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Spring 2009
A Quarterly Informational Publication for EMS Providers
What’s Inside:
PAGE
3 EMS SERVICE SPOTLIGHT
Rothschild Fire and EMS
4 E M S C O O R D I N AT O R
U P D AT E S
6 F E AT U R E S T O R Y
Spirit Medical
Transportation Services
Marks 15th Anniversary
7 N C R TA C U P D AT E S
What is the RTAC’s Role in
Reviewing EMS Trauma Care
8 Trauma Care Through
a Lifetime
9 T R A U M A E D U C AT I O N
Alcohol and Trauma
9 Safety is Not by Accident
10 F O R Y O U R I N F O R M AT I O N
Everyone Goes Home
11 P O S T - T E S T
FOR
C O N T I N U I N G E D U C AT I O N
12 U P C O M I N G E V E N T S
From the Director’s Chair
Trauma in the Pregnant Patient
This knowledge should be tempered by the fact
rauma is the leading
that pregnant women may appear stable but have
cause of death in
Twomen
injuries that place the fetus at risk. With any
of child bearing
age and the leading cause
of death during
pregnancy. Common
causes of trauma deaths
in this patient population
include MVA (55%),
falls (22%), assaults
(22%), and burns (7%).
Pregnancy is divided into three trimesters;
each trimester is three months, with a normal
pregnancy lasting nine months, from
conception to delivery. It is important to know
how far along the patient is in her pregnancy
as this determines the risks and types of
injuries, exam findings, and patient
management decisions.
There are significant physiologic changes
that occur in women during pregnancy. Late
in the second trimester, baseline blood
pressure typically drops by 5 to 15 mmHG.
This is accompanied by a 10 - 15 percent
increase in heart rate and an increase in
maternal blood volume. The combination
of relatively low blood pressures with
tachycardia often misleads the EMS
provider to assume the patient is in
shock when in fact these can be
normal vital signs late in pregnancy.
maternal injury resulting in significant blood loss,
blood flow is shunted away from the fetus in an
effort to compensate for the maternal blood loss.
More than one million women are victims of
domestic violence in the U.S. every year;
10 - 30 percent of these women are pregnant and
in the first four to five months of their pregnancy.
Common injuries include blunt trauma to the
head, neck, breasts and abdomen as well as
penetrating injuries from gunshot and knife
wounds.
Injuries from falls are more common in the
second and third trimester due in large part to the
change in the mother’s center of gravity of her
body as the uterus enlarges to accommodate the
growing fetus.
Initial management of the pregnant trauma patient
is no different than any other trauma patient.
After evaluating and correcting any problems
with airway, breathing, and circulation, the patient
should be fully exposed and the secondary exam
should be performed, preferably by a female
EMS provider. If the patient is of child bearing
age, ask if she is pregnant, and if so, how far
along she is in her pregnancy. As a general rule,
women that are more than 24 weeks into their
pregnancy are considered to have a fetus that
Continued on page 2.
C O N TA C T
I N F O R M AT I O N
V
ital Connections is a shared
effort of Saint Joseph’s Hospital
and Saint Joseph’s Children’s
Hospital in Marshfield and Saint
Clare’s Hospital in Weston. This
quarterly publication serves to
provide readers with information on
current EMS topics and issues. It is
our combined hope to continue to
bring you an informative newsletter
that will reflect expertise, knowledge,
technology and EMS information
from both facilities. As always, we
invite your comments and/or
suggestions for improvement. You
can contact us via the various
resources listed below.
If you have questions, concerns or
ideas/information for articles in
future publications, or if you would
like to be added to our mailing list,
please contact either Sandy or Don
via the contact information provided
below. Please include your name,
mailing address, phone number,
e-mail address (if applicable), service
affiliation, and level of provider.
Sandy R. Johnson, RN, NREMT-P
EMS Coordinator
Saint Joseph’s Hospital
611 Saint Joseph Avenue
Marshfield, WI 54449-1898
From the Director’s Chair
Trauma in the Pregnant Patient (continued)
could survive a premature delivery if
necessary, due to maternal injuries. This is
critical information to relay to the emergency
department so that an obstetrician can be
involved early in the care of the pregnant
trauma patient.
The uterus is protected by the pelvis during
the first 12 weeks of pregnancy. As the uterus
continues to grow to accommodate the
enlarging fetus, it becomes an abdominal
organ and is susceptible to blunt trauma from
falls and MVA and penetrating injuries.
Attempt to palpate the uterus. Is the uterus
tender, rigid, are there contractions?
Document these findings.
All pregnant trauma patients should be
placed on high flow oxygen; this will benefit
both the mother and the fetus. Pregnant
patients beyond 20 weeks gestation that are
placed supine can experience a drop in blood
pressure from the weight of the uterus and
fetus collapsing the mother’s large vessels
14th Annual
Spirit Medical Transportation
Services Conference 2009
What’s Hot
and What’s Not
in Trauma
OFFICE: 715.393.2945
[email protected]
FAX: 715.393.2905
2
With knowledge of the types of injuries
during different stages of pregnancy and
specific pre-hospital management unique to
pregnant trauma patients, the EMS provider
can provide optimal care for both mom and
the baby. Steven H. Mickel, MD
Medical Director,
Spirit Medical Transportation Service,
Marshfield Base
Save the Date!
Thursday, August 13
and
Friday, August 14
Ramada Inn
Stevens Point, Wisconsin
For additional information,
please contact:
Audrey Schmeeckle,
conference coordinator, at
[email protected]
OFFICE: 715.387.7995
[email protected]
FAX: 715.389.4030
stjosephsmarshfield.org/ems
Don Kimlicka, NREMT-P, CCEMT-P
EMS Coordinator
Saint Clare’s Hospital
3400 Ministry Parkway
Weston, WI 54476-5220
that return blood from the lower half of the
body to the heart. For this reason, pregnant
patients in their late second or third trimester
should always be transported on cots in the
left lateral decubitus position. If the patient
has been immobilized, the spine board should
be tilted at least 15 degrees to the left. Both
these measures will improve circulation and
blood pressure.
