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Ultrasound in Pre Hosptial Care

EMS uses of Ultrasound...an introduction. This is a quick video created with the help of my friend Peter Bonadonna. Pete is the Paramedic Program Director at Monroe Community College and leader in EMS education. In this clip, we look at uses, training, and other issues surrounding the use of Ultrasound in the pre hospital environment. We recorded the ultrasound images live (Peter was scanning himself) via internet.  This video will also appear on our "Videos" page (see top row of tabs) and on Mitigation Journal.  Join me, Matt and Peter as we discuss EMS and Ultrasound on Mitigation Journal podcast edition #198...available 11/29/2010...click the Podcast Player in the right sidebar to listen.

Trauma Assessment Tips

Five assessment tips to better trauma assessments

Tip #1: It’s okay to be distracted by traumatic injuries. It’s not okay to be fooled by them.
Traumatic injuries to the face, to the head, or open injuries to the chest, abdomen and to the extremities can certainly be distracting to your assessment. Being distracted by The devastating injury or injury pattern is a natural, human response. The paramedic cannot be fooled, no matter how devastating these injuries may appear, that they are the only injuries or the most serious injuries the patient has. The point is that no matter what is ripped open sticking out or impaled into the patient, the paramedic must fully assess the patient, mechanism of injury, and the surroundings. Bottom Line - You can be distracted...just don’t be fooled: as long as momentary distraction does not lead to being fooled by a nasty looking, less serious injury

Tip #2: What lies beneath? Anatomy!
Understanding of anatomy in relation to injuries, injury patterns and mechanism of injury. It’s not enough to simply observe and injury from the surface. The paramedic must understand the implication of that injury on the tissues, structures and, organs that lay beneath. What appears to be a superficial soft tissue injury on the outside can have substantial structural/organ injury underneath. Only by possessing a solid foundational understanding of anatomy will the paramedic be able to relate exterior body damage to where the true injury is… that is to the structure, organ, or system that’s impacted by the trauma. Bottom Line: Think about what lies beneath...Anatomy lies beneath and your understanding of anatomy will lead to better treatment.

Tip #3: Assess all critical areas...even if they're not injured.

No matter what the injury, injury pattern or MOI is, always assess the head, neck, chest, abdomen, pelvis, and long bones. These areas often go unchecked one-way focus on a single area of the body. The point here is, that no matter where the injury is all of these areas have to be assessed… even if they appear on injured. Note on the neck...we spend a lot of time worrying about c-spine injuries and trauma to the posterior neck...thats good thing. But, we cant ignore the injuries to the lateral and anterior neck...vessels and airway. Bottom Line: Always assess the critical areas...head, neck, chest, abdomen, pelvis, and long bones...even if they’re seemingly uninjured.

Tip #4: Change you view...you'll get a better look!
We too often assess trauma patients while they’re supine starring straight down on them. After all, that's how you were doing it in practice in EMT class...To be effective, change your point of view. Get down on the patients level and examine from the side, survey the patient from a short distance, observe a few breaths while kneeling at the patients feet or head. Bottom Line: Change your view...move around and look at the patient from various views and from a distance...get as much of the picture as you can before you leave...you're the only one who is going to be able to do this!

Tip #5: Assess any trauma patient for hypothermia and any hypothermic patient for trauma. Think: Trauma=hypothermia, hypothermia=trauma. Trauma patients may loose the ability to thermoregulate and have a difficult time keeping warm...especially if there is uncontrolled internal or external hemorrhage. Hypothermic patients may not be able to feel the pain of an injury or have the mental ability to comprehend the injury and report it. Bottom Line: Trauma and hypothermia...they go hand in hand. Any trauma patient should be assessed for hypothermia and any hypothermia patient should be assessed for trauma.

Cooking Safety from the USFA

Cooking Safety...Don't let fire or injury put your holiday to a bad end.

