Journal of Critical Care 2014;29:823 Heart & Lung : the Journal of Critical Care 2016 Oct 22; Ultrasound-guided deep-arm veins insertion of long peripheral catheters in patients with difficult venous access after cardiac surgery. Adam Fabiani, Lorella Dreas, Gianfranco Sanson PMID: 27780607
EMCrit by Scott Weingart.
Journal of Critical Care 2014;29:823 Heart & Lung : the Journal of Critical Care 2016 Oct 22; Ultrasound-guided deep-arm veins insertion of long peripheral catheters in patients with difficult venous access after cardiac surgery. Adam Fabiani, Lorella Dreas, Gianfranco Sanson PMID: 27780607
EMCrit by Scott Weingart.
Danger, Disruption, and Reub Strayer
EMCrit by Scott Weingart.
Danger, Disruption, and Reub Strayer
EMCrit by Scott Weingart.
"Haven't seen him in a week," said the man who called us to his home.
Like a lot of folks in the industrial city of Providence, Rhode Island he lived on the second floor of the three level home, rented the first floor to his mom, and the third to whoever answered the ad he posted and seemed decent enough.
"Is that unusual?" I asked.
"He stays to himself mostly, but there's usually some sign of life up there, footsteps, a TV, doors closing, you know."
Yeah, I know. Wish I didn't. I wish I had some Vicks to rub under my nose.
"How old is he?"
"Not too old, 50 maybe," said the man.
Fifty. Not too old. Ha ha. My own 50 years seemed to take a lifetime to reach.
We entered the rear hallway. The stairs led straight up to a landing and a door. There was a shamrock decal stuck there and greasy fingerprints around the doorknob.
"Is that smell normal," I asked the landlord who had followed us?
"He's not the cleanest tenant, but this is bad."
"Yeah, it is."
The landlord opened the door and the smell got worse. A clean stove — not because the tenant was a neatnik, rather it was seldom used. Some empty cans of canned spaghetti and balls of whatever they called meat were on a folding card table that served as his dinette. Dirty dishes spilled out of the sink and onto the counter.
The refrigerator stood in the corner inviting me to open it up. Nothing in there, not even a beer.
"Hello, anybody home?" I shouted, knowing the only answer would be my echo.
He was home alright. I could smell him.
I followed the trail to three doors in a rear hallway. Door number one, door number two or door number three. One of the doors had a string of neckties tied together, starting at the door handle and going over the top.
"Rescue 1 to Fire Alarm, start the police to this address."
"Roger Rescue 1, nature?"
"Possible suicide."
I pushed the middle door. It gave a little but would not open. So I pushed a little harder.
"Here he is."
It was now a crime scene, but I needed to confirm that the man was gone. I got the door open about a foot, squeezed through and watched a dead man's weight force the door shut. He had tied the last of the neckties around his neck, strung the rest over the top of the door, tied the last to the opposite side doorknob, kneeled in front of the door, inside his bedroom, facing the back of the door and closed it.
Slowly?
Quickly?
Did he slam the door?
Did he lean into it?
I couldn't figure out the mechanics of it and realized I was spending way too much time thinking about it. Everything inside him had let go. He was bloated, stiff and dead.
Pictures of a woman and some kids had been pinned to the back of the door. I squeezed back through the doorway, pushing the body with the door.
Thankfully you can look at pictures, but they can't look back.
"Does he have any friends or family?"
"He's lived here for a year, since he got out of prison. Nobody visits that I've seen."
Nobody.
The man at the end of the ties was a lot like the homeless ex-con that had been in the ambulance a few hours before we responded to this home. He was intoxicated, but able to talk. His main concern was finding work. He had no address, no references, no money and no past to put on an application. He had been staying at a shelter, waiting for a break. He seemed like a nice enough guy so I told him about a place my brother, a correctional officer told me about, a place that gave ex-cons a chance.
It is difficult to not judge the people that we meet during our shift. As years in EMS add up, and similar experiences begin to appear the same and the people who make up those experiences say the same things, have the same complaints and even look the same, our empathy can fade. For some EMS providers it takes years while others lose it rather quickly. Then there are those who keep it together for their entire career.
Instead of dwelling on the man who gave up, I was able to focus on the one who looked like a living version of the dead guy, who now had a business name for an apartment and an address in his top pocket. I didn’t know it when I handed the note to him, but the look of gratitude on his face would get me through a difficult call, and the rest of the shift.
This article first appeared on FireRehab.com, sponsored by Masimo.
By Jay MacNeal with Todd Daniello, Ken Hanson, Mitch Li, Sean Marquis, John Pakiela, Matt Smetana and Chris Wistrom
The ability to rapidly and reliably perform laboratory testing at the patient bedside has taken huge leaps in recent years. There are devices to quickly check a patient's blood sugar, electrolytes, INR, cardiac enzymes, lactic acid and other biomarkers.
