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S ummer time is vacation time and



     JUNE 2003                                                                                     VOLUME 18      ISSUE 3

Summertime Driving: Buckle Up! Every Ride! Every Time!
By Mona Mena                                injuries by 46% in cars with front         age 4.
                                            passenger seat airbags (30% with no             Don’t drink and drive. Alcohol
S   ummer time is vacation time and
    thousands of people will ‘hit the
roads’ trekking families to their fun
                                            front airbags). Children from 5 to 9
                                            years of age should use belt
                                                                                       was involved in 41% of all traffic
                                                                                       related deaths in the US in 2001.
                                            positioning booster seats, yet only             Don’t speed. Speed was
destinations. Sadly, and as EMS well        19% of those children are placed in        indicated as the primary collision
knows, many will experience tragedy         them. Motor vehicle occupant injury        factor in 28% of fatal and injury
on the highways. Oftentimes, these          is the leading cause of death for          collisions in California in 2001.
unfortunate events could have been          children ages 5 to 14. Children
prevented. This article will highlight                                                 Child safety seat tips:
                                            under age 1 have a motor vehicle
some statistics that EMS professionals      occupant injury death rate 1.5 times            Make sure the child passenger
can use to help get the message out         that of all children.                      safety seat is installed correctly.
to Buckle Up!                                                                          82% of child passenger safety seats
                                            To access a copy of the full report,       are installed or used incorrectly.
The National Safe Kids Campaign             check the Safe Kids website at:
released a report in May, 2003 entitled                                                     Children 12 and under should
                                            ww w . s afe k i d s. o rg. F or m or e    be properly restrained in the back
“A Report to the Nation: Trends in          information on child passenger safety
Unintentional Childhood Injury                                                         seat of the car on every ride.
                                            check up events or material on child            Infants should ride in a rear-
Mortality, 1987-2000.” The report           passenger safety, contact the EMS
documents that the unintentional injury                                                facing seat until they are at least 12
                                            Injury Prevention Program at (510)         months old and weigh 20 pounds.
death rate for children 14 and under        618-2051 or check out the EMS web
has decreased by 40% since 1987.                                                            Children over 1 weighing 20 to
                                            site-look for “car seat check up events”   40 pounds should ride in forward-
While great strides have been made in       in the quick links box.
reducing injury deaths, there are more                                                 facing child safety seats.
opportunities to reduce unintentional       Alameda County EMS coordinates                  All children over 40 pounds
injury, especially motor vehicle            and staffs the Alameda County Safe         should be secured in a booster seat
occupant injuries.                          Kids Coalition. The coalition is           until the adult lap and shoulder belts
                                            actively engaged in developing             fit correctly (approximately by age 8).
Although the motor vehicle death rate       educational programs to reduce
for children 14 and under has               unintentional injury, hosting car seat
decreased, it is still the major cause of   check up events, walk-to-school day,
fatal unintentional injuries of children                                               Inside this issue:
                                            and safety fairs. If you are interested
in the US. Motor vehicle crashes are        in participating in the Safe Kids          GC of the Eyes                       2
the cause of 28% of these deaths.           Coalition, contact Barbara Cheatham        From the Medical Director - CPAP     3
What is disturbing is that 55% of           at or
children killed in motor vehicles were      (510) 618-2051.
                                                                                       Tick Talk                            4
not wearing restraints. It is estimated
                                            Motor vehicle safety tips:                 Hazards of Medications               5
that 14% of children under 14 ride
unrestrained, and that one-third of              Always use seatbelts. Car             2004 Policy Process                  5
children ride in the wrong car seat for     seats reduce the risk of injury by 50%     SIPP Conference Outcome              5
their age and size.                         for children over age 9.
                                                 Always restrain children in           Smallpox Vaccination Update          5
Of all children killed in motor
vehicles, 35% were riding in the front      child passenger safety seats. Child        EMT/Paramedic News                   6
seat. Riding in the back seat is            safety seats reduce the risk of death
                                                                                       News & Announcements                 6
known to reduce the risk of fatal           by 55-70% for children from birth to
Ocular Infection of the Strange Kind
By Bob Nixon, EMT-P                      is confirmed.    Your partner has         and, ultimately blindness.
