Professionals May-June 2017
The Official Publication of the Wisconsin EMS Association â€“ Your Voice For EMS
Community Emergency Medical Services in Wisconsin Results of the Wisconsin EMS Assessment Completed by the Office of Rural Health
Annual EMS Week Issue EMS Week May 21-27, 2017
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The Official Publication of the Wisconsin EMS Association – Your Voice For EMS
Community Emergency Medical Services in Wisconsin By Dr. Kim Litwack
Columns 6. Director's Dialog
Marc Cohen Wisconsin EMS Association Executive Director
56. Challenges On The Scene
It's Not Always a Duck! Frederick Hornby EMT-Critical Care Paramedic
58. Legal Brief
More Patient Confidentiality and CQI Gregory West Attorney, EMT-Paramedic
60 Straight from The State
Wisconsin EMS Assessment Attributes of Success By John Eich and Penny Black
Funding Assistance Program Applications Open James Newlun EMS Section Chief
62. Tips and Tricks A Point Worth Making David Myers EMT-Intermediate Tech
Departments 4. WEMSA at Work
System Alarms By Ben Feinzimer and Ben Kessel
8. Service Spotlight 10. EMS News 12. Dear EMSpert 14. Did You Know 15. Research
Professionals – May-June 2017
The Official Publication of the Wisconsin EMS Association – Your Voice For EMS
Volume 41 • Number 3 26422 Oakridge Drive Wind Lake, WI 53185-1402 1-800-793-6820 414-431-8193 Fax 414-431-8744 www.WisconsinEMS.com WEMSA@WisconsinEMS.com
Wisconsin EMS Association At Work Complimentary Issue For throughout the state. In 2013, WEMSA National EMS Week partnered with the Office of Rural Health To help celebrate EMS Week, a complimen- and for the first time added first responder tary copy of EMS Professionals magazine has organizations to the poster. been provided to every ambulance and first Working again with the Office of Rural responder service, hospital, training center Health, the 5th edition of the poster has both and legislator in Wisconsin. The electronic been updated, and increased in size to give version of the magazine is also available to an even large view of all of the EMS provideveryone online free of charge. ers throughout Wisconsin. A complimentary Even in this age of social media and the copy will be provided to EMS stakeholders Internet, EMS Professionals remains a one- in Wisconsin, including ambulance services, stop source for emergency services news and first responders, fire departments, hospitals, information. training centers and others. Additional postIf you or your EMS organization are not ers will be available from WEMSA. Watch members of WEMSA, we encourage you to for the release in the next few weeks. contact the office and find out how you can join over 6,000 individuals and more than 360 New Leadership Congratulations to the 2017-18 members organizations who receive all of the benefits of of the WEMSA Board of Directors and membership, including this magazine. Call Executive Committee. Based on your votes, us at 800-793-6820 or join online at www. the members listed below have been chosen WisconsinEMS.com, to find out more informato serve your association. tion or become a member in minutes. That way The new board held their first board meetyou'll never miss an issue of EMS Professionals. ing in April, with many exciting and creative ideas being discussed about how to serve Fifth Edition Poster Being you and add value to your membership. The Released board members live and serve in all areas of Since the late 1990s, the Wisconsin EMS the state, so please reach out to them with Association has produced a poster depicting any questions, comments, and ideas. all of the EMS provider services and locations
WEMSA Board of Directors for 2017-2018 Name
6/30/2019 Reedsburg Ambulance Area Service
6/30/2020 Clintonville Area Ambulance Service
6/30/2019 Elm Grove EMS
Member at Large
6/30/2018 Chippewa Valley Technical College
6/30/2018 Oak Creek Fire and EMS
6/30/2020 New Berlin Fire Department
6/30/2018 Union Grove-Yorkville Fire and Rescue
6/30/2019 Baldwin Area EMS
6/30/2020 Regions Hospital & St. Croix EMS
6/30/2020 Oakdale Area First Responders
6/30/2019 Gold Cross Ambulance
6/30/2018 Clintonville Area Ambulance Service
Professionals – May-June 2017
Layout and Design HG Studio Copy Editor KC Inc.
ssociation Officers and Staff Members A President Joshua Kowalke Vice President Don Kimlicka Secretary/Treasurer Jeff Munson Board Member-At-Large Chris McHenry Executive Director Marc Cohen Sales & Conference Manager Fred Hornby Bookkeeper Debbie Couey Office Administrator Lori Krause Board Of Directors
Karen Barker RN, CCRN, Paramedic
New Berlin, WI
Kirk Gunderson Paramedic
Roger Kieffer Critical Care Paramedic
Oak Creek, WI
Don Kimlicka Critical Care Paramedic
Joshua Kowalke Critical Care Paramedic
Tony Lash Paramedic
Jeff Munson Critical Care Paramedic
Cliff Peterson Critical Care Paramedic
Jennifer Smith Advanced EMT
Sara Vnuk Critical Care Paramedic
Union Grove, WI
Stacey Zellmer Emergency Medical Responder
Medical Director/Advisor Legal Advisor Registered Lobbyist
Dr. Mark Schultz Waukesha, WI Robert Ginther Forbes McIntosh
Wisconsin EMS Association Membership Service and Corporate Membership
EMS Professionals is owned and is published bimonthly by the Wisconsin Emergency MedicalTechnicians Association, Inc., 26422 Oakridge Drive, Wind Lake, WI 53185-1402, ©2017. All creation is done in-house. Printed at Times Printing, Random Lake, WI. Mailed standard mail at Random Lake, WI, Hales Corners, WI, and others. Distribution restricted to Wisconsin EMS Association members, Wisconsin licensed ambulance providers, Wisconsin-based hospital emergency departments and Wisconsin Legislators. Membership is $25 of which $15 is for annual subscription to EMS Professionals. Articles, photos and advertising should be submitted in electronic form. Reasonable care will be taken in handling, but the Wisconsin EMS Association assumes no responsibility for material submitted. The post office will not forward third class mail. Send address changes to Wisconsin EMS Association, 26422 Oakridge Drive, Wind Lake, WI 53185.
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Parts and Service
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Director's Dialog Marc Cohen, Wisconsin EMS Association Executive Director
We at WEMSA are excited to share with you some changes and growth ideas that we will be exploring and implementing throughout the year. Membership Survey It has been a few years since we reached out to our membership and surveyed you on how we are doing, and what would add value to your membership, and asked for your feedback on some new and innovative programs we are planning. The survey will be sent out electronically, so if you have a new email address or have been meaning to contact us with changes, please do so. This is your association and we need your input. The survey will be sent out just after you receive this issue of EMS Professionals. Please fill it out and encourage other members to do so as well. As an added incentive, every completed survey will enter you in a drawing for a ZOLL AED. We will be giving away two ZOLL AEDs, so please fill out the survey when you receive it. Legislative Update This has been a busy legislative season for EMS, and there is still more to come. I represented WEMSA at the Capitol for our partners at the American Heart Association to educate legislators on dispatcher-assisted CPR, which will be coming up shortly. I was honored to testify with WEMSA member, Baraboo Chief, and PAAW board member Dana Sechler, and PFFW President Mehlon Mitchell before the legislature on aligning the Wisconsin service level descriptions with the NAEMT nomenclature. It was a great opportunity to continue to build bridges and work together for our cause. I also testified on WEMSA’s behalf regarding our support for Community EMS. Assembly Bill 151 was spearheaded by Rep. Loudenbeck and her staff, and with bipartisan support, this bill has been four years in the works and has undergone many changes. I am pleased to share with you that although there are many details to be worked out in the Administrative 6
Professionals – May-June 2017
Code, there is strong support for the intent of the bill by all parties involved. The bill would create an approval process for Community EMTs at all levels, and emergency medical services providers. It also establishes criteria for an approval as a Community EMT including completion of a training program approved by DHS. An individual may provide services as a Community EMT only if they are a volunteer or employee of an ambulance service provider or non-transporting provider that has approval, or if he or she is an employee of, or under contract with, a hospital, clinic, or physician. All EMTs are required to follow any protocols and supervisory standards established by DHS or their medical director. The services performed may be provided for which they are trained, that are not duplicative of services already being provided to a patient, and that are either approved by the hospital, clinic, or physician or are incorporated in the patient care protocol of their service. A Community EMT and service provider may include in its patient care protocols only those services that do not require a license, certificate, or other credential from any of the following examining boards: medical; physical or occupational therapy; podiatry; nursing; chiropractic; dentistry; optometry; pharmacy; psychology; marriage and family therapy, professional counseling, and social work; hearing and speech; or as an acupuncturist.
Later this summer we will be launching a new online store through the WEMSA website. This store will be able to customize your services logo or one from the library of logos, including WEMSA, on hundreds of items at a significant discount only to our members. We are planning a two-day service directors’ workshop that we will be repeating in different parts of the state throughout the year. If you are interested in helping us coordinate a workshop in your area, please let me know. Our biggest news is the announcement of WEMSA Consulting Services and WEMSA Training. We have heard from dozens of member services that they need help and support with operational plans, writing or editing protocol, and other service-related items. We have heard your concerns and recognize your need for assistance from WEMSA in these areas. We are putting together a menu of consulting services that can be delivered in a number of different ways. For example, we can review your plans electronically before submitting them to DHS, either electronically, or with a Skype call, whichever would be more helpful. We can even provide an on-site review at your convenience. We will be adding value to your membership through WEMSA Consulting Services. With regards to WEMSA Training, we know that continuing education courses are hard to schedule and are inconvenient when renewal deadlines are looming. As an authorized Training Center, WEMSA will New Initiatives There are a number of new initiatives on the be working with your schedule, your medihorizon that I am excited to share with you as cal director, and your location to provide well as ask for your feedback. We are in the continuing education courses that are conprocess of looking at new membership soft- venient for you and your service. Watch for ware. The program we are using has reached more information coming soon. Spring is alive with growth, change, and its useful life, and we have been testing new and much more user-friendly membership excitement at WEMSA and throughout management software. This software will Wisconsin. Please fill out the survey when it allow you better access and reporting, clearer arrives, let us know what you think of the information, and will be easier to use for new initiatives, share your thoughts on legrenewal and conference registration. Part of islation, and congratulate all of the new and this new software will include a new website, returning board members for their commitment and service. which will be easier to navigate.
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Service Spotlight Dickeyville EMS
Q: How many stations and apparatus does your service have? A: We respond from the Dickeyville Paris Fire and Rescue building in the village of Dickeyville, while the Jamestown First Responder truck is at the Jamestown Fire Station about four miles away. Our current ambulance is a 2016 Freightliner with a Horton box, which is very different from the 1949 Buick station wagon we used as our Q: What level of care do first ambulance. Our department recently The Dickeyville Area Rescue Squad is you provide and how are you purchased a 15’ x 20’ inflatable tent with made up of a group of committed volun- staffed? a heater and a trailer to be able to provide teers who generously give their time to A: We are a volunteer Advanced EMT better firefighter rehab. We also have access help others in their time of need. (AEMT) service, staffed by 15 commuto the fire department’s ATV with a rescue nity members that are nurses, AEMTs, basket for patient movement. Q: What can you tell us about or EMTs. We also utilize drivers who are your service response area and firefighters or law enforcement providers. Q: Tell us something unique call volume? Furthermore, we are partnered with the about your service and A: The Dickeyville Area Rescue Squad Jamestown First Responders who provide response area. was established in June 1957, and is located 10 EMRs. in the very southwest corner of Wisconsin with our service district bordering Iowa and Illinois. We cover approximately 100 square miles of rural area, including Dickeyville, Kieler, and the townships of Paris and Jamestown, with a population of about 3,500 residents. We respond to a constantly rising call volume, reaching a record 188 calls in 2016.
Professionals – May-June 2017
Q: What do you foresee your A: Our service district includes areas along the Mississippi River, railroads, and a chemi- service's main challenges to be cal plant. Several of our members are on the in the next year and what are Southwest Wisconsin Regional Technical your plans to address them? A: Our main challenge, as we also share Rescue Team with technician level certifications for HAZMAT, high-angle rope, ice with other rural volunteer services, is recruitwater, swift water, structure collapse, grain ment. All of our current members have bin, trench, and confined space rescues. A full-time jobs, many of which are outside our technical rescue truck is based at our station village, so daytime help is always welcome. We will be celebrating our 60-year anniverfor a more rapid delivery of these services. sary this June, and plan to go door-to-door delivering recruitment flyers and discussing Q: Tell us about any commuEMS opportunities in hopes of finding more nity programs your service is volunteers for our service. involved with. Our rescue squad and first responder A: The Dickeyville Rescue Squad hosts three American Red Cross blood drives members are extremely dedicated. At any every year. We provide on-scene standby time, day or night, they leave their family coverage at the Kieler 4th of July Picnic, the and friends to help others in need without Dickeyville Labor Day Weekend Picnic, hesitation. the Lionâ€™s Club End of Summer Fireworks, Q: Why did your service and a local tractor pull. Every December, we host a Cookies With Santa fun day. choose to become members of Annually, we partner with the Dickeyville WEMSA? What member benefit and Jamestown fire departments to dis- does your service value most? A: WEMSA is a great resource for us to stay cuss fire prevention and safety in the grade schools. Our members provide AED train- up to date on the best policies and procedures. ing for the grade schools and coaches in our As a 23-year member, WEMSA continues to area, and have helped provide CPR instruc- provide education and networking opportunities for us. tion to high school students.