Do these devices have a role in the rehab area, or are they only suited for in-hospital care" Glucometers, pulse oximetry, end-tidal carbon dioxide and carbon monoxide (CO) oximetry are all common in EMS, but the use of i-STAT or other point-of-care testing devices is a bit outside the norm of most EMS operations.
To examine the appropriateness of these point-of-care testing options, we must consider the costs and human resources it will require to maintain the processing device, sampling equipment and replacement cartridges, perform calibration and training, obtain CLIA waivers, apply interpretation of the results to immediate patient care and other challenges important to EMS.
With all of that in mind, let’s explore some available point-of-care testing tools and their potential usefulness or application for on-scene rehab of firefighters and other emergency personnel.
ECG and 12-lead EKG
Probably the least frequently used point-of-care test in the rehab environment is the one that has been around the longest. An EKG is an excellent tool in analysis of the person with chest pain or persistent shortness of breath, but it is much more versatile.
By using intervals and morphology of QRS, QTc and T waves we can glean insight into severe electrolyte disturbance, including hypo- or hyperkalemia and hypo- or hypernatremia. Both of these are significant concerns in sports medicine, and it makes sense that we would have the same issues in heat-stressed responders.
One of the steps in risk stratifying patients who have chest pain in the hospital is to subject them to a stress test. This involves exercising or stressing the heart to ensure its ability to maintain adequate perfusion and oxygenation during high demand periods.
Any degree of active or even passive firefighting involves the release of adrenaline and generation and sometimes impaired loss of heat, as well as significant exertion, which all equate to stress on the heart.
Firefighters are at a higher than average risk for heart disease and sudden death than the general population. The complaint of chest pain on the fire scene should most certainly be taken seriously and prompt an appropriate evaluation, including the performance of an on-site 12-lead EKG and timely transport to the hospital for further evaluation.
Lactate levels
The measurement of point-of-care lactic acid levels is an interesting notion. We know that lactic acid is a product of aerobic and anaerobic metabolism. It is found in high levels in those who are hypoperfused, such as sepsis and shock patients [1].
This biomarker as a prehospital point-of-care test is not widely used, but it may become an important assessment tool as mobile integrated health care progresses. Its utility in rehab is uncertain.
CO exposure
Carbon monoxide and cyanide are commonly found in the air on scene of active fires. CO needs to be a concern in confined-space operations as well. Any worker with headache, nausea, vomiting, weakness or altered mental status must be considered for CO exposure.
The Rad-57 is a commonly carried oximeter that will read O2 and CO saturations. It is important to note that whether using Rad-57 for routine CO screening or COHb blood testing in the hospital, a level of CO means almost nothing without a correlating physical examination.
Any patient with symptoms consistent with CO poisoning should be placed on high-flow oxygen and transported for formal laboratory evaluation and thorough workup at the emergency department. Any fire victims or exposed responders with altered mental status should be assumed to have high CO and cyanide levels and need to be aggressively treated.
ETCO2
Carbon dioxide along with water and ATP are produced as a byproduct of cellular metabolism as our bodies consume oxygen and glucose. Following its production, CO2 is transported in the blood and is exhaled through the lungs, where it provides a convenient source to be measured. CO2 measured at the end of an exhaled breath is known as ETCO2.
Basic physiology dictates that as the body becomes more acidic, the carbonic acid buffering system balance shifts toward producing more CO2. A normal ETCO2 is between 35-45 mm Hg. Quantitative ETCO2 is directly related to cardiac perfusion, with a decrease in perfusion leading to a lower ETCO2. A patient with low cardiac output from any number of shock states does not deliver as much CO2 back from the bloodstream to the lungs to be exhaled, which subsequently results in decreased ETCO2 levels.
The use of capnography to measure ETCO2 has been gaining popularity in EMS, with applications from intubation confirmation to sepsis detection. Use of ETCO2 has long been the standard for ventillatory monitoring during anesthesia and procedural sedation.
It is not unrealistic to see ETCO2 utility in firefighter rehab as more and more ALS and BLS services use this technology on a routine basis.
In addition to the quantitative number that is generated, the capnography waveform can also be used to assist in diagnosis of the firefighter in rehab. A bronchospasm waveform is characterized by changes in the ascending phase with loss of the sharp upslope resulting in a shark fin appearance. This is due to uneven emptying of CO2 by the alveoli during exhalation. Correlated with a physical exam, this measurement can also be used to guide treatment and the response to treatment in the firefighter with bronchospasm.
Finally, when using quantitative capnography a respiratory rate is displayed, which can assist in quickly gathering and trending vital signs of firefighters who present to rehab. This saves time and resources over counting respirations, which is frequently inaccurate and time-consuming.
Use of ETCO2 can be an excellent diagnostic aid in the rehab sector of firefighting operations, but remember that diagnostic tests, regardless of their ability and value, must be interpreted in the context of the patient’s clinical picture.
