The September 2014 newsletter of the National Association of EMS Physicians
19
In This Issue: NAEMSP ® Board of Directors Elections 3 From the Field: DEM Volunteering Medical Relief in Haiti 4 NHTSA EMS Update: Federal Highway Administration Launches Website for EMS and Highway Safety Collaboration 5 Journal of Emergency Dispatch Presents Awards 6 Introducing the Ultra-Medical Team 7 A Case Report: Catecholamine Induced Flash Pulmonary Edema 8 IAED News Release: Ambulance Service in Qatar Receives First ACE for Middle East 9 Pre-hospital Management of Acute Angiotensin Converting Enzyme Inhibitor-Induced Angioedema: A Case Report 10 Guidelines for Evaluation of US Patients Suspected of Having Ebola Virus Disease 11 Nomination for NAEMSP ® Awards 14 NAEMSP ® /Physio-Control EMS Medicine Medical Director Fellowship Application 15 Welcome New Members 19 NEWSLETTER OF THE NATIONAL ASSOCIATION OF EMS PHYSICIANS ® News News SEPTEMBER 2014 Vol. 23 No. 3 continued on page 2 E very summer, the NAEMSP ® Board gathers to perform the work of the Association. This year, the Board met in rainy (we asked for authentic weather!) Portland, Ore. Instead of the usual one day meeting, this meeting lasted another half day. This extra half day allowed us to embark on a strategic planning retreat. NAEMSP ® continues to transition to a subspecialty society. The Board felt that it was a good time to plot the future course. AMP Vice President, Dede Gish-Panjada facilitated an afternoon meeting in which we reviewed the past and started formulating a future. Overall, it was an exciting session that solidified some thoughts. The draft plan will be available for membership comment soon on the NAEMSP ® Communities portion of our website. The final plan will be approved by the Board in January (in New Orleans). Celebrating Accomplishments The first order of business was to review the current strategic plan and celebrate our accomplishments. When the last strategic plan had been prepared, ABEM had just approved the specialty. NAEMSP ® felt that providing support for our membership during this transition was key and created goals related to transition. A key accomplishment was to partner with ACEP to successfully present a board preparation course. We also provided many opportunities for EMS Fellowship Directors to meet, network and help each other through the initial accreditation process. Mission and Leadership We took a look at our mission statement to make sure that it was still representative of the organization. The mission statement was conspicuous in that our specialty was not mentioned by name. The Board, therefore, proposed and approved a new mission statement: NAEMSP ® is an organization of physicians and other professionals partnering to provide leadership and foster excellence in the subspecialty of EMS medicine. The next step was discussing current trends in non-profit governance. The challenge is to be nimble and responsive as a Board but still be representative of our membership. The trend nationally is to have smaller Boards. After extensive discussion, the Board felt that the current makeup of the Board was both representative and effective. President’s Corner Ritu Sahni, MD, MPH NAEMSP ® President (2013-2015) Plotting NAEMSP's ® Future
A Case Report: Catecholamine Induced Flash Pulmonary Edema . . .8
IAED News Release: Ambulance Service in Qatar Receives First ACE for Middle East . . . . . . . . . . . . . . . . . .9
Pre-hospital Management of Acute Angiotensin Converting Enzyme Inhibitor-Induced Angioedema: A Case Report . . . . . . . . . . . . . . . . .10
Guidelines for Evaluation of US Patients Suspected of Having Ebola Virus Disease . . . . . . . . . . . . . . . . . . 11
Nomination for NAEMSP® Awards . .14
NAEMSP®/Physio-Control EMS Medicine Medical Director Fellowship Application . . . . . . . . . . .15
Welcome New Members . . . . . . . . .19
NEWSLETTER OF THE NATIONAL ASSOCIATION OF EMS PHYSICIANS®
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Vol. 23 No. 3
continued on page 2
Every summer, the NAEMSP® Board gathers to perform the work of the
Association. This year, the Board met in rainy (we asked for authentic weather!) Portland, Ore. Instead of the usual one day meeting, this meeting lasted another half day. This extra half day allowed us to embark on a strategic planning retreat. NAEMSP® continues to transition to a subspecialty society. The Board felt that it was a good time to plot the future course. AMP Vice President, Dede Gish-Panjada facilitated an afternoon meeting in which we reviewed the past and started formulating a future. Overall, it was an exciting session that solidified some thoughts. The draft plan will be available for membership comment soon on the NAEMSP® Communities portion of our website. The final plan will be approved by the Board in January (in New Orleans).
Celebrating AccomplishmentsThe first order of business was to review the current strategic plan and celebrate our accomplishments. When the last strategic plan had been prepared, ABEM had just approved the specialty. NAEMSP® felt that providing support for our membership during this transition was key and
created goals related to transition. A key accomplishment was to partner with ACEP to successfully present a board preparation course. We also provided many opportunities for EMS Fellowship Directors to meet, network and help each other through the initial accreditation process.
Mission and LeadershipWe took a look at our mission statement to make sure that it was still representative of the organization. The mission statement was conspicuous in that our specialty was not mentioned by name. The Board, therefore, proposed and approved a new mission statement:
NAEMSP® is an organization of physicians and other professionals
partnering to provide leadership and foster excellence in the
subspecialty of EMS medicine.
The next step was discussing current trends in non-profit governance. The challenge is to be nimble and responsive as a Board but still be representative of our membership. The trend nationally is to have smaller Boards. After extensive discussion, the Board felt that the current makeup of the Board was both representative and effective.
