Fit Responder

I’m working with Bryan Fass to help promote the Fit Responder training programs. Fit Responder is the only safety-based blended learning system built by and for first responders.

We offer a validated methodology using evidence-based standards proven to reduce injuries, extend career longevity and promote wellness.

We use a flexible training model which can be individually tailored to meet virtually any departments size and budget.

Please review our website and contact me directly if we can be of service.

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University of Arizona Initiative Doubles Survival Rates After Severe Traumatic Brain Injury

The University of Arizona recently released the results of an important study to the media with the headline, “UA-Led Initiative Doubles Survival Rates After Severe Traumatic Brain Injury“. Dr. Dan Spaite, Chair of Emergency Medicine at the UA was the lead author on the study which was published May 8 in JAMA Surgery: The Journal of the American Medical Association.

The study looked at the success of the Excellence in Pre-hospital Injury Care Project, or EPIC. The initiative was led by the University of Arizona, the Arizona Department of Health Services and more than 130 fire departments and pre-hospital EMS agencies across the state. They compared the results from those using the new guidelines to the results of those not using the guidelines.

The project was funded by a $3.6 million grant (NS071049) from the National Institute of Neurological Disorders and Stroke, part of the National Institutes of Health.

They trained more than 11,000 paramedics and EMTs in a new treatment protocol for patients who have a Traumatic Brain Injury or TBI. When the EPIC protocol was applied, the survival rate of severe TBI victims doubled. The survival rate tripled among TBI victims who were also intubated. These are astonishing results.

EPIC is the first major pre-hospital interventional project to evaluate the impact of new TBI treatment guidelines that contradicted decades of widely practiced treatment protocol.

The findings have huge implications for field treatment of severe TBI. Implementation of this new protocol nationally could save many lives.

Under EPIC, first responders are taught to treat and prevent the “Three H-bombs”, hyperventilation, hypoxia and hypotension.

Prior to the implementation of EPIC, first responders were taught to hyperventilate TBI patients with a BVM. This was thought to reduce intracranial pressure and improve survivability. Recent research shows that while hyperventilation reduces intracranial pressure it also deprives the brain of blood and oxygen by constricting blood vessels.

First responders tend to ventilate too fast, leading to hyperventilation. The solution they implemented was simple, using a timing light on the BVM.

The second “H-Bomb” is hypotension. So initiating an IV early is critical.

The last “H-Bomb” is hypoxia. To prevent this, first responders are taught to use high-flow oxygen as soon as possible.

While similar guidelines have been widely used in acute care, this is the first large-scale study that looked specifically at the results of their implementation in the field.

For the complete paper see

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The Why Didn’t I Think Of That NPA?

Mercury Medical has a truly innovative nasopharyngeal airway, that they don’t even really market that much to EMS. But it is very cool. I’ve rarely used NPA’s. They are just an awkward fit in EMS.

If a patient is breathing, most of us lean towards a non-rebreather mask. If they aren’t we lean towards an ETT or SGA and a BVM. But this product has changed my mind about both when and how we treat a significant subset of patients we serve regularly.

The typical narcotic overdose is somebody still breathing, but maybe not breathing that great. Respirations 6-8, obviously diminished and dropping respiratory drive. Dropped O2 Sats, Increasing CO2. So what do you do?

Most folks immediately start bagging to assist respirations. Then they bang a big load of Narcan. What happens is the patient wakes up in a few seconds going through withdrawals. EMS looks like a street hero. The patient suffers unbelievable pain.

What if we did this a little differently? The Naso-Flo Nasopharyngeal Airway Device is a soft and gently placed NPA which has an oxygen port. It both helps improve airway control and passively delivers oxygen at the same time.

The real beauty of an NPA is the patient can easily and safely self-remove it. No balloon, they just yank and it’s over. No harm, no foul. Now imagine an airway which is that inherently safe, that can also improve O2 Sats. Clever don’t you think?

The way I would use it is to lubricate the Naso-Flo, slide it in and then hook it up to O2. Then I’d start a line and very slowly start giving small slow carefully titrated doses of Narcan. Just enough to get them breathing decently. Not enough to wake them up or send them into the screaming heebie jeebies.

I don’t have to become an aging WWF wrestler, the patient does not unduly suffer, and we get to take him somewhere where there are professionals that can be his detox support. When you leave a guy on the street after an OD, anything can happen. Maybe they die later today and then you look kinda bad. It has happened.

