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ROC on
Dr. Eisenberg
Steve Perry
Administrivia
CPR
Highlights
Lowlights
Application of skills
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Any Changes?
ROCKING on or off?
Rock is still alive and well
Analyze early and late and ITD are done Oct
2009
1600 enrolled
 94% cases correctly enrolled with AE/AL and ITD
 89 % correctly enrolled with ITD
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Receiving downloads fast then ever following
HOT CALLS
Don’t Forget:
EMS witnessed
 Every time compressions are started on a non
traumatic patient
 Cardiac arrest after Medics arrive
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You’ve done such a good job******
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More to come
Mickey Eisenberg, MD
Medical Director
King County EMS
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Eisenberg’s Pet Peeves
Review of cardiac arrest survival
ROC trial summary
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CPR protocol changes
DART trial summary
New MIRF for 2010
Emphasis for 2010
Revision in Protocol Book (Blue Book)
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Pulse oximeter is not a pulse detector. The old
fashioned way to feel a pulse is the ONLY way
to feel a pulse
A seizure may be the first sign of cardiac arrest.
Do not use oxygen saturation to verify cardiac
arrest
Glucose level must be documented after
therapy
Remember IOS and MOI when using sick/not
sick
Survival from Witnessed VF
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NIH has stopped ROC-PRIMED and ITD
because of similar survival in all arms of the
study.
NO harm identified
Revision in King County CPR protocol in light
of ROC Trial
Assess ABCs. Assess ABCs. If not breathing, open airway
and provide two ventilations. If no pulse, perform
chest compression while attaching defibrillator. Give
verbal report and count compressions. When
defibrillator is attached complete 30 compressions,
clear patient, analyze rhythm, and shock if indicated.
Always provide 30 compressions prior to any rhythm
analysis. Subsequent CPR intervals should begin and
end with 30 chest compressions and each interval
should be 2 minutes (or slightly longer depending
when 30 compressions end).
Exception: When the patient goes into VF while monitored or
attached to an AED a defibrillatory shock may be
administered immediately.
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Essentially a slightly modified analyze early
Confirm need for CPR, open airway, look listen
and feel, two ventilations, 30 chest
compressions (during which AED is attached),
analyze, shock, 30:2:30:2:30:2:30 (for
approximately 2 minutes or slightly longer –
start and end with 30 chest compressions),
analyze, if no shock indicated check pulse, if
shock indicated shock, 30:2 etc
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Dispatch Assisted Resuscitation Trial
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King County, Thurston County, London
Comparing chest compression only versus
chest compression and mouth-to-mouth
No difference in survival between the two
messages
Chest compression delivered earlier with chest
compression only
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Every patient to receive backer
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Must complete the electronic record
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Only exceptions are DOA patients, patients that
leave the scene, or AMA patients
Case will be left open until record is complete
Please verify phone and address
Not Transported
Your condition did not require emergency vehicle
transport at this time. Please understand that
your situation may still require follow up medical
attention. If your condition worsens, seek medical
help or call 9-1-1.
Transported
You are being transported to a medical facility for
further medical care. You may be billed for
this service.
Low Blood Sugar
Your fire department measured your
blood sugar during your medical
emergency. Before treatment, your
blood sugar level was
_________________.
Your low blood sugar was treated by
the following method:
□ No Treatment
The EMTs gave no immediate treatment
because_________________________
□ Oral Glucose _______ gm
□ Other ____________________
After administration of glucose and/or
prior to the departure of the EMS
Team, your blood sugar level was
________________ .
If you are choosing to
stay at home:
Eat a FULL MEAL NOW.
Contact your doctor before you
take your next insulin dose. If you
are unable to contact your doctor,
reduce your next insulin dose by
25%. Keep trying to contact
your doctor.
Check your blood sugar
frequently for the next several
hours.
DO NOT: stay alone or
drive/operate dangerous
machinery for the next six (6)
hours
If your condition worsens or
initial signs and symptoms return,
CALL 911 IMMEDIATELY!
High Blood Pressure
Your fire department took your blood pressure
during your medical emergency.
Your blood pressure was very high.
Blood Pressure Categories
Systolic
Diastolic
160
140
120
<120
Hypertension
Stage 2
Hypertension
Stage 1
Prehypertension
Normal
100
90
80
<80
Your Reading
High blood pressure can lead to life-threatening disease such as
heart disease, stroke, or kidney failure. There are good treatments
for lowering high blood pressure. You need to talk with a doctor.
We recommend that you have your blood pressure
checked again as soon as possible.
Community Resources
The Crisis Clinic offers support services available to
everyone in King County. Their staff gives immediate,
confidential assistance for people in need of help. Language
interpretation is available.
