Israeli Paramedic Efi Roe Discusses Multi-Casualty Situations at Center for MEDICS

An urgent call comes in: a suicide bomber detonated a bomb in a hotel dining room where 250 people are eating. In the ambulance en route, you put on a vest, helmet and gloves. Listening to the radio, you determine the best driving route and learn whether other dangers exist in the vicinity. You mentally review initial lifesaving procedures. Then you arrive at the scene.
Guest presenter paramedic Efi Roe covers this true event, which occurred in Israel in 2002, and discusses how paramedics can handle multi-casualty situations most effectively and efficiently. At the Center for MEDICS in Cambridge, MA, Roe lectures about open-air and bus bombings, drawing on more than 15 years of EMS experience in Israel as a paramedic and volunteer.
With the help of photographs and short videos, Roe explains the kinematics associated with a bomb blast. The heat, light and pressure waves, coupled with projectiles that may be attached to a bomb, can cause a range of critical injuries. For example, nails and screws on a bomb can cause penetrating wounds. Victims’ clothing and lungs may be burned from the heat, and extremities may be fractured or amputated. Vision and hearing losses also frequently occur.
The paramedics learn what they should do upon arriving at a scene. After finding out who the leader is, they should locate the zones for the different levels of casualties and follow any instructions they are given. Quickly surveying the injured, they should treat with emergency lifesaving measures until more personnel arrive. Urgent patients should be evacuated first and transported to designated hospitals.
Once the incident is over, paramedics should debrief to review their performance, as well as share emotional responses they experienced.
Roe’s presentation is part of a series of guest lectures at the Center for MEDICS designed to broaden paramedics’ training. While paramedics receive extensive training in their courses, guest presenters further add to their learning by sharing specific areas of expertise.
Reviewing an example of a multi-casualty incident allows Roe to illustrate how the EMS system in Israel operates. He believes it is crucial for paramedics to learn about emergency medical systems from other countries.
You need to open your mind to what other people are doing, Roe says, “If you think another group may be doing something better, you can give it a try.”
As Israel is much smaller than the U.S. – it’s roughly the size of Maryland – their EMS system consists of 11 dispatch zones. For every one employee, they have approximately 10 volunteers. In addition to routine patients and car accidents, terrorist actions are another element keeping ambulances and crews busy, not only in the major cities but throughout the country. Similar to U.S. personnel, Israeli employees and volunteers are trained as EMTs and paramedics.
Besides being a paramedic, Roe was a longtime EMT instructor in Israel. He acknowledges the importance of classroom learning, but maintains that some essential paramedic skills can only be learned while on the job. He began riding on ambulances as a 15-year-old volunteer in 1989. Details of the first major accident he assisted with – including the patient’s near-death state, amount of blood, and the vehicle wreckage – have stayed with Roe to this day.
“You can never learn how to stay cool unless you are in the field. You learn to deal with it, or you leave. You can’t panic,” Roe said.
He recognizes that treating badly injured individuals can take getting used to. “The first time you see someone seriously injured, it stays with you,” he says.
Learning how to manage and take care of people in an emergency situation is another skill that is honed through experience. Paramedics can learn how to interview patients in a course; however, Roe has found that each patient presents a unique challenge. A paramedic might initially interview patients similarly, but he or she will need to adjust further questions depending on factors such as the person’s medical condition, age, gender and language spoken.
As a job choice, Roe recommends being a paramedic. “I think it’s a great career,” he says, “It’s a way of life, helping people.” Yet he reiterates that paramedics aren’t always successful at saving lives. “As long as you’ve done the maximum, you need to be content with the results.”
He knows this firsthand; his father’s best friend died of a myocardial infarction after Roe and other workers tried unsuccessfully to save him. While Roe realized that he did everything to resuscitate the man, it didn’t make informing his father about the friend’s death any easier.
Roe received his paramedic training as part of his bachelor’s degree in EMS from Ben-Gurion University of the Negev. Other than university programs, paramedics in Israel can receive their training in two ways: through the army or through the national EMS. Both of these programs allow their graduates to complete a Bachelor of EMS degree in two years instead of three.
After Israel, Roe lived in Switzerland for three years before coming to the U.S. in 2008. With a master’s degree in business, he currently works in the medical field for Premier Research Group. He and his wife live in Andover, MA, and have two young sons.
Working in the emergency medical field runs in Roe’s family. His father worked as a nurse, and his sister is a paramedic volunteer. In addition, years ago before they were married, Roe convinced his wife to ride as a volunteer on the ambulance with him.
Roe looks forward to riding on an ambulance again to keep up his lifesaving skills, and plans to obtain his paramedic license in the U.S.
Being a paramedic is very gratifying, he says, “You can never help people enough.”

