities for hur- Fire chiefs had offered to send over their lost power at its South Hub—a key location for
ricane planning during orientation to better own paramedics to work on Sunstar Paramed- service in south Pinellas County. The South
prepare them to plan for working several days ics’ ambulances. However, Sunstar Paramedics Hub was able to move its operations to a local
and potentially not returning home. actually had more paramedics on duty than hotel based on its pre-existing agreements. The
the ambulance fleet. hotel happened to be in a small area that didn’t
WEATHERING THE STORM Instead, Sunstar Paramedics sent a para- lose power and hotel management offered
It wasn’t long after Sunstar Paramedics com- medic to a fire department that had an EMT the use of a conference room as a temporary
pleted pre-storm preparations and evacuations and rescue ambulance in reserve help transport command center as well as storage space to
that all Pinellas County emergency services— patients. Together the agencies were able to restock ambulance supplies. Ambulances filed
from police to EMS—were pulled off the road respond to all held calls in only three hours, in at the hotel’s valet loop and exited along the
and shut down because sustained winds had while at the same time responding to new neighboring street.
reached 45 mph with gusts reaching 90 mph. incoming calls. This had never been done After two days of enduring Hurricane Irma
EMS operations were down for eight hours, before in Pinellas County, and it was an effec- and the increased calls that came along with
which meant all 9-1-1 calls were on hold. tive partnership. it, employees were feeling its effects. Cobb,

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1803JEMS_46 46 2/9/18 3:20 PM

 along with the management team, organized
a massage therapist to provide chair mas-
sages and brought in therapy dogs to allevi-
ate employee stress.
There were a couple of important takeaways
and lessons learned during and immediately
following the storm.
Taking care of employees: Food and rest
are essential for EMTs and paramedics to be
sharp while responding to emergencies in dif-
ficult environments after a storm. Although
in-house treats and large, family style dinners
may seem like minor benefits, it made a big
difference to employees. Treating everyone
equally, regardless of their rank, was another
key to success.
Considering mechanical needs: Sunstar
Paramedics’ ambulance mechanics went above
and beyond to keep all of its ambulances, as well
as the strike teams’ ambulances, in top shape
and ready for the next call. However, the all-
call didn’t extend to mechanics so some went
home during the storm, and some were unable The Sunstar Paramedics leadership team arranged for therapy dogs to help alleviate employee stress during
to return because of the weather conditions. Hurricane Irma.
In the future, management plans to include
mechanics in the all-call and have more sup- and disaster preparedness plan was essential to management and executives stayed at head-
port staff on-hand, if possible, to assist with the overall synchronization of the countywide quarters throughout the pre-storm prepara-
the immense workload that goes along with EMS system. But as in all disaster situations, tions, during the storm, and after the storm,
having 85 ambulances out on the road. adjustments had to be made, important les- and they also went to the primary employee
sons were learned and resulted in several key shelter, as well as both deployment hubs
ASSESSING THE RESPONSE takeaways following post-storm assessment. to meet with employees and inspect facili-
Hurricane Irma proved to be a great test for Solidarity from top to bottom: Top ties. Seeing members of the leadership team
Pinellas County’s EMS system. Sunstar Para-
medics prepared for the storm as if it could Figure 1: Results of Sunstar Paramedics employee satis-
make landfall anywhere from a Category 3 to faction survey evaluating Hurricane Irma response
a Category 5, but the storm ended up veer-
ing east in the final hours, so its impact was a My personal needs (e.g., shelter and food) were met
by the company before, during and after the storm. 3.7
Category 1 or less when it hit Pinellas County.
Even though Irma wasn’t as strong as
expected, the high winds, rain, flooding, evac-
My professional needs (e.g., IT and equipment) were met
uations, and downed trees and powerlines still 4.1
by the company before, during and after the storm.
put pressure on the EMS system and tested
emergency preparations.
Throughout Hurricane Irma, Sunstar Para- I felt prepared and informed before,
medics alone had two record transport days during and after the storm. 3.4
within four days of each other, and the coun-
ty’s entire EMS system was very busy.
“The entire EMS system was under tre- I felt safe while at work before,
mendous pressure throughout the storm,” said during and after the storm. 4.1
Richard Schomp, director of operations for
Sunstar Paramedics. “I think the key to our
success was threefold: 1) our pre-storm plan- My workload and schedule were handled
as best as possible during the disaster. 3.8
ning initiatives; 2) the collaboration with local
agencies and strike teams; and 3) the commit-
ment from our employees.”
Sunstar Paramedics’ extensive hurricane
0 1 2 3 4 5

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1803JEMS_47 47 2/9/18 3:20 PM

 PREPARING FOR IRMA
working alongside employees helped to build
and maintain team morale. It also created a
strong sense of comradery and desire to help.
Success of the all-call: Putting out an all-
call for more than 600 employees can be a
daunting task, and managing staff once they’re
onsite can be even more challenging. Sunstar
Paramedics’ management was aware of what
was being asked of employees, and took into
consideration that staff had personal lives and
challenges posed by the storm. Employees
were encouraged to have open conversations
during every briefing or with individual man-
agers if they were having trouble or needed to
go home. Anyone who needed to leave was
able to, but was asked to come back as soon
as they could. In the end, very few employees
left during the all-call, but employees were
glad to know they had the option and under-
standing from management.
Strike team accommodations: Strike teams
who came down to Pinellas County were well
fed and sheltered as best as possible, but Sun-
star Paramedics will now plan ahead of time to
accommodate up to five strike teams, including
personnel and equipment.
Employee surveys: Following Hurricane
Irma, Sunstar Paramedics sent employees an
anonymous survey to allow management to
determine what was done well and what could
be improved in the future. Employees were
asked to rate their satisfaction on a number
of factors, including distribution of workload,
communication, sleeping arrangements, avail-
ability of food at additional locations outside
of headquarters and whether employees felt
personally prepared for the storm. The surveys
highlighted several positive aspects during a
challenging time, and are quantitative evidence
of Sunstar Paramedics’ dedication to providing
for its employees. (See Table 2.)
CONCLUSION
Hurricane Irma brought together all aspects
of EMS in Pinellas County. Sunstar Paramed-
ics, Pinellas County government officials and
agencies, local fire departments and the strike
teams all worked collaboratively before, during
and after the storm.
Interagency relationships, both inside
and outside of Pinellas County, were solid-
ified and improved. Each agency has a better
understanding of their own contribution and
the contributions of others, and have agreed
to continue to collaborate to maintain and
strengthen a unified EMS system and a united
front in the face of any future natural disas-
ter. JEMS
John Peterson, MS, MBA, EMT-P, is chief operating officer
of Sunstar Paramedics and president of the Florida Ambu-
lance Association.
View the online version of this article at
www.jems.com/sunstar-hurricane to
download a PDF of the Sunstar Paramedics
Hurricane Preparedness Handbook and a
PDF of the Sunstar Paramedics Hurricane
Safety Poster.