DIAL 2-1-1
(available Monday thru Friday from 8 am to 6 pm)
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Caregiver & Disability Resources
Domestic Violence
Emergency Shelter
Financial Assistance for Rent or Utilities
Food & Clothing
Health Care & Support Groups
Legal Help
DIAL (206) 461-3222 • (866) 427-4747
(available 24 hours a day)
 Emotional Crisis & Trauma
 Suicide Prevention & Education
www.crisisclinic.org
Heart Attack Warning Signs
Call 9-1-1 if you have:
Chest Discomfort
Uncomfortable pressure, squeezing, fullness, or pain in the center of
the chest that lasts more than a few minutes, or goes away and comes
back.
Discomfort in Other Areas of the Upper Body
May be felt in one or both arms, the back, neck, jaw, or stomach.
Shortness of Breath
Often occurs with or before chest discomfort.
Other Signs
May include breaking out in a cold sweat, nausea, or
lightheadedness.
Stroke Warning Signs
Call 9-1-1 if you have:
 Sudden numbness or weakness of the face, arm or leg,
especially on one side of the body
 Sudden confusion, trouble speaking or understanding
 Sudden trouble seeing in one or both eyes
 Sudden trouble walking, dizziness, loss of balance or
coordination
 Sudden severe headache with no known cause
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Continued emphasis on 3 major conditions:
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CA (we can achieve 50% survival for VF)
Code ACS (recognition, STEMI, determination of
onset, aspirin, expedited scene time and transport to
hospital by paramedics)
Code CVA (recognition, determination of onset,
expedited scene time and transport to hospital by
EMTs
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Recognition and expedited care
Provide aspirin
Determine time of onset
Emphasis on STEMI and early alerting of
hospital
Expedited transport to hospital by paramedics
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FAST exam
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Facial weakness
Arm weakness
Speech abnormality
Time last seen normal
Check glucose, should be >60
Determine if patient is taking coumadin
(Warfarin)
Time hospital alerted
Expedited transport to hospital by EMTs
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Current version was issued in 2007
Suggestions for updates and changes are
welcome
AFTERCARE
Not
Transproted
Transported
Low Blood
Sugar
High Blood
Pressure
Community
Resources
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Type code 234: 2190 patients coded as
CVA/TIA. (2.3% of all EMS calls)
13% received ALS care at the scene
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16% required intubation, 42% required IV line
Transport
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87% transported by BLS (60% by private ambulance)
7% ALS
3% not transported
2% POV
Falls
If you are 65 or older and fell at home, there are two
programs in King County that can assist you in staying
healthy, independent, and safe in your home.
Please call for more information.
One Step Ahead
King County Emergency Medical Services
(206) 369-5817
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Individualized health evaluation in your home
Free for those who qualify
Home safety check
Installation of home safety devices
Harborview Fall Prevention Clinic
(206) 744-4191
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Individualized health evaluation at Harborview
Home safety suggestions
Medication review, balance and vision checks
AFTERCARE
Not
Transported
Transported
Low Blood
Sugar
High Blood
Pressure
Falls
Community
Resources
De-Fibrillation Coordinator
Steve Perry
King County EMS
Training Division
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AED / Defib Program Up-date
Quality Assurance
Through June 2009
 425 CPR Cases
 57 of those cases were bystander-witnessed
arrest due to CAD
 28 had VF as initial rhythm
 49%
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Where we are and what do we know??
Compressions
 Compressions
 Compressions
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The more time on the chest the better
The more time on the chest the better!!
 Minimize time for analysis
 Minimize time from defibrillation –resuming
chest compressions.
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Practice makes
perfect practice.
Audio Information
is important.
Stay focused.
Review your own
cases.
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Confirm cardiac arrest – turn on AED while performing CPR
ID self, company, approx age of pt, witnessed or not, pad
application, clearing to analyze.
Proceed with 30:2 compression to ventilations in adults
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15:2 x 2 in child
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SHOCK if indicated – immediately start 2 mins CPR
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If NO SHOCK - check pulse – immediately start 2 mins CPR
Prior to January 2005 our resuscitation rate was <
36%....
We are currently > 48%......
We’re all in this together
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We have a
problem….
No one wants to be
that guy 
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CC of Angina & RA SaO2 = 99%. When asked
why no oxygen was applied, the comment was:
“You can’t get higher than 100% so what’s the
point?”
Uncons/Unresp & snoring after being struck
by a car and the most important thing was to
get the patient’s tennis shoes off.
OD with RA SaO2 of 96%, uncons, & snoring.
(We were told “No O2 until SaO2 is <95%”
Since when is checking cervical dialation
within an EMT’s standard of care??
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“His pulse is 70 bpm…According to the pulse
ox..That’s what it says, is 70”
CC of respiratory distress applied a NRB at 8
lpm because: ”That’s how we were taught”
Mistake a hypoxic sz (VF) for an ill diabetic
determined to get a blood glucose reading.
Female with NO BP sitting on toilet awaiting a
doppler from a second due medic unit (“white
as rice paper”)
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Remember who we are here for and why.
Check our egos at the door
Bed side learning is optimal
Chances are similar issues are occurring in
other agencies so let’s help one another out!
Patient
EMT/
CBT Instructor
Training / Education
Establish Continuity
ID Training Needs (We are here for you!)
