Behind the scenes: How an EMS agency made a PSA about the dangers of distracted driving

This video was created to bring awareness to local young drivers of the risks associated with distracted driving. Check out the full video here.

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Behind the scenes: How an EMS agency made a PSA about the dangers of distracted driving

This video was created to bring awareness to local young drivers of the risks associated with distracted driving. Check out the full video here.

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Behind the scenes: How an EMS agency made a PSA about the dangers of distracted driving

This video was created to bring awareness to local young drivers of the risks associated with distracted driving. Check out the full video here.

from EMS via xlomafota13 on Inoreader http://ift.tt/1RKH9QI

Behind the scenes: How an EMS agency made a PSA about the dangers of distracted driving

This video was created to bring awareness to local young drivers of the risks associated with distracted driving. Check out the full video here.

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Double amputation can't stop paramedic quest

Minutes after waking up from a medically induced coma Noah Filer asked his girlfriend Jenni two important questions.

His first question to Jenni, now his wife, was, "Where in the hell are my arm and leg?"

He says he took a minute to process the loss of his arm and leg and then asked his second question, "What about my paramedic?"

Four weeks earlier, April 1, 2012, Filer had been in a serious motorcycle collision that resulted in a traumatic brain injury and the loss of his left arm and left leg.

Eager to learn
Filer, now 27 and licensed paramedic, can't recall what specifically caused him to join the Durand (Ill.) Fire Department in 2007, but he quickly realized that if he wanted a radio he needed to become an EMT. He completed EMT training in the fall of 2008 and responded to as many calls as he could when he wasn't working at a Lowes' distribution center.

"I worked 12-hour shifts Friday, Saturday, Sunday so I was always willing to go to calls on Monday through Thursday," Filer said. "I was going to calls to learn as much as I could."

As he gained experience, Filer got a full-time EMT position on the Durand ambulance. After four years of EMT work, Filer set his sights on a paramedic license to better his chances of joining the Rockford (Ill.) Fire Department.

Launching a firefighter-paramedic career
Filer started the SwedishAmerican hospital 12-month paramedic program in August 2011. The accredited program starts with nine months of didactic lectures, skills instruction, clinical experiences and is followed by an ambulance ride-time internship.

The SwedishAmerican paramedic students meet two days a week from August to May. Tonja Radford, paramedic, lead instructor and clinical coordinator recalls Filer as "very good student" in the 2011-2012 student cohort.

Paramedic class, even the challenges of anatomy and physiology, was coming together well for Filer. "I was busting my butt on clinical hours, class and still working full time," he said about the weeks leading up to his accident. "I was working hard and not having any problems with paramedic class," which had just started the trauma section of lectures and skills.

Mom had a bad feeling
On April 1, 2012, Filer finished his Durand EMT shift at 8 a.m. He went home to change clothes before leaving with a friend to buy his first motorcycle.

Before leaving the house, his mom warned him she had bad feeling about him buying a motorcycle. That morning he rode a used motorcycle — his first time on a bike — in the farmyard with his friend Jeff. The pair decided to ride to Rockford, about 20 miles away.

Filer's last memory of that morning is gassing up the motorcycle in Durand.

"Jeff said I reached up to scratch something above my eye. When I did that I crossed the center line and collided head-on with a car."

His injuries were devastating. A Durand ambulance picked him up. Three of his co-workers, two EMTs and a paramedic, cared for him on-scene and en route to the hospital.

"They told me later that I had equal chest rise and fall, no JVD, but they supported with BVM," Filer said of his injuries. "They described my leg as foot backwards pointing towards head, femur broken mid-shaft with arterial bleeding, and left thumb almost amputated from the impact."

He was wearing a helmet, but was unconscious. "My blood pressure was around 200 and I alternated between decerebrate posturing and seizures in the ambulance."

Trauma care and amputations
Filer was in a coma for about four weeks as decisions were made and acted upon to replace his femur with a rod, amputate his left leg below the knee, and amputate his left arm above the elbow.

Noah Filer in the ICU three days after his motorcycle accident

"I have half a tricep and half a bicep," Filer says of his left arm.

After the surgeries — 17 all tolled — and a multi-week stay in the trauma ICU, Filer was transferred to a rehab center.

Close-up of Filer's left leg and knee after surgery

Nine days after the crash, Filer gave his first purposeful hand squeeze. It took four weeks for him to speak his first words and be moved out of the ICU. On May 10, he moved to the rehab center. It was there that he woke from the coma and declared his desire to finish his paramedic certification.

Filer didn't go home on June 6 because he was ready, but because he was adamant to not miss an annual fishing trip with his grandfather. Instead of going AMA, he was discharged and had a successful family fishing trip using an electric reel given to him by his cousin.

Filer refused to miss an annual family fishing trip just two months after his motorcycle collision

60-hours and several years left to paramedic
Before the accident Filer didn't stand out to Dr. John Underwood any more than the other students. "When I was called to visit him at the rehab center, I learned he was the top student in his class, way ahead on clinical and ahead of expectations," Underwood said.

Underwood, the medical director for the SwedishAmerican paramedic education program, visited with Filer in the rehab center. He was unsure what to expect from a young man that had been severely injured and in very tenuous condition while hospitalized.

"Underwood told me I had 60 hours left of clinical and I was doing academically better than anyone else in the class," Filer recalls of Underwood's visit. "He told me he would 'do whatever it takes' because of all the hard work I had done."

But it would be several years before Filer was able to complete his clinical time. The process of fitting prosthetics, learning to use a body-powered harness to open his left hand prosthesis and rehab injured muscles was grueling.

Filer wearing an above the knee prosthetic leg

Testing cognitive and kinesthetic domains
EMS instruction is often categorized into three domains: cognitive, kinesthetic and affective. Filer had been excelling in all three before his accident.

Tom Pratt, SwedishAmerican EMS manager, described the need for Filer to do all the things expected of a paramedic with only reasonable accommodations. Filer completed all sorts of testing to see his adaptability to succeed with the right equipment and resources, Pratt said.

One of the ways his caregivers and paramedic instructors tested Filer's brain function — performance in the cognitive domain — was by reviewing his paramedic textbook and retaking course tests. The paramedic textbook was also useful for reading and speech-related rehabilitation.

"The most effort (to pass the tests) had to come from him," Radford said of Filer's progress and drive to finish his paramedic course.

Filer rejoined Radford's paramedic class in January 2013. To everyone's surprise and relief Filer, a top student before the accident, did as well or better on the tests he retook. He was able to recall information he previously studied, learn new information and apply that information on examinations.

Eligibility and accommodations
While Filer was rehabbing, Underwood went to work on determining the eligibility of a double amputee to become a paramedic in Illinois and advocating on Filer's behalf with the Illinois Department of Public Health.

Although the IDPH initially requested that Filer be evaluated for his physical ability, Underwood determined there was no statutory or regulatory authority for Filer's physical ability to be evaluated. All that was required was Filer's completion of a paramedic training program — making him eligible for the IDPH written paramedic examination — and successfully passing the exam.

The Americans with Disabilities Act prohibits discrimination against people with disabilities in employment, transportation, public accommodation, communication and governmental activities. One of the ADA's key provisions is that employers make a reasonable adjustment to a job or work requirement to make it possible for an individual with a disability to perform a job duty.

To complete his paramedic, Filer who is right handed, had two significant kinesthetic skills to demonstrate competency — endotracheal intubation and intravenous cannulation. "We were waiting on the prosthetic leg, then arm at the end of the didactic class to figure out ways to do the hands-on skills," Radford said.

Filer had three endotracheal intubations still to perform. He got an airway manikin and airway kit to practice on his own. "I had to learn how to position my body to open my left hand using the body-powered harness," Filer said.

Despite learning how to position his body to manipulate the harness, he could not securely hold a laryngoscope handle to perform direct laryngoscopy.

"The left hand couldn't hold the laryngoscope," Filer said. "The hand would slip and I would pry (the manikin's jaw). It was not good airway control."

Video laryngoscopy emerged as a reasonable accommodation for Filer. "The screen on a video laryngoscope kept the handle from sliding through my hand."

Equipped with a VL system purchased with a grant from the SwedishAmerican Health System Foundation, and accompanied by Underwood, Filer went to the operating room to complete his three intubations.

Filer's left hand prosthesis holding a King Vision video laryngoscope as he prepares to intubate a manikin

"I tagged along to see if there were any concerns with Noah's one handedness in the OR," Underwood said. "But it was quickly obvious he was doing fine."

"I was able to get four intubations and could have gotten more, but I only had four of the disposable (VL) blades for the laryngoscope," Filer said.

One of the patients presented a difficult airway to Filer. "The patient had a swollen epiglottis," Filer said. He could not pass the endotracheal tube. Without taking his eyes off the vocal cords he used a bougie and then slid the ET tube over the bougie.

Finding his own job accommodations
Many of the steps of intravenous access can be performed with a single hand. As Filer completed his clinical time he couldn't tie a tourniquet with just his right hand and his prosthetic left hand couldn't be manipulated to complete the task.

"I went online and found a one-handed, reusable tourniquet," Filer said. "I bought one, for a few dollars, tried it and it worked." Filer now has a pack of the reusable tourniquets that he can secure single handed.

As Filer's instructor Radford knows, there are multiple ways to perform patient assessment and treatment procedures. "How else can we do this," Radford encourages other instructors to ask to help students with disabilities find other ways to get things done.

Filer wrapped up his clinical time with three days at the hospital for pediatric and obstetric patient contacts. He did the remaining hours on the ambulance with preceptors who he said were "helpful and encouraging."

Patients on the ambulance didn't have any problem with a paramedic student who also had a prosthetic. "I offered it up to patients," Filer said.

