Merg’s Corner Newsletter of Summer 2009

Over the years, the Cambridge Fire Department, Police Department, Emergency Communications Department, and Pro EMS have developed a unique public-private partnership that has enabled us to build one of the best EMS systems in the country.
 
This partnership reflects our collective commitment to setting high standards for training and technology so that we can provide the highest quality EMS services to the City of Cambridge. It also demonstrates our commitment to fostering and supporting the community – whether they are residents of Cambridge or members of the EMS system, such as hospitals and other emergency providers.
 
We were reminded of the importance of this community when we honored retired Cambridge Police Officer Robert “Bo” Ahern at the dedication of the new Cambridge Police North Cambridge Reporting Station at Pro EMS. Police officers, firefighters and paramedics joined Bo’s sons, grandchildren and other family members to remember Bo, who served the City for more than three decades. We’d like to thank everyone who joined us for this special occasion.
 
I’d also like to thank Keri Cook for her efforts as Pro EMS Director of CQI. Keri has been integral to the development of the continuous quality improvement program. From investigating new technologies, to setting the standards for EMTs and paramedics and – importantly — upholding them, Cambridge’s EMS system has benefited from Keri’s dedication.
 
Each year, Keri is among a group representing the Cambridge EMS System that attends the annual “Gathering of Eagles” conference in Texas. The group investigates new procedures and technologies presented at the conference, and makes recommendations on how the Cambridge EMS system can implement them. This year, those recommendations included therapeutic hypothermia, details of which you can also read about in this newsletter.
 
As always, thank you for your hard work and dedication to EMS.
 
-Merg
 

Pro EMS Medical Director Dr. Gary Setnik Receives Two Teaching Awards From Harvard Medical School

For the past 20 years, Dr. Gary Setnik, South Middlesex EMS (SMEMS) Medical Director, has helped Harvard Medical School students prepare for the realities of their careers as physicians by teaching a course on Emergency Medical Care. His dedication to the students was recognized by the school this year with the granting of two awards.
 
Setnik shared The Best Clinical Teacher at Mount Auburn Award as well as the Faculty Prize for Excellence in Teaching, established in memory of Charles McCabe, M.D. Setnik’s accomplishments were recognized at both Harvard Medical School’s graduation and at the school’s Faculty Awards ceremony in June.
 
The Emergency Medical Care course, currently Harvard Medical School’s second-largest elective, was created about 40 years ago at the behest of students who wanted more experience with the practical application of their skills before becoming interns.
 
With that objective in mind, when Setnik took over the course, he employed a variety of teaching tools to help the medical students get ready for emergency situations they might encounter as house officers. The activities range from lectures that can be accessed online; to case- and procedure-based simulation training; to the use of an online textbook -– which Setnik created himself.
 
“I have received notes from many students over the years telling me how helpful certain elements of the course were to them in their subsequent training years,” he said.
 
One former student – called upon to assist a fellow airline traveler who suddenly became ill – later thanked Setnik for teaching them how to handle emergencies in flight.
 
Part of Setnik’s class also involved paramedics from Pro EMS, who were asked to teach and certify the students in BLS and ACLS.
 
“The [Pro EMS] paramedics are outstanding instructors – truly amazing,” he said. “I would not have received these two awards had it not been for the participation of those individuals.”
 
In his role as SMEMS Medical Director, Setnik provides medical oversight to the local area’s EMS organizations, including Cambridge, Belmont, Arlington, Watertown and Lexington. He credits Chris Kerley, director of the Pro EMS Center for MEDICS, for the high caliber of its providers.
 
“Chris is one of the primary reasons our training has been so successful. He has the highest standards, and that shows in every one of the medics and in their techniques.”
 
Having worked at both Harvard Medical School and Mt. Auburn Hospital for 32 years, Setnik currently serves as the Department of Emergency Medicine Chair at Mt. Auburn Hospital. He is also an assistant professor at the medical school.
 
As SMEMS Medical Director, Setnik’s responsibilities include participating in quality assurance programs, signing off on medics’ credentials, and leading monthly morbidity and mortality rounds with SMEMS Executive Director John Conceison.
 
Setnik and his wife live in Winchester, MA. They have three children, one of whom is an emergency physician in New Hampshire. They also have four grandchildren.
 

Profile: Keri Cook, Pro EMS Director of CQI

At 6 a.m. each morning, paramedic Keri Cook arrives at the offices of Pro EMS and collects the latest reports detailing the emergency calls recently handled by her colleagues.
 
“I review every single patient care report, whether it was a transport or cancelled,” said Cook, who serves as Pro EMS’s Director of Continuous Quality Improvement (CQI).
 