Merg’s Corner: Spring 2009 Newsletter Edition

Welcome once again to our newsletter. Our focus this month is on EMS education and our Pro EMS Center for MEDICS. Much has transpired over the past few months.
First and foremost, the Pro EMS Center for MEDICS has been formally accredited as an EMT Training Institution by the Massachusetts Department of Public Health Office of Emergency Medical Services. Following a significant application process and site visit, we received our accreditation to train EMTs at every level including Paramedic. Thanks to the hard work of many, we have cleared this hurdle.
Next on the agenda, national accreditation through the Committee on Accrediation of Educational Programs for the EMS Professions (CoAEMSP). I look forward to reporting on our continuing progress.
I want to thank Israeli Paramedic Efi Roe for his great contribution to this newsletter, and to our students and staff in his role as a Pro EMS Center for MEDICS Instructor. Efi brings great experience and a fresh perspective to all of us as we learn about EMS, tactics, and treatment modalities in Israel. Efi adds another element of international flavor to our Pro EMS Center for MEDICS, adding to Chris Kerley’s relationships with EMS providers in Ireland and South Africa. Again, my personal thanks to Efi for his work and dedication to EMS education.
Our recent addition of even more office space has allowed us to expand our Simulation Lab. We have now added a complete apartment setting in a room joined to our existing hospital setting by a new control room. The new control room and configuration will allow us to run two simulations simultaneously with full A/V, recording, and debriefing capabilities. To date, hundreds of providers from Fire Departments, ambulance services, and hospitals have been through our Sim Lab with tremendous experiences and results.
In the coming months, the Cambridge EMS system, Cambridge Fire Department and Pro EMS, will be adding a package of new equipment to provide some of the latest elements of clinical sophistication to manage difficult airways.
Airtraq ( will be deployed in vehicles to assist with difficult intubations. The King LTS-D ( will also be deployed as the new rescue airway throughout the system. Finally, the Rusch QuickTrach will be deployed to improve our capability to treat airways that are completely occluded (
As with all new devices and treatment modalities, we will be training all providers over the coming month and will begin tracking patient care outcomes and ultimate results through our Cambridge EMS CQI System.
Next on the agenda, therapeutic hypothermia after cardiac arrest. Stay tuned.
A busy couple of months that are made easier by the focus and dedication of all Cambridge EMS providers to continuously improve.
Thank you all.

Pro EMS Center For MEDICS Receives Accreditation from the Commonwealth of Massachusetts

Pro EMS Center for MEDICS receives accreditation from the Office of Emergency Medical Services (OEMS) under the Department of Health, the Commonwealth of Massachusetts, for Its State of the Art Training for Emergency Personnel
Cambridge, Mass., January 2009 – Professional Ambulance Service (Pro EMS), one of the premiere providers of emergency medical services in Massachusetts, is pleased to announce that the company’s Center for MEDICS has achieved accreditation from the state’s Office of Emergency Medical Services. According to OEMS, accreditation is a signature of training excellence achieved through strict compliance to the highest standards. OEMS mandates accreditation compliance for all initial Emergency Medical Technician (EMT) and Paramedic training programs conducted in the Commonwealth.
The Pro EMS Center For MEDICS simulation lab for emergency medical services is the first fully functioning one in the Northeast, and includes emergency room and apartment settings for its patient care scenarios, computer systems that record every step a trainee takes in treating these manikin patients, and a video screen for trainees and instructors to watch and evaluate the handling of each patient care scenario. EMTs, paramedics, emergency room doctors and nurses, police departments, and military personnel across Massachusetts come to the Center for MEDICS for the latest in emergency medical training. The state-of-the-art lab also boasts lifelike adult, child, and infant patient simulators that can speak and demonstrate symptoms of illness and trauma.
“The six month process for OEMS accreditation promotes continuous self analysis that leads to improved EMT and Paramedic Training Programs,” said Chris Kerley, Director of the Center for MEDICS. “We are thrilled to have completed and been awarded accreditation from the Commonwealth of Massachusetts.”
OEMS Accreditation enables EMT and Paramedic Training programs to help their graduates deliver the highest level of care to the public. Accreditation is both a status and a process. As a status, accreditation provides public notification that an institution or a program meets standards of quality set forth by an accrediting agency. As a process, it consists of ongoing evaluation, and frequent program improvement.
The Center for MEDICS trains staff from Professional Ambulance and the Cambridge Fire and Police Departments, as well as staff from other fire and police departments and doctors and nurses from area hospitals. The simulation center’s programs include training on emergency medical procedures that are difficult to practice anywhere else because the equipment is not widely available.
The Center for MEDICS’ mission is to assist EMS and other healthcare providers in their work to continuously improve through education and high fidelity patient simulation. For more information about the Center for MEDICS, visit
About Professional Ambulance Service
Professional Ambulance Service (Pro EMS) provides emergency medical services to the City of Cambridge, Massachusetts in conjunction with the Cambridge Fire, Police, Emergency Communications and Public Health Departments. Additionally, Pro EMS provides emergency medical services to Harvard University and the Massachusetts Institute of Technology. Professional Ambulance has proudly served the citizens, students, and visitors of Cambridge for over 35 years. For more information, visit

