Letter to Our Readers
The Prehospital Care Research Forum at UCLA believes that it’s the responsibility of emergency medical professionals worldwide to develop a body of evidence that examines prehospital emergency care. Our mission is to assist, recognize and disseminate prehospital care research conducted at all provider levels.
Each year, we acknowledge those authors who have contributed to the science of EMS through the publication of this supplement and their subsequent presentations. As part of our ongoing pledge, the Prehospital Care Research Forum at UCLA continues to educate the medical community through a variety of seminars, lectures and workshops throughout the country. These presentations are designed to demystify the research process and provide participants with the tools to conduct research in their community.
I would like to thank our volunteer Board of Advisors and Associates. Without the dedication of these volunteers none of this would be possible.
In addition to the hard work of many, many people, much of our success can be attributed to the commitment of several organizations dedicated to research in prehospital care. I would like to acknowledge our Founding Partners: Jems Communications (now known as Elsevier Public Safety), Benefactor: SSCOR Inc., Partner: ZOLL Medical Corp., Contributors: Armstrong Medical and FISDAP. The generous support of these fine organizations and our affiliation with the National Association of EMS Educators and the National Association of EMTs are what enable the Research Forum to fulfill our mission.
The future of EMS depends on the quality and quantity of research we produce. We invite you to take a stand, conduct research in your community and submit it in 2011 for the greater benefit of EMS.
Baxter Larmon, PhD, MICP
Director, Prehospital Care Research