The Evolution of Military EMS
by Dr. Joseph Heck

Greetings from Iraq! As you may have heard, I am currently mobilized in the Army Reserves for a 90-day tour with the 325th Combat Support Hospital, located at Al Asad Air Base, where I am serving as Chief of Emergency Services. Because of my current location, I thought it would be interesting to write about prehospital techniques and procedures used in the combat setting. Throughout the 20th century, the military was a leader in prehospital care. During that time, military EMS experienced innovations in extraction, stabilization, resuscitation and transport modalities. In the latter half of the century, the military lost its leading edge as civilian agencies more quickly embraced newer technologies and practices. The current conflicts, however, have seen advances in military prehospital care that may soon make their way into civilian EMS practice.

The Primary Survey

Data has shown that 10 percent of battlefield fatalities occur from peripheral hemorrhage, while only 1percent is due to airway obstruction. Therefore, the primary survey is modified to look for exsanguinating hemorrhage prior to addressing airway and the ABCD neumonic with which we are all familiar has been modified to XABCD (eXsanguinating hemorrhage).

Hemorrhage Control

Based on the above change to the primary survey and the emphasis on controlling life-threatening bleeding from the extremities, the early use of tourniquets is encouraged. With limited resources the ability to quickly stop the bleeding and move to the next patient is vitally important. Every soldier is issued an Individual First Aid Kit (IFAK) which contains a one-handed tourniquet, in case he needs to use it on himself. For less severe wounds, hemostatic agents are used extensively, with the HemCon bandage as the most commonly used dressing. This product is made from chitosan, a naturally occurring, bio-compatible polysaccharide, and possesses an adhesive-like action that seals the wound and controls bleeding. A HemCon bandage is also a component of the IFAK.

QuikClot is another hemostatic agent in use on the battlefield. This is an inert mineral that rapidly takes in the smaller water molecules from blood leaving the larger platelet and clotting factor molecules in the wound in a highly concentrated form. The original formulation was associated with a significant exothermic reaction that resulted in partial thickness burns to surrounding tissues. Because of this, QuikClot is only carried by combat medics and is to be used only when all other methods of hemorrhage control, including a tourniquet, have failed.

Fluid Resuscitation

The long-time standard for fluid resuscitation of the trauma victim has been "two liters of lactated Ringer’s through two large bore IVs." Recent research has called this rule into question with better outcomes demonstrated from "small-volume" or "controlled" resuscitation. In this manner, a patient who presents with controlled hemorrhage and without signs of shock has a saline lock inserted but does not receive any fluids. A patient with a controlled hemorrhage and signs of shock would receive 250 cc of a hypertonic solution (Hespan/Hextend) or 500 cc of an isotonic solution like normal saline. If the patient has an uncontrolled hemorrhage (intrathoracic or intrabdominal) and evidence of shock, he would receive small volume boluses to maintain cerebral perfusion.

Another change is a move away from the 14 gauge angiocatheter. Current thinking is it is better to get an 18 gauge in without difficulty rather than spend the time and possibly blow an otherwise good vein by attempting to place the larger catheter. Flow studies have clearly demonstrated that the difference in fluid delivery over time is not statistically significant.

While the above practices are not yet routinely accepted outside of the military, as further evidence is gathered that either proves or disproves their efficacy, we may see them making their way into our protocols.

Seeking Nominations for Responder of the Year

In recognition of National Emergency Medical Services Week, the Southern Nevada Health District will honor exceptional local EMS personnel who are recognized by their peers.

The ideal candidate:

• is a practicing EMT-B, EMT-I, EMT-P, CCEMT-P, EMS R.N., or EMD
• demonstrates excellent patient care, clinical skills and exemplary professionalism
• made exceptional contributions and commitment to the success and advancement of EMS

One person from each of the nine EMS agencies will be recognized for his or her service during the 2008 Responder of the Year award ceremony at the health district’s Ravenholt Public Health Center on May 19, 2008 at 10 a.m.

Please take a moment and nominate someone who you feel represents the best of EMS.

Ask the Trainer
By Ted Milano, certified personal trainer, NREMT – I

Dear Ted,

I’m new to EMS and am having trouble trying to eat well during my shifts. When we even get the opportunity at all, we eat fast food on the run and I’m putting weight on as a result. Any ideas what I can do about it?

J. T. , EMT-B

Dear J.T.,

My first day on the job I asked my paramedic partner that very same question. He said, "Welcome to EMS…" Actually, your question is probably one of the most common challenges street medics face in a high-call volume community. There are no conventional lunch hours, eating when and if the system allows. You are based in areas of the city where fast food is your only option and a 911 call can be assigned to your unit at any given moment.

But if you think about it, EMS is actually one of the few occupations where you have more control over your diet than traditional jobs. It’s just not common thinking in today’s EMS. Consider if you worked in a traditional setting where employees are limited in their eating habits designated by a specific time of the day.

Street medics have the distinct advantage in that their office is an ambulance. They can bring their food and drink with them in a concealed cooler or portable refrigerator, having it available wherever, whenever. It seems like an obvious solution but is not usually what crews do. Rather, they rely on what is available on the four assigned street corners when hunger hits. They pull into the closest burger joint, hot dog stand or mini mart. A few months later, they’re trading in their uniform pants for a larger size. A few years of that lifestyle and they may also be looking at some impending health issues.

Myth: Fast food is cheaper than store-bought food.

