My articles

September 11, 2001

September 11, 2001 (Photo credit: wallyg)

Here are some of my published articles reprinted below:

Dealing with the Psychological Aftermath of Terrorism

I HEARD THE CALL FOR HELP OVER THE RADIO, TWO-Six David calling central,” the radio chirped.

The dispatcher answered, “Proceed Two-Six David.”

“We have 14 children and two adults involved in a school bus accident …. I need three more BLS and a supervisor, central; staging is located at East Tremont and Morris Park Avenue.”

The short pause of radio silence was interrupted, “Conditions 55, respond to the 10-32, Ground Transport Incident.”

I acknowledged the assignment, “10-4, Conditions 55 responding.”

I responded as a supervisor to this motor vehicle accident to oversee Medical Branch Operations as dispatch began assigning units ….

“Two-Six Boy, Twenty Adam, I need you ….”

On arrival, I found a small school bus involved in an accident with a van. The bus had minor front-end damage. The emergency medical technicians (EMTs) requesting backup were triaging 14 children as additional units were arriving. The children had minor injuries requiring only evaluation at the hospital. The biggest obstacle seemed to be packaging and transporting the children.

While tracking the patients, I was recording each patient’s name, age, triage status, and hospital destination. EMT William Heilman began reading off the information on his patients: Their birthdays in particular stood out-August 15, 2001; September 7, 2001; September 11, 2001. I quickly realized that these children were all five years old and were born right around or on September 11, 2001. Events during this school bus collision reminded me of just how real an issue post-traumatic stress is.

I thought to myself, How will being born around September 11, 2001, affect these children? A happy occasion of childbirth for their mothers was overshadowed by terrorism. I wondered how this event will affect these kids. I thought I alone was thinking about the children born on September 11, 2001.

But, when I made a passing comment to Heilman, he looked up with glassy eyes and echoed my concern, “That’s messed up, Lou; all these kids were born around 9/11.” Each of the EMTs in earshot looked up with the same distressed look. I then became aware that the skin on my arms had tightened and gooseflesh had formed. In an instant, September 11 was back and a very vivid memory for all of us. I realized I was not alone; the event I thought I had put behind me was still in all our minds. What seemed like a minor motor vehicle accident and a routine response evoked deep-seated emotions in EMS providers on the scene-even five years after 9/11!


While working as a paramedic in the Bronx for many years, I had always thought that critical incident stress was a fallacy, something experienced by other people. I learned first-hand in the months following 9/11 how events can work their way into our minds and overwhelm us.

Fire Department of New York Chief Daniel Nigro spoke during the EMS Week 2002 Memorial Ceremony held to commemorate the loss of the EMTs and paramedics on 9/11. He spoke inside St. Paul’s Chapel, located next to the World Trade Center recovery site. He began his speech, “Here we stand today as the Trade Center casts a shadow over all of us.” As I thought to myself, “The Trade Center is gone; what is he saying?” he continued, “The World Trade Center will always cast a shadow over our minds for the rest of our lives; there is no getting over this one.” His words were the truest I have heard relating to the World Trade Center attack and post-traumatic stress.

Prior to the 9/11 attacks, the idea of emergency responders’ needing help was commonly perceived as a sign of weakness. The concept of “seeking help” by going to counseling has been made acceptable because the effects of 9/11 were so widespread within the fire service, EMS, law enforcement, and the general public.

Critical incident stress debriefing (CISD) counseling is now a more accepted practice. I have learned how to recognize the signs of post-traumatic stress disorder (PTSD) in myself and in my coworkers and to deal with critical incident stress in a healthful manner. I think we can help each other by sharing our experiences and supporting others through tough times caused by stress resulting from terrorism and other factors in our line of work.

During our careers, we see life at the absolute worst times. We like to think we are “used to it” and take it all in stride. How do firefighters, EMTs, and paramedics deal with the psychological aftermath of critical incidents? Some traumatic incidences are not easy to put aside. PTSD is a reality in emergency services work. Even after you have forgotten an incident, one sight, smell, sound, or thought can bring you back to the moment and stimulate a vivid memory of a traumatic incident. We each react differently to these stimuli.


What can we do to deal with these reactions and prevent our job from affecting our personal lives? “Post-traumatic stress disorder is the development of characteristic symptoms following a psychologically stressful event outside of the normal range of human experience …. The characteristic symptoms involve re-experiencing the traumatic event, avoidance of stimuli associated with the event or numbing of responsiveness, and increased arousal.”1

Stress reactions are frequently caused by “triggers” that remind us of incidents we found traumatic. Triggers are emotional trip wires that evoke memories of traumatic incidents. They can be sights, sounds, smells, and feelings and are timeless, capable of making memories years later feel as if they occurred yesterday. Traumatic events like 9/11 create large multicasualty incidents; mark the loss of our illusion of safety from attack; and take the lives of firefighters, EMTs, and paramedics. Incidents that create PTSD can be large critical incidents or small individual incidents. Examples of large-scale incidents that may cause PTSD include mass fatalities, multiple burn patients, incidents where a possibility of a rescuer’s death occurs or is possible, and terrorist incidents.

In a study completed before 9/11, the rate of PTSD in American and Canadian firefighters was found to be 22 percent and 17 percent, respectively.2 Schlenger, et al, found the PTSD level in New York civilians following the 9/11 attack to be 11.2 percent.3 The prevalence of PTSD for civilians after terrorist attacks varies from 12 percent4 to 36.8 percent.5 From these statistics, we can see that firefighters have had an abnormally high incidence of PTSD even prior to the terrorist attacks. In PTSD, an event in the present, perhaps unnoticed at the time, triggers a memory from the past, leading to feelings similar to those experienced in the first event. For example, an individual blown under a bus by the “black cloud” of debris on 9/11 could some time later pass a smokestack and, without being consciously aware of the reason, begin to experience anxiety and emotional feelings resulting from the “black cloud” event. Responding through a particular neighborhood or hearing a familiar song may trigger the memory of a coworker lost in the line of duty. Triggers differ for each person. The common experience of the EMS workers’ recognizing that the children in the motor vehicle accident above were born around 9/11 is one example of how everyday stimuli can provoke a reaction in responders with PTSD.