"He passed everything we were asking of everyone else," Radford said. "Just like all the other students."

Master of the affective domain
Those who have worked with and taught Filer are quick to mention his mastery of the affective domain. His positive attitude, always smiling demeanor, sense of humor and willingness to help others have always set him apart.

"I am proud to have Noah as a co-worker," said Pratt, who has been a nurse for 30 years. "Noah said he was going to 'keep at it — adapt and overcome,' which he has done."

"He has drive. (Filer) is more than willing for work it," Radford said. "He told me, 'You can take half my body, but you can't take my will.'"

Radford and other instructors appreciated Filer's jokes and sense of humor just as much after the accident as they did before his injury.

"I tell people I am always a guy to help out," Filer quipped. "In fact I am glad to give a hand — my left hand — to anyone that needs it."

Another of Filer's go-to jokes to put others at ease plays on his health care knowledge. "If I ever have diabetes mellitus and need an amputation I want them to take my left leg first."

Final written test to be a paramedic
With his clinical time complete, Filer passed the SwedishAmerican paramedic course. In Illinois, paramedic students can choose the Illinois State Licensing Exam or the National Registry Exam. In early 2016 Filer took the Illinois computer-based test.

Filer's originally chose the SwedishAmerican 12-month program because it was fast and convenient. Now almost five years after he started he was determined to become a paramedic. "I put in so much time and effort," Filer said.

But it wasn't enough. He didn't pass the exam on his first attempt.

After that setback Filer realized he needed to do even more to get ready. "I spent 105 hours using EMTPrep.com and passed the IDPH written exam on March 28, 2016."

On the job and back home
Since receiving his paramedic certification, Filer has worked as an emergency department clinical greeter at SwedishAmerican three days a week. During his 12-hour shifts, he greets patients in the waiting room, assesses the nature of their illness, triages patients to be seen immediately, begins the registration process and reassesses patients who are waiting to be seen.

Although he is still on the roster at Durand, Filer doesn't think becoming a firefighter-paramedic is "in the cards." He recently celebrated his daughter's second birthday and likes the flexibility that comes with working three 12-hours shifts a week with four days off to spend with his family. 

"Everyone has good days, bad days," Filer says about learning to live with prostheses. "If there is pain it is a fit issue."

Filer says he has an awesome prosthetist who helps makes sure the fit is good and he has the right size prosthetic to meet the demands of his job, which includes lifting and moving patients.

Filer regularly works out and lifts weights. He is able to squat lift 350 pounds and dead lift 250 pounds so he needed a leg prosthetic that could accept a load of at least 475 pounds — his body weight plus his maximum squat lift.

If Filer decides to seek work on an ambulance, Radford would not hesitate to have him as a partner. She also noted that all paramedics, including those who are able- or full-bodied frequently call for help lifting or treating patients.

For aspiring paramedics who are also amputees Filer's advice from his experience is to "stay patient and keep working." 

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Double amputation can't stop paramedic quest

Noah Filer comes out of a coma and learns he's a double amputee — then completes his goal of becoming a paramedic

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Glenohumeral Hematoma Mimicking Persisting Anterior Shoulder Dislocation After Reduction

Publication date: Available online 31 May 2016
Source:The Journal of Emergency Medicine
Author(s): Robert Knotter, Mischa Veen




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Reply

Publication date: Available online 31 May 2016
Source:The Journal of Emergency Medicine
Author(s): John Constantine Sakles, Jarrod M. Mosier




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Arizona's Emergency Medical Services for Children Pediatric Designation System for Emergency Departments

Publication date: Available online 31 May 2016
Source:The Journal of Emergency Medicine
Author(s): Natasha Smith, Tomi St. Mars, Dale Woolridge
BackgroundIn 2012, a voluntary certification program called Pediatric Prepared Emergency Care (PPEC) was established in Arizona as a system for pediatric emergency preparedness. Emergency medicine and pediatric specialists generated basic, intermediate, and advanced designation criteria. Dedicated medical management by a pediatric emergency specialist is required for advanced centers. Designation follows a site visit, review, and approval by the subcommittee and the Arizona Chapter of the American Academy of Pediatrics.DiscussionArizona has 5 designated pediatric emergency departments, all of which are in the southeast part of the state. Therefore, a designation system was implemented so that all emergency departments statewide can receive more training, support, and supervision of pediatric care. The goal was to create a self-sustaining network with active participation from member institutions while fostering the pediatric commitment. Since its inception, 39 hospitals and 5 tribal facilities have joined PPEC, equating to 51% of Arizona's emergency facilities. Of the hospitals, 7 are advanced, 6 are intermediate, and 17 are basic centers. In 2015, all of the 9 sites due for recertification were recertified. The multiple tiers allow for mutual accountability, sharing of resources, and improved quality of care for pediatrics in emergency departments statewide.ConclusionPPEC enhances the quality of pediatric emergency preparedness by means of voluntary certification. The primary limitations are sustainability and funding, because an Emergency Medical Services for Children grant has offset the cost until now. The number of member facilities in this designation system is continually growing, and universal recertification shows sustainability.



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Comment on: “Timely Pain Management in the Emergency Department”

Publication date: Available online 30 May 2016
Source:The Journal of Emergency Medicine
Author(s): Brandi Michelle Galindo




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Psychiatric Emergencies for Clinicians: The Emergency Department Management of Thyroid Storm

Publication date: Available online 30 May 2016
Source:The Journal of Emergency Medicine
Author(s): Christopher S. Sharp, Michael P. Wilson, Kimberly Nordstrom




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Diagnosis of Acquired Uterine Arteriovenous Malformation by Doppler Ultrasound

Publication date: Available online 31 May 2016
Source:The Journal of Emergency Medicine
Author(s): Drew Scribner, Robert Fraser
BackgroundAcquired uterine arteriovenous malformation (AVM) is a rare cause of postpartum vaginal bleeding and can often be confused with retained products of conception (RPOC). Certain findings on ultrasound (US) increase the likelihood for AVM, such as hypoechoic areas in the myometrium and high velocity, multidirectional blood flow. Recognizing these changes on bedside US can cue the physician to send the patient for further studying and lead to the correct diagnosis.Case ReportA 31-year-old, multigravida, multiparous female presented 5 weeks post–cesarean section with heavy, intermittent vaginal bleeding. Patient had multiple previous visits for similar bleeding, including an evaluation for RPOC. Upon current presentation, the patient underwent an US in the emergency department with color and pulse wave Doppler. US revealed a hypoechoic area within the myometrium, with high velocity, bidirectional blood flow, raising the clinical suspicion for uterine AVM. Following confirmatory studies, the patient underwent successful embolization of the AVM.Why Should an Emergency Physician Be Aware of This?The proper diagnosis of AVM is crucial, because the primary treatment modality for the alternative diagnosis of RPOC (i.e., dilation and curettage) can worsen vaginal bleeding and lead to shock or death, and is therefore contraindicated for uterine AVM. US is a quick bedside tool that can be used for rapid diagnosis of uterine AVM.



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Double amputation can't stop paramedic quest

Minutes after waking up from a medically induced coma Noah Filer asked his girlfriend Jenni two important questions.

His first question to Jenni, now his wife, was, "Where in the hell are my arm and leg""

He says he took a minute to process the loss of his arm and leg and then asked his second question, "What about my paramedic""

Four weeks earlier, April 1, 2012, Filer had been in a serious motorcycle collision that resulted in a traumatic brain injury and the loss of his left arm and left leg.

Eager to learn
Filer, now 27 and licensed paramedic, can't recall what specifically caused him to join the Durand (Ill.) Fire Department in 2007, but he quickly realized that if he wanted a radio he needed to become an EMT. He completed EMT training in the fall of 2008 and responded to as many calls as he could when he wasn't working at a Lowes' distribution center.

"I worked 12-hour shifts Friday, Saturday, Sunday so I was always willing to go to calls on Monday through Thursday," Filer said. "I was going to calls to learn as much as I could."

As he gained experience, Filer got a full-time EMT position on the Durand ambulance. After four years of EMT work, Filer set his sights on a paramedic license to better his chances of joining the Rockford (Ill.) Fire Department.

Launching a firefighter-paramedic career
Filer started the SwedishAmerican hospital 12-month paramedic program in August 2011. The accredited program starts with nine months of didactic lectures, skills instruction, clinical experiences and is followed by an ambulance ride-time internship.

The SwedishAmerican paramedic students meet two days a week from August to May. Tonja Radford, paramedic, lead instructor and clinical coordinator recalls Filer as "very good student" in the 2011-2012 student cohort.

Paramedic class, even the challenges of anatomy and physiology, was coming together well for Filer. "I was busting my butt on clinical hours, class and still working full time," he said about the weeks leading up to his accident. "I was working hard and not having any problems with paramedic class," which had just started the trauma section of lectures and skills.

Mom had a bad feeling
On April 1, 2012, Filer finished his Durand EMT shift at 8 a.m. He went home to change clothes before leaving with a friend to buy his first motorcycle.

Before leaving the house, his mom warned him she had bad feeling about him buying a motorcycle. That morning he rode a used motorcycle — his first time on a bike — in the farmyard with his friend Jeff. The pair decided to ride to Rockford, about 20 miles away.

Filer's last memory of that morning is gassing up the motorcycle in Durand.

"Jeff said I reached up to scratch something above my eye. When I did that I crossed the center line and collided head-on with a car."

His injuries were devastating. A Durand ambulance picked him up. Three of his co-workers, two EMTs and a paramedic, cared for him on-scene and en route to the hospital.