Contracted Partner
of Spirit Medical
Transportation
Services
Spring 2009
E M S
S
E R V I C E
S
P O T L I G H T
Rothschild Fire and EMS
Leah Toboyek, CCEMT, Paramedic, Spirit MTS Weston Base
Glen Engebretson, EMT, Driver-Spirit MTS, Assistant Chief, Rothschild Fire Dept
T
he Rothschild Fire/EMS Department is
located off of Grand Avenue in the
Village of Rothschild. The service covers
approximately 27 square miles within the
Village of Rothschild and provides mutual
aide to surrounding departments when
requested. The fire department was
organized in the early 1900s and started
with about 15 men. The equipment
consisted of a cart on wheels and a hose.
In 1944, first aid was instituted in the fire
department and was the standard until the
first EMT class. A few members of the
Rothschild Fire Department attended the
first class that was held in Wausau. Some of
the state EMT license numbers below #20
were held by members of the department.
EMT #1282 is still currently with the
department.
Currently, the department has 36 members,
of which 29 are EMT-Basic or EMT-IV
Tech. They have several fire apparatus as
well as two ambulances, and are expecting
delivery of a new Med-Tech ambulance in
March as well as a new Pierce fire engine
sometime this summer.
The service went IV-Technician in 2005.
Prior to that, they provided Basic EMS. The
service transports patients to Saint Clare's
Hospital and Aspirus Wausau Hospital.
Their medical director is Michael Curtis,
MD, from Saint Clare's Hospital.
Rothschild EMS was the first ambulance
service to bring a patient to Saint Clare's
Hospital on the day it first opened on
October 4, 2005.
The members of the Rothschild Fire/EMS
Department are paid on-call with the
exception of Monday through Friday, from
8 a.m. – 4 p.m. During these hours, there is
a crew at the station consisting of two
EMTs (one of which is IV-Technician).
Members of the department participate in
many community-based events/fundraisers,
including the Annual Semi-pull Fundraiser
at Cedar Creek, Badger State Games and
Annual MDA Motorcycle Ride Fundraiser.
They also host an open house annually at
their station.
For more information on Rothschild Fire &
EMS, please call 359.3660 or email
[email protected]. SAINT JOSEPH’S HOSPITAL
EMS Appreciation Event
May 19, 2009
6 p.m. Dinner • 7 – 9 p.m. Guest Speaker
Mother Francis Streitel Conference Center – Saint Joseph’s Hospital
Marshfield, Wisconsin
“I Believe … Lessons I’ve Learned in 30 Years of EMS”
Dwight Polk is the paramedic
program director at the
University of Maryland Baltimore County (UMBC) in
Baltimore, Maryland, and is a
familiar face at conferences
around the country. Along with
being a full time educator, he is
a volunteer paramedic and co-author of Jones
& Bartlett’s Prehospital Behavioral Emergencies
and Crisis Response.
Additionally, he has written for JEMS magazine,
publishing several articles on mental illness.
Dwight has a master’s degree in occupational
social work and is a crisis counselor for the
Grassroots Crisis Center in Columbia, Maryland.
He is also a mental health professional on the
Baltimore City Fire Department and Maryland
Department of Natural Resources Critical Incident
Stress Management (CISM) teams.
Dwight shares with you some of his experiences
and the lessons he has learned (often the hard
way) after 30 year of experience in EMS. This
humorous and thought-provoking presentation
will have you nodding your head and saying,
“Yep, I’ve seen that…”
Saint Joseph’s
Hospital
salutes
our local
and area
EMS providers
for their
expertise and
excellent care
given to our
patients,
24 hours a day,
seven days a
week.
Join Us For
An Evening of
Celebration!
Look for your
invitation in
the mail!
3
E M S
I
s your EMS service
prepared to handle the
impact of a pandemic
disease outbreak?
We hear this word
“pandemic” frequently in
the news, we read about
it in magazines and listen
to experts debate about
the effect of a pandemic on society.
According to the World Health Organization
(WHO), a pandemic can start when three
conditions have been met:
1. The emergence of a disease new to
a population.
2. Infectious agents infect humans, causing
serious illness.
3. Infectious agents spread easily and are
easily sustained among humans.
An epidemic is a contagious disease that
spreads rapidly and extensively among many
individuals in an area. In contrast, a pandemic
is an epidemic that is spread over an especially
wide geographic area, for instance a continent,
or even worldwide, and comes from the Latin
word, pandemies meaning “of all the people.”
This is the very reason that pandemics can be
so deadly and disruptive to society.
There are numerous accounts of epidemics and
pandemics throughout history caused by
various infectious agents: typhus, smallpox,
cholera, typhoid fever and pandemic flu, just to
name a few. Seasonal flu should not be
confused with pandemic flu. Seasonal flu is a
respiratory illness that most people have some
immunity to, either through exposure or
vaccination. Seasonal flu may infect large
numbers of people, but is only generally lifethreatening to the very old and the very young
and has an overall low mortality rate.
The first pandemic flu, recorded in 1510,
traveled from Africa, and spread across Europe.
Flu pandemics have happened before, including
three during the 1900s. The “Spanish Flu” was
first identified in March 1918, in U.S. troops
training at Camp Funston, Kansas. By October
1918, it had spread to become a worldwide
pandemic on all continents, and eventually
infected 2.5 - 5 percent of the human
population. In six months, some 50 million
were dead; some estimates put the total number
of those killed worldwide at over twice that
4
number, which included 675,000 in the U.S.
The second pandemic, the 1957-58 “Asian
Flu,” caused about 70,000 deaths in the U.S.,
and was first identified in China in 1957. The
third pandemic to hit the U.S. was the “Hong
Kong Flu” in 1968-69. This virus was detected
in Hong Kong in early 1968 and spread to the
U.S. later that year, causing about 34,000
deaths.
