Maintenance Medicine: Maryland`s Tactical EMS Protocols Aimed at Keeping the Cops Online

     In this era of dangers numerous and unknown, the use of law enforcement special operations teams has proliferated, and with it the need for tactical medical support. The specialty of tactical EMS has consequently grown, but without, in many cases, much of a specific medical framework to underpin it.

     With the creation last year of specialized protocols for EMS supporting law enforcement operations, Maryland became the first state to take official steps to remedy that lack. Its tactical EMS protocols are now being piloted by the Maryland State Police's Tactical Medical Unit, and could be embraced elsewhere soon.

     What they amount to is basically occupational medicine: keeping tactical operators healthy and intact during unpredictable, often-violent, sometimes-lengthy operations.

     "The challenge was, how do we keep officers, who are elite-trained folks-and there are very few of them-in service for days at a time?" explains state EMS medical director Richard Alcorta, MD, FACEP. "In the past, we've had standoff situations that have lasted multiple days. And during those, we have to rotate personnel in and out, and some of those personnel can have injuries or illnesses that need to be addressed. So it's a protocol that allows EMS personnel who are cross-trained as law enforcement officers to essentially provide occupational medicine to their colleagues, to keep them in service."

     The idea originated with two doctors, Kevin Gerold and Don Alves, who provide medical direction for the MSP's tactical unit. They approached officials at the Maryland Institute for EMS Systems (MIEMSS) about developing a set of protocols to assist their officers under the unique circumstances of special operations. Alcorta and MIEMSS' protocol committee set to work, tapping the expertise of law enforcement. They eventually produced both BLS and ALS versions.

     An obvious consideration was the safety of the EMS providers themselves. "We can't really project personnel into the special operations environment, because it increases the risk," Alcorta says. "So what we really addressed was just keeping tactical personnel functional."

     That means medics won't be venturing into hot zones, opening chests and removing bullets. Rather, they'll be in the cold or warm zones, performing maintenance and minor repairs. And while the new protocols are designed for the benefit of law enforcement operators, the providers using them will of course treat all comers, including hostages, bystanders and even bad guys.

     The tactical protocols differ in a few ways from the state's regular medical protocols. They permit the use of adhesives and stapling to close wounds, and include steps for the removal of darts from electro-conductive weapons like Tasers. They include medications for minor injuries and over-the-counter products (e.g., ibuprofen, cimetidine, Mylanta, NoDoz) to help keep operators online.

     The idea was to supplement, not replace, the state's existing medical protocols. To participate, memoranda of understanding are required between involved providers, their local EMS medical director and the tactical team's medical director, if different. Providers have to be trained, and each time the protocols are used, they're to file a quality assurance report and notify both medical directors. A copy also goes to Alcorta's office.

     In January, the MSP further bolstered the program by announcing a tactical physician component. Under this, docs from the Johns Hopkins University Department of Emergency Medicine will deploy with tactical operators in high-risk situations and assist in on-scene care.

     The protocols were first deployed last September, and as of early January, there had been around a dozen utilizations of them. Find the state's medical protocols, including the tactical component, at https://miemss.umaryland.edu/MdMedProtocols2006.pdf.John Erich, Associate Editor

IOM Opens the Floor for Comments With Workshop Series
     Working to keep its Future of Emergency Care reports in the spotlight and at the front of the line for legislative action, the Institute of Medicine hosted the third of four followup workshops for the series on November 2 in New Orleans.

     Like previous Emergency Care Dissemination Workshops in Salt Lake City and Chicago, the New Orleans event allowed emergency-care providers to discuss the reports' strengths, weaknesses, associated issues and plans of action that might help realize their recommendations. This workshop had a particular focus on EMS issues, which were the subject of the series' EMS at the Crossroads report.

     Following an overview of EMS, hospital and pediatric issues identified by the IOM (the other reports in the series were Hospital-Based Emergency Care: At the Breaking Point and Emergency Care for Children: Growing Pains), U.S. Senator David Vitter (R-LA) discussed Congressional healthcare priorities and vowed to reintroduce the Access to Emergency Medical Services Act in the next Congress.

