Оглавление
Группа авторов. Emergency Medical Services
Table of Contents
List of Tables
List of Illustrations
Guide
Pages
Emergency Medical Services. Clinical Practice and Systems Oversight
Contributors
Foreword
Preface
References
About the Companion Site
CHAPTER 1 History of emergency medical services
Before 1966: Historical Perspectives
1966: Accidental Death and Disability: The Neglected Disease of Modern Society
Box 1.1 Key findings of the 1966 NAS‐NRC report
1973: The Emergency Medical Services Systems Act
Box 1.2 The Fifteen Essential EMS Components
1973–1978: Rapid Growth of EMS Systems
Personnel
Physicians
Prehospital Clinicians
Public Education
Communications
Transportation
Hospitals
1978–1981: EMS at Midpassage
Financing
Research
1981: The Omnibus Budget Reconciliation Act
1982–1996: Changing Federal Roles
Emergency Medical Services for Children Program
EMS Physicians 1982‐1996
Training 1982‐1996
Transportation 1982‐1996
1996‐2008: The Role of the Federal Government Matures, the United States Faces Terrorism, and EMS is at the Breaking Point. EMS Agenda for the Future
Box 1.3 EMS Agenda for the Future attributes of the EMS system
EMS Education for the Future: A Systems Approach
National Ambulance Fee Schedule
National EMS Information System
September 11, 2001
Advocates for EMS
Federal Interagency Committee on EMS
National EMS Advisory Council
Trends in Air Medical Services
Institute of Medicine Report on the Future of Emergency Care
2009–2020: A Period of Incremental Progress. Subspecialty in EMS Medicine
EMS Clinician Education
Community Paramedicine
National EMS Culture of Safety Project
EMS Agenda 2050
Acknowledgment
References
CHAPTER 2 EMS airway management: system considerations
The skills of airway management:an illustrative vingnette
Introduction
Challenges of airway managementin the field
Which airway, when, and how?
Considerations for basic airway interventions
Considerations for endotracheal intubation
Is prehospital ETI associated with improved outcomes?
Are adverse events common during prehospital ETI?
Should EMTs perform ETI?
Should EMS personnel limit the number of ETI attempts?
Considerations for drug‐facilitated intubation
Considerations for video laryngoscopy
Considerations for SGA
Considerations for surgical airways
Considerations in pediatric airway management
Who should manage the airway?
Clinician training and competency
Airway management protocol development and equipment selection
Quality management
Research
Critical decision making: an illustrative vignette
References
CHAPTER 3 Airway procedures
Introduction
Personal protective equipment during airway interventions
Basic airway interventions. Oxygen cannulas and face masks
Bag‐valve‐mask ventilation
Demand valve ventilation
Oropharyngeal and nasopharyngeal airways
Noninvasive positive‐pressure ventilation
Advanced airway management
Tracheal intubation
Orotracheal intubation
Video laryngoscopy
Nasotracheal intubation
Other intubation techniques
Supraglottic airways
Laryngeal tube
Laryngeal Mask Airway (LMA)
Other supraglottic airways
Surgical airways
Cricothyroidotomy
Transtracheal jet ventilation
Confirmation of airway placement
Methods for securing endotracheal tubes and supraglottic airways
Drug‐facilitated intubation
Rapid sequence intubation
RSI technique
Sedation
Paralysis
Sedation‐assisted endotracheal intubation
Other drug‐facilitated techniques
Conclusion
References
CHAPTER 4 Airway management: special situations
Introduction
Ground‐level airway management
Face‐to‐face intubation
Intubating under low light conditions
Minimizing airway management equipment
Telemedicine‐assisted airway management
Airway management in the tactical setting
Providing airway management during combat or tactical operations
Surgical airways in the tactical setting
Pandemic airway management
Conclusion
Acknowledgment
References
CHAPTER 5 Respiratory distress
Introduction
Prehospital assessment and diagnosis
Box 5.1 Common causes of respiratory distress in the EMS setting. Pulmonary
Cardiovascular
Upper Airway
Metabolic
Toxic Ingestions
Other
Box 5.2 History and exam findings by disease state. Asthma
Chronic Obstructive Pulmonary Disease
ADHF with Volume Overload
ADHF with Low Cardiac Output State
Sympathetic Crashing Acute Pulmonary Edema
Pneumonia
Pneumothorax
Pulmonary Embolism with Infarction
Pulmonary Embolism with Saddle Embolism
General treatment
Asthma
Chronic obstructive pulmonary disease
Acute decompensated heart failure and SCAPE
Pneumonia and infectious respiratory disease
Pulmonary embolus
Pneumothorax
Tracheotomy
Summary
References
CHAPTER 6 Oxygenation and ventilation
Introduction
Assessment of Oxygenation
Assessment of Ventilation
Box 6.1 Conditions that impair ventilation
Box 6.2 Factors that affect EtCO2
Assisting Oxygenation and Ventilation
Noninvasive Positive‐Pressure Support
Bag‐Valve‐Mask Ventilation
Mechanical Ventilation
Modes of Ventilation
Ventilator Settings and Troubleshooting
Pneumothorax
Box 6.3 Conditions associated with pneumothorax
Summary
References
CHAPTER 7 Hypotension and Shock
Introduction
Pathophysiology
Evaluation
Box 7.1 Signs and symptoms of shock
Additional Modalities to Assess Shock
Treatment
Hypovolemic Shock
Distributive Shock
Obstructive Shock
Cardiogenic Shock
Shock of Unclear Etiology
Pediatric Shock
Shock Interventions. Fluids
Ventilation
Vasopressors
Other Medications
Controversies. Shock Science
Sepsis
Hemorrhagic Shock
Protocol
Conclusion
References
CHAPTER 8 Vascular access
Introduction
Benefits
Risks
PERIPHERAL IV ACCESS. History
Technique (See Video Clip 8.1) 1. Preparation
2. Site selection
3. Clean the site
4. Insertion of the IV
5. Removing the needle
6. Securing the IV
Intraosseous Access
Technique (See Video Clip 8.2) 1. Preparation
2. Identify the landmarks and site
3. Clean the site
4. Insert the IO
5. Assess IO patency
6. Secure the IO needle
Central intravenous access
Special considerations. Accessing dialysis catheters and indwelling catheters
Other Alternative Vascular Access Points
Pediatric considerations
Ultrasound‐guided IV access
Conclusion
References
CHAPTER 9 Chest pain and acute coronary syndromes
Introduction
General approach
Box 9.1 Historical aspects of chest discomfort: the PQRST method
Role of emergency medical dispatch
The 12‐lead electrocardiogram
Prehospital electrocardiogram interpretation
Box 9.2 Causes of ST‐segment elevation on 12‐lead electrocardiogram
Medications
Oxygen
Aspirin
Nitroglycerin
Opiate analgesics
Beta‐Blockers
Prehospital fibrinolysis
Systems of care for STEMI
Prehospital notification/field cardiac catheterization laboratory. Activation
EMS transport
Destination protocols
Air medical evacuation of STEMI patients
Expanding the role of basic life support (BLS) clinicians
Other common causes of chest discomfort
Box 9.3 Causes of chest discomfort that are immediate life threats
Aortic dissection
Pericarditis
Pneumothorax
Pulmonary Embolism
Esophageal Perforation
Summary
References
CHAPTER 10 Cardiac dysrhythmias
Introduction
Evaluation
Step one: identify symptoms and how they relate to the rhythm
Step two: identify stable and unstable patients
Step three: classify the electrocardiogram findings
Rate
Regularity and duration
Unstable tachydysrhythmias
Step four: focus actions to evaluate stable but symptomatic and borderline patients
History
Physical examination
Stable narrow‐complex tachydysrhythmias
Stable wide‐complex tachydysrhythmias
Controversies. Rhythm strip versus monitor interpretation
Synchronization and sedation during countershock
Pediatric dysrhythmias
Torsades de pointes
Rhythm disturbances in renal failure patients
Protocols
Summary
References
CHAPTER 11 Cardiac procedures and managing technology
Introduction
Short‐term mechanical circulatory support devices
Intra‐aortic balloon pump
Non‐IABP percutaneous mechanical circulatory support devices
Extracorporeal membrane oxygenation
Long‐term mechanical circulatory support devices. Ventricular assist devices
Box 11.1 Examples of LVADs by generation. First generation (pulsatile blood flow)
Second generation (continuous flow)
Third generation (centrifugal flow)
Fourth generation
Box 11.2 Complications encountered in LVAD patients. LVAD‐specific complications
LVAD‐associated complications
Electrical cardiac support devices