Because flu viruses are always changing,
scientists are positive that another flu pandemic
will happen, although they cannot say for sure
when it will happen. Nor can they tell how
severe a pandemic will be, as it depends on the
exact strain of the virus and how much can be
done to prevent the spread of the disease.
In February 2004, avian influenza virus was
detected in birds in Vietnam, increasing fears of
the emergence of new variant strains or types of
the virus. It is feared that if the avian influenza
virus combines with a human influenza virus,
(in a bird or a human), the new subtype created
could be both highly contagious and highly
lethal to humans.
By November 2007, numerous confirmed cases
of the avian flu strain had been identified across
Europe; however, by the end of October, only
59 people had died as a result, which is atypical
of previous influenza pandemics. To date, avian
flu cannot be categorized as a pandemic,
because the virus cannot yet cause sustained
and efficient human-to-human transmission.
Cases so far are recognized to have been only
transmitted directly from bird to human.
Taking a look at our history can give us the
advantage of planning for our future. Other than
the obvious human suffering and loss of life
that is inevitable in a pandemic, we need to
consider the other life-altering effects that a
pandemic will have on society. Communities
may need to take public measures to prevent
the spread of the virus. These measures could
include closing schools and business, and
placing limits on travel and large gatherings.
Businesses should plan for up to 40 percent of
their workforce being absent due to sickness or
having to care for family members.
Hospitals and other health care centers may be
overwhelmed with patients. There may not be
enough supplies and medications on-hand.
Health care workers may be absent due to
illness or the need to care for family members.
C
O O R D I N A T O R
There may be a need for quarantines or selfisolation of infected persons—who will care for
them? There is real concern that public services
such as electricity, water, food and gasoline
could be disrupted due to the shortage of
healthy workers. Ethical dilemmas and issues
regarding civil liberties will flourish.
What can EMS do to prepare
for pandemics?
Know that the Wisconsin Health Department
and public health officials throughout the U.S.
are focusing efforts on ways to detect the virus
early and prevent the spread of the disease,
which will help to limit the number of those
exposed. Proper planning strategies for a flu
pandemic are mandatory to achieve the greatest
good for the greatest number of patients.
EMS leaders will have to plan and make adjustments in their system to maintain service to the
community because EMS is a critical element
that must remain in operation. Without sufficient
planning and established protocols in place
prior to any events, EMS systems may fail their
communities in their time of greatest need.
To that end, the Department of Health and
Human Services (HHS) and the Centers for
Disease Control and Prevention (CDC) have
developed a checklist to help EMS assess and
improve its preparedness for responding to
pandemic influenza. EMS will be involved in
the care and transport of acutely ill patients
with known or suspected pandemic influenza to
emergency departments. This checklist
identifies key areas for pandemic influenza
planning. EMS can use this tool to self-assess
and identify strengths and weaknesses of
current planning. The list is comprehensive, but
not all-inclusive, and each EMS organization
will have unique and unanticipated concerns
that will also need to be addressed.
Collaboration among EMS, hospital, public
health and public safety personnel are
encouraged during all phases of preparedness
planning.
This checklist can be found at
hhs.gov/pandemicflu/plan/sup3.html#app2
Additional information regarding pandemic flu
in general can be found at
pandemicflu.gov
Spring 2009
U
P D A T E S
Pandemic flu preparedness is also taking place at
the state level, according to Dana Sechler,
paramedic program coordinator, Bureau of Local
Health Support and EMS. Sechler states, “The
Wisconsin Department of Health Services,
Division of Public Health has identified
coordination with EMS as a high priority in
planning for an influenza pandemic. The goal is
to improve preparedness for responding to
pandemic influenza by involving EMS, to
establish protocols for triaging patients and to
ensure that EMS staff is protected in a pandemic.
Since EMS organizations will be involved in the
transport of acutely ill patients with known or
suspected pandemic influenza to emergency
departments or alternate care sites, it is essential
that EMS organizations be involved in pandemic
influenza planning efforts.”
Sechler continues, “In addition, the EMS section
has begun the process of identifying how EMS
organizations can assist in aiding the public
health sector, should an influenza pandemic
occur. The EMS office staff recently approved
two pilot projects which allowed EMTs and
paramedics to receive training and education, and
work in partnership with their local county health
department in administering flu vaccinations.
The data from the pilot is still being collated, but
the preliminary results appear to be quite
positive.”
For more information about the pilot projects, or
pandemic-related information for EMS providers,
please contact any of the following individuals:
• Brian Litza, EMS Section Chief, at
[email protected]
• Dana Sechler, Paramedic Program
Coordinator, at [email protected]
• Paul Wittkamp, Communications
Coordinator, at [email protected]
Do not be caught off-guard when pandemic flu
hits. Take the time to collaborate with key
resources within your community now, in order
to get your pandemic protocols/procedures in
place. Once your plan is in place, consider
conducting a tabletop exercise to test the strength
and effectiveness of your efforts. Learn from the
past, plan for the future. Sandy R. Johnson, RN, NREMT-P
EMS Coordinator,
Saint Joseph’s Hospital, Marshfield
Sources: CDC.gov, Wikipedia, WI Department of Health
and Family Services.
S
afety is an important
component of our
lives every day. The best
safety measure is to
avoid a situation before
it happens. This can be
accomplished through
many methods,
including preventive
measures or preplanning.
In emergency services, safety is strongly
emphasized, from before the call until the
return to your facility. Just as in our personal
lives, safety begins with prevention and preplanning.
An important area that has recently come to
our attention is the use of red lights and siren
(RLS). The question is, “Does running RLS
truly make a difference?” Research reveals that
RLS was originally added as a way to get the
patient to the hospital quicker. This was before
the day of trained EMTs who provided life
saving or stabilizing measures. With our ability
to bring significant care measures to patients, is
it prudent to run emergently with red lights
flashing and the siren blaring?