President’s CornerRitu Sahni, MD, MPH
NAEMSP® President (2013-2015)
Plotting NAEMSP's® Future
NAEMSP® is an organization of physicians and other professionals partnering to provide leadership and foster excellence in the subspecialty of EMS medicine.
The NAEMSP® newsletter is designed to inform members of interesting developments in the field of EMS . Members are encouraged to send information which may be of interest to others reading this publication .
NAEMSP® News is the official newsletter of the National Association of EMS Physicians® (NAEMSP®) .
Opinions expressed in articles in NAEMSP® News are those of the authors and not necessarily those of NAEMSP® nor the editor of NAEMSP® News . Reproduction in whole or part is strictly forbidden without prior consent of the editor .
Correspondence and inquiries should be sent directly to:
NAEMSP® Executive Office, P . O . Box 19570, Lenexa, KS 66285913-895-4611; 800-228-3677; Fax: 913-895-4652Email: [email protected]; Website: www.NAEMSP.org
Articles for inclusion in the newsletter must be submitted by email (Word) . To submit material for publication, contact the editor by telephone or email .
NAEMSP® News Editor, Joseph DeLucia: 314-422-1244 . Email: jlinde001@mail .com
Moving the Organization ForwardContinued support of the subspecialty was the main theme that emerged, along with discussions on how to add value to the NAEMSP® Membership. A number of initiatives were discussed:
y Formally placing the Council of EMS Fellowship Directors in the bylaws
y Explore how to implement “Fellow” of NAEMSP® status
y Continue to provide a board review course
y Formalize legislative advocacy efforts
y Create new and improve existing opportunities for mentorship with the subspecialty.
y Explore new educational technologies – such as podcasting.
Hopefully, the newly adopted strategic plan will serve as a guide for the growth and development of NAEMSP® for many years.
NAEMSP® Board of Directors ElectionsFor Terms January 2015 — Annual Meeting January 2017
The NAEMSP® Nominating Committee, chaired by Immediate Past President, Ronald G. Pirrallo, MD, MHSA, is pleased
to present you with the following exceptional candidates for the open positions on the NAEMSP® Board of Directors. We were fortunate this year to have 14 candidates submit nominations.
The NAEMSP® Board of Directors candidate slate is as follows:
Jose Cabanas Alex Isakov Alex Garza Jeffrey S. Lubin Toni Gross Jon C. Rittenberger Francis Guyette
The candidates listed above are members in good standing with NAEMSP® and have agreed to serve the membership and the best interests of the association if elected.
In the case of a tie in voting, a subsequent election will be held for those candidates involved in the tie. If a tie results after two elections, the NAEMSP® Board of Directors shall determine the winner by a simple majority vote of the members of the Board.
IMPORTANT! The NAEMSP® election will be conducted online. Each eligible voting member with an active email in the NAEMSP® database should have received email instructions and a link to the election website with a unique identifier. Each member may only cast one ballot.
Members for whom we either do not have an email address in the NAEMSP® database or the email address does not work, will receive a postcard at the physical mailing address we have on file. The postcard will provide detailed instructions about accessing the voting website.
Voting will be open from Sept. 15 – Oct. 31, 2014, at 5:00 p.m. Eastern Time. No votes will be accepted after this time. If you have any questions, or have not received notification about voting via email or postcard, please contact NAEMSP® at 913-895-4611 or by email at [email protected].
Voting is open to all physician, professional, international, resident and fellow members of the NAEMSP® in good standing. Medical students and honorary members are not eligible to vote.
Thank you for taking time to place your vote for your NAEMSP® Board of Directors.
Be sure to check out the most updated version of the EMS Calendar at www.NAEMSP.org.
EMSCalendar
NAEMSP® NEWS 4 SEPTEMBER 2014
Occasionally, staff members at San Francisco Department of Emergency Management (DEM) have an opportunity to
travel abroad. They frequently write back with their observations. The following journals a recent trip by DEM Emergency Medical Services Agency staff members, Crystal Wright and John Brown, who went to Haiti to volunteer their personal time and professional expertise to the rural town of Leon.
Crystal Wright, EMT-P, and John Brown, MD, recently returned from a week of volunteer work in rural Leon, a town of some 8,000 people in the Grande Anse province of southwestern Haiti. The reason for their visit was to support a local dispensary staffed with a nurse, a pharmacist, a dentist and a tuberculosis program health aide. The medical operation, begun in 2000 by the Seattle King County Disaster Team (a member of the Disaster Medical Assistance Team program of the U.S. Health and Human Services Department) as a training mission for health care providers to learn how to provide quality care in an austere environment, now provides services to the clinic every four months with a multi-disciplinary team of nurses, physicians, paramedics, EMTs, laboratorians and pharmacists.
Crystal (pictured far left) with the King County Disaster Team .
Dr. Brown has participated in this effort annually since 2004 and finds enjoyment in seeing returning patients and families from treatment given in previous years. He has noticed a slow but steady improvement in some infrastructure support since the significant earthquake in January 2010, and the improving overall health of the patients with chronic diseases such as hypertension and diabetes. The teams conform to World Health Organization standards for disease treatment and medications, and work with the local health care system, including the Haitian Health Foundation, to deliver preventive medicine teaching and supplies, and refer high risk patients to the nearby city of Jeremie for treatment.