Pacemakers
Box 11.3 Pacemaker codes
Implantable cardioverter defibrillators
Wearable cardioverter defibrillator
Pericardiocentesis
Conclusion
Acknowledgment
References
CHAPTER 12 Cardiac arrest systems of care
Introduction
Epidemiology of Cardiac Arrest
Elements of a Community Cardiac Arrest Care System
Bystander Recognition of Arrest and Calling for Help
Bystander Cardiopulmonary Resuscitation
Public‐Access Defibrillation
First‐Responder and Basic Life Support Care
Basic Life Support
Advanced Life Support
Communicable Disease Considerations
Post‐Resuscitation Care
Role of the Medical Director
Training and Equipment
Optimizing System Design
Hospital Liaison
Quality Improvement Program
Summary
References
CHAPTER 13 Cardiac arrest: clinical management
Introduction
Specific interventions. Chest compressions
Defibrillation
Airway management
Ventilation
Medications
Additional therapies
Principles of management. Resuscitation protocols
High‐performance CPR: the pit crew approach
When to initiate transport
COVID‐19 considerations
Withholding resuscitation
Dead on arrival
Termination of resuscitation
Post cardiac arrest care
Cardiac arrest referral centers
Summary
References
CHAPTER 14 The challenge of the undifferentiated patient
Introduction. The Call‐Taking Process
En Route to the Patient
History Taking
Physical Examination
Adjuncts to the History and Physical Examination: Prehospital Diagnostic Tests
The truly Undifferentiated Patient
Transition of Care to the Receiving Facility
Consequences of an Undifferentiated Condition
Strategies for Minimizing Errors in Clinical Reasoning
Conclusion
References
CHAPTER 15 Altered mental status
Introduction
Assessing mental status
Approach to the patient with AMS
Airway, ventilation, and oxygenation
Other vital signs
Physical exam
Head
Neck
Chest
Abdomen
Neurological
Skin
Historical and environmental clues
Initial management
Presentations, etiologies, and treatments
Box 15.1 Mnemonic for causes of altered mental status
Pediatric altered mental status
Alcohol
Time‐critical causes
On‐scene treatments and dispositions
Box 15.2 Causes of altered mental status in alcoholics
Glucose evaluation and administration
Opioid overdose
Refusal of care after resolution of AMS
Conclusion
References
CHAPTER 16 Syncope
Introduction
Pathophysiology
Assessment
Differential diagnosis
Treatment
Disposition
Summary
References
CHAPTER 17 Seizures
Introduction
Pathophysiology
Differential diagnosis
Box 17.1 Differential diagnosis of seizures in adults
Classification of seizure types
Box 17.2 Classification of seizure types
Symptomatic seizures
Febrile seizures
Status epilepticus
Box 17.3 Proposed terminology: status epilepticus
Box 17.4 Differential diagnosis of generalized convulsive status epilepticus
EMS evaluation and response
Box 17.5 Initial EMS approach to a patient with generalized seizures
Pharmacological interventions
Box 17.6 Initial benzodiazepine dosing for generalized convulsive status epilepticus in adults
Box 17.7 Initial benzodiazepine dosing for generalized convulsive status epilepticus in children
Seizure‐associated trauma
Continuing management
Refractory generalized convulsive status epilepticus
Conclusion
References
CHAPTER 18 Stroke
Introduction
Emergency medical dispatch
Prehospital care
Box 18.1 Mimics of stroke
Box 18.2 Inclusion and exclusion criteria for intravenous tPA. Inclusion criteria
Exclusion criteria
Relative contraindications
Relative contraindications for the 3‐ to 4.5‐h treatment window
Definitive treatment options
Box 18.3 Time interval goals for fibrinolytic therapy
EMS transport
Innovations in prehospital stroke management
Disparities
Summary
Acknowledgments
References
CHAPTER 19 Abdominal pain
Introduction
Approach to the patient with abdominal pain
Anatomy and physiology considerations
Box 19.2 Systemic causes of abdominal pain
History and physical examination
Box 19.3 Etiologies of abdominal pain by anatomical location. Right upper quadrant
Right lower quadrant
Left upper quadrant
Left lower quadrant
Box 19.4 OPQRST questions in abdominal pain
Management
Disposition
Special populations
Elderly
Females of Childbearing Age
Children
Immunocompromised
Obesity and bariatric surgery patients
Summary
References
CHAPTER 20 Diabetic emergencies
Introduction
Prehospital assessment. General
Other considerations
Measurement of glucose
Prehospital treatment. Hypoglycemia
Hyperglycemia
Pediatric Considerations
Pregnancy
Medication overdose
Disposition
Protocols
Summary
References
CHAPTER 21 Allergic reactions
Introduction
Physiology of allergic reactions
Box 21.1 Types of hypersensitivity reactions and anaphylaxis production
Box 21.2 Definition of anaphylaxis
Causative agents
Assessment and general approach
Prehospital treatment
Box 21.3 Common causes of allergic reactions. Medications
Foods
Stings/bites
Environmental exposures
Special considerations
Conclusion
References
CHAPTER 22 Renal failure and dialysis
Introduction
A brief review
Renal replacement therapy
Hemodialysis
Peritoneal dialysis
Renal transplant
Complications of renal disease
Fluid overload
Potassium
Magnesium
Pericarditis
Cardiovascular disease
Hematologic
Infection
Rhabdomyolysis
Complications of hemodialysis. Hypotension
Air embolism
Uncontrolled hemorrhage from shunt site
Disequilibrium syndrome
Complications of peritoneal dialysis
Special considerations. The missed dialysis patient
Hyperkalemia
Rapid sequence intubation and hyperkalemia
Use of dialysis access for resuscitation
EMS pearls. Focused history
Destination selection
Resource planning
Convalescent Transportation
References
CHAPTER 23 Infectious and communicable diseases
Introduction
EMS Clinician and Patient
General Approach and Patient Assessment
Specific Illnesses. Influenza
Avian Influenza
Tuberculosis
Coronaviruses
Biological Weapons
Anthrax
Box 23.1 Centers for Disease Control and Prevention categorization of bioterrorism agents. Category A
Category B
Category C
Botulism
Plague
Smallpox
Tularemia
Viral Hemorrhagic Fevers
Varicella Zoster Virus
Meningococcal Meningitis
Conclusion
References
CHAPTER 24 Choking
Introduction
Pathophysiology and epidemiology
Patient assessment
Management
Medical oversight considerations
Controversies
Summary
References
CHAPTER 25 Submersion injuries and drowning
Introduction
Epidemiology
Pathophysiology of drowning
Clinical management. Dispatch life support
Scene and crowd control
Management of the drowning victimin cardiac arrest
Management of non‐cardiac arrest drowning
Management of concurrent trauma
Rewarming of drowning victims
Destination decisions
Grief reactions
References
CHAPTER 26 Trauma systems of care
Trauma system organization
Box 26.1 Criteria for statewide trauma systems
Trauma care facilities
Communications
Emergency response
Medical oversight
Box 26.2 Audit filters for prehospital trauma care
Data collection
Emergency management
Injury prevention
Summary
References
CHAPTER 27 Blunt trauma considerations
Introduction
Effect on EMS
Training for EMS clinicians
Resuscitation and initial assessment
The primary survey
The secondary survey
The role of basic life support, advanced life support, and prehospital critical care assets
Constellations of blunt traumatic injury
Issues in specific patient populations. Blunt trauma in pregnancy
Geriatric trauma
Pediatric trauma
Medical oversight issues in trauma
Guidelines for out‐of‐hospital management
Air medical transport
Hospital destination
Trauma scoring
Prevention and other public health issues
References
CHAPTER 28 Motor vehicle crashes
Introduction
Effect on EMS
MVC injury biomechanics
Safety restraints
MVC types
Planar crashes
Frontal
Side
Rear
Rollover crashes
Unusual crashes
Crashes involving vulnerable road users
EMS crash assessment priorities
Extrication
Field Triage
Unique MVC problems
Batteries
Airbags
Emerging technology. Advanced automatic crash notification
Available education
References
Chapter 29 Penetrating trauma
Introduction
Physics and mechanics of penetrating trauma
Ballistics
Size
Velocity
Shape and deformation
Stability
Types of weapons. Knives and Arrows
Handguns
Rifles
Shotguns
High‐velocity projectile injury
Direct injury
Pressure Wave
Cavitation
Entry and exit wounds
Resuscitation and initial assessment
Scene safety
Impaled objects
Spinal motion restriction