Fact: Wrong. The average fast food meal will cost you about $6 or more. Multiply that by an average of three meals a day in a 12-hour shift, four-day work weeks, 16 shifts a month. Compare that to healthier store-bought foods that may require some pre-planning, but can cut your food bill in half and save you a pant size or two along the way.

Myth: If I only eat once or twice a day, I can keep my weight under control and stay under my food budget.

Fact: Actually, this pattern of behavior is what most commonly causes rapid weight gain. Limiting calories, especially poor quality ones, forces your body to go into a starvation mode grinding your metabolism to a screeching halt. It burns its fuel slowly and steadily to conserve energy. That means, what little food you do eat will be stored as fat.

Myth: If I stick to energy drinks and caffeine to keep my energy levels up, I won’t feel as hungry throughout the day.

Fact: Energy drinks are extremely high in sugar, caffeine and mystery stimulants — the ingredients that give you that quick boost. But it’s very temporary and not without consequence. What goes up must come down. Artificially, it may raise your heart rate but the inevitably your energy level will plummet. They are far from meal replacements and the nutritional value is virtually zero. Studies show that a steady diet of this stuff can lead to serious heart and blood sugar issues.

So I say it again, the solution to taking control of your diet needs:

• Research foods that are healthy and will sustain your energy throughout your shift. Invest in a good quality cooler or portable refrigerator. Also, look for non-perishable items.
  
  
• Prepare everything prior to your work week so you can simply collect a day’s supply without further effort. (Trying to prep it each day is a grind and is a discipline generally not maintained for long.)
  
  
• Eat small amounts and as often as possible throughout your shift to maintain steady blood sugar/energy levels. This will also keep your body’s metabolism revved up and keep your weight managed.
  
  
• Stay away from fast food, energy drinks and most ER cafeteria options.

Ted Milano is the Employee Health and Physical Education Coordinator for Medic West Ambulance-Las Vegas. He is also a certified personal trainer specializing in strength, conditioning and injury prevention. If you have a question about health and wellness in Emergency Medical Services, contact him at: Ted.Milano@gmail.com

EMS News Reel

The Medical Advisory Board (MAB) meets on the first Wednesday of each month at 11 a.m. in the Clemens Room at the Ravenholt Public Health Center, 625 Shadow Lane. Following is a summary of the meeting on Feb. 6, 2008:

• Clark County Fire Department was approved to use the Boussignac CPAP device on a trial basis for the next 90-120 days.
  
  
• The Quality Improvement Directors Committee reiterated the importance of following the Trauma Field Triage Criteria (TFTC) and transporting TFTC patients to the appropriate catchment areas.
  
  
• The MAB is also looking into the possibility of having a Stroke Destination protocol. Three work groups will be formed to review the financial impact of having a stroke protocol, to select the criteria for the designation process of a stroke center and to create a draft stroke protocol.
  
  
• Trish Beckwith encouraged everyone to visit the improved EMSTS web pages, which include a calendar of all EMS educational opportunities in Clark County: www.southernnevadahealthdistrict.org/ems/ems.htm

Ask the EMS Office

What are the office hours for the Southern Nevada Health District Office of Emergency Medical Services & Trauma System (SNHD-OEMSTS)?

Monday - Friday, 7:30 a.m. to 4:30 p.m. Closed weekends and holidays.

How do I get a copy of the protocols for Clark County?

There are three ways to get a copy of the protocols:

• Download the BLS/ILS/ALS Protocol Manual
• Stop by the SNHD-OEMSTS office and purchase the manual for $5
• Call (702) 759-1050 and the manual will be mailed to you for $7.50

What is the difference between a certificate and a license?

A Nevada certificate is issued when you successfully complete an approved training course conducted within Clark County. An attendant license is issued when you are acting in the capacity of an attendant and provide patient care for a Clark County permitted agency.

Do licensed attendants need to carry the SNHD-OEMSTS issued attendant license while on duty with a permitted ambulance agency?

Yes. Failure to carry a SNHD-OEMSTS issued attendant license while on duty or failure to wear appropriate identification as approved by SNHD-OEMSTS is considered grounds for suspension or revocation of license.

Are there specific requirements to become an EMS instructor?

Yes. See “District Procedure for Secondary EMS Instructor Training” (page 18) in the EMS Procedure Manual.

For more information refer to the EMS Procedure Manual or the EMS Regulations on the SNHD website at www.SouthernNevadaHealthDistrict.org.

EMS Instructor Symposium

Learn how to achieve and inspire higher levels of professionalism in emergency medical services at the Southern Nevada Health District’s EMS Instructor Symposium. Hear from nationally recognized speaker Bryan Bledsoe, DO, emergency physician and author, as well as other prominent EMS professionals. Topics include: the new national education standards for emergency medical services, successful internship programs and the active learning theory.

This free symposium takes place Friday, April 11, 2008 from 8 a.m.-4 p.m., at the College of Southern Nevada — West Charleston Campus, Room B105, 6375 W. Charleston Blvd., Las Vegas, Nevada. RSVP to Trish Beckwith at the Southern Nevada Health District at beckwith@snhdmail.org.

This opportunity has been approved for 8 hours of continuing education credit by the Southern Nevada Health District EMS & Trauma System Office.

We Welcome Your Submissions

The editors of the EMS Advisor welcome submissions related to the EMS profession. If accepted, the editors reserve the right to edit all copy for length, style and clarity without prior notification to authors. All submissions must be submitted electronically via email to EMSAdvisor@snhdmail.org. Photographs must be at least 300 dpi and require a signed consent form.