"They told me later that I had equal chest rise and fall, no JVD, but they supported with BVM," Filer said of his injuries. "They described my leg as foot backwards pointing towards head, femur broken mid-shaft with arterial bleeding, and left thumb almost amputated from the impact."

He was wearing a helmet, but was unconscious. "My blood pressure was around 200 and I alternated between decerebrate posturing and seizures in the ambulance."

Trauma care and amputations
Filer was in a coma for about four weeks as decisions were made and acted upon to replace his femur with a rod, amputate his left leg below the knee, and amputate his left arm above the elbow.

Noah Filer in the ICU three days after his motorcycle accident

"I have half a tricep and half a bicep," Filer says of his left arm.

After the surgeries — 17 all tolled — and a multi-week stay in the trauma ICU, Filer was transferred to a rehab center.

Close-up of Filer's left leg and knee after surgery

Nine days after the crash, Filer gave his first purposeful hand squeeze. It took four weeks for him to speak his first words and be moved out of the ICU. On May 10, he moved to the rehab center. It was there that he woke from the coma and declared his desire to finish his paramedic certification.

Filer didn't go home on June 6 because he was ready, but because he was adamant to not miss an annual fishing trip with his grandfather. Instead of going AMA, he was discharged and had a successful family fishing trip using an electric reel given to him by his cousin.

Filer refused to miss an annual family fishing trip just two months after his motorcycle collision

60-hours and several years left to paramedic
Before the accident Filer didn't stand out to Dr. John Underwood any more than the other students. "When I was called to visit him at the rehab center, I learned he was the top student in his class, way ahead on clinical and ahead of expectations," Underwood said.

Underwood, the medical director for the SwedishAmerican paramedic education program, visited with Filer in the rehab center. He was unsure what to expect from a young man that had been severely injured and in very tenuous condition while hospitalized.

"Underwood told me I had 60 hours left of clinical and I was doing academically better than anyone else in the class," Filer recalls of Underwood's visit. "He told me he would 'do whatever it takes' because of all the hard work I had done."

But it would be several years before Filer was able to complete his clinical time. The process of fitting prosthetics, learning to use a body-powered harness to open his left hand prosthesis and rehab injured muscles was grueling.

Filer wearing an above the knee prosthetic leg

Testing cognitive and kinesthetic domains
EMS instruction is often categorized into three domains: cognitive, kinesthetic and affective. Filer had been excelling in all three before his accident.

Tom Pratt, SwedishAmerican EMS manager, described the need for Filer to do all the things expected of a paramedic with only reasonable accommodations. Filer completed all sorts of testing to see his adaptability to succeed with the right equipment and resources, Pratt said.

One of the ways his caregivers and paramedic instructors tested Filer's brain function — performance in the cognitive domain — was by reviewing his paramedic textbook and retaking course tests. The paramedic textbook was also useful for reading and speech-related rehabilitation.

"The most effort (to pass the tests) had to come from him," Radford said of Filer's progress and drive to finish his paramedic course.

Filer rejoined Radford's paramedic class in January 2013. To everyone's surprise and relief Filer, a top student before the accident, did as well or better on the tests he retook. He was able to recall information he previously studied, learn new information and apply that information on examinations.

Eligibility and accommodations
While Filer was rehabbing, Underwood went to work on determining the eligibility of a double amputee to become a paramedic in Illinois and advocating on Filer's behalf with the Illinois Department of Public Health.

Although the IDPH initially requested that Filer be evaluated for his physical ability, Underwood determined there was no statutory or regulatory authority for Filer's physical ability to be evaluated. All that was required was Filer's completion of a paramedic training program — making him eligible for the IDPH written paramedic examination — and successfully passing the exam.

The Americans with Disabilities Act prohibits discrimination against people with disabilities in employment, transportation, public accommodation, communication and governmental activities. One of the ADA's key provisions is that employers make a reasonable adjustment to a job or work requirement to make it possible for an individual with a disability to perform a job duty.

To complete his paramedic, Filer who is right handed, had two significant kinesthetic skills to demonstrate competency — endotracheal intubation and intravenous cannulation. "We were waiting on the prosthetic leg, then arm at the end of the didactic class to figure out ways to do the hands-on skills," Radford said.

Filer had three endotracheal intubations still to perform. He got an airway manikin and airway kit to practice on his own. "I had to learn how to position my body to open my left hand using the body-powered harness," Filer said.

Despite learning how to position his body to manipulate the harness, he could not securely hold a laryngoscope handle to perform direct laryngoscopy.

"The left hand couldn't hold the laryngoscope," Filer said. "The hand would slip and I would pry (the manikin's jaw). It was not good airway control."

Video laryngoscopy emerged as a reasonable accommodation for Filer. "The screen on a video laryngoscope kept the handle from sliding through my hand."

Equipped with a VL system purchased with a grant from the SwedishAmerican Health System Foundation, and accompanied by Underwood, Filer went to the operating room to complete his three intubations.

Filer's left hand prosthesis holding a King Vision video laryngoscope as he prepares to intubate a manikin

"I tagged along to see if there were any concerns with Noah's one handedness in the OR," Underwood said. "But it was quickly obvious he was doing fine."

"I was able to get four intubations and could have gotten more, but I only had four of the disposable (VL) blades for the laryngoscope," Filer said.

One of the patients presented a difficult airway to Filer. "The patient had a swollen epiglottis," Filer said. He could not pass the endotracheal tube. Without taking his eyes off the vocal cords he used a bougie and then slid the ET tube over the bougie.

Finding his own job accommodations
Many of the steps of intravenous access can be performed with a single hand. As Filer completed his clinical time he couldn't tie a tourniquet with just his right hand and his prosthetic left hand couldn't be manipulated to complete the task.

"I went online and found a one-handed, reusable tourniquet," Filer said. "I bought one, for a few dollars, tried it and it worked." Filer now has a pack of the reusable tourniquets that he can secure single handed.

As Filer's instructor Radford knows, there are multiple ways to perform patient assessment and treatment procedures. "How else can we do this," Radford encourages other instructors to ask to help students with disabilities find other ways to get things done.

Filer wrapped up his clinical time with three days at the hospital for pediatric and obstetric patient contacts. He did the remaining hours on the ambulance with preceptors who he said were "helpful and encouraging."

Patients on the ambulance didn't have any problem with a paramedic student who also had a prosthetic. "I offered it up to patients," Filer said.

"He passed everything we were asking of everyone else," Radford said. "Just like all the other students."

Master of the affective domain
Those who have worked with and taught Filer are quick to mention his mastery of the affective domain. His positive attitude, always smiling demeanor, sense of humor and willingness to help others have always set him apart.

"I am proud to have Noah as a co-worker," said Pratt, who has been a nurse for 30 years. "Noah said he was going to 'keep at it — adapt and overcome,' which he has done."

"He has drive. (Filer) is more than willing for work it," Radford said. "He told me, 'You can take half my body, but you can't take my will.'"

Radford and other instructors appreciated Filer's jokes and sense of humor just as much after the accident as they did before his injury.

"I tell people I am always a guy to help out," Filer quipped. "In fact I am glad to give a hand — my left hand — to anyone that needs it."

Another of Filer's go-to jokes to put others at ease plays on his health care knowledge. "If I ever have diabetes mellitus and need an amputation I want them to take my left leg first."

Final written test to be a paramedic
With his clinical time complete, Filer passed the SwedishAmerican paramedic course. In Illinois, paramedic students can choose the Illinois State Licensing Exam or the National Registry Exam. In early 2016 Filer took the Illinois computer-based test.

Filer's originally chose the SwedishAmerican 12-month program because it was fast and convenient. Now almost five years after he started he was determined to become a paramedic. "I put in so much time and effort," Filer said.

But it wasn't enough. He didn't pass the exam on his first attempt.

After that setback Filer realized he needed to do even more to get ready. "I spent 105 hours using EMTPrep.com and passed the IDPH written exam on March 28, 2016."

On the job and back home
Since receiving his paramedic certification, Filer has worked as an emergency department clinical greeter at SwedishAmerican three days a week. During his 12-hour shifts, he greets patients in the waiting room, assesses the nature of their illness, triages patients to be seen immediately, begins the registration process and reassesses patients who are waiting to be seen.

Although he is still on the roster at Durand, Filer doesn't think becoming a firefighter-paramedic is "in the cards." He recently celebrated his daughter's second birthday and likes the flexibility that comes with working three 12-hours shifts a week with four days off to spend with his family.

"Everyone has good days, bad days," Filer says about learning to live with prostheses. "If there is pain it is a fit issue."

Filer says he has an awesome prosthetist who helps makes sure the fit is good and he has the right size prosthetic to meet the demands of his job, which includes lifting and moving patients.

Filer regularly works out and lifts weights. He is able to squat lift 350 pounds and dead lift 250 pounds so he needed a leg prosthetic that could accept a load of at least 475 pounds — his body weight plus his maximum squat lift.

If Filer decides to seek work on an ambulance, Radford would not hesitate to have him as a partner. She also noted that all paramedics, including those who are able- or full-bodied frequently call for help lifting or treating patients.

For aspiring paramedics who are also amputees Filer's advice from his experience is to "stay patient and keep working."

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EMT and paramedic rehab: Get off your butt and move

Research shows sitting is the new smoking and for EMS providers who sit a lot more movement is needed

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EMCrit Podcast 175 – A Follow-Up on the Fluids in Sepsis Panel with Phillipe Rola

Fluids in Sepsis

EMCrit by Scott Weingart.

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EMCrit Podcast 175 – A Follow-Up on the Fluids in Sepsis Panel with Phillipe Rola

Fluids in Sepsis

EMCrit by Scott Weingart.