External hemorrhage
Permissive hypotensive resuscitation
Tranexamic acid
Transport issues “Scoop and Run” versus “Stay and Play”
Penetrating chest trauma
Lungs and bronchial tree
Heart and great vessels
Diaphragm
Penetrating abdominal trauma
Penetrating neck trauma
Penetrating head and facial trauma
Penetrating extremity trauma
Prevention and public health issues
Medicolegal issues
Forensic issues
Prehospital termination of resuscitation in penetrating trauma
Summary
References
CHAPTER 30 Traumatic Brain Injury
Introduction
Primary assessment
Secondary assessment
Other Assessment Considerations
Prehospital intubation
Additional treatments
Concussion and Sports‐Related Head Injuries
Pediatrics
Prevention
Transportation and Destination Decisions
Summary
Acknowledgments
References
CHAPTER 31 Electrical injuries
Introduction
Pathophysiology
Voltage
Type of current
Amount of current
Resistance
Pathway of the current
Duration of contact
Evaluation and treatment. Scene considerations
Assessment and management
Special circumstances. Lightning injury
Pediatrics
Pregnant patients
Conclusion
References
CHAPTER 32 Blast injury
Introduction
Explosive devices
Blast injury
Primary blast injury
Secondary blast injury
Tertiary blast injury
Quaternary blast injury
Quinary blast injury
Prehospital resuscitation and treatment
Medical oversight. Training
Hazardous materials
Forensic science
Medical threat assessment
Preventive medicine and force health protection
Improvised explosive devices and terrorist activity
Community risk assessment
Secondary devices and scene safety
Summary
References
CHAPTER 33 Thermal and chemical burns
Introduction
Pathophysiology
Severity
Depth
Burn size
Inhalation injury
Chemical burn
Specific training requirements
Burn‐specific patient assessment and care
Box 33.1 Basic fluid guidelines for burn injuries
Special considerations. Compartment syndrome
Pain management
Hydrofluoric acid burn
White phosphorus burn
Airbag burns
Guidelines for out‐of‐hospital management
Box 33.2 American Burn Association Burn Center Referral Criteria
Requirements for transfer
Prevention
Box 33.3 Burn injury prevention
Conclusion
References
CHAPTER 34 Crush injury
Definition and concepts
Pathophysiology of crush injuries
Clinical setting
Management of crush injury
Management of crush injury with suspected crush syndrome
Transport destination considerations
Conclusion
Acknowledgment
References
CHAPTER 35 Hemorrhage control
Introduction
Assessment
Diagnosis of hemorrhagic shock
Treatment modalities. Pressure
Tourniquets
Nonmedical personnel training
Rapid wound closure
Internal occlusion
Advanced hemostatic agents
Box 35.1 Ideal properties for hemostatic agents used in the prehospital setting
First generation: zeolite
Second generation: Celox
Second generation: Combat Gauze
Third generation: Celox‐XG
Adjunctive therapy. Permissive hypotension
Prevention of hypothermia
Transfusion
Medications. Recombinant factor VIIA (Novoseven)
Tranexamic acid (TXA)
Antiplatelet and anticoagulation medications
Summary
References
CHAPTER 36 Orthopedic injuries
Introduction. Epidemiology
General approach to management
Anatomy, fractures, and dislocations. Upper extremity. Upper extremity neurovascular exam
Clavicle
Scapula
Shoulder
Humerus
Elbow
Forearm
Wrist
Hand/fingers
Pelvis
Lower extremity. Lower extremity neurovascular exam
Hip
Femur
Knee
Leg injuries
Ankle and foot injuries
Spine
Splinting. Indications and basic technique
Splinting materials
Traction splints
Reductions with (and without) medications. Field reduction versus definitive care
Common field reductions without medications
Special considerations: partial or complete amputations and neurovascular injuries
Conclusion
References
CHAPTER 37 Ocular trauma
Introduction
Epidemiology
Evaluation
Specific eye injuries. Ocular burns
Globe injuries
Traumatic hyphema
Corneal injuries
Retinal injuries
Summary
References
CHAPTER 38 Bites, stings, and envenomations
Introduction
Animal bites. General. Scene safety and planning
Refusal concerns
Animal‐specific concerns. Mammals
Rabies
Reptiles. Venomous Snakes
Nonvenomous Snakes
Other Reptiles
Marine animals
Insect bites and stings. Butterflies, moths, and caterpillars
Hymenoptera
Spiders
Scorpions
Ticks
Nonindigenous animals
Transport
Summary
References
CHAPTER 39 Field trauma triage
Background
History of the field triage decision schemes
Accuracy of field triage
Field triage decision scheme
Step one: physiological criteria
Step two: anatomical criteria
Step three: mechanism of injury criteria
Step four: special considerations
Pediatric concerns
Older adults
International trauma triage models
Future research for field triage
Conclusion
References
CHAPTER 40 Trauma‐stabilizing procedures
Introduction
Needle thoracostomy
Indication
Technique
Complications
Tube and finger thoracostomy
Indication
Technique
Complications
Pericardiocentesis
Indication
Technique without ECG or ultrasound guidance
Technique with ECG guidance
Technique with ultrasound guidance
Complications
Spinal motion restriction
Indications
Selective spinal motion restriction
Application of cervical collar
Indication
Technique
Complications
Application of a long spine board (backboard)
Indication
Equipment
Long spine board technique
Scoop stretcher technique
Vacuum mattress technique
Extrication device technique
Complications
Padding
Children
Summary
Acknowledgments
References
CHAPTER 41 Physiology of pregnancy
Introduction
General considerations. Critical care and trauma
Airway
Box 41.1 Anatomical and physiological considerations affecting the obstetric airway
Breathing
Circulation
Toxicology
Box 41.2 Indications for hyperbaric oxygen therapy in the pregnant patient
Pregnancy Effects by System (Box 41.3) Box 41.3 Physiology changes in pregnancy
Cardiovascular
Respiratory
Hematologic
Gastrointestinal
Renal
Endocrine
Neurology
Summary
References
CHAPTER 42 Emergencies of pregnancy
Introduction
Evaluation and transport of the pregnant patient
Miscarriage
Ectopic pregnancy
Patient history
Physical examination
Management
Placental abruption
Patient history
Physical examination
Management
Placenta previa
Patient history
Physical examination
Management
Hypertension during pregnancy
Preeclampsia
Patient history
Management
Eclampsia
Management
Conclusion
Acknowledgment
References
CHAPTER 43 Normal childbirth
Introduction
Pregnancy. Definitions
Gestational age
Evaluation of the pregnant patient
Ultrasound in pregnancy
Labor and delivery. Active labor
Imminent delivery
Delivery of the neonate
Postdelivery: care of the neonate
Delivery of the placenta
Challenges of prehospital deliveries
Special considerations. Pregnant trauma patient
Pregnant patient in cardiac arrest
References
CHAPTER 44 Childbirth emergencies
General considerations and resource management
Management of abnormal presentations. Umbilical cord prolapse
Breech
Shoulder dystocia
Vaginal hemorrhage
Conclusion
References
CHAPTER 45 Perimortem cesarean section
Background
Potential benefits of perimortem C‐section
Performance of perimortem C‐section in the field
Indications for perimortem C‐section
Education
Procedure
Ethical and legal considerations
Conclusion
References
CHAPTER 46 Principles of toxicology
Introduction
Evaluation
History
Physical examination
Toxidromes
Cardiac monitor and electrocardiogram
Box 46.1 Sodium channel‐blocking drugs
Box 46.2 Drugs that block efflux from potassium channels causing QT prolongation
Treatment
Decontaminating the poisoned patient
Dermal decontamination
Ocular decontamination
Gastrointestinal decontamination
Antidotes
Atropine
Flumazenil
Naloxone
Cyanide antidotes. Sodium thiosulfate
Sodium Nitrite
Hydroxocobalamin
Special considerations. Radiation exposures
Caustic exposures
Protocols
Summary
Acknowledgments
References
CHAPTER 47 Treatment and evaluation of specific toxins
Introduction
Specific agents. Organophosphates and nerve agents
Pathophysiology and clinical presentation
Decontamination and PPE
Detection and diagnosis
Treatment and disposition
Gases (irritants and hydrocarbons)
Carbon monoxide
Cyanide
Hydrogen sulfide
Vesicants
Summary
References
CHAPTER 48 Cold exposure illness and injury
Introduction
Accidental hypothermia. Definition
Mechanisms
Prevention
Recognition/diagnosis
Treatment
Disposition