The State of Wisconsin EMS Advisory Board
recently adopted a position on this topic. The
recommendation is that the use of RLS should
be avoided as often as possible and reserved
for unstable medical conditions. At that point,
it’s reasonable to believe that their use will
lead to a clinically relevant time saver, to
delivery, to definitive care.
Furthermore, patient care goals are outlined:
• Identify patients for whom using RLS can
potentially reduce morbidity and mortality.
• Eliminate unnecessary use of RLS to
improve patient comfort, reduce anxiety and
enhance safety.
The position also outlines a suggested
procedure list:
• RLS transport does not necessitate
exceeding posted speed limits.
• Road type, traffic and weather conditions
must always be considered when using RLS
• When approaching an intersection, the
unit should come to a complete stop,
regardless of traffic control devices present
on the unit or when the unit has an apparent
right of way.
• When using RLS:
- Never pass in a no-passing zone unless a
vehicle is well over on the shoulder and
comes to a complete stop.
- Come to a complete stop 100 feet in front
or behind a school bus with flashing lights
activated.
- Never force the right of way or assume
you have the right of way.
- Never tailgate another vehicle even if
they have not moved to the right or come
to a stop.
• Specific medical or trauma conditions are
outlined primarily with unstable cardiac,
respiratory, trauma or neurological patients.
• Transports where reducing time to definitive
care is clinically indicated, consider all
options before using RLS.
• Critical care or inter-facility transports
should not automatically indicate RLS use.
• When there is a conflict of use between an
on-board physician or nurse, attempt to
resolve the issue or utilize Medical Control.
• RLS should be avoided in DNR patients,
inter-facility transports to a lower level
facility, transport of human organs, blood or
transplant teams, and unsalvageable
patients.
This position was drafted from a position
statement released by the National Association
of Emergency Medical Services Physicians
(NAEMSP) back in November 1993, and can
be found at:
naemsp.org/documents/
UseWarnLightsSirens.pdf
The Wisconsin EMS Association also released
a position statement on emergency driving,
which includes use of RLS which can be
found at:
wemsa.com/docs/
Emergency%20Vehicle%20Operations.pdf
As you can see, this is an area of great
concern. Now would be the perfect time for
your service members to sit down with your
medical director and consider developing a
policy. Please contact me or Dr. Michael Curtis
if you need more information or assistance. Don Kimlicka, NREMT-P, CCEMT-P
EMS Coordinator, Saint Clare’s Hospital, Weston
5
Spirit Medical Transp
th
Marks 15 Anniversa
Spirit N611SJH
taking off from Saint
Joseph’s Hospital.
I
n November 1993, Ministry Health Care
launched Spirit Medical Transportation
Services to provide ground and air
medical transport services to the people of
central and northern Wisconsin. Last year
marked the 15th anniversary of its
founding and a long history of service to
the region.
Spirit Medical Transportation Services’
mission is to provide comprehensive,
regionally-integrated ground and air
transportation for adult, pediatric,
neonatal, and high-risk obstetrical critical
care patients from referral institutions and
scenes of injury. Spirit Medical
Transportation Services was started in
Marshfield at Saint Joseph’s Hospital, and
as the service has grown, it has evolved
into a comprehensive Ministry service
with ground bases in Weston, Woodruff
and Rhinelander.
Providing interfacility transportation for
patients requiring advanced life support
(ALS) or critical care management to or
from tertiary hospitals is of particular
importance, and is one of the primary
reasons Spirit services is are needed.
Spirit Medical Transportation Services
was also designed to support, supplement,
and assist local and regional ambulances
and other emergency services that play the
initial key role in any emergency medical
transport.
Nurses and paramedics staff the helicopter
and each of the ground ambulance bases.
Transport nurses have several years of
critical care and emergency department
experience. Our paramedics are welltrained in critical care and advanced skills
and also have several years in emergency
medical services.
On average, the Spirit helicopter flies over
600 missions a year, while the ground
6
Ground units based in Marshfield at Sa
Key Facts About Spirit
Medical Transportation Services:
transport teams average over 2,900 calls.
The combined team provides the most
comprehensive medical transport service
in the region.
High-risk newborns that need specialized
care and treatment are often transferred to
Saint Joseph's Hospital Level III NICU.
For these transports, the Spirit Medical
Transportation Service crew is joined by a
neonatal transport nurse and respiratory
therapist. This team has advanced training
in the stabilization and care of critically ill
neonatal patients during transport.
This team effort of more than 100 employees i
*comprised
of Medical Control Physicians, nurses
paramedics, EMTs, pilots, ambulance drivers,
communication specialists, support staff and mecha
* Top transport types are cardiac, medical and trau
* Covers a 35-county radius.
* Average flight run is 1.25 hours.
can travel between 130 - 160 mph
* Helicopter
under normal flight conditions, with an
average speed of 145 mph.
Looking back over the 15-year history of
the program, Saint Joseph’s Hospital
Executive Vice President Terri Richards
noted, “Our program has grown to
continue to meet the needs of our
communities with a highly skilled team
that pays special attention to safety. The
Spirit crews demonstrate every day our
commitment to quality and the highest
level of patient care.”
The 15th anniversary will be celebrated
with a variety of events and activities
across the region. As the anniversary year
comes to a close, the program will take
ownership of the new American
Eurocopter EC145 helicopter, one of the
most advanced airships in service for
medical transportation today. Mock Farm accident scene working with the
Pittsville Fire Department.
Sp
Spring 2009
portation Services
ary
N C R TA C U P D A T E
What is the
RTAC’s Role in
Reviewing EMS
Trauma Care?
Michael Fraley, BS, NREMT-P, NCRTAC Coordinator
O
ccasionally I get calls or emails asking me if the
RTAC should review a particular pre-hospital
call. My response is usually, “What does your
service normally do to review calls?”
int Joseph’s Hospital.