The trip was Crystal Wright’s first opportunity to participate in this mission, which she found rewarding and reinforcing of
From the Field: DEM Volunteering Medical Relief in HaitiBy Kristin Hogan Schildwachter (sfdemkristin)
her commitment to caring for people. She said, “Working with the Seattle King County Disaster Team was excellent; we had meetings every night to discuss our plans and performance at the clinic. And like Dr. Brown, I did enjoy visiting the orphanage and hiking around the community, as well as greeting as many persons as possible when our clinic had closed. My hope is to continue working with this team and seeing progress and improvement in the future.”
New this year was the integration of an emergency physician from Canada, who had extensive knowledge of Haitian history and culture, and the improved care of women’s health needs based on a study done by the Seattle King County Disaster Team last fall to evaluate care for breast disease and sexually transmitted infections. The team regularly screens patients for HIV disease and refers high risk patients to a local treatment program.
Dispensary Silo
Next year the team hopes to resume partnering with the Haitian health ministry to work with young Haitian MDs stationed at the clinic. They also hope to provide outreach services to several more remote villages in the Leon region that do not have dispensaries via mobile teams, which convert the community’s schoolhouse into a temporary clinic.
Supporting a well-functioning EMS system and engaging emergency medical services in the state’s highway safety planning process are essential factors to reduce highway fatalities and serious injuries on public roads.
Across the nation, state departments of transportation (DOT) are charged with addressing safety on the roadways through the development of a strategic plan including the four E’s of highway safety – engineering, education, enforcement and emergency medical services (EMS).
This plan, the Strategic Highway Safety Plan (SHSP), provides a comprehensive framework for reducing highway fatalities and serious injuries on all public roads. It is during the SHSP process that statewide goals, objectives, and key emphasis areas are established, and it is vital that all four E’s are engaged.
“Engaging EMS in the SHSP process is not only important because it’s a legislative requirement, but because EMS plays a vital role in the Toward Zero Deaths strategy by reducing fatalities in the post-crash phase,” said Tony Furst, FHWA Associate Administrator for Safety.
After detailed discussions with state SHSP managers and state EMS directors, the Federal Highway Administration (FHWA), identified that state EMS directors were not always as engaged in the planning process as representatives from engineering, education and law enforcement.
To address the need for further EMS involvement in road safety planning, FHWA has created a website to encourage further collaboration with EMS officials in the SHSP process.
“Saving Lives Together: The Highway Safety & EMS Connection” includes a compilation of information about both
EMS and the SHSP, tips and suggestions for reaching out to both state highway safety professionals and EMS officials and a self-assessment tool to help identify the current level of EMS engagement in the SHSP process. It also provides information about states that have successfully incorporated EMS-related strategies into the state’s SHSP.
The website is designed to meet the unique needs and challenges both highway safety professionals and EMS officials have in the collaboration process, providing specific suggestions to help both groups’ better understand the others’ abilities and limitations to provide data and support of highway safety improvement.
The website specifically addresses the need for additional information about EMS for the highway safety professional, while also providing detailed information about the highway safety plan to help EMS officials better understand the development, funding and implementation of an SHSP.
Sections of the website, such as that titled “Why EMS Should Participate in the SHSP Process,” provide information including:
What is a Strategic Highway Safety Plan (SHSP)?
y Benefits of an SHSP
y How is the SHSP relevant to EMS Officials?
y EMS-Related Highway Safety Plans
y Other Resources for SHSP Development, Implementation, and Evaluation
The website also provides suggestions for collaboration, communication tips and state success stories for EMS inclusion in the SHSP.
“This is a very impressive web site,” said Michael K. Harryman, MA, director of emergency operations and EMS and trauma system for the state of Oregon’s health authority. “For a State EMS Official who has been in this position a little more than 18 months, the information provided is more than anything I’ve come across to help me be better interact with the highway safety staff who develop the SHSP.”
The Highway Safety and EMS Connection site is available here and additional information or questions can be addressed by Jennifer Warren at [email protected].
Federal Highway Administration Launches Website for EMS and Highway Safety Collaboration
The NAVIGATOR 2014 Conference was held by the International Academies of Emergency Dispatch (IAED) during in Orlando, Fla. They are pleased to present the following awards.
1. ACE presentation – photo shows, IAED Associate Director, Carlynn Page congratulating, Hamad Medical Corporation Ambulance Service (Qatar) QI Manager, Sonia Bounouh and, Operations Manager, Ezeldin al-Yafei for achieving an Accredited Center of Excellence (ACE). The comm. center associated with the Hamad Medical Corporation Ambulance Service is the first center in the Middle East to achieve ACE.
1.
2. Dispatcher of the Year – photo shows OnStar Dispatcher Bryan Anta holding the Dispatcher of the Year Award 2014, and to his right is Margaret Moran, vice president, public safety (Moran’s company sponsors the award).
3. Leadership – photo shows Paul Stiegler, MD, during his acceptance speech; Jeff Clawson, M.D., presented the award at the NAVIGATOR closing luncheon. Dr. Stiegler is the EMS director for the Dane County Public Safety Communications Center in Madison, Wis., and OnStar.