Nonfreezing cold injuries of the foot. Definition
Prevention
Recognition/diagnosis
Treatment
Frostbite/Freezing Cold Injury. Definition
Prevention
Recognition/Diagnosis
Treatment
Cold‐water immersion
Conclusion
References
Additional References
CHAPTER 49 Heat‐related illness
Introduction
Physiology of thermoregulation
Pathophysiology
Heat edema
Treatment
Heat syncope
Treatment
Heat tetany
Treatment
Heat cramps
Treatment
Heat exhaustion
Treatment
Heat stroke
Treatment
Cooling techniques
Exertional heat stroke
Summary
References
CHAPTER 50 High‐altitude illnesses
Introduction
Physiology
Acute mountain sickness. Pathophysiology
Symptoms/diagnosis
Treatment
High‐altitude cerebral edema. Pathophysiology
Symptoms/diagnosis
Treatment
High‐altitude pulmonary edema. Pathophysiology
Symptoms/diagnosis
Treatment
Portable hyperbaric chambers
Considerations for the medical director
Conclusion
References
CHAPTER 51 Effects of flight
Introduction
Aerodynamic forces
Effects on humans
Atmospheric effects
Aircraft effects
Other concerns in the flight environment
Summary
References
CHAPTER 52 Diving injury
Introduction
Types of diving. Freediving
Scuba diving
Surface‐supplied diving
Saturation diving
Overview of diving physics
Boyle’s Law
Dalton’s law
Henry’s law
Diving injuries
Injuries of descent
Ear barotrauma
Sinus barotrauma
Other barotraumas of descent
Injury at depth
Nitrogen narcosis
Oxygen toxicity
Box 52.1 Symptoms of CNS and pulmonary oxygen toxicity
Shallow water blackout
Injuries of ascent. Barotrauma of ascent
Pulmonary barotrauma
Decompression illness
Arterial gas embolism
Decompression sickness
Approach to management of diving injuries
Box 52.2 ABCs for the injured diver
Box 52.3 Targeted questions for diving casualties
Specific interventions for DCI (DCS and AGE)
Box 52.4 Divers Alert Network (DAN) emergency hotline
Transportation considerations
Conclusion
Acknowledgment
References
Note
CHAPTER 53 The special needs of children
Epidemiology of prehospital pediatric care
Evaluation of children
Pediatric Assessment Triangle
Vital signs
Heart rate
Respiratory rate
Blood pressure
Pain
Weight measurement
Specialized equipment needs
Developmental approach
Infants
Toddlers
Preschoolers
School‐aged children
Adolescents and teenagers
Children with special health care needs
Consent issues
References
CHAPTER 54 Pediatric medical priorities
Introduction
Respiratory and airway problems
Pediatric respiratory anatomy and physiology
Upper airway
Lower airways
Respiratory failure and apnea
Bag‐valve‐mask
Supraglottic airway
Endotracheal intubation
Advanced airway conclusion
Brief resolved unexplained events (BRUE)
Seizures and seizure mimics
Shock
Cardiac arrest
Bystander and dispatcher‐assisted CPR
Cardiopulmonary resuscitation
Post‐cardiac arrest care
Medication dosing safety
Summary
References
CHAPTER 55 Pediatric trauma priorities
Introduction
Anatomical/physiological considerations and resulting injury patterns. General
Head
Airway
Spinal Column
Cardiovascular
Chest, abdomen, musculoskeletal, and skin
Resuscitation and management priorities. General
Pain management
Nonaccidental trauma
Field triage
Summary
References
CHAPTER 56 Technology‐dependent children
Introduction
The caregiver as a resource and the emergency information sheet
The technology. DOPE mnemonic
Noninvasive positive pressure ventilation
Tracheostomy tubes
Ventilators
Home oxygen
Gastrostomy/gastrojejunostomy tubes
Vagus nerve stimulators
Cochlear implants
Ventriculoperitoneal shunts
Central venous catheters
Conclusion
References
CHAPTER 57 Approach to the geriatric patient
Introduction
Changes of normal aging
Assessment of the geriatric patient
Geriatric medical conditions. Cognitive Impairment
Depression
Falls
Medications and drug toxicity
Altered mental status
Cardiac arrest
Trauma
Social emergencies
Medication and alcohol abuse
Elder abuse and maltreatment
Caregiver fatigue and burnout
Special considerations
Nursing homes and assisted living facilities
Public health. Community paramedicine
Infectious disease
Summary
References
Chapter 58 Behavioral health emergencies
Introduction
Evaluation of the problem
Assessment and treatment
The suicidal patient
The agitated and violent patient
Patient restraint
Verbal de‐escalation
Physical restraint
Medication to treat agitation
Benzodiazepines
Butyrophenones
Ketamine
Excited delirium syndrome
Other situations
Controversies and common mistakes
Summary
Acknowledgment
References
CHAPTER 59 Bariatric patient challenges
Introduction
Airway
Breathing
Circulation
Bariatric surgery
Patient packaging and movement
Summary
References
CHAPTER 60 Intimate partner violence
Introduction
Scope of the problem
Risks and vulnerabilities
Understanding IPV
Typologies of IPV
Duluth Power and Control Wheel
IPV as a health care issue
EMS clinician safety
Assessment and examination
[R]ecognize the indicators of IPV
[R]espond
[R]efer
[R]ecord
Additional considerations for EMS personnel
Assessing risk
Safety planning
Using a trauma‐informed approach
Realistic expectations
Summary
Acknowledgment
Recommended Resources:
References
CHAPTER 61 Sexual assault
Background
Consent
Drug‐facilitated sexual assault
Male sexual assault
Transgender sexual assault
Psychological care of the patient
Physical care of the patient
Culture and sexual assault
Legal aspects
Documentation
Preservation of evidence
Chain of custody
Mandatory reporting
Sexual assault nurse examiners and sexual assault response team programs
Summary
Acknowledgment
References
CHAPTER 62 Child maltreatment
Introduction
Role of the prehospital clinician
Child maltreatment
Assessment and general approach
Secondary survey: signs and symptoms suggestive of abuse or neglect
Bruising
Burns
Fractures
Transport Decisions
Scene Survey
Getting the History
Communicating with the child and caregivers
Documentation
Medical conditions that may be confused with child abuse
Sexual abuse
Responding to intimate partner violence calls
Medicolegal duties
Summary
References
CHAPTER 63 Human Trafficking
Introduction
Definitions
Myths
The scope of the problem
The traffickers and the victims
Red flags and indicators
Clinical practice: EMS patient evaluation and care. Goals of patient interaction: safety first
Trauma‐informed care
Screening tools, checklists, and field reference guides
Barriers to recognition and trauma‐informed care
Disposition and transport (including patients who decline transport or assistance)
Victim support
Documentation and reporting
Ethical considerations
System oversight/medical direction considerations
Education and training
Screening tools, checklists, and field reference guides
Protocols, procedures, and policies
Resource Information for Patients
Debriefing and performance improvement
Conclusion
Acknowledgment
Selected resources to assist with clinical practice and system oversight(**Highly Recommended) Human trafficking
Videos
Trauma‐informed care
References
CHAPTER 64 Ethical challenges
Introduction
Refusal of treatment and transport
Triage decisions
Termination of resuscitation
Confidentiality
Truth‐telling and error disclosure
Personal risk
Training and research
Treatment of minors
Summary
References
CHAPTER 65 Death, dying, and end of life issues
Introduction
Ethical foundations of end of life care
Background
Culture, customs, and racial disparity
Advance directives
The Physician Orders for Life‐Sustaining Treatment Program (POLST)
Do not resuscitate orders
End of life resources and other considerations. Palliative care and hospice
Hospice and EMS
Care of the grieving survivors
Considerations during a pandemic
Summary
Dedication
References
CHAPTER 66 Family and bystanders
Introduction
Family support in patient care
Ethnicity and culture of EMS clinicians
The future of EMS and the role of family
Social isolation
Isolation during quarantine
Bystanders
Spontaneous volunteers and civilian‐led rescue
Bystanders and physicians on the scene
EMS and violent bystanders
Summary
References
CHAPTER 67 Analgesia
Introduction
Oligoanalgesia
Opioids
Box 67.1 Desired characteristics
Fentanyl
Morphine
Nitrous oxide
Ketamine
Nonsteroidal anti‐inflammatory drugs (NSAIDs)
Acetaminophen
Nonpharmacological interventions
Assessment of pain
Addressing common myths
Summary
References
CHAPTER 68 Point‐of‐care testing in EMS
Introduction
Is POC right for EMS?