Professionals â€“ May-June 2017
EMS News PLAIN – Struggling to find new members to fill the roster, one volunteer Wisconsin ambulance service decided to get the word out, and saw a huge response in return. Placing a post on a popular Sauk County Facebook page has helped Plain Ambulance to reverse a state and national shortage of volunteer responders. Plain volunteer paramedic Michael Weiss knew that recruiting volunteers to help would be hard work, so he took to social media to help. "We are in desperate need of recruits," Weiss explained in the post, which received more than a hundred likes and shares on the Baraboo Scanner Facebook page, where he hoped that people who already had an interest in emergency services might reply. Rather than just listening to the calls as they occurred, they could start actually responding! The recruitment effort did so well that the March class was filled with a total of 19 new recruits sponsored by Plain Ambulance. Classes started in March. "It's amazing, there were so many people out there saying, 'I'm willing, sign me up'," Weiss explained to a local television station reporter.
The nearly hour-long 911 call ended sud- WAUSAUKEE – After losing some of denly when the man walked outside of his their most active members last year, the home and was taken to the ground by the Wausaukee Rescue Squad decided to host a Oneida County Special Response team. public, town-hall-type meeting on April 2. According to the sheriff's office, the elderly The squad roster is down to 10 active memman was not obeying directions from police, bers, only five of which are licensed EMTs. so he was "decentralized." "We acted on the Approximately 35 people attended with information that we had," said the depart- most of them representing other squads in ment spokesperson. "We couldn't have acted Northern Marinette County. The group any other way. We needed to keep the com- discussed a wide range of topics over nearly munity safe as well as our officers safe, and three hours, including recruitment, public we just did the best that we could with the relations, lack of understanding in the cominformation that we had." The sheriff's office munity of what EMS does, use of the recent has since offered an opportunity for county statute change to allow for first responders to residents to have any special needs coded staff the ambulance, training time for EMTs into their address to help aid dispatchers. and First Responders, and much more. The man suffered cuts to his knees, and a While those representing area squads were bump and scrapes on his head as a result of disappointed that more community membeing taken to the ground. He was eventu- bers did not attend, they accumulated a ally taken to the hospital where he remained variety of ideas and action items, including for several days. involving town boards, going to the County Board for help, recruitment opportunities at SUN PRAIRIE – If at least 15 students fairs and other public events, consolidation sign up, Sun Prairie High School and Prairie of area services into a single entity, creation Phoenix Academy may soon team up with of a county-run ambulance service, and more. the Sun Prairie Fire Department to offer an opportunity to become a state-certified fire- MONROE – Green County EMS fighter before they graduate from high school. recently had 10 members complete their Students would spend three mornings a week transition training to move from the EMTRHINELANDER – A 65-year-old-man in Madison College’s Fire Academy course Intermediate (I-99) level to EMT-Paramedic. with Parkinson's disease who called 911 with while obtaining college credit. Students All but one of the new paramedics also have difficulty breathing on April 7 ended up with would also spend some mornings at the Sun full-time jobs outside of their involvement a full SWAT response, including dozens of Prairie fire station, where they would earn with the service. According to the service officers, a bomb squad, and special respond- independent study high school credit. At director, "They did their training and voluners from the Oneida County Sheriff's Office. the end of the year, students would have 200 teer for us on top of working their actual jobs. According to family members, the senior hours of firefighting training which prepares They’re just incredible.” cannot speak, so the 911 operator had him them for the state firefighter certification As part of the transition course, the original communicate by using the key pad on his examination. 350 hours required to obtain their EMTSimilar programs have been offered in Intermediate license was applied to the total phone – a method that had not been used "in forever," according to a sheriff's office other areas of Wisconsin with good suc- training requirements. The classes were held spokesperson. Based on the pushing of but- cess for both training high school students over 15 months, allowing the students to tons on his telephone during the 56-minute to become EMTs as well as firefighter cer- continue working full time, running calls, call, law enforcement reportedly thought tification. The introduction to emergency and fulfilling family responsibilities. that another man, armed with explosives and services at a young age has helped staffing Green County EMS moved to the paracrunches with volunteer-based services medic level in September 2016 by operating guns, was holding the patient hostage. The man's son disagreed, saying, "When a while allowing career opportunities for under the staffing phase-in bridge to 24-hour person cannot communicate, he has short- students. coverage. The 10 new paramedics bring the The Sun Prairie program is scheduled to total number of paramedics at Green County ness of breath, you're going to press every begin with the fall semester later this year. button on the phone to get help." EMS to 14. 10
Professionals – May-June 2017
When seconds count, we count on you. As much as we dream and plan and prepare, life will always be unpredictable. So when sudden, urgent, unexpected events stop us in our tracks, it’s the fearless first responders we count on most.
AURORA HEALTH CARE SAYS THANK YOU to all the EMS and firefighter personnel for the life-saving services you provide our communities and the compassion you show us, every day.
For more information, please contact one of our EMS offices. Aurora BayCare Medical Center in Green Bay • 920-288-8045
Aurora Medical Center in Two Rivers • 920-794-5125
Aurora Lakeland Medical Center in Elkhorn • 262-741-2083
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Aurora Medical Center in Hartford • 262-434-1995
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Aurora St. Luke’s Medical Center in Milwaukee • 414-649-7310
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aurora.org x48625 (04/17) ©AHC
Dear EMSpert: I am reasonably new to the EMS field and have been put on my fire department's committee to order a new ambulance. I had some questions about the Star of Life. I know that it represents EMS in general, but that is about all I know. Can you give me some insight as to what it means? Signed, Mark from Southwest Wisconsin Dear Mark: It has been a while since I have looked at the Star of Life and thought In the middle of the star, there is a serpent and staff. This has been about its meaning. Since we are coming into EMS Week, this letter identified as the staff of Asclepius, who was an ancient Greek physicame just at the right time! cian defined in Greek mythology as the god of medicine. The serpent The National Highway Traffic Safety Administration (NHTSA) and staff together represent medicine and healing. The serpent is identified the need for a distinctly recognizable symbol for EMS. This significant because of its ability to shed its skin. This shedding is need was first identified in the Highway Safety Act of 1966, followed indicative of renewal, according to NHTSA. by the congressional approval of the Highway Safety Guidelines on The Star of Life has become synonymous with emergency medical Emergency Medical Services. The implementation of a comprehen- care around the globe. This symbol can be seen as a means of idensive EMS system nationwide was identified to decrease morbidity tification on ambulances, emergency medical equipment, patches or and mortality. This implementation is still in the works today as we apparel worn by EMS providers, and materials such as books, pamlook from the 1996 EMS Agenda for the Future 1 to the EMS Agenda phlets, manuals, reports, and publications that either have a direct 2050 2, a concept that was recently introduced. application to EMS or were generated by an EMS organization. It This identification was made for both EMS providers as well as the can also be found on road maps and highway signs indicating the general public to use in identifying those vehicles and equipment location of or access to qualified emergency medical care.”3 associated with Emergency Medical Services. On February 1, 1977, So there you have it, Mark. You can go back to your committee NHTSA registered what we now know as the Star of Life with the with a better understanding of the Star of Life and what it means not Commissioner of Patents and Trademarks. only to you as an EMS provider, but also to the general public around The star itself was adapted from the long-standing medical iden- the world as a sign of those that are there to help. tification symbol of the American Medical Association. Each point Incidentally, there have also been publications about the “how” and of the star represents one of the six EMS functions identified by “why” of the use of the Star of Life. The first of these is the NHTSA NHTSA. “Star of Life” Manual which can be found at www.ems.gov/vgn-exttemplating/ems/sol/index.htm These functions include: • Detection References • Reporting 1. www.ems.gov/pdf/2010/EMSAgendaWeb_7-06-10.pdf • Response 2. http://emsagenda2050.org/ • On-Scene Care 3. www.ems.gov/staroflife.html • Care in Transit • Transfer to Definitive Care 12
Professionals – March-April May-June 2017 2017
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Did You Know Patients Reported to be Calling Uber and Lyft Rather Than 911 News media outlets from the Today Show. and Inside Edition, to the Daily Mail, have all been reporting on the seemingly increasing use of ride-booking services Uber and Lyft to transport patients to the hospital rather than requesting an ambulance. Ride-booking drivers have been telling their stories of taking passengers to the emergency department with broken bones, difficulty breathing and even going into labor. While figures are difficult to come by, the drivers say it has become increasingly common, with more stories emerging of people using both Uber and Lyft for their medical emergencies. There are several reasons being reported as to why riders might choose a ride-bookng service over 911, including short wait time, low cost, and a choice of hospital. Dozens of Uber drivers have been sharing their stories of being called as a substitute for emergency services in an online chat room. One driver was summoned to pick up a girl from a party who was violently vomiting and possibly suffering from alcohol poisoning. When he arrived, her friends asked him to take her to the hospital, saying she "might die from drinking too much." The driver, an off duty firefighter/ paramedic, asked, "You believe she has alcohol poisoning?" he wrote. They responded, "Yes please take us to the hospital." The off-duty paramedic informed them, "Medically, she needs an ambulance and I can't legally let her just puke and pass out in my backseat." Before the driver had a chance to call 911, the group got out to summon another Uber. Another driver reported picking up a woman who was having a severe allergic reaction to a bee sting. About 10 minutes into the ride, she began swelling up and taking short, raspy breaths. "I broke all kinds of laws getting her to the closest hospital, and they had to bring out a wheelchair to get her into the ER," the driver wrote. "Since when do you call Uber in a medical emergency???? I honestly thought about pulling up to the nearest ER," the driver wrote. 14
Professionals – May-June 2017
Patients have been reporting multiple reasons for choosing ride-booking services to go to the hospital. Reasons include the $600 to $1,000 average price of an ambulance transport. Meanwhile, charges for ride-hailing apps rarely hit three figures, and customers know the approximate price when they request their ride. They claim that ambulance providers send bills long after they are used, and often the final amount is unknown until the bill is received. Uber provides an estimate of how much you'll pay before you ride. Another reason for the surge is that riders know the wait time. When an Uber driver confirms your request, the app displays a map of the car's location in relation to you and how long it will take to get there. Actress Jaime King revealed on The Tonight Show, nearly three years ago, that she opted for an Uber over an ambulance when she went into labor. "I know Uber says three minutes away and an ambulance you don't know." The EMS industry has shot back with the many reasons against using a ride-booking service in an emergency, including the fact that trained personnel arrive on every ambulance. They also point out that once the person gets to the ER they may have to wait to be checked in and for someone to see them. According to Uber, some providers and policy makers are incorporating ride-booking services into their transportation options for certain patients. In her proposed budget, Washington D.C. Mayor Muriel Bowser has suggested embracing ride-booking services as a way to transport "non-emergency, low-acuity" patients. Such calls "accounted for nearly half the city's 911 calls in 2015," according to a report released in February. Under the concept, operators would connect people experiencing medical emergencies with a triage nurse who could determine whether the call requires an ambulance, a ride-hailing service, or another option. Even some physicians agree that ridehailing services could help supplement
ambulances. An ED physician in Baltimore says it makes sense that transportation options would vary based on the situation. "If you need medical care en route, a private car is a bad idea, because they won't have the personnel or equipment to treat you," he said. But he added that ride-booking could help increase the supply of ambulances for true emergencies. As for Uber, they have issued this official statement: “We’re grateful our service has helped people get to where they’re going when they need it most. However, it’s important to note that Uber is not a substitute for law enforcement or medical professionals. In the event of any medical emergency, we encourage people to call 911.” American Society of Addiction Medicine Delivers Troubling Statistics at Annual Conference A total of 2,100 participants attended the American Society of Addiction Medicine annual conference held in New Orleans during the first week of April. The event, now in its 48th year, bills itself as the nation’s premier conference on the latest science, research, best practices and innovations in addiction medicine. Addiction medical professionals had the opportunity to hear the latest updates and information, including on the opiate addiction and overdose epidemic hitting the United States. During the event, Patrice Harris, MD, MA, Chair of the American Medical Association Board of Trustees, provided an alarming array of updated information. According to statistics from 2015, the last year for which data exists, 91 people are now dying from an opioid overdose each day in the United States. That number is up from 78 opioid overdose deaths per day in 2014. That’s depressing news according to Harris, because the amount of opioids prescribed in the USA has been dropping since 2014, a little before the American Medical Society’s call to action to address opiate prescribing practices. From 2013 to 2015, the
total amount of opioids prescribed dropped Community EMS Bill Passes House and Moves to State Senate by about 10%. It took less than three weeks for a bipartiPreliminary data for 2016 is showing a further increase in mortality. The fatal overdose san bill on Community Emergency Medical rate both in Wisconsin and across the nation Services to pass the Assembly by unanicontinues to increase despite multiple and mous vote and move to the Wisconsin varied initiatives and programs to stop the State Senate. Assembly Bill 151 was introduced on March 17 and passed on the progression. All but one state now has a prescription Assembly floor on April 4 with one technimonitoring program and database, with cal amendment. Wisconsin has already seen a sizeable many more physicians being signed up to use their states’ prescription monitoring pro- number of Community Paramedic programs grams. Pushes to increase the number of first start to flourish and operate throughout the responders who carry naloxone and changes state. This bill will create a formal approval in law to allow naloxone to be dispensed mechanism for Community Paramedics, without a prescription have occurred in many EMTs and EMS providers, and help streamstates. Medication take-back and drop-off line and support future providers to offer programs, designed to keep controlled sub- these services. stances from falling into unintended hands, “Over the last 18 months, we have worked have been implemented. A push to increase with several stakeholder groups to create a treatment availability has also occurred in bill that we believe encourages partnerships many states. Wisconsin has addressed, offered, to provide quality care for people all across and implemented all of these initiatives, along Wisconsin," said Rep. Loudenbeck. "We wanted to find balance while providing flexwith others, in recent years. Unfortunately, even with all of these pro- ibility for these programs to truly reflect the grams and changes, the number of fatal needs that each individual community faces,” he said. overdoses continue to increase each year.
