Archive for month: March, 2020

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North East Ambulance Service (NEAS) dispatch supervisor has won a national Control Room Award for going above and beyond the call of duty. 

Dispatch supervisor for unscheduled care, Martin Lonsdale was nominated by his colleagues after he saved a passenger from a burning car.

He was shortlisted out of three others and won in the category for special recognition for bravery and courage. 

As a dispatch supervisor, Martin is at the central core of the Trust, sending emergency ambulances to patients.

As a former Royal Marine, serving in Afghanistan and recently becoming a qualified volunteer community first responder to life-threating emergencies; he has the essential instinct to save lives.

Whilst driving on his way into work for his shift at NEAS headquarters, he came across an over turned car in the road. He ran over to find three people in the car, one of which was trapped in the rear seats.

Martin said, “When I was inside the vehicle trying to get the person out, within minutes, flames engulfed the front of the car.’

“People around me were shouting to get out of the way as it looked dangerous. But I just couldn’t go without attempting to save the passengers life.’

“My instinct was purely to help save those people.’

“I managed to get the seatbelt undone but the patient fell on top of me, trapping me in the confined space inside the car.’

“I had a moment where I genuinely thought I was going to die alongside the patient. I thought of my family and that’s when I managed to find the strength to get the patient out of the car.

“Many others were helping me and the person to get to safety and after we got a few yards away from the vehicle, it exploded, taking everything with it. Had we been any longer in the car, it would have been a very different story.”

Assistant dispatch service manager Andy Bell has worked with Martin for many years and wanted to recognise his heroic efforts by nominating him for the control room award.

Andy said, “Martin’s actions didn’t surprise me; he showed the upmost gallantry and valour in a life-threatening situation.’

“He always tries his best and shows great integrity with everything that he does. His family would have been at the front of his thoughts throughout the whole incident.’

“Even though the situation meant Martin risked his own life, we were relieved to hear that he left the scene unscathed. Fortunately, everyone escaped unharmed thanks to his heroic actions.’

“I am so proud of Martin — he is an inspiration to us all.”

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Lynne Baird believes her son Daniel would have survived had he been treated with a bleed control kit.

Daniel was 26 when fatally stabbed at a pub in Digbeth, Birmingham, following a night out with friends and, to prevent others from suffering the same fate, Lynn started a foundation distributing bleed kits in London’s financial district.¹

Baird’s precautionary contribution is not isolated.

Taxi Alliance Liverpool received training in bleeding control and bleeding control kits from the Aintree University Hospital’s trauma centre as part of a KnifeSavers campaign.

The kits contain scissors, gloves, tourniquets and trauma dressings as well as military-grade gauze and chest wound sealant.²

KnifeSavers was the brainchild of Nikhil Misra, consultant general and trauma surgeon at Aintree University Hospital, who wanted to make tools that could prevent death closer to the scene.

“Equipping people with the knowledge and tools to prevent massive blood loss at the scene of a stabbing is the single most effective step we can take towards improving the chances of survival for victims.”³

Knife crime has reached a new record high in England and Wales, with official figures revealing almost 44,700 offences in 2019.⁴ UK Office of National Statistics show that the City of London saw a steep rise in knife crime last year, up 43 percent to 57 incidents in 2018-19.⁵

A fifth of the crimes – more than 4,500 – were committed by children aged between 10 and 17.⁶

Would you know how to help someone with major bleeding? Uncontrolled, life threatening hemorrhaging is one of the leading causes of preventable death following a traumatic injury, and a person who is bleeding uncontrollably can die from blood loss within five minutes.

Think tourniquet. They’re back in EMS vogue as a device in hemorrhage control following a decline of the tourniquet in favor of applied pressure during WWI.

Medical tourniquets now play an essential role in complex medical procedures and emergencies to regulate blood flow.

These devices are used to prevent blood loss by compressing blood vessels and assist medical professionals in carrying out medical procedures with minimum blood loss.

Tourniquets are not limited to a one-style fits all description but come in several varieties to accommodate the purpose.

They include tactical, pediatric, military, surgical, and the emergency medical tourniquet.