Conclusion
The assessment of anyone going through the rehab process should be dictated primarily by patient history, physical exam and field-proven point-of-care testing. It is unlikely that on-scene labs will be used routinely in the rehab sector unless costs decrease considerably. Pulse oximetry, EKG, ETCO2 and CO oximetry will likely continue to be the mainstays of rehab operations for some time to come.
Having formal rehab protocols, sign-in sheets, individual accountability and the support of incident commanders is crucial to rehab operations. Once in rehab, the responders become the responsibility of those running rehab.
EMS providers who are responsible for rehab operations should be familiar with local EMS protocols and NFPA 1584. In the event that a specific protocol does not cover a condition encountered on scene, medical direction should be contacted and transport initiated. We need to take a conservative approach to protecting the well-being and lives of our responders.
References
1. Hunter et al: End-tidal carbon dioxide is associated with mortality and lactate in patients with suspected sepsis. American Journal of Emergency Medicine (2013) 31, 64–71
"Haven't seen him in a week," said the man who called us to his home.
Like a lot of folks in the industrial city of Providence, Rhode Island he lived on the second floor of the three level home, rented the first floor to his mom, and the third to whoever answered the ad he posted and seemed decent enough.
"Is that unusual"" I asked.
"He stays to himself mostly, but there's usually some sign of life up there, footsteps, a TV, doors closing, you know."
Yeah, I know. Wish I didn't. I wish I had some Vicks to rub under my nose.
"How old is he""
"Not too old, 50 maybe," said the man.
Fifty. Not too old. Ha ha. My own 50 years seemed to take a lifetime to reach.
We entered the rear hallway. The stairs led straight up to a landing and a door. There was a shamrock decal stuck there and greasy fingerprints around the doorknob.
"Is that smell normal," I asked the landlord who had followed us"
"He's not the cleanest tenant, but this is bad."
"Yeah, it is."
The landlord opened the door and the smell got worse. A clean stove — not because the tenant was a neatnik, rather it was seldom used. Some empty cans of canned spaghetti and balls of whatever they called meat were on a folding card table that served as his dinette. Dirty dishes spilled out of the sink and onto the counter.
The refrigerator stood in the corner inviting me to open it up. Nothing in there, not even a beer.
"Hello, anybody home"" I shouted, knowing the only answer would be my echo.
He was home alright. I could smell him.
I followed the trail to three doors in a rear hallway. Door number one, door number two or door number three. One of the doors had a string of neckties tied together, starting at the door handle and going over the top.
"Rescue 1 to Fire Alarm, start the police to this address."
"Roger Rescue 1, nature""
"Possible suicide."
I pushed the middle door. It gave a little but would not open. So I pushed a little harder.
"Here he is."
It was now a crime scene, but I needed to confirm that the man was gone. I got the door open about a foot, squeezed through and watched a dead man's weight force the door shut. He had tied the last of the neckties around his neck, strung the rest over the top of the door, tied the last to the opposite side doorknob, kneeled in front of the door, inside his bedroom, facing the back of the door and closed it.
Slowly"
Quickly"
Did he slam the door"
Did he lean into it"
I couldn't figure out the mechanics of it and realized I was spending way too much time thinking about it. Everything inside him had let go. He was bloated, stiff and dead.
Pictures of a woman and some kids had been pinned to the back of the door. I squeezed back through the doorway, pushing the body with the door.
Thankfully you can look at pictures, but they can't look back.
"Does he have any friends or family""
"He's lived here for a year, since he got out of prison. Nobody visits that I've seen."
Nobody.
The man at the end of the ties was a lot like the homeless ex-con that had been in the ambulance a few hours before we responded to this home. He was intoxicated, but able to talk. His main concern was finding work. He had no address, no references, no money and no past to put on an application. He had been staying at a shelter, waiting for a break. He seemed like a nice enough guy so I told him about a place my brother, a correctional officer told me about, a place that gave ex-cons a chance.
It is difficult to not judge the people that we meet during our shift. As years in EMS add up, and similar experiences begin to appear the same and the people who make up those experiences say the same things, have the same complaints and even look the same, our empathy can fade. For some EMS providers it takes years while others lose it rather quickly. Then there are those who keep it together for their entire career.
Instead of dwelling on the man who gave up, I was able to focus on the one who looked like a living version of the dead guy, who now had a business name for an apartment and an address in his top pocket. I didn’t know it when I handed the note to him, but the look of gratitude on his face would get me through a difficult call, and the rest of the shift.
The electrocardiograph (ECG) is an essential tool in initial management and risk stratification of patients with suspected acute coronary syndrome (ACS). A six-point reporting criterion has been proposed to facilitate standardized clinical assessment of patients presenting to the emergency department (ED) with suspected ACS. We set out to evaluate the efficacy of these criteria in identifying patients with major adverse cardiac events (MACE), Type 1 myocardial infarction (T1MI), Type 2 myocardial infarction (T2MI), and one-year mortality in a cohort of emergency patients with chest pain.