“I’m proud that this bipartisan bill has passed the Assembly after years of work on this vital legislation,” said Rep. Shankland. “Assembly Bill 151 increases access to care, especially for people living in rural areas. It creates jobs for Community Paramedics, who can help address and fill in the gaps in undeserved communities, rural communities, and areas of the state with high healthcare demands. Community paramedicine can also reduce emergency room costs and will strengthen public health across Wisconsin.” As more and more communities consider establishing CEMS, one of the challenges they encounter is a lack of state standards to follow, and no specific qualifications or guidance regarding services that can be provided. This bill creates training standards, sets parameters for working with a hospital, and gives the Department of Health Services (DHS) the ability to approve individuals for a credential and various training programs." Details about Community EMS or Mobile Integrated Healthcare as it is sometimes called, is included in the cover feature story starting on page 16 of this edition of EMS Professionals.
RESEARCH Subcutaneous Fentanyl Administration by Basic Life Support EMTs This study, conducted in a rural and adverse events subsequent to fentanyl ED. Only 1.6% of patients experienced suburban prehospital setting in Levis, administration. Feasibility was defined adverse events, including hypotension Quebec, Canada, involved Basic Life as successful fentanyl administration by (0.8%), nausea (0.4%), and Ramsay level >3 (0.4%). Support EMTs supported by a regional the EMT. Study researchers believe that the Two hundred and eighty-eight paonline medical control center. The study embarked to determine the feasibility, tients between 14 and 93 years old results show that prehospital subcutasafety, and effectiveness of not only the with pain scores greater than 7 were el- neous fentanyl administration by BLS subcutaneous (SC) route of fentanyl ad- igible for the study. Of the 284 (98.6%) EMTs with the support of an OLMC ministration, but also by BLS EMTs, with who successfully received subcutane- center is a safe and feasible approach the support of an online pain manage- ous fentanyl, 35 had missing records or to pain relief in prehospital settings, and data, leaving 249 (86.5%) who were in- is not associated with major adverse ment medical control center. This retrospective study used patients cluded in the analyses. The average re- events. Effectiveness, subsequent to who received subcutaneous fentanyl ported pain score pre-fentanyl was 8.9 subcutaneous fentanyl administration from, and were transported by, BLS ± 1.1. The protocol involved a maximum is characterized by a decrease in pain EMTs to the emergency department first fentanyl dose for patients less than over the course of transport to the ED. (ED) of an academic hospital between 70 years of age of 1.5 microgram/kilo- Further studies are needed to compare July 1, 2013, and January 1, 2014. Fen- gram of body weight. For patients 70 the effectiveness of SC administration tanyl orders were obtained from emer- years or older, the initial and maximum by EMS with other routes of administragency physicians via an online medical dose was 50 mcg. tion and other analgesics. The researchers found that the recontrol (OLMC) center. Effectiveness was defined by changes in pain scores ported pain scores decreased signifi- Source: Prehospital Emergency Care, Volume issue 5, 2016, pages 648-656. Johann Lebon, at 15 minutes, 30 minutes, and 45+ min- cantly following fentanyl administration 20, PhD, Francis Fournier, MD, François Bégin, MD, utes after initial fentanyl administration. and the proportion of patients achiev- FRCPC, Denise Hebert, BcSc-Inf, Richard Fleet, Safety was evaluated by measuring vi- ing pain relief increased significantly PhD, MD, CCMF, Guilaume Foldes-Busque, tal signs, Ramsay sedation scores, and over the course of transport to the PsyD, PhD, and Alain Tanguay, Msc, MD. Professionals – May-June 2017
Community Emergency Medi Kim Litwack, PhD, RN, APNP
Professionals â€“ May-June 2017
ical Services in Wisconsin Professionals â€“ May-June 2017
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have all seen it; the familiar address that pops up on a midnight run. You know exactly who it is, exactly what you will find, and exactly what will happen. And your fellow EMT/paramedics will get to experience the exact same thing in another week or two. Evelyn Scott has been calling 911 at least two to three times a week for the last four months, ever since being discharged from the hospital following a diagnosis and hospitalization for heart failure. Other known addresses are for Tenesha Watson, the 32-yearold female with asthma, who has yet to remember to get her inhalers refilled, so she needs you for her neb treatment. And let’s not forget Mrs. Samuelson, the 92-year-old who calls just to have someone come to her house for company. We have all thought it. There has to be a better way. This is not cost effective. It is not a good use of resources. Why is Ms. Scott continuing to get readmitted? Why can’t Tenesha get her inhalers refilled? And where is Mrs. Samuelson’s family?! Thankfully, now, there is a better way. In 2001, the Institute of Medicine Committee on the Quality of Health Care called for an urgent need to redesign the American healthcare system. There was a renewed focus on bringing healthcare to the patient, to improve outcomes and to reduce costs. One proposed solution, among many, was the concept of Mobile Integrated Health. Mobile Integrated Health (MIH) is emerging as a new initiative among Emergency Medical Service providers as a means to improve health, and to improve outcomes at a lower cost. Referred to as the “triple aim,” today’s EMS providers, including EMTs and paramedics, are embracing a new care delivery model known as “Community Paramedicine,” bringing care into the home. Terms like Community Paramedic and Community EMT are now being referred to as Community Emergency Medical Services (CEMS), expanding on the familiar EMS-Emergency Medical Services. Community EMTs and Paramedics act as a bridge between healthcare providers and healthcare systems in optimizing patients within their home environments, with the goal of preventing readmission or emergent admission for chronic health conditions. In some settings, preventative care has become part of the scope of practice. Community EMTs/Paramedics operate in a non-emergency setting, under the direction of a physician, to provide treatment outside of a hospital. As part of the Affordable Care Act, the Hospitals Readmission Reduction Program was implemented, which requires CMS (Centers for Medicare/Medicaid Services) to reduce payments for any patient readmission within 30 days following certain diagnoses, including acute myocardial infarction, heart failure and pneumonia. This list was expanded to then include chronic obstructive pulmonary disease (COPD), and hip and knee replacements. In 2017, the list was again expanded to include patients following coronary artery bypass grafts. Penalties have been increased based on their readmission rates over time, as well as per patient, to further encourage hospital systems to evaluate discharge decision-making. In 2013, 64% of hospitals were penalized; by fiscal year 2015, the 78% of hospitals affected had been penalized $428 million in total penalties. $428 MILLION! Community EMTs and Paramedics have entered into cooperative arrangements with hospitals to follow these patients upon discharge, with the goal to prevent readmission. Many of the readmissions have been found to be due to socioeconomic factors that are often beyond the control and assessment of current hospital systems capacity for care. In performing a home visit, the Community Paramedic can provide real-time assessments, and provide important information back to the healthcare provider and system to prevent readmission. The Community EMT/Paramedic can perform a targeted physical exam, Professionals – May-June 2017
assess medication use and understanding, and answer questions. Many patients leave the hospital so bombarded with information, that even when written instructions are provided, the patient may still not understand the teaching, nor what they are expected to do after going home. The Community EMT/Paramedic can reinforce teaching, as well as clarify misunderstandings. They can perform medication reconciliation to prevent medication misuse, duplication, and errors of omission. Community EMS initiatives have been developed on the local level in many communities in the US, and now in Wisconsin, to address other issues in addition to preventing readmission. Other initiatives include working to reduce high 911 utilizers,
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or the “frequent flyers.” By reaching out proactively, Community EMTs/Paramedics can meet with these individuals to try to prevent the phone calls for emergency care such as the asthmatic patient who calls repeatedly for wheezing or a neb treatment, simply because she cannot access her PCP or get her inhalers refilled. The Community EMT/Paramedic can work one-on-one with that patient, in a non-emergency visit, to try to determine the reasons for lack of access to the PCP and medications. Maybe the patient is not on a bus route, or has mobility limitations that make accessing the bus impossible. Or the individual may have multiple small children to care for, preventing her from making and keeping appointments. Perhaps the medications prescribed are not covered medications
and she cannot afford her “control” medication, and as a result has to continually “rescue.” In rural communities, CEMS providers can perform posthospital wound checks to remove sutures or staples, check glucose levels or obtain blood or other samples, and review posthospital care. CEMS providers fill gaps not served by other care providers, including primary care providers and close hospital or health care facility access. In other states, Community EMTs/ Paramedics have helped with neighborhood flu immunizations clinics, have assisted with monitored tuberculosis treated regimens, have performed in-home wound assessments and care, and have done post-delivery check-ups. Community EMS providers
partner with hospitals, insurance companies, physicians, nurses and communities to reach patients in their homes. Care provided in this setting is well received, with a high level of patient satisfaction, at a lower cost, and is achieving measureable outcomes in reducing readmissions, decreasing inappropriate 911 use, decreasing EMS transports, and in achieving better patient outcomes. Community EMTs and Paramedics are directly impacting the â€œtriple aim.â€? A New Level of Knowledge As EMT and paramedics are trained and skilled in recognizing and responding to emergent and emergency situations, a change in educational preparation is required for
Professionals â€“ May-June 2017
CEMS providers often complete a physical exam including obtaining vitals, EKGs, blood testing and many other aspects typical of a medical visit with a healthcare provider.