We who need to perform in crises have developed coping strategies so we can perform to the best of our ability and survive emotionally. We have learned to maximize the use of our intellect in crisis and to distance ourselves emotionally. We do this to protect ourselves and our patients; we can’t help them if we aren’t okay ourselves. We may convince ourselves that “I can handle this; I have seen this stuff before.” The difference with incidents such as the attacks on the World Trade Center and the Pentagon and Hurricane Katrina is that the consequences and the death toll are increased dramatically.

Traumatic experiences heighten our feelings; each moment operating at a traumatic incident is recorded by our mind. While we work and suppress our feelings, our mind records the sights, sounds, and visual images. On a deeper level, we also do not realize how working in a truly unsafe environment with buildings collapsing, terrorist attacks, or severe hazards makes us feel unsafe. Combining the sights, smells, sounds, and feelings with the hazardous environment makes an event stand out. Somehow, we tuck in our feelings, button up our turnout coats, step forward, and get the job done. After the event is over, the psychological effects may surface.


What are the symptoms of stress we can watch for to indicate that stress is building? Repeated exposure to stressful incidents or a catastrophic event like 9/11 can overwhelm and surpass our protection. It is not pathology or weakness but our humanity and compassion that make it possible. Traumatic events are timeless. When they are triggered, we can feel years later as if they had just occurred-with accompanying vivid memories and strong feelings.

A person?s reaction to stress is individual. It is affected by previous exposure to the stressor, one?s perception of the event, general life experiences, and personal coping skills. Triggers vary as well. Some responders feel affected following a pediatric cardiac arrest. A bad burn patient and the smell of smoke may remind you of a firefighter who died in the line of duty. In the years since 9/11, many have had their memories triggered by watching a newsreel or documentary shows. Some remember the collapse of the World Trade Center when an elevated train passes overhead. The thundering noise of the train reminds them of shuddering steel as the World Trade Center collapsed. Even a fun activity, a familiar song, or bagpipes may make you remember a coworker who died in the line of duty.

I noticed that details I never even expected to affect me did-the smell of gypsum board and loud noises, for example. I couldn’t sleep at night. The common trigger for responders to the World Trade Center is perhaps the clear blue sky that was the ironic background for the horror that was 9/11. To this day, firefighters mourn the loss of 343 brother firefighters and refer to 9/11 simply as “that day.”

We can deal with these triggers by recognizing what situations, sights, smells, or sounds may evoke a reaction within us. By learning the signs and symptoms of PTSD and the strategies for dealing with it, we can become aware of a reaction within ourselves or our coworkers and deal with the feelings effectively.

People with PTSD tend to be edgy, irritable, nervously watchful, and easily startled.6 PTSD may also manifest itself as grief, fatigue, and anger. You may also observe signs such as short-term memory loss resulting in repeating questions, losing vehicle keys, or trouble concentrating while reading. Short-tempered behavior may result in your or a coworker’s frequently “losing it” when stressed out. You might be hypervigilant about hazards in the workplace and your safety and find it difficult to concentrate. You may become detached and withdrawn or lose interest in activities you once found enjoyable. Some may abuse medications or alcohol and engage in risky behavior such as dangerous driving. Survivor’s guilt may affect you when you think of those close to you who were lost. You might feel guilty that you survived while others did not. You might find that you are angry, bitter, or perhaps numb, unaffected by emotion. Physical symptoms include headaches, anxiety, insomnia, and an increase in diseases caused by stress. “Prolonged stress can have a negative impact on your health. Prolonged grief, anger, or even boredom can undermine the body’s physiological systems, most notably the integrity of the immune system.” (6)


The problem with PTSD is that you are not able to sense that you are “in need” of help. PTSD creeps up on you slowly. How do you help a coworker suffering from stress without intruding? Pointing a fellow firefighter to help should be done in steps. First, reach out to coworkers with the simple line, “You look a little down; is everything okay?” Throwing a “lifeline” to coworkers or friends makes them realize that someone cares. Our coworker’s validation that we are important and someone cares may be enough to start the recovery process. When trying to help a coworker, listen to what the person has to say, understand his feelings, and express empathy. Sharing your personal experiences may also help the coworker realize he is not alone. In trying to help a coworker, you are trying to encourage him to seek help, not to force help on him.

People may deny there is a problem. Avoidance is common with PTSD. By sharing your experiences and the actions you have taken to help yourself, you may be able to motivate your coworkers to get help and get back on track. When a “bad job” is bothering everybody in the station, a roundtable discussion helps members realize they all feel the same. A senior member of the company, a peer counselor, or an officer leads the discussion. During a roundtable discussion, we can discuss the call and how it was handled. Important lessons for future responses may be realized. During discussions of bad calls, it is crucial not to place blame. Venting thoughts and reviewing the chronology may be helpful in evaluating all aspects of the response and how performance can be improved next time.


The alternatives for helping a stressed-out coworker who won’t seek help and whose actions are affecting his health include getting others to come forward with the same observation to that person and peer counseling. You can invite a CISD peer support member to the station or mention your observations to your officer. Officers have the ability to talk to employees and give the benefit of their experience and perspective. Above all, coworkers talking about a specific suicide plan or exhibiting suicidal tendencies should be immediately brought to an emergency department that provides psychiatric care.

The days of looking at PTSD counseling as a sign of weakness are over. If we have PTSD, it is important that we get over our barriers and realize we’re human. We need to take care of ourselves to be there for others. We cannot be on the inside of a problem and view the solution as can a person who is distanced from the problem. By recognizing these signs and symptoms within our coworkers, we can help one another through a tough time.


Strategies for protecting yourself from stress include diversifying your interests, pursuing a hobby, eating a balanced diet, and getting regular exercise. We often bring stress on ourselves by working overtime, volunteering, and inadvertently overstimulating ourselves. It is important to find personal and family time to help strike a balanced and healthful lifestyle. By nature, we give to others and deny ourselves. By recognizing the signs of stress, we can realize when we need to take “a personal time out.” Emergency service work compels us to work long hours and holidays and push our limits. However, we have an obligation to ourselves to take the necessary actions to recover when we are stressed out and ineffective.

Five days, five years, 10 years-as noted earlier-trauma is timeless. If you or someone you know is affected by trauma, it is important to find help. To seek treatment, you can reach out to peer counselors and department employee assistance programs. Insurance companies and the American Academy of Experts in Traumatic Stress are two additional resources that can help you find an experienced clinician.