It adds up to more than 20,000 cases a year. But for Cook the process allows her to collect and analyze clinical data – and gives her the ability to directly impact the quality of the services provided by Pro EMS.
 
As Director of CQI, Cook spearheads one of the biggest initiatives at Pro EMS: To increase the clinical sophistication of every member of the Pro EMS team, and in doing so, improve the quality of patient care.
 
The CQI process that Cook helps to implement involves a continuous loop of analyzing data from emergency calls; providing consistent feedback to field members; enhancing skills through training; and implementing the latest technologies in order to advance care.
 
Importantly, Pro EMS also incorporates customer satisfaction surveys in its review process so that the patients themselves have a voice in the quality of the care they have received.
 
“Our job is to make them better EMTs,” Cook says. “People who join Pro EMS are drilled from the moment they’re interviewed. The training never ends.”
 
A Resource, Not a Reprimand
 
A paramedic for 15 years, Cook draws on her field experience as she reviews cases and provides feedback.
 
Whether praising situations that were handled particularly well, or pointing out when protocols were not followed, Cook stresses the educational aspect of this process. Her goal is to frame the feedback as a learning experience.
 
Cook’s firm, yet fair, guidance has encouraged EMTs and paramedics to approach her as a resource, instead of seeing her reviews as punitive.
 
EMTs and paramedics anticipate Cook’s feedback, and routinely seek out her advice. Many days, arriving for her daily shift, Cook finds messages waiting in her inbox that begin, “I did a call last night and wanted to run it by you…”
 
Gaining Perspective
 
Cook’s experiences as a paramedic, and as a manager, also expanded her perspective on what it means to “make a difference” – a big reason many individuals say they want to get into EMS as a career.
 
Twenty years ago, as a new EMT working at Pro EMS, Cook eagerly anticipated the “blood and guts” calls and their accompanying adrenalin rush.
 
Over time, Cook learned, calls are often less exciting: the 80-year-old woman who is lonely and not feeling good in the middle of the night, or the intoxicated homeless man who routinely requires transportation to the hospital.
 
While treating a gunshot or stabbing victim can be overtly lifesaving, Cook has come to realize that even on seemingly mundane calls, she and her colleagues can positively impact a patient’s life.
 
“Most people [in EMS] want to make a difference and are in it to help others,” Cook states, “It’s not for the financial gain.”
 
In fact, dedication and commitment are qualities Cook and her colleague Rachid Sbay, Director of Operations at Pro EMS, seek when initially interviewing potential employees.
 
“We interview by committee…and tell people that [at Pro EMS] we want to make them the best EMT or medic they can possibly be.”
 
Adding Technology to the Field
 
In addition to acting as an educational resource, Cook and some of her colleagues are charged with the task of finding cutting-edge technologies and new protocols for patient care.
 
Over the past few years, a group of top managers from Pro EMS attended the annual “Gathering of Eagles” Conference that’s held in Texas and hosted by the U.S. Metropolitan Municipalities EMS Medical Directors Consortium (known as the “Eagles” Coalition). Attended by the 30 largest EMS systems in the country, this conference discusses the newest advances in pre-hospital patient care.
 
“We find that we stack up well with the rest of the country, but we always bring one or two things back,” Cook says.
 
Constant attention to new, evidenced based treatment modalities and equipment has allowed the Cambridge EMS system to be early adopters of the EZ-IO (intraosseous) drill; myriad advanced airway procedures; continuous positive airway pressure (CPAP); and the implementation of a therapeutic hypothermia after cardiac arrest protocol.

 

Lifelong Commitment
 
Cook always knew that she wanted to work in the medical field. After graduating from high school in 1987 in Cambridge, MA, she first considered a career in nursing.
 
“I didn’t want to stay inside all the time,” she says.
 
She became an EMT in 1989 and started working at Pro EMS. Cook recalls being terrified on her first calls.
 
“It took about six to seven months to get used to the job,” she said.
 
After a year on the road, Cook began working in dispatch. In 1993, to further her education, she enrolled in a paramedic training program in Hyannis, MA, and graduated a year later.
 
She’s since served in various roles, including Operations Supervisor and Field Training Officer. But it’s her current role that really makes Cook feel that she has a personal stake in the success of Pro EMS and the people who work there.
 
Speaking with potential employees, she and Sbay describe the unique culture of the company.
 
“We weed out a lot of people. We are looking for people who want to do the job and be great,” she says.
 
A resident of Tewksbury, MA, Cook is married and has an 11-year-old daughter.
 

Police Officer Robert “Bo” Ahern Honored as New Cambridge Police North Cambridge Reporting Station Dedicated to His Memory

police_annex1 2On Wednesday, June 17th, members of the Cambridge Public Safety Community, as well as their friends and family, gathered at Pro EMS for the dedication of the new Cambridge Police North Cambridge Reporting Station in memory of Officer Robert “Bo” Ahern.
 