This was an analysis of data from 2349 patients who presented to the Emergency Department with chest pain between 2008-2013. Data were collected as part of two prospective trials. ECGs were recorded at presentation and categorized according to the six-point criteria by local cardiologists blinded to all clinical information. The primary outcome was 30-day MACE, including T1MI, T2MI, unstable angina pectoris, revascularization and 30-day mortality. The outcome was adjudicated by cardiologists on the basis of all clinical information and test results. Likelihood ratios and odds ratios for 30-day MACE were reported for each ECG category.
MACE were diagnosed in 264 (11.3%) patients. Increasing ischemic abnormalities in ECGs, as categorized by the standardized reporting criteria, were associated with increasing rates of MACE. Within 30 days, T1MI occurred in 148 (6.3%) patients and T2MI occurred in 59 (2.5%) patients. Risk for T1MI increased with higher classification of ECG abnormalities. T2MI rates were highest in patients with ECGs of non-specific changes.
The rates of MACE, T1MI and one-year death can be stratified according to standardized ECG criteria in patients presenting to the ED with chest pain. The ECG findings in patients with T2MI are variable, and the ECG is less helpful in defining risk in this group.
This article is protected by copyright. All rights reserved.
Patients with chronic diseases often have to seek emergency care for exacerbations. In the face of large predicted increases in the prevalence of chronic diseases, there is increased pressure to avoid hospitalizing these patients at the end of the ED visit, if they can obtain the care they need in the outpatient setting. We performed this scoping study to provide a broad overview of the published literature on the transition of care between ED and primary care following ED discharge.
We performed a MEDLINE search of English-language articles published between 1990 and March 2015. We created a data-charting form a-priori of the search. Papers were organized into themes, with new themes created when none of the existing themes matched the paper. Papers with multiple themes were assigned preferentially to the theme that was consistent with their primary objectives. We created a descriptive numerical summary of the included studies.
Of 1,138 titles, there were 252 potentially relevant abstracts, and among those 122 met the inclusion criteria for full paper review. An additional 11 papers were acquired from reference review. From the 133 papers, 85 were included in the study. The papers were categorized into seven themes. These included Follow-up compliance and its predictors (38 studies), Telephone calls to discharged ED patients (15 studies), ED navigators (14 studies), The current system (nine studies), Ways to alert primary care providers (PCPs) of the ED visit (seven studies), Patient views and PCP information requirements (one each). In the Follow-up compliance and predictors theme, the two most frequently identified significant predictors for increasing the frequency of follow-up care were the provision of a follow-up appointment time prior to ED departure and the presence of health insurance. Follow-up telephone calls to patients resulted in better follow-up rates, but increased ED return visits in some studies. In the current system patients themselves are the conduit, and the barriers to follow-up care can be high. Email and/or electronic medical record alerts to the PCP are relatively new, and no studies limited the alerts to patients who had a defined need for follow-up care.
A plethora of work has been published on the transition of care from ED to primary care. In order to decrease hospitalizations among the upcoming wave of patients with chronic diseases, it appears that the two most efficient areas to target are a primary care follow-up appointment system and health care insurance. Further research is needed in particular to identify the patients who actually need follow-up care, and to develop information technology solutions that can be effectively implemented within the current emergency healthcare system.
This article is protected by copyright. All rights reserved.
To determine the effect of frailty on risk of 30-day mortality in non-severely disabled older patients with acute heart failure (AHF) attended in emergency departments (EDs).
The Frailty-AHF Study is a retrospective analysis of a multicentre, observational, prospective, cohort study (Older-AHF Register). This study included consecutive patients ≥ 65 years of age without severe functional dependence or dementia attended for AHF in 3 Spanish EDs during 4 months. Frailty was defined by frailty phenotype as the presence of 3 or more domains. Baseline and episode characteristics and 30-day mortality were collected in all the patients.
A total of 465 patients with a mean age of 82 (SD 7) years were included, 283 (61.0%) being female and 225 (51.3%) with severe comorbidity (Charlson index ≥ 3). Frailty was present in 169 (36.3%). The rate of 30-day mortality was 7.3%. Frailty adjusted for potential confounding factors was an independent factor associated with 30-day mortality (adjusted HR=2.5; 95%CI 1.0-6.0; p=0.047).
The presence of frailty is an independent risk factor of 30-day mortality in non-severe dependent older patients attended with AHF in EDs.
This article is protected by copyright. All rights reserved.
Poorly controlled hypertension (HTN) is extremely prevalent and if left unchecked, subclinical hypertensive heart disease (SHHD) may ensue leading to conditions such as heart failure (HF). To address this, we designed a multidisciplinary program to detect and treat SHHD in a high-risk, predominantly African American community. The primary objective of this study was to determine the cost effectiveness of our program.