Spirit crew loading a
patient for transport.
is
s,
nics.
uma.
Weston ground unit outside
Saint Clare’s Hospital.
Captain
Nils Strickland
Night time shot after snow fall Marshfield base.
Spirit crew member working
with a pediatric patient.
pirit crew members rushing a patient
into the Emergency Department.
A well-publicized, tragic event is not the best time
to start a Process Improvement (PI) program. A
better option is having a PI plan already in place and
reviewing calls based on set inclusion criteria, not
just because it seems like a particular call should be
under the spotlight. Doing this tends to put the
participants in a defensive “What did we do
wrong?” mindset rather than viewing it as “How can
we improve our system?”
The RTAC’s PI Committee may provide a forum for
doing case reviews, but more importantly, we’ve
already provided several tools to individual services
to build a PI program. An example of a simple PI
program is reviewing all trauma calls using the
NCRTAC Trauma and Triage Guidelines to
determine if a trauma patient was properly identified
as critical or not, and if they were transported to an
appropriate level trauma center. From there, you can
look at scene times, whether or not ALS or
helicopters should have been used, and
documentation of important data such as mechanism
of injury, a primary survey and initial vital signs,
including GCS. The NCRTAC also has a sample PI
form available for selective spinal immobilization
cases. Others can be developed at your request.
A service could also set up criteria to do a more
thorough review of a call if it met certain inclusion
criteria, such as a trauma death, pediatric patients,
etc. Inclusion of your medical director is important.
He or she may not be able to review all cases but
should be consulted for questionable runs. Services
should also have a system to review calls referred
back to them by the Trauma Program Manager at
the receiving trauma center. All hospitals should be
including EMS care as part of their PI processes,
and you should be part of the feedback loop.
Contact your hospital’s Trauma Program Manager to
ask how you can be included. 7
Trauma Care Through a Lifetime
Mary Jo Casey, BSN, RN, Trauma Program Manager, and Amy Schmidt, BSN, RN, Pediatric Trauma Program Coordinator
The call goes out: car versus deer,
vehicular rollover, four occupants. As
you respond to the scene, your thoughts
are racing as you anticipate what you
will discover.
Throughout Wisconsin, there are more than
100 hospitals. For trauma care, most are selfdesignated or state designated Level III or IV
Trauma Centers. Nine hospitals in Wisconsin
are American College of Surgeons (ACS)
Verified Level I or II Adult Trauma Centers,
providing the highest level of trauma care.
Only three hospitals in Wisconsin are
Pediatric ACS Verified Trauma Centers—
they include Saint Joseph’s Hospital in
Marshfield, Children’s Hospital of Wisconsin
in Milwaukee, and University of Wisconsin
Hospital and Clinics in Madison. Saint
Joseph’s Hospital is distinguished in our
region as the only ACS Verified Adult and
Pediatric Level II Trauma Center.
You arrive at the car and find a family—
dad, mom, son, and daughter. Dad and
son—are un-responsive, the daughter has
a deformity to her upper arm and facial
bruising, and mom has no apparent
injuries. The call is placed for ALS air
and ground transport. Ground arrives
and transports the daughter and mom to
the local Level III Trauma Center. Your
assessment reveals both father and son
are severely injured and are transported
from the scene to Saint Joseph’s Hospital,
an ACS Verified Adult and Pediatric Level
II Trauma Center. Once there, both adult
and pediatric trauma activations are
called. You hand off care, your run report
is completed, yet the patients’ and family’s
stories are just beginning.
Decisions made in the field can impact life.
The physician’s admission note reads:
“Prior to transport, the patient
developed signs of respiratory distress
with absent breath sounds noted on the
right. Needle decompression was
performed with improvement in breathing.”
8
Transport decisions made in the field may
determine how a family responds and copes.
Physical separation of family members
creates stress during an already stressful
time. If one family must be taken to different
hospitals, communication with each hospital
about the location of other family members is
needed. Thinking beyond the Emergency
Department to the long-term needs of the
patient and family can positively affect the
outcomes for everyone concerned.
The father and son are airlifted to Saint
Joseph’s Hospital and admitted to the
Intensive Care Unit and Pediatric
Intensive Care Unit, respectively. Mom
alternates between her husband and
son’s bedside, only leaving to sleep at the
nearby Ronald McDonald House, a
facility unique for a rural community.
The separation from her daughter is
difficult, but mom will be okay. Her
husband and son need her more. Her
daughter is being cared for by relatives
since her discharge from the hospital.
Patient care requires more than physicians
and nurses. It is a multi-disciplinary team
working in unison to provide skilled care and
decision-making for successful patient
outcomes.
Hospital staff provided mom with a
journal to keep track of her loved-ones’
progress. One of mom’s journal entries
reads: “Today has been hard. Ron was in
Physical and Occupational Therapy for
what seemed like hours today… Benji’s
recovery has been more difficult. He is
quiet, only laughing when the Child Life
Specialists come to see him. They help
distract him from the pain of his injuries.”
Trauma patients might require rehabilitation
to re-learn and adapt skills within the limits
of their injury in order to regain
independence and to return to their
communities.
The days continue and stretch into
weeks. Dad has made enough progress to
be admitted to the inpatient
rehabilitation center. The son, with his
severe traumatic brain injury, has a
prolonged hospital stay. With intensive
pediatric rehabilitation, the son is
discharged home with home health and
follow-up appointments.
Trauma Center staff thinks beyond the
Emergency Department, beyond in-patient
care, to rehabilitation and integration back
into the community. Saint Joseph’s Hospital’s
Rehabilitation Unit is accredited by the
Commission on Accreditation of
Rehabilitation Facilities (CARF) in three
areas: adult rehabilitation, child/adolescent
rehabilitation, and as a stroke specialty
program.