Improve Performance
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EMTAC – EMT Advisory Committee.
Paramedic Instructor Group
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Non-punitive
Constructive
Informative
Feedback loop
Site visits
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The Fire Service 100 years of tradition
unimpeded by progress
Progress - one retirement at a time
Competition
Ownership
Lead by example
Instructors as ambassadors
Care and Feeding
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State
County
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301 Soft Tissue
435 Abdominal Discomfort
443 Altered LOC
537 Pediatric Emergencies
165 Sick vs. Not Sick
938 Street Medicine
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Care for burns?
Penetration to the box?
Care for Tensions Pnuemothorax
Treatment of contusions, abrasions, lacerations,
avulsions and amputations
Put the wet
stuff on the
red stuff. But
what about the
patients?
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Immediate Life Threats
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Hypoxia/Respiratory Insufficiency
Trauma
 Hypotension
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Persistent dry cough
Poor Skin Signs
Decreased Mentation
Hoarse Voice
Patient was in a confined space
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Burns to Face, Nose, Mouth and Chest
Singed Nasal Hair, Eyebrows and Hair
Sooty Sputum
Abnormal Breathing
Inadequate chest expansion
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Thermal
Electrical
Chemical
Nuclear
Superficial
Partial thickness
Full Thickness
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Treatment of
Pneumothorax
 Tension Pneumothorax
 Contusions
 Abrasions
 Lacerations
 Amputations
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Pain usually
interpreted as colic;
a severe, intermittent
cramping pain.
Referred pain
Perceived pain at a
distant point of the
body caused by
irritation of the
visceral peritoneum
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Perforation of an ulcer
Gallstones that lead to inflammation
(cholecystitis)
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Inflammation of the pancreas (pancreatitis)
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Inflammation or infection of appendix
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Inflammation of pouches in large intestine
(diverticulitis)
IHOP
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Causes of pain
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Menstrual cycle
Pelvic inflammatory disease
Ectopic pregnancy
Always
consider an ectopic with
women having abdominal pain of
child bearing years.
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Aneurysm
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Pneumonia
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Weakness in aorta
May cause ileus and abdominal pain
Hernia
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Protrusion through a hole in the body wall
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Determine whether patient
can relax abdomen on
command.
Determine whether
abdomen is tender when
palpated.
Palpate gently—rough
palpation could cause
further damage.
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Initial
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BP ,Pulse, Respirations, LOC
Postural Vital Signs
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Findings
 20 points Systolic drop in BP
 20 point rate increase
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Contraindications
Pressure of 90 or below
 Trauma
 3rd Trimester bleeding
 Cardiac
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TIA’s
Strokes
Decreased LOC
Why
Why
Why
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Brain attack
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Interruption of blood flow to the brain that
results in the loss of brain function.
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Thrombosis — Clot that
forms at the site
Arterial rupture —
Rupture of a cerebral
artery
Cerebral embolism —
Obstruction of a cerebral
artery caused by a clot
that was formed
elsewhere and traveled
to the brain
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Left hemisphere
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Aphasia: Inability to speak
or understand speech
Receptive aphasia: Ability to
speak, but unable to
understand speech
Expressive aphasia: Inability
to speak correctly, but able
to understand speech
Right hemisphere
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Dysarthria: Able to
understand, but hard to be
understood
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Pipes –Pumps-Fluid
Noxious Stimuli
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Response
Why?
Alcohol and it’s effects
Cardiac Arrest
OD’s
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Opiates
 Oxycodone
 Oxycotin
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Ecstasy
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Spinal Immobilization
Pediatric Triangle
Abuse
Febrile Seizures
Make a Decision!
SICK
NOT SICK
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Fluid
Clinical Picture
Evolving evolution
Go with it
Make a Decision!
Chief Complaint/N.O.I.
Respirations
Pulse
Mental Status
Skin Signs/Color
Body Position
The Clinical Picture
SICK
DECIDE
NOT SICK
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Unexplained bruises and welts seen after
absences, weekends, or vacations.
Unexplained burns, cigarette burns, especially
burns found on palms, soles of feet, abdomen,
buttocks; immersion burns producing ";
"doughnut shaped" on buttocks or genital area.
Rope burns.
delay in treatment; burns in the shape of
common household utensils or appliances
Stories different from caregivers
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The majority of children with febrile seizures
have rectal temperatures greater than 102
degrees F. Most febrile seizures occur during
the first day of a child's fever
Children rarely develop their first febrile
seizure before the age of 6 months or after 3
years
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Online Course and Round Table
Scene safety
Yours
 Look but don’t touch everything
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Evidence preservation
Documentation
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Documentation
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Written
Camera
Documentation
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Notes
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O2 sats are NOT pulse indicators
Seizures may be your first sign of a cardiac
arrest A B C’s
Glucose MUST be documented after treatment
REMEMBER
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IOS and MOI when using sick not sick
Life begins and ends with Compressions
Time is Muscle or Brain and in some areas
these people don’t have grey cells to lose