                                         gonorrheal conjunctivitis of the eyes.
You respond to a ‘woman in labor’                                                  Treatment - Gonorrhea is treated with
call. Upon arriving at the residence,    Nature and Spread of the                  antibiotics such as ceftriaxone and
you are greeted by a man who             Disease - Gonorrhea is typically          ciprofloaxicin. If chlamydia is also
rushes you inside saying, “Our           caused by the bacterium Neisseria         present, doxycycline may be used.
baby’s coming now!” You introduce        gonorrhoeae also referred to as           Antibiotics such as bacitracin &
yourself to the woman who, screams,      gonococcus. It is transmitted by sexual   gentamycin ointment are used for
“It’s coming out now!” You begin         or intimate contact with an infected      uveitis and conjunctivitis.
preparing the OB kit while your          person; however, orogenital contact       Back to the Call - After the initial
partner leans over the woman to          can transmit it to the mouth and          shock has worn off, you and your
assess the imminence of delivery.        throat. A newborn’s eyes can become       partner realize that the woman in
There is little time to prepare, and     infected during vaginal delivery. Eye     labor transmitted the disease to your
your partner assists the woman in        infections in adults are rare. If left    partner. This could have happened
completing the delivery.                 untreated the infection can become        because he failed to wash hands
                                         bloodborne.                               after the call. In between calls, your
Upon arriving at the emergency
department, you turn the patient over    Signs and Symptoms - The incuba-          partner could have rubbed his eye
to the staff, remove your gloves, and    tion period for gonorrhea ranges          causing the infection. Or it could
give a brief report to the emergency     from two days to three weeks. In          have happened during the labor,
department staff while your partner      some patients there will be no            delivery, and postpartum care if
readies the vehicle for the next call.   obvious signs and symptoms of             splashing of body fluids inadvertently
You receive an urgent call to a motor    infection. (see box below).               occured.
vehicle accident with three people       Complications - If genital disease is     Personal Protective Equipment -
trapped. Heading to your vehicle,        left untreated, it can spread             When responding to a call to assist a
your partner removes the latex           internally. In men, the bacterium         woman in labor, personal protective
gloves worn on the previous call,        can spread to the prostate and            equipment must initially consist of
tosses them into the trash, and walks    testes. In women, it can spread into      gloves. Once it has been determined
out of the hospital. Accidentally or     the uterus and fallopian tubes. If        that the EMS crew will allow the
intentionally, your partner did not      allowed to continue, the bacterium        delivery to occur on the scene or in
take time to wash the hands.             can enter the blood and spread to         the back of the ambulance,
                                         other organs such as the heart,           universal precautions must to be
                                         meninges, joints, peritoneum, and         used, including gloves, protective eye
                                         skin. Ocular infections that are left     wear face mask, and, perhaps a
                                         untreated, can lead to perforation of     gown.
                                         the cornea along with formation of
                                         abscesses, scarring of the cornea

                                         Signs/Symptoms in Men                     Signs/Symptoms in Women
                                           Up to 40% of men are                      Up to 80% of women are
                                           asymptomatic                              asymptomatic
                                           Painful or burning urination              Lower abdominal pain
A week later, your partner complains
                                           Increased frequency of urination          Painful or burning urination
that his eyes are beginning to itch.
                                           Whitish fluid discharge from penis        Increased frequency of urination
Without touching, you look at eyes
                                           Discharge increases over time             Whitish discharge from cervix
that are red and irritated. “Hmm,
                                           Discharge changes to yellow-green         Discharge changes to yellow-green
you mumble, looks like conjunctivitis.