Is this POC test right for my service?
Specific POC tests for consideration in the EMS setting. Detection of coagulopathy. Is it valid?
Is it logical/feasible for EMS?
Will it matter clinically? In trauma:
In stroke:
Troponin. Is it valid and reliable?
Is it practical?
Will it make a difference clinically? In chest pain:
Lactate. Is it reliable?
Is it practical?
Will it make a difference clinically? In trauma:
In sepsis:
Brain natriuretic peptide (BNP)
Carbon monoxide (CO)
Capnography. Is it valid and reliable?
Is it practical/feasible?
Will it make a difference to patient care clinically?
Unique aspects of POC testing in mobile integrated health/community paramedicine
Other tests
Information sharing and decision support
Conclusion
References
CHAPTER 69 Ultrasound applications in the prehospital setting
Introduction
Why Prehospital Ultrasound?
Settings of Field Use
Indications
Trauma
Pulmonary
Cardiac and Resuscitation
Abdominal
Obstetrics
Musculoskeletal
Neurologic
Other
Prehospital Ultrasound Protocols
Disaster and Mass Casualty Triage
Military
Role of Non‐Physicians/EMS Training
Tele‐ultrasound
Feasibility of Ultrasound in the Field
Future Directions
Video 69.1
Video 69.2
References
Appendix Chapter Mapping to the 2019 Core Content of EMS Medicine
Glossary
Index
Emergency Medical Services. Clinical Practice and Systems Oversight
Contributors
Foreword
Preface
References
About the Companion Site
CHAPTER 70 Medical oversight of EMS systems
Introduction
The evolution of the subspecialty of EMS
State requirements for EMS medical direction
Box 70.1 Qualification of an EMS medical director
Barriers to effective medical oversight of EMS
Box 70.2 Authority, support, and resources required by an EMS medical director. Authority to
Supported by administration to
Resources
Position within the organization
Indirect medical oversight
EMS clinician education
Verification of competency and EMS clinician credentialing
System quality and performance improvement
Protocol development
Base stations and hospital engagement
Designation and oversight of trauma and specialty centers
EMS clinician safety and well‐being
EMS administrative issues–management and finance
Legal and regulatory issues
Box 70.3 State and federal laws that may affect an EMS medical director
EMS Research
Public health–public education, prevention, and response to catastrophic health events
Direct medical oversight
Field clinical supervision
Direct patient care in the field
Box 70.4 Potential interventions by EMS physicians that are typically not in the scope of practice of other EMS clinicians
Longevity of the medical director
Conclusion
Acknowledgment
References
CHAPTER 71 Principles of EMS system design
Introduction
System Design Goals
Services
Prevention and Public Education
Triage
Medical First Response
Ambulance Response and Transport
Mobile Integrated Health Care/Community Paramedicine
Pre‐Arrival Instructions
Assessment and Treatment
Medical Transportation
Mass Gatherings
Disaster Preparedness and Management
Interfacility/Critical Care Transport
Air Medical Transport
Hazardous Materials Response Medical Support
Tactical Response Medical Support
Vehicles Equipment and Supplies
Delivery Settings
Urban/Suburban
Single Versus Multiple Ambulance Service Providers
ALS and/or BLS Levels of Care
Tiered Response
Hospital Destination Policies
Rural
Industrial
International
Provider Organization Considerations
Fire Department EMS
Law Enforcement EMS
Municipal EMS
Private EMS
Military EMS
Unionized Workforce Considerations
Deployment Planning
Performance Standards and Assurances
Transparency and Accountability
Acknowledgments
References
CHAPTER 72 Emergency care regionalization
Regionalization
A case example
The emergency medical care system
Historical background
Categorization and designation
Federal efforts: Public Law 101‐590
Simultaneous processing
Outcomes
Trauma
Stroke
STEMI
Diversion and bypass
Payer and funding issues
Future directions
Conclusion
References
CHAPTER 73 Telemedicine and emerging telecommunications
Introduction
EMS telemedicine applications
Teleconsultation
Telecardiology
Telestroke
Refusal of medical care
Patient transport decision making
Mobile integrated health care/community paramedicine
Telemonitoring
Telementoring
Airway management
Ultrasound
Combat and tactical EMS
Mass casualty incidents and disaster medicine
Conclusion
References
CHAPTER 74 Interfacility transportation
Introduction
Level of care
Personnel
Clinical indications for interfacility transportation
Trauma
Cardiac
Stroke
Burns
Spinal trauma
Obstetrics
Pediatric and neonatal
Hazards associated with interfacility transportation
Lights and siren
The unstable patient
Volatile gatherings
Disaster
Medical oversight of interfacility transport
Legal considerations in interfacility transportation
Mode of transport
Interstate licensing
EMTALA
Videoconferencing
Summary
Acknowledgments
References
CHAPTER 75 Air medical services
Introduction
Background: History to Current. Military Medicine
Civilian Medicine
System Design, Growth, and Costs
Clinical Efficacy, Appropriateness, and Outcomes
Potential Benefits to Patients
Potential HEMS Benefits to Systems
Extension of Advanced Care Throughout a Region
Provision of ALS “Backup”
Minimizing Transport Times and Direct Transport to Specialized Centers
Transport Flexibility in Overloaded Hospital Systems
Disaster Response
Go Teams
Safety, Quality, and Standards
Quality
Standards
Accreditation
Box 75.1 Association of Critical Care Transport Standards Elements
Integration and Regulations
Regulation
Federal Aviation Regulations
Operations
Clinical Operations
Vehicles/Mode of Transport
Rotor‐Wing Aircraft/Helicopters
Fixed‐Wing Aircraft/Airplanes
Vehicle Attributes and Considerations. Space
Weight
Auditory
Lighting
Electronic Medical Equipment
Operational Challenges
Weather and Visibility
Ambient Temperature
Hazardous Materials or Infectious Disease
Unusual and Ad Hoc Operations
Summary
References
CHAPTER 76 EMS personnel
Introduction
Scope of practice
The interdependent relationship between education, certification, licensure, and credentialing
Market forces and the need for governmental supervision
Regulating health care professions
Regulatory options
Occupational regulation
The regulation of EMS personnel
Box 76.1 Complementary national, state, and local processes
National EMS certification
State licensure
Rule making
Assessment of initial competence
Establishment of entrance requirements
Ensuring continued competence
Discipline
Local Credentialing
Summary: the synergy of three layers of public protection
Acknowledgments
References
CHAPTER 77 Protection of EMS personnel from occupationally acquired infections
Introduction
Standards, laws, and regulations. CDC guidelines
OSHA regulations
Ryan White Act
NFPA standards
Blood‐borne pathogens
Hepatitis B virus
Box 77.1 Body fluid infectivity
Hepatitis C virus
Human immunodeficiency virus
Airborne, droplet, and contact transmission of infection
M. tuberculosis
Recommended immunizations
Reporting an exposure
Summary
Acknowledgment
References
CHAPTER 78 Medical surveillance of emergency response personnel
Regulatory framework
Overview
Initial employment exam
Baseline exam
Annual or periodic examination
On‐scene medical monitoring
Exposure‐specific examination
Termination or exit exam
Summary
References
CHAPTER 79 EMS clinician wellness
Introduction
Wellness of EMS personnel
General health
Body weight, tobacco use, and physical inactivity
Work‐related stress and violence
Sleep and fatigue
Shift work
Recommendations
References
CHAPTER 80 Occupational Injury Prevention and Management
Introduction
Occupational fatalities
Occupational injuries
Injury prevention
Comparing studies
References
Note
CHAPTER 81 Prevention and intervention for psychologically stressful events
Introduction
Emergence of occupational behavioral health as a fire and EMS priority