Mom’s final journal entry: “I give thanks
to everyone who has touched our family
and provided the care we needed to go
home. Their knowledge and skills saved
our family. I give thanks for providing a
place for us to be together. I give thanks
for life.”
Trauma Centers and Emergency Medical
Services provide ongoing excellence for
patients and communities which they serve.
This commitment is shown through
education and training. Saint Joseph’s
Hospital offers educational classes for EMS,
including Pre-hospital Trauma Life Support,
Pediatric Education for Pre-hospital
Professionals, Spirit Medical Transportation
Services Conference, and outreach visits to
EMS. Other offerings include Advanced
Trauma Life Support and Advanced Trauma
Care for Nurses, Trauma Nurse Core
Curriculum, Emergency Nursing Pediatric
Course and Outreach education, including
Rural Trauma Team Development Course
and outreach to hospitals.
Together; EMS, Ministry Health Care,
hospitals, regional and state trauma advisory
councils are all part of a trauma system. It’s a
system devoted to meeting the needs of the
injured patient, from injury prevention
through rehabilitation. Spring 2009
T
R A U M A
E
D U C A T I O N
Alcohol and Trauma
Amy Schmidt, RN, BSN, Injury Prevention/Outreach & Pediatric Trauma Program Coordinator, Saint Joseph’s Hospital Trauma Services
It’s midnight and the hospital trauma
pager goes off. The activation reads:
Level I adult trauma, bay 2, ETA 15
minutes. Nurses responding to the
activation look to the board for the
patient information, including if
alcohol was involved.
Not only will alcohol mask the pain from
traumatic injuries, it can also delay the
identification of injury during the exam.
A cervical collar needs to remain in place
until the patient is sober, and the intoxicated
patient cannot be discharged. Hospital
admission for observation is guaranteed.
vehicle collisions—consider a potentially
intoxicated hypothermic patient. Other
sources of alcohol-related trauma are
snowmobile collisions, fires and burns,
falls, drownings, tree stand falls, suicides,
aggravated assaults, and any other source
of injury you can imagine.
T
The respiratory system is also
compromised—alcohol can disrupt
ventilatory effort, leading to possible
interventions. Plus, the gag reflex is
depressed, increasing the risk of gastric
aspiration. Add sedating medications, and
you have a potentially serious situation.
How often are trauma patients admitted to
the hospital with positive blood alcohol
levels? Based on the Saint Joseph’s
Hospital Trauma Registry, in 2008, 22.31
percent of adults greater than age 18 had
positive blood alcohol levels.
he presence of alcohol in a trauma
patient is posted not for curiosity, but as
a factor in the physical assessment. EMS is
the first line of patient care. Information
that assists in guiding the trauma
resuscitation includes history, interventions,
and mechanism of injury. Early suspicion of
alcohol use will also assist in guiding the
initial assessment, and will impact the
patient’s hospital stay.
What can alcohol do?
It can mask injuries. Belligerence and noncompliance may be attributed to alcohol,
yet these are also signs of a head injury. A
change in mental status cannot solely be
attributed to alcohol, nor can one say there
is no cerebral injury in the presence of
alcohol. This necessitates a head CT.
Alcohol can adversely affect early
physiological responses to injury. For
example, the immunosuppressive
consequences of alcohol lead to antibiotic
use. The impaired cardiovascular response
to acute blood loss may lead to more
invasive monitoring. Acute alcohol
ingestion reduces the electrical threshold
(ventricular arrhythmias) and promotes
electro-mechanical dissociation (Moore,
2005).
Alcohol is involved in more than just motor
So what can EMS do? First, consider the
presence or suspicion of alcohol as part of
the assessment or the mechanism of injury.
This is vital information for trauma
physicians caring for the patient. Second,
make a difference in your community,
before the call comes. Consider becoming a
voice for injury prevention. Become an
agent for change. You may just save a life.
Reference: Moore, E. E. (2005) Alcohol and
Trauma: The Perfect Storm. The Journal of Trauma
Injury, Infection, and Critical Care, 59(3), 53-57.
Safety is Not by Accident
Deb Martin, RN, MSN, CCRN, CMTE, Flight Nurse, Spirit MTS
“…Spirit currently lifting, three souls
on board, 1 hour 20 on fuel, enroute to
________ with a heading of ________.
Estimated time en route __________...”
T
his daily verbiage is “normal” in our
dispatch center, and is mirrored 24/7 in
many communication centers both regionally
and across the country.
It’s difficult to remember when air medical
transport was not an option for rapid transfer
of the critically ill or injured. In fact,
availability is such that our geographic region
is privy to the response of no less than eight
different flight programs. While
advantageous if needed for multiple/mass
response, it also emphasizes the need for
vigilant safety practices.
Spirit Medical Transportation Services does
not take safety for granted, and is proud that
thousands of patients have been safely
transported since its inception in November
1993. However, we can never assume that
safety will “happen on its own.”
The recent unacceptable increase in the
national air medical accident rate has grasped
attention of media, the air medical transport
industry, EMS, fire, and law enforcement,
governmental agencies, and the public.
Numerous meetings and discussions have
been held, with inclusion of industry leaders,
the FAA, and NTSB. Subsequently, the need
for improved technology and reduction in
“human error” factors has been identified as
initial approaches to decrease known risk.
More stringent weather and operational
requirements are being integrated by many
vendors. Other improvements include
advancements in safety-related equipment
expected to become standard on newer
helicopters. These include but are not limited
to: state-of-the-art helicopter terrain
Continued on page 12.