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EMS providers can't afford to be obese

In a world where "super size me" is still a mantra and video games keep us on the couch, trying to stay fit is a monumental task. It’s no wonder that, according to the National Institutes of Health, more than a third of Americans are obese and that 1 in 20 are extremely obese.

For EMS providers, being overweight is not only a lifestyle issue, it’s a safety issue. We have one of the more hazardous jobs out there, suffering more sprains, strains and other occupational injuries than police officers or firefighters.

We sit, sometimes for hours at a time, at an on-the-road posting location or in a lounge chair watching videos. Then we are expected to rapidly respond to an emergency incident, lift hundreds of pounds without stretching or warming up and maintain our balance in the back of a moving vehicle while performing detailed tasks.

It’s a recipe for physical disaster.

So it should come as no surprise that some EMS agencies are requiring their employees to be physically fit for the job, not only upon entry, but continuously like a South Carolina county EMS agency's proposed fit-for-duty testing program. Frankly, it’s a wonder there aren’t more organizations with this requirement. Given the physicality of the job, it’s imperative that providers stay in shape for the sake of their patients and their coworkers.

Do you need more incentive to get fit"

Obesity is linked to hypertension, diabetes, coronary artery disease, certain types of cancer and osteoarthritis. You are more likely to trip, slip or fall if you are obese. Back injuries are more prevalent in people who are obese.

How many of us know of at least one person who is suffering from some physical ailment related to being very overweight" Or, how many have an obese coworker who is out for weeks because an injury"

The next time you are in a large group of EMS colleagues take a quick count of how many are overweight. I’m willing to bet that it’s more than a third of the group.

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Practice of hemodynamic monitoring and management in German, Austrian, and Swiss intensive care units: the multicenter cross-sectional ICU-CardioMan Study

Hemodynamic instability is frequent and outcome-relevant in critical illness. The understanding of complex hemodynamic disturbances and their monitoring and management plays an important role in treatment of ...

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EMS providers can't afford to be obese

Being overweight is a threat to our patients, to our health and to our livelihood

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Public use of tourniquets, bleeding control kits

Although large scale multiple casualty incidents such as the Boston Marathon bombing and the San Bernardino shooting capture the nation’s attention smaller scale MCIs are much more common. The National Association of State EMS Officials provides one definition of an MCI as any incident "which generates more patients at one time than locally available resources can manage using routine procedures [1]. Using that definition, researchers estimate the yearly incident rate in the United States is about 13.0 MCIs per 100,000 population [2].

Hemorrhage is the second leading cause of death for patients injured in the prehospital environment, accounting for 30-40 percent of all mortality [3]. Many of the patients who hemorrhage do so after suffering vascular injuries in one or more extremities. The annual incidence of extremity vascular injuries in the United States ranges from a low of 12.4 injuries at a rural trauma center in Missouri [4] to a high of 55 lower extremity injuries at a high-volume urban trauma center in Houston [5]. In a study of isolated penetrating injuries to the extremities, 57 percent of the patients who died had injuries that might have been amenable to tourniquet application [6].

There is little debate about the value of rapid hemorrhage control for improving outcomes in critically injured trauma patients. The American College of Surgeons Committee on Trauma has stated that bleeding must be controlled by prehospital providers as quickly as possible.

For maximum efficiency, health care providers must apply tourniquets before the patient has developed shock [7]. During Operation Iraqi Freedom, tourniquets applied in the field and before the onset of shock were strongly associated with survival [8].

Unfortunately, in cases of severe bleeding, trained professionals may not always arrive in time to prevent exsanguination. Researchers in Austria and Germany found that when traumatic injury occurs, bystanders with varying levels of first aid training are often present on scene before EMS arrives [9].

In addition, these bystanders often attempt to provide hemorrhage control for patients suffering from an exsanguinating injury. Although prior first aid training increased the probability of successful hemorrhage control by the bystander, the lack of first aid training did not prevent bystanders from attempting to control bleeding and a significant percentage were successful.

Can the public help
A central question is whether these bystanders who are present on the scene and are willing to help control severe bleeding can become part of a trauma chain of survival. There is very little data in support of this position. However, studies involving a cardiac arrest chain of survival demonstrate that trained bystanders can safely and effectively use defibrillators to resuscitate victims of out-of-hospital cardiac arrest [10-14]. Even sixth graders with no previous medical training can achieve performance goals similar to those achieved by trained medical responders [15].

Similarly, is it reasonable to think ordinary citizens would be able to safely and effectively apply tourniquets when indicated before the arrival of EMS personnel. Limited available evidence suggests it is.

During a simulated explosion, one in five people with no medical training were able to correctly apply a commercially available tourniquet to a manikin’s leg in less than 60 seconds [16]. Providing instructions on a notecard with the tourniquet more than doubled the rate of successful placements.

During the Boston Marathon bombing, 29 patients with life-threatening limb exsanguination had 27 improvised tourniquets applied in the field [17]. EMS personnel applied one-third of those tourniquets and non-EMS personnel or an unknown person applied the remainder.

In a 10-year evaluation of isolated penetrating or blunt extremity injury requiring either arterial revascularization or limb amputation at Boston Medical Center, only 2 percent of patients had a tourniquet applied before arriving at the trauma center and all were improvised tourniquets applied by police officers or bystanders [18]. An additional 2 percent of patients had a tourniquet applied by emergency department staff within one hour of arrival. While a very small number of patients without a tourniquet exsanguinated, no patient with a tourniquet died.

During a seven-year period, researchers at Boston Medical Center identified 11 patients who had an improvised tourniquet applied in the field by EMS [19]. Only one patient died, however, that patient was in cardiac arrest when EMS arrived on the scene. Of the 10 patients who survived, all had complete neurologic function in the affected extremity despite having the tourniquet in place for as long as 167 minutes (mean 75 +\- 38 minutes).

One concern about bystander application of a tourniquet is whether the bystander will be able to apply the device tightly enough to be effective. Indeed, a manikin study involving non-medical trained bystanders found that 70 percent of the incorrectly placed tourniquets were judged to be too loose [16]. However, a battlefield evaluation found that although morbidity remained high with partially ineffective tourniquet application (persistent distal pulses), mortality actually improved when compared to totally ineffective tourniquets (continued bleeding) [20]. This suggests that even when tourniquets are not tight enough to be totally effective, they may still be better than no tourniquet at all.

Hemorrhage-control training courses for the lay rescuer
The American College of Surgeons convened a special committee to identify changes necessary to improve survival following active shooter and MCIs [21]. One of the major themes to emerge from these series of meetings, known as the Hartford Consensus, is that the public will act as responders to provide aid before the arrival of professional rescuers.

Another major theme of the Hartford Consensus, which was the focus of the second Hartford Consensus Conference, is the value of a comprehensive educational program for all members of this trauma chain of survival. Critical to this concept and the focus of third Hartford Consensus Conference, is educational campaigns targeting members of the general public, which should include training on how to apply direct pressure, how to use hemostatic dressings, and how to apply tourniquets [22].

In response to the Hartford consensus, the EMS Education Department of the Denver Paramedic Division, in cooperation with the Prehospital Trauma Life Support committee of the National Association of EMTs developed training program targeting ordinary citizens [23]. The 2.5-hour Bleeding Control for the Injured course combines didactic lectures with hands-on training to teach the lay rescuer important life-saving skills such as hemorrhage control and how to open an airway [24].

Also in response to the Hartford Consensus, the White House launched the "Stop the Bleed" campaign [25]. This campaign hopes to provide public awareness to the simple steps that anyone can take to slow life-threatening bleeding. The campaign also promotes the placement of Bleeding Control Kits in public spaces that would allow members of the general public access to life-saving supplies, similar to public access defibrillation programs.

In 2015, the Harvard School of Public Education and the Harvard School of Government began a bleeding control pilot program at Charlotte Douglas International Airport [26]. The team placed bleeding control kits inside of each AED cabinet in the airport. Each kit contained pressure dressings, hemostatic dressings, tourniquets, and personal protective gloves. After training the airport emergency staff on the contents, use and location of the kits, the pilot team in conjunction with airport police, conducted three active shooter scenarios. After-action reporting indicated the responders were able to locate and appropriately use the kits in a simulated incident.

Bystander action is a result of competence from training
The military experience has demonstrated that complications associated with tourniquet use are rare, even when the tourniquet is improvised. The limited civilian data supports the safety of the tourniquets

Bystanders are often present on the scene of a traumatic injury before professional rescuers. In some cases, bystander care may mean the difference between whether the patient survives or not. Experience with CPR and AEDs has demonstrated that bystanders will attempt to intervene especially if they are trained and have easy access to the equipment.

Bystanders who self-report a feeling of competence to provide emergency first aid are more likely to help victims of traumatic injury [27]. That feeling of competence is positively correlated to first aid training. Those with first aid training feel competent to provide care before EMS arrives on the scene to take over [28].

With untrained bystanders as part of the definition of a first responder, the Office of Health Affairs at the Department of Homeland Security recommends the availability of both tourniquets and hemostatic agents in the early management of severe bleeding [7]. Lay rescuers play a vital role in providing immediate bleeding control while awaiting the arrival of traditional first responders [29].

