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ALAMEDA COUNTY EMERGENCY MEDICAL SERVICES AGENCY 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 firstname.lastname@example.org 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 email@example.com. 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 co.alameda.ca.us 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 Encephalopathy 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 firstname.lastname@example.org. Smallpox Vaccination Program SIPP Conference Update 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 email@example.com. 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 firstname.lastname@example.org 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, http://acgov.org, 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 email@example.com ■ 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 http://acgov.org 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
"S ummer time is vacation time and"