An emergency medical tourniquet is commonly used to control arterial blood flow.

Numerous studies supporting the tourniquet’s return has the device counted among the essential gear
of re/EMS systems and stationed alongside AEDs at airports, popular nightlife venues, and places of potential mass casualty incidents.

The International Academies of Emergency Dispatch (IAEDTM) is a charter member of the US ‘Stop the Bleed’ campaign and instructions for tourniquet use are available in the Medical Priority Dispatch SystemTM (MPDS) system version 13.2.

Protocol T: Tourniquet was developed by an Academy research team that spent the better part of a year drafting the proposal and pre-testing prior to a volunteer focused study conducted at selected venues in Salt Lake County, Utah (USA), and enlisting 246 volunteers.

The objective was determining whether layperson callers can effectively stop simulated bleeding using an improvised or a commercial tourniquet, when provided with scripted instructions via phone from a trained protocol-aided EMD.

According to the study rationale, if tourniquets are going to be placed in public locations, emergency medical dispatchers (EMDs) should be prepared to answer callers’ questions regarding situations requiring them, and enthusiastically provide instructions on their use.⁶

At each study sight, participants called a simulated 911 line (comparable to the UK 999 three-digit emergency exchange) and reported a victim with life-threating bleeding to the leg, which is identified in the real world as⁷:

• Blood that is spurting out of the wound

• Blood that won’t stop coming out of the wound

• Blood that is pooling on the ground

• Clothing that is soaked with blood

• Bandages that are soaked with blood

• Loss of all or part of an arm or leg

The emergency dispatcher verified the catastrophic nature of the bleed and proceeded in giving the step-by-step instructions while a research team member timed how long it took the “caller” to stop the bleeding with the tourniquet, according to the control device.

“We could watch how people reacted [in response to the instructions] but we couldn’t step in,” said Chris Olola, Ph.D., Director, Biomedical Informatics and Research, IAED. “It took a lot of testing and revision before adding it to the existing protocol.”

According to results, a majority of participants (80.49%) were well within the critical five-minute time limit, with an overall median time for all trials (i.e., elapsed time from the start to the end of the simulation) of 3 minutes and 19 seconds.⁸

“Of course, in a chaotic, uncontrolled, and emotionally charged real-world event (such as a knife stabbing) it might be unrealistic to expect the high success rate of patient survival that was demonstrated here”, Olola said.

“Nevertheless,’ he said, “This study provides ample evidence that life-saving tourniquet application by untrained laypersons is possible with the bene t of dispatch-directed EMD assistance.”

The Tourniquet protocol doesn’t replace direct pressure in most bleeding situations, cautioned Greg Scott, Operations Research Analyst, IAED.

“A tourniquet is the best way to stop the bleeding from catastrophic injury. Direct pressure is still the preferred method for abrasion.”

As in the EMD’s First Law of Safety, the bystander is cautioned against creating “more victims at the scene.”

Bystanders must ensure their own safety and provide care to the injured person if the scene is safe to do so.

If safety is threatened, the bystander should move from the danger, taking the victim if possible, to find a safe location.

Not surprisingly, demand for surgical tourniquets has surged based on their reintroduction to trauma care and the rising adoption rate of trauma care devices, along with increasing numbers of accidents, injuries, and emergencies.

Additionally, the range of new devices being developed offer promise for bystanders, first responders, and surgeons delivering emergency services and these devices are expected to play crucial roles in reducing the emergency response times and improving the survival rates for patients.⁹