References

1. National Association of State EMS Officials. (2012). Extended definition document NEMSIS/NHTSA 2.2.1 data dictionary. Retrieved from http://ift.tt/1WuVN6w.
2. Schenk, E., Wijetunge, G., Mann, N. C., Lerner, E. B., Longthorne, A., & Dawson, D. (2014). Epidemiology of mass casualty incidents in the United States. Prehospital Emergency Care, 18(3), 408–416. doi:10.3109/10903127.2014.882999
3. Kauvar, D. S., Lefering, R., & Wade, C. E. (2006). Impact of hemorrhage on trauma outcome: An overview of epidemiology, clinical presentations, and therapeutic considerations. The Journal of Trauma, Injury, Infection, and Critical Care, 60(6), S3-S11. doi:10.1097/01.ta.0000199961.02677.19
4. Humphrey, P. W., Nichols, W. K., & Silver, D. (1994). Rural vascular trauma: A twenty-year review. Annals of Vascular Surgery, 8(2), 179-185.
5. Feliciano, D. V., Herskowitz, K., O'Gorman, R. B., Cruse, P. A., Brandt, M. L., Burch, J. M., & Mattox, K. L. (1988). Management of vascular injuries in the lower extremities. Journal of Trauma, 28(3), 319-328.
6. Dorlac, W. C., DeBakey, M. E., Holcomb, J. B., Fagan, S. P., Kwong, K. L., Dorlac, G. R., Schreiber, M. A., Persse, D. E., Moore, F. A., & Mattox, K. L. (2005). Mortality from isolated civilian penetrating extremity injury. Journal of Trauma, 59(1), 217-222.
7. Department of Homeland Security. (2015). First responder guide for improving survivability in improvised explosive device and/or active shooter incidents. Retrieved from http://ift.tt/1TUxsDG
8. Kragh, J. F. Jr., Walters, T. J., Baer, D. G., Fox, C. J., Wade, C. E., Salinas, J., & Holcomb, J. B. (2009). Survival with emergency tourniquet use to stop bleeding in major limb trauma. Annals of Surgery, 249(1), 1–7. doi:10.1097/SLA.0b013e31818842ba
9. Pelinka, L. E., Thierbach, A. R., Reuter, S., & Mauritz, W. (2004). Bystander trauma care – effect of the level of training. Resuscitation, 61(3), 289-296. doi:10.1016/j.resuscitation.2004.01.012
10. MacDonald, R. D., Mottley, J. L., & Weinstein, C. (2002). Impact of prompt defibrillation on cardiac arrest at a major international airport. Prehospital Emergency Care, 6(1), 1-5. doi:10.1080/10903120290938689
11. O’Rourke, M. F., Donaldson, E. E., & Geddes, J. S. (1997). An airline cardiac arrest program. Circulation, 96(9), 2849-2853. doi:10.1161/01.CIR.96.9.2849
12. Page, R. L., Joglar, J. A., Kowal, R. C., Zagrodzky, J. D., Nelson, L. L., Ramaswamy, K., Barbera, S. J., Hamdan, M. H., & McKenas, D. K. (2000). Use of automated external defibrillators by a U.S. airline. New England Journal of Medicine, 343(17), 1210-1216. doi:10.1056/NEJM200010263431702
13. Valenzuela, T. D., Roe, D. J., Nichol, G., Clark, L. L., Spaite, D. W., & Hardman, R. G. (2000). Outcomes of rapid defibrillation by security officers after cardiac arrest in casinos. New England Journal of Medicine, 343(17), 1206-1209. doi:10.1056/NEJM200010263431701
14. Wassertheil, J., Keane, G., Fisher, N., & Leditschke, J. F. (2000). Cardiac arrest outcomes at the Melbourne Cricket Ground and Shrine of Remembrance using a tiered response strategy — a forerunner to public access defibrillation. Resuscitation, 44(2), 97-104. doi:10.1016/S0300-9572(99)00168-9
15. Gundry, J. W., Comess, K. A., DeRook, F. A., Jorgenson, D., & Bardy, G. H. (1999). Comparison of naïve sixth-grade children with trained professionals in the use of an automated external defibrillator. Circulation, 100(16), 1703-1707. doi:10.1161/01.CIR.100.16.1703
16. Goolsby, C., Branting, A., Chen, E., Mack, E., & Olsen, C. (2015). Just-in-time to save lives: A pilot study of layperson tourniquet application. Academic Emergency Medicine, 22(9), 1113-1117. doi:10.1111/acem.12742
17. King, D. R., Larentzakis, A., & Ramly, E. P. (2015). Tourniquet use at the Boston Marathon bombing: Lost in translation. Journal of Trauma and Acute Care Surgery, 78(3), 594-599. doi:10.1097/TA.0000000000000561
18. Kalish, J., Burke, P., Feldman, J., Agarwal, S., Glantz, A., Moyer, P., Serino, R., & Hirsch, E. (2008). The return of tourniquets. Original research evaluates the effectiveness of prehospital tourniquets for civilian penetrating extremity injuries. Journal of the Emergency Medical Services, 33(8), 44–54. doi:10.1016/S0197-2510(08)70289-4
19. Bulger, E. M., Snyder, D., Schoelles, K., Gotschall, C., Dawson, D., Lang, E., Sanddal, N. D., Butler, F. K., Fallat, M., Taillac, P., White, L., Salomone, J. P., Seifarth, W., Betzner, M. J., Johannigman, J., & McSwain, N. Jr. (2014). An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma. Prehospital Emergency Care, 18(2), 163-173. doi:10.3109/10903127.2014.896962
20. Kragh, J. F., Walters, T. J., Baer, D. G., Fox, C. J., Wade, C. E., Salinas, J., & Holcomb, J. B. (2008). Practical use of emergency tourniquets to stop bleeding in major limb trauma. Journal of Trauma Injury, Infection, and Critical Care, 64(Suppl 2), S38–S49. doi:10.1097/TA.0b013e31816086b1
21. Jacobs, L. M., Wade, D., McSwain, N. E., Butler, F. K., Fabbri, W., Eastman, A., Conn, A., & Burns, K. J.. (2014). Hartford consensus: A call to action for THREAT, a medical disaster preparedness concept. Journal of the American College of Surgeons, 218(3), 467–475. doi:10.1016/j.jamcollsurg.2013.12.009
22. Jacobs, L. M. Jr., & the Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass-Casualty and Active Shooter Events. (2016). The Hartford consensus IV: A call for increased national resilience. Bulletin of the American College of Surgeons, 101(3), 17-24.
23. Pons, P. T., Jerome, J., McMullen, J., Manson, J., Robinson, J., & Chapleau, W. (2015). The Hartford consensus on active shooters: Implementing the continuum of prehospital trauma response. The Journal of Emergency Medicine, 49(6), 878–885. doi:10.1016/j.jemermed.2015.09.013
24. National Association of EMTs. (2016). Bleeding control for the injured. Retrieved from http://ift.tt/1WuWgWp
25. The White House, Office of the Press Secretary. (2015). Fact Sheet: Bystander: “Stop the Bleed” broad private sector support for effort to save lives and build resilience. Retrieved from http://ift.tt/1TUx3kI
26. National Preparedness Leadership Initiative. (2015). Public access bleeding control: An implementation strategy. Retrieved from http://ift.tt/1WuVUyS
27. Thierbach, A. R., Pelinka, L. E., Reuter, S., & Mauritz, W. (2004). Comparison of bystander trauma care for moderate versus severe injury. Resuscitation, 60(3), 271-277. doi:10.1016/j.resuscitation.2003.11.008
28. Steele, J. A. (1994). The effects of first aid training on public awareness of the management of a seriously injured patient. Journal of the Royal Society of Health, 114(2), 67–68. doi:10.1177/146642409411400204
29. Jacobs, L. M. Jr., & the Joint Committee to Create a National Policy to Enhance Survivability from Intentional Mass-Casualty and Active Shooter Events. (2015). The Hartford consensus III: Implementation of bleeding control – if you see something, do something. Bulletin of the American College of Surgeons, 100(7), 20-26.

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Bystander CPR: A key link in the chain of survival

With 359,000 people suffering out-of-hospital cardiac arrests in 2013, death by cardiac disease continues to be the number one killer in the United States [1]. Significant research in cardiac resuscitation has been ongoing since the 1950s, with time, effort and money examining the multiple variables affecting survival rates.

One component of the cardiac chain of survival, bystander CPR, appears to play a major role in the increase of survival to discharge rates in cardiac arrest. It is critical that EMS agencies play their part in strengthening this part of the resuscitation strategy in order to improve community health.

In 1988 the phrase "chain of survival" was coined to describe a series of events that if strung together and performed in a timely manner, would greatly improve the chances of survival from sudden cardiac arrest in the out of hospital setting [2]. These events include:

• Early access to the emergency cardiac care system by recognizing sudden cardiact arrest quickly and calling 911
• Early CPR by those nearest to the sudden cardiac arrest, bystanders
• Early defibrillation of ventricular arrhythmias
• Early advanced level care by trained professionals

Throughout the 1990s focus was placed on the back end of the chain of survival, i.e. the medications and procedures being done by paramedics and emergency department staff to improve survival rates. However, by the 2000s attention turned toward the improvement of the front end of the chain, specifically how to improve the incidence of bystander-provided CPR at the moment of collapse.

It was already known by the mid-1980s that early CPR by members of the public, performed before the arrival of trained responders, improved sudden cardiac arrest survival rates [3]. Yet the numbers of bystanders trained in CPR remains low and range considerably from one community to the next. Rates of 15 to 30 percent of sudden cardiac arrest receiving bystander CPR have been reported [4, 5]. Southern states, especially in areas with higher proportions of Hispanic and African American populations and lower median incomes have lower rates of CPR training [6].

Why are bystander CPR rates so low"
There have been a number of theories as to why bystander CPR rates have remained historically low, including fear of cross infection, fear of liability, the complexity of traditional CPR instruction that included mouth-to-mouth breathing techniques, and ultimately a lack of confidence in performing correctly in real life situations [7].

Regardless of the cause, it is essential to increase the percentage of sudden cardiac arrest patients who receive prearrival CPR, as a cost effective and efficacious method to improve survival to discharge rates.