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The New Jersey EMS Task Force provided relief to EMS providers in the U.S.
Virgin Islands as well as all-terrain mini-ambulances and other equipment
to help gain access to areas of the islands that were inaccessible to regular
ambulances. Photos courtesy New Jersey EMS Task Force (NJEMSTF)
www.jems.com
1803JEMS_51 51
N.J. EMS Task Force delivers
resources & relief to the
hurricane-ravaged U.S.
Virgin Islands
By Richard Huff, NREMT
S
teve Cicala, a task force leader with the New Jersey EMS Task
Force (NJEMSTF), questioned why a specialty EMS group
from the Northeast would be deployed for hurricane relief in
the U.S. Virgin Islands.
“Why were we chosen out of all the 50 states?” Cicala recalls wondering.
He found an answer quickly.
The U.S. Virgin Islands had been devastated by not one, but
two powerful Category 5 hurricanes—Maria and Irma—and was
in need of the specialty equipment and personnel the NJEMSTF
could provide. In addition to extensive training and experience
in responding to storms, the NJEMSTF also had equipment to
self-sustain for extended periods of time, and a cache of all-terrain
mini-ambulances that could respond to areas unreachable by U.S.
Virgin Islands EMS crews.
Based upon their identified needs, officials in the U.S. Virgin Islands
requested the NJEMSTF through an Emergency Management Assis-
tance Compact (EMAC), a mutual aid agreement that allows states
and territories to share resources in response to manmade and nat-
ural disasters.
mARcH 2018 | JEMS 51
2/9/18 3:20 PM
 ISLAND AID
Task Force Leaders Michael Bascom (left) and John Grembowiec (right), along with Devin Kerins of FEMA (center),
deliver specialized baby formula donated by McCabe Ambulance Service in New Jersey.
LONG WAY FROM HOME
The NJEMSTF was the primary component of
a team of 59 people deployed on Oct. 1, 2017,
to the U.S. Virgin Islands to help the devastated
region. All totaled, there were 30 members of
the NJEMSTF, 25 New Jersey State Troopers
and four Disaster Mental Health Counselors
from the New Jersey Department of Health.
What started out as a two-week mission was
extended to three weeks. That deployment was
quickly followed by a second two-week mis-
sion that put 26 members of the NJEMSTF
there for a period that included the Thanks-
giving holiday.
“We saw a lot of devastation from the storm,”
Task Force Leaders Michael Bascom (left) and Louis Raniszewski (center) and Safety Officer Robert Contreras
(right) work from within the Western Shelter system to develop a work schedule for deployed personnel.
52 JEMS | MARCH 2018
1803JEMS_52 52
Cicala says of arriving in the region. “My first
reaction was, OK, we’re going to have a lot of
work to do.”
“It was bad,” says John Grembowiec, chair-
man of the NJEMSTF who was part of the
first deployment. “People were pretty desper-
ate and trying to get the basic necessities.”
The NJEMSTF was also in a unique posi-
tion to help. The organization was created in
the wake of the 9/11 terrorist attacks and con-
sists of 250 career and volunteer EMS profes-
sionals who are trained to respond to disasters
and provide EMS support at preplanned events.
The organization has been integral to the
responses of such natural events as Superstorm
Sandy, Hurricane Irene and blizzards, as well
as preplanned events such as Super Bowl 2014,
the New Jersey Marathon and more.
Since its formation, and given New Jersey’s
history of natural disasters, the NJEMSTF
has developed, tested and reworked a variety
of plans for hurricanes and tropical storms.
Indeed, conceptual conversations about the
NJEMSTF someday being called to respond to
the U.S. Virgin Islands began about five years
before the actual deployment. The idea was
raised as a possibility by former NJEMSTF
planner Devin Kerins, now an individual and
community preparedness officer with FEMA’s
Region 2, who had created plans for hurricane
responses in the region.
Kerins was serving as the emergency services
group supervisor for FEMA on St. Thomas
when the first and second storms hit the islands.
Because New Jersey was out of the path of the
multiple hurricanes that hit the United States
in 2017, deploying the NJEMSTF to the U.S.
Virgin Islands made sense. Kerins helped the
territory’s officials with the EMAC request,
coordinating a military flight down for the New
Jersey-based first responders, and was key in
integrating them into the local systems.
“Every disaster and response is unique,” says
Christopher Rinn, former acting commissioner
of the New Jersey Department of Health. “This
was the first time the team was deployed out-
side of the continental U.S. to a region as hard
hit with back-to-back hurricanes.”
Deploying so far away from home created
some new challenges that the organization
hadn’t faced before—especially in such a short
period of time. Although the NJEMSTF trains
for longer deployments, the team had never
actually done so to a region where they were
expected to survive and operate solely on what
they brought with them.
“Normally in EMS, we don’t think of the
response as a challenge,” Rinn says. “Getting
to a hurricane-ravaged area was a challenge.”
“Deploying outside of the continental U.S.
is significantly different than deploying state to
state. There are built-in delays, such as arranging
air or maritime transport and assuring that you’re
bringing what’s absolutely needed and leaving
behind those items and personnel who aren’t
absolutely essential to the core mission. There’s
not an option of driving home for personal issues,
nor even calling home for much of the time,”
says Michael Bascom, NJEMSTF leader and
incident commander for the first deployment.
“It was not difficult finding personnel
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2/9/18 3:20 PM
 who were willing to make the commitment
to deploy, the difficulty was in leaving behind
team members who were eager to help.”
There’s also the personal side, Rinn says.
Sending people into such situations puts them
at risk, and takes them away from their fami-
lies and regular work commitments.
“I’m mindful of [the danger] and I’m also
mindful of the personal sacrifice,” says Rinn.
“Many did that—putting the mission first.”
That mission started with identifying assets
and people to make the trip. Because they
would be deployed using military airplanes
out of Joint Base McGuire-Dix-Lakehurst,
N.J., each item carried aboard would have to
go through the process of being certified to fly.
“It was, in my career, the toughest thing I’ve Large washouts plagued the main roadways of St. Thomas and St. John, making many inaccessible to full-
ever had to plan,” says Joe Grassi, who han- size ambulances.
dled logistics for the deployment.
The challenge, Grassi says, “was being so far Western Shelter tents, 10 HVAC units, two ARRIVING ON SCENE
from home and having nowhere to turn if you 1,200 gallon per hour water purifiers, two 500 The New Jersey deployment arrived in the U.S.
needed equipment, food, water or housing.” gallon water tanks, satellite communications, Virgin Islands at night. As the sun began to rise,
That meant shipping enough supplies radio repeaters, 40 portable radios, 1,700 gal- they were able to get a real sense of the disas-
to get by—and then some. Grassi and the lons of bottled water, more than 3,700 meals ter zone they would face. Power was out in the
logistics team coordinated the delivery of one ready-to-eat (MRE) and three weeks’ worth entire region, meaning there were no traffic sig-
refrigerated box truck, a skid steer, four tents, of BLS and ALS supplies. nals or communications. Some roadways were
four pickup trucks, one SUV, seven all-ter- “We went in recognizing what they were going washed out or blocked. Homes were destroyed.
rain mini-ambulances, four towable genera- to need in the short term, and the mid-range And the EMS system they were there to help
tors, two flat-bed trailers, a logistics trailer, 10 term,” says Bascom. “We were well prepared.” had been serving their communities since the