A retired Cambridge police officer of 36 years and a U.S. Marine Corps veteran, Bo was remembered as “a man’s man, and a cop’s cop” who was “second to none,” by Pro EMS Chief Executive Bill Mergendahl, who opened the dedication ceremony. Before his unexpected death in January, Bo volunteered tirelessly as director of the Ahern Foundation and as a member of the Plymouth VFW and Plymouth Elks.
 
The Cambridge Police North Cambridge Reporting Station, located at the Pro EMS headquarters at 31 Smith Place, will help to decrease the Department’s response times during shift changes. The new Reporting Station reflects the unique way in which all three forces — the Police and Fire Departments along with Pro EMS – work together to provide the City of Cambridge with the high standards of emergency services that the city expects and deserves, Cambridge Police Commissioner Robert C. Haas said at the dedication ceremony.
 
Bo was a strong representative of that unique partnership. While on the Cambridge Police Department, Bo took medical classes, and was dedicated to EMS, having worked with Pro EMS founder Larry Stone for years.  “Bo was always there for you, always took care of you,” said Cambridge Fire Chief Gerald Reardon at the ceremony. Chief Reardon also thanked all who came to the ceremony to show support to the Cambridge Police Department, the Ahern family, and to Pro EMS.
 
Among the family at the dedication ceremony were Bo’s three sons: Stephen and Christopher, both Cambridge police officers, and Robert, a State Police Officer. Stephen spoke on behalf of the family, and thanked everyone who came to the dedication to immortalize his father.  He called the new facility “fitting to immortalize my father’s legacy.”  Stephen also thanked Pro EMS, the Cambridge Police Commissioner, and Command Staff for this wonderful tribute to his father, especially right before Father’s Day.
 
The three Ahern brothers closed the ceremony with the unveiling of a plaque next to the doorway of the space that reads, “Cambridge Police, Robert “Bo” Ahern, North Cambridge Reporting Station.”
 

Cambridge Fire, Police and Pro EMS Provide High School Students With a Live Demonstration of the Perils of Drunk Driving

On Thursday morning, May 14th, Students against Drunk Driving (SADD) from North Cambridge’s Matignon High School hosted Cambridge Fire and Police Department along with Pro EMS for a live demonstration of the consequences of drunk driving.
 
With their prom that night, the students took a proactive approach to one of the most dangerous behaviors of high school students: driving while drinking. According to the National Highway Traffic Safety Administration, motor vehicle crashes remain the number one cause of death among youth ages 15-20.
 
Matignon_HS_Simulation 2Members of Matignon’s SADD demonstrated to their fellow students the dangers of what can happen when people drink and drive by showing two cars colliding by drivers under the influence of alcohol. Students were dressed in prom attire and seated in the cars as if they were just in the collision. Fake blood and goriness adorned the injured. Cambridge Fire apparatus along with Pro EMS ambulances came screaming in with their sirens along with several Cambridge Police vehicles. Cambridge firefighters and paramedics used the “jaws of life” to pry open the cars to free the trapped students. Fire personnel and Pro EMS paramedics and EMTs simulated life-saving maneuvers on the injured while taking them away on stretchers to the awaiting ambulances. The Cambridge Police arrested the “drunk driver” and removed him in front of the watching student body to the police wagon.
 
Vice Principal, Patricia D’Angelo said the school invites the Cambridge Fire and Police Departments to demonstrate to the students the real life consequences of teens driving while drinking. “I believe this brings home the dire outcomes of risky behavior in drunk driving”, said Ms. D’Angelo. “We are thrilled that the city of Cambridge provides our students with this realistic demonstration.”
 
SADD’s mission is to provide students with the best prevention tools possible to deal with the issues of underage drinking, other drug use, impaired driving and other destructive decisions.
 

Advancing Clinical Sophistication: The Introduction of Therapeutic Hypothermia Treatment

Advancing Clinical Sophistication: The Introduction of Therapeutic Hypothermia Treatment
 
A person whose heart suddenly stops beating effectively survives less than 5% of the time; if defibrillated within minutes, immediate survival rates rise to 30-45%. The majority of patients with return of spontaneous circulation (ROSC), however, do not ultimately fare well. Less than half of these patients survive to hospital discharge, and many have residual long-term neurological damage.
 
Inducing mild hypothermia after ROSC in certain patients has been shown to mitigate the extent of brain damage. In fact, it is the only post-cardiac arrest therapy demonstrated to increase survival rates.
 
A 2002 European study found that patients who received therapeutic hypothermia after ROSC were living independently and working at least part time more often than those who had not received the treatment (55% vs. 39%).
 