By Audrey Fraizer, Managing Editor
Journal of Emergency Dispatch Presents Awards
NAEMSP® NEWS 7 SEPTEMBER 2014
Introducing the Ultra-Medical Team By Martin Hoffman, MD; Nick Nudell, MS, NRP; and Jennifer Berry, EMT
Ultra-marathons are foot races that typically range from 31 to 200 miles in length, or are duration-based events of 24, 48, and 72 hours or longer. They are generally held on trails and fire roads in rural and remote areas. The most commonly held events are 50 km (31 miles) which provide “road marathoners” the next level of challenge and often serve as a bridge between road and ultra-marathon running. Participation in ultra-marathons has seen exponential growth in recent years, with nearly 70,000 ultra-marathon finishes in North America last year and at least 125 ultra-marathons of 100-miles in length scheduled for 2014 in North America.
Many ultra-marathon runners train extensively for these races by running 50-150 miles a week and performing cross training targeting aerobic fitness and strengthening. Much of the training is designed to build not only physical endurance but also mental and emotional endurance – a key factor that makes ultra-marathon runners different than your typical patient.
The immediate or even urgent medical care needed during ultra-marathon training or racing is generally focused on three areas known as the 3 F’s: 1) fuel, 2) fluid, and 3) feet. After several hours of continuous running, glycogen stores become depleted and runners who are not adequately adapted may “bonk” due to difficulty mobilizing fat stores. Inadequate management of water and/or electrolytes can lead to hyponatremia and its sequelae. Lastly, one of the greatest challenges for runners is not surprisingly, foot care to prevent blisters and addressing them once formed.
How prepared are your EMS providers, in or out of hospital, to evaluate the management of the 3 F’s? If presented with a “bonking” runner, would their efforts be unnecessarily similar to a hypoglycemic diabetic patient? Do they know how to recognize exercise-associated hyponatremia (EAH)? Do they have hypertonic saline available to treat EAH or would they be likely to use a 0.9% normal saline fluid bolus which can lead to seizures, coma, and death? Do your providers know how to provide blister and wound care?
In 2013, the Paramedic Foundation was formed as a non-profit which developed the Ultra Medical Team (UMT) with Martin Hoffman, MD as its Chief Medical Officer and paramedic Nick Nudell as the Executive Director. Together they have built a team of volunteer medical providers, who are also often, but not always, ultra-marathon runners who are contracted by race organizers to provide in-race medical care. Some are physicians, paramedics, nurses, chiropractors, physical therapists, and others. The UMT is also developing a training and credentialing
program to give providers a common baseline level of understanding of the unique needs and treatments pertinent to ultra-marathon runners.
A paper entitled “Medical Services at Ultra-Endurance Foot Races in Remote Environments: Medical Issues and Consensus Guidelines” was recently published in the journal Sports Medicine by Dr. Hoffman and an international group of experts. These consensus guidelines provide a foundation for the services offered by the UMT at ultra-marathons. Armed with knowledge of medical issues unique to ultra-marathon runners, the UMT fills a pre-911 gap by helping otherwise healthy and often intrepid runners with avoiding unnecessary, high risk, and resource intensive emergency response and transport for easily corrected transient conditions.
The UMT invites physicians, paramedics, nurses, chiropractors, physical therapists, and others who are interested in ultra endurance medicine to visit the UMT website at http://ultramedicalteam.org/events/ or its Facebook page at https://www.facebook.com/ultramedicalteam or contact the authors ([email protected] (760) 405-6869 or [email protected]) for more information.
Chief Complaint: Dyspnea 63-year-old white female with past medical history of mild diastolic heart failure presented via EMS with respiratory distress. Patient is a teller at a local bank and developed sudden onset dyspnea after being held at gunpoint in a robbery. Initial oxygen saturation on EMS arrival was 70 percent with RR of 40, HR of 110, and BP of 180/90. Initial ECG showed wide complex tachycardia. EMS interventions included amiodarone bolus, CPAP, 0.4 mg sublingual nitro, and 1 inch nitro paste.
DiagnosisOn arrival to ED, patient placed on BiPAP with continued respiratory distress. Portable CXR showed significant pulmonary edema. With impending respiratory failure, sublingual nitro sprays (0.4 mg) for a total of 14 were given every five minutes by the physician. There was no hypotension while awaiting nitroglycerin drip. Respiratory status improved, the patient no longer needed BiPAP and was weaned to 2 L NC prior to admission to the floor. She was back at her baseline the following morning and off oxygen prior to being discharged home.
DiscussionThis patient’s CHF exacerbation was most likely secondary to the catecholamine surge precipitated by the fear associated with the robbery. This caused her to go into flash pulmonary edema and respiratory failure. Catecholamine is thought to cause increased pulmonary capillary permeability and
increase the hydrostatic pressure in the pulmonary bed leading to fluid leaking into the alveolar space (3). In the setting of diastolic dysfunction, the catecholamine surge increases the HR which decreases the time the stiff ventricle has to fill, leading to increased LA and pulmonary venous pressures (3). Catecholamine cause an increase in SVR, which then causes an increase in LA/pulmonary venous pressure (3).
The treatment of flash pulmonary edema is respiratory support with invasive or non-invasive positive pressure ventilation, diuresis, and vasodilators. High dose nitrates are an emerging strategy in the treatment of severe decompensated heart failure (2). The standard nitroglycerin drip parameters are 10-20 mcg/min with titration by 5 mcg/min every five minutes for desired effect. Compare this to a sublingual spray of nitroglycerin that is 400 mcg and generally completely absorbed in over five minutes. Many early studies have shown a significant decrease in the rate of intubation, BiPAP, ICU, myocardial infarction, and ICU admission with minimal hypotension in the high dose nitrates strategy (2).