9
H
E L P F U L
W E B
R E S O U R C E S
F
I
O R
Y O U R
N F O R M A T I O N
T
Everyone Goes Home
Wisconsin Department of Health Services, Emergency Medical Services
– The majority of questions pertinent to ambulance operations and
points of contact in Wis. can be found at this site.
dhs.Wisconsin.gov/ems
Scott Owen, Deputy Fire Chief, Marshfield Fire & Rescue Department
he following is a list of useful e-mail addresses with current
application to Emergency Medical Service operations:
North Central Regional Trauma Advisory Council – Excellent site to
follow the Trauma Advisory Council progress.
ncrtac-wi.org
Wisconsin Trauma Care System – Includes information about the
Wisconsin Trauma System for health care providers, legislators and
the public. Trauma brochures, Power-Point presentations, and a White
Paper are available for download.
wisconsintraumacare.org
Wisconsin Department of Transportation – Find Ambulance inspection
forms. Trans 309 and other news.
dot.wisconsin.gov/statepatrol/inspection/ambulance.htm
National Association of Emergency Medical Technicians – Resource site
for all EMS levels. Includes links for PHTLS and the AMLS programs.
naemt.org
National Registry of EMTs – Questions and answers to National
Registry issues, as well as exam dates and various criteria for students.
nremt.org/about/nremt_news.asp
Federal Emergency Management Administration – Source for disaster
preparedness and management, current and historical national news.
fema.gov
American Ambulance Association – Highlights current issues pertaining
to ambulances and hospital interaction.
the-aaa.org
Paramedic Systems of Wisconsin – Provides continuing education for
administrators of Advanced Life Support (ALS) ambulance services to
share information and work together for the betterment of Emergency
Medical Services in Wisconsin.
psow.org
Wisconsin EMS Association – Represents and supports the views and
interests of our membership in Wisconsin communities by promoting
education, sharing information and facilitating legislative action.
wemsa.com
American Heart Association – Main page for all links to the heart
association, including guidelines regarding the 2006 changes.
americanheart.org
National Highway Traffic and Safety Administration (NHTSA) –
Resources regarding federal rules for EMS and other traffic programs.
EMS is listed under “traffic safety.”
nhtsa.dot.gov/portal/site/nhtsa/menuitem
10
T
he fire service is filled with myths,
both large and small. Often times, we
act in unsafe ways because “it’s the
way we’ve always done it.” Unsafe
myths permeate our business, our
tradition, and our culture, passed on
from one generation to the next. These
myths gain acceptance within our
culture because they glamorize what we
do. New firefighter students are
taught correct and safe
ways to operate at fires
and emergencies, but
often, when they
join a department,
they’re “reeducated” as to
the ways “real
firefighters do
it.” Of course,
they want to fit in
and they strive to
emulate the perfect
picture of fire service
strength that the myths
perpetuate. And so the cycle
continues.
Take a minute and think back to when
you first started in the fire service. Were
you ever told by the other firefighters
that wearing your chin strap is
dangerous, or that you don’t need to
wear seatbelts because they will only
slow you down? How about the one
about “save your air for when you
really need it,” and “don’t put the
training fire out, let it burn a little.”
Perhaps you heard “real firefighters
don’t need all their PPE—your coat and
helmet is good enough.” These are just
a few items to get you thinking about
the way we have done business for
many, many years. In no way do I want
to take anything away from this great
job or its traditions, but I do want to
remove the tradition of death and dying
in the fire service. We will continue to
have an uphill battle if bad information
keeps getting passed along from one
generation to the next.
In 2004, the National Fallen
Firefighters Foundation (NFFF) held
the first annual Firefighter Life Safety
Summit in Tampa, Florida, to address
the need for change within fire and
emergency services. As a result of this
meeting, 16 Life Safety Initiatives were
produced to ensure that
Everyone Goes Home at
the end of the day. It
also gave the fire
service a blueprint
for making changes
to reduce the
number of
preventable
firefighter line of
duty deaths
(LODD).
Firefighters must
have the courage to
face a multitude of risks in
order to save lives and protect
their communities. Their courage
allows them to willingly risk their own
lives so that others can be saved.
However, a different type of courage is
required to stay safe in potentially
dangerous situations by avoiding
needless risks and tragic consequences.
I urge everyone to take a personal
inventory of their knowledge and
experience base. Are you passing along
the bad information and myths? Are
you buying into unsafe practices
because it makes the job more
glamorous, or because “that’s the way
it’s always been done?” Are you one of
those fire chiefs or line officers that
make up the excuses for your crews
because of their inadequate skills? We
don’t need to make this job more
difficult than it already is. By
continuing the cycle of safety abuse,
we’re helping to ensure that the number
Continued on the next page.
Spring 2009
Everyone Goes Home
of our line-of-duty deaths and injuries also
continues.
On the face of it, the Life Safety Initiatives
are fairly basic. Promoting their value to the
fire service should be like selling baseball
pitchers on the importance of the curveball
and the changeup. But it’s not as easy as that.
Few firefighters take issue with the
individual Life Safety Initiatives, in concept.
While the process of implementing specifics
within the Initiatives should yield healthy
discussions, the conceptual framework is not
P
O S T
-
T E S T
(continued)
only sound, but practically inarguable. What
makes the task of reducing line-of-duty
deaths and injuries so challenging is that
certain negative behaviors, attitudes, and
systems are engrained in many fire
department cultures. Our success in reducing
deaths and injuries on the job is directly
related to our ability to change behaviors and
attitudes—to change culture.
I encourage all emergency responders,
whether fire or EMS, to take the time and
visit the Everyone Goes Home Web site at
F O R
C
everyonegoeshome.com and attend one of
these firefighter life safety presentations. This
program is a must-see for all who care, share,
and have a feeling for the safety of all
firefighters. For more information, or to
inquire about scheduling a training
presentation, please contact me at
[email protected] or at the
Marshfield Fire & Rescue Department at
715.486.2094.
Be safe and ensure Everyone Goes Home at
the end of the day. O N T I N U I N G
E
D U C A T I O N
The following questions were taken from the various articles in this edition of Vital Connections.
Continuing Education Hours (1.5 hours) will be awarded for completing the following post-test.
1. Common injuries in pregnant patients include blunt
trauma to the head, neck, breasts and abdomen
as well as penetrating injuries from gunshot
wounds and knife wounds.