We could all use a good reminder about fire safety in the kitchen. Especially us responders. The United States Fire Administration has a few good tips for use to keep in mind...at home and away.

According to the U.S. Fire Administration:

Watch What You Heat

• The leading cause of fires in the kitchen is unattended cooking.

• Stay in the kitchen when you are frying, grilling, or broiling food. If you leave the kitchen for even a short period of time, turn off the stove.

• If you are simmering, baking, roasting, or boiling food, check it regularly, remain in the home while food is cooking, and use a timer to remind you that you're cooking.

• Stay alert! To prevent cooking fires, you have to be alert. You won't be if you are sleepy, have been drinking alcohol, or have taken medicine that makes you drowsy.

• Plug microwave ovens and other cooking appliances directly into an outlet. Never use an extension cord for a cooking appliance, as it can overload the circuit and cause a fire.

Keep Things That Can Catch Fire and Heat Sources Apart

• Keep anything that can catch fire - potholders, oven mitts, wooden utensils, paper or plastic bags, food packaging, towels, or curtains - away from your stovetop.

• Keep the stovetop, burners, and oven clean.

• Keep pets off cooking surfaces and nearby countertops to prevent them from knocking things onto the burner.

• Wear short, close-fitting or tightly rolled sleeves when cooking. Loose clothing can dangle onto stove burners and catch fire if it comes into contact with a gas flame or electric burner.

Short Steps to Better Planning

 Steps to better Pre-Incident Planning

Pre-incident planning is known by many terms: emergency, contingency, disaster, crisis management planning all say the same thing. Regardless of the type of term you apply to the situation Pre-incident planning is essential for successfully minimizing the effects of crisis and disaster situations in any community. We've all heard the old adage “failing to plan is, planning to fail” . But how many of us put enough time into our pre-incident planning to do all we can to prevent “failing”? Here are some simple steps… a few things to think about… when doing your pre-incident planning:

What are you planning for? 

Pre-incident plans are valuable for any crisis situation or emergency. That is, anything that happens suddenly–disrupts daily activities, jeopardizes citizens and the economy, and of course, demands your immediate attention. The pre-incident phase is exactly as it sounds; planning before the situation happens. In order to do this effectively you have to know or at least be able to predict the possibilities that your community may face. You make these predictions based on your hazard assessment and risk assessment. Your pre-incident plans also become an important tool for successful training activities later on.

Planning Overview

Pre incident planning has a single yet complicated goal; that is to minimize effects of any given situation. again, we have to assess the threat, the vulnerability, and the potential risk of emergency or crisis. Keep in mind that there is no one single plan or pre-incident plan for every community. Also, your pre-incident plan is only as good is the data you build the plant on that is, you only get out what you put in.
Remember, most pre-incident plans don't deal with normal or everyday situations… and routine policies, procedures, standard operating guidelines may not apply in certain crisis situations. Therefore it becomes important to develop policies procedures and standard operating guidelines for disaster situations that go along (hand-in-hand) with your pre-incident disaster plans.

Planning expected outcomes

your pre-incident planning process will help you ensure that appropriate levels of personnel supplies and equipment are available at times of disaster or crisis. Your planning process will also add your organizational structure and make sure the structure is in place and updated. Another major benefit of the pre-incident planning process is the ability to make recommendations in through the audit process; ensure that these recommendations are implemented. Pre-incident plans can also validate your risk assessment and hazard analysis by bringing all the data into one place.

Pitfalls in planning

 Above all else you must avoid Optimism Bias in your planning process. As said earlier, your plans are only as good as the data you used to build them. Along with that you have to evaluate your ability to implement the plan. Again, you have to be realistic and don't assume you have all the capabilities or resources you'd like. Emergency and disaster case studies throughout history underscore the need for pre-incident planning that emphasizes delivery of a sufficient operation over a standard operation.