References

1 Wright M. “Pubs and clubs in London’s nancial district to be given stab kits.” 2019; Nov. 19. https://www.telegraph.co.uk/news/2019/11/18/ pubs-clubs-londons-financial-district-given-stab- kits/ (accessed Feb. 10, 2020).
2 Hughes L. “Five minutes is all it takes to bleed to death but this kit could change that.” Liverpool News. 2019; Oct. 21. https://www.liverpoolecho.co.uk/news/liverpool-news/five-minutes-takes-bleed-death-17117547 (accessed Feb. 10, 2020).
3 See note 2.
4 Dearden L. “Knife crimes reach record high as prosecutions fall to record low.” The Independent. 2020; Jan. 23. https://www.independent.co.uk/ news/uk/crime/knife-crime-uk-stabbing-ons-police-england-wales-prosecutions-a9298166.html (accessed Feb. 10, 2020).
5 See note 1. 5 See note 4.
6 Scott G, Olola C, Gardett M, et al. “Ability of Layperson Callers to Apply a Tourniquet Following Protocol-Based Instructions from an Emergency Medical Dispatcher.” 2020; Jan. 21. Prehospital Emergency Care. http://mc.manuscriptcentral.com/pec (accessed Feb. 10, 2020).
7 Pons PT, Jacobs L. “Save a life: What everyone should know to stop bleeding after an injury.” Chicago, IL: American College of Surgeons. 2016. https://www.bleedingcontrol.org/resources/how-to-stop-the-bleed (accessed Feb. 10, 2020).
8 See note 6.
9 “Surgical Tourniquets – Creating a “Bloodless” Field of Vision for Surgeons.” Future Market Insights. 2 Aug.; 2019. https://www. futuremarketinsights.com/reports/surgical-tourniquets-market (accessed Feb. 10, 2020).

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Imagine an ordinary day at work. The coffee is fresh, and you wait for your next assignment. Then it happens.

The disaster alarm goes off and it is yours and your teams’ responsibility to respond. It could be a natural disaster or a terrorist attack.

Hundreds, maybe thousands of people, are affected. Hundreds may need health care; many may already have lost their lives. Civilians are already at the scene facing the calamity.

In these circumstances, one can easily be overwhelmed by the magnitude of the situation, but at the same time the EMS personnel are trained to respond to emergencies, no matter how small or big they are.

It is in our backbone to always provide medical care and offer help.

The above imaginary scenario is no longer unthinkable, and the reality is that you, as a first responder, one day could be the one on duty when the alarm goes off on a massive disaster or a critical security incident.

This article will introduce you to the NO-FEAR project¹ (Network Of practitioners For Emergency medicAl systems and cRitical care) and describes some of the challenges associated with bystanders and non-organized volunteers, whilst outlining how you can engage with the project activities.

The NO-FEAR Project

EMS plays a vital role in assisting wounded and sick people after security incidents.

However, there are several challenges that need to be addressed. As a response to these challenges, the pan-European NO-FEAR project was launched in 2018.

This coordination and support action project brings EMS, suppliers, academia, decision makers and policy makers together to collaborate and exchange knowledge, good practices and identify lessons learned.

Many of the NO-FEAR partners are practitioners who were directly involved in the terrorist incidents in Paris, Nice, Berlin, Madrid and Barcelona.

Based on their experiences, the consortium initiated the project to better prepare and respond to several challenges that EMS face, and to overcome difficulties, such as:

• A fragmented chain of actors responding to security related incidents.

• A need for actors to respond to new threats such as terrorism and armed convicts.

• A lack of communication between the practitioners working in the eld and suppliers providing goods and services.

• No common methodologies and standardised actions.

The threat and risk situations today are quite different from just a few years ago, and security and preparedness plans are constantly being adapted to respond to new challenges.

Cross-border collaboration to develop a common understanding of the innovation potential gives this project a unique opportunity to improve the capabilities of EMS to respond to new threats, and assist casualties after security incidents.

This in turn will fill operational gaps and identify areas for future research, making EMS more resilient.

A higher frequency of natural disasters, critical security incidents and terrorist attacks are a growing trend in Europe and beyond.

The correlative rescue work is unpredictable, challenging and involves well known dilemmas and potentially dangerous situations.

When disaster strikes, we must be prepared, but what about the people already on site – the bystanders?

Civilians: The First to Save Lives

Bystanders and non-organized volunteers usually initiate life-saving measures quickly. It is a misconception that people become helpless or panic during a crisis.

Although one may be affected by fear, the desire to help is stronger. The official report after the shootings at Utøya in Norway, 22nd of July 2011² points out what a valuable resource the ordinary man and woman are when disaster strikes.

At Utøya, in addition to logistics on water, civilians also performed first aid, provided warm blankets and clothing, and showed tremendous care and compassion.