I love the Naso-Flo because it’s a kindler gentler way. We do what the patient needs, airway and O2 support. We don’t do a bunch of stuff they don’t really need. A good idea don’t you think?

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Personal Kits in EMS

Question; Does anyone carry their own personal kit on the job anymore?
For many years I carried my own personal kit on the job. I’m not sure if the idea would be received well today but I had good reasons for doing it. I used to carry an oversized fanny pack. I usually just slung it over my shoulder. Once in a rare while, I would put it around my waist when I needed both hands for getting up and down on a ladder, or handling a stretcher on complicated terrain.
Inside it I had all the stuff I used on most calls. My Tycos single tube hand-held BP cuff. Because the crappy 15$ Chinese service cuff was junk when it was brand new and was never calibrated. I carried my DRG stethoscope, because the service provided garbage stethoscopes. I never wore it around my neck for two reasons.
One, it’s a great way to ruin a scope wearing it under the sun for UV to degrade it. Second, it was not fun when a lunatic decided to twist and pull on it. I also carried my White Pulmonary Resuscitator, because I never thought a BVM was much good for anything except starting a fire.
I carried some 4 x 4’s, a few 5 x 9’s, tape, a tube of instant glucose and an Ace wrap. I also carried a pair of spring-loaded German cast scissors, that would pretty much cut through anything. I carried my personal laryngoscope with my favorite #3 Guedel blade and a 7.5 ETT. I had a few ammonia amps for resuscitation of the perfectly fine. The goal was having everything I needed on most calls, organized the way I wanted it, in a bag I knew intimately.
I would add or delete items fairly frequently. My rule was that if I did not use something in it for months, it probably did not belong in my bag.
I just did not trust the quality of products in my issued first in bag. I also did not trust my fellow workers to re-stock them properly. With my own kit I did not have to worry about these issues.
Does anyone do this anymore? Just wondering how much EMS has changed. Back in my day I was not the only guy that did it. Others did too.
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Memory is a Fickle Master

Most EMT’s and Medics measure their abilities on a metric of regurgitation. They are proud of their memory. They are easily able to recite algorithms and treatments, drug doses and protocols effortlessly. They think this is what matters. It’s not.

There are very few things in EMS that are really that time sensitive. By itself that is probably a tough nut to swallow. But it’s true.

We race to the scene with lights and sirens, risking our own lives and those on the roads around us. How many times have you seen a driver on the road suddenly hear your emergency warnings and make about the least logical lane change imaginable?

The most time running hot can save you getting on scene is two minutes. Ditto the trip to the hospital. The trip to the hospital running hot is even less wise. Who can hear, feel, or see much of anything while they are being bounced around in the back of a piece of repurposed farm equipment?

I’ve always wondered if we drove to every scene with no lights and sirens and then did the same thing to the hospital would any patient really be affected? We don’t actually know. But here’s my real point. You can do a great job on every call without remembering much of anything. You don’t need to be in a rush.

In my last paid EMS gig I made a bunch of EMT/Drivers completely crazy because I never went to the hospital hot. I’m not saying I was morally opposed to it or anything. I’m just saying the absolute necessity to do it never came up. I could handle it. Two minutes would not have made a difference. Sure, multi-system trauma with low BP might have pushed me to roll hot. But in a very long time I never had one of those.

You probably carry a smart phone. You can use it to look up almost any information available on the planet. Can’t remember a drug dose? Just look it up, it will only take 30 seconds. Can’t remember how to estimate a burn? Just look it up. Can’t remember how to calculate proper ETT size on a peds patient? Just look it up.

I learned this lesson long ago, when I worked in a busy Emergency Department. One of the best nurses gently reminded me to always use the reference books on the med cart before I gave some drug I was not very familiar with.

I vividly remember the time right before I first gave a patient IV Fentanyl. Long before this was a household word. As I read the reference, my pupils dilated and my heart skipped a few beats. Boy I’m glad I followed her advice and took just a few seconds to pick up the dang book. Now you don’t even need a book. You have a smart phone.

What the phone can’t tell you is how to care for your patient. It can’t teach you compassion. It can’t teach you respect. It can’t teach you empathy.