For more information, visit JEMS.com/rs and enter 16.

1803JEMS_53 53 2/9/18 3:20 PM

 ISLAND AID
first storm, with little time to address the dam-
age that their own homes had sustained.
For many of those on the two deployments,
the response was reminiscent to their work
during Superstorm Sandy, which hit the New
Jersey coast in 2012, and damaged the homes
of some responders. Though their scenarios
were different, the contingent from New Jersey
knew all too well what it was like to respond in
their home area, knowing that their own fami-
lies and property were at risk.
“Having Sandy really prepared us mentally
for that trip,” says Grembowiec, whose New Jer-
sey home was surrounded by water during Sandy.
“After Sandy, I didn’t get to my house for
14 days,” says Bascom, whose home was also
flooded and uninhabitable for months after
Sandy. “I knew the impact that had on my family.
We were insistent when we got there that they
take a break and get home. We also took time
to sit with them and talk about their recovery.”
Indeed, part of the mission was to provide
some relief to local EMS providers, many of
whom had their homes severely damaged, yet
continued to respond to emergency calls in the
aftermath of the record storms.
“For a lot of us, having lived through Sandy,
it made us more empathetic and more under-
standing of their situation,” says Grembowiec.
“I think as we related our stories to the people
working on the Virgin Islands it helped them
understand where we were coming from. It
was personal for us, too. For us, we were pay-
ing back a little bit.”
Members of the task force worked with U.S. Virgin Islands EMS personnel to transport patients via ambulance
boat from St. John, where there’s no hospital, to St. Thomas.
54 JEMS | MARCH 2018
1803JEMS_54 54
Before they could do that, however, mem-
bers needed to make sure their lives at home
were settled. The first deployment was set for
two weeks and extended to a third.
In the days leading up to the trip, mem-
bers were told there could be times when they
might not have contact with home and it was
unlikely that they could get back quickly in
an emergency.
Task Force member Robert Contreras under-
stood that well. As the father of a young daugh-
ter, he must always be conscious of a backup
plan for child care. A multi-week deployment
into a new region exponentially increases the
need for outside help at home.
“I think because the nature of our jobs and
what we do, we always have to have a type of
plan in place,” Contreras says, adding that he’s
fortunate in that regard. “I think if you wait
until the disaster, it doesn’t work.”
Among the many challenges facing out-of-
area deployment is fitting seamlessly into local
operations. Communications systems may be
different. Local customs may require adjust-
ments. Local protocols for emergency medical
systems can vary widely—and that’s on top of
the challenges of simply getting to the region.
The first task when the team arrived was
getting good situational awareness of the geog-
raphy where they’d be operating.
“When the task force mobilized for Super-
storm Sandy, it was a ‘home game’ for us,” says
Neel Mehta, a planner with the NJEMSTF.
“We knew the state and the majority of the
stakeholders we would work with. In the U.S.
Virgin Islands, we were dealing with two islands,
24-hour operational periods, new emergency
response personnel to interact with, establish-
ing two bases of operations, and adapting to
the environmental obstacles with working in
a disaster zone.”
Mehta adds, “The moment we exited the
back of the U.S. Air Force C-17, it was game
on, and all lessons learned through the years of
exercise/training, in state deployments, support-
ing high profile events was going to be put to
use over the next few weeks.”
Bascom says learning local customs right
away was critical to that process.
“One of the things we did as soon as we got
there was to have a conversation with their lead-
ership about local customs, for example, how
they greet each other,” says Bascom. “Getting
to know the customs is a big thing, it helps us
to better understand the expectations of those
we were working with as well as the commu-
nity that we were there to serve.”
Grembowiec agrees, saying it was important
to understand the group dynamics, and getting
to know those providers they would be working
with side-by-side.
“I wanted them to see us as help and not a
threat,” Grembowiec says.
They also needed to adjust to the heat and
high humidity, taking care of themselves while
also getting used to the hilly terrain, destroyed
roads and driving on the left side of the road.
Once settled, NJEMSTF members rode on
EMS calls with local providers, and responded
to a variety of illnesses and injuries on St. Johns
and St. Thomas, two of the three U.S. Virgin
Islands. A tent, initially set up to provide hous-
ing, became a makeshift care center for locals,
who thought it was a medical tent. During
the first deployment, the team responded to
more than 200 calls, ranging from severe car-
diac issues, motor vehicle crashes, broken bones
and lacerations.
Patients were transferred to the ED of
Schneider Regional Medical Center. In one
instance, crews had to reach a patient in a
severely damaged home on the top of a moun-
tain, only accessible with multipurpose vehicles.
On another call, crews responding had to
lower the patient in a stretcher down a drive-
way using ropes because the incline was too
steep and the roadway conditions didn’t allow
closer access. More critical patients were sta-
bilized and often transferred to the mainland
U.S. via helicopter.
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2/9/18 3:21 PM
 LESSONS LEARNED
Though the NJEMSTF was initially there to
help provide the all-terrain mini-ambulances
to gain access to areas of the islands that were
inaccessible to regular ambulances, the mis-
sion was expanded to allow EMS providers in
the U.S. Virgin Islands to get some rest and
return to normalcy.
The NJEMSTF members who worked
the deployment say there were many lessons
learned that will help them on the next mis-
sion, and will also be brought back home to
be adopted by their organization and in their
local communities.
“The success of these deployments was
because of the dedication and commitment Task Force leadership and crews worked from a 19' x 35' Western Shelter tents at the base of operations
to complete mission by the leadership and located just outside of Schneider Regional Medical Center on St. Thomas.
most importantly the men and women of the
NJEMSTF,” says Mehta. “Every event, whether it be a preplanned team took a military transport to the U.S. Vir-
“Just operating in such an austere environ- event or an actual emergency, you get lessons gin Islands, but flew on commercial airlines
ment with the incident command structure,” learned,” says Grembowiec. “That’s why we do back home, which meant they faced differ-
says Grassi. “It was really imperative to stick the after-action reports. Each time it happens, ent rules in terms of baggage and what they
to it there. There was no freelancing. It was we learn from it. We get ideas for new equip- could bring home.
doing what you were told and answering up ment, new protocols, and how to do things “Also,” Bascom says, “bring enough of a
the chain. Communications issues, too. I’d more efficiently. Everything leads to a better crew so that you can give your people down
never been in an environment where com- performance for the next one.” time. They’ll work to exhaustion. They’re there
munications were wiped out for such a long When planning for another similar mission, because they’re needed. No one wants a break.
period of time.” Cicala suggests, when possible, send an inci- Safety was important, too.”
Grassi adds that had the task force not gone dent advance team in first to get a good sense “Our team and the community benefited
through Sandy, responded to Hurricane Irene, of what supplies will be needed and what the from the presence of our New Jersey State
or provided onsite care for marathons and par- working conditions may be. The tendency, he Troopers who not only provided a law enforce-
ticipated in major drills like Gotham Shield says, is to bring too many supplies. ment presence, but conducted community out-
at MetLife Stadium in New Jersey, the team Planning ahead in terms of what to bring reach, responded with us on every EMS call
wouldn’t have been as well-prepared for the on a deployment and how to get it home is on St. Thomas and in the Coral Bay area of
trip to the Virgin Islands. key, according to Bascom. The NJEMSTF St. John and — Continued on page 63