ReferencesKwiatkowski, G. M., et al. “Nitroglycerin for Treatment of Acute,
Hypertensive Heart Failure: Bolus, Drip or Both?” Annals of Emergency Medicine 60(4):S9.
Levy, P., et al. (2007). “Treatment of severe decompensated heart failure with high-dose intravenous nitroglycerin: a feasibility and outcome analysis.” Ann Emerg Med 50(2):144-152.
Rimoldi, S. F., et al. (2009). “Flash pulmonary edema.” Prog Cardiovasc Dis 52(3):249-259.
A Case Report: Catecholamine Induced Flash Pulmonary Edema
By Brent Weber MD, Indiana University Emergency Medicine Resident
Ambulance Service in Qatar Receives First ACE for Middle East
April 20, 2014, is a date that will go down in the history of Hamad Medical Corporation Ambulance Service (Doha, Qatar) emergency communication.
Although the day started out along the same routine—if there is such a thing for an ambulance service—by mid-day Sonia Bounouh was ready to put on her jogging shoes after completing one of the longest races of her life.
“We were ACE (Accredited Center of Excellence),” said Bounouh, the center’s quality improvement manager. “We received word that weekend, and I knew we’d be running to NAVIGATOR.”
Not only did Hamad Medical’s comm. center achieve accreditation through the International Academies of Emergency Dispatch® (IAED™) but it also was the first center in the Middle East to become an ACE. Bounouh was intent on getting to the conference festivities in the U.S. on time and then returning home to present the certificate.
“We’re going to have a big celebration,” she said. “ACE was a huge project and we want to show our thanks for all the work of everyone involved.”
During NAVIGATOR 2014 (April 30-May 2 in Orlando, Fla.), Bounouh and Ezeldin al-Yafei, operations manager for the center in Qatar, were among representatives from 10 international agencies accepting certificates for achieving new medical and fire ACEs. Forty-six comm. centers qualified for medical and fire re-accreditation.
“Going on stage to accept ACE certificates is an event that agencies look forward to,” said Carlynn Page, IAED associate director.
“They are very proud to accept the honor in the presence of peers,” she said. “ACE says so much about the high level of service they provide.”
In addition to the recognition of the new and re-accredited centers, Page stepped up the ACE awareness this year with the introduction of purple lanyards worn by every individual attending the conference from an Accredited Center of Excellence.
“We wanted every ACE to be a stand-out in the NAVIGATOR crowd,” Page said. “Seeing the lanyard gave others the chance to congratulate everyone who has ever achieved ACE.”
The IAED, through its College of Fellows, established the ACE program to provide the tools necessary to achieve this high standard of excellence in emergency dispatch. There are currently 146 ACEs worldwide.
NAVIGATOR 2014 attracted a record 1,350 attendees from 13 nations featuring more than 100 educational sessions punctuated by a gala reception, exhibit hall, special events, and guided tours of Osceola County Sheriff’s Office and Reedy Creek Improvement District communication centers.
The IAED develops and maintains the fire, medical, and police dispatch protocols used by more than 3,000 communication centers worldwide. For more information, go to the IAED website at www.emergencydispatch.org/.
Pre-hospital Management of Acute Angiotensin Converting Enzyme
Inhibitor-Induced Angioedema: A Case Report
By Nabil El Sanadi, MD, MBA, FACEP, FACHE
Acute angioedema is a true medical emergency due to high mortality rate resulting from airway compromise.
Angioedema can be either hereditary or acquired. The acquired form is a rare but well-recognized side effect of angiotensin-converting enzyme (ACE) inhibitors. ACE inhibitor-induced angioedema is more common in African Americans and is more severe in older African American females (1).
Emergency medical services (EMS) personnel are often the first contact for patients with acute angioedema. Paramedics must act rapidly while using the correct management protocols for patients presenting with symptoms consistent with this possibly fatal condition.
Case ReportIn June 2013, a 66-year-old African American female contacted 911 complaining of “swelling to tongue” which began 10 minutes prior to calling EMS. She complained only of shortness of breath and denied any other symptoms. She was observed to be seated upright, breathing in the tripod position. The patient was noted to have swelling to mouth, tongue, and lips. The patient had been taking Lisinopril for two days. The patient was treated by paramedics with 3.00 LPM oxygen via nasal cannula, and 0.3 mg epinephrine 1:1,000 SQ. A 4-lead EKG showed sinus tachycardia. The patient was also treated with 50 mg diphenhydramine IV, 125 mg methylprednisolone IV, and an additional 0.3 mg nebulized epinephrine 1:10,000. Upon arrival in the ED, the patient’s condition continued to deteriorate.
Patient Vital Signs Pre and Post Treatment (a 15 minute interval)
BP (mmHg)
HR (beats/min)
RR (breaths/min)
O2 Set (%)
Before Treatment 200/20
122 18 92 (room air)
After Treatment 230/70
130 22 66 (oxygen)
In this case report a patient who recently began taking Lisinopril developed severe angioedema. Despite promptly calling 911 and the appropriate medical management by EMS personnel, the patient’s condition continued to worsen. More aggressive measures such as emergency tracheostomy may be the best and first life-saving option by EMS personnel for patients with life-threatening airway compromise.