Thanks to Randy Bleiwas, CSW, MA, C.A.S.A.C., CHT, post-traumatic stress counselor, for his assistance with this article.


1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Washington, D.C., 1987.

2. Beaton, R, S Murphy, C Johnson, K Pike. “Exposure to Traumatic Incidents and Prevalence of Posttraumatic Stress Symptomology in Urban Firefighters in Two Countries.” Journal of Occupational Health Psychology; 1999, 4:2, 131-141.

3. Galea, S, H Resnick, J Ahern, J Gold, M Bucuvalas, D Kilapatrick, et al., “Post-traumatic stress disorder in New York City after the September 11 Terrorist Attacks,” Am J. Epidemiol; 2003, 158: 514-524.

4. Shalev, A Y, and S Freedman, “PTSD Following Terrorist Attacks: A Prospective Evaluation,” Am. J. Psychiatry; 2005, 162: 1188-1191.

5. Schlenger, W E, J M Caddell, B K Ebert, K M Jordan, D Wilson, et al., “Psychological Reactions to Terrorist Attacks: Findings from the National Study of Americans’ Reactions to September 11,” JAMA; 2002, 288:1188-1191.

6. Seaward, Brian Luke, PhD. Managing Stress. (Sudbury, Mass.: Jones and Bartlett Publishers, 2000.)

Pediatric Seizures: Routine or Danger in Disguise?

Fire Engineering – Pediatric Seizures: Routine or Danger in Disguise?
At 2:24 p.m. on a Sunday afternoon, paramedics and an engine company are dispatched to a “child not breathing.” Dispatch reports a hysterical female caller reporting her seven-year-old son unresponsive and possibly not breathing. Arriving responders find an approximately seven-year-old boy lying on the living room couch. The patient’s head and shoulders are draped over the arm rest, and he barely notices the firefighters entering the room despite the noise of their equipment and radios. The patient has a vacant stare, is very pale and diaphoretic, and barely responds to painful stimuli.

Paramedic Miguel: What happened?
Mother: He’d been feeling ill since 11:00 this morning. All of a sudden, he had a seizure. It scared the life out of me!
Miguel: Does he have a history of seizures?
Mother: No, never. He has mild asthma, but no other problems.

The crew places the patient on oxygen via nonrebreather mask, obtains a set of vitals, and places ECG electrodes. With a little stimulation, the patient’s respirations increase from 10 to 16.

Bob from the CFR engine company reports the vitals: “BP 150/100, 124 and regular on the pulse, 16 and shallow on the resps; he responds to stimuli but is disoriented, skin warm and moist, pulse ox is 94 percent.” Bob puts a stethoscope to the boy’s chest, “clear and shallow bilaterally.”

Miguel (to mother): What did the seizure look like?
Mother: His head went back, and his arms were shaking up and down. (She demonstrated how her son’s arms were positioned during the seizure. Her reenactment resembled classic decorticate posturing, with arms flexed and fists rotated inward.)
Chris (Miguel’s partner): How long did the seizure last?
Mother: About three minutes.
Chris: What was he doing before he got sick?
Mother: He was playing video games all morning. He stopped at 11 when he didn’t feel well and took a nap.
Chris: Has he ever had seizures before or felt ill while playing video games?
Mother: No, he plays those games all the time.
Miguel (to Chris): What could cause a first-time seizure in a seven-year-old with no neuro history?
Chris: Maybe trauma or an overdose.
Chris (to mother): Could the boy possibly have taken any medications or poisons?
Mother: No, I was watching him all morning, and he took his nap right here on the couch.
Chris: Does he take any medications, ma’am?
Mother: An inhaler for his asthma; I think it’s called albuterol.
Chris: Is he treated for any other medical problems?
Mother: No.
Chris: Any allergies to medications?
Mother: No.
Chris: Any recent injuries or falls?
Mother: No.

As Chris begins to gather equipment to start an IV, Miguel discusses the differentials for a first-time seizure in a healthy child. Thinking back, Miguel reviews the acronym OPQRST—Onset, Pain duration (if pain is present), Quality, Radiation, Severity, and Time—to ensure they have obtained a complete history of the present illness (HPI), and pertinent positives for seizures.

Considering past medical history (PMH), Miguel reviews the mnemonic device SAMPLE—Signs and symptoms, Allergies, Medications, Past medical problems, Last oral intake, and Events leading up to the seizure.

Miguel (to mother): What was the last thing he ate or drank?
Mother: He had breakfast at about 7 a.m., but he only ate toast.
Miguel (thinking of past medical problems): Ma’am, when was he in the hospital last?
Mother: Three weeks ago for nasal polyps.
Miguel: Did he stay overnight or just go to the emergency room?
Mother: He went in for surgery to remove some nasal polyps and ended up staying there for five days.
Miguel: Do you have any of the discharge paperwork or instructions?
Mother: Yes. (She digs the paperwork out of a pile in the kitchen table.). Here it is.
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Miguel scans the discharge paperwork given to patients following surgery, information about nasal polyps and a prescription for Augmentin® (amoxicillin/clavulanate).

Miguel (to mother): Did you fill this prescription?
Mother: No, I don’t have insurance, and they wanted $130 for those pills.
Miguel: Ma’am, Augmentin® is an antibiotic, which prevents infection. Your son may have an infection from his surgery.
Miguel: Thank you, Ma’am.
Miguel (calling out from the kitchen): Chris, Lieutenant, have everybody wear masks and gloves; he may have encephalitis or meningitis.
Chris: Meningitis? Where did you pull that one out of, Miguel?
Miguel: He was admitted for nasal polyps and never received antibiotics on discharge. It could be an infection, encephalitis, sepsis, or meningitis.
Lieutenant: Good job. Gloves and masks, boys, and let’s bag the gear coming out for decon at the station.

Chris and Miguel place an isolation mask over their patient’s nonrebreather, don their N-95 masks, and start an IV of normal saline.

Chris (performing a finger stick blood glucose): His sugar is 48; let’s get rolling. We can give him some dextrose during transport.

When they sit the child upright for transport, he vomits yellow bile. En route to the hospital, the patient receives 0.5 grams per kilogram of 25 percent dextrose IV; no improvement. When the D25 is repeated, there is no change in the child’s mental status. Chris asks the child if he has any neck pain; the boy shakes his head weakly, indicating no. Palpation of the posterior neck and flexing of the legs do not provoke pain; pain would indicate meningeal irritation from meningitis.