Expanding CPR training opportunities
Up until the late 2000s, CPR courses taught to bystanders took several hours to complete, were costly and resource intensive, creating a barrier to readily accessible training opportunities. With the 2010 American Heart Association guideline recommendation that compressions-only CPR training may be more effective in training bystanders, organizations around the nation made an effort to train large numbers of bystanders in this technique. Without the extra burden of having to teach manual ventilation techniques and focusing on high-quality chest compressions practice, the time frame for training shortened considerably. Research has supported that change; studies comparing compressions only CPR versus "standard CPR" by nonprofessional bystanders showed a higher survival rate for sudden cardiac arrest patients who received compression only CPR [8,9].

Self-instructional kits have been created by the AHA and other training organizations that allows video-driven instruction to occur any time, and in any space [10]. School district CPR programs have used these kits to train middle and high school students during class, with the intent of having the students bring the kits home and train family members. This has resulted in a large number of citizens being trained in CPR at a modest cost [11, 12].

Internet-based CPR training has also drawn attention. A small study indicated that students who viewed an animation of CPR being done on a manikin performed ventilations and chest compressions just as well as students who received one hour of instructor-led training [13].

Widespread adoption of dispatch-assisted CPR training
Despite increasing access to CPR training, it is still likely that at the temporal moment of sudden cardiac arrest, the person closest to the victim is capable of performing hands-only CPR. 911 telecommunicators can provide just in time, over-the-phone guidance for individuals who are willing to provide CPR. Multiple studies have shown the efficacy of dispatch CPR instructions in improving sudden cardiac arrest survival rates [14, 15].

Providing reassurance to the would-be lay rescuer
The AHA has recommended that bystanders be educated on the virtually nonexistent risk of disease transmission during CPR. Information about relevant Good Samaritan laws should be provided, and worksites and public spaces should have basic personal protective equipment such as gloves and pocket masks co-located with public access automated external defibrillators [16].

The role of EMS agencies
As the first professionally trained link in the chain of survival, EMS agencies can play a critical role in training its community members in CPR and AED use. Examples include:

• Sponsoring large-scale, one-day events such as Save-A-Life Saturday
• Training middle school health teachers how to teach compression-only CPR to their students and providing training equipment when needed [17]
• Implementing dispatch-assisted CPR protocols within the 911 call center
• Advocating for legislative changes that encourage or mandate CPR training in public schools
• Work with government officials and other stakeholders to place AEDs in public areas and locations where the likelihood of SCA is higher
• Publically recognize bystanders who make the effort to perform CPR at the temporal moment of SCA

SCA is a public health disease that responds to carefully planned interventions based on evidence. Given the growing body of evidence that shows the benefit of bystander CPR, EMS agencies can take the lead to improve their community's ability to respond when seconds truly count.

References

1. American Heart Association. Cardiac Arrest Statistics. http://ift.tt/1RWfAJJ retrieved 20 April 2016.

2. Newman M (1989). "The chain of survival concept takes hold". JEMS 14: 11–13.

3. Ritter G et al. The effect of bystander CPR on survival of out-of-hospital cardiac arrest victims. Am Heart J. 1985 Nov;110(5):932-7.

4. De Maio VJ et al. Ontario Prehospital Advanced Life Support (OPALS) Study Group. CPR-only survivors of out-of-hospital cardiac arrest: implications for out-of-hospital care and cardiac arrest research methodology. Ann Emerg Med. 2001; 37: 602–608.

5. Lateef F, Anantharaman V. Bystander cardiopulmonary resuscitation in prehospital cardiac arrest patients in Singapore. Prehosp Emerg Care. 2001; 5: 387–390.

6. Anderson ML et al. Rates of cardiopulmonary resuscitation training in the United States. JAMA Intern Med. 2014 Feb 1;174(2):194-201.

7. Swor R et al. CPR training and CPR performance: do CPR-trained bystanders perform CPR" Acad Emerg Med. 2006; 13: 596–601.

8. Hüpfl M, Selig FS, Nafele P. Chest Compression-Only CPR: A Meta-Analysis. Lancet. 2010 Nov 6; 376(9752): 1552–1557.

9. Dias JA et al. Simplified dispatch-assisted CPR instructions outperform standard protocol. Resuscitation. 2007; 72: 108–114.

10. American Heart Association. CPRanytime.org website. www.cpranytime.org.

11. Isbye DL, Meyhoff CS, Lippert FK, Rasmussen LS. Skill retention in adults and in children 3 months after basic life support training using a simple personal resuscitation manikin. Resuscitation. 2007;74:296–302

12. Lorem T, Palm A, Wik L. Impact of a self-instruction CPR kit on 7th graders' and adults' skills and CPR performance. Resuscitation. 2008;79:103–108

13. Choa M-H, Park I-C, Chung HS, Yoon YS, Kim S-H, Yoo SK. Internet-based animation for instruction in cardiopulmonary resuscitation. J Telemed Telecare. 2006; 12 (suppl 3): 31–33.

14. Hallstrom AP, Cobb LA, Johnson E, Copass MK. Dispatcher assisted CPR: implementation and potential benefit: a 12-year study. Resuscitation. 2003;57: 123–129.

15. Dias JA et al. Simplified dispatch-assisted CPR instructions outperform standard protocol. Resuscitation. 2007; 72: 108–114.

16. Abella BS et al. AHA Scientific Statement: Reducing Barriers for Implementation of Bystander-Initiated Cardiopulmonary Resuscitation. Circulation. 2008; 117: 704-709.

17. Daubs B. Local students and Save Lives Sonoma take CPR lessons to heart. The Healdsburg Tribune, 19 February 2014. http://ift.tt/1WuVI2Q retrieved 5/5/16.

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National EMS Week: Budgeting for PTSD

By Allison G. S. Knox, M.A., EMT-B, faculty member at American Military University

Post-traumatic stress disorder (PTSD) has received a lot of public attention in recent years as American service members returned from deployments in Iraq and Afghanistan. The struggles of these military personnel returning with PTSD have shed light on the issues and challenges of this often debilitating disorder. It is nothing short of a terrible illness for the ways it hijacks the lives of individuals.

In recognition of National EMS Week from May 15 to 21, it is important to understand how PTSD affects emergency medical technicians (EMTs), paramedics, and other members of the first responder community.

[Related: Today, Tomorrow, or Next Year" Coping with PTSD in EMS]

Responding to emergency medical calls can be traumatic; individuals working in such an environment are often profoundly affected by it. But what is often misunderstood is that even scenes that are not particularly gruesome can also have a lasting effect on responders. ​

​Full story: National EMS Week: Budgeting for PTSD

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Public use of tourniquets, bleeding control kits

Bystander application of a tourniquet to 'Stop the Bleed' may mean the difference between life and death for a patient with severe hemorrhage

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Bystander CPR: A key link in the chain of survival

EMS agencies should promote public involvement in cardiopulmonary resuscitation and AED use to improve community health

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Variations in inpatient rehabilitation functional outcomes across centers in the traumatic brain injury model systems (TBIMS) study and the influence of demographics and injury severity on patient outcomes

Archives of Physical Medicine and Rehabilitation

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Contribution of histological chorioamnionitis and fetal inflammatory response syndrome to increased risk of brain injury in infants with preterm premature rupture of membranes

Pediatric Neurology

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Telephone out patient score: The derivation and validation of a telephone follow-up assessment tool for use in clinical research in children with croup

Pediatric Emergency Care

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Association between severity of hypoglycemia and loss of heart rate variability in patients with type 1 diabetes mellitus

Diabetes/Metabolism Research and Reviews

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Trajectories of life satisfaction following spinal cord injury

Archives of Physical Medicine and Rehabilitation

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Alarmingly high level of alcohol use among fishermen: A community based survey from a coastal area of south India

Journal of Forensic and Legal Medicine

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Risk factors of occupational injuries and related disabilities among auto mechanics in the informal sector of Kumasi, Ghana

Value in Health

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Bending without breaking: A narrative review of trauma-sensitive yoga for women with PTSD

Complementary Therapies in Clinical Practice

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Meta-analysis to determine risk for serious bacterial infection in febrile outpatient neonates with RSV infection

Pediatric Emergency Care

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The impact of facility relocation on patients' perceptions of ward atmosphere and quality of received forensic psychiatric care

Journal of Forensic and Legal Medicine

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An audit of top citations published in pediatric emergency care

Pediatric Emergency Care

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Factors associated with recurrent falls in individuals with traumatic spinal cord injury – a multi-center study

Archives of Physical Medicine and Rehabilitation

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Preclinical reproductive and developmental toxicity profile of a glycine transporter type 1 (Glyt1) inhibitor

Birth Defects Research Part B: Developmental and Reproductive Toxicology

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Radiological assessment of paediatric cervical spine injury in blunt trauma: The potential impact of new NICE guidelines on the use of CT

Clinical Radiology

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World Health Assembly agrees new Health Emergencies Programme

WHO news

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Neutrophil-to-lymphocyte ratio as a diagnostic biomarker for the diagnosis of acute mesenteric ischemia

Abstract

Purpose

Due to the diagnostic challenges and dreadful consequences of delayed treatment of acute mesenteric ischemia (AMI), a variety of diagnostic markers have been previously studied. However, the diagnostic value of neutrophil-to-lymphocyte ratio (NLR), which has been suggested to be a predictor of inflammation, has never been studied for AMI.

Methods

The data of 70 patients who underwent laparotomy (n = 8) and/or bowel resection (n = 62) for AMI (n = 70) between January 2009 and March 2014 were retrospectively analyzed. To investigate the studied parameters’ role in the differential diagnosis of AMI, control groups were selected from most common reasons of inflammation-related emergent surgery, acute appendicitis (AA, n = 62) and normal appendix (NA, n = 61). White blood cell (WBC), red cell distribution width (RDW), NLR and mean platelet volume (MPV) values were recorded. Outcome variables of the study were defined as diagnostic and prognostic role of NLR in AMI.