But it can do pretty much everything else. My advice is to concentrate on what matters. Communications, understanding, compassion and respect. You can’t get that on a smart phone. But honestly, you can get pretty much everything else. You don’t have to trust your memory anymore. Besides, human memory is pretty frangible. Eyewitness testimony in court is notoriously flawed.

Let’s all slow the heck down and concentrate on what makes a real difference in our patients’ perception of our care. Speed doesn’t matter that much if you are a competent clinician. Being able to instantly spew the latest ACLS revision probably isn’t either.

What really matters is communicating that you care and how committed you are to your patient getting better. If you measure your performance on memory you need to understand, memory is a fickle master and is probably not what matters most.

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How to Introduce Yourself

One of my pet peeves with EMS providers is how they introduce themselves to their patient. So many seem to feel this is unimportant and what really matters is their clinical skills. You could not be more wrong. How you forge your relationship with your patient in the first few seconds can be determinative in the outcome.

“Hi, my name is Dan and I’m here to help you.” Look them directly in the eyes. No sunglasses. You need to see into their eyes and they need to see into yours. Don’t erect artificial barriers. Then smile. Shake their hand. I use two hands, one above and one below. It’s an embrace. Be totally sincere. If I had a dollar for every time I’ve seen a Medic skip this important step I could ride buses for free until the day I die.

Let me break it down for you. If they don’t trust you immediately then they are likely to omit telling you things that directly affect your treatment. Sure, you will figure it out eventually. But how long will it take? Isn’t it kind of stupid to build in delays to your care? Aren’t you EMS?

When I worked in an Emergency Room, the smart ER doctors built in a cooling off period. It gave them a chance to sort things out. How many times have you run lights and sirens to the hospital, only to have your patients inexplicably put on a gurney to chill? Sometimes it is because they are busy. But trust me, more often than not it was done on purpose. A little time gives a chance for truth to percolate to the surface. Medics have a very different job.

You need all the information, now. It is so much easier when the patient just tells you up front what all the mitigating factors are. Do you really want to be a veterinarian? That’s the hardest medical job in the world. Imagine you have a 2000-pound patient who cannot say one single word. They can’t even tell you where they hurt or how long this has been going on. I have major respect for vets because they have to do everything based solely on their assessment and clinical findings.

Don’t try to be a human vet. It’s just too hard. We have the incredible blessing of patients that can tell us everything we need to know. All it requires is your willingness to listen and their willingness to tell you. Their willingness to share will largely be based on how you introduce yourself. They have never laid eyes on you before. It’s all they know about you. Think about the implications of this simple but essential step in delivering quality care.

You think you look cool in sunglasses? Fine, leave ‘em in the truck and look cool on the way back to station.


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The Fainting Goats of Public Safety

I’m struggling to understand the many posts and stories of LEO’s overcome by trace topical skin exposure to Fentanyl. The typical story line is this stuff is so toxic if it touches you at all you could die. The “victims” wind up getting a lot of paid time off and sympathy.

One of my earliest calls in EMS was to a Baptist church on a Sunday morning. We entered the church and a very large woman was lying on the floor non-responsive. Other women were crowded around her, one of them furiously fanning her face. I could see she seemed to be breathing fine. I shouldered through the crowd and knelt down to take a pulse while asking what happened.

“She fell out” was the reply. I responded, “What did she fall out of?” while scanning around quickly to see if there was a balcony or something she might have fallen from. Boy was I green. Most of you in EMS can probably guess the rest of the story.

More recently I’ve seen FB posts with funny videos of fainting goats. Goats that very similarly to that church lady so long ago, “fall out” with the slightest provocation. I think a version of this behavior is what we are seeing today with these media reports of cops topically exposed to fentanyl.

These LEO’s are the fainting goats of public safety. At least the goats have an excuse, a scientifically explained condition. Notice nobody is pumping them full of Narcan either.

Getting a little Fentanyl on your skin has zero chance of permeating to enter the bloodstream. If it could EMS would be running a whole lot of calls on drug dealers bagging this poison up for retail. It is just nonsense without a shred of clinical evidence backing the claims.

We need to just say no to these hyped up hysterical stories. We have entered the age of The Twilight Zone, a fact free world where truth is not what you can prove but merely what you believe. Medical professionals need to hold themselves to a higher standard. Science demands we stand up to nuttiness.


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