Better see the doc at the ER.” After     Other Signs and Symptoms
the next call, your partner talks with     Orogenital - complaints of sore throat and difficulty swallowing.
the emergency physician about his          Ocular - edema of the eyelids, reddened eyes, and profuse watering
eyes. After a brief wait the diagnosis

       Page 2
                                                                              From the Medical Director
By Jim Pointer, MD                                                                 tions. Absolute contraindications in-
                                                                                   clude age less than 8 years, respira-
A Non-Invasive Treatment For                                                       tory or cardiac arrest, agonal breath-
Pulmonary Edema - You are called                                                   ing, depressed level of conscious-
to the home of a 79 year-old male                                                  ness, systolic BP less than 90, pneu-
with a history of congestive heart fail-                                           mothorax, major trauma, facial
ure (CHF) who has been having trou-                                                anomalies, or vomiting. Complica-
ble breathing for the past 8 hours                                                 tions are rare but include hyperten-
and is unable to lie flat. He is dia-                                              sion, pneumothorax, and corneal
phoretic and appears in obvious dis-                                               drying.
tress. The patient’s wife tells you that
he has a history of myocardial in-
                                              X-ray showing pulmonary edema
farction four years ago, coronary ar-                                              Several studies have
tery bypass graft, hypertension, and                                               shown that CPAP re-
                                           Pulmonary edema is a true life
high cholesterol. He is taking fu-                                                 duces the require-
                                           threatening emergency. Its symptoms
rosemide, Altace, and PRN nitroglyc-                                               ment for intubation
                                           include fatigue, nocturia, dyspnea,
erin.                                                                              and decreases hos-
                                           chest pain, orthopnea, and gastro-
                                                                                   pital stay and ICU
                                           intestial symptoms. The physical
His physical exam shows a heart rate                                               admission. Overall,
                                           exam includes some or all of the fol-
of 145, BP 220/120, respiratory rate                                               it decreases costs in
                                           lowing: anxiety, pallor, clammy skin,
of 28, and O2 saturation of 82%. He                                                patients with pulmo-
                                           tachypnea, confusion, edema, hyper-
presents with distended neck veins,                                                nary edema. CPAP CPAP device in use
                                           tension, diaphoresis, rales, rhonchi,
rales in both lung fields, pitting ankle                                           is non-invasive, easily discontinued
                                           tacycardia, S3 gallop, jugular venous
edema, and a Glasgow score of 14.                                                  or adjusted, does not require seda-
                                           distension, pink frothy sputum, cya-
                                                                                   tion, and is usually well-tolerated by
                                           nosis, displaced point of maximum
Treatment - Your assessment is pul-                                                the patient. In the near future, we
                                           impulse. The hypothetical patient in
monary edema. You sit the patient                                                  will have the opportunity to pilot the
                                           this case was administered continu-
upright, administer high flow oxygen,                                              use of CPAP at Hayward Fire Depart-
                                           ous positive airway pressure (CPAP)
0.8 mg nitroglycerin, and fu-                                                      ment. CPAP represents an advance-
                                           in the prehospital setting.
rosemide. You are considering at-                                                  ment in our care of pulmonary
tempting endotracheal intubation,                                                  edema and near drowning.            As
                                           CPAP has been successfully demon-
but instead, you place a mask on the                                               usual, I solicit your comments and
                                           strated as an effective agent in the
patient attach it to a CPAP machine,                                               suggestions. Please contact me at
                                           management of pulmonary edema
turn a few control knobs, and ad-                                                  618-2022 or email at
                                           secondary to CHF. This modality
minister oxygen through the mask to                                      
                                           may prove to be a viable alternative
the patient. You explain to the pa-        in many patients that previously re-
tient, “You are having trouble             quired endotracheal intubation by       CE Providers
breathing because your heart is not        paramedics. CPAP works by in-
pumping well enough right now, and                                                 Many Alameda County CE providers
                                           creasing pressure within the airway.
fluid is backing up into your lungs. I                                             are due to renew their approval
                                           The airways, which are at risk for
am going to put this mask on your                                                  status during the next 6 months. In
                                           collapse from excess fluids, are
face to help push air into your lungs                                              order to maintain continuous
                                           stented open.     Gas exchange is
and push the fluids out.” You moni-                                                approval, you should complete an
                                           maintained, and increased work of
tor the patient’s heart rate, respira-                                             application along with the required
                                           breathing is minimized.
tory rate, BP, and oxygen saturation.                                              documentation and mail or e-mail it
In five minutes you obtain the follow-                                             to John Vonhof jovonho@
                                           The prehospital indications for CPAP
ing vital signs: heart rate 110, BP                                       at least 60 days
                                           include pulmonary edema associ-
170/120, respiratory rate 18, oxy-                                                 prior to the expiration date.