Occupational health approach; organizational systems perspective
Help seeking predilections vs. help delivery systems
Building an integrated system
The final fundamental: personal wellness and fitness
Summary
References
CHAPTER 82 EMS practitioner education
Introduction
Theories of adult learning
Self‐directed learning
Social learning theory and self‐efficacy
Transformative learning theory
Context‐based learning
Experiential learning
Language of learning. Education delivery systems
Domains of learning
Learning styles
Initial education. Early EMS education
The EMS Agenda for the Future
EMS Agenda: 2050
EMS education agenda: a systems approach
National EMS core content
National EMS Scope of Practice Model
National EMS Education Standards
National EMS accreditation
The accreditation process
Medical direction required for accreditation
Certification tied to accreditation
National EMS certification
Credentialing
Continuing education in EMS
Evidence‐guided education
Professional education
CAPCE accreditation
Evaluating education
Remediation and work force reentry
Identification
Strategies
Evaluation
Conclusion
References
CHAPTER 83 Legal issues
Introduction
The legal framework of the physician/EMT relationship
Sources of authority
Statutes/regulations
Contracts
Box 83.1 Minimum provisions of contracts
Sources of accountability
Federal law and regulations
Civil rights
State statutes and regulations
Local ordinances
Immunity laws
Sovereign immunity
Good Samaritan statutes
Court decisions
Areas of liability
Liability. Failure to perform responsibilities
Negligent supervision
System concerns
Dispatch
Response
Scene handling
Destination
Failure to transport
Denial of ambulance transport
Box 83.2 Management of calls resulting in no transport
Patient refusal
Documentation of refusal
Transport against will
Interfacility Transfers
Documentation
Equipment
Summary
Box 83.3 Protective measures related to the use of equipment
Acknowledgments
References
CHAPTER 84 Legislation, regulation, and ordinance
Introduction and brief history
The role of legislation, regulation, and ordinance
The language and structure of legislation, regulation, and ordinance
Authorities established by states and examples of state‐specific language
Federal legislation, regulation and policy affecting EMS
The future of EMS legislation, regulation, and ordinance
Summary
Acknowledgment
References
CHAPTER 85 Due Process
Introduction
Law in the federal system
Law
State legislation
Due process of law
Due process—procedural versus substantive
Elements of due process
Governmental action
Ambulance companies
Medical directors
Medical review committees
National accreditation entities
An opportunity to present reasons why the proposed action should not be taken
Life, liberty, or property
Employment and licenses as a property interest
The liberty interest
Impartiality of tribunal
Notice
Time for hearing
Standard of proof
Right to counsel
Summary
Acknowledgments
References
CHAPTER 86 Risk management
Introduction
Components of prehospital risk management. Risk assessment
Initial training
Pre‐Employment Screening and Orientation
Medical supervision
Continuing medical education
Documentation
Quality management and risk management
Other factors
Patient expectations
Patient care incident management
Patient care incident
Establishing a comprehensive mechanism
Incident Identification
Serious or critical patient care incidents
Incident investigation
Box 86.1 Incident investigation checklist
Investigation findings
Incident investigation using root cause analysis
Indicated actions
Documentation
Future directions–prehospital medical error
Summary
References
CHAPTER 87 Politics and advocacy for the EMS physician
Introduction
Case Studies
The Unification of the Denver EMS System
Amending the Controlled Substances Act
What is Advocacy?
A History of EMS Advocacy
Political Action Committees
Navigating the Politics of Medical Direction
Philosophy, Perspective, and Bias
Preparing Yourself
Principles of Action
Sustaining the Drive
Summary
Acknowledgment
References
CHAPTER 88 Dispatch
Introduction
Public safety answering points
Emergency medical dispatch
Use of L&S
Anatomy of an EMD program
Quality improvement
Summary
Acknowledgments
References
CHAPTER 89 Ambulance safety
Introduction
Risks to Providers
Risks to Others
Legal Risks
Other Considerations
Contributing Factors
Fatigue
Driver Training
Passenger Restraint
Distractions
Ambulance Structural Design
Diesel Fumes
Recommendations
Using the Four Es of Injury Prevention: Education, Engineering, Economics, and Enforcement
Fatigue
Driver Training
Use of Warning Lights and Sirens
Passenger Restraints
Driving History
Driver Behaviors
Vehicular Design
Diesel Fumes
Vehicle Safety
Research
Conclusions
Acknowledgments
References
CHAPTER 90 Communications
Introduction
The context of EMS information communications technology
System readiness/access/demand management
Dispatch
Field clinician interaction and collaboration with medical direction
A further note on telehealth/telemedicine
The evolution of current‐day information communication system infrastructure and technical components
Land mobile radio systems
VHF radio systems
UHF radio systems
700‐MHz and 800‐MHz public safety trunked systems
Telephone and cellular telephone systems
2.4‐ to 5.9‐GHz systems and fiber‐based connections
Land mobile satellite communications
Evolving system infrastructure and components. Multiband radio and software‐defined radio
FirstNet–the nationwide public safety broadband network
Resources for communications planning
References
CHAPTER 91 Principles of finance
Managerial accounting. Sources and use of costs in decision making
Costs
Managerial accounting as a decision‐making tool
Productivity analysis. Measuring production
Unit hour utilization
Cost of production. Cost per patient transport
Applying theory to real‐world decisions
Wall time
Choices
Sustainable integrated health care
Conclusion
References
CHAPTER 92 State EMS Offices
Introduction
System leadership, organization, regulation, and policy. System leadership and organization
Regulation and policy
Scope of practice
Resource management–financial
Resource management–human resources
Resource management–transportation
Resource management–facility and specialty care regionalization
Public access and communications
Public information, education, and prevention
Clinical care, integration of care, and medical oversight
Information, evaluation, and research
Large‐scale event preparedness and response
Conclusion
References
CHAPTER 93 EMS–public health interface
Introduction
Understanding public health
Epidemiology
Health promotion and needs assessment
Surveillance and databases
Cardiac arrest: a public health emergency
Public access defibrillation
Crowdsourcing community CPR
Mass vaccinations and paramedics
Conclusion
Acknowledgments
References
CHAPTER 94 EMS physicians as public spokespersons
Introduction
Perspectives and Caveats About Public Speaking
The Challenges of Bite‐Speak
The Most Important Point
The Unique Challenges of Print Media
Press Conferences
Box 94.1 Participants in a Sample News Conference To Announce Implementation of a Community‐Wide Automated External Defibrillation (AED) Program
Ten Golden Rules for Public Speakingor Dealing with Media
Box 94.2 Ten Easy‐to‐Remember Axioms to Guide One’s Approach to Each Public Speaking Event
Rule #1: Always Tell the Truth, But Do It in a 10‐Second Soundbite
Rule #2: Respond Quickly and Accurately, and Become a Readily Available, Familiar, and Helpful Resource
Rule #3: Be a Human Being: Act Like One and Talk Like One
Rule #4: The Glass is Half Full on Issues, Less Optimistic on Individual Patients
Rule #5: Make Others Look Good and You Will Look Good
Rule #6: Provide A Good “Hook;” Suggest a Simple Valuable Lesson
Rule #7: Provide Simple Statistics and Graphics
Rule #8: Stay on the Mark: Remember the Three Rs of Repetition, Redundancy, and Reiteration