Results

RDW and NLR values were found to be higher in the AMI group than the AA group (p < 0.001 and p < 0.001). Also, WBC and MPV values were higher in the AMI group than the NA group (p = 0.001 and p < 0.001). Combined sensitivity, specificity, positive predictive value and negative predictive value of RDW and NLR for recommended cut-off values were 69.4, 71.2, 57.8 and 80.4 %, respectively.

Conclusion

High NLR value (>9.9) seems to be a valuable diagnostic marker of acute mesenteric ischemia. Combined use of NLR, RDW and other clinical assessment, could help the diagnosis of AMI, especially in the absence of advanced imaging modalities and expert radiologic interpretation.

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Blunt abdominal trauma and mesenteric avulsion: a systematic review

Abstract

Purpose

The aim of this study is to establish the biomechanics, presentation and diagnosis of mesenteric avulsions following blunt abdominal trauma and reach a consensus on their overall management.

Materials and methods

A systematic review of literature in MedLine, Embase, Scopus and CINHAL in English language from 1951 to November 2014 was performed. A total of 20 reported cases were identified. Variables including patient’s demographics, signs and symptoms, mechanism of injury, investigative modality, management, length of stay, follow-up and outcomes were reviewed and analyzed.

Results

The median age of the cohort was 28.5 years (range 10–58 years), with a male-to-female ratio of 3:1. The commonest mechanism of injury was road traffic accident due to seat belt restraint (n = 12, 60 %). The commonest presentation was diffuse abdominal tenderness (n = 10, 45 %) followed by ecchymosis/bruising (n = 9, 40 %). Computed tomography (CT) remained the investigative modality of choice (n = 9, 45 %). All cases had an emergency exploratory laparotomy (n = 18, 90 %) within the initial 24 h and the median length of stay was 19 days (range 4–90 days). The overall mortality was 15 % (n = 3).

Conclusion

Mesenteric avulsion is rare and has a complex and vague presentation. Due to its potential mortality and morbidity, emergency physicians should keep a high index of suspicion in individuals with blunt abdominal trauma from any mechanism of injury.

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Is augmentation plating an effective treatment for non-union of femoral shaft fractures with nail in situ?

Abstract

Purpose

There are few reports of non-union femur shaft fractures treated with plate fixation with the nail in situ. This study reports our results in 40 cases.

Methods

Retrospective series of non-union and delayed union of femoral shaft after intramedullary nailing treated with plate fixation. Patients were serially followed-up till 12 months. Fracture union, time to union, knee range of motion, deformity, shortening and complications were recorded. Descriptive statistics were performed as applicable.

Results

There were 40 patients with mean age of 35 years (18–65). There were 14 cases of hypertrophic non-union, 24 cases of atrophic non-union and 2 cases of delayed union. The average time of surgery was 1 ½ h and average blood loss was 300 ml. Exchange nailing was done in 9 cases. Union was achieved in 39 patients. The mean time to fracture union was 4 months. Post-operative knee range of motion was >120° in 35 patients. One patient developed deep infection which was treated with removal of implants and exchange nailing with a vancomycin coated nail and union was achieved.

Conclusion

Plating is an effective treatment for non-union of diaphyseal femur fractures after intramedullary fixation with the nail in situ.

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Management of prehospital shoulder dislocation: feasibility and need of reduction

Abstract

Purpose

Dislocation of the shoulder is rare in the prehospital setting. The medical specialities of the emergency physicians are heterogeneous, and the level of experience is different. Aim of this study was to evaluate the feasibility, sufficiency, and need of prehospital reduction.

Methods

Over 12 months, 16 rescue stations in Germany and Austria documented cases. Points of examination were: incidence of reduction, influence of pathological findings, therapy and effectiveness of reduction.

Results

We included 70 patients. A reduction was undertaken in n = 47 (66.6 %). In n = 70 (100 %) perfusion was without pathological finding after reduction, all n = 7 (10 %) neurological pathologies declined after reduction. There was no significance in total implementation of prehospital reduction between surgeons and anaesthetists. N = 63 (90 %) of all patients received an immobilisation of the shoulder. N = 68 (97 %) of all patients were transported to a hospital. Time to arrival in hospital was in n = 50 (71.4 %) ≤10 min, in n = 17 (24.2 %) ≤20 min and in n = 3 (4.4 %) ≤30 min.

Conclusion

Implementation of reduction is independent of pathological neurological or vascular findings. Knowledge and skill is enough to perform a reduction quiet effectively in all emergency physicians. No specific technique can be recommended for prehospital use, the importance of being skilled is more important than one method. Early reduction was performed most rapidly in surgeons, but as well in the recommended time by other medical disciplines. On documented timings to admission hospital waiver of reduction is doubt. Therefore, a reduction in the prehospital setting is possible, but not obligatory.

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Vitamin D deficiency in adult fracture patients: prevalence and risk factors

Abstract

Purpose

Although vitamin D levels are not routinely monitored in outpatient fracture patients, identification of fracture patients with a deficient vitamin D status may be clinically relevant because of the potential role of vitamin D in fracture healing. This study aimed to determine the prevalence of and risk factors for vitamin D deficiency in non-operatively treated adult fracture patients.

Patients and methods

Vitamin D levels were determined in a cross-sectional study of adult patients, who were treated non-operatively for a fracture of the upper or lower extremity in the outpatient clinic of a level 1 trauma center, during one calendar year. Potential risk factors for (severe) vitamin D deficiency were analyzed using multivariable logistic regression analysis.

Results

A total of 208 men and 319 women with a mean age of 49.7 years (SD 19.9) were included. In this population, 71 % had a serum calcidiol <75 nmol/L, 40 % were vitamin D deficient (serum calcidiol <50 nmol/L) and 11 % were severely vitamin D deficient (serum calcidiol <25 nmol/L). Smoking and season (winter and spring) were independent risk factors for vitamin D deficiency. An increasing age, a non-Caucasian skin type, winter and smoking were identified as independent risk factors for severe vitamin D deficiency. The use of vitamin D, alcohol consumption and higher average daily sun exposure were independent protective factors against (severe) vitamin D deficiency.

Conclusion

Given the potential role of vitamin D in fracture healing, clinicians treating adult fracture patients should be aware of the frequent presence of vitamin D deficiency during the winter, especially in smoking and non-Caucasian patients. Research on the effect of vitamin D deficiency or supplementation on fracture healing is needed, before suggesting routine monitoring or supplementation.

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Impact of age on the clinical outcomes of major trauma

Abstract

Purpose

In view of demographic changes over the past few decades, the average age of trauma patients is progressively increasing. We therefore aimed to summarize the specific characteristics of geriatric trauma and to identify potential fields for further research to improve the care of elderly trauma patients.

Methods

Review of the literature.

Results

Due to the diverse risk factors (e.g., pre-existing conditions, limited physiological reserve), geriatric patients are prone to developing severe complications, even after less severe trauma. Yet, age is not considered as the only predictor of worse outcomes, and it should not be considered the only criterion for limiting care in those patients. It is crucial that age-specific treatment guidelines are developed to optimize the outcomes for senior trauma patients. Based on the current literature, these guidelines should emphasize the importance of field triage directly to a trauma center, along with the activation of the trauma team. Furthermore, early intensive monitoring, aggressive resuscitation, and time of surgical intervention are of upmost importance to reduce mortality.

Conclusion

The impact of several factors [age, premedical conditions (PMC), decreased physiological reserves, and impaired immune function] on the post-traumatic course of elderly trauma patients needs to be clarified in future experimental and clinical studies for the early identification of geriatric high-risk patients and for the development of age-adapted therapeutic strategies.

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Evaluation of the influence of the definition of an isolated hip fracture as an exclusion criterion for trauma system benchmarking: a multicenter cohort study

Abstract

Purpose

To assess whether the definition of an IHF used as an exclusion criterion influences the results of trauma center benchmarking.

Methods

We conducted a multicenter retrospective cohort study with data from an integrated Canadian trauma system. The study population included all patients admitted between 1999 and 2010 to any of the 57 adult trauma centers. Seven definitions of IHF based on diagnostic codes, age, mechanism of injury, and secondary injuries, identified in a systematic review, were used. Trauma centers were benchmarked using risk-adjusted mortality estimates generated using the Trauma Risk Adjustment Model. The agreement between benchmarking results generated under different IHF definitions was evaluated with correlation coefficients on adjusted mortality estimates. Correlation coefficients >0.95 were considered to convey acceptable agreement.

Results

The study population consisted of 172,872 patients before exclusion of IHF and between 128,094 and 139,588 patients after exclusion. Correlation coefficients between risk-adjusted mortality estimates generated in populations including and excluding IHF varied between 0.86 and 0.90. Correlation coefficients of estimates generated under different definitions of IHF varied between 0.97 and 0.99, even when analyses were restricted to patients aged ≥65 years.

Conclusions

Although the exclusion of patients with IHF has an influence on the results of trauma center benchmarking based on mortality, the definition of IHF in terms of diagnostic codes, age, mechanism of injury and secondary injury has no significant impact on benchmarking results. Results suggest that there is no need to obtain formal consensus on the definition of IHF for benchmarking activities.

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Clinical and radiologic outcomes associated with the use of dynamic locking screws (DLS) in distal tibia fractures

Abstract

Background

The locked screw plate construct is often cited as being too rigid and prolonging healing in patients with metaphyseal fractures. The newly introduced dynamic locking screws (DLS) allow 0.2 mm of axial motion, which should optimize healing near the near cortex. The purpose of this study was to analyze the clinical results of dynamic locking screws in distal tibia fractures.