Community Paramedics. This means providing paramedics with a new knowledge and skill set to equip them with an understanding of what it means to be a community health worker, as well as the knowledge about chronic disease management. Rather than seeing patients as “red lights and sirens,” the goal of the educational program is to provide knowledge of chronic diseases to allow the paramedic to recognize “yellow light” or borderline stable patients, with the goal of working with healthcare providers and the healthcare system to optimize these patients to “green light” stability and to prevent “red light” emergencies. The North Central EMS Institute developed an educational curriculum that provides information about health promotion, population health, community assessment, as well as health education, chronic disease management, mental health, prevention and wellness. The program, while well defined, also is designed to address specific needs and resources of individual communities. While not all communities have adopted or utilized this Core Curriculum in the preparation of their Community Paramedics, it is the foundation for the proposed Community Paramedic Certification exam,
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(http://communityparamedic.org/Portals/ CP/Documents/CP-C%20DCO%20 2016%20for%20public%20release. pdf?ver=2016-01-04-155408-583), and is proposed to become the standard for Community Paramedic Education nationally. It is the curriculum utilized by Hennepin Technical College (Minnesota), one of the nation’s first training programs, and is the curriculum utilized at the University of Wisconsin-Milwaukee, the first collegiate training program within Wisconsin. There are other training programs within Wisconsin, developed by hospital systems and communities to meet immediate needs. As the change from emergency care to health promotion and health prevention, initiatives and educational programs that partner Community EMS providers with nursing education and nursing providers builds on the collective strengths of both professions. The program at the University of Wisconsin-Milwaukee is offered through the College of Nursing. Community Paramedic Programs in Wisconsin The Community Paramedic concept in Wisconsin has been readily accepted with innovative models being implemented throughout the state. There has been media coverage of programs in Madison, Baraboo, Milwaukee, West Allis, Grand Chute, and Racine, among others. Community Paramedics in Madison are working at a Community Resource Center; in Grand Chute, they are implementing a fall prevention program in senior housing; Milwaukee Community Paramedics are directing their efforts towards high 911 utilizers. In West Allis, Community Paramedics are targeting high risk elderly patients following discharge from both an in-hospital stay as well as emergency department visits that do not result in admission. In addition, West Allis has protocols to identify at-risk patients following falls and other in-home accidents. Obstacles to Expansion The photos that accompany this article of the CEMS Role were taken during a ride-along with the West Allis Fire Department as they visited one of Perhaps the biggest obstacle to the expanthe patients currently enrolled in the CEMS sion of the Community Paramedic initiative program. is the current defined scope of practice in West Allis has a strong working relationWisconsin, which limits the current scope of ship with Aurora Healthcare that includes practice of EMTs and paramedics to emercontinuous communication and feedback in gency care. Through the efforts of bipartisan order to identify patients in need as well as legislators (with special thanks to Wisconsin coordinate care for patients who can get the State Representatives Amy Loudenbeck and most benefit from CEMS. The department Katrina Shankland, and State Senators Terry dedicates two paramedics to the program.
Moulton and Janet Bewley), and with the support and endorsement of groups representing emergency providers and their employers — Professional Ambulance Association of Wisconsin (PAAW), the Professional Fire Fighters of Wisconsin (PFFW), the Wisconsin EMS Association (WEMSA), the Wisconsin State Fire Chief ’s Association, the Milwaukee County Fire Chiefs’ Association, Wisconsin Office of Rural Health, City of Milwaukee, and the Milwaukee Fire Department — a new Professionals – May-June 2017
Interfacing and communicating with hospital staff on a regular basis is often a key component of successful CEMS programs.
Professionals â€“ May-June 2017
assembly bill (AB 151), in conjunction with previously-approved Assembly Bill 59 which addressed terminology, was introduced at a public hearing in the Madison Capitol, in the Assembly on Health, on March 22. Members of that committee then voted unanimously, on March 29th, to advance the bill to the full Assembly on April 4th. On that date, Assembly Bill 151 passed the Assembly floor, also unanimously. As the bill advances, more and more legislators have endorsed the bill as co-sponsors. It now advances to the Senate for a vote. It is expected that by the time this article is in press that the bill will have cleared the Senate, after which it is forwarded to the Governor for signature. The bill not only addresses scope of practice of EMT and paramedics, but in addition, provides the standards for the development of a Community Paramedic program, including requiring Wisconsin Department of Health Services (DHS) approval of educational programs preparing Community Paramedics, and creates training standards. Having a common definition, defined scope and training allows for a statewide understanding of the role of the Community Paramedic. Uniform standards are required for acceptance and growth. The bill will allow hospitals, private ambulance companies, and
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municipal EMS providers to develop new strategies for delivering quality care, in the right place, and at the right time. Benefits of Community EMS Programs
Many services have a dedicated staff member, or sometimes several dedicated personnel whose main function with the department is the CEMS program.
Given the endorsement of the Community Paramedic Initiative by so many, it is obvious that the Community Paramedic model makes sense. By targeting at-risk populations, employing Community Emergency Medical Services can improve patient outcomes, and as a result, reduce the costs of healthcare to individuals, hospitals, insurance providers and communities. Community EMT and Paramedics can help reduce hospital readmissions, reduce high 911 utilizers, and improve access to care in rural areas, where there are shortages of primary care providers and other healthcare facilities. Freeing emergency responders such that they are able to respond to true emergencies also benefits the health and safety of communities. Let’s go back to Evelyn Scott, our patient with heart failure. Community Paramedics met with her, weekly, for four months. They reviewed her medications, made sure that she had follow-up appointments, and explained
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Professionals – May-June 2017
Coordinating the aspects of a patient's care is a strong component of CEMS. For many patients, their first contact will be with their Community EMS provider.
the reason why she was being asked to weigh herself daily, to watch her salt intake and to check her ankles for swelling. More importantly, they listened to her. She did not like taking her water pill, as she kept waking up throughout the night to urinate. As a result, she stopped taking her diuretic. She liked salt. She relied on canned soups (very high in sodium). Her transportation was limited, and she could not get to her doctor appointments, which were always scheduled at 8 a.m., and she could not get moving that fast. The Community Paramedics listened, and asked the right questions to get that data. And then they acted. They explained she could take her water pill in the morning so that she would not be up all night urinating. She was asked to weigh herself and check her ankles, as increased weight and swollen ankles meant that her heart was working harder to deal with all of that extra fluid. They taught her about other spices that could make food taste good without salt, and showed her ways to make her own soups. They also called her doctor to get her appointment times moved to the afternoon. As a result, Evelyn has stayed out of the hospital. WIN for her, WIN for her provider, WIN for the hospital, WIN for the paramedics, and WIN for the insurance company.
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The same story played out with Tenesha. The paramedics arranged for her inhalers to be DELIVERED to her home so that she never runs out, they made sure that she had a functioning nebulizer, and they got her an appointment with a new PCP. They took the time to explain why asthma control was so much better than midnight asthma rescues. No more midnight calls for neb treatments! And as for Mrs. Samuelson, she really did not have any family locally. So the Community EMTs visited monthly. They checked her home for safety issues, replaced blown light bulbs, made sure that there was food in the fridge, and found a nearby community center that would pick her up weekly for activities. Win. WIN. WIN! The Future of CEMS in Wisconsin With the passage of Assembly Bill 151, and the changes in terminology already approved in AB 59, it is expected that CEMS will expand in the state. Paramedics from Milwaukee, Madison, Racine, Dousman, North Shore, South Shore, West Allis, Wauwatosa, Spring Valley, Grand Chute, Mount Pleasant, Greenfield, and Baraboo
have already completed training programs. Fire departments as well as private ambulance companies are seeking training and developing programs in their local communities. The University of Wisconsin-Milwaukee will be starting their fourth cohort of students in May 2017. Other states have addressed, and are addressing the issue in a similar fashion, and with each state success, other states follow. A certification exam has been developed. The Wisconsin Department of Health Services (DHS) will begin review and approval of Community EMS programs. But most importantly, CEMS will impact the health of citizens in Wisconsin, and as a result, will improve outcomes, reduce cost and improve patient satisfaction.
Kim Litwack PhD RN APNP, is the Interim Dean in the College of Nursing at the University of Wisconsin-Milwaukee and the Director of their Community Paramedic Education Program. Over the last two years, she has worked with 15 different Fire Departments and private ambulance companies in preparing Community Paramedics. For information on the next class, please contact her atÂ litwack@ uwm.edu.
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Wisconsin’s EMS Assessment Attributes of Success By John Eich And Penny Black Wisconsin Office of Rural Health
Professionals – May-June 2017
n the summer of 2016, a survey was emailed out to every EMS provider in the state. Titled “Attributes of a Successful Ambulance Service,” the survey listed 18 factors considered essential to long-term sustainability and high performance. The intent was to assess the overall capacity of Wisconsin’s EMS system so that resources could be used to strategically address identified needs. The survey addressed these topic areas:
Staff Support • A written call schedule • Continuing education • A written policy and procedure manual • Incident response and mental wellness Finance • A sustainable budget • A professional billing process Quality • Medical director involvement • A quality improvement/assurance process • Contemporary equipment and technology • The agency reports data Public Relations • A community-based and representative board • Agency attire • Public information, education, and relations (PIER) • Involvement in the community Human Resources • A recruitment and retention plan • Formal personnel standards • An identified EMS operations leader with a succession plan • A wellness program for agency staff Developed by the Wisconsin Office of Rural Health with a national group of veteran EMS providers, the survey was implemented in collaboration with the State EMS Office. Each of the 18 attributes are assessed on a 1-5 scale, with examples for each scale point. This ensures that all respondents verify their adoption levels the same and the results are more accurate. It also means that within the survey is a road map of steps to take to achieve the “5” or gold-star level of adoption of model practices. The survey can be obtained for free at any time, printed out for discussion within a service, and used for planning and goal-setting. An example is shown in Figure 1 on the right. The results of the assessment (located on the WI-ORH website) can also be used by state agencies and organizations to target funding 34
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to topics or areas of greatest need, as well as provide hard data to EMS advocates in their efforts to lobby for change. When WEMSA and other advocates speak with policy makers about obstacles before EMS, they can point to the results of the assessment. Responses At the time of the assessment, there were 416 ambulance services in Wisconsin. Of those services, representatives from 324 completed a survey, or 78% of the total. Response ratios were fairly evenly divided between urban, small urban, and rural services, between service license levels, and between regions of the state. Some regions are more sparsely populated, so there was a smaller number of responses, but we received a similar ratio of responses to total services. In order to classify services by “rurality”, we used a definition developed by our office. It divides municipalities into Urban, Small Urban, and Rural. “Small Urban” covers both small towns far from larger cities, or suburban communities on the fringes of cities. Large Urban is reserved for populations of 50,000 or more. See Figure 3 for the responding services and their rurality. For the regional analysis, DHS’s Healthcare Coalitions were used. See Figure 2 for the responding services and their rurality. Because we asked the respondents to identify their service and answer a few questions about it, we were also able to look at the results by career services vs volunteer and by license level. Out of the 324 services that responded, 29% were all volunteer, 9% were a mix of volunteer and paid, and 62% had no volunteers (Chart
1); 29% had Basic licenses, 32% had Advanced licenses, 2% had Intermediate licenses, and 37% had Paramedic licenses (Chart 2). The characteristics of the agencies that responded align very closely with the characteristics of all of the agencies in the state so we feel very confident in the results of the assessment.
Responses by Roster Type
Responses by License Type
Attribute: A Sustainable Budget 1. There is no written budget. 2. A budget has been developed; however, it is not followed. 3. A budget is in place and financial decisions and actions are based upon it. 4. A budget and policies are in place regarding proper purchasing procedures, purchase limits and authorizations, and procedures for procuring equipment either not in the budget or over the stated budget. An operating reserve of at least three months is in the bank. 5. A budget and polices are in place regarding proper purchasing procedures, purchase limits and authorizations, and procedures for procuring equipment either not in the budget or over the stated budget. An operating reserve of at least six months is in the bank and the reserve has been in place for at least one year. Figure 1 Example attribute
Healthcare Coalition Region Response Rates • • • • • • •
Northwest: 46 / 52 total = 88% North Central: 50 / 59 total = 85% Northeast: 27 / 35 total = 77% Fox Valley: 19 / 26 total = 73% Southeast: 84 / 110 total = 76% South Central: 77 / 104 total = 74% Southwest: 18 / 22 total = 82%
Figure 2 Rural is green, Small Urban yellow, and Large Urban orange.
In addition to comparing results (between career and volunteer, rural and urban, etc.), we identified fixed standards. For our office’s purposes, a score under 3 is considered struggling in that attribute. As we look at offering training and other resources for EMS, having a score helps us target attributes, areas, and services in greatest need. Results The full report, downloadable for free at www.worh.org/ambulance-service-assessment, shows not only statewide results, but slices the data by rurality, by volunteer/career, by license level, by roster size, by annual call volume, and by region. This large amount of robust data consequently allows anyone to find a set of benchmarks for many different types of and varieties of emergency medical services. What this will do is allow rural, volunteer services, operating at a Basic license level to compare to other services that are very similar to them, rather than have to compare against urban, paid, paramediclevel services that they may have very little in common with.
Senior EMS Education Specialist Join our team and be part of the talent that makes UW Health the best work and academic environments. The EMS Education Specialist Senior teaches all levels of hospital staff, medical faculty and staff, University students and employees, prehospital care providers, fire department employees, technical college students and members of the general public during conduct of their training and educational activities. Work Schedule: 40% FTE, 16 hours per week. Day/Evening, 8/10 hour shifts between 8:00am - 4:30pm with some weekend hours required. UW Health offers a competitive compensation and benefits package. Work experience that is relevant to the position will be taken into consideration when determining the starting base pay.