Rule #9: Don’t Trust Everyone—There is No Such Thing as “Off the Record”
Rule #10: Anticipate the Worst and Expect the Mediocre
Summary
Acknowledgments
References
CHAPTER 95 Incident command system and National Incident Management System
ICS standardization
Summary
Acknowledgments
References
CHAPTER 96 Medical management of mass gatherings
Introduction
Mass gathering types, definitions, and goals
Mass gathering risk management
Case study 96.1 Love parade
Mass gathering event planning and operations
Mass gathering personnel needs
Care Teams
Physician placement
Mass gathering event training and drills
Converting into MCI operations and postevent review
Postevent review
Case study 96.3 Route 91 Harvest Festival, Las Vegas mass shooting
Conclusion
Acknowledgment
References
Chapter 97 Disaster preparedness and management
Introduction
Federal Framework for Disaster Management
Box 97.1 The Five Preparedness Mission Areas
Catastrophic Events
Non‐governmental Organizations
Medical Reserve Corps
Community Emergency Response Teams
State Response and Assistance
Federal Response and Assistance
Health and Medical Resources. National Disaster Medical System
Special Response Considerations
Modified Standards of Care
Allocation of Scarce Resources
Provider Credentialing Issues
References
CHAPTER 98 The federal medical response to disasters
Introduction
Overview of federal medical response to disasters
National Response Framework. History
Organization
Base document
Annexes. ESF annexes
Support annexes
Incident annexes
ESF‐8: Public Health and Medical Services
Policies
Concept of operations
Select response components of ESF‐8
National disaster medical system
U.S. Public Health Service
Legal authorities
Emergency Management Assistance Compact
Robert T. Stafford Disaster Relief and Emergency Assistance Act (Public Law 100‐707)
The Pandemic and All‐Hazards Preparedness Act (Public Law 109‐417), the Pandemic and All‐Hazards Preparedness Reauthorization Act (Public Law 113‐5), and the Pandemic and All‐Hazards Preparedness and Advancing Innovation Act (Public Law 116‐22)
Social Security Act (Public Law 74‐271, as amended, 42 USC 7, et. seq.)
Homeland Security Act of 2002 (Public Law 107‐296)
National Guard (Title 32 of the U.S. Code)
Homeland Security Presidential Directive—HSPD‐5, Management of Domestic Incidents
Presidential Policy Directive/PPD‐8: National Preparedness
Homeland Security Presidential Directive—HSPD‐21: Public Health and Medical Preparedness
National Security Presidential Memorandum—NSPM‐14: Support for National Biodefense (National Biodefense Strategy)
Disclaimer and Acknowledgment
References
CHAPTER 99 Prehospital triage for mass casualties
Introduction
Primary Triage Systems
Primary Triage Categories
SALT Triage
START Triage
The Evidence Base for Primary Triage
Triage Tags
Secondary Triage
Tertiary Triage
Box 99.1 What principles should guide ventilator allocation?
Population‐Based Triage
Conclusion
References
CHAPTER 100 Mass casualty management
Philosophy
Investment
Command
Role
Mitigation and preparedness
Key personnel and resources
Policy, protocol, and training development
Intelligence and communication infrastructure
Response
The Role of the medical director in mass casualty incident response
Incident command structure
Triage
Treatment
Transport
Resource escalation
Recovery
Patient tracking and family reunification
Mental health
After‐action review
Special considerations. Health care coalitions
Emerging technologies
Vulnerable populations
Summary
References
CHAPTER 101 Mass casualty evacuation and patient movement
Introduction
Estimate
Threat
Notice versus no notice events
Threat assessment
Characteristics of the area
Terrain
Weather
Environmental factors
Population density and demographics
Location of medical institutions
Structural integrity of medical institutions
Electrical power of medical institutions
Regional transportation
Estimating requirements for medical evacuation
Modes of Transportation
Planning
Execution
Casualty collection points
Ambulance exchange points
Patient evacuation from medical facilities
Patient evacuation using the NDMS
Summary
References
CHAPTER 102 Temporary treatment facilities
Introduction
Type of event
Planned versus unplanned events
Notice versus no‐notice events
Hospital surge and alternate care facilities
Planning and design of temporary treatment facilities
Design of temporary treatment facilities: type of structure and structure characteristics
Portable medical units
Fixed structures
Public‐ or private‐sector facilities
Level of care
Staffing
Staff support
Equipment
Other considerations. Sanitation
Communications
Medical records
Demobilization and after‐action considerations
Summary
References
CHAPTER 103 Medical support for hazardous materials response
Introduction
Developing standard operating procedures
Identifying potential threats
Medical response planning
Personal Protective Equipment
Levels of protection for work involving hazardous materials
Types of respiratory protection. Self‐contained breathing apparatus
Supplied‐air respirators (SARs)
Cartridge respirators
Accompanying accessories and attachments
Implications of PPE use. Physical limitations
Communications
Health risks
Responding to hazardous materials. Assessing the situation and scene size up
Determining threat risk and initial response actions
Establishing the perimeter
Establishing incident command
Product identification
Monitors and detection devices
Evacuations
Decontamination. General principles
Methods of decontamination
Physical removal techniques
Chemical removal techniques
Decontamination implementation
PPE in decontamination area
Decontamination location
Rapid mass decontamination
Mass decontamination
Medical decontamination
Additional considerations
Technical decontamination
Emergency decontamination
Medical monitoring of response personnel
Conclusion
References
CHAPTER 5 Chemical properties of hazardous materials
Introduction
Types of Contamination
General categories of hazardous materials
Chemical
Biological
Radiation/nuclear
Basic properties of hazardous materials. Physical properties of hazardous materials
General chemical properties of hazardous materials
Solubility
Acids and bases
Identifying basic properties of hazardous materials
Conclusion
References
CHAPTER 105 Radiological and nuclear response
Radiation: definition and effects
Normal radiation environment
Radiation threats
Types of ionizing radiation
What radiation does not do
Resources for the responder
Resources in reserve
Resources to contact
Training
How to protect yourself
Irradiation
Time–obey the clock
Distance–radiation magic
Shielding–the thicker, the better
Contamination
Ingestion
Effects on emergency personnel
Dirty bombs, exposure burns, and ingestion injury
Exposure burns
Ingestion injury
Nuclear weapons
Blindness, burns, blast, and radiation
Electromagnetic pulse
Effect on medical care
Myths that can paralyze medical response
The greatest hazard: overwhelming public demand
Summary. Radiation effects are science, not magic
Simple, clear steps
Pharmaceuticals
Conclusion
References
Additional resources
CHAPTER 106 Weapons of mass destruction
Introduction
Unique aspects of WMD
Special requirements for WMD response
Conclusion
References
CHAPTER 107 Tactical emergency medical support
Introduction
History of tactical teams and TEMS
The TEMS environment and limitations of traditional EMS response
Operational considerations for clinician and casualty
Unique attributes of TEMS
Box 107.1 Unique TEMS attributes
Box 107.2 Unique TEMS skills
Zones of care
Weapons safety and less‐lethal weapons
Chemical agents
Kinetic impact projectiles
Noise/flash diversionary devices
Conducted electrical weapons
Hazardous materials
Forensic evidence collection
Special patient populations and excited delirium
Preventive medicine
Primary care
Special equipment
Tactical training
Unique TEMS skills. Commander’s medical conscience