     A regional response panel that included National Registry executive director Bill Brown then dissected the reports' key points and missing elements, as well as top areas for and impediments to action. Brown said that on EMS workforce issues, recruitment is less of a problem than retention-that EMS is getting people in, just not keeping them. Tying into the reports' focus on regionalization, panelist James Moises, MD, president of the Louisiana chapter of the American College of Emergency Physicians, noted that not all emergency departments are appropriate destinations for all time-sensitive issues, and New Orleans Health Department Deputy Director Sandra Robinson, MD, briefly discussed the coordination of patient destinations in her city during Mardi Gras.

     Relatedly, Louisiana State Health Officer Jimmy Guidry, MD, described the Louisiana Emergency Response Network, which uses regional self-designation by hospitals to help direct patients to the right facilities, specialists and equipment. During Katrina, Guidry said, "We knew where the beds were"-out of state. Around 12,000 patients were moved to other states for care, he said, because the rest of Louisiana couldn't accommodate them.

     Former NHTSA head Jeff Runge, MD, now Chief Medical Officer for the Department of Homeland Security, emphasized that preparedness is local, and that America must continue to develop a culture of preparedness, right down to the family level. He also noted that at barely 30 years old, the EMS is still growing, and that its current woes require "evolution, not revolution."

     Afternoon panels examined advancing EMS and disaster preparedness. One focus was ED congestion: Kurt Krumperman, Rural/Metro's VP of Federal Affairs and Strategic Initiatives, cited Idaho and Orange County, NC, as jurisdictions where overcrowding is being ameliorated by strategies like alternative destinations and treat-and-release. Arthur Yancey II, MD, Deputy EMS Director in Fulton County, GA (Atlanta area), described his community's nurse call-center referral system, which has relieved EMS/ED burdens by linking callers to clinics, primary-care programs and other sources of assistance besides EMS. By better matching EMS resources and skills to the right calls, Yancey said, response times are reduced, disaster preparedness is enhanced, and money is saved.

     A fourth "capstone" workshop was planned for Washington, DC, in December. Architects of the series hope to use the results of the workshops to produce a followup document capturing the "essence of the dialogue and discussion" that occurred there.     -John Erich, Associate Editor

FUNDS COMING FOR RETIRED, DISABLED FDNY VETS
     More than 300 EMS workers and their families are due thousands in retroactive pay they haven't received because FDNY couldn't find them, the New York Post reported in January. The funds are due to retired and disabled workers and the families of personnel who have died.

     Department officials say the checks couldn't be delivered because the information they have for those providers is outdated. The money is from pay raises awarded between 2002 and 2006; they range from $100-$1,000, based on seniority and rank.

     According to the Post, the delayed payments were discovered when a group of retired EMS personnel began seeking money that was due to them and realized some checks hadn't been issued. An FDNY spokesman told the paper some discrepancies could be attributed to different databases used by the agency.

     The Post specifically profiled current FDNY medic David Reeve, whose paramedic wife, Deborah, died in 2006 from lung cancer her family believes could be traced to her work at the World Trade Center site following 9/11. David Reeve got his back pay last year, but never received $10,000 his wife was due for the years she worked before becoming disabled.

     "I was never notified by the city or the fire department that they were holding a check for my wife-never," David Reeve told the Post.     -New York Post

NAEMT RELEASES NEW POLICY PLATFORM
     The National Association of EMTs cited 10 areas as the core of its 2007-08 Policy Platform, released for the new year as a companion to the group's biennial Strategic Plan. The Policy Platform areas are:

1. Workforce Issues-Personnel shortages in EMS may be related to several factors; more study is needed.
2. Cooperation and Relationships-EMS providers and organizations must work closely with the greater medical community and others.
3. Federal Leadership-NAEMT supports the creation of a single, high-level federal EMS entity in the U.S.
4. Preparedness-EMS is a vital part of the national response to disasters and crises, and should be part of all funding and planning.
5. Universal Access to EMS Care and Funding-NAEMT believes in universal access to EMS care regardless of location or ability to pay, and urges parties to work together to create balanced and equitable funding for EMS that ensures reasonable access to it.
6. Quality Educational Programs-NAEMT supports quality educational programs for EMS personnel.
7. Military EMS Support-EMS personnel serving in hostile foreign theaters should be able to maintain their credentials.
8. International EMS-NAEMT supports outreach to and collaborations with providers around the world.
9. Organizational Integrity and Transparency-NAEMT believes in operating with integrity and transparency. Leaders embrace a Code of Ethics and Conflict of Interest policy.
10. Research-NAEMT supports and advocates for research in areas relevant to EMS.

DHS OFFERS $1.7 BILLION IN COUNTERTERROR FUNDS
     The Department of Homeland Security has released grant guidance and application kits for five fiscal-year 2007 grant programs that will provide an estimated $1.7 billion for the counterterrorism efforts of state and local governments.

     The five programs, which together comprise the Homeland Security Grant Program (HSGP), encourage a regional approach to strengthening homeland security, the DHS says. Communities facing the highest risk levels will receive the majority of the funds. Priorities for this year's grants include reducing risks in the areas of improvised explosive devices (IEDs) and radiological, chemical and biological weapons. They emphasize interoperable communications, information sharing and citizen preparedness.

     The bulk of the funds, $746.9 million, will go to the Urban Areas Security Initiative (UASI); another $509.3 million is slated for the State Homeland Security Program. The Law Enforcement Terrorism Prevention Program will get $363.8 million, the Metropolitan Medical Response System $32 million and the Citizen Corps Program $14.6 million.

     This year, for the first time, the six highest-risk UASI cities will be permitted to apply up to 25% of their awards toward current state and local personnel dedicated exclusively to counterterrorism field operations.

     DHS expects to announce grant allocations by summer.     -DHS

VIDEO TO HELP PREVENT INJURIES TO CHILDREN
     Safe Kids Worldwide, an alliance of organizations dedicated to prevent accidental childhood injury, and the MetLife Foundation are combining to produce a video to help parents and caregivers protect children aged 4-7 from unintentional injury.

     The video, to be produced this spring, will emphasize key safety facts for major risk areas, including water safety, pedestrian safety, bike and wheeled-sports safety, passenger safety and fire prevention and preparedness. Injury-prevention messages will be directed at both parents and children.

     The videos will allow Safe Kids Worldwide to reach caregivers who read at a low level or cannot read at all. They will be distributed in DVD and VHS, with English and Spanish versions.     -PR Newswire

VIRTUAL EMS MUSEUM
     A group of EMS officials from across the country are working to establish a virtual museum that will feature historical pictures, interviews and documents, the website EMSResponder reported in January.

     National EMS Museum Foundation organizers are also working on a traveling display to appear at EMS trade shows. Under their working concept, EMSers would bring their artifacts to shows to display and share, but would not relinquish possession.

     Officials hope to have the virtual museum operational by summer, with the traveling show kicking off next year. They invite providers to get involved with the project; see https://nationalemsmuseum.org.     -EMSResponder.com

ENGLISH FIREFIGHTERS DON'T HAVE TO RENDER AID
     Firefighters in a pair of English jurisdictions don't have to answer emergencies on behalf of their local ambulance services despite being medically trained to do so, the nation's High Court ruled in January.

     The court ruled that medical assistance was not part of firefighters' contractual duties. Officials in Lincolnshire and Nottingham had claimed providing medical treatment was part of the firefighters' role as "coresponders," but the Fire Brigades Union said it was too dangerous.

     More than a third of fire and rescue authorities in England rely on medically trained firefighters for such assistance.     -BBC

SCORECARDS EXAMINE INTEROPERABILITY
     The Department of Homeland Security has released scorecard assessments of interoperable communications capabilities in 75 urban and metropolitan areas across the U.S., identifying key gaps and areas for improvement. The department's findings include:

• Policies for interoperable communications are now in place in all 75 areas.
• Regular testing and exercises are needed to effectively link disparate systems and facilitate communications between responders across jurisdictions.
• Cooperation among first responders in the field is strong, but formalized governance across regions is not as advanced.