Management options such as surgical airways need to be discussed and studied in the pre-hospital management of acute angioedema.
NAEMSP® NEWS 11 SEPTEMBER 2014
U.S. hospitals can safely manage a patient with EVD by following recommended isolation and infection control procedures. Please disseminate this information to infectious disease specialists, intensive care physicians, primary care physicians, hospital epidemiologists, infection control professionals, and hospital administration, as well as to emergency departments and microbiology laboratories.
BackgroundCDC is working with the World Health Organization (WHO), the ministries of health of Guinea, Liberia, and Sierra Leone, and other international organizations in response to an outbreak of EVD in West Africa, which was first reported in late March 2014. As of July 27, 2014, according to WHO, a total of 1,323 cases and 729 deaths (case fatality 55-60%) had been reported across the three affected countries. This is the largest outbreak of EVD ever documented and the first recorded in West Africa.
EVD is characterized by sudden onset of fever and malaise, accompanied by other nonspecific signs and symptoms, such as myalgia, headache, vomiting, and diarrhea. Patients with severe forms of the disease may develop hemorrhagic symptoms and multi-organ dysfunction, including hepatic damage, renal failure, and central nervous system involvement, leading to shock and death. The fatality rate can vary from 40-90%.
In outbreak settings, Ebola virus is typically first spread to humans after contact with infected wildlife and is then spread person-to-person through direct contact with bodily fluids such as, but not limited to, blood, urine, sweat, semen, and breast milk. The incubation period is usually 8–10 days (ranges from 2–21 days). Patients can transmit the virus while febrile and through later stages of disease, as well as postmortem, when persons touch the body during funeral preparations.
Patient Evaluation Recommendations to Healthcare ProvidersHealthcare providers should be alert for and evaluate suspected patients for Ebola virus infection who have both consistent symptoms and risk factors as follows: 1) Clinical criteria, which includes fever of greater than 38.6 degrees Celsius or 101.5 degrees Fahrenheit, and additional symptoms such as severe headache, muscle pain, vomiting, diarrhea, abdominal pain, or unexplained hemorrhage; AND 2) Epidemiologic risk factors within the past 3 weeks before the onset of symptoms, such as
contact with blood or other body fluids of a patient known to have or suspected to have EVD; residence in—or travel to—an area where EVD transmission is active; or direct handling of bats, rodents, or primates from disease-endemic areas. Malaria diagnostics should also be a part of initial testing because it is a common cause of febrile illness in persons with a travel history to the affected countries.
Testing of patients with suspected EVD should be guided by the risk level of exposure, as described below:
CDC recommends testing for all persons with onset of fever within 21 days of having a high-risk exposure. A high-risk exposure includes any of the following:
y percutaneous or mucous membrane exposure or direct skin contact with body fluids of a person with a confirmed or suspected case of EVD without appropriate personal protective equipment (PPE),
y laboratory processing of body fluids of suspected or confirmed EVD cases without appropriate PPE or standard biosafety precautions, or
y participation in funeral rites or other direct exposure to human remains in the geographic area where the outbreak is occurring without appropriate PPE.
For persons with a high-risk exposure but without a fever, testing is recommended only if there are other compatible clinical symptoms present and blood work findings are abnormal (i.e., thrombocytopenia <150,000 cells/µL and/or elevated transaminases) or unknown.
Persons considered to have a low-risk exposure include persons who spent time in a healthcare facility where EVD patients are being treated (encompassing healthcare workers who used appropriate PPE, employees not involved in direct patient care, or other hospital patients who did not have EVD and their family caretakers), or household members of an EVD patient without high-risk exposures as defined above. Persons who had direct unprotected contact with bats or primates from EVD-affected countries would also be considered to have a low-risk exposure. Testing is recommended for persons with a low-risk exposure who develop fever with other symptoms and have unknown or abnormal blood work findings. Persons with a low-risk exposure and with fever and abnormal blood work findings in absence of other symptoms are also recommended for testing.
Guidelines for Evaluation of US Patients Suspected of Having Ebola Virus Disease
By The CDC Health Advisory
continued on page 12
NAEMSP® NEWS 12 SEPTEMBER 2014
Asymptomatic persons with high- or low-risk exposures should be monitored daily for fever and symptoms for 21 days from the last known exposure and evaluated medically at the first indication of illness.
Persons with no known exposures listed above but who have fever with other symptoms and abnormal bloodwork within 21 days of visiting EVD-affected countries should be considered for testing if no other diagnosis is found. Testing may be indicated in the same patients if fever is present with other symptoms and blood work is abnormal or unknown. Consultation with local and state health departments is recommended.
If testing is indicated, the local or state health department should be immediately notified. Healthcare providers should collect serum, plasma, or whole blood. A minimum sample volume of 4 mL should be shipped refrigerated or frozen on ice pack or dry ice (no glass tubes), in accordance with IATA guidelines as a Category B diagnostic specimen. Please refer to http://www.cdc.gov/ncezid/dhcpp/vspb/specimens.html for detailed instructions and a link to the specimen submission form for CDC laboratory testing.
[Update 8/8/2014: Subsequent to the issuance of HAN 364, CDC has made a minor revision and now recommends that healthcare workers contact their state and/or local health department and CDC to determine the proper category for shipment based on clinical history and risk assessment by CDC. State guidelines may differ and state or local health departments should be consulted prior to shipping. For updated guidance on specimen submission, visit http://www.cdc.gov/ncezid/dhcpp/vspb/specimens.html for detailed instructions and a link to the specimen submission form for CDC laboratory testing.