Carbon Monoxide Background

Carbon monoxide exposure is one of the most common poisonings in the United States.  Although we often think of CO is a “winter time” problem, carbon monoxide exposure and poisonings can take place at any time of the year. Carbon monoxide exposure incidents tend to increase during the winter months we can also see an increase in these events at any time when a population uses auxiliary heating or power generating equipment; such as seen during major power failures or other natural events.

Carbon monoxide is known as the “Great Imitator” and can mimic a variety of other medical problems such as cold and flu. In fact a study done in 2006 indicated that one in four patients presenting to a hospital with cold and flu symptoms actually had carbon monoxide exposure. Carbon monoxide has also been linked to cardiac events after chronic exposure. Failure to recognize the potential of carbon monoxide exposure can lead to a deadly missed diagnosis. In some cases, carbon monoxide exposure and poisoning has been mistaken for substance abuse.

Common signs and symptoms of carbon monoxide exposure include headache, drowsiness, confusion, tachycardia. Continued exposure to carbon monoxide also lead to impaired thinking and sensory perception.  These effects of carbon monoxide reduce the ability of a person to recognize a hazard or self rescue from an environment.

Symptoms of carbon monoxide differ from person to person and level of exposure. Mild exposures (15 to 20% COHb) symptoms may include headache, nausea, vomiting, dizziness, and blurred vision. Moderate exposure is defined as 21 to 40% COHb and may present as confusion, syncope, chest pain, dyspnea, and general weakness. The severe exposure (41 to 59% COHb) may result in myocardial ischemia, rhythm disturbances seizures, and respiratory as well as cardiac arrest. Exposures to levels of carbon monoxide greater than 60% are usually considered fatal. It's important to note that CO exposure and COHb  levels do not have the same symptoms with all patients.

 Carbon monoxide alarm technology is reliable and found in many residential and commercial structures. In general, there are two types of carbon monoxide detection equipment. The first type is known is a biomimetic style detector. This type of detector uses a synthetic hemoglobin that reacts to acute and chronic carbon monoxide. Biomimetic style detectors are very common and usually resemble smoke alarms or are manufactured in combination with a smoke alarm.  These units typically have a module sensor built-in the battery compartment. Some of the most common manufacturers estimate a module life of two years and a total unit life of 10 years. This type of carbon monoxide detector can be influenced greatly by exposure to cooking products.
Another style of carbon monoxide alarm is the semiconductor style. this style of alarm uses an electronic sensor to measure carbon monoxide  and is typically plugged into a power outlet or other power supply. The general recommendation is that the unit be replaced every 5 to 10 years. Most carbon monoxide alarms activate at an estimated 10% of carboxylhemoglobin or 100 ppm of carbon monoxide.

A few notes on Type A flu

In this post will explore several areas of seasonal influenza. We'll take a look at what influenza is and is not, what causes it, and the various types. We'll also discuss the normal impact of influenza and the potential extraordinary impact of influenza.

1. Terminology.
The first thing in the need to know about influenza is the terminology… and we've come to recognize quite a bit of terminology surrounding the flu. Seasonal flu (sometimes called the common flu) is exactly what it sounds like; that strain of flu that circulates a given area every year. Avian flu (highly pathologic avian influenza) is the name given to a strain of flu that mainly circulates in Asia impacting various bird species with limited transmission to humans. Swine flu on the other hand, is the name given to a strain of influenza that emerged from South America–Mexico–in late 2008. This strain of influenza was particularly troublesome because it seemed to impact otherwise healthy people in a very dramatic way. And lastly, the term pandemic. A pandemic has been seen by the media as a term that indicates large numbers of deaths from disease. Although throughout history this is often the case, a pandemic is not an automatic term for mass fatalities. The term pandemic simply means the disease has spread around the globe and impacted many areas of population.