In the minutes following a critical incident, there will normally only be the wounded and bystanders on site before the police and EMS arrive.

These minutes can be critical for severely injured people and can mean the difference between life and death. Bystanders who understand the urgency of the situation may feel an immense responsibility.

Getting an overview of the situation and simultaneously trying to save lives with minimal resources contributes to additional stress³.

Reports tell the story of former bystanders who say that leaving someone behind is not an option, even with a “great personal risk and subsequent injury”4.

When the shootings at Utøya started, it did not take long before people at the landside understood that something was wrong. They heard gunshots and saw youths jump into the water, swimming for their lives.

We have also learned from the reports that young survivors from Utøya tried to help friends escape the gunshots.

Residents on the landside and camping guests collaborated to rescue the hypothermic and injured teenagers.

Whilst the youths immediately started to help each other, the residents and the camping guests got their boats on the water and went out to rescue the cold and injured teenagers. Some of the volunteers were shot at while saving lives2.

Nevertheless, they kept transporting injured persons to the mainland. These volunteer efforts continued for some time after the police and EMS had arrived.

At some point, volunteers even provided water transportation for the police. Later they said: “the collaboration with the professionals was good, but it took them a long time to arrive”5.

The concern is not about people’s willingness to contribute when disaster strikes, but whether there should be limitations to what actions one can expect from bystanders.

Although it is sometimes necessary for first responders to make use of bystanders and non-organized volunteers to effectively meet the needs of the injured, the ethical reflections around whether professional responders put non-professionals in harm’s way, either physically or emotionally, must be taken into consideration and further discussed.

Given the unpredictable nature of any crisis, we understand that being near or on the site of the incident involves personal risks, but EMS has a duty to act, balanced by a duty to consider relative risk6.

At the end of the day, we are the ones who need to prepare for, and gain knowledge of, how to leverage bystanders and non-organized civilians as medical force multipliers during MCIs (mass casualty incidents)4.

The Perception of the Bystanders’ Efforts?

Even those who work with adverse events may perceive a crisis as surprising and threatening. At the same time, they are expected to make decisions very quickly and with overwhelming pressure7.

Hence, it is not difficult to understand if and why professional first responders associate bystanders with increased chaos and stress, rather than as essential resources in the rescue work.

However, research8 has previously shown that the inherent altruism of the population is crucial to the efforts made to save lives under acute incidents.

This selfless concern for the wellbeing of others may explain why people help each other, carry out life-saving measures and stand together in times of crisis. Empirical evidence suggests that the civilian population can provide valuable resources which have not been fully utilized.

One reason may be the argument that when many want to “do well”, chaos and ambiguity can arise, which in turn can be problematic for the professionals8.

One cannot stop people from arriving to offer help, but too many people with the desire to contribute can also be a burden and an obstacle to the professionals doing their job.

This can lead to negative attitudes and wrong assumptions towards the bystanders. Nevertheless, we know that it takes time for professionals to respond to critical incidents and, in the immediate aftermath, the affected must rely on themselves.

Bystanders and non-organized volunteers can and should be considered a resource in crises, from which EMS can benefit.

By coordinating efforts and eventually taking over full responsibility, the information and work already carried out can be utilized for:

• A better understanding of the situation.

• Efficient and correct crisis management.

• A better outcome for both lives saved and psychosocial aspects following the disaster.

This form of crisis management is based on collaboration to achieve control of the situation7. However, it is important to keep in mind that each crisis is unique.

The affected will have varying degrees of knowledge and needs, thus presenting different reactions to a situation.

Raising awareness of the inevitable interaction between the EMS and bystanders is crucial in achieving a better understanding of the value each group has when joining efforts to save lives.

National guidelines for establishing easily available first-aid courses to the public could be a way of strengthening the societal resilience.

But first and foremost, it is important that training in managing the bystanders and non-organized are embedded in a standardized education for EMS.

There will always be civilians who are first at the scene of injury and in many cases initiate life-saving measures, sometimes also further safeguarding the disaster area.

As a resource, bystanders are currently not fully exploited, meaning a considerable potential for strengthening society for emergency purposes remains to be utilised.