CDC has also posted Interim Guidance for Specimen Collection, Transport, Testing, and Submission for Patients with Suspected with Ebola Virus Disease at http://www.cdc.gov/vhf/ebola/hcp/interim-guidance-specimen-collection-submission-patients-suspected-infection-ebola.html]
Recommended Infection Control MeasuresU.S. hospitals can safely manage a patient with EVD by following recommended isolation and infection control procedures, including standard, contact, and droplet precautions. Early recognition and identification of patients with potential EVD is critical. Any U.S. hospital with suspected patients should follow CDC’s Infection Prevention and Control
Recommendations for Hospitalized Patients with Known or Suspected Ebola Hemorrhagic Fever in U.S. Hospitals (http://www.cdc.gov/vhf/ebola/hcp/infection-prevention-and-control-recommendations.html). These recommendations include the following:
y Patient placement: Patients should be placed in a single patient room (containing a private bathroom) with the door closed.
y Healthcare provider protection: Healthcare providers should wear: gloves, gown (fluid resistant or impermeable), shoe covers, eye protection (goggles or face shield), and a facemask. Additional PPE might be required in certain situations (e.g., copious amounts of blood, other body fluids, vomit, or feces present in the environment), including but not limited to double gloving, disposable shoe covers, and leg coverings.
y Aerosol-generating procedures: Avoid aerosol-generating procedures. If performing these procedures, PPE should include respiratory protection (N95 filtering facepiece respirator or higher) and the procedure should be performed in an airborne isolation room.
y Environmental infection control: Diligent environmental cleaning and disinfection and safe handling of potentially contaminated materials is paramount, as blood, sweat, emesis, feces and other body secretions represent potentially infectious materials. Appropriate disinfectants for Ebola virus and other filoviruses include 10% sodium hypochlorite (bleach) solution, or hospital-grade quaternary ammonium or phenolic products. Healthcare providers performing environmental cleaning and disinfection should wear recommended PPE (described above) and consider use of additional barriers (e.g., shoe and leg coverings) if needed. Face protection (face shield or facemask with goggles) should be worn when performing tasks such as liquid waste disposal that can generate splashes. Follow standard procedures, per hospital policy and manufacturers’ instructions, for cleaning and/or disinfection of environmental surfaces, equipment, textiles, laundry, food utensils and dishware.
Recommendations to Public Health OfficialsIf public health officials have a patient that is suspected of having EVD or has potentially been exposed and intends to travel, please contact CDC’s Emergency Operations Center 1 (770) 488-7100.
NOMINATION FOR THE FOLLOWING AWARD: Ronald D. Stewart Award This award is given annually to a person who has made a lasting, major contribution to the EMS community nationally. This is often considered a lifetime achievement award. Recent recipients have included Dr. Daniel Storer, Dr. Mickey Eisenberg, Jim Page, Dr. Jon Krohmer, Dr. Edward Cain, Dr. Roger White, Dr. William Jermyn, Dr. Daniel Spaite, Dr. Debra G. Perina, William E. Brown, Jr., Jeff J. Clawson and Norman M. Dinerman,
Keith Neely Outstanding Contribution to EMS Award This award is presented to an active or past member of NAEMSP® (physician or non-physician) who has provided significant leadership to the association. Recent recipients have included Lawrence Brown, EMT-P, Dr. Ray Fowler, Dr. Rick Hunt, Dr. Ted Delbridge, Dr. Jullette Saussy, Dr. David Persse, Beth Adams, Dr. Robert O’Connor, Dr. Douglas Kupas, Dr. Brian Schwartz, Dr. James J. Menegazzi. E. Brooke Lerner and Dr. Michael Levy.
Friends of EMS Award This award is presented to a individual who has been an advocate to further NAEMSP®'s mission nationally through influencing or implementing public policy. The award is typically given to a governmental individual or organization, EMS organization or congressional leader. Recent recipients have included Mr. Robert Niskanen, the Laerdal Family, Dr. Jeff Runge (NHTSA administrator), Drew Dawson (NHTSA EMS Chief), Dr. Richard Carmona (Former U.S. Surgeon General), Dan Kavanaugh (EMSC), Susan McHenry (NHTSA), William Ball (GM OnStar), Gary Freeman (ZOLL Medical Corporation), Dr. Richard C. Hunt (National Center for Injury Prevention and Control), Kevin McGinnis and Physio-Control.
REASON FOR NOMINATION (attach separate page if necessary):
Please submit form by October 1, 2014 to: NAEMSP®, Attn: Stephanie Newman at [email protected] or Fax: 913-895-4652
NAEMSP® is also soliciting applications for the EMS Fellowship Recognition Awards. Criteria for this recognition, and submission forms, are available on the NAEMSP® website under Fellowships. Submissions are due by Oct. 1, 2014.
NAEMSP® NEWS 15 SEPTEMBER 2014
NAEMSP®/ PHYSIO-CONTROL EMS MEDICINE MEDICAL DIRECTOR FELLOWSHIP
APPLICATION AND SELECTION PROCESS INFORMATION
PURPOSE: To select the single best candidate to receive a 12 month, $80,000 EMS Fellowship Award annually.