For more details and to apply visit UW Health on the web at: www.uwhealth.org/madison-health-care-jobs/main/11113 or the jobs board at www.WisconsinEMS.com
Professionals – May-June 2017
Billing 4.7 Billing Call schedule 4.1 Call schedule Policy manual 4.0 Policy manual Budget 3.5 Medical Director Equipment 3.4 Budget Attire 3.4 Attire Quality Improvement 3.4 Continuing education Continuing education 3.3 Quality Improvement Data 3.3 Equipment Medical Director 3.3 Data Leader 3.0 Personnel stand’s Personnel stand’s 3.0 Leader Board 2.9 Incident response Incident response 2.8 Board Recruit 2.3 Community Community 2.1 Recruit PIER 1.8 PIER Wellness 1.4 Wellness Figure 3 Rural, Small Urban, Urban Performance
4.7 4.0 3.9 3.9 3.8 3.8 3.8 3.7 3.6 3.5 3.3 3.1 3.1 2.9 2.6 2.5 2.4 1.7
Call schedule Billing Policy manual Medical Director Attire Equipment Budget Quality Improvement Personnel stand’s Continuing education Leader Data Incident response PIER Community Board Recruit Wellness
4.5 4.5 4.4 4.3 4.3 4.2 4.1 4.1 4.1 4.0 3.9 3.9 3.4 3.3 2.9 2.8 2.7 2.6
Overall, ambulance services in Wisconsin, regardless of rurality, license level, or any other characteristic, struggle with several attributes: • A community-based and representative board • A recruitment and retention plan • Involvement in the community • Public information, education, and relations (PIER) • A wellness program for staff Speaking in the most general terms, the types of services shown to be most in need were rural (versus urban or small urban), and volunteer (versus career). That was expected. However, something surprising was that the highest-scoring attribute was “A professional billing process.” Not only that, but rural and small urban services scored higher than urban services on that front. In Figure 3 above, we have broken out the average attribute scores by rurality. Attributes in green are those considered as ‘doing well’ by their scores. Orange shows attributes in the ‘struggling’ range, with a few on the bubble in yellow. While you can see that the number of ‘struggling’ attributes grows as services become more rural, there is a consistency across the board in attributes at the top and bottom. This allows interventions addressing lower-scoring attributes to be useful to all services, regardless of rurality. 36
Professionals – May-June 2017
Additional Feedback from Respondents At the end of the survey, respondents were given an open-ended statement to respond to: “Feel free to share anything else you would like us to know about the attributes of a successful EMS agency. A lot of suggestions were made, with some clear overlap. Many believed there were additional factors influencing success. Crew dynamics, the relationship between crew members, and the personality characteristics of crew members were frequently suggested. The service’s culture, their ability to keep up with change, and effective communication (both internally and with external agencies) were called out. Whether a service had fulltime, paid staff and Emergency Medical Responders were both listed as important. Other suggestions were made that related to the existing attributes: whether the “Community-Based and Representative Board” fully understands EMS; if the service’s “Involvement in the Community” was matched with community support in return; and finally, if the “Identified EMS Operations Leader with a Succession Plan” displayed strong, effective leadership. Next Steps Both the State’s EMS Section and the Office of Rural Health are committed to incorporating the results of the assessment into their strategic plans. At the Office of Rural Health, our annual funding to support rural EMS can now be targeted to services that are most in need of support and designed to address the topic areas identified as ‘struggling’. This data will also help us justify our funding requests from federal grants for the EMS programming. EMS advocates can point to the weaknesses in the system, as determined by the assessment, and justify their policy change requests with real data. Individual services can download the survey and the report, and benchmark their scores against comparable groups. The examples within the attributes provide a road map of steps toward the gold standard in each. Furthermore, our office hired the National Paramedic Foundation to write an accompanying workbook, or toolkit, that describes how to move from a 1 to a 5 in every attribute. This is available for free, and downloadable from the same page as the assessment: http://worh. org/attributes-successful-rural-ambulanceservice.
Dedicated for life. Thank you
to all of our EMS providers for your commitment and dedication to our patients’ health and well being.
Eau Claire, WI sacredhearteauclaire.org
Professionals – May-June 2017
Nationally, our office is working to get other states on board, so that we can compare our system’s results against those across the nation. So far, North Dakota, Nebraska, Kansas, Michigan, South Carolina, and Ohio have used or begun the process of using this assessment. Other states have shown interest as well, and the assessment was highlighted at last year’s National Rural EMS Conference and is on the agenda for this year. Along with the State EMS Section, we intend to roll this survey out again next summer, in 2018. Our goal is to receive a response from 100% of the ambulance services in the state. When it emerges next year, please help us promote it to your peers and colleagues, so we can get a true census of EMS agencies in Wisconsin. If you have any questions or suggestions, feel free to reach out via email or phone.
John Eich is the Director, and Penny Black is the Epidemiologist, for the Wisconsin Office of Rural Health. John can be reached at 608261-1890, and Penny can be reached at 608-261-1887, or through the Office of Rural Health website at www.worh.org.
Figure 4 Healthcare Regions of Wisconsin
MUNICIPAL FIRE/EMS ASSIGNMENT ELKHORN AREA FIRE DEPARTMENT
Paratech Ambulance Service is currently seeking AEMT/Firefighters to support an exciting new Fire/EMS Staffing contract with the Elkhorn Area Fire Department. We are seeking goal oriented, motivated persons with a strong desire to serve to fill these immediately available positions. The Elkhorn Area Fire Department located in Walworth County, Southeastern Wisconsin, is a progressive department that has the largest response area for a municipal fire department in Walworth County. The department responds to approximately 1,400 EMS calls and 400 Fire calls annually. The department relies on Paid on Premise (POP) and Paid on Call (POC) staffing for call response. We currently have 24-hour POP staffing. The department is also responsible for providing Fire and EMS Service to multiple scheduled events in their response area. The primary duties of the POP staff will be to provide emergency Fire and EMS response and services. This position will also perform other duties as determined by the Fire Chief. Full-time and Part-time Positions Available • Full time POP staff will be assigned to a 40-hour workweek, 8-hour day/night shifts withthose hours primarily occurring Monday—Friday, overtime is possible. • Part-time POP staff will be assigned to a 16-hour workweek, 8-hour day/night shifts withthose hours primarily occurring on Saturday and Sunday • Wage: $14.69 per hour (is dependent on applicant licenses/certifications) • Successful applicants will be afforded the opportunity to join the department as a POCmember, if interested. Required Licenses and Certifications: • The qualified candidate will be Wisconsin licensed as an AEMT or higher AND certified as a Firefighter 1 (Will consider EMT-Basic/Firefighter 1 with experience. Additional Fire certifications are desirable.) • The qualified candidate must possess a valid State of Wisconsin driver’s license with a clean record. How To Apply Call 414.365.8900 or visit our website at www.paratechambulance.com Specific department questions can be directed to Fire Chief Rod Smith at (262) 723-2277 or EMS Division Chief David J. Fladten at (262) 723-5080
Professionals – May-June 2017
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Past Assessment Efforts EMS Assessment: Time Critical Diagnoses In November 2015, the Office of Rural Health conducted an initial EMS assessment, this one focusing on policies and procedures related to time-critical diagnoses (TCD) – STEMI, stroke, trauma, and cardiac arrest. The purpose of the assessment was, as with the Attributes assessment, to identify needs so that resources could be strategically directed. Representatives from 296 ambulance services completed a survey, providing valuable information and insight. For each TCD, agencies were asked a series of questions regarding: • Protocols • Protocols review • Training • Quality assurance policies • Working with receiving hospitals on quality assurance.
Professionals – May-June 2017
In addition, agencies were asked about 12-lead ECG transmission, advanced life support, patient transport or destination determination policies, and telemedicine capacity. A copy of the survey is available from the Office of Rural Health; a report of the results of the survey is forthcoming. Highlighted Findings • Over 75% of responding agencies reported having STEMI, stroke, and trauma protocols based on state or national standards. • 75% have 12-lead ECG and ECG-transmitting capability. • For those who do not have these, the top two reasons cited were cost of equipment and lack of cell service (especially in rural, remote areas) • 13% reported having used telemedicine to treat patients
• Average scores were higher, in general, for protocol review and training and lower for quality assurance. • On average, rural agencies scored higher than or equal to small urban and urban agencies in all TCD areas. • On average, agencies with Basic licenses scored lower than agencies with Advanced, Intermediate, and Paramedic licenses in all TCD areas. The results of the assessment are currently being used to target customized assistance to agencies that scored lowest. In the coming months, the Office of Rural Health will identify additional areas of need that we hope can be addressed on a larger scale.
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Professionals – May-June 2017
Are you able to find your If you can't find your organization listed here, they are not one of more than 360 Wisconsin EMS Association Service and Corporate members. Call us at 800-793-6820 or visit www. WisconsinEMS.com to find out how your organization can join the others on this page as a Service or Corporate member.