All-terrain miniature ambulances proved to be the appropriate resource for the challenging terrain and washed out roads in the U.S. Virgin Islands.

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1803JEMS_55 55 2/9/18 3:21 PM

 Special response team from Arkansas
provides relief & support to local EMS
crews after Maria’s devastation
By Andrew Ney, BA, NRP
O
n Tuesday, Oct. 24, Pafford Medi-
cal Services Corporate Director of
Operations Clay Hobbs asked me if
I’d be interested in joining his company’s hur-
ricane deployment assignment in St. Croix on
the U.S. Virgin Islands.
I jumped at the opportunity. Little did I
know that I’d face a hospital closing, a nearly
deserted EMS system, failing electrical power
and a multiple gunshot wound victim flagging
us down all on the first day.
INTEGRATING PERSONNEL
At 6 p.m. on Oct. 25, 2017, I joined 11 other
members of Pafford boarding the Garrett
Memorial Church Bus to head from Hope,
Ark., to Dallas, to catch a commercial flight
56 JEMS | MARCH 2018
1803JEMS_56 56
to St. Croix the next morning.
At 4:00 a.m. the next day, we checked in
a total of 28 suitcases and each of us carried
on multiple bags and equipment—everything
from monitor/defibrillators to ventilators
and medications.
At 3:30 p.m., our flight landed on the
runway of a storm-torn airport on the rural
island of St. Croix—more than 2,000 miles
from Arkansas.
We were greeted by the airport’s fire chief
as well as U.S. Virgin Islands EMS Director
David Sweeney, who briefed us on the current
situation St. Croix EMS was experiencing.
Hurricanes Irma and Maria had devas-
tated the island. Power lines were destroyed,
trees were uprooted and many houses had
Hurricanes Irma and Maria devastated the U.S. Virgin
Island of St. Croix, destroying power lines, uprooting
trees, collapsing houses and beaching boats along
the island’s shore. Photos courtesy Andrew Ney
collapsed—the Cruzans, as the island’s res-
idents are known, were left in devastation.
Some of the EMS staff had decided to
retire, as their homes were destroyed and
they wanted to use this as an opportunity to
move stateside and start the next chapter of
their lives.
The rest of the staff had to change their
12-hour rotating shifts to 24-hour shifts to
make sure two ambulances were always staffed.
This caused staff to burn out quickly, as the
call volume increased after the storm and they
had fewer resources. They were in dire need
of support and relief.
As a collaborative effort, the St. Croix Fire
Department began to supplement the EMS
agency with one firefighter per ambulance.
But with little experience, they weren’t pro-
viding the needed relief. The U.S. National
Guard supplied solider medics, having 4–5
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2/9/18 3:21 PM
 personnel on an ambulance, all operating with
vastly different experience, wasn’t the answer.
With the arrival of Pafford’s Special
Response Team (SRT), the National Guard
medics and firefighters were released from
providing support, and the Pafford SRT pro-
vided an EMT and paramedic for each truck.
Roles for each provider were well-defined.
A U.S. Virgin Islands EMS provider (EMT,
advanced EMT, or paramedic) would navi-
gate the ambulance to the scene of emergen-
cies, communicate with dispatch, begin the
documentation of dispatch and patient info,
and fill out the billing form.
The Pafford SRT EMT and paramedic
took the primary role in providing patient The Pafford Special Response (SRT) team packed up equipment and supplies in Hope, Ark., in preparation
care and were responsible for completing the to assist EMS crews on St. Croix in the U.S. Virgin Islands.
documentation before locking the chart. Rig
checks conducted at the beginning of each There was no pattern to how communities color, and it’s on the right with a red car out
shift, as well as restocking the ambulances were named and assigned numbers; and GPS front.” Having U.S. Virgin Islands EMS staff
with supplies were shared by all crew members. wouldn’t work on the island. navigate the roads was a must.
St. Croix EMS was able to return to 12-hour For example, dispatch would page, “EMS, House numbers weren’t laid out in a set pat-
shifts with two fully staffed ambulances, one I need you to respond to X house number in tern on each street, but rather assigned in the
starting at noon and the other midnight. William’s Delight for a patient experiencing order of when they were built. It was unlike
On the fourth day of providing staff, one a seizure.” EMS would respond and acknowl- anything I’ve ever experienced.
of the U.S. Virgin Islands EMS staff mem- edge the page. After a few days on the island, we learned
bers failed to show up for work. The plan was When Pafford personnel ask for directions, that Gov. Juan F. Luis Hospital was heavily
adjusted, and Pafford SRT providers began U.S. Virgin Island personnel would respond, damaged by Maria and might be condemned.
working 48-hour shifts, to ensure an EMT “Take a right at the shanty next to the Captain Western Shelter tents were going to then be
and paramedic would be staffed on each truck Morgan distillery, go over four speed bumps set up in the parking lot and staffed by FEMA
no matter what the situation. The U.S. Vir- and take the sixth right. The house is beige in Disaster Medical Assistance Teams.
gin Islands EMS staff continued to work
12-hour rotations.

