BY AARON DEAN
What does the term “emergency medical services” (EMS) mean to you? Why do you-a highly trained and highly skilled prehospital care provider-do what you do in your routine EMS activities? What will you do tomorrow when you report for your shift?
In 1966, under the supervision of the National Research Council, the National Academy of Sciences issued a paper titled “Accidental Death and Disability: The Neglected Disease of Modern Society.” This paper is known historically as “The White Paper.” It provided a great impetus in American society to understand how EMS worked prior to 1966. According to The White Paper, approximately 12,000 morticians (at the time of its writing) were inadequately trained and were operating ill-equipped, ineffectively designed ambulances, which accounted for 50 percent of the nation’s in-service ambulances. The White Paper is credited with providing awareness and momentum within the national EMS arena by laying a foundation to modernize emergency care and treatment of the sick and injured.
The time you entered the EMS system will determine what you think is “normal.” If you worked in the late 1960s in New York City; Miami, Florida; or Seattle, Washington, you were part of developing EMS for the entire country. If you worked in California and your paramedic card number is P34XXX, you had recently obtained your paramedic license. Yet, those are the two extreme ends of the EMS personnel pool today: the innovators and the fresh faces of the future. Many of us have seen changes in what we do, how we do it, and why we do it. Following are some practices, equipment, and culture shifts that have occurred in the past 20 years of paramedicine and what may be coming in the future.
Glucometers
Glucometers are a good thing! Obtaining a blood sugar reading was not always as easy as it is today. At one point in the past, a paramedic may not have obtained a glucose reading but would have given D50 prophylacticly for an altered level of conciousness. Or, perhaps the paramedic may have been forced to ask for a urine sample in which to dip a stick and match the color. In 1962 at the Medical College of Alabama, a device was created to measure blood glucose using a glucose enzyme electrode.1 Having a glucose reading has dictated how protocols are written and how we treat patients. Glucometers have certainly helped EMS personnel rule out hypoglycemia, making our jobs much easier today.
Infrared and Raman Technology
In the very near future, first responders and patients may be able to use a less painful and much cleaner alternative for obtaining a glucose level. Infrared (IR) technology has shown great potential to provide a current glucose level. For first responders, this means no more sharps, no more blood for a possible exposure, and no more trying to pull the plastic strip off the adhesive bandage while wearing gloves!
Whether it is using IR or Raman technology, research and developing easier ways to monitor glucose levels may be just at our earlobes. One company, Integrity Applications, is making strides in developing a noninvasive glucose monitoring device using real-time measurements by a personal earlobe clip, much like a finger probe for a pulse oximeter (pulse-ox).2
The Massachusetts Institute of Technology’s spectroscopy lab is conducting research using Raman technology. As first responders, we recognize Raman technology as part of the hazmat aspect of our job. Vibrational spectroscopy creates a “fingerprint.”3 In EMS, a probe is placed directly onto the skin, capturing the vibrations off the chemical bonds of various molecules in the skin. The resulting data are transformed by an algorithm and correction factor, subsequently extrapolating a useful glucose reading.4 Other methods of glucose readings and diabetes-related testing are actively being explored.5
Pulse Oximetry
Skin signs never lie. Trying to determine why a patient is short of breath can still be a challenge today. If he becomes sweaty, chances are his ailment is legitimate. To help quantify our observed patient signs, pulse oximetry is a useful tool. In 1935, a German physician created a device to measure oxygen (O2) saturation. In the 1940s, this device was further developed by an American physiologist, creating the first portable pulse oximeter. In the 1970s, two major companies-Biox and Nellcor-commercialized pulse oximetry. As it is with any new advancement, there were patent and legal issues. Today, with the help of the modern pulse-ox, we use the finger probe, which we can quickly place onto a finger and obtain a 94-percent O2 saturation with a corresponding pulse rate of 84!6
Pulse oximetry may now also include the measurement in change of volume of arterial blood. Each beat of the heart directly affects the flow of blood. First responders can interpret the corresponding waveform and its signal strength. It is shown as a plethysmograph. The pleth waveform (pleth) has provided invaluable information concerning a patient’s heartbeat or lack thereof; it has proven extremely beneficial in revealing possible cardiac irregularities.
Moreover, measuring carbon monoxide (CO) and hemoglobin in the field is now possible. Since a standard pulse-ox does not measure hemoglobin containing CO, a normal reading may be displayed and possibly misinterpreted by a first responder. Devices similar to a standard pulse-ox are available to measure the carboxyhemoglobin of patients and firefighters alike. In 2008, National Fire Protection Association (NFPA) 1584, Standard on the Rehabilitation Process for Members During Emergency Operations and Training Exercises, became the standard for firefighter rehab to consider the CO level as a standard vital sign in the medical monitoring aspect of the NFPA standard.7
Electrocardiogram Monitor
The electrocardiogram (EKG) monitor has become much more than a three-lead cardiac monitoring device. No longer does one have to physically move the three leads on the patient’s chest. Also, we now have four electrodes stuck to the patient. With the push of a button, one can easily switch from Lead II to a Modified Chest Lead, or we can confirm the absence of a cardiac rhythm in two leads. A combination EKG device can take a blood pressure, use pulse oximetry, and even perform a 12-lead EKG with interpretation. It has also changed our cardiac protocols. Does anyone still charge and defibrillate at 360 joules? Who still uses paddles? Hands-free bi-phasic is the “new cool.”