To contact Anna and find out more about the NO-FEAR project, you can email her at: [email protected]

References:

1 http://no-fearproject.eu/
2 Departementenes servicesenter Informasjonsforvaltning. (2012). Rapport fra 22. juli- kommisjonen (NOU 2012:14). Oslo: Departementenes servicesenter.
3 Kruke, B. I. (2012). Samfunnssikkerhet og krisehåndtering: Relevans for 22. juli 2011. Notat: 7/12. Risikostyring og samfunnssikkerhet, Krisehåndtering,
4 Universitetet i Stavanger. https://www.jems.com/2016/08/01/leveraging-bystanders-as-medical-force-multipliers-during-mcis/
5 Haug, C.S. & Folvik, A. E. (2011, 24. juli). Han reddet 20-30 ungdommer fra terroristene på Utøya. Dagbladet. http://www.dagbladet.no/2011/07/24/nyheter/innenriks/terror/utoya/anders_behring_breivik/17436710/
6 https://www.jems.com/2018/11/13/safety-is-third-not-first-and-we-all-know-it-should-be/
7 Rosenthal, U., Boin, R. A. & Comfort, L. K. (2001) “The changing world of crisis and crisis management”. I: Rosenthal, U., Boin, R. A. & Comfort, L. K. (Eds.) Managing crises: threaths, dilemmas, opportunities. Spring eld III., Charles C. Thomas.
8 Helsloot, I. & Ruitenberg, A. (2004). Citizen Response to Disasters: a Survey of Literature and Some Practical Implications. Journal of contingencies and crisis management, 12 (3), s. 98-111. http://www.researchgate.net/publication/227847952_Citizen_Response_to_Disasters_a_Survey_of_Literature_and_Some_ Practical_Implications?enrichId=rgreq-8ae3e470-bb43-42ed-82ba-79145833939d&enrichSource=Y292ZXJQYWdlOzIyNzg0Nzk1MjtBUzoxMzE1MjIzOTY5NTQ2MjRAMTQwODM2ODc5MTI1NQ%3D%3D&el=1_x_2

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This article has been reproduced with permission for Ambulance Today by NAEMT and is also featured in NAEMT’s own publication, NAEMT Pulse Spring 2020 .

The 3rd edition Advanced Medical Life Support (AMLS) textbook was recently published, featuring new chapters covering critical illnesses which EMS practitioners often encounter in the field.

In this edition of Ambulance Today, Dr. Stein Bronsky, emergency physician and medical director for the Colorado Springs Fire Department and American Medical Response (AMR) in El Paso County, Colorado, discusses pharmacology in the field of EMS.

Bronsky is a contributing author of the new AMLS chapter on pharmacology.

Q. Before we talk about pharmacology, can you tell us what got you interested in EMS?

When I was 17 years old, I got in a car accident – a bad car accident. I was driving and I fell asleep on a really narrow canyon road, the kind where if you swerve you may go off the edge of the cliff.

A bus driver saw us swerve. He sped up, swung wide and hit us to plow us up against the canyon wall and keep us from falling off the edge. I don’t remember a lot, but I remember having to be extricated.

I had a lot of broken bones. I almost lost my lower leg, and I had a head injury. I didn’t have any internal organ damage, but my passenger did.

The emergency crews knew how to handle the situation, and it was really impressive. I became an EMT shortly after that, and worked as a ski patroller in Utah while I was in college.

Q. Did you always plan on eventually becoming a doctor?

No. My dad is a pediatric immunologist and I wanted to do something different, so I went to Israel to study Middle Eastern studies.

But while I was there, I became a paramedic. During the late 80s and early 90s, there was a lot of trauma there. There were an unbelievable number of car accidents.

They didn’t have traffic police, so there was nobody stopping anyone for speeding or driving poorly.

There were also terrorist attacks – mostly suicide bombers and backpacks left in crowded tourist areas, loaded with explosives.

They would just wait for somebody to pick up the backpack, and boom.

Israel got very, very good at MCI triage and treatment.

One thing they learned is that people will not stick around and wait to be triaged or wait for an ambulance.