TIMELINE:Open application process 01 July (approximately) Close applications 01 October @ 5:00 pm central time Notification of award 01 November (approximately) Awardee announcement of fellowship site
required15 December
SELECTION COMMITTEE: Formed annually by the NAEMSP® President with approval of the Board of Directors to include four (4) previous Physio-Control EMS Fellows and one (1) NAEMSP® Board Member.
Award Selection Committee Members
Kevin Mackey NAEMSP Board representative Ronald Pirrallo Chair, 1991 Theodore Delbridge 1992David Persse 1993Christian Martin-Gill 2009
ELIGIBILITY: Expectation that the applicant will meet all qualifications for American Board of Emergency Medicine (ABEM) EMS subspecialty certification upon completion of the Fellowship.
1. Diplomate in good standing of any American Board of Medical Specialties (ABMS) memberboard or be a graduate of an ACGME accredited residency and eligible to take an ABMSmember board-certifying examination at the anticipated commencement of fellowship.
2. The physician must be in compliance with the ABEM Policy on Medical Licensure. Licensesmust be valid, full, unrestricted and unqualified, except for current residents of ACGMEaccredited programs who may possess an educational or temporary license.
3. Member in good standing of NAEMSP®.
4. Intended enrollment in an ACGME approved EMS Medicine Fellowship Program.
Only online applications accepted. Visit www.naemsp.org for link.
New Fellowship Begins 01 July, 2015
NAEMSP® NEWS 16 SEPTEMBER 2014
APPLICATION PACKET: All items must be completed and received through the NAEMSP®
electronic submission web-based format prior to review.1. Curriculum Vitae2. Three letters of Recommendation clearly labeled with the applicant’s name and emailed to
[email protected]. One from the Residency Training Program Director or equivalent.b. Two additional letters that address the applicant’s qualifications as a potential EMS
fellow and the applicant’s potential for leadership as an EMS subspecialist.3. Fellowship Interrogative (See Appendix A)4. Signed Application Attestation Statement (See Appendix B)
OVERVIEW OF APPLICATION PROCESS: Each applicant will be judged based on his/her potential for a career as an EMS medical director and to become a national leader in EMS.
1. The Award is designated for the successful applicant and dispersed to the fellowshipprogram the awardee chooses for training. The awardee may apply to any ACGME -accredited EMS fellowship program to complete his or her training.
2. Once the awardee is selected, he or she will have until 15 December to be accepted intoand commit to an ACGME-accredited EMS fellowship program.
3. If for any reason the awardee is unable to or cannot be accepted into an ACGME-accreditedEMS fellowship program by 15 December, the Award will be forfeited and an alternateapplicant will be selected.
USE OF AWARD DOLLARS: 1. Award is for 12 months of contiguous training.2. Award will be issued 01 July for $80,000 to the host Fellowship Program.3. Award is intended to support the Fellow’s education and training costs.
a. No funds may be used for facilities and administrative costs (“indirects”).b. No funds may be used for mentorship salary, secretarial support, equipment, or vehicle
costs.c. Funds may be used for educational travel expenses.
4. Prior to dispersal of funds, host fellowship program must submit a 12 month budget toNAEMSP® for final approval.
AWARDEE REQUIREMENTS AND EXPECTATIONS:1. Attend the NAEMSP® Annual Meeting.2. Maintain NAEMSP® membership in good standing.3. Provide 6 and 12 month progress reports that can be shared with the industry sponsor.4. Visit the industry sponsors, at their invitation, for a mutually educational exchange of ideas
and information.5. Upon graduation, become ABEM EMS subspecialty certified.
Only online applications accepted. Visit www.naemsp.org for link.
NAEMSP® NEWS 17 SEPTEMBER 2014
NAEMSP®/PHYSIO-CONTROL EMS MEDICINE MEDICAL DIRECTOR FELLOWSHIP
INTERROGATIVE
Instructions: Please answer the following 9 questions using 300 words or less for each.
Introspection
1. Why do you wish to receive this Award?
2. Why are you the most qualified to receive this Award?
3. What will you do if you don't receive this Award?
Character
4. Which of your attributes will make you an effective EMS Physician?
5. What are the most important values you demonstrate as a potential national EMS leader?
Vision
7. Where do you see yourself 5 years from now?
8. How do you plan to achieve this station?
Open Forum
9. Anything else you would like to share with the Selection Committee?
SAMPLE - DO NOT COPY OR DISTRIBUTE
Only online applications accepted. Visit www.naemsp.org for link.
APPENDIX A
NAEMSP® NEWS 18 SEPTEMBER 2014
NAEMSP®- PHYSIO-CONTROL EMS MEDICINE MEDICAL DIRECTOR FELLOWSHIP
APPLICATION ATTESTATION STATEMENT
Print Full Name: ________________________________________
I attest that at the time of entrance into the EMS Fellowship:
1. I am a Diplomate in good standing of an American Board of Medical Specialties (ABMS)Member Board or will be a “Board Eligible” graduate of an ACGME accredited residency.
2. I comply with the ABEM Policy on Medical Licensure. Licenses must be valid, full,unrestricted and unqualified including educational or temporary licenses.
3. I am a member in good standing of NAEMSP®.
4. I agree to attend an ACGME accredited EMS Fellowship Program.
Signature: _____________________________
SAMPLE - DO NOT COPY OR DISTRIBUTE
Only online applications accepted. Visit www.naemsp.org for link.