Medical threat assessment
Remote assessment methodology
Medicine across the barricade
Direct physical assessment techniques
Hasty decontamination procedures
Tactical medical clinicians. The TEMS medic
The tactical physician
Medical oversight
Operational team member
Controversies in TEMS. Sworn versus civilian medics
Armed versus unarmed
Summary
Acknowledgment
References
CHAPTER 108 Technical rescue, confined space, and limited access situations
Technical rescue
Urban search and rescue
Confined space medicine
Rescuer safety
Specific clinical problems
Dust airway impaction
Prolonged care
Summary
References
CHAPTER 109 Wilderness EMS
Introduction
Current Operations and Epidemiology
Standardization
Scopes of Practice. New Scope of Practice Model
Levels of WEMS Practitioners. Wilderness EMR and WFR
Wilderness EMT
Wilderness Advanced Emergency Medical Technician
Wilderness Paramedic
Wilderness Nurse/Wilderness Nurse Practitioner/Wilderness Physician Assistant
Wilderness Physician
Medical Oversight. Direct Medical Oversight
Indirect Medical Oversight
Operations
Communications
Protocols
1. Wound Care
2. Termination of Resuscitation
3. Joint Reductions
4. Spinal Cord Protection
5. Anaphylaxis and Severe Asthma
WEMS‐Specific Extrication, Treatment, Transport Equipment
Survival Skills and Capability for Autonomous Operation
Challenges to WEMS Systems. Paramedic Shortage
Volunteerism
Ranger Shortage
Physician Shortage
Funding
Summary
Author Disclosures
Box 109.1 Suggested wilderness emergency medical services internet resources
References
CHAPTER 110 Mobile integrated health and community paramedicine
Introduction
Brief history to present day
Types of MIH‐CP programs
Within 9‐1‐1
Unscheduled non‐9‐1‐1
Scheduled/proactive
ET3
Telemedicine
Personnel education
Medical oversight
Integration with health care systems
Box 110.1 Finances
Conclusion
Acknowledgment
References
CHAPTER 111 Patient safety culture
Introduction to patient safety. Introduction
How accidents happen. The Swiss cheese model
System factors
Human factors and ergonomics
Judgment and clinical thinking
Doing things right. Guiding publications
Patient safety in EMS. The unique environment
Defining patient safety in EMS
Measuring adverse events in EMS
Just culture and adverse event reporting
Evaluating organizational safety culture
Changing organizational culture
Safety management systems in EMS
Methods to improve patient safety in EMS. Advances in simulation
Checklists in the prehospital environment
The future of patient safety in EMS
Conclusion
References
CHAPTER 112 The evolution of quality concepts and methods
Introduction
Origins of improvement science
History of quality improvement in health care
Professional education reform
Evaluation of quality
Regulation and accreditation
Public reporting and pay for performance
National academy of medicine initiatives
Frameworks for quality improvement
Six Sigma
Model for Improvement
History of quality improvement in EMS
Quality assurance versus quality improvement
Defining quality in EMS
EMS quality measure development and evaluation
Future directions of quality improvement in EMS
Conclusions
References
CHAPTER 113 Defining, measuring, and improving quality
Introduction
Vision: Defining Quality
Box 113.1 Key elements of the National Association of EMS Physicians position statement “Defining Quality in EMS”, 2018
Setting Priorities for Quality in EMS
Standardizing Approach to Quality in EMS
Need to Build a Quality Foundation
Building Quality Locally (Nuts and Bolts)
Strategy: Using the Science of Quality and Performance to Create Improvement. The Model for Improvement
Aim (the Compass): What is the Team Trying to Accomplish?
Box 113.2 Strong and weak aim statements
Measurement Strategy (the Map): How Will the Team Know That a Change is an Improvement?
Change Theory: What Changes Can Be Made That Will Result in an Improvement?
Systematically Testing Change: The PDSA Model
Useful Tools for Quality Improvement
Ishikawa Diagrams
Driver Diagrams
Graphic Displays of Data
Run Chart
Control Charts
Tactics: Reimagining the EMS Quality Improvement Program
Direct Observation
Chart Review
Use of Trigger Tools to Identify Risks to Patient Safety
Hospital Outcomes
Box 113.3 Using a 2 × 2 Table with Hospital Outcomes as a Quality Tool
Patient Feedback
Summary
References
CHAPTER 114 Information systems
Introduction
Historical foundations
Existing registries and health care databases. Health care databases
Law enforcement database
Public health surveillance data systems
EMS information system design
EMS system types
EMS operations from a data perspective
Public safety answering point
EMS systems for 2030: a look at the future. Personnel 2030
EMS information system components. Dataset
Hardware
Software
Maintenance
Security
Elements of successful information systems
References
CHAPTER 115 EMS research basics
Why prehospital research?
Getting started. Ask a simple but important question
Write a hypothesis or a clear objective
Review the current literature
Select a study design
Descriptive studies
Analytical designs. Observational
Experimental
Newer designs and approaches
Conclusion
References
CHAPTER 116 Informed consent in EMS research
The development of uniform requirements for the protection of human subjects
The Belmont report
The Common Rule
Modernization of the Common Rule
The role of the IRB
Issues affecting prehospital research
Public perception of prehospital care
Informed consent
History of the EFIC for emergency research
Exception from informed consent and WIC regulations
Community consultation and public disclosure
Conclusion
References
Additional resource
CHAPTER 117 Out‐of‐hospital cardiac arrest research
Introduction
Clinical research designs
Consistent definitions and the denominator
Population description
Data collection and reporting
Outcome Assessment
Outcome sources
Statistical analyses
Ethics and consent
Quality control and monitoring in clinical trials
Conclusions
Acknowledgment
References
CHAPTER 118 Trauma research methodology
Prehospital trauma study types
Design Issues in Prehospital Trauma Studies. Patient Informed Consent
Inclusion and Exclusion Criteria
Randomization and blinding
Establishing the clinical therapy of standard care patients
Selection of outcome measures
Other considerations for prehospital trauma research
Involvement of the EMS system
Single vs. multiple EMS agencies and trauma centers
Roles of direct medical oversight
Data analysis and trauma severity scoring
Military prehospital trauma research
Acknowledgment
References
CHAPTER 119 Pediatric research methodology
Introduction
The Need for Pediatric Prehospital Care Research
Status of Pediatric Prehospital Research
Challenges Unique for Pediatric Prehospital Researchers
Defining the “Pediatric” Patient Population
Sample Size
Epidemiology
Informed Consent: Pediatric Assent
Institutional Review Board Approval
Pediatric Prehospital Research Priorities
Moving Forward: Challenges and Opportunities
Box 119.1 RESOURCES
Box 119.2 Organizations with EMS/EMS for Children research interest
References
CHAPTER 120 Cost analysis research
Introduction
State of cost analysis research in EMS
Types of cost analyses
Conducting a full economic evaluation
Charges versus costs
Perspective
Framework for EMS costs
Joint production
Conclusion
References
CHAPTER 121 Statistical concepts for research in emergency medical services
Introduction
Classical hypothesis testing
Type I error
Type II error and power
Power analysis and sample size determination
Statistical tests
Parametric tests
Nonparametric tests
Confidence intervals
Multiple comparisons
Interim data analyses
Subgroup analysis
Intention‐to‐treat analysis
Multivariable analyses
Clustering
Missing data
Using statistical consultants
References
Appendix Chapter Mapping to the 2019 Core Content of EMS Medicine
Glossary
Index
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