2. Types of Influenza.

There are several types of influenza viruses… so more concerned about, others, not so much. Influenza virus belongs to the category of diseases known as Orthomyxoviruses.   The three types of flu are Type  A, Type B,  and Type C. Type A influenza is known as a multi-host pathogen infecting both humans, swine, and birds. This is the most virulent  group and is classified by its surface antigens into subtypes. It is these subtypes that make up the H and N that we hear so much about on the news. H stands for hemagglutinin and N indicates neurominidase.  Both of these are surface proteins on the virus that allow the virus to get into a host cell, reproduce, and then escape. Remember, viruses are parasites and need to have a host to survive. There are 15 different types of H's and nine types of N's giving us a total of 135 potential combinations of type A influenza. Type B influenza is seen mostly in humans and although it's very common it is much less severe than Type A influenza. Epidemics involving type B influenza occur much less often than those involving Type A. It's important to note here that human seasonal flu vaccine includes two strains of Type a and one strain of Type B protection. Given that there are 135 potential type a influenza combinations and only two are included in the seasonal flu vaccine, indicates why we have years when the seasonal flu vaccine is less effective than others… that is, scientists have to guess which two strains of influenza should be included in the vaccine. Type C influenza infects humans and swine and has a completely different pattern of surface proteins. Normally Type C presents with rare occurrences and has mild or no symptoms. In fact, by age 15 most people have antibodies against Type C influenza.

3. Impact.

During an average flu season in the United States there are 35,000 to 45,000 deaths attributed to seasonal flu. The hardest hit by seasonal flu include those with severe medical conditions,  impaired immune systems, or extremes of age… young or old. Epidemics tend to occur in the winter months with peaks of hospitalization and death related influenza during this time.



Further Consideration.
Prevention of transmission of flu sometimes takes on a life of its own. We need to remember that the flu virus is one of the most infectious pathogens we know of and that type a influenza is prone to subtle changes in its structure that make it a challenge to our immune systems year after year. It's also important to remember that droplets aerosols and direct contact can spread influenza.  The flu virus can remain active on a contaminated surface or item for up to 48 hours.

We'll discuss prevention strategies, P. P. E., and pharmacology versus non-pharmacology strategies in our Medical/Biological posting next week.

Re-Introducing LOCATE.
(Originally posted December 28, 2005 in Mitigation Journal)


LOCATE is a system to guide the EMS provider on assessing the patient, the scene, and as a decision making aid.  

It seems simple enough; before you can provide treatment and transportation you have to find the person in need of your service. Actually finding the patient is only part of the job. Providers of emergency medical service (EMS) at all levels must prepare themselves prior to reaching the scene or patient for a variety of potential actions and outcomes. Waiting to arrive on-scene to develop a care plan or mental review of the potential scenarios places both provider and patient at a disadvantage. The fire services use the process of pre-incident planning and size-up to prepare firefighters for potential needs or dangers of any given situation. Pre-incident planning can be used to anticipate additional resources and special needs of a situation. Emergency medical services can and should do the same.

EMS and fire service text are filled with acronyms that have become part of daily conversation. Acronyms are memory aids that range from the simple ABCDE’s that remind us of the basics of patient assessment to SLUDGE as a memory jog for organo-phosphate exposure symptoms. In this installment we will introduce the acronym LOCATE as a means of assessing not only the patient, but the scene and patient needs as a whole.

Location. In the real estate business location is everything and so it is for EMS. What do we as EMS providers need to know about the location we are responding to in order to accomplish our goals and objectives? What can we tell about a situation before we enter the environment? Let’s consider the following questions:
What type of occupancy are we at?
How well do you know your response district?
What geographical special needs or special hazards have to be considered?

Response to group homes, rehabilitation centers, and senior living centers demand special attention by the responder. The structure itself can yield important clues as to the special needs of those inside and impact your options. Calls to medical facilities and clinics add yet another dimension to your response such as dealing with medical professionals and therapy-in-progress. The key to situational assessment is to anticipate, not stereotype.