Methods

Data were acquired retrospectively. Only distal meta-diaphyseal tibia fractures treated with minimally invasive plate osteosynthesis and DLS were evaluated. Cortical and locking head screws were used for distal plate fixation to minimize soft tissue irritation over the medial malleolus, and DLS were used in the proximal plate fixation. Clinical and radiographic data were evaluated after 6 weeks, 3 months, 6 months and 1 year until fracture union.

Results

Twenty-two patients were treated with minimally invasive plate osteosynthesis and DLS. Six patients could not be evaluated because they returned to a foreign residence after the procedure. Fourteen fractures healed after a mean of 3.1 months. Two fractures with insufficient reduction showed delayed union and healed after 9 and 9.5 months, respectively. The callus index peaked at 6 months.

Conclusions

Dynamic fracture fixation might be a promising concept to reduce the frequency of metaphyseal non-unions in distal tibia fractures. But nevertheless, the dynamic construct cannot compensate for insufficient reduction.

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Geriatric hip fracture management: keys to providing a successful program

Abstract

Background

Hip fractures are a common event in older adults and are associated with significant morbidity, mortality and costs. This review examines the necessary elements required to implement a successful geriatric fracture program and identifies some of the barriers faced when implementing a successful program.

Intervention

The Geriatric Fracture Center (GFC) is a treatment model that standardizes the approach to the geriatric fracture patient. It is based on five principles: surgical fracture management; early operative intervention; medical co-management with geriatricians; patient-centered, standard order sets to employ best practices; and early discharge planning with a focus on early functional rehabilitation. Implementing a geriatric fracture program begins with an assessment of the hospital’s data on hip fractures and standard care metrics such as length of stay, complications, time to surgery, readmission rates and costs. Business planning is essential along with the medical planning process.

Conclusion

To successfully develop and implement such a program, strong physician leadership is necessary to articulate both a short- and long-term plan for implementation. Good communication is essential—those organizing a geriatric fracture program must be able to implement standardized plans of care working with all members of the healthcare team and must also be able to foster relationships both within the hospital and with other institutions in the community. Finally, a program of continual quality improvement must be undertaken to ensure that performance outcomes are improving patient care.

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Answering the call: 911 dispatchers can be difference between life, death

By Patrick Buchnowski
The Tribune-Democrat

CAMBRIA COUNTY, Pa. — Thomas Leamer answers telephone calls for a living.

One caller says a child is choking, another one tells him a friend is overdosing on heroin.

Someone is bleeding and unconscious after a car crash, someone else is shot dead during a family argument. Then a young hiker goes missing in the woods or a deer hunter goes into cardiac arrest.

Just another day for Cambria County 911 dispatchers.

Leamer is one of 28 full-time dispatchers fielding emergency calls throughout the county of more than 136,000 residents.

They are led by a team of seven full-time supervisors.

All understand they are on the front lines when tragedy hits home. What a dispatcher says and does the second a 911 call comes into the Ebensburg center often means the difference between life and death.

“When they call us, it could be the worst day of their life,” Leamer said. “This might be our 12th or 13th call, but for them this is a defining moment they’re going to remember.”

The job of a dispatcher is more than just sending an ambulance. The job is ever evolving as technology develops and emergency care improves, county 911 Director Robbin Melnyk said.

“It has changed compared to 20 years ago where we took the call, got the address and sent help,” Melnyk said. “Today the protocols are designed to actually start patient care, tell people how to preserve evidence on police calls as well as give safety instructions on fire calls.

“You’re taking someone in a very frightening situation, getting the address and getting them to start taking care of that patient before that ambulance gets there,” she said.

In Pennsylvania, every 911 center is required to give pre-arrival instructions, Melnyk said.

That means dispatchers must instruct callers how to perform CPR, how to control bleeding and how to deliver a baby.

Recent changes include dispatchers giving instructions on how to administer Narcan to an overdose patient.

That also means dispatchers must be well trained.

And continued training is mandated after someone becomes a dispatcher, Melnyk said.

The group tries to stay ahead of the learning curve.

“When there’s something new coming out, we’re getting our people trained,” she said. “I like to think our dispatchers are better trained than anywhere else in Pennsylvania.”

Leamer, who is married and has one child, became a county dispatcher in 2007 after working about three years as an EMT with Hastings EMS.

Answering emergency calls at times becomes an emotional roller coaster. More so when it involves children.

“We had a call from one of the stores where a child was going through the doorway but put their hand on the wrong side of the door and it took the end of his fingers off,” Leamer said. “I had a little one at home at the time. I instructed them to put pressure to control the bleeding.”

Sudden Infant Death Syndrome cases can be some of he most emotional calls.

“Those are always tough,” he said.

“They wake up one morning and the child isn’t breathing.

“While the ambulance is on the way we help them to do CPR to try to bring the child back.”

Someone who calls 911 needs to be able to tell dispatchers where to find them.

“It doesn’t matter if it’s a fire, a shooting, a seizure. If we don’t know where they are we can’t help them,” Leamer said.

“These are people with their loved ones and you’re trying to help them,” he said. “They rely on us to be there.”

Copyright 2016 The Tribune-Democrat

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EMS Billing Manager - North East Mobile Health Services

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IPSA’s 2016 symposium to address contemporary issues facing EMS

GOODYEAR, Ariz. — The International Public Safety Association’s 2016 Fall Symposium is scheduled for October 25 to the October 26 in Tempe, Arizona. Contemporary issues facing today’s emergency first responders are include: critical incidents, active shooter, terrorism, mass casualty incidents, mental health and leadership will be addressed. The peer-to-peer exchange of information and lessons learned during this event will lend itself to be a truly valuable and educational forum for all emergency first responders. 
 
“This will be a true networking and information sharing experience between all emergency first responders. It’s not very often a law enforcement official is in the same type of educational setting gleaning from his/her counterpart in the fire service or EMS. Our Symposium will include moderated panels, traditional presentations, and facilitated round table discussions to encourage information sharing and networking with everyone in attendance," Heather R. Cotter, International Public Safety Association's Executive Director said. 
 
This "all hands on deck" Symposium is open to the entire public safety community and registration is open to both Members and Non-Members. Space is limited and early registration is advised.  
 
Being a Sponsor of the International Public Safety Association’s Fall Symposium provides networking opportunities and corporate visibility for public sector companies interested in promoting their services and solutions within the public safety vertical. The four-tiered sponsorship levels include Platinum, Gold, Silver and Bronze. 
 
The International Public Safety Association, a 501(c)3 non-profit organization, was established July 2014 in the State of Arizona to bring the public safety community closer together by offering opportunities to network, cross-train and build a stronger public safety community capable of an effective joint response to all incidents.

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Frequent Flyers: Chest pains

See all of Lenwood Brown's comics.

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Psychiatric Emergencies for Clinicians: Emergency Department Management of Neuroleptic Malignant Syndrome

Publication date: Available online 28 May 2016
Source:The Journal of Emergency Medicine
Author(s): Michael P. Wilson, Gary M. Vilke, Stephen R. Hayden, Kimberly Nordstrom




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Texas town approves ambulance station

By Joseph Alderman
The Rockwall County Herald-Banner

HEATH, Texas — Residents of Heath may sleep a little safer, if perhaps a little less soundly, as the city council of Heath approved a conditional use permit for Rockwall EMS to house an ambulance station within city limits.

Despite a change in meeting date, a number of Heath residents came out to hear the council’s decision regarding the ambulance station. The issue has been one of contention due to the fact that the site chosen for the station is residentially zoned and some neighbors and council members expressed concern over lights, noise and traffic dangers the station may pose.

Martin Ramirez of Rockwall EMS addressed a number of these concerns, stating that lights and sirens would be avoided in residential areas whenever possible, and that the dangers to pedestrians and traffic are unfounded.

“This is our job,” Ramirez said, “we know how to not hit kids. This station will probably have a safer view than our other stations.”

Following the opening of the floor to the public and the council considering a number of different issues regarding the station, council member Barry Brooks motioned to approve the conditional use permit with a clause limiting the permit to five years. After five years, the Rockwall EMS may reapply if no violations of the permit have been committed.

This motion, seconded by Rich Krause, passed unanimously among the council.

“I think the community is better served by having it in the residential area than not at all,” Brooks said.

The council also unanimously approved a rate increase to Atmos Energy for natural gas service to the city. The increase, which would total $29.9 million across the region, will translate to a $1.26 increase per month to residents and will go toward making improvements to pipelines and ensuring the safety and reliability of their infrastructure. This total had been negotiated down from what originally would have been a $1.52 increase per resident per month.

A construction contract for repairs on a section of McDonald Road was also awarded by the council, as well as the approval of the purchase of a new fire engine.

Motions to table items were approved for the purchase of a building for the housing of public works equipment and to approve a license agreement with Travis Ranch regarding landscaping, irrigation and signage. The council stated that both issues required further investigation.

Copyright 2016 the Rockwall County Herald-Banner

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Training Blue light drive on commentary

U.K. Drivertraining seems to be mutch like Norwegian. Good job with the commentary ..! I could not run my mouth that fast, -getting thirsty just listening to him :-) Here in Norway you can only test 3 times in life, seen as not talented enough if you need more. ExEMTNor

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Training Blue light drive on commentary

U.K. Drivertraining seems to be mutch like Norwegian. Good job with the commentary ..! I could not run my mouth that fast, -getting thirsty just listening to him :-) Here in Norway you can only test 3 times in life, seen as not talented enough if you need more. ExEMTNor

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