Study costs associated with identifying and treating patients with SHHD were calculated and a sensitivity analysis was performed comparing the effect of four parameters on cost estimates. These included prevalence of disease, effectiveness of treatment (regression of SHHD, reversal of left ventricular hypertrophy [LVH], or blood pressure [BP] control as separate measures), echocardiogram costs, and participant time/travel costs. The parent study for this analysis was a single center, randomized controlled trial comparing cardiac effects of standard and intense (<120/80 mm Hg) BP goals at 1 year in patients with uncontrolled HTN and SHHD. A total of 149 patients (94% African American) were enrolled, 133 (89%) had SHHD, 123 (93%) of whom were randomized, with 88 (72%) completing the study. Patients were clinically evaluated and medically managed over the course of one year with repeated echocardiograms. Costs of these interventions were analyzed and, following standard practices, a cost per quality-adjusted life year (QALY) less than $50,000 was defined as cost effective.
Total costs estimates for the program ranged from $117,044 to $119,319. Cost per QALY was dependent on SHHD prevalence and the measure of effectiveness but not input costs. Cost effectiveness (cost per QALY less than $50,000) was achieved when SHHD prevalence exceeded 11.1% for regression of SHHD, 4.7% for reversal of LVH, and 2.9% for achievement of BP control.
In this cohort of predominantly African American patients with uncontrolled HTN, SHHD prevalence was high and screening with treatment was cost effective across a range of assumptions. These data suggest that multidisciplinary programs such as this can be a cost effective mechanism to mitigate the cardiovascular consequences of HTN in ED patients with uncontrolled BP.
This article is protected by copyright. All rights reserved.
Roadways are the most dangerous scene types for EMS providers and require increased safety measures from hazardous exposure to minimize death and serious injury of public safety personnel.
We regularly share news stories of fire apparatus struck while attending a motor vehicle collision, EMS providers struck while tending to a patient and police officers killed after stopping a speeding driver or checking on a disabled vehicle.
In late October, a medical helicopter was struck and tipped over in New Mexico by an intoxicated driver who drove around barricades meant to block traffic. The reckless driver also hit a fire truck. No injuries were reported, but we don't know the impact of the transport delay on the patient's outcome. We also don't know the potential impact of traumatic stress on the EMS and fire personnel who were in the midst of caring for a patient when a out-of-control vehicle plowed into their scene.
Six months ago, nearly to the day, another medical helicopter was struck by a drunk driver who swerved through emergency vehicles before striking the helicopter's tail rotor. The impact of this central Florida incident on the patient's outcome, as well as the emergency responders, is unknown.
Because of the frequency with which emergency personnel, vehicles and now helicopters are struck, we need to accept that erecting barricades, parking a couple of blocking vehicles, waving orange flags or setting-up temporary signs is inadequate scene protection. High-visibility apparel looks great, but if the fire truck and flashing lights don't get a drunk or distracted driver's attention, then a neon-reflective vest is the equivalent of an invisible cloak.
Roadway is a hazardous materials hot zone
Any time you are working on or near a roadway, you are in the hot zone of a hazardous materials incident. Vehicles, blunt trauma-inflicting machines, hurtle around you under the loose control of undertrained, often impaired and often distracted operators. Protect your life, livelihood and family's future by protecting yourself with time, distance and shielding.
Time: As little as possible
A lethal dose exposure on a roadway can happen in a fraction of a second. Minimize EMS personnel exposure by clearing the patient to an area of relative or improved safety as quickly as possible. Pick helicopter landing zones with limited and securable access.
A firefighter injured in a structure fire is not treated in the midst of the flames and smoke — a highly hazardous and unstable environment. Instead, the firefighter is evacuated quickly and aggressively out of the structure. The awaiting ambulance or helicopter is parked well outside of the building's collapse zone. Start visualizing any roadway incident as a fully-involved, multiple story structure fire.
Distance: Get out of the striking zone
Visual warnings — signs, flares, spotters — to drivers are nice, but not enough. Increase the frequency, visual loudness and upstream distance of warning signs from the incident.
It's even better to get out of the striking zone. Move the ambulance off the road as quickly as possible. Load and go to a parking lot, access road or location that is well outside of the striking range of impaired and reckless drivers. Find and use landing zones that are not within the accessible distance of a driver.
Shielding: Bigger and stronger wall
If personnel are stuck on the road because the patient requires prolonged extrication, build a bigger and stronger wall that is impenetrable by motor vehicles. If the opportunity exists to go around, through or over the wall of blocking vehicles, we can be sure that a determined, distracted or impaired driver will make an attempt to break through the shielding.
Finally, our brains are wired to see what we are expecting to see and poorly wired to see what we are not expecting. If you have ever driven west across South Dakota, you know that there are Wall Drug signs every few miles. Because your brain is expecting Wall Drug signs, you see nearly every one regardless of its size, distance from the road or message.