Obstacles such as ramps, lifts and the presence of customized vehicles should prepare you for the special needs of the person inside the location and warn you about special hazards of getting in and out with all your equipment (including your lumbar spine) safe and intact. Commercial buildings and public places offer some challenges that are not as obvious. Small elevators may prevent your crew from arriving or returning together. Who will stay with the patient and what vital equipment will you keep with you? In public places on-lookers can become an obstacle. Patient dignity and privacy in the public venue must be addressed differently than in a private residence in effort to preserve the comfort and cooperation of the patient during treatment. The responder must also consider the presence of security video surveillance, camera phones, and other digital recorders. Responders must anticipate that a majority of the public owns some type of digital recording device and consider the impact these devices may have on privacy and care.

Conditions such as post medical conditions are a routine part of EMS assessment. Now consider the living conditions you find the patient in. By being observant to living conditions; EMS providers have a unique opportunity not available to others in the health care system. Situational awareness can yield important clues that must be relayed and addressed by the health care system. The GEMS diamond used in Geriatric Education for Emergency Medical Services is a good example. The EMS provider must again ask themselves a number of questions:
Are the patient, the family, and the care givers able to carry our daily activities?
Has there been a change in how the patient cares for themselves? If so, is the cause of the change medical in nature, such as in the setting of CVA/TIA, or social a aspect such as the loss of a spouse or other supporting person?
Family support or lack thereof plays an important role in every situation. The EMS provider must not only find medications but assess if the patient is physically and mentally able to take them.

The presence or absence of Accessories is closely related to conditions and considers physical items.
Is the patient using the cane or walker? If not, is lack of use or lack of the device a cause of falls and injuries?
Has the patients’ ability to use such a device changed and are they no longer able to use their accessories?
Other accessories that should be assessed include home oxygen units, air-powered nebulizers, ventilators, hospital beds and lifts, commodes, and orthopedic devices. The presence of basic medical supplies can also indicate the level of care a person should receive on a daily basis. The presence of many other medical accessories may also indicate the need for another and arguably more important need; and educated caregiver in the home. There is no substitute for the love and compassion provided by a family in the home-care situation. EMS providers must harness the educated family or caregiver as a precious piece of the assessment puzzle. Failure to do so can result in the loss of valuable information, inaccurate diagnosis and treatment, and poor public relations.

Treatment is what you do for the patient. Your assessment should lead to a working diagnosis list and guide your treatment. Treatment provided by previous EMS responses and discharge paperwork from previous emergency department visits is also important. We all have a list of frequent users of our services but, do we communicate what we’ve done to help these people? We shouldn’t have to reinvent treatment each time we see a previously treated patient. Multiple requests for “lift assists” for example, may indicate subtle changes in patient condition or change in social status indicating the need for augmented services. The key is to anticipate, not stereotype.

Evaluate the need for Education and Extra help. The EMS provider has the ability to see the patient in their surroundings as they are every day. EMS should also be knowledgeable of patient education topics pertaining to safety and well-being, social programs, and signs of abuse. Consider the following questions:
Are you aware of the signs of elder, child, or domestic abuse? If so, what are your reporting requirements?
Are you aware of the community programs that may be of benefit to those in crisis?
Being able to provide information on social programs and domestic support are vital for the EMS provider.
Evaluation must begin prior to response. Weather conditions and time of day must also play a role here. Other events; natural disasters and intentional events locally, nationally, and internationally must also be taken into account. It is here that you have the opportunity to help any member of the public prepare for crisis…even those that are not medically related.

Summary
The ability to assess the scene and the patient before you arrive is a skill learned with experience. The acronym LOCATE is:
Location
Obstacles
Conditions
Accessories
Treatment
Evaluate, Educate, Extra help
Use LOCATE to guide your patient care plans on-route, on-scene, and after care to build your assessment of the patient as whole. Pre-planning and size-up are important aspects of patient care; if you LOCATE each patient you will be better able to keep these points and patient care in focus.