OPERATIONAL CHALLENGES
The U.S. Virgin Island EMS has four ambu-
lances on the island of St. Croix, but staff
only two. The two older Type 3 ambulances
had mechanical problems, and the two newer
Type 1 ambulances had issues with the Power-
Load systems. Pafford’s fleet manager ensured
there were at least two operational ambulances.
Following the devastation of Hurricane
Maria, ambulances had difficulty reaching
multiple scenes because of the downed power
lines and trees. U.S. Virgin Islands EMS man-
agement says that EMS wouldn’t respond to
calls after a certain time because the island
was pitch dark at night and a majority of the
roads were blocked.
After Pafford’s SRT arrived, most of the
roads were at least open to one lane, despite
many being severely damaged and full of
pot holes. A special response team from Pafford Medical Services and Virgin Islands EMS crews responded to an
Dispatch communications on the island uptick in EMS calls, such as this motor vehicle crash. Nighttime was particularly dangerous because the
is much different than in the mainland U.S. island was pitch dark and a majority of the roads were blocked or severely damaged.

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1803JEMS_57 57 2/9/18 3:21 PM

 ST. CROIX DEPLOYMENT
Pafford SRT personnel worked 48-hour shifts to ensure an EMT and paramedic would be staffed on each
U.S. Virgin Islands EMS ambulance.
One of the unknowns for an EMS deploy-
ment such as this is estimating the necessary
supplies and equipment to bring. Our 28 suit-
cases were filled to the brim with trauma dress-
ings, fluids, gloves, suction canisters, catheters
and tubing, medications, ECG electrodes and
12-lead cables, defibrillator pads, ventilator
tubing, thermometers, lancets, syringes, bat-
teries, OB kits, oxygen devices and tubing, dis-
posable CPAP, hand soap, rain jackets, safety
glasses and more. We stocked four jump bags
Pafford SRT stored supplies in a room at the U.S. Virgin Islands EMS station.
58 JEMS | MARCH 2018
1803JEMS_58 58
and four pediatric bags. We carried on three
monitor/defibrillators and one ventilator. U.S.
Virgin Islands EMS personnel was happy to
see we were prepared for anything.
The Pafford SRT staff stayed on a cruise ship
on the Frederiksted Pier on the west side of the
island, alongside FEMA workers and air med-
ical staff. Each crew partnered up to one room
that contained two beds and a bathroom. Two
food areas were open on the ship to get break-
fast, lunch and dinner on our off-shift days.
It was comfortable; however, I was empa-
thetic for the U.S. Virgin Island EMS staff, who
continued to stay in their homes without power.
After a few weeks of working together, the
teams working on each ambulance were solid.
We all knew what we needed to do for each
of our patients. Not only did I get to know
the U.S. Virgin Islands EMS staff, but I also
forged friendships with Pafford SRT staff
that I barely knew prior to this deployment.
COMING HOME
I returned home to my job at Paramount
Ambulance in Dubuque, Iowa, on Monday,
Nov. 27. The long 30-day deployment to the
U.S. Virgin Islands was an unforgettable expe-
rience. I’ve made multiple friendships that will
last a lifetime. JEMS
Andrew Ney, BA, NRP, is a paramedic and in charge of busi-
ness development for family-owned Paramount Ambulance
in Dubuque, Iowa.
Acknowledgement: I would like to thank Clay Hobbs and
Jamie Pafford-Gresham for giving me this opportunity as well
as acknowledge the Pafford SRT members I had the privilege
to work with and whom I now consider my friends: Andrew
Amante, Eric Ryan, Mallory Ryan-King, Jaret King, Eric Street,
Josh Forrest, Suzie Gresham, Dusty Rogers, Nash Lindley and
Leon Cheatham. I would also like to send thoughts and prayers
out to the families and friends of three members of Pafford
Air One Bravo, who passed away on Nov. 19, 2017, in an air
ambulance incident while responding to a call: Flight Nurse
Jim Spruiell, Flight Paramedic Trey Auld and Pilot Mike Bollen.
The Pafford SRT staff stayed on a cruise ship on the
Frederiksted Pier on the west side of the island, along-
side FEMA workers, linemen and air medical staff.
www.jeMs.CoM
2/9/18 3:21 PM