If they can get up and physically move away from a scene, they will get as far away as possible. It’s human nature. If they are too injured, the people around them will pick them up and extricate them out of that circumstance.

Israel learned emergency crews will not get there in time to treat the majority of patients. There may be somebody who freezes up and doesn’t move, or who looks dead but is not quite dead and so people left them.

But it is single digit percentages of people who are still at the scene when EMS arrives, and who are still alive so you can do anything to try to save them.

Nearly all of the action is at the nearest hospital. Not a trauma center, and not the place best equipped to help them, but whichever hospital happens to be the closest. After my time in Israel, I knew I wanted to go to medical school and become an ER doctor.

Q. What do EMS practitioners need to learn about pharmacology?

Pharmacology is the study of interactions between a medication and the human body. As an EMT or first responder, you learn practically nothing about pharmacology. When we get to paramedic school, we learn more.

But what we don’t really learn is the 10,000-foot view: what are the different classes of medications, why do we use them, what are our expectations when using one, and what are the effects, wanted and unwanted?

Opioids are a perfect example. We want to alleviate the person’s pain but there are other effects, including depressing respiration and lowering blood pressure. Those are consequences we have to know about.

Typically, as eld providers, we receive a cache of drugs. You are taught about those specific drugs and when to give them.

But what happens if you don’t have one of those drugs because there is a shortage? How can providers make decisions about what to give when the situation requires critical thinking?

For example, let’s say you have a patient who has broken their leg versus one who has a huge, penetrating exsanguinating injury and their blood pressure is low.

You have to be able to use critical thinking – what is unique about this patient’s physiology and pathology? The drug I’m about to give for pain has some good effects and some bad. Is one of those bad effects something I need to worry about?

Let’s say you have morphine, fentanyl and ketamine. Which one would you give to a patient who is elderly, hypotensive, has an unstable pelvis after a fall and is in a lot of pain, vs. somebody who is young and healthy with a pinned limb who needs to be extricated?

I may give ketamine to somebody who is young, healthy and needs pain management during a prolonged extraction. You may have difficulty getting to them.

Fentanyl is short-acting and you may need to multi-dose the patient and monitor their respiratory drive or give supplemental oxygen, which may not be possible.

Ketamine would manage their pain and be a hemodynamically stable drug that does not affect the respiratory drive. Ketamine lasts longer and the dissociative effects of ketamine may be a good thing if you have to do an amputation.

But for an elderly patient with a broken pelvis, we want to use a pain medicine that will not lower blood pressure. Morphine and hydromorphone (Dilaudid) are out.

Could I use ketamine? I could, but ketamine has unpredictable side effects in elderly patients. Sometimes it works fabulously, but occasionally patients become unresponsive even with a small dose.

So we need to be very, very cautious and use critical thinking to assess which drugs are best in a given situation.

Q. What steps can EMS practitioners take to avoid medication errors?

Dosing errors are the most common errors made on patients outside and inside the hospital. To reduce these errors, we need good, systematic communication, and methods of organizing our system.

Hospitals have set up extremely elaborate programs to make sure you are giving the right dose, and the right medication, to the right person. In the field, we don’t necessarily have those systems in place yet.

In Colorado Springs, we’ve taken some steps to mitigate that, such as standardized doses.

We have also gone to volume-based dosing for pediatrics, so you don’t have to do the math. Math is not most people’s strong point, especially not at 3 a.m. when you’re exhausted.

We also ask everybody at our agency to tell us when there is a medication error. This is a non-punitive process. We want to understand how we set you up for that failure and change our system so it doesn’t happen again.

Q. There’s a lot of concern about opioid addiction and the overuse of opioids.

In the EMS setting, is there a greater risk of EMS overtreating pain or undertreating pain?

We have gone from potentially over-treating pain, to now potentially undertreating pain because of concerns about opioids. Today we have a greater recognition of the potentially harmful side effects of the acute use of opioids, as well as the addictive properties.

One positive change coming out of this is that we have started to think about other possibilities for pain management, such as acetaminophen (oral and intravenous), NSAIDs (nonsteroidal anti-inflammatory drug) and ketamine.