Learning Intubation with Airtraq at the Simulation Lab at Center for MEDICS

Paramedic trainees need to complete 10 successful endotracheal intubations (ETIs) in an operating room (OR) for their minimum skills requirement under the Office of Emergency Medical Services (OEMS) in Massachusetts.
Yet meeting this requirement is becoming more difficult. As operating rooms are increasingly using breathing devices other than endotracheal tubes (ETTs) to support patients, trainees may have fewer opportunities to obtain the certification points they need.
In addition to the lack of opportunity for practice is the technical difficulty associated with intubating in the field. A March 2009 JEMS article looked at the success of prehospital ETT placement. The studies reviewed showed the incidence of misplacement to be anywhere from 5 percent to 9 percent, and even higher.
Despite these factors, paramedics need to become competent at ETIs for lifesaving purposes. At the Pro EMS Center for MEDICS in Cambridge, MA, this need for more sophisticated training in intubation skills is being addressed.
Under Director Chris Kerley, the Airtraq laryngoscope is now being used at the Center for MEDICS as a practical learning tool for ETIs both in classes and in the Simulation Lab. Paramedic students are able to hone the skills they learn in the classroom on lifelike human manikins.
Not only do trainees learn the technique of intubation at the Center, but they are also able to practice ETIs in a wide variety of simulated settings.
“One thing we teach is to anticipate difficult airways. A difficult airway is something to anticipate, not experience,” Kerley says.
In the Simulation Lab, different cases and scenarios can be recreated, so that paramedics become familiar with, and more comfortable in, challenging situations.
Kerley is also a member of the state’s Airway Committee of the OEMS, which analyzes BLS and ALS airway skills in Massachusetts, and reviews data and new equipment.
“We want to embrace new ideas and analyze the current data out there so that we are taking an evidence-based approach to airway management,” he says.
In addition to using Airtraq in their training center, Pro EMS is training their staff to use this laryngoscope in the field. All paramedics in the Cambridge EMS system – including Pro EMS and the Cambridge Fire Department – will soon use the Airtraq for ETIs.
Kerley believes that Pro EMS is one of the first services on the East Coast to use the Airtraq. Describing the new laryngoscope, he says,
“It’s the first disposable device of its kind on the market. That’s why we like it. You just use it once, and then dispose of it.” He cites its lower cost as an added benefit.
The Cambridge EMS system performs about 120 ETIs a year; numbers for the state of Massachusetts have not been available in the past. As part of its new regulatory requirements, however, the state will begin collecting and analyzing this data, Kerley says.
Becoming adept at performing ETIs takes practice. While learning to place an ETT in a controlled, operating room environment with an unconscious patient on a waist-high stretcher is helpful, it does not reflect the reality of placing an ETT in an emergency setting.
Many conditions make intubating in the field challenging for paramedics. Patients are often in positions that make airway access difficult; they may be lying on the ground or cramped in a tight space. Tubes that are placed can become dislodged while moving a patient onto a stretcher or into the ambulance. Intubating in a moving ambulance presents additional challenges.
Patients may need to be intubated for a variety of reasons, including cardiac or respiratory arrest. Patients who cannot protect their airway, for example, or those who have lost their gag reflex due to a stroke, will need an ETT as well.
Improperly performed intubations can lead to a host of complications. If the ETT enters the esophagus, the patient will be inadequately ventilated. An endobronchial intubation could result in barotrauma to the intubated lung. Laryngeal and other soft tissue swelling or trauma may also occur.
In addition to reducing cross-contamination, the Airtraq has other benefits. Using a conventional laryngoscope often requires paramedics to move a patient’s head and hyperextend the neck – a maneuver that can be dangerous when the patient has an unstable cervical spine. In contrast, the Airtraq requires minimal repositioning of the head. It can also be used to intubate patients who are in a sitting position.
Click Here for More information about Airtraq.