TROOP SUPPORT
Providing medical care for law enforcement during
Hurricane Harvey
By Mark E.A. Escott, MD, MPH, FACEP, NRP
A
s Hurricane Harvey approached, Aus-
tin and other cities along the Texas
gulf coast prepared for the worst.
Although Austin escaped Harvey’s wrath,
Houston and many other cities and counties
across Texas were batted by wind and inun-
dated by historic flooding.
In addition to water rescue teams from Aus-
tin and Travis County, who plucked countless
people from the floodwaters in south Texas,
a large force from the Texas Department of
Public Safety (TxDPS) and the Texas Divi-
sion of Emergency Management (TDEM)
responded to the area.
The TxDPS and TDEM sent more than
1,000 personnel from across the state to sup-
port law enforcement and rescue operations in
the hurricane and flood-ravaged areas.
One of those assets was a task force of the
legendary Texas Rangers. This group of 84
personnel performed 915 rescues and helped
almost 1,500 people by meeting life-sustain-
ing needs. As a critical part of “Task Force
Ranger,” we have full-time tactical paramed-
ics, John Dunn and Ryan Schaffer, and four
other Special Operations Group (SOG) med-
ics who were responsible for providing medical
care for the Texas Rangers and other TxDPS
assets in the region.
I have the privilege of serving as the medi-
cal director for TxDPS and TDEM. Though
there were plenty of challenges associated with
caring for evacuees, there were also many obsta-
cles in the provision of “troop support” for our
state law enforcement officers.
PREVENTION
The first issue the medics faced was providing
immunizations for our personnel. Approxi-
mately half of the task force was unsure about
their tetanus status and eager to get protected as
concerns about stagnant floodwaters increased.
After dozens of tetanus boosters were
www.jems.com
1803JEMS_59 59
EMS DOCS’ PERSPECTIVES ON STREET MEDICINE
administered by the medics, the next question
was whether or not to vaccinate for hepatitis A.
Conventional opinion is that it’s not necessary
because it takes 1–2 weeks for the vaccine to
take effect. At that stage, we weren’t sure how
long the deployment would last and how soon
the next water emergency would be coming.
As soon as the vaccines were procured, the
first round of hepatitis A immunizations was
administered, including the documentation
and scheduling for the second round.
With the prophylaxis out of the way, atten-
tion turned to other forms of prevention—
“village medicine stuff,” as Dunn calls it. This
included general education about foot care,
small wound care, field sanitation, and hygiene.
It wasn’t the high-speed medicine that
these tactical medics are used to as part of
the Texas Rangers SWAT team, but it was
certainly familiar territory from their days of
military service. The education was invaluable
and helped prevent additional problems in the
austere environment of south Texas.
CHALLENGES
Another challenge encountered was one unmis-
takable characteristic of the affected areas: the
smell. Even weeks after the floodwaters sub-
sided, the smell of mold was a growing and
significant concern for our task force members.
As you can imagine, N95 masks were hard
to come by, but we were able to secure them
through TDEM logistics. This is definitely
an important consideration for future flood-
related deployments.
The deployment was met with a number
of illnesses and injuries. Luckily none were
severe. The medics took care of multiple cases
of brief diarrheal illness and handed out over-
the-counter meds for aches and pains as well
as upper respiratory illnesses.
Many personnel were treated for abrasions
and lacerations that were irrigated and cleaned.
FIELD PHYSICIANS
They then received treatment with antibiotics
from the team’s supply cache following approval
by medical control. Others required coordina-
tion of local assets or referrals to urgent care
centers for repair. For minor musculoskeletal
issues, a few other prescriptions were called in
for other medications not carried by the team.
Although there was a large contingency of
medical assets in the area, having dedicated
and experienced tactical paramedics deployed
with the task force was a key component for
mission success.
MISSION SUCCESS
Despite the disastrous conditions, the long
hours, and the tedious work, the medics kept
the team healthy and functional throughout the
deployment. The capabilities that they brought
with them, enhanced by online telemedicine
support and local resources, proved to be a
remarkable success.
The TxDPS and TDEM personnel
deployed during Hurricane Harvey, as well
as those leaders and administrators in Aus-
tin and throughout Texas, are a credit to this
state and nation.
Statewide, more than 21,000 personnel,
approximately 2,000 vehicles and aircraft, and
377 boats performed 34,062 rescues, 37,758
evacuations, and more than 2,000 animal res-
cues and evacuations.
To the personnel from around the country
to came to our aid—Texas thanks you! JEMS
Mark E.A. Escott, MD, MPH, FACEP, NRP, is
the medical director for Austin-Travis County
EMS System. He’s also a medical director and
founder of Rice University EMS in Houston,
Texas and a clinical assistant professor at the
University of Texas Austin Dell Medical School. He’s the chair
of the American College of Emergency Physicians Section of
EMS and Prehospital Medicine and is board-certified in emer-
gency medicine and subspecialty board-certified in EMS.
mARcH 2018 | JEMS 59
2/9/18 3:21 PM
 HANDS ON
PRODUCT REVIEWS FROM STREET CREWS

Basic CPR Feedback

“Push hard, push fast.” That’s the basic mantra for compression-only CPR, which we know can save
lives during cardiac arrest. How do we know when students in our citizen CPR classes have the right
compression depth, rate and full release? For compression
rate, we might use a metronome or play “Stayin’ Alive.” To VITALS
assure proper depth, we may use manikins with a clicker, Dimensions: 3.9" x 3.9" x 4.3"
although monitoring compression release requires some Weight: 8.5 oz. (without batteries)
sort of electronic device. The new cprCUBE from I.M. Lab Power: DC 3 V; 4 AA batteries
provides a compact, low-cost, easy-to-use CPR feedback Price: $59.00
coach. Students simply push on the top of the urethane www.cprcube.com
foam block, and a sensor analyzes output in real-time. +82-70-5056-3900
Once the student has the correct depth, rate and release,
a series of LED lights around the base is activated. This allows an instructor to easily see which stu-
dents are performing CPR properly and those who require additional coaching.

Simple Vein Visualization

VITALS
Dimensions: 4" long; 1" diameter
Weight: 2.5 oz. (with batteries)
Power: 3 AAA batteries
Price: $24.99
www.illumivein.com
Over the past 30 years, the technology to improve accuracy
for difficult IV sticks has been revolutionary. This technology
is at the top of many paramedics’ wish list. There are several
tricks of the trade, such as holding a light at a low angle, that
also work. The new Illumivein from Easy-RN LLC, uses nine
high-powered LEDs to provide red illumination that helps
visualize veins when the light is placed against the skin.
To use the Illumivein, you simply turn the light on, place it
against the skin in an area of venous access, and move the
light across the skin until you see the shadow of the vein
underneath the light. You can then more easily cannulate the
vein, since you can now see it as well as feel it.

Handy USB Power

How many items of technology do you carry that can be
recharged with a USB cord? The new USB Dual Port 4.8 VITALS
power outlet from Kussmaul Electronics gives you easy Dimensions: 1.73" x 0.96" x 2.19"
access to two USB ports without the need for chargers that Weight: 16 oz.
plug into a vehicle cigarette lighter. This is especially con- Power input: 10–30v
venient since many ambulance chassis no longer come with Power output: 4.8 amps max
lighters, since you can’t smoke in an ambulance. Designed Price: $24.99
to fit in the standard opening of an emergency lighting www.kussmaul.com
switch panel, the Kussmaul USB Dual Port 4.8 offers two, 800-346-0857
2.4 amp outlets that allows you to charge two tablets or
large cell phones at a rate faster than a 1.0 amp outlet.

Fran Hildwine, BS, NRP, is the AHA Training Center Coordinator at the Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del. He’s also an
EMS instructor at Good Fellowship Ambulance Club in West Chester, Pa. Contact him at fran100b@zoominternet.net.