Drones
Has playing video games strengthened your EMS skills? In Holland, graduate industrial design student Alec Mormot of TU Delft University developed a drone equipped with an automated external defibrillator (AED) plus a video camera, a microphone, and a speaker.8 The operator can fly this “AirAED” to the person helping the patient. The pads eject from the front of the drone to be applied to the patient. It is a very nice use of technology coupled with life-saving equipment. You can see a video of this device in action at www.medgadget.com/2014/11/ambulance-drone-delivers-defibrillator-by-air-video.html.
Electric Gurney
The electric gurney has saved many shoulders and backs. Although it is difficult to determine who the first person was to put the electrically elevating EMS gurney into the system, it is much better than the old two-person cots that were loaded into a very low station wagon-type ambulance.
Not only have gurneys come a long way, so, too, have ambulances. Built specifically for patient care and transport, the modern ambulance provides a place of refuge from an unruly scene and inclement weather as well as a place to use the radio to make hospital contact. On a quiet, early morning shift, it may have even provided solitude to relax and recharge from the events of the previous night.
In terms of trauma, MAST pants are out, and tourniquets are in. The military has proven just how effectively properly applied tourniquets can save lives.9
Medications
With new drugs being invented and implemented, older drugs are becoming obsolete. Morphine and Valium are slowly making their way out of the protocols and are being replaced with Fentanyl and Versed. Whatever happened to bi-carb as a first-line cardiac resuscitation drug? Amiodarone is now routinely used during a pulseless, apneic patient. Drug suppliers are constantly attempting to keep supply up with demand. In today’s EMS system, it is not uncommon for protocols to be temporarily altered because of the lack of a supply of medications.
How we administer medications has also changed over the years. From having a plethora of IV solutions from which to choose such as D5-½ NS to D5W and from Ringers lactate to normal saline, EMS has streamlined the IV solution of choice to simply NS. Heparin locs gave way to saline locs.
Pushing medications down the endotracheal tube is no longer preferred. Rather, we can administer certain medications intranasally. Rectal has also gone out of vogue; intraosseous infusion (IO) is now standard. When was the last time you started an IO using just the needle and hand-boring technique? The IO drill has made this skill much easier.
Airways
Airways have also undergone extensive change. Does anyone remember the esophageal obturator airway or the esophageal gastric tube airway? If we had a difficult intubation, we could count on the combi-tube. The King tube is now an effective airway adjunct. A basic life support airway, such as an oropharyngeal airway, is also acceptable with good bag-valve-mask ventilations.
Finally, the next innovation may be the most innovative and effective noninvasive device EMS has in use today: continuous positive airway pressure (CPAP). Without question, the use of this simple, easy-to-use, cost-effective device has positively impacted many prehospital patients. Depending on the date your local EMS agency implemented its use, the relatively short time CPAP has been used in the field has proved its effects to be quite positive. Captain Kurt Dittig of the Sacramento (CA) Fire Department spent 32 years in the fire service. On his retirement in December 2014, Dittig said, “The CPAP is the biggest EMS tool that made a difference, in my opinion.”
As firefighters and EMS personnel continue to retire from this most rewarding career, who or what will replace them? Are drones the answer to staffing issues? Will the national standard be to use a modernized version of the Star Trek tri-corder? Will we respond to 911 calls for service by text message? Will our meals never get interrupted? Well, we know one thing will never change: A cold meal is better than no meal.
REFERENCES
1. Yoo EH, Lee SY. “Glucose Biosensors: An Overview of Use in Clinical Practice.” Sensors. 2010;10: 4558-4576. http://www.mdpi.com/1424-8220/10/5/4558/pdf.
2. Gal A, et al. “Enabling frequent blood glucose monitoring at home using a truly non-invasive device.” Integrity Applications, Israel. www.integrity-app.com/wp-content/uploads/2012/10/DTM-Poster-1-Nov-2014.pdf.
3. Raman spectroscopy description. www.ahurascientific.com/product-technologies/raman/index.php.
4. Dillow C. “MIT’s new glucose meter checks blood sugar levels with painless infrared light.” Popular Science. August 11, 2010. www.popsci.com/technology/article/2010-08/mit-glucose-meter-checks-blood-sugar-levels-painless-ir-light.
5. Clark R, et al. “Using infrared light to detect blood glucose levels.” www.drsaliterman.com/Projects%202011/Infrared%20Light%20to%20Detect%20Blood%20Glucose%20Levels.pdf.
6. Oximetry.org: “History of Pulse Oximetry.” www.oximetry.org/pulseox/history.htm.
7. Fraley M. “A silent death.” EMS World. November 1, 2010. www.emsworld.com/article/10319139/carbon-monoxide-poisoning.
8. MedGadget. “Ambulance drone delivers defibrillator by air.” November 3, 2014. www.medgadget.com/2014/11/ambulance-drone-delivers-defibrillator-by-air-video.html.
9. Risk CG, Augustine JJ. “Civilian EMS should consider tourniquets.” JEMS. March 2012. www.jems.com/article/patient-care/civilian-ems-should-consider-tourniquets.
AARON DEAN, M.S., is a 14-year member and an apparatus operator for the Sacramento (CA) Fire Department (SFD). He began his fire career as a volunteer in Shasta County, California, in 1990. He teaches high school students in the career technical education for the Shasta Union School Fire Tech Program. He is also the SFD coordinator for the Every 15 Minutes program, and he participates in the annual Guns & Hoses charity football game.