Adell First Responders Albany Area EMS Algoma Fire & Rescue Algoma First Responders Town Of Allenton Vol FD Inc Amery Area EMS Andres Medical Billing Antigo Fire Dept City Of Antioch Fire Department Arcadia Ambulance Serv Arena Emergency Medical Services Argyle EMS Arlington EMS Ashippun Fire & EMS Ashland Fire Dept Ashwaubenon Public Safety Aspirus MedEvac Athens Area Ambulance Service Aurora South Market Baileys Harbor Fire and Rescue Baldwin Area EMS Baraboo District EMS Barneveld Area Rescue Squad Batavia Vol Fire Dept & First Responders Bayfield Community Ambulance Beaver Dam EMS Belgium Fire Department, Inc. Bell Ambulance Inc. Belmont Ambulance Service Beloit Fire Dept City Of Beloit Fire Dept Town Of Bennington Rescue Squad Berlin Emergency Medical Svc Big Bend Fire Department Birchwood Ambulance Service Black River Falls EMS Blanchardville Fire Dept Bloomer Area First Responders Bloomer Comm Amb Service Bloomfield Genoa City Fire & Rescue Blue River Volunteer Rescue Squad Boscobel Rescue Squad Inc Boulder Junction Fire Dept Boyceville Comm Amb District Boyd Edson Delmar FD Amb Brazeau Ambulance Town Of Brodhead Area EMS Inc Brookfield Fire Dept City Of Brussels-Union EMRs Burlington Rescue Squad Inc Burnett First Responders Butternut EMS Cadott Community Amb Cambria Community Amb Svc Professionals â€“ May-June 2017
Camp Douglas Rescue Inc Campbellsport Fire Dept Cascade First Responders Cassville Rescue Squad Cazenovia Area Ambulance Cedar Grove First Responders Cedarburg Fire / Rescue Central Fire & EMS District Central Price Co Amb Svc Chetek Ambulance Service Chippewa Falls Fire & Emer Svc Chippewa Fire District Chippewa Valley Technical College City of Lake Mills Fire Dept City of New Berlin Fire Department Clayton Fire Rescue Clear Lake EMS Cleveland First Responders Clinton Fire Prot Dist-EMS Clintonville Area Amb Svc Clyman First Responders Coleman Area Res Sq Inc Community Ambulance Service Conover Ambulance Service Cornell Area Ambulance County Rescue Services, Inc. Crandon Area Res Sq Inc Crescent First Responders Crivitz Rescue Squad Inc Cuba City Area Rescue Sq Cudahy Fire Department Curtis Universal Ambulance, Inc Dallas Area Amb Service Dane County District One EMS Darien Emergency Medical Svcs De Pere Fire Rescue Deer-Grove EMS District Delavan Rescue Squad Town Of Dells Delton EMS Commission Dickeyville Rescue Squad Dodgeville Area Ambulance Svc Dollar Bay Medical First Responder Door County Emergency Services Dousman Fire District Durand Municipal Amb Svc Eagle Fire Department Eagle III East Troy Fire/Rescue Eden First Responders Edgerton Fire Protection District Elkhart Lake First Responders Elkhorn Area Fire Department Ellsworth Area Amb Svc Elm Grove EMS Village of
Elmwood Area Amb Service Elroy Area Ambulance Erickson Ambulance Service Evansville EMS Everest Emergency Vehicles, Inc. Farmington Emergency Medical Team, Inc. Fennimore Rescue Squad/Rural Fire Dept. Fitch-Rona EMS District Flambeau Hospital Amb Svc Flight For Life Florence Rescue Squad Fond Du Lac Fire Dept City Of Footville Community Fire/ EMS District Foster Coach Sales Fox Lake Fire Department Franklin Fire Department Fredonia Fire Dept - Ambulance Fremont Wolf River EMS Ltd Galesville-Ettrick First Responders Gardner First Responders Germantown Fire Department Gillett Area Ambulance Serv Glen Haven First Responders Goodman Armstrong Rescue Squad Gordon-Wascott EMS Grafton Fire Department Granton Area First Responders Green Bay Metro Fire Dept Green Co EMS Inc Green Lake Brooklyn First Responders Greendale Fire Department Greenville First Responders Greenwood Area Ambulance Service Gundersen MedLink Air Gundersen Tri-State Ambulance Inc. Hales Corners Fire Dept Harrison First Responders Hartford Fire & Rescue Hartland Fire Dept Rescue Hatley Area Ambulance Service Highland EMS Hilbert Potter EMR's Hiles Fire Department - Station B Hillpoint First Responders Hillsboro Area Amb Svc Horicon EMS Hortonville Area EMS Howards Grove First Responders Hustisford First Responders Iola Ambulance Service Iron Ridge First Responders Iron River Ambulance Ixonia EMS Town Of Jackson Fire Department
organization on this list? Janesville Fire Dept Amb Svc Jefferson EMS Juneau EMS Kenosha Fire Department Kewaskum Fire Dept Kewaunee Area Amb Svc Kickapoo Valley Rescue Squad Kohler Company Rescue Squad La Farge Area Ambulance Service Lake Country Fire & Rescue Lake Geneva Fire Dept, EMS Div Lake Mills EMS Lakeview EMS Lakeview Medical Center Amb Lamartine Fire Dept First Responders Lancaster EMS Inc Land O Lakes Amb Svc Langlade Fire Dept Town Of Lauderdale-LaGrange Fire Dept Lebanon EMS Life Link III LifeQuest Billing Services Lifestar Emergency Medical Services Ljh Ambulance Inc Lodi Area EMS Loganville Area First Responders Lone Rock Rescue Unit Long Lake-Tipler Rescue Squad Loyal Ambulance Svc Luxemburg Rescue Squad Madeline Island Ambulance Svc Madison College Madison Fire Dept Town Of Manawa Rural Ambulance Maple Bluff Fire/Rescue Marquette Co EMS Mason Area Ambulance Svc Mauston Area Amb Assoc Inc Mayville EMS McFarland Fire & Rescue Dept Mellen Fire and Rescue Melrose First Responders Menominee Tribal Rescue Svc Menomonee Falls Fire Dept Menomonie Fire Dept Mequon Fire Department Merrimac Fire & Rescue Inc Merton Community Fire Department, Inc. Metro Medical Services Inc Middleton EMS, City Of Milwaukee Co EMS Mineral Point Rescue Squad Minong Area Amb Service Mishicot Area Amb Service Mondovi Ambulance Service Monona Fire Dept Montfort Rescue Squad, Inc. Monticello Fire Department Mountain Ambulance Service Mt Calvary Amb Svc Inc Mt Horeb Fire & EMS Mukwonago Fire Dept Muscoda EMS Nekimi First Responders New Glarus Area EMS New Holstein First Responders New Richmond Area Ambulance Service
Newburg Fire Department Newton First Responders North Crawford Rescue Squad Inc North Fond du Lac Fire & EMS North Land Municipal Amb Inc North Memorial Ambulance Svc North Park Fire Prot District North Prairie Fire Dept North Shore Fire Dept Northcentral Technical College Northern Door First Responders Northwest First Responders Oak Creek Fire Dept Oakdale Area First Responders Oakland Vol Fire Dept Oconomowoc Fire Dept Oconto Ambulance Service Oconto Falls Area Ambulance Svc. Ocooch Mountain Rescue Inc Omro Rushford Vol Fire Dept Ontario Fire & Rescue Amb Oostburg Ambulance Orfordville Fire Protection District Osceola Area Amb Service Oshkosh EMS Town of Osseo Fire and First Response Owen-Withee Com Amb Svc Inc Pardeeville District EMS Paris Rescue/Fire Town Of Pembine Dunbar Beecher Rescue Sq Pewaukee Fire Dept Pickerel Vol Fire & Rescue Sq Pittsville Fire Department, Inc. Plain Fire Dist Amb Svc Pleasant Prairie Fire & Rescue Plover Fire/EMS Department Plum Lake Ambulance Plymouth Fire Dept Ambulance Portage County Ambulance Potosi Rescue Squad Poynette Dekorra EMS Prentice Ambulance Service Presque Isle Vol FD Princeton Ambulance Service Racine Fire Dept Randall Fire Department Town Of Randolph Amb Assoc Random Lake Fire Dept Readstown EMS Reedsburg Area Ambulance Service Reedsville First Responders Regions Hospital EMS Richfield Vol Fire Co Rio EMS Ripon Guardian Amb Svc/Ripon EMS River Falls EMS Riverside Fire District Rochester Vol Fire Department Rosholt Area First Responders Rural Medical Amb Service Rusk Co Ambulance Svc Sacred Heart Hospital-Eau Claire Salem Fire/Rescue Town Of Saratoga EMS Town Of Sauk Prairie Amb Assn Saukville Ambulance Saxeville-Springwater Fire Engine Co
Scenic Valley EMS Scout Leaders Rescue Squad Sevastopol First Responders Seymour Rescue Sharon EMS, Township of Shawano Ambulance Service Sheboygan First Responders Town Of Sherman First Responders Town Of Shullsburg Ambulance Service Silver Cliff Rescue Squad, Inc. Silver Lake Rescue Squad Inc Somerset Fire & Rescue South Milwaukee Fire Dept South Shore Area Amb South Shore Fire Department Southern Green Lake Co Amb Svc Southwest Health EMS Spring Green Fire Prot Dist Spring Valley Area Ambulance St Croix EMS St Lawrence Fire Company Stone Bank Vol Fire Dept Stoughton Area EMS Taylor County Ambulance Service Tess Corners Vol Fire Dept Theresa Ambulance Svc Thiensville Fire Department Tigerton Area Ambulance Service Tomah Area Amb Svc Town of Fond Du Lac EMR Town Of Raymond Fire & Rescue Trempealeau Fire Dept. First Responders Troutland Rescue Squad Inc Twin Bridge Rescue Squad Twin Lakes Vol FD & Rescue Squad Union Grove-Yorkville Fire Dept United Emergency Medical Response Utica First Responders Utica Vol. Fire Dept. Varna Fire Prot District Amb Vernon Fire Department Wales-Genesee Fire Department Walworth Rescue Squad Washburn Area Amb Svc Waterloo Fire Dept Waubeka Fire Dept Waukesha Fire Dept Town Of Waumandee First Responders Waunakee Area EMS Wausau Fire Dept Wausaukee Rescue Sq Inc Waushara County EMS Wauwatosa Fire Dept Webb Lake Area First Responders West Grant Rescue Squad Inc Western Buffalo Co Amb Svc (Alma) Whitewater Fire Dept Inc. Williams Bay Rescue Squad Wilson First Responders Town Of Wilton Ambulance Village Of Winchester Volunteer Amb Town of Wind Lake Vol Fire Co Inc Winneconne Poygan First Responders Wisconsin EMS Association Wisconsin Rapids Fire Dept Wittenberg Area Ambulance Woodboro First Responders Worzalla Publishing First Responders Professionals â€“ May-June 2017
Professionals â€“ May-June 2017
Seven features that point to specific pathologies By Ben Feinzimer and Ben Kessel
Professionals â€“ May-June 2017
or those of you who teach, whether their teenager has been feeling poorly for to an audience of first graders or three days; sleeping a lot, vomiting, and now doctoral students, you understand behaving strangely. As you probe a bit deeper, the apprehension. There’s a subtle the patient’s mom makes a subtle suggestion but persistent angst, at least for instructors that her son had some trouble with her prepassionate about their craft. It’s a low-level, scription pills last year. She hopes he hasn’t nagging voice, a little guy (or girl) who sits “slipped.” Dad adds that there’s been a “flu atop your shoulder watching as you create a bug” going around the house. And the diaglecture, develop training, or write an article. nostic dance begins. “Is this interesting enough? Will that part Your exam is remarkable for a thinly built hold their attention? Would even I be bored male. He is globally weak, answering your listening to those points?” questions with his eyes closed, and intermitNo, this piece is not a guide to better teach- tently confused. He also has noticeably dry ing. It is, however, a description of attention mucous membranes. The physical exam congrabbers. As an instructor, the effort is to tinues and includes moderate tachycardia, capture a moment, to stimulate the audience, borderline blood pressure, normal oxygen and to draw focus. When delivering your saturation and temperature, but a respiratory radio report, consider yourself in that posi- rate in the upper thirties. Your partner registion. Your job is to create an all-stop. The ters a blood sugar of 485. radio nurse, physician, or whomever, should I’m sure by now you have a diagnosis… redirect their energy to you and to your diabetic ketoacidosis. DKA, when recogpatient. OK; sounds great, but how? nized early, is certainly treatable and when Here’s how. Compile a library. Not a library managed efficiently, leaves no sequelae. If in the literal sense, but more of a figurative recognition is delayed or, more dangerously, list; a series of signs and symptoms that missed, however, prolonged hospitalization, quickly paint a picture of specific illnesses, comorbidities, and even death are possible. unique diseases, and impending decompenHyperglycemia, easy; no explanation needed. sation. Volumes of books, pages of research Rapid breathing, a bit more subtle, or at least summaries, and months in the classroom are more involved from a pathophysiological all important to establish baseline knowledge standpoint. Tachypnea, in this case, is the and to set up a similar language, but they compensatory mechanism engaged to blow are minimally helpful when compared to off excess acid. Add altered mental status, low experience and clinical instinct. So let’s use carbon dioxide, abdominal pain, and vomitsome real-world judgment and actual cases, ing and we have a slam dunk diagnosis. and create that list of symptom alarms; the Bottom line: hyperglycemia + tachypnea few items that rapidly capture the essence, should raise a high suspicion for DKA. and danger, of your sickest patients. Some are in groups, others individual, but in each scenario it takes fewer than 20 seconds to describe what might amount to life-altering assessment and management.
and a previous heart attack. He takes Plavix, prescribed by the cardiologist who has placed stents in three different vessels on two separate occasions. You look at your uncle and immediately notice his lips seem pale, and in the proper light his face has lost some color, too. He denies it, of course. He also downplays his dyspnea but Aunt Maggie describes an exertional capacity that has gone from two blocks to 10 steps. She is worried that he has had another heart attack but admits he’s too stubborn to see the doctor. Being a thorough medical professional, you venture into the uncomfortable realm of poop descriptors. Your uncle initially rejects your attempt as borderline inappropriate, but ultimately acknowledges several days of black stool. What’s the diagnosis? Yep, GI bleeding. Not such a big deal, right? Typically it’s not…until it is. In other words, your uncle can handle some bleeding. His hemoglobin dropping a couple of grams is reasonably well tolerated. Once he reaches a threshold, though, his organs might take a hit. Depriving the heart, kidneys, and brain of oxygen for long enough could result in shortand long-term damage. You get the point. The pale skin — right, lost blood, of course. The dyspnea is a result of insufficient oxygen-carrying capacity; a decreased number of red blood cells escaping circulation and ending up in the toilet. Bottom line: dyspnea + pallor + blood thinner use should make GI bleeding number one on your differential. Let’s speed things up a bit.