Very few drivers are ever overtaken by an emergency vehicle and thus often default to blissful unawareness or fight-or-flight driven erratic movement. Even fewer drivers are expecting a helicopter to be parked on the center line. Don't expect or rely on their impaired or distracted cognitive function to identify and react appropriately to this unexpected and never before encountered environmental change.
It is estimated 15-25% of patients with a mild traumatic brain injury (MTBI) diagnosed in the emergency department (ED) will develop post-concussive syndrome (PCS). The objective of this study was to determine if patients randomized to graduated return to usual activity discharge instructions had a decrease in their Post-Concussion Symptom Score (PCSS) 2 weeks after MTBI compared to patients who received usual care MTBI discharge instructions.
This was a pragmatic, randomized trial of adult (18-64 years) patients of an academic ED (annual census 60,000) diagnosed with MTBI occurring within 24 hours of ED visit. The intervention group received cognitive rest and graduated return to usual activity discharge instructions, and the control group received usual care discharge instructions that did not instruct cognitive rest or graduated return. Patients were contacted by text message or phone 2 and 4 weeks post ED discharge and asked to complete the PCSS, a validated, 22 item questionnaire, to determine if there was a change in their symptoms. Secondary outcomes included change in PCSS at 4 weeks, number follow-up physician visits, and time off work/school.
118 patients were enrolled in the study (58 in the control group and 60 in the intervention). Mean age was 35.2 (13.7) years and 43 (36.4%) were male. There was no difference with respect to change in PCSS at 2 weeks (10.5 vs 12.8; ∆ 2.3, 95% CI: 7.0, 11.7) and 4 weeks post-ED discharge (21.1 vs 18.3; ∆ 2.8, 95% CI: 6.9, 12.7) for the intervention and control groups, respectively. The number follow-up physician visits and time off work/school was similar when the groups were compared. Thirty-eight (42.2%) and 23 (30.3%) of patients in this cohort had ongoing on-going MTBI symptoms (PCSS > 20) at 2 weeks and at 4 weeks, respectively.
Results from this study suggest graduated return to usual activity discharge instructions do not impact rate of resolution of MTBI symptoms 2 weeks after ED discharge. Given patients continue to experience symptoms 2 and 4 weeks after MTBI, more investigation is needed to determine how best to counsel and treat patients with post-concussive symptoms.
This article is protected by copyright. All rights reserved.
Don Prince is a former fire chief, firefighter and EMS provider. He's also a recovering alcoholic, which is why he's a former fire chief, no longer a fire department member and not providing EMS care. In an article Prince wrote:
"One of the biggest things I could not let go of was my embarrassment, disappointment in myself and shame of having to resign my position as chief and my membership after almost 17 years of being a part of something that meant so much to me and for which I was not willing or able to make a choice to correct in order to try and save. Drinking was more important than my career and family at that time. I now see that if I had addressed my addiction years ago and sought the help that was offered to me none of this would have happened [1]."
Some EMS providers just like the patients they serve struggle with alcoholism and addiction. The daily stress of EMS work, as well as some cultural norms, may cause some EMS providers to unwind with friends and colleagues in situations where alcohol flows freely.
Research on alcohol use in EMS and fire
Science defines binge drinking as five or more servings for men or four or more servings for women. The definition is based on blood alcohol content — that consuming that many drinks within two hours typically raises BAC to 0.08 g/dL or higher [2].
In a study, funded by a grant from Federal Emergency Management Agency's Research and Development, firefighters were asked about their alcohol use. Data was collected from 656 male firefighters from 24 departments in the Missouri Valley region [3].
So, how do firefighters compare to the general male population in the United States" According to the 2013 National Survey on Drug Use and Health, 62 percent of males reported consuming alcohol in the past month — significantly lower than the fire service [4].
In 2010, the Centers for Disease Control and Prevention published data on binge drinking from more than 176,000 males. They found that 23 percent of males reported binge drinking in the month previous — half the rate of binge drinking reported in the fire service research [5].
We also know from anecdotal news reports, social media sharing and personal observation that EMS providers and firefighters seek solitude in the privacy of their own home in the company of a bottle of wine, beer or spirits. For a handful of addicts, the access to patient and agency medications can lead to a downward spiral of narcotics abuse, addiction and theft.
Substance treatment programs
The goal of substance abuse treatment is to stop drug or alcohol abuse and allow addicts to lead active lives in their family, workplace and community. One continual challenge, however, is keeping patients in treatment long enough for them to achieve this goal. That is why finding the right treatment for a person's specific needs is critical.
Drug abuse treatment is not one size fits all. Treatment outcomes depend on the [7]:
To help addicts find appropriate care, the National Institute on Drug Abuse created a brief guide that asks five questions to answer when searching for a treatment program [8]:
Information resources on drug and alcohol addiction
The Substance Abuse and Mental Health Services Administration is the agency within the U.S. Department of Health and Human Services that leads public health efforts to advance the behavioral health of the nation. SAMHSA's mission is to reduce the impact of substance abuse and mental illness on America's communities.