On arrival at the hospital, Miguel gives a presentation, including HPI, pertinent positives, PMH, and vitals. The Emergency Department staff places the patient on meningitis isolation precautions. After a 10-day stay in the hospital on intravenous antibiotics, the boy was discharged neurologically intact.


Many, if not most, of our responses to calls for seizures involve patients with diagnosed epilepsy. EMS providers tend to regard seizure calls as routine responses and rely on standard diagnoses of epilepsy or febrile seizures. This response, involving a lethargic seven-year-old boy following a first-time generalized seizure, is a significant incident that is sure to raise an eyebrow of even the most experienced fire department responders.

Begin pediatric patient care with a “doorway” assessment. When accessing a scene involving a pediatric patient, visualize the child to determine if he is conscious and alert or lethargic and apathetic. Children who fail to respond to the arrival of the fire department very likely have a serious pathology altering their mental status.


The Pediatric Assessment Triangle (PAT) (Figure 1) is a standardized assessment tool for initial evaluation of the pediatric patient. The PAT consists of assessing the child’s appearance, breathing, and circulation. Evaluating appearance includes assessing the patient’s muscle tone, mental status, interaction with the caregiver, consolability, gaze, and speech. A quiet, lethargic child is a patient in need of immediate resuscitation. Evaluating breathing involves assessing the patency of airway, oxygenation, and ventilation. Assess airway by looking at body position, chest excursion, respiratory rate and effort, and lung sounds. Sniffing position and tripod position are hallmark signs of respiratory distress. Grunting and paradoxical respirations are ominous signs of respiratory failure. Assessment of circulation evaluates the adequacy of cardiac output and perfusion to vital organs. To assess circulation in a pediatric patient, observe the skin color, end organ perfusion, and level of consciousness. Mottled skin, restlessness, and oliguria (low urine output) are signs of circulatory failure.

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Using the PAT to gain an initial impression of the pediatric patient’s condition gives prehospital providers a tool for rapidly sizing up a child’s potential life threats.

Once threats to life have been identified and treated, we can obtain a thorough HPI. A systematic HPI and physical are the keys to diagnosing the presenting medical problem and determining the correct course of treatment. Systematic collection of patient information leads to quality care. Most presenting problems are easy to determine and are accepted at face value. Thorough prehospital care providers consider the obvious diagnosis and then dig deeper to search for and consider other possible diagnoses. The most interesting diagnoses, like this case of meningitis in a seven-year-old with a seizure, are made with a careful history and consideration of possible alternative diagnoses. Without a thorough history and considering the possible causes of the child’s seizure, the firefighters, paramedics, and hospital staff would have been unnecessarily exposed to meningitis and would likely have required antibiotic prophylaxis. Depending on the infectious agent found, the EMS equipment could well have cross-infected other patients on subsequent calls or the crew members themselves. The case in this article was diagnosed using the information about the patient’s recent surgery, elicited from the HPI, coupled with knowledge about causes of altered mental status.


The differential diagnosis of altered mental status (AMS) in a patient can be facilitated by using SAMPLE for the PMH and the acronym AEIOU-TIPPS (Table 1) to review the causes of AMS/seizures.1 Systematic assessment, HPI, and PMH are essential to accurately and rapidly diagnose your patients. AEIOU-TIPPS is yet another tool to help you systematically consider causes of AMS/seizures in addition to the first impression you form on-scene. In the case presented, consideration of all causes of AMS resulted in better patient care and increased safety for responders and hospital staff.

Memorize AEIOU-TIPPS or, more practically, laminate and mount it on your clipboard or med bag for quick reference on-scene.


Fire EMS providers may make a presumptive diagnosis of febrile seizure in children with a history of illness and rapid increase in fever. Febrile seizures occur in two to five percent of children under six years of age; most occur between 18 months and six years of age. In practice, seizures should not be diagnosed as febrile until other causes can be excluded,2 including uremia, infection, brain or spinal cord lesions, and electrolyte imbalances.

In this case, providers presented with a seven-year-old male status post seizure, fever was absent, and the patient was more than six years old, making a diagnosis of febrile seizure unlikely. Febrile seizure may be a dangerous assumption in the prehospital pediatric patient, especially in the presence of AMS. Consider all possible causes of seizure before making a definitive diagnosis of febrile seizure.


In this case, the recent history of nasal surgery and lack of follow-through with antibiotic coverage were key elements alerting firefighters to the possibility of meningitis. Meningitis is an illness involving inflammation of the tissues covering the brain and spinal cord. Viral or “aseptic” meningitis is the most commonly seen and is caused by one of several types of viral infections. In the United States, annual hospitalizations for viral meningitis range from 25,000 to 50,000 cases.3 Bacterial meningitis is far more severe than viral forms and can lead to coma and death following a rapid onset. One such bacterial form is staphylococcal meningitis, which can occur following a penetrating head wound or neurosurgical procedures.

Meningitis occurs when an infection breaches the natural protection of the central nervous system. The blood supply of the meninges lies adjacent to the venous system of the nasopharynx, mastoid process, and middle ear. When an organism eludes the immune system and enters the cerebral circulation through one of these openings, infection spreads quickly through the subarrachnoid space.4 Meningitis can occur with or without neck pain. Even when present, neck pain may be difficult to assess in young children or in patients with AMS. Nuchal rigidity, or stiffness of the neck with movement, may not be present in younger children with meningitis. Verbal children with meningitis often complain of headache and neck pain. Symptoms often are accompanied by vomiting in the younger pediatric population.

Meningitis can have a gradual or sudden onset. Gradual onset meningitis is preceded by several days of lethargy, fever, GI and respiratory symptoms, and increased irritability. Meningitis with rapid onset often will present with shock, petechiae (small pinpoint red spots on the skin), purpuric spots (large purple or black spots), tendencies toward excessive bleeding, and reduced levels of consciousness. Without treatment, death frequently occurs within 24 hours.

Physical symptoms of bacterial meningitis depend on the age of the patient, underlying medical conditions, and the causative organism. A respiratory illness or sore throat often precedes the more characteristic symptoms of fever, headache, stiff neck, and vomiting. Kernig’s5 and Brudzinski’s 6 signs appear in about half of patients. In children, the presence of nuchal rigidity is a more reliable indicator of meningeal irritation than Kernig’s or Brudzinski’s sign.To detect nuchal rigidity in older children, ask them to sit upright and touch their chin to their chests. Persuade younger children to touch their chin to their chest by following a small toy or light beam.7 Although adults may become desperately ill within 24 hours, children often progress more quickly. Seizures occur in about 30 percent of patients. In patients two years of age and older, changes in consciousness progress through irritability, confusion, drowsiness, stupor, and coma.8


Management of a patient with meningitis begins with proper personal protective equipment (PPE) (gloves, mask and gown, or BBP ensemble). In the management of a critical pediatric patient with suspected meningitis, attention to the PAT and life-saving interventions such as airway maintenance, suctioning, oxygenation, and fluid resuscitation are essential. In the AMS child, administration of dextrose (0.5 grams per kilogram) will help establish normal glucose levels. In the event of seizure activity, administer anticonvulsants (such as diazepam or midazolam) to stop seizure activity. Monitoring the airway and ventilation, especially following benzodiazepine administration, is critically important. Capnography is an excellent early warning tool for hypoventilation in any patient.

• • •

Considering the progression of events, it would seem that a call for new onset seizures in any patient should be considered a serious call. This article reviewed the importance that a detailed history of present illness and a thorough past medical history can have in improving accuracy of the diagnosis. There is clear danger not only to the patient but potentially to the crew, transport personnel, and hospital staff from incorrectly assuming a patient has had a febrile seizure. Proper PPE for seizure patients with continued AMS is crucial for protecting firefighters, family members, the public, and other health care providers. Febrile seizures are isolated seizures that typically occur in children between 18 months and six years of age who have a fever. Febrile seizures can only be diagnosed after ruling out all other causes, including infection, which cannot be definitively done in the prehospital environment. Use of the AEIOU-TIPPS acronym is helpful for systematically considering all possible causes of AMS. By being diligent in detecting life threats, eliciting a thorough history, and considering all the causes, we can best help our patients and better protect ourselves. The discerning and outstanding prehospital provider will always think, “It looks like this is the problem; what else should I consider?”


1. Caroline, Nancy. Emergency Care in the Streets (Sudbury, Mass.: Jones and Bartlett Publishers, 2008). Book 3: 41-42.

2. Merck Manuals online Library. “Febrile Seizures.”, accessed 08/13/2008.

3. Centers for Disease Control and Prevention. “Viral (“Aseptic”) Meningitis FAQs”; accessed on 08/13/2008.

4. Aehlert, Barbara. Comprehensive Pediatric Emergency Care. . (St. Louis, Mo.: Elsevier/Mosby, 2005).

5. Kernig’s sign: An indication of meningitis in which complete extension of the leg at the knee is impossible when the individual lies on his back and flexes his thigh at a right angle to the axis of the trunk. The American Heritage® Medical Dictionary, © 2007, 2004, Houghton Mifflin Company, online.

6. Brudzinski’s sign: A physical sign of meningitis, evoked by passive flexion of one leg resulting in a similar movement on the opposite side, or if the neck is passively flexed, flexion occurring in the legs. McGraw-Hill Concise Dictionary of Modern Medicine, © 2002, online.

7. Bates’ Guide to Physical Examination – 9th edition. Bickley, Lynn S. and Peter G. Szilagyi. (Lipincott Williams & Wilkens, 2007). 751.

8. Merck Manuals online Library. “Acute Bacterial Meningitis.”; accessed on 08/13/2008.

BLS CPAP: Improving Breathing in the Prehospital Setting

Fire Engineering – BLS CPAP: Improving Breathing in the Prehospital Setting
The clock reads 1:45 a.m. as Carl opens his eyes with the uneasy feeling of not being able to catch his breath. Once awake, he realizes he also has tightness in his chest. He begins to cough up pink-tinged white phlegm.

Carl’s wife (awakens): “Carl, you are very pale and sweaty. Are you okay?”

Carl (grunting): “I … I … don’t … know.”

Carl’s wife: “I told you not to eat all the food at the wedding last night.”

Carl (stammering): “How often … does … your … niece get married, dear? My chest really hurts, honey.”

Carl’s wife calls 911.

At the Station

At 1:53 a.m., the tones sound.

“Ambulance 1, Engine 14, a Delta response to 55 Dutch Hills Lane for a 65-year-old male, conscious and alert with severe respiratory distress.”

Ambulance 1 acknowledges, responding.

As the experienced crew of this rural ambulance responds to the call location, personnel begin reviewing the dispatch information. Kevin and Don know several things. First, at this time of night, this is probably a real call. Second, it is straight out 45 minutes to the nearest hospital. Thankfully, the valley pass will not be icy tonight. As Ambulance 1 glides over the suburban roadway moving closer to the call, First Responder Engine Company 14 arrives by Carl’s side with oxygen and an automated external defibrillator (AED).

Engine 14: “Engine 14, advise Ambulance 1 we have a 65-year-old male with acute shortness of breath, blood pressure (BP) 160/110, pulse 124, respirations 30, O2 sat 88 percent on a nonrebreather. Ambulance 1, read direct.”

Kevin: “Ambulance 1, thanks for the update; we are eight minutes out.”


On arrival, the crew of Ambulance 1 finds Carl in a tripod position leaning on the edge of his bed, pale in color, his undershirt dripping with sweat. The engine company has administered oxygen by nonrebreather mask at 12 liters per minute and is assisting Carl with self-administration of a second tablet of his prescribed nitroglycerin.

Kevin: “Good morning, Lieutenant, what do you have?”

Lieutenant: “Carl is a 65-year-old male complaining of shortness of breath for about 15 minutes. He is coughing up pink-tinged sputum and is also complaining of tightness in the chest.

Kevin: “Thanks, Lieu.”

The senior partner then asks Carl’s wife the history of present illness and past medical history.

Partner: “How long has he been short of breath? What brought on this episode? Has this ever happened before? Does he sleep flat or with his head elevated on pillows?”

Meanwhile, Don speaks to Carl.

Don: “Anything else bothering you besides the trouble breathing?”

Carl: “Heavy.” (He rubs his sternal area.)

Don: “Have you ever experienced pain like this before?”

Carl’s wife (in annoyed tone): “Yes. He’s had heart failure with fluid in his lungs three times and still doesn’t learn to eat right.”

Don checks the fire department pulse oximeter attached to Carl, which now reads 86 percent.

Firefighter (as he finishes taking vitals): “He has a BP of 170/110, pulse 130, lungs are filled with rales halfway up.”

Kevin: “He has a history of type II diabetes, high BP, and had a stent placed for unstable angina a year ago. He takes Diabinese®, nitro as needed, and hydrochlorothiazide. Shortness of breath woke him out of his sleep 20 minutes ago; breathing is worse when he lies down, chest pain mid-sternal tightness. Sounds like pulmonary edema.”

Don: “Let’s call for advanced life support (ALS).”

Kevin (calling dispatch): “Ambulance 1, we have a 65-year-old male with pulmonary edema; requesting you advise on availability of ALS.”

Dispatch: “Ambulance 1, I have been checking; no ALS available at this time.”

Kevin and Don package Carl and carry him out to the ambulance with the first responder engine company.

In the ambulance, Carl’s vital signs are reassessed: BP is 182/118, pulse is 130, respirations are 32, with intercostal retractions.

Don: “He is working harder to breathe. I think we should call Medical Control for CPAP.”

Kevin agrees.

Kevin contacts Medical Control as Don prepares the CPAP device.

Kevin: “Ambulance 1 to Valley Medical Control.”

Valley: “Valley Hospital, go ahead 1.”

Kevin: “We have a 65-year-old male who awakened with shortness of breath 30 minutes ago. The patient has a productive cough of white, blood-tinged sputum and substernal chest tightness, nonradiating. History of hypertension, diabetes, and a stent one year ago. The patient has JVD, rales all the way up on both sides, and 2+ pedal edema to the pretibial area. We are requesting permission to administer CPAP.”

Valley: “Go ahead, Ambulance 1; sounds like pulmonary edema. Administer CPAP, and assist the patient in taking one nitro every five minutes as long as the blood pressure is above 130 systolic. Monitor respiratory effort, and assist ventilations if necessary. What is your ETA?”

Kevin: “We are 45 minutes out.”

Valley: “We will be expecting you, Ambulance 1.”

Don and Kevin apply the CPAP device to Carl’s face, reassuring him that it may be uncomfortable at first, but it will help him breathe.


On arrival at Valley Medical Center, Carl is breathing with less exertion, his lungs are only one-third full with rales, and he is calmer.

In fact, Carl received the very same standard of care from his BLS providers as an ALS unit would have delivered, if one had been available: nitroglycerin administration and CPAP. This level of care not only shortened his hospital stay, but it also avoided intubation and days of mechanical ventilation in an intensive care unit; it also likely helped him to survive the 45-minute ride to the hospital.


The function of the respiratory system is to bring oxygen into the lungs through ventilation. From the lungs, oxygen diffuses into the bloodstream. Respiration begins with the contraction of the diaphragm, which expands the volume of the chest, thereby lowering pressure in the lungs, which causes air to rush into the lungs to equalize the pressure. As air fills the lungs, oxygen travels through the trachea, the bronchi, and the bronchioles to the alveoli. The alveoli are single-cell structures encased in capillaries that allow for the transfer of oxygen and carbon dioxide.

During respiration, oxygen-rich air is brought into the alveoli and diffuses into the alveoli, binding with hemoglobin. Carbon dioxide diffuses from the blood stream into the alveoli, where there is a lower pressure of CO2 gas. The exchange of oxygen and CO2 in the bloodstream by diffusion is essential to cellular oxygenation. Without oxygenated blood to transport oxygen and remove CO2, cells would become hypoxic and acidotic. Several disease processes can interfere with ventilation and diffusion of oxygen, causing shortness of breath and hypoxia.


Diseases may limit expansion of the chest and control of breathing, obstruct flow of air into the lungs, or delay the diffusion of oxygen into the lungs. Pulmonary edema delays the absorption of oxygen into the blood through the alveoli by filling the alveoli with fluid. Pulmonary edema is caused by a weakened left ventricle, resulting in backup of fluid in the pulmonary veins and vasculature of the lungs or by an overload of fluid in the body. As pressure in the pulmonary veins increases, fluid seeps into the lungs, filling alveoli and small bronchioles at the bases of the lungs. As fluid continues to build, other areas of the lungs become filled, causing a shunting of nonoxygenated blood back into the circulatory system. As pulmonary edema increases, hypoxia and anxiety increase. Patients with pulmonary edema feel short of breath and often have a sensation of drowning in their own fluid. As hypoxia increases, the left ventricle becomes increasingly strained, causing ischemia of the heart muscle. The combined effects of a weakened left ventricle, lungs filling with fluid, and hypoxia cause increased CO2 retention, respiratory acidosis, and a downward spiral effect of patient deterioration.

Pulmonary edema can be caused by gradual progression of heart failure over a prolonged period. The patient history would typically include increased shortness of breath on exertion and sudden shortness of breath that awakens the patient from sleep (called paroxsysmal nocturnal dyspnea, or PND). Pulmonary edema can also be caused by increased permeability of the capillaries in the lungs caused by carbon monoxide poisoning, inhalation of chemicals, or sepsis.


Continuous positive airway pressure (CPAP) applies positive pressure through all phases of the respiratory cycle. The positive pressure opens collapsed alveoli. Pulmonary edema, pneumonia, and pulmonary embolism are medical problems that may cause collapsing of the alveoli. You may remember from anatomy class that alveoli are the one-cell terminal ends of the bronchioles where gas exchange takes place between inspired air in the lungs and the hemoglobin in a patient’s blood. The collapse of alveoli is referred to as “atelectesis.” “Atelectesis is the loss of lung volume caused by inadequate expansion of air spaces. It is associated with shunting of inadequately oxygenated blood from pulmonary arteries into veins.”1 The effect of many alveoli collapsing in a section of the lung is the inability to exchange gas. Similar to a train that passes through a station unable to unload or take on new passengers, blood passes through the lungs unable to release carbon dioxide or pick up oxygen, thereby passing through the lungs without oxygenating. The extent of shunting depends on whether a lobe or an entire lung is filled with fluid.

Prehospital care of pulmonary edema by paramedics traditionally includes the acronym LMNOP:

Lasix®, a diuretic, is used to increase the elimination of excess fluid through urination.

Morphine and Nitroglycerin are used to facilitate the pooling of blood in the distal veins to reduce the preload on the left ventricle (preload is the amount of blood the left ventricle receives and must pump out during systole).

Oxygen is used to increase the concentration of available oxygen in the lungs, thereby maximizing the concentration of oxygen in the blood.

Positioning a pulmonary edema patient in an upright position of comfort causes fluid to rest in the bases of the lungs, opening more lung surface area in the upper lobes for oxygen to pass into the bloodstream.

CPAP has been successful in reducing the use of endotracheal intubation in pulmonary edema2-3 and is easy and effective for EMTs to use. (3)

EMTs and paramedics must understand when administering CPAP that it provides additional pressure during inspiration but cannot ventilate an apneic patient. It is not a ventilation system (photo 1). CPAP, when used with a mask, provides positive pressure with a patient’s respiratory effort but not enough pressure to inflate the chest. When using CPAP, providers must diligently monitor the patient’s respiratory status and level of consciousness. When respiratory failure is present, respirations must be assisted with BVM attached to high-flow oxygen. Respiratory failure is detected by monitoring adequate chest rise, skin color, level of consciousness, and oxygen saturation.

(1) A typical prehospital CPAP unit. (Photos courtesy of Emergent Respiratory Products, Inc., Irvine, California.) Click here to enlarge image


CPAP can be beneficial to your patient when your assessment reveals pulmonary edema and sufficient respiratory effort. Treat patients who meet criteria for CPAP in accordance with your local protocols with CPAP equipment following the manufacturer’s recommendations for your particular delivery system. When administering CPAP, have a BVM with high-flow oxygen and a suction unit with a rigid large-bore suction catheter available in case your patient deteriorates during CPAP administration.

CPAP is secured by elastic straps that encircle the head and secure the mask tightly over the nose and mouth (photo 2). Some systems use nasal masks, which cover only the nose. Before placing the mask on your patient, explain the procedure and benefit to your patient. Be sure to explain that this mask fits tightly over his face because a tight seal is important to ensure pressure. Explain to your patient that the pressure will make breathing easier.

(2) CPAP therapy in use on a patient.Click here to enlarge image

CPAP will not ventilate your patient. Once CPAP is applied and the patient has grown accustomed to the treatment, continually monitor and reassess the patient’s respiratory effort and level of consciousness.


Pneumothorax and aspiration are two possible consequences of CPAP. “Problems with administering CPAP by mask include gastric insufflation … aspiration of gastric contents can occur if the patient vomits while the mask is strapped to the face.”4 Programs using CPAP have not found pneumothorax to be a significant problem from EMS administration of CPAP.5 EMS providers who are effectively trained in assessment, CPAP application, and monitoring the patient’s respiratory status can successfully administer CPAP. An effective CPAP program necessitates training in respiratory assessment, CPAP administration, strong medical control, continuous quality control monitoring, and a CME component. Above all, providers must understand CPAP is not a substitute for artificial ventilation. When a patient’s respiratory effort is no longer effective, providers must cease CPAP use and ventilate the patient.

CPAP use has progressed from in-hospital to prehospital administration. It has proven effective in the treatment of pulmonary edema, reducing the number of patients who have to be intubated during the treatment of their pulmonary edema. The system’s medical director should evaluate CPAP use, considering the frequency of pulmonary edema patients seen in your system. CPAP use will continue to increase in regions where ALS is not available or is a scarce resource. Evaluation of CPAP use in EMS should continue as prehospital CPAP use increases.


1. Kumar, V, S Ramzi, S Robbins, MD. Robbins Basic Pathology. (Philadelphia, PA: Saunders), 2003, 454.

2. Hubble M, M Richards, T Jarvis, T Millikan, D Young, “Effectiveness of Pre-Hospital Continuous Positive Pressure in the Management of Acute Pulmonary Edema,” Prehospital Emergency Care; 2006, 10:430-439.

3. Marchetta M, M Resanovich, L Edmunds, “Pre-Hospital CPAP reduces the need for intubation in respiratory emergencies (abstract).” NAEMSP, 2006.

4.Scanlan, Wilkins, Stoller, Egan’s Fundamentals of Respiratory Care, 7th edition, (St. Louis, MO: Mosby-Year Book), 1999.

5. Wesley, Keith, MD, “The ‘Basic’ Skill of CPAP,” Journal of Emergency Medical Services; 2007, 32:10, 21-22.

“Patients” in EMS Education

EMS Responder – “Patients” in EMS Education

Feb 2004

By Mary Wirtz, MPH, NREMT-P, & Steve Kanarian, MPH, EMT-P
Early in the semester, my EMT-Basic students participated in a relay race for bonus points on their next exam. Each team was instructed to perform specific skills on a patient before progressing to the next station. First the teams had to perform obstructed-airway techniques, then CPR, airway maneuvers and oxygen administration. In between each station, each team had to move its patient from room to room, sometimes floor to floor. I watched in horror as members of one group became so caught up in placing first that they brutally dropped the patient on his head, then proceeded to carry him roughly up a flight of stairs, almost separating his arm from his torso in the process. Luckily, the “patient” was one of our manikins, not a real person.

The next time my class did this race, we used real people as patients. The students still worked quickly to place first, but this time no patients were dropped. After this experience, we reviewed the use of manikins, students and outside personnel for skill labs.

The Educational Process

EMS education is an intricate process of leading students through classroom training, skill labs and clinical rotations to assist them in becoming certified and delivering patient care in the field. Students may have limited patient-care experience before entering an EMS class. The quality of training will determine the provider’s ability to care for patients after graduation. Training should enable students to demonstrate knowledge and skills within a challenging learning environment. To enhance learning, education should be as realistic as possible.

EMS educators are faced with the dilemma of providing the best possible learning opportunities for the varying levels of students in a class. When providing skill training, there are several modalities available. Choices include manikins, using students as patients, hiring outside people to act as patients and using actual patients in the clinical setting. Which of these provides students the best education while remaining legally and ethically sound? Let’s take a look at each of these modalities.