     The scorecards illustrate current capabilities for each area and make recommendations for improvement. The reviews were conducted by panels consisting of state and local public-safety and communications-technology experts, in addition to personnel from DHS's Wireless Management Office and SAFECOM.

     The reviews focused on three main areas: governance (leadership and strategic planning); standard operating plans and procedures; and use of equipment.

     To view the report: www.dhs.gov.     -Dept. of Homeland Security

MEDIC SUSPENDED AFTER FINDING LIVE MAN DEAD
     A Vancouver, WA, firefighter-paramedic lost his paramedic certification and was suspended for a month without pay after wrongly determining that a suicidal patient was dead.

     Jesse Avery, who has been with the Vancouver Fire Department for three years, can continue working as a firefighter, but will be on probation for 3-5 years, chief Don Bivins said.

     Avery responded to a city location on December 3, 2006, finding a homeless man in a garage with what appeared to be a suicide note on his lap. He examined the man, concluded he was dead and left the scene, while police and a coroner's official remained. An hour later, however, the VFD crew was called back when the man was found to still be breathing.

     The man was not identified, nor the details of his case disclosed, but he was said to have ultimately been discharged from a local hospital.     -The Columbian

FOUR WAYS TO HELP EMS, COURTESY NAEMT'S NEW PSA
     The National Association of EMTs has released a public service announcement that encourages people to support their local emergency medical services.

     Featuring appearances by real EMS professionals, the PSA describes four ways in which the public can support and recognize the value of EMS, including becoming an EMT; pulling over when an ambulance approaches; learning CPR; and urging their elected officials to support EMS.

     For more: www.naemt.org.     -NAEMT

MCFERREN ELECTED NEW HEAD OF AMD
     K. Alan McFerren, engineering manager of Medtec Ambulance, has been elected president of the National Truck Equipment Association's Ambulance Manufacturers Division.

     McFerren has been a member of the AMD executive and technical committees for the past 12 years and has served as the organization's first and second vice president as well as treasurer. He succeeds Phil Braun.

     Other new officers are: David Cole, Life Line Emergency Vehicles, first vice president; Randy Hanson, American Emergency Vehicles, second vice president; and Tim Morrow, Crestline Coach, treasurer.     -NTEA

HERO EMT THWARTS ATTEMPTED SUBWAY SUICIDE
     An FDNY EMT's quick action in January saved an apparently suicidal woman who was trying to throw herself in front of a city subway train.

     Wearing an FDNY jacket, Daniel Fitzpatrick, 38, was returning from a paramedic training class when he was alerted by a bystander that a woman was preparing to jump. He approached her and tried to calm her, according to news accounts, but she retreated to a catwalk just above the tracks. He pursued and pinned her against a railing. The woman fought, Fitzpatrick told Newsday, wriggling and kicking, and the initial bystander assisted to hold Fitzpatrick's head clear of a passing train. "If he didn't do that," Fitzpatrick said, "I would've been hit." Other onlookers snapped pictures of the life-or-death struggle with their cell phones.

     The woman continued to resist, but the 190-pound EMT held her in a bear hug until a police officer arrived, and together they got her handcuffed. Officers took the woman to Bellevue Hospital Center.

     Fitzpatrick "didn't hesitate to put his life on the line for a complete stranger," FDNY Chief of Department Salvatore Cassano said in a statement. "He displayed great courage in the face of danger."     -Newsday

HOUSE MOVES TO ENACT 9/11 GROUP'S RECOMMENDATIONS
     The new Congress moved quickly in January to implement recommendations of the 9/11 Commission, with a bill to do so passing the House overwhelmingly on January 9. It was with a Senate committee at press time.

     Among its provisions, H.R. 1 would reform grant formulas, establish new communications grants and create new information-sharing partnerships.     -IAFF