                                           ated with volume overload and near-
gen saturation 98%. The patient re-                                                Not sure of your expiration date or
                                           drowning.     This modality may be
ports that he is feeling much better                                               need an application? Check out the
                                           used in patients 8 years-of-age and
by given you the “thumbs up” sign.                                                 EMS website.
                                           over who present with these indica-

                                                                                                        Page 3
Tick Talk - Ticks and Lyme Disease
By Bob Nixon, EMT-P                              requires a single blood meal. Ticks     erythema migrans that appears as an
                                                 can be very difficult to spot,          expanding red ring in the area of the
As the weather warms and spring                  especially in the larval and nymph      bite.    The lesion has also been
tur n s i nto s u mmer, outdoor                  stages during which the tick may be     described as a ‘bulls-eye’ with
recreational activities increase.                no bigger than the head of a pin.       alternating light and dark rings.
Likewise, the risk of contracting
vector-borne diseases also rises.                Ticks are more active in the spring,    Treatment and Prevention
One such disease is Lyme disease – a             summer and fall and are primarily       Lyme disease is treated with
bacterial infection transmitted to               found in grassy areas such as           antibiotics in the early stages of the
people by ticks. This purpose of this            woodlands or bushy areas. In their      disease. Starting therapy in the later
article is to review information about           search for a meal, ticks will feed on   stages may require prolonged or
ticks and Lyme disease.                          any number of animals including         repeated antibiotic therapy. In some
                                                 people, dogs, cats, deer, mice, and     cases, treatment has failed and
Nature and Spread of the Disease                 birds.      Lyme disease is not         relapse occurs.     Until recently, a
Lyme disease is caused by the                    transmitted from one person to          vaccine against Lyme disease,
bacterium, Borrelia burgdorferi, a               another.     No special precautions     LYMErix, was available, but low
spirochete whose main reservoir is               need to be taken when caring for a      demand and poor sales pulled the
the white footed mouse. Ticks take               patient with Lyme disease.              drug from the market.
blood from the victim by inserting
their mouth into the skin, which                 Signs and Symptoms                      The key to prevention is awareness of
attaches the tick to the victim                                                          risk and taking preventive measures
allowing them to slowly take in                                                          to reduce chance of a tick bite.
blood.      An infection generally                                                       Measures include: repellants with
develops after the tick as been                                                          permethrins or DEET, avoiding places
feeding for two or more days.                                                            where ticks are common, using
                                                                                         personal protective techniques,
The incidence of the disease is                                                          surveying your body for ticks, and
worldwide and throughout the United                                                      clearing overgrown areas.
States; however, the majority of cases
are found in New England. While                                                          Summary
ticks transmit the disease, not all ticks                                                EMS personnel may be at risk if they
are infected or infectious.           For                                                are called to a wooded area to assist
example, a common tick is the dog                Erythema migrans.        Courtesy CDC   with search and rescue or assist a
tick that is larger than the deer tick,                                                  patient found in an area that has
                                                 The incubation period typically
but does not carry the bacterium that                                                    excessive vegetation. EMS personnel
                                                 ranges from 7 to 14 days; however,
causes Lyme disease.                                                                     may be more at risk off duty when
                                                 the range is 3 to 30 days. In some
                                                                                         they are enjoying the outdoors with
                                                 cases, a patient is asymptomatic or
The tick has three life stages; larval,                                                  family and friends. By understanding
                                                 has non-specific complaints such as
nymph, and adult, each of which                                                          the illness, the risks associated with
                                                 fever, headache, fatigue, and muscle
                                                                                         ticks, and preventive measures to
                                                 aches. In about 50 percent of the
                                                                                         lower the risk, EMTs and paramedics
                                                 cases, the patient will develop a
                                                                                         may be able to avoid exposure to this
                                                 characteristic single lesion called
                                                                                         vector-borne disease.

