Emergency Medical Services, 2 Volume Set: Clinical Practice and Systems Oversight
- Length: 1184 pages
- Edition: 3
- Language: English
- Publisher: Wiley
- Publication Date: 2021-10-18
- ISBN-10: 1119756243
- ISBN-13: 9781119756248
- Sales Rank: #7941918 (See Top 100 Books)
The two-volume Emergency Medical Services: Clinical Practice and Systems Oversight delivers a thorough foundation upon which to succeed as an EMS medical director and prepare for the NAEMSP National EMS Medical Directors Course and Practicum. Focusing on EMS in the ‘real world’, the book offers specific management tools that will be useful in the reader’s own local EMS system and provides contextual understanding of how EMS functions within the broader emergency care system at a state, local, and national level.
The two volumes offer the core knowledge trainees will need to successfully complete their training and begin their career as EMS physicians, regardless of the EMS systems in use in their areas. A companion website rounds out the book’s offerings with audio and video clips of EMS best practice in action. Readers will also benefit from the inclusion of:
- A thorough introduction to the history of EMS
- An exploration of EMS airway management, including procedures and challenges, as well as how to manage ventilation, oxygenation, and breathing in patients, including cases of respiratory distress
- Practical discussions of medical problems, including the challenges posed by the undifferentiated patient, altered mental status, cardiac arrest and dysrhythmias, seizures, stroke, and allergic reactions
- An examination of EMS systems, structure, and leadership
Cover Volume I Title Page Copyright Page Contents Contributors Foreword Preface 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 1973: The Emergency Medical Services Systems Act 1973–1978: Rapid Growth of EMS Systems Personnel 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 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 Section I Airway 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 drug-facilitated intubation Considerations for video laryngoscopy Considerations for SGA Considerations for surgical airways Considerations in pediatric airway management 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 Supraglottic airways Surgical airways Confirmation of airway placement Methods for securing endotracheal tubes and supraglottic airways Drug-facilitated intubation Rapid sequence intubation Sedation-assisted endotracheal intubation 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 Section II Breathing Chapter 5 Respiratory distress Introduction Prehospital assessment and diagnosis 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 Assisting Oxygenation and Ventilation Noninvasive Positive-Pressure Support Bag-Valve-Mask Ventilation Mechanical Ventilation Modes of Ventilation Ventilator Settings and Troubleshooting Pneumothorax Summary References Section III Circulation Chapter 7 Hypotension and Shock Introduction Pathophysiology Evaluation 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 Intraosseous Access 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 Role of emergency medical dispatch The 12-lead electrocardiogram Prehospital electrocardiogram interpretation Medications Oxygen Aspirin Nitroglycerin Opiate analgesics Beta-Blockers Prehospital fibrinolysis Systems of care for STEMI Prehospital notification/field cardiac catheterization laboratory 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 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 Unstable tachydysrhythmias Step four: focus actions to evaluate stable but symptomatic and borderline patients 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 Electrical cardiac support devices Pacemakers 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 Summary References Section IV Medical Problems 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 Pediatric altered mental status Alcohol Time-critical causes On-scene treatments and dispositions 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 Classification of seizure types Symptomatic seizures Febrile seizures Status epilepticus EMS evaluation and response Pharmacological interventions Seizure-associated trauma Continuing management Refractory generalized convulsive status epilepticus Conclusion References Chapter 18 Stroke Introduction Emergency medical dispatch Prehospital care Definitive treatment options 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 History and physical examination 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 Causative agents Assessment and general approach Prehospital treatment 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 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 Section V Trauma Problems Chapter 26 Trauma systems of care Trauma system organization Trauma care facilities Communications Emergency response Medical oversight 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 Special considerations Compartment syndrome Pain management Hydrofluoric acid burn White phosphorus burn Airbag burns Guidelines for out-of-hospital management Requirements for transfer 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 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 Pelvis Lower extremity 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 Animal-specific concerns Mammals Reptiles Marine animals Insect bites and stings 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 Complications Padding Children Summary Acknowledgments References Section VI Obstetrics and Gynecology Problems Chapter 41 Physiology of pregnancy Introduction General considerations Critical care and trauma Airway Breathing Circulation Toxicology Pregnancy Effects by System (Box 41.3) 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 Section VII Toxicological Problems Chapter 46 Principles of toxicology Introduction Evaluation History Physical examination Toxidromes Cardiac monitor and electrocardiogram Treatment Decontaminating the poisoned patient Dermal decontamination Ocular decontamination Gastrointestinal decontamination Antidotes Atropine Flumazenil Naloxone Cyanide antidotes 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 Gases (irritants and hydrocarbons) Vesicants Summary References Section VIII Environmental Problems 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 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 Injury at depth Shallow water blackout Injuries of ascent Decompression illness Approach to management of diving injuries Specific interventions for DCI (DCS and AGE) Transportation considerations Conclusion Acknowledgment References Section IX Special Populations Chapter 53 The special needs of children Epidemiology of prehospital pediatric care Evaluation of children Pediatric Assessment Triangle Vital signs Weight measurement Specialized equipment needs Developmental approach References Chapter 54 Pediatric medical priorities Introduction Respiratory and airway problems Pediatric respiratory anatomy and physiology Respiratory failure and apnea 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 Section X Special Considerations 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 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 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 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 Troponin Lactate Brain natriuretic peptide (BNP) Carbon monoxide (CO) Capnography 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 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 References Appendix Chapter Mapping to the 2019 Core Content of EMS Medicine Glossary Index Volume II Title Page Copyright Page Contents Contributors Foreword Preface About the Companion Site Section I Principles of Oversight and Design Chapter 70 Medical oversight of EMS systems Introduction The evolution of the subspecialty of EMS State requirements for EMS medical direction Barriers to effective medical oversight of EMS 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 EMS Research Direct medical oversight Field clinical supervision Direct patient care in the field 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 Tiered Response 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 Integration and Regulations Regulation Federal Aviation Regulations Operations Clinical Operations Vehicles/Mode of Transport Vehicle Attributes and Considerations Operational Challenges Summary References Section II Human Resources 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 National EMS certification State licensure 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 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 Note References 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 National EMS core content National EMS Scope of Practice Model National EMS Education Standards National EMS accreditation National EMS certification Credentialing Continuing education in EMS Evaluation Conclusion References Section III Legal and Legislation Chapter 83 Legal issues Introduction The legal framework of the physician/EMT relationship Sources of authority Statutes/regulations 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 Patient refusal Documentation of refusal Transport against will Interfacility Transfers Documentation Equipment Summary 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 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 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 Section IV Dispatch and Communications Chapter 88 Dispatch Introduction Public safety answering points Emergency medical dispatch Use of L&S Anatomy of an EMD program Quality improvement Summary 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 Section V Finance and Public Interfaces 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 Cost of production 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 Ten Golden Rules for Public Speakingor Dealing with Media 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 Section VI Extraordinary Circumstances 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 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 Conclusion Acknowledgment References Chapter 97 Disaster preparedness and management Introduction Federal Framework for Disaster Management 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 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 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 Characteristics of the area 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 Level of care Staffing Staff support Equipment Other considerations Sanitation Communications Medical records Demobilization and after-action considerations Summary References Section VII Special Hazards 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 Accompanying accessories and attachments Implications of PPE use 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 104 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 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 Chapter 106 Weapons of mass destruction Introduction Unique aspects of WMD Special requirements for WMD response Conclusion References Section VIII Special Environments 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 Unique TEMS skills Tactical medical clinicians The TEMS medic The tactical physician 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 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 References Chapter 110 Mobile integrated health and community paramedicine Introduction Brief history to present day Types of MIH-CP programs ET3 Telemedicine Personnel education Medical oversight Integration with health care systems Conclusion Acknowledgment References Section IX Safety and Quality 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 Setting Priorities for Quality in EMS Standardizing Approach to Quality in EMS Building Quality Locally (Nuts and Bolts) Strategy: Using the Science of Quality and Performance to Create Improvement The Model for Improvement Useful Tools for Quality Improvement Tactics: Reimagining the EMS Quality Improvement Program Direct Observation Chart Review Use of Trigger Tools to Identify Risks to Patient Safety Hospital Outcomes 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 Section X Advancing Knowledge 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 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 EULA
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