Manikins are an excellent educational tool because they enable students to practice numerous skills, including intubation, chest decompression, IVs and cricothyrotomy. Manikins can simulate a difficult airway, a choking patient, or let you start intraosseous therapy. They come in various sizes, from neonates through large adults, and allow students to become comfortable performing skills in a non-threatening environment. Manikins are valuable for teaching skills that cannot be practiced on real patients.

However, there are limitations to using manikins for education. Their ability to simulate realistic patient care is limited. Manikins do not simulate provider-patient interaction. There are no consequences for handling manikins roughly. Manikins are excellent for skill practice, especially early in training; however, we need to remember these limitations.


Another common choice is to use students as patients and have them take turns performing skills on each other. This allows students to become used to touching people, while also providing students the opportunity to feel empathy toward patients by teaching what it feels like to be a patient. Think of the look of absolute terror on new EMT students’ faces as their classmates carry them down a flight of stairs on a stair chair. The student who has experienced that terror will be more empathetic toward the patients they carry down stairs.

With the use of students, there are ethical and legal issues to consider. Recently, one of my female colleagues, who is in her first year of nursing school, found herself in a predicament. In her nursing class, the students were expected to perform breast exams on each other. Understandably, she was uncomfortable having such a personal exam performed during class by a classmate. She refused, and her nursing school later revisited this practice. The legal ramifications of using students to practice breast exams are huge-in fact, it meets my college’s definition of sexual harassment. The ethical ramifications are just as serious; students do not learn if they do not feel safe in the classroom environment. This certainly was an invasion of privacy, and definitely not a sound educational practice.

My colleague’s experience made me, as an educator, sit back and revisit the issue of using students as patients. In my program, we frequently have students perform skills and assessments on each other (none, however, as personal as a breast exam). They do EKGs (but only on male students), IVs, spinal immobilization and vital signs, just to name a few. Using students as patients is cost-effective and can be a useful learning experience, but must be done with sensitivity and limitations.


Another option is to hire outside people to act as patients. We tried this in our program with students from the Performing Arts department. The actors were briefed about what to expect. We always made sure nothing was done to invade their privacy or offend their modesty. So far, this has worked well for us. The Performing Arts students are great at acting out patient scenarios, and our EMS students have the benefit of practicing assessments and skills on real “patients.” Another benefit is that since these are not medical people, they grow suspicious of strange equipment they have never seen before, just like real patients in the field. This forces students to take the time to explain exactly what they are doing, like they will need to in the field. Actors may be most useful when students have become competent with skills and need a more realistic learning experience. This realism is especially useful late in the program to challenge students with scenario-based learning.

As actors usually have no medical training, they must be extensively briefed as to how to portray a patient with an illness or injury. They also must be educated about how to react to different treatments. This time-consuming preparation has been our biggest limitation to using actors as patients. However, overall it has been a great educational tool and well worth the time and cost.

Real Patients

Another common practice is to have students practice on real patients, either in the field or in the hospital setting.

I remember my first cardiac arrest as a paramedic student. It was at a wedding reception; one of the family members collapsed. I remember running the arrest with a circle of bystanders that included the bride and groom and the entire family watching. As nervous as I was, the call went smoothly. The pressure I felt simply could not be simulated in a classroom with my classmates and instructor watching.

In my program, our paramedic students do about 900 hours of clinical time in which they’re exposed to actual patients. They spend time intubating patients in an operating room. They are in the labor and delivery unit, assisting with delivering newborns. They are on the ambulance, taking care of patients in the field. They participate in group therapy during their psychiatric rotations. They work in the emergency department alongside physicians and nurses. The benefits are enormous: Students get to practice in a realistic environment where they encounter a variety of patients and perform assessments and skills under the watchful eye of their preceptors.

However, there are drawbacks. Patients are subject to having skills performed by an inexperienced provider. How many times have we sat and watched a student fish for the IV we could easily do? How many awkward assessments have we watched from students who are not yet comfortable talking to patients? And for the field or clinical preceptor, this certainly is a strain. In medicine there’s a saying: “Show me a student who only triples my work, and I’ll kiss their feet.” Having a student slows us down and makes more work. However, the benefits to the student’s education, and the future of our profession, make this a worthwhile endeavor.


A sound educational program uses a variety of methods to teach students. Ideally, a program should integrate all the different modalities of teaching skills: using manikins, students and actors as patients. EMS education also needs to include real patients in the field and hospital environments under the oversight of a preceptor. By integrating these methods, we can provide a good educational experience for our students as they develop into prehospital care providers.

5 Tips to Survive a Terrorism Related MCI

Everyday EMS Tips – 5 Tips to Survive a Terrorism Related MCI
On this anniversary of 9/11 EMS responders reverently watch the flag and remember those that were lost on September 11, 2001. Many EMS providers who have not experienced a large scale MCI may wonder, “How will I stay safe during a terrorist attack or large scale MCI?

Scene size up. Stop. Look, Listen and Think. Allow time for your mind to process the scene you are faced with. While responding to a MCI you should monitor PD and FD frequencies. Upon approaching an MCI you should stop at a distance and observe what is happening. Has there been large-scale incident? Are numerous responders and victims experiencing SLUDGEMS? Should I wait for specialty resources to check for bombs and snipers? Staying in staging and waiting may be the hardest thing to do.

All Hazards approach. Focus on the hazards, the cause is often not known initially. For example the Oklahoma City Bombing was initially thought to be a gas explosion. The first attack on the World Trade Center was thought to be a transformer fire. Follow universal safety rules:

1. Stay upwind for heavy smoke
2. Stay uphill for liquid spills
3. Stay out of the collapse zone (Stage operations 2-3 times the height of the building away)
4. Expect secondary explosions/incidents Personal Protection. Wear the appropriate level of protection. Wear respiratory protection, BBP protection and your helmet. If the incident is beyond your personal protection or training, stage at a safe distance, request specialty resources and wait for scene to be stabilized.

YOUR safety comes first. Stay in teams, avoid freelancing and frequently reassess hazards. Terrorist incidents may evolve and often use multiple attacks to focus on patients and responders.

Training. Cross train in various medical and rescue specialties. Prepare by thinking out of the box. Broaden your abilities by planning drills that challenge rescuers and exceed our normal range of experiences. Terrorist MCIs increase in lethality dramatically with each attack. “Worst case” scenarios may be a reality. Drills should be held with all players included. If you practice together you will succeed together at an MCI.

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