2. Dyspnea + Pallor + Blood Thinners Aunt Maggie tells you that your Uncle Bert hasn’t been feeling well for about a week. You are the family expert in all things medi1. Hyperglycemia + Tachypnea cal and have been not so subtly tasked with an evaluation. You know your uncle is not the healthiest of fellas. He has high blood You’re called for a 17-year-old male “ill.” pressure, high cholesterol, a roundish belly, Family is of limited help. They explain that 46
Professionals – May-June 2017
3. Headache + Vomiting + Altered Mental Status Especially if the headache is abrupt and the decreased level of arousal is precipitous, intracranial hemorrhage should be at
Professionals â€“ May-June 2017
Professionals â€“ May-June 2017
Here’s a question for you: “What body the top of your problem list. Remember though, we are not discussing cognition structure connects everything together?” here. Specifically the “alteration” here is The answer: aorta. If this guy’s aorta is a measure of arousal level or wakefulness. tearing, symptoms will reflect the locaA 57-year-old fully awake but unable to tion of the tear and associated vessels that understand your questions or only inter- are now compromised. So if his dissection mittently able to reproduce his birthday, begins in the arch he would certainly have the president, or season would more likely chest pain. If it travels all the way down be suffering an ischemic stroke. These defi- into the left iliac artery, his leg would now cits are in orientation, not alertness. The be affected. Kind of cool, right? I know, head bleed patient, on the other hand, I know, not for the patient, but for your becomes sleepy as the pressure in the brain brain it’s certainly worth the training and builds. He has trouble maintaining normal classwork. The following few cases have been hanalertness. That pressure is also the reason dled either by me or by my partners. A for his vomiting. Bottom line: headache + vomiting + 54-year-old female with a STEMI, ready decreased level of arousal is quite suspi- to go to cath lab. The astute nurse took seriously the lady’s subtle report that her cious for head bleed. legs felt heavy. The nurse pulled the sheets The next two scenarios point to the same back and shockingly noticed pallor. Both pathology; the most dangerous pathology legs had become ischemic. Her dissection we encounter. It is so time sensitive, in went from “stem to stern,” and this poor fact, that your recognition will undoubt- woman had torn all the way into both femoral arteries. How about simultaneous, edly alter patient outcome. severe interscapular pain and abdominal pain? This scenario would be a proximal dissection that includes the branch vessels supplying the intestines. Or what about a chest pain-er who also says he’s paralyzed from the waist down? What?! Yep, dissection that knocks off the artery supplying the lower spinal cord. Thankfully, situations like the ones portrayed here are rare. But you took this job to figure out the tough ones, the dangerous cases, and for the people you can bring back from the brink, today, now. You work not for the 90% mundane, but for the 10% excitement! 4. Above + Below the Diaphragm Bottom line: abrupt symptoms above and below the diaphragm should worry We’re dealing primarily with medi- you and aortic dissection must be atop cal patients here. Trauma can of course the differential list. result in symptoms both above and below the diaphragm, that’s not what we’re discussing. You’re called for a 51-year-old male with chest pain. Upon arrival you immediately recognize, “This guy’s sick!” He is in obvious pain, he’s pale, he’s sweating, and he’s got that look. Your history reveals fairly abrupt onset retrosternal chest pain. The EKG shows some abnormalities, maybe some ST elevation; you’re not entirely sure. Then you notice the patient isn’t really helping himself to the cot. He claims his left leg is heavy. Initially you dismiss that complaint, incredulous that this guy can 5. Unrelated Body Systems have both a heart attack and leg problem at the same time. Professionals – May-June 2017
Your STEMI patient now displaying signs of a stroke could be telling you something. Your interfacility transport of a heart attack patient who has new kidney failure, neglected by the transferring team, or the chest pain patient with severe face pain. These are all patients who might be suffering an aortic dissection. Once again, the aorta links all body systems. So the heart attack might not just be a heart attack. If the dissection includes a coronary artery (branching off the aorta as it exits the left ventricle) you might see a STEMI. If that same dissection then goes up to a carotid artery which then splits off to the face you might have ischemic facial pain. As already described above, you may also see stroke symptoms if the dissection goes up further into the brain. Or maybe the dissection goes downward into the renal arteries. Anyway, the point is, if you’re baffled, and wondering why your patient is displaying symptoms that don’t seem to go together, blowing it off might be dangerous. Bottom line: symptoms in two seemingly unrelated body systems might be a sign of aortic dissection.
Pediatric deaths are the most difficult to handle. Thankfully, some providers can go an entire career without experiencing a dying or dead young person. For those less fortunate, much of our training efforts go toward recognition, intervention, and prevention of pediatric decompensation. For the sake of simplicity, understand that true syncope during exertion may signify a congenital cardiac problem. Whether it’s an anomalous coronary artery, a sodium-channel abnormality, or some other electrical or structural variant, these patients need a workup. 6. Exertional Syncope Now, we recognize that they may look well in a Young Person in front of you. That does not free you from the responsibility of a careful exam, though. What would you do if you were called to In particular, the 12-lead will serve as a a school or a gym for syncope? If it was for critical component in your patient’s course. a juvenile, you might have slightly more There is reliable data proving that ED phyanxiety than for an adult. On both runs, sicians actually change their management though, I would venture to guess that based on the field EKG. Even when the hosyour level of concern would not be par- pital 12-lead is unremarkable, if there are ticularly high. Syncope calls are frequent, concerning findings on the prehospital tracrarely significant, and let’s face it, kind of ing, the child’s workup might be adjusted. boring. There are certain scenarios, howBottom line: exertional syncope in a child ever, wherein syncope can be a harbinger warrants thoughtful intervention, most of true badness. importantly, a high-quality EKG.
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Professionals â€“ May-June 2017
concerned as the commercialized complaints. Unusual fatigue, new dyspnea, nausea and vomiting without an obvious GI source, or even unexplained anxiety can all signify unstable angina or even heart attack. How about epigastric discomfort? Sure. What about unusual jaw or teeth pain? Yep, especially if it’s exertional. Or, have you ever heard someone describe that feeling of impending doom? Usually that complaint comes with some sort of obvious chest-related symptom. We’ve seen it on its own, believe it or not. Finally, the sign most specific for ACS… 7. Atypical Cardiac Symptoms sweating. We acknowledge that the above signs and symptoms can accompany patholoThe topic of cardiac symptoms that gies other than coronary artery occlusion. don't present as many of us would expect We simply want to impress upon this them to has been thoroughly covered by audience the importance in recognizing many. Despite that coverage, there conthe atypical ones. tinues to be a pattern of dismissal and Bottom line: investigate atypical angimissed diagnoses. In the elderly, female, nal equivalents in certain populations and diabetic population we need to with as much vigor as your more typical retrain ourselves. Chest pressure, squeezchest pain patients. ing, heaviness, or just plain ole pain are not necessary for the diagnosis of acute coronary syndrome. There exist angiOf course, this medium is not appronal equivalents that should make us as priate for an exhaustive review of patient
presentations. It is, however, a great opportunity to touch upon a few; the few that might help save a life. It doesn’t require months of advanced training, a tackle box full of high-powered drugs, or on-line medical direction. It requires intuition, a certain amount of instinct, and a daily reminder to avoid complacency. The list above is straightforward, and if you have a patient that fits into one of these boxes, your presentation should reflect your suspicion. Diagnostic momentum is a critical piece to patient care. When harnessed appropriately you can alter the outcome. Take that responsibility seriously and respect it, and you will always act in the patient’s best interest.
Ben Feinzimer, DO, MS, began his EMS career as a firefighter/EMT. He is currently the EMS/ TEMS medical director for Kenosha County EMS. Ben Kessel, NREMT-P, has spent 16 years in EMS, continuing his professional education as a physician assistant. He is the assistant medical director for Kenosha County EMS.
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Challenges On The Scene Frederick Hornby, EMT-Critical Care Paramedic
It's Not Always a Duck! “If it looks like a duck, and quacks like a duck, we have at least to consider the possibility that we have a small aquatic bird of the family Anatidae on our hands.” – Douglas Adams Many of us have heard the above saying. Maybe not quite like it is written, but you definitely have heard that if all of your senses tell you something, then going down that path will most likely prove that you correct. In the case above, all signs point to the bird in question being a “small aquatic bird of the family Anatidae” or, quite simply, a duck. I have been told by every EMS instructor at every level that a female of child-bearing age with abdominal pain should be assumed to be having an ectopic pregnancy until proven otherwise. I think that in EMS instructor school, there were a minimum number of times that you must have been required to share that information before you get your OK to teach on your own. That sets us up for this time's "Challenges on the Scene." As you sit down for lunch, as it always happens, you hear the familiar voice of your dispatcher over the loudspeaker following your tones. “Ambulance-3, Ambulance-3, respond to the single-family dwelling at 1313 Mockingbird Drive. You have a 24-year-old female patient that keeps on passing out. Time out 1200.” Wonderful, you think, another missed lunch, as you scurry to put on your coat and make your way to your ambulance. While you are responding, many things enter your mind. Could it be cardiac? Could 56
Professionals – May-June 2017
it be OB/GYN? Could it be GI/GU? How long is it going to be until you can get back for your lunch? Among others things. After a short, five-minute response time, you arrive at the house to which you were dispatched. You do your scene size-up and see that this is a well-kept house with no obvious dangers to the safety of you or your partner. You grab your trauma bag, your radio, and the computer tablet, and make your way to the door. When you knock at the door, you are met by a man who seems to be in his early thirties. You introduce yourself and your partner and you can see behind him that the house is kept up well. When asked, the man states that he does not have any animals that would put you in harm’s way. He also tells you that your patient, his wife, is in the back bedroom. Upon your arrival in the bedroom, you introduce yourselves to the patient. She is awake, acknowledges your presence and asks that you call her Lynn. She is currently lying in a left lateral recumbent position with a pillow between her legs, and her knees are somewhat flexed. You observe that Lynn’s airway is open and clear of any obstruction, she is able to speak in full sentences without any dyspnea or retractions noted, and her skin has good color and even appears to be a bit tanned. No diaphoresis noted. You ask Lynn what seems to be going on today. She states that for the past two or three days, she has felt “crummy.” You dive a bit further into your assessment as your partner prepares to take a set of vital signs for you. The patient, Lynn, says that she has had an ache in her
belly that was not bad until today. She tells you that she has also had nausea, vomiting and diarrhea today that were not there yesterday. She tells you that it is probably the same flu that everyone else in her office has. You tell her that that may be the case, but you would like to get some more information before you get going to the hospital. Your partner tells you that the patient’s blood pressure is 98/76, her pulse is 80 and regular, and her respirations are 16. You obtain a blood glucose that reads 88 and her pulse oximetry on room air is at 99%. You ask Lynn what her normal blood pressure is and she said that it is normal to low. She says that she works out regularly and that she just participated in a 10K run three days ago. You ask her if the pain in her abdomen started right after the run and she reports that it was shortly thereafter. You continue your interview and find out that the patient has no medical history other than a tubal ligation about a year ago. She says that she has no allergies except one to penicillin. While you are doing your hands-on assessment, you ask Lynn when her last menstrual period was. She reports that it started for her yesterday. She reports that this cramping is not like her normal period and that this is much worse. Her menstrual period seems heavier than usual, soaking three pads since she woke up this morning. She also tells you that when she tried to get up to go to the bathroom, she felt like she was going to pass out. Additionally, she tells you that she has never felt like this before and she is a bit scared. You calmly reassure her that the
hospital will get to the bottom of whatever the space equal to a little more than 1/4L of is going on, and you ask if you can see her blood. But how much does she need? Should abdomen. the IV fluid boluses keep on being infused Lynn allows you to assess her and as she or should you wait? You decide to re-asses turns from her side to obtain better access your patient and find that her blood pressure to her abdomen, she suddenly complains of is not 84/48 which increases the MAP to right shoulder pain that goes away quickly. 60mmHg which is significantly better than You assess her shoulder and note nothing the previous 50mmHg, but does she need out of the ordinary. This situation has you more fluid? actively wondering what is going on. Lynn’s The rule of thumb is that permissive hypoabdomen is slightly distended with some tension is not a bad thing. Just how much guarding and pain upon palpation. No has not accurately been identified, but most rebound tenderness is noted and no obvious physicians will agree that the number sits signs of any trauma, which Lynn confirms. somewhere between 80 and 90 systolic. If You are only 15 minutes from the local Level you raise the blood pressure too much, you IV Trauma Center and 30 minutes from the will increase the pressure on the barorecepLevel I Trauma Center. What do you do? tors in the aortic arch and fool the body into As you move Lynn over to your stretcher, thinking that it is no longer in shock. The she suddenly complains of the right shoul- vasoconstriction and tachycardia will stop, der pain again, and becomes notably pale and then guess what happens? Yep, worsenand diaphoretic. She tells you that she is ing shock! With that in mind, you decide to going to vomit and then, true to her word, hold off on the fluids. Your patient is still vomits approximately 75cc of clear stom- alert and orientated X 4 and the skin is someach contents. You call for an intercept and what diaphoretic. She is not short of breath make your way to the local trauma center 30 and her pulse oximetry is now at 98% with minutes away since you know that Lynn will the oxygen you are infusing. You have defineed surgical interventions that are not avail- nitely made a difference in this person’s life able 24/7 at the local hospital. While you today. are transporting, you make Lynn warm with The patient is admitted to the ER where blankets and administer oxygen to her. Since blood tests are performed, as well as a type first assessed, her blood pressure has dropped and cross for packed RBCs. The ultrasound to 70/40 (MAP of 50mmHg), her pulse has is performed and is suspicious for an ectoincreased to 120 and regular, and her respi- pic pregnancy. She then is promptly taken to rations have also increased to 20. The ante the surgical suite. The surgeon talks to you is now increased. Level I Trauma Center or and you explain what you observed and what local Level IV Trauma Center? What about the patient told you, as well as the treatment an intercept with the paramedic service? You have some decisions to make, but you are definitely leaning toward the diagnosis of an ectopic pregnancy. You make the decision to go to the Level I Trauma Center due to the need for rapid surgical intervention, or “bright lights and cold steel.” You begin your transport, and five minutes into the transport are met by the intercept, who comes aboard your ambulance, and the transport continues. The Specializing in: patient is in sinus tachycardia on the monitor and two 18G IV catheters are placed with E.M.S. Reimbursement a bolus of 500cc initiated. You give the destiFire Department Billing nation facility the heads up of your findings and ETA so they can be prepared for your arrival. Over 50 years experience The transport goes without further incident in ambulance billing and the fluid bolus is followed by another for a total of 1L of fluid infused. You know that 3cc of crystalloid fluid occupies the same space as 1cc of blood and completely understand that the fluid that is being infused has no ability to carry oxygen. You have infused
modalities that you completed. You ask him to let your service know how the patient does in surgery and what her actual diagnosis was. He is happy to involve you in the patient’s care. What is your diagnosis of Lynn? As it turns out, she had a ruptured fallopian tube along with about 1L of blood that needed to be evacuated. The surgeon tells you that she will survive. Your treatment modality and initial diagnosis of an ectopic pregnancy was right on! The ability to rapidly assess your patient and make the decision of “is this person sick or not” is essential to the overall positive outcome. It is also important to continually reassess the patient to document changes in their condition that may cause a change in your treatment or transport choice. If you would have transported this patient to the local Level IV hospital, they may not have been able to do immediate surgery and would either have had to call in a surgeon, or transfer to a hospital that would have had the necessary resources for a positive outcome. So remember, in EMS, if it looks like a duck and quacks like a duck, it needs further assessment to determine what it actually is!