60 JEMS | MARCH 2018 www.jeMs.CoM

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 For more product reviews: www.jems.com/Hands-On

Individual First Aid Kit (IFAK)

If you served in the military, you’re likely familiar with an individual
first aid kit. IFAKs hold the essential items needed to save yourself or
your buddy from a major trauma, such as a gunshot wound or other
penetrating trauma. The new IFAK Pouch from Rescue Essentials fits
the bill, incorporating space for a variety of supplies, such as an oral
airway, nasal airway, tourniquet,
field dressing and homeostatic VITALS
agent into a heavy duty, light- Dimensions: 7.5" x 6" x 3.5"
weight, 500D Cordura nylon pouch Weight: 12 oz.
with multiple attachment points, Color: Black
MOLLE webbing, D rings and elastic Price: $26.95
straps to organize your gear as you www.rescue-essentials.com
need to. 866-711-4843

Light Up a Difficult Airway

A difficult airway is an EMS nightmare. You can’t ventilate well,
if at all, and you know that intubation will be difficult. One of the
limitations of the traditional laryngoscope is the light source only
illuminates half of the pharynx. This makes it difficult to see exactly
where bleeding is coming from, or to see enough of the vocal cords
VITALS while suctioning emesis. The new Vie Scope from Adroit Medical
Price: $79.00 has a clear, circular blade that’s fully illuminated and provides a
www.adroitsurgical.com bright light inside the entire pharynx. Since the blade is circular, the
877-723-7642 intubation technique is altered—you visualize the vocal cords and
pass a bougie through the barrel of the Vie Scope into the trachea,
removing the scope while holding the bougie in place and then
sliding the tube over the bougie into the trachea.

O2 Tank-Saving CPAP
Continuous positive airway pressure (CPAP) has radically changed
the way we treat congestive heart failure and pulmonary edema.
Some CPAP units connect to the high-pressure oxygen port and
use a high volume of oxygen, which often limits CPAP use inside a VITALS
residence to 10 minutes or less when using a size D cylinder. The Flow rate: 10 Lpm
new GO-PAP from Pulmodyne operates off the low-pressure oxy- PEEP: 5, 7.5, 10 cm H2O
gen port at a flow rate of 10 Lpm. This flow rate provides an FiO2 Price: Call for price
of 30% and a runtime of 42 minutes on a full cylinder (size D). The www.pulmodyne.com
positive end-expiratory pressure (PEEP) is set independent of flow 317-246-5505
and can be maintained at 5, 7.5 or 10 cmH2O. The small package
size of the GO-PAP makes it easy to keep in your regular O2 duffle.

IN THE NEXT ISSUE: >> American Red Cross BigRed CPR Manikin >> CPR Shield >> Samsara Fleet Tracking
>> Bryx Emergency Alert Software >> Nitecore EMS Light >> New Gear Medical Backpack

www.jems.com mARcH 2018 | JEMS 61

1803JEMS_61 61 2/9/18 3:21 PM

1803JEMS_62 62
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 ISLAND AID
— Continued from page 55
helped us to build relationships and identify
helpful resources within these communities,”
Bascom says.
Bringing crisis counselors is also key to such
a mission, says Bascom. “The crisis counselors
were deployed to provide support to respond-
ers and officials in the U.S. Virgin Islands, and
to train community groups to provide similar
services to their constituents, but their presence
amongst our team and belief in what they’re
doing led them to provide similar services to
our responders, who benefited from the stress
relief without knowing that they were being
counseled. They will now be a part of any future
deployment we do.”
“There’s always room to grow and learn
from our experiences,” says Mehta. “The one
thing is how can we better train ourselves
to provide excellent medical care in an aus-
tere prehospital setting? You’re in an absolute
disaster zone. There’s nobody going to help
you. You’re the help. You’re the final answer.”
Task force officials as well as the state’s top
as successes, given how quickly the trips came
together, the use of the EMACs, how every-
one overcame logistical hurdles and the sheer
number of responses on the ground—which
was more than 400.
“It’s more than numbers, it’s people,” says
former acting N.J. Department of Health Com-
missioner Rinn.
“You have to remember, at the end of the
day, you have to pay attention to the success
stories, the personal impacts on the lives that
were touched throughout the deployments,
those are the stories that need to be told to
quantify the success,” Rinn says. “Those who
braved danger going up a mountainside to
rescue someone who was disabled and needed
care. … Those are the stories that a lot of the
members of the team will carry with them
and that’s where the rubber meets the road.”
CONCLUSION
Despite some minor challenges with getting
there and completing the mission, it did have
a lasting impact on those who participated.
“I think it makes everybody a better person,”
that, you know, we sign up to help people. We
change peoples’ lives every day. But when you
can do it on a larger scale, it changes everybody.”
“It is actually a life experience, without
question,” says Bascom, adding he learned
patience and resilience through the experience.
“I was amazed by the understanding of the
process and the acceptance of how they live
on an island—and while most were without
electricity and running water. They accepted
it and figured out how to deal with it.”
“I’ve been in EMS well over 30 years and
it was probably one of the most rewarding
large-scale incidents I’ve ever been on,” says
Cicala, whose son participated in the second
deployment to the U.S. Virgin Islands.
“Just being able to help your EMS fam-
ily, and the people down there. The residents
came up and thanked you, not even knowing
who you are.” JEMS
Richard Huff, NREMT, is a network television communications
executive, an author and an award-winning journalist. He’s a
member of the New Jersey EMS Task Force and is a former chief
of the Atlantic Highlands (N.J.) First Aid and Safety Squad. He

! health executives view the two deployments Contreras says. “I think it’s life-changing in can be reached at richardmhuff@gmail.com.

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1803JEMS_63 63 2/9/18 3:21 PM

 LAST WORD
THE UPS & DOWNS OF EMS

COMM CENTER COMMENDATION

The Cypress Creek Communications Center provides dis-
patch for 11 fire departments, three EMS providers, the Har-
ris County Fire Marshal’s Office and the county’s hazmat team. These
agencies all provided first response during devastating Hurricane Harvey.
The week that Harvey made landfall in Texas, calls increased by an
average of 196%, peaking at 614%. The previous week, the Comm Cen-
ter responded to 1,834 incidents, but from August 25–31, it answered
5,426 incidents and more than 12,000 calls total. To accommodate the
high call volume, call takers, dispatchers and supervisors ate and slept at
the Comm Center. Cots were even placed in classrooms at the center.
The successful emergency response was a collaborative effort. Teams
at the Comm Center mapped out roads that were flooded, and routed
ambulances to patients and hospitals avoiding high-water areas. EMS
providers reported impassable areas to the Comm Center, and notes
were compared with law enforcement.
Because of their incredible efforts, the CommCenter was awarded
Telecommunicator of the Year at the 2017 Texas EMS Conference in
Fort Worth.
We give a huge thumbs up to the incredible workers at the Comm The Cypress Creek Communications Center was named Telecommunicator of the
Center. Their tireless efforts improved transport, streamlined rescue Year at the 2017 Texas EMS Conference, based largely on the incredible work
missions and saved lives. during and immediately after Hurricane Harvey. Photo courtesy Cypress Creek EMS