                                                  Nervous System         Musculoskeletal System           Cardiovascular System
                                                  Meningitis             Joint and muscle pain            Myocarditis (rare)
                                                  Facial nerve palsy     Join swelling                    AV block (rare)
                                                  Polyneuropathy         Intermittent joint swelling
Ticks – from left – Adult female, adult male
                                                  Cognitive disorders
nymph, larva.                     Courtesy CDC    Personality changes
                                                  Death from Lyme disease is rare

        Page 4
Hazards of Medications in the Elderly                          2004 Policy Review Process
                 Medication use by seniors poses a unique      Draft #1 of the policies in this year’s process can be
                 threat that EMTs and paramedics may be        found on the EMS website.        The dates have been
                 the first to recognize.                       modified slightly. Written comments on the draft policies
                                                               are now due into the EMS Agency no later than July 1st.
                According to a study funded by the federal
Agency for Healthcare Research and Quality and the             Although there are no major changes to the policies, here
National Institute on Aging, up to 1.9 million drug-related    are a few of the highlights:
injuries occur annually in the senior population. These           The amiodarone trial study has been completed.
injuries may be caused by medication errors or adverse            Amiodarone is now part of the local option scope of
effects of the drug. According to the study 180,000               practice for paramedics. In addition, policy #7207
injuries were life-threatening or fatal and more than half        has been changed to delete Lidocaine and add an
were preventable                                                  additional 150 mg dose of amiodarone. Paramedics
                                                                  still need to “call-in” Amiodarone cases to 618-2023
Additionally, a review of the preventable adverse drug            CCT-Ps: A sedation policy for ventilator/agitated
events revealed that nearly 60% involved prescribing the          patients and monitoring amiodarone drips.
wrong drug or dose, not educating the patient, or giving          A visual analog scale has been added to the adult pain
the patient a drug that has a known drug interaction with         management protocol, plus the FACES scale and a
another medication. However, 20% of the preventable               behavioral tool for assessing pain in young children to
medication-related injuries were caused by patients’              the pediatric pain management protocol.
failure to adhere to the instructions they were given.
                                                               The EMS Agency is asking field personnel if they would
For more details, refer to “Incidence and Preventability of    like to see the field manual organized alphabetically,
Adverse Drug Events Among Older Persons in the                 rather than numerically, within sections. If you have an
Ambulatory Setting” in JAMA, Vol. 289, No. 9, March 5,         opinion about this or any of the policies e-mail your
2003.                                                          suggestions to Kris Helander-Daugherty at

Smallpox Vaccination Program                                   SIPP Conference Update
                                                                                 The Senior Injury Prevention Project
The under whelming response of the Health Care                                   (SIPP) hosted the Third Annual Senior
Community to become vaccinated in the Phase 1                                    Injury Prevention Conference on May 1
Smallpox Vaccination program has led the Federal                                 & 2, 2003. This year’s event was
Government to question the whole project. There is much                          hosted in conjunction with the Center
debate at this point, and it is unclear when, if at all, the                     for Injury Prevention Policy & Practice
next phase will begin. The plan to vaccinate the first                           and was the first statewide conference.
responders (Phase 2) would include EMS, Fire, Law
Enforcement and others. This part of the program was           In addition to providing an opportunity for creating links
scheduled to start in the spring/ summer of 2003.              with other older adult injury prevention advocates
                                                               throughout the state, the 115 attendees participated in
We will keep you posted as to the ever-changing                workshops that provided intervention information on
evolution of this monumental project.       For more           specific types of injuries as well as the factors contributing
information contact Zerlyn Ladau at (510) 208-5951 or          to those injuries. Very informative workshops were also                                      offered on political and media advocacy which SIPP will
                                                               use during the coming year to promote the growth of
                                                               injury prevention efforts in older adults.