True or False
2. Pregnant patients in their late second or third
trimester should always be transported on cots in
the ____ _______ _________ position.
3. The initial management of the pregnant trauma
patient is no different than any other trauma
patient.
True or False
4. List the three conditions that must be met before a
pandemic can be declared:
1._____________________________________________
_______________________________________________
2._____________________________________________
_______________________________________________
3._____________________________________________
_______________________________________________
5. Proper planning strategies for a flu
pandemic are mandatory to achieve
the greatest good for the greatest
number of patients.
True or False
6. The use of “Red Lights and Sirens”
should be avoided as often as possible
and reserved for unstable medical
conditions when it is reasonable to
believe that the use of them will lead
to a clinically relevant time saver, to
delivery, to definitive care.
True or False
7. Spirit Medical Transportation Services:
a. Covers a 35-county radius
b. Is a team effort of more than 100
employees, comprised of: nurses,
paramedics, pilots, ambulance drivers,
communications specialists, support
staff and mechanics.
c. Average flight run is 1.25 hours
d. The helicopter can travel between
130 -160 mph under normal flight
conditions.
e. All of the above.
8. What affects can alcohol have on the Trauma
patient?
a. Alcohol can mask injuries and the pain from
injuries.
b. Belligerence and non-compliance may be attributed
to alcohol, but may also be a sign of head injury.
c. Alcohol can compromise ventilatory effort.
d. Alcohol depresses the gag reflex increasing the risk
of aspiration.
e. All of the above.
9. List some of the safety-related equipment expected
to become standard on newer helicopters:
_______________________________________________
_______________________________________________
_______________________________________________
10. Ongoing education, including landing zone
training, specialized patient care topics, and safety
concerns are paramount, and may also influence
optimal patient outcomes. Spirit MTS remains
committed to providing specialized
training/classes as requested by regional
agencies, hospitals and organizations.
True or False
(Please print legibly)
Name: ______________________________________ Address:__________________________________________________
City: ___________________________________________________________ State: ________
ZIP: __________________
Please return this completed post-test by May 25, 2009, to:
Don Kimlicka, EMS Coordinator, Saint Clare’s Hospital, 3460 Ministry Parkway, Weston, WI 54476-5220
A certificate will be sent to you.
11
U
P C O M I N G
E V E N T S
May 17 – 23
National EMS Week
May 19
Saint Clare’s Hospital EMS Appreciation
Event, 6 – 9 p.m., Saint Clare’s Hospital
Conference Center, Weston, Wis. For more
information, contact Don Kimlicka at
[email protected]
Saint Joseph’s Hospital EMS Appreciation
Event, featuring Dwight Polk, presenting, “I
Believe … Lessons I’ve Learned in 30 Years
of EMS,” Saint Joseph’s Hospital - Mother
Streitel Conference Center, Marshfield, Wis.
For more information, contact Sandy Johnson
at [email protected]
August 13 & 14
14th Annual Spirit Medical Transportation
Services Conference – “What’s Hot and
What’s Not in Trauma,” Ramada Inn,
Stevens Point, Wis. For more information,
contact Audrey Schmeeckle at
[email protected]
*Accreditation Statement: Marshfield Clinic is accredited by
the Wisconsin Medical Society to provide continuing medical
education for physicians.
Safety is Not by Accident
awareness and avoidance warning systems,
satellite tracking, in-flight weather radar, and
Night Vision Goggle capability, all of which
will be included in delivery of Spirit’s new
EC-145 later this year.
Additionally, various “human factors” have
been identified as the major contributor to
air medical crashes. Regionally, there are
many things we can do to minimize risk:
Recognize that responsibility for air medical
safety includes not only flight program staff,
but also agencies that request these services.
For scene response, this includes EMS, fire,
and law enforcement, while regional
hospitals fulfill a vital communications role
during interfacility transport. Regardless of
scenario, clear, concise and updated
information/radio traffic is paramount to
operational safety. Pre-planning and practice
“drills” should be vital components of all
supporting agencies, in order to effectively
plan for those “what ifs” and “atypical”
situations. If more than one helicopter is
being requested, it is vitally important to
share that information ASAP with all
services responding—to enhance
communication and safe operations for
everyone, both in the air and on the ground.
Always have a “Plan B” (for potential
ground transport need). As frequently
experienced here in the Midwest, “Mother
Nature” routinely influences whether
(continued)
conditions are safe for flight. While we
understand the frustration that a “weather
no-go” may cause for those at a hectic scene
or in a busy ED, conditions have been
deemed as unacceptable for safe flight at that
particular time. That said, due to geographic
location, there may be rare instances when
one program may be able to perform a
transport while another can not. While it is
recognized that “helicopter shopping” may
occur, this practice can be dangerous if all
information is not readily shared upfront.
Therefore, it is crucial that if another
program has already turned down a
transport, that this information is shared
prominently if calling another service.
Additionally, ongoing education, including
landing zone training, specialized patient
care topics, and safety concerns, are
paramount, and may also influence optimal
patient outcomes. Spirit MTS remains
committed to providing specialized
training/classes as requested by regional
agencies, hospitals, and organizations.
For more information, please contact Spirit
MTS at 715.387.7110 with your request, and
the appropriate crew representative will
contact you. Combined with the efforts of
our regional providers, we look forward to
further serving our shared patients in a
safety-enhanced environment. Non-profit Organization
U.S. POSTAGE
PAID
Wausau, WI
Permit No. 611
Vital Connections is
an EMS publication of
Saint Joseph’s Hospital
& Saint Clare’s Hospital.
Please send comments to:
Sandy Johnson, EMS Coordinator
Saint Joseph’s Hospital
611 Saint Joseph Avenue
Marshfield, WI 54449-1898
OR
Don Kimlicka, EMS Coordinator
Saint Clare’s Hospital
3400 Ministry Parkway
Weston, WI 54476-5220