SAFETY ASSURANCES
In February 2017, we gave a thumbs
down to the Center for Domestic Pre-
paredness (CDP) for accidentally exposing
first responders to deadly ricin during training
exercises for five years, when it should have
been using a less potent version. We’re happy
to report the agency has made strides toward
preventing this debacle from happening again.
The CDP has selected a new vendor to
supply the substance for training. Staff from
the CDP has visited and approved the facil-
ity where it’s created, and plans to first ship
the substance to the Department of Home-
land Security’s National Bioforensic Analysis
Center for testing before it’s sent to the CDP.
The agency has also implemented improved
respirator masks for students and staff, updated
its ventilation system in its training facilities
and hired additional facility staff including a
safety and occupational health officer, environ-
mental management specialist and a quality
assurance analyst. Additionally, it’s assem-
bled an advisory board comprised of national
occupational safety and health and compliance
assurance experts.
We give a thumbs up to the CDP for tak-
ing this issue seriously, and making significant
adjustments that’ll help avoid a similar inci-
dent. We were optimistic our reporting might
help prompt change, and we’re glad the CDP
has remedied this potentially deadly mistake.
MENTAL HEALTH APP
First responders deal with a host of
mental hurdles, in addition to phys-
ical hurdles on the job.
Issues such as stress, anxiety, post-traumatic
stress disorder and burnout are far too com-
mon. Tragically, first responders are 10 times
more likely to attempt suicide than people
in other occupations—a startling truth that
ImageTrend is tackling with its newly devel-
oped app, CrewCare.
CrewCare is a free smartphone app that
helps first responders examine and gain insight
into their mental health. The app enables users
to track their daily moods, associated activities
and questions related to life’s stressors. It then
displays the results in easy-to-digest charts
and graphs to help give first responders an
overall view of their own mental health over
time. They can also compare themselves to
aggregate information from other app users.
Additionally, the app provides the user with
topical resources, as well as national and local
support networks, all while keeping the user’s
identity confidential.
Not only does the collected data help indi-
viduals assess their own mental health, it also
assesses non-identifiable aggregated data to
provide for research and to help paint a pic-
ture of the current state of mental health
across EMS, fire, law enforcement and the
armed services.
The CrewCare app is available in the App
Store and Google Play. For more information,
visit www.crewcarelife.com.
We give a thumbs up to ImageTrend for
developing a free tool that not only raises
awareness but seeks to improve the mental
health of all first responders. JEMS

JEMS (Journal of Emergency Medical Services)® (ISSN 0197-2510) USPS 530-710, JEMS is published 12 times a year, monthly by PennWell® Corporation, 1421 S. Sheridan Rd., Tulsa, OK 74112. Periodicals post-
age paid at Tulsa, OK 74112, and at additional mailing offices. SUBSCRIPTION PRICES: Send $20 for one year (12 issues) or $30 for two years (24 issues) to JEMS, 26395 Network Place, Chicago, IL 60673-1263
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for employees of corporations licensed under the Annual Authorization Service offered by the Copyright Clearance Center Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, or by calling CCC’s Customer
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work. If you do not want to receive those offers and/or information via direct mail, please let us know by contacting us at List Services JEMS (Journal of Emergency Medical Services), 1421 S. Sheridan Rd.,
Tulsa, OK 74112. Printed in the USA. GST No. 126813153. Publications Mail Agreement no. 40612608.

64 JEMS | MARCH 2018 www.jeMs.CoM

1803JEMS_64 64 2/9/18 3:21 PM

 Taking Noninvasive Monitoring
to New Sites and Applications ™

EMMA™ Rad-57® MightySat™ Rx

Capnograph Handheld Pulse CO-Oximeter® Fingertip Pulse Oximeter

EtCO 2 RR SpO 2 PR Pi SpMet ®

SpCO
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SpO 2 PR Pi

For over 25 years, Masimo has been an innovator of noninvasive patient

monitoring technologies, striving to improve patient outcomes and reduce
the cost of care.

Masimo offers leading technology to care providers across the continuum

of care — including mobile settings, Emergency Medical Services (EMS),
and other post acute care areas.1

For more information, visit www.masimo.com

PLCO-001425/PLMM-10669A-1017

Caution: Federal (USA) law restricts this device to sale by or on the order of a
physician. See instructions for use for full prescribing information, including
indications, contraindications, warnings, and precautions.
PLLT-10356B

© 2017 Masimo. All rights reserved.

1
Not all Masimo products are intended for use in all care areas.

For more information, visit JEMS.com/rs and enter 18.

1803JEMS_C3 3 2/9/18 3:22 PM

 Vascular Access is
Always Within Reach.
The Arrow® EZ-IO ® System is indicated for emergent, urgent,
and medically necessary situations in which vascular access
can be difficult or impossible to obtain for up to 24 hours
and provides peripheral venous access with central venous
catheter performance.1-2*†

teleflex.com/ems

Rx only
References:
1 Hoskins SL, Nascimento P Jr., Lima RM, Espana-Tenorio, JM, Kramer GC. Pharmacokinetics of intraosseous and central venous drug delivery during cardiopulmonary
resuscitation. Resuscitation 2011; doi:10.1016/j.resuscitation.2011.07.041. Research sponsored by Teleflex Incorporated. (preclinical study)
2 Hoskins SL, Zachariah BS, Copper N, Kramer GC. Comparison of intraosseous proximal humerus and sternal routes for drug delivery during CPR. Circulation 2007;
116:II_993. Research sponsored by Teleflex Incorporated. (preclinical study)
*Compared to single lumen Central Venous Catheters (CVCs).
†
Based on Adult Proximal Humerus EZ-IO® insertion data. For more information, visit JEMS.com/rs and enter 19.

Teleflex, the Teleflex logo, Arrow, and EZ-IO are trademarks or registered trademarks
of Teleflex Incorporated or its affiliates, in the U.S. and/or other countries.
© 2016 Teleflex Incorporated. All rights reserved. MC-002926

1803JEMS_C4 4 2/9/18 3:22 PM