 Trauma Facts: (penetrating vs. blunt - adult)
                                                               For more information on the conference or SIPP, contact
          2000             2001             2002               Colleen Campbell at or
          B    P           B      P         B      P           (510) 618-2047
 Eden 1113 110            1266 121        1186 106
 HGH    975 365            970 418         865 510
                                                                                                           Page 5
              Alameda County
   Emergency Medical Services Agency
  A Division of the Public Health Department
                                               EMT-P License Renewal Late Fee
1850 Fairway Drive
                                               The Emergency Medical Services Authority (EMSA) in Sacramento has decided
San Leandro, CA 94577                          to crack down on the high number of paramedic renewals that are submitted
(510) 618-2050                                 late. Even though regulations require renewals to be submitted at least 30 days
(510) 618-2099—fax                             prior to expiration, 40% fail to file on time—jeopardizing EMSA’a ability to
Board of Supervisors                           process cards before the license expiration date.
Scott Haggerty, District 1
Gail Steele, District 2
Alice Lai-Bitker, District 3
                                               Beginning September 2003 and thereafter, a $50.00 late service charge will be
Nate Miley, District4                          assessed when a paramedic license renewal is postmarked or hand delivered
Keith Carson, District 5                       to EMSA fewer than 30 days prior to the license expiration date. If a renewal
Health Care Services Agency                    application is received late, a new license will not be issued until the late service
David J. Kears, Director                       charge has been paid.
Public Health Department
Arnold Perkins, Director                       Live Scan Application Available on the Website
Anthony Iton, MD, Health Officer
                                               The Live Scan form is now available online. All EMTs applying for initial
Emergency Medical Services Agency
Cindy Abbissinio, RN, Director                 certification or doing their first recertification since last September are required
James E. Pointer, MD, Medical Director         to submit a background check through the Department of Justice’s Live Scan
Newsletter Production                          fingerprinting process. With the form online now all the certification/
Bob Nixon, Editor                              recertification forms are instantly available to anyone with internet access.
Kris Helander-Daugherty, Design & Layout
                                               The forms can be obtained by going to the EMS website,,
                                               clicking on “Departments” and then “EMS.” The form is under the “Live Scan
What’s New on the Web                          Application” button. The accompanying “Background Check – EMT” button has
                                               the instructions for completing the Live Scan form and getting the fingerprinting
■ Expanded information on
                                               done. Be sure to print out three copies of the Live Scan form—one for the Live
  the AED/PAD Program
                                               Scan agency, one to submit to EMS with your application and one for your
■ Live scan form available on-line!
                                               records. Questions can be directed to John Vonhof at
■ CE provider renewal information
                                               or 510-618-2038.

                           News & Announcements . . .
                     In case you were             were instrumental in bringing about                    Meeting Notes
                     wondering…When               the use of 12-lead ECGs within the
                     submitting protected         department.                                           EMOC: Thursday
                     health information                                                                 August 21, 2003,
      (PHI) to the EMS Agency, HIPAA              CPAP is on the horizon. Shortly,                      9:00 — 10:30 a.m.
      authorizes such disclosure to the           Hayward Fire Department will              Research Committee: Thursday
      Agency as a public health oversight         begin a trial study using CPAP (see       August 21, 2003, 10:30 a.m. -
      agency for the purpose of                   the article on page 3 in this             12:00 p.m.
      surveillance, audits, investigations,       Newsletter).
      and licensure.       Thus, sending
      Utstein data for cardiac arrest             New dates for the 2004 Policy
      studies and calling PHI information         Review Process Draft #1 will be
      for the amiodarone study relayed            available June 2nd (check them out
      on the dedicated phone line do not          at the EMS website). Written
      need the patient’s permission. (See         comments will now be due back to
      45 CFR 164.512)                             the EMS Agency by July 1st. The
                                                                                                      EMS website:
                                                  draft policies are scheduled for
      Emeryville Fire Department has              discussion at the August 21st
                                                                                                “departments” then “EMS”
      begun using 12-lead ECG tracings.           EMOC meeting. (See article on
      Chief Steve Cutright and Fire-              page 5.)
      fighter/Paramedic Steven Marks

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