We also need to consider the hazards of opioid medication diversion. Traditionally there isn’t a great chain of custody for controlled substances in the EMS system.

It behooves everybody to ensure they have systems to track these medications so we can reduce diversion and, if diverted, have a better chance of figuring out how it was diverted. Access to controlled substances is a risk factor for addiction.

Q. How can bias impact pain management decisions?

Bias can be on opposite ends of a spectrum. Some providers may say, ‘I believe it’s our priority to make sure that every person who is experiencing pain is completely out of pain.’

Or you can have the opposite bias where you’d say, ‘I understand this person is in a lot of pain, but pain isn’t going to kill you. No way am I going to give an opiate medication. They can get opioids at the hospital.’

Cultural biases based on gender, socioeconomics, and race are also well-documented in the prehospital administration of pain medication.

Medics may be less likely to offer pain relief to a homeless person, or somebody they believe meets the picture of a drug-seeking person.

I don’t claim to have all the answers. But overcoming bias requires taking a really hard look at your personal beliefs and recognizing bias.

Although most people don’t self-reflect on this topic — they see their beliefs as facts and they don’t see another way of looking at it.

Q. Are there pain management medications that you think are underused in the prehospital setting?

I think there are several medications that are underused. As a culture in medicine, we think of opiates as
the answer to pain management in emergency situations.

Almost all other medications and all other classes of medications are systematically and historically ignored as a possibility for treatment.

We need to do everything we can to broaden that view and determine when it is appropriate to use opiates and when it’s appropriate to use other types of medications.

Often in the prehospital environment, if a patient is deemed to be in tremendous pain they get an opiate, and if they’re not in that much pain they don’t get anything. But we can do better.

Say somebody has severe strep laryngitis (strep throat). We don’t think of that as a life-threatening emergency, but it can cause a lot of pain.

It’s hard to swallow, so they don’t want to put anything in their mouth and they can become dehydrated. Does this kid or adult deserve pain management in the prehospital environment?

Yes, they do. We could use topical medications, such as topical or nebulized lidocaine, which would provide tremendous relief. Tylenol or an NSAID would also help.

Even for bone fractures, not everybody needs an opiate — especially kids who respond very, very well to acetaminophen and NSAIDS.

Adults do too, although they are more mentally inclined to think over-the-counter medication isn’t going to help, whereas kids haven’t formed those beliefs yet.

Q. Studies show that anaphylaxis is under-recognized and potentially undertreated in the prehospital setting.

What does EMS need to recognize about anaphylaxis and the use of epinephrine to treat it?

The emphasis on recognizing anaphylaxis has traditionally centered around airway issues. If your throat is closing up, you can’t swallow and you’re having a hard time breathing — you’re having a bad allergic reaction and we want the provider to use epinephrine.

Anaphylaxis is a systemic process that can manifest in different ways – and not always with throat swelling. If you’re thinking only about the respiratory system, you may be missing other systemic effects, such as a full body rash or hives.

GI issues are common; people who ingest an allergen may have nausea, vomiting or abdominal cramping. Wheezing may make EMS practitioners think more about albuterol than epinephrine, but wheezing may also be part of an anaphylactic reaction.

Hives, GI issues, wheezing, hypotension – these kinds of symptoms should trigger using more aggressive treatments, including epinephrine, as well as histamine-blockers such as diphenhydramine (Benadryl) and famotidine (Pepcid).

From an educational standpoint, we need to do a better job explaining what is happening in the body during anaphylaxis, so EMS practitioners are not just focused on the airway.

Some of this also involves changing the culture at EMS agencies. EMS practitioners are often taught to only give epinephrine when you are sure somebody is in anaphylaxis.

If the symptoms aren’t exactly what they were taught, they are afraid that if they give epinephrine they will get into trouble. That environment impedes people from using their brains to work through a situation.

In our system in Colorado, we promote the idea that if you think it’s the right thing to do, even though it doesn’t check all the little boxes, you write down your reasoning and the thought process you went through.

Even if you’re wrong, you’re not in trouble. Guess what? Doctors get it wrong at times too. We want you to think critically. Sometimes you will be wrong, but a lot of times you will be right.

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