Frederick Hornby has been involved in EMS as a paramedic, educator and administrator for over 30 years. He spent 5 years as the Paramedic and Education Coordinator at the State EMS office, prior to becoming the Sales and Conference Director for the Wisconsin EMS Association in 2015.
708-478-5694 Professionals – May-June 2017
Legal Brief Gregory West, Attorney, EMT-P
More Patient Confidentiality and CQI Can an EMR agency receive informa- the minimum number of people necessary to tion about a patient’s status after care is perform the function related to the disclosure. Simply stated, if the specific patient informatransferred to a transporting ambulance service? Can a hospital share patient out- tion does not need to be shared to accomplish come data and information to ambulance the purpose of the disclosure, then it should not be shared. Additionally, those who receive services and EMR agencies? The short answer here is that both HIPAA5 such information should include only those and Wisconsin’s health care services review law6 necessary within the organization to process allow for disclosures of patient health infor- the data for the permitted use. mation to other covered entities for quality From a practical standpoint, patient identifiAre EMR agencies covered by HIPAA? improvement activities. As a matter of fact, the cation data must be shared by a hospital to an HIPAA provisions apply only to specific Assistant Secretary for the U.S. Department EMS agency so that the EMS agency can “link” “covered entities” as defined within the of Health and Human Services Office of that outcome data to its own information for law. Covered entities include healthcare Preparedness and Response drafted a letter in that specific patient. That information, however, providers “who transmit any health infor- 2012 that reaffirmed the ability of hospitals to should be forwarded to only one contact person mation in electronic form in connection share this data with ambulance providers with- within the EMS agency. Once that outcome with a transaction covered by [HIPAA].”1 out it being considered a HIPAA violation.7 data has been correlated to the EMS agency’s So, if you are an EMR agency that does not Therefore, information related to patient out- records by the designated individual, subsequent transmit patient information electronically, comes may be shared with all covered entities sharing of the information for internal CQI does are you covered by HIPAA? The short (and, presumably, their business associates) as not need to include unique patient identifiers. In answer is, probably yes. The reason is that necessary to accommodate mandated CQI most cases, simply sharing that the patient was a EMR agencies interface with a transport- functions. Agencies receiving this information “53-year-old female” (for example) is enough to ing ambulance service, which is considered are still bound by the HIPAA privacy rule and put the patient into context for the purposes of a covered entity under HIPAA. As the Wisconsin’s patient confidentiality law, which performing CQI on that run. Hopefully, this provides some additional EMR agency creates, receives, or transmits means whatever information received as a part protected health information on behalf of this exchange of patient outcome informa- clarification on not only patient confidentiality of the ambulance service, HIPAA would tion is still protected and cannot be disclosed laws, but how they apply to the CQI process as well as EMR agencies and providers. probably consider the EMR agency to be outside of the formal CQI process. a business associate2 of the transporting 1. 45 CFR §160.103. ambulance service, meaning all provisions Are there limits as to what patient infor2. Id. of the HIPAA privacy rule would apply to mation can be shared or disclosed as a part 3. Wis. Stat. 146.82 the EMR agency. of CQI functions? 4. Wis. Stat. 146.81(1)(s) 5. 45 CFR §164.501 Remember that Wisconsin also has a state Yes, there are limits as to what patient infor6. Wis. Stat. 146.38 law regarding patient health care records mation can be shared as a part of an ambulance 7. http://www.naemsp.org/Documents/HIPAA%20 3 confidentiality and the law does indeed or EMR service’s CQI activities. To begin, Wis. Letter-NAEMSP.PDF include EMRs (first responders) within the Stat. 146.38(3) and (3m) state that CQI infor8. 45 CFR §164.502(b) definition of a health care provider required mation cannot disclose the patient’s identity to comply with the confidentiality provi- (unless an exception applies). HIPAA also sions within that law.4 Thus, while HIPAA has a provision called the “minimum neces- Gregory West is a licensed attorney in Wisconsin more than likely applies to an EMR agency, sary requirement” that requires covered entities and has over 23 years of experience as an EMS state law definitely applies, which means to “make reasonable efforts to limit protected provider and firefighter. West is the Dean of EMR agencies and providers must maintain health information to the minimum neces- Protective and Human Services at Waukesha patient confidentiality to the same extent sary to accomplish the intended purpose of County Technical College. He teaches law to emeras transporting ambulance services and the use, disclosure, or request.” 8 Minimum gency providers on a part-time basis and also serves providers. necessary has also been interpreted to include as a member of the State EMS Board. In previous columns, we explored some of the legalities related to both patient confidentiality and continuous quality improvement (CQI) activities. I have received some additional questions recently about the two topics and how they relate to each other as well as EMR agencies/providers, so let’s delve into some additional nuances related to these two topics.
Professionals – May-June 2017
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Straight From The State James Newlun, EMS Section Chief
Funding Assistance Program Applications Open We are pleased to announce the EMS the FAP. Both of these forms are available Funding Assistance Program (FAP) applica- online. tion period for state fiscal year 2018 opened on April 1, 2017. As in other programs, Disbursement If your service is municipal-owned, or changes have been made to the SFY2018 you are a contracted private for-profit serEMS FAP to fully align with Wisconsin vice, the “Remit To” section is filled out Statute chapter 256. indicating your municipality. Wisconsin The FAP has been in place for over 25 years statute mandates that allocations to priand provides eligible Wisconsin EMS servate-for-profit ambulance services must vices with funding to help offset training and be paid to the contracting municipality. other expenses. The original 1989 Wisconsin If you are a nonprofit service, the “Remit Act 102 provides funding to ambulance To” section is filled out indicating your services that provide first-in 911 patient service. transport ambulance response to a particular The core formula remains intact so that geographic area. each service that applies will receive $3,588, Funds allocated under this program are plus 3 cents per capita. The remaining funds intended to supplement existing budgeted are identified in Wis. Stat. § 256.12(5) as monies of an ambulance service provider being applicable only to EMT-Basic trainand may not be used to replace, decrease or ing and examination costs. Because of release for alternative purposes the existing this, half of the EMT-Basic portion will be budgeted monies provided to the ambuequally divided among those services that lance service provider. Examples of eligible have at least one EMT-Basic on the service expenses expenditures can include initial roster. The second half of the remaining and/or refresher training expenses, computfunds will be divided among all services that ers and computer software purchased for apply, based on call volume as validated in training purposes, medical equipment, and the Wisconsin Ambulance Run Data System many others. (WARDS). Additional Forms New this year, two additional forms are Use of Funds being required as part of the FAP subThe EMT-Basic training funds are to be mission process. The IRS W-9 and State used only for EMT-Basic training and examof Wisconsin DOA-6457 STAR Vendor ination costs. You will have the ability on the Information forms must be completed and SFY2018 application to “opt out” of receivreturned, in order to receive payment for ing any EMT-Basic training funds if you 60
Professionals – May-June 2017
believe that you will not be able to use these funds exclusively for EMT-Basic training. In addition, these EMT-Basic training funds do not need to be returned if unused, and can be escrowed. Application Process The SFY2018 application process will be conducted through the Wisconsin E-Licensing system. The application and expenditure report will no longer be available for download. Also, manual population verification by the municipal clerks will no longer be required as an attachment to the FAP application. These populations will be entered into the application by the service director for the municipalities covered by the EMS service. The DOA 2016 Municipality Population Estimate is provided as the source to determine municipal populations. The 2016 Municipality Population Estimate page is located on the DHS website. Reminders Applications are due by 5 p.m. on May 31, 2017. Any applications submitted after this date will be denied. Services will not receive funds if the completed application is not received via E-Licensing by this date. No exceptions will be granted. The FAP application is only visible to those with “Service Director” or “Financial Staff ” designation in E-Licensing. Disbursement will be made to the services no later than
August 31. The application asks for the number of EMT-Basics on the roster, and the number of ambulance runs that the service completed for the previous SFY. This year, a report will be run from E-Licensing and WARDS to verify this information. If there is a significant difference between the numbers in the report and those on the application, the numbers in the WARDS report will be used to calculate the disbursement for your service. We encourage you to check your application against your data in WARDS to be sure that the numbers align. Expenditure reports for the previously completed state fiscal year should be submitted to the State EMS Office with the SFY2018 FAP application. This means that the expense report should be for SFY2016, which ran from July 1, 2015, to June 30, 2016. The expenditure report is required in order to renew the service license per Wis. Stat. § 256.12(4)(c) that states “the department shall require, as a condition of relicensure, a financial report of expenditures under this subsection….” We realize that this does not coincide with many services’ fiscal years, but this is the reporting period that we are required to keep on file. For SFY2018, the expense report should be for SFY2016, which ran from July 1, 2015, to June 30, 2016. As part of our statutory and fiscal responsibility, we are required to review and approve expenses. Per state statute, we will be monitoring that purchases are appropriate. Please review the updated expense form for clarification of allowable expenses. If you have any questions, please refer to the Wisconsin EMS website at: http:// dhs.wisconsin.gov/ems or contact Paul Wittkamp at paul.wittkamp@wisconsin. gov or 608-261-9306. Don’t forget that the deadline is coming up quickly. Failure to complete the W-9 and DOA-6457 forms and apply by May 31, 2017, may result in delay or denial of EMS-FAP funding for State Fiscal Year 2018.
James Newlun is the Chief of Emergency Medical Services for the State of Wisconsin EMS office at the Department of Health Services. He is an AEMT and certified firefighter who has been involved in EMS since 2000. Contact the EMS Office by calling 608-266-1568 or via email at email@example.com.
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Tips and Tricks David Myers, EMT-Intermediate Tech
A Point Worth Making Driven by proven success and ease of with high costs, there can frequently be use in the military, the use of interosseous confusion in high stress situations as to needles has spread over the last few years which needle size to use. Some manufacto include use by everyone from advanced turers color-code their needles, but unless EMTs to critical care paramedics. There you can remember what each of those are so many different device options avail- colors are in the heat of the moment, there able, from drills to spring-loaded “guns” to is a high likelihood of using the wrongmanual insertion options. However, new sized needle. technology often comes with high prices, Here’s my idea: take blank address labels with many of the options costing around (Avery or any other brand will do) and print one hundred dollars per needle. Along the intended use on them – pediatric, adult,
large adult, etc. – using a large, bold font. Place these labels on all sides of the corresponding IO packaging to make recognition easier, ensuring appropriate use. So, remember a point worth making!
David Myers is an EMT Instructor/Coordinator with Waukesha County Technical College and a Wisconsin State EMT examiner.
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The official publication of the Wisconsin EMS Association - Your Voice For EMS. Get more information at www.WisconsinEMS.com. See the huge E...