With a goal of improving cerebral function after a cardiac arrest, the American Heart Association (AHA) in 2005 recommended that therapeutic hypothermia be incorporated into post-resuscitation support. Many hospitals have since instituted relevant protocols.
 
Now, people who experience an out-of-hospital cardiac arrest in Cambridge, MA, will be able to receive this potentially lifesaving treatment before they even arrive at an emergency department.
 
Pro EMS plans to implement a therapeutic hypothermia protocol for adult patients with ROSC after out-of-hospital cardiac arrest.
 
Responding to a call, paramedics will now bring chemical ice packs and chilled intravenous fluids (IVF) to a patient’s bedside along with their equipment and medications.
 
If a patient remains unconscious, yet hemodynamically stable, after CPR and defibrillation, paramedics may induce mild hypothermia by placing ice packs adjacent to the patient’s neck, groin and axillae. Two liters of chilled IVF will also be infused.
 
To insure that a patient’s core temperature does not drop below the desired 34ºC, a nasopharyngeal esophageal monitor will be placed.
 
Once at the hospital, paralytic agents will be administered to prevent shivering and its associated increase in body temperature. While maintained on the hospital’s cooling protocol for a total of 24 hours, patients can undergo diagnostic testing and procedures, including angiography.
 
Prehospital induction of therapeutic hypothermia is an emerging treatment. Currently, only about 100 of the 24,000 EMS organizations in the United States have begun using it.
 
Future studies on prehospital therapeutic hypothermia will help clarify which patients will benefit most and what techniques are optimal.
 
Pro EMS already collects data on patient care as part of its continuous quality improvement. Data collected on this new protocol will help hone procedures so the best possible care can be delivered to patients.
 
The AHA recommends therapeutic hypothermia for adult patients with ROSC after out-of-hospital cardiac arrest and remaining unconscious when the initial heart rhythm was ventricular fibrillation (class IIa) or non-ventricular fibrillation (class IIb). Their recommendation is for patients to be cooled to 32-34ºC for 12-24 hours
 
Not all patients with ROSC should receive this treatment, however. Therapeutic hypothermia is not appropriate for cardiac arrest patients who initially presented as hypothermic, remain hypotensive after resuscitation, have had recent major surgery or trauma, or have had a prolonged cardiac arrest.
 
Other contraindications include patients who are pregnant, have a systemic infection, or were vegetative or comatose prior to the cardiac arrest.
 
While therapeutic hypothermia can be neuroprotective, it can also be associated with various complications. Thrombocytopenia, infections or arrhythmias may occur. Most complications, however, occur when a patient’s core temperature drops below 32-34ºC or when a patient remains hypothermic for longer than 24 hours.
 
In a cardiac arrest, brain cells are injured both from the initial injury, when deprived of oxygen and nutrients, as well as with reperfusion, when an increase of free radicals, stimulatory neurotransmitters and other factors causes cell death.
 
Mild hypothermia causes physiologic changes that counteract brain cell damage and death, including reducing cerebral metabolism, reducing excitatory amino acids, and restoring normal intracellular processes.
 
Annually, an estimated 250,000 to 450,000 people – men more often than women – experience sudden cardiac arrest.
 
The immediate cause of a sudden cardiac arrest is a disruption of the heart’s electrical conduction system or arrhythmia, such as ventricular fibrillation. Underlying causes vary; coronary artery disease or coronary heart disease is the most common.
 
Other cardiac causes of a cardiac arrest include myocardial infarction (MI), cardiomyopathy, valvular disease, congenital heart disease, or a primary heart rhythm abnormality, such as long QT syndrome.
 
Cardiac arrests also occur from non-cardiac conditions. Some of these include hypovolemia, hypoxemia, pulmonary embolism, sepsis, electrolyte abnormalities (such as hypokalemia or hyperkalemia), tension pneumothorax, intoxication, or severe physical stress to the body.
 
Before losing consciousness during an arrest, people may subjectively report a variety of symptoms, including feeling dizzy or lightheaded, or experiencing a racing heartbeat, chest pain or nausea.
 
In addition to its use with ROSC, therapeutic hypothermia is being formally studied for other conditions such as traumatic brain injury with elevated intracranial pressure in adults, acute stroke, traumatic spinal cord injury, and cardiac arrest in newborns due to perinatal asphyxia.
 
For more information:
 
American Heart Association Circulation 2008
Post-Cardiac Arrest Syndrome
http://circ.ahajournals.org/cgi/content/full/118/23/2452
 
American College of Emergency Physicians
Focus on: Therapeutic Hypothermia
http://www.acep.org/publications.aspx?id=26776
 
Medline Plus: Cardiac Arrest
http://www.nlm.nih.gov/medlineplus/cardiacarrest.html#cat3