One of SAMHSA’s programs is the National Registry of Evidence-based Programs and Practices, a repository and review system designed to provide the public with reliable information on mental health and substance abuse interventions. All interventions in the registry have met NREPP's minimum requirements for review. The programs' effects on individual outcomes have been independently assessed and rated by certified NREPP reviewers [9].
The Joint Commission is an independent, not-for-profit organization that accredits and certifies nearly 21,000 health care organizations and programs in the United States. The Joint Commission accreditation and certification of substance abuse treatment centers is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards [10].
Addiction treatment programs
A variety of treatment options are available. Some treatment programs serve a diverse patient population while others focus their efforts on the specific characteristics of public safety personnel.
The Watershed is an addiction treatment program, licensed by the Florida Department of Children and Families, Substance Abuse Program Office and accredited by the Better Business Bureau. The Watershed also maintains Gold Seal accreditation through The Joint Commission. The Watershed has provided inpatient addiction, detoxification and rehabilitation services for over 14 years and successfully treated over 35,000 people [11].
The Watershed Addiction Treatment Programs website includes a wealth of resource including links for treatment programs in each of the 50 U.S. states.
In just three years, the Brattleboro Retreat Uniformed Service Program in Vermont has helped about 1,200 uniformed service professionals deal with issues including stress, substance abuse, trauma and depression [12]. Participants come to Brattleboro from throughout the United States, as well as military bases in Europe.
The Brattleboro Uniformed Service Program is a rigorous, brief — average stay is 10 days — partial hospitalization program for active or retired members of a uniformed service, such as police, fire, corrections, military and emergency medical service. Its structured and supervised psychotherapy program focuses on rapid clinical change, reduction of symptoms and stabilization and transitioning to outpatient service providers [13].
American Addiction Centers owns and operates adult drug and alcohol treatment and rehabilitation facilities nationwide. AAC has treatment facilities located in California, New Jersey, Florida, Texas, Nashville and Las Vegas [14].
The Rosecrance Florian Program for firefighters and paramedics incorporates occupational factors into the treatment process. The program’s director is an active-duty Battalion Chief/EMT with more than 25 years of experience with the Chicago Fire Department. Operational medical control is provided by a board-certified psychiatrist and addictionologist who is trained and experienced in treating firefighters and paramedics for co-occurring disorders [15].
Do your research
Don Prince, the former fire chief, took his new "lease on life" as a recovering alcoholic and sought training and education from The Addictions Academy to become a Certified Recovery Coach and Interventionist through. The Addictions Academy is one of the nation’s leading and accredited centers for individuals seeking training and certification in the fields of addiction treatment services, recovery/sober coaching and intervention.
During my e-mail exchange with Prince, he expressed the need for EMS providers looking for substance abuse treatment options to be cautious. "I would like to share with you my opinion of what the truth is as far as what is out there for one of us who needs help. It is not a very good situation given the current state of the substance abuse industry." [16].
Regarding some residential treatment facilities, Prince wrote, "The idea that a majority of the providers are in it to save lives and help you is not their primary intended mission. That comes secondary to filling beds and making a profit. What suffers is the quality of care during your stay at a facility and, even more importantly, is the lack of aftercare when you leave and get home and back on the job."
According to Prince, 80 percent of people leaving an addiction treatment center relapse within the first year of discharge. Nine out of ten of the addicts who relapse do so within their first 90 days after discharge. "Working with a Recovery Coach can significantly reduce the likelihood of relapse during this crucial period," wrote Prince. "Recovery Coaching is often the missing link, bridging the gap between an individual leaving a treatment center and maintaining long term sobriety."
References
1. Prince, D. Fighting the Devil Within. [Available: On-line] http://ift.tt/2fj3rlF"trk=mp-reader-card
2. FireRescue1. Firefighters and alcohol, what the data says. http://ift.tt/2ePVZLS
3. Ibid.
4. Ibid.
5. Ibid.
6. National Institute on Drug Abuse (NIDA/NIH). Anyone Can Become Addicted to Drugs. YouTube. https://youtu.be/SY2luGTX7Dk
7. National Institute on Drug Abuse. Seeking Drug Abuse Treatment: Know What to Ask. http://ift.tt/24uY7io
8. Ibid.
9. Substance Abuse and Mental Health Services Administration. National Registry of Evidence-based Programs and Practices. http://ift.tt/1SIOoyj
10. The Joint Commission. About The Joint Commission. http://ift.tt/1kWWHXK
11. The Watershed Addiction Treatment Programs. Frequently Asked Questions. http://ift.tt/2ePXb1W
12. Brattleboro Retreat. Uniformed Service Program. http://ift.tt/2fj7vC8
13. New England Psychologist. Program helps service professionals. http://ift.tt/2ePZNgm
14. American Addiction Centers. Frequently Asked Questions. http://ift.tt/2fj3wph
15. Rosecrance Florian Program. Firefighter & Paramedic Substance Abuse Treatment Program. http://ift.tt/2ePZa6r
16. Prince, D. Personal Communication via LinkedIn. April 14, 2016.
By Anonymous Paramedic, Sacramento, Calif.
Some days it's a lot to handle. It's a hard thing to describe. I've never been one for talking about my feelings. The more important it is, the more powerful the feeling, the less I will say about it. The best I can do is to say that it is a feeling of crushing emptiness.
There is always a lot of talk about how this job can effect us. People die while we try to keep them from doing so. That is definitely a humbling feeling. I have worn other people's blood on my skin. I have heard the last words of people I have just met. I have felt my paradigm shift, and my ego crumble when I realize that I cannot help my patient and I do not know why.
I have experienced many of the stereotypical, harrowing experiences associated with this profession. I do not mean to underestimate the effects that those experiences can have on us, but for me personally it feels a little self-aggrandizing.
Those are the stories people expect.
When someone sees me staring into space, lost in my thoughts, it's easy for them to imagine those things running through my mind. I wish that were the case.
Make no mistake, I am struggling.
This job does eat away at me every day. There have been days that the toll is taken in one fell swoop, with a fast-paced, high pressure, traumatizing call.
Most days that isn't the case. Most days I don't have such a convenient target to point at when those feelings hit me. Most days it comes down like a light rain all around me.
There is no big wave. There is no crashing and breaking. Just a slow, steady rain, soaking into everything.
I see death every day, but it doesn't always make for a thrilling story. I see elderly patients over and over, slightly worse each day. I see demanding, high maintenance patients who really only called because they needed someone to talk to, someone to focus on them for a while. I see patients ashamed of themselves. Ashamed of their size, their appearance, or their hygiene. Ashamed that they need us. I see so much sadness. Not the potent sadness of an acute pain or loss. Not the sadness that allows for catharsis. I see a chronic sadness. Less a sharp stab, more a dull ache. A sadness that I don't realize is there until I begin to bend under the weight. Now I'm left searching for the source.
I do look back on certain calls and feel the twinge of the intense feelings that they evoked. I feel regret. I feel guilt. I feel incompetent. At least I feel a sense of understanding. I can understand the hurt of those calls. I can paint a picture in my mind. I can quantify the pain.
Those are not the thoughts running through my mind when I am lost in it all. Instead, I am left here wondering what is causing this. Why am I feeling this way" Why do the highs seem so much lower than they used to be" When did my life become the sum of so many minor injuries"
By Anonymous Paramedic, Sacramento, Calif.
Some days it's a lot to handle. It's a hard thing to describe. I've never been one for talking about my feelings. The more important it is, the more powerful the feeling, the less I will say about it. The best I can do is to say that it is a feeling of crushing emptiness.
There is always a lot of talk about how this job can effect us. People die while we try to keep them from doing so. That is definitely a humbling feeling. I have worn other people's blood on my skin. I have heard the last words of people I have just met. I have felt my paradigm shift, and my ego crumble when I realize that I cannot help my patient and I do not know why.
I have experienced many of the stereotypical, harrowing experiences associated with this profession. I do not mean to underestimate the effects that those experiences can have on us, but for me personally it feels a little self-aggrandizing.
Those are the stories people expect.
When someone sees me staring into space, lost in my thoughts, it's easy for them to imagine those things running through my mind. I wish that were the case.
Make no mistake, I am struggling.
This job does eat away at me every day. There have been days that the toll is taken in one fell swoop, with a fast-paced, high pressure, traumatizing call.
Most days that isn't the case. Most days I don't have such a convenient target to point at when those feelings hit me. Most days it comes down like a light rain all around me.
There is no big wave. There is no crashing and breaking. Just a slow, steady rain, soaking into everything.
I see death every day, but it doesn't always make for a thrilling story. I see elderly patients over and over, slightly worse each day. I see demanding, high maintenance patients who really only called because they needed someone to talk to, someone to focus on them for a while. I see patients ashamed of themselves. Ashamed of their size, their appearance, or their hygiene. Ashamed that they need us. I see so much sadness. Not the potent sadness of an acute pain or loss. Not the sadness that allows for catharsis. I see a chronic sadness. Less a sharp stab, more a dull ache. A sadness that I don't realize is there until I begin to bend under the weight. Now I'm left searching for the source.
I do look back on certain calls and feel the twinge of the intense feelings that they evoked. I feel regret. I feel guilt. I feel incompetent. At least I feel a sense of understanding. I can understand the hurt of those calls. I can paint a picture in my mind. I can quantify the pain.
Those are not the thoughts running through my mind when I am lost in it all. Instead, I am left here wondering what is causing this. Why am I feeling this way? Why do the highs seem so much lower than they used to be? When did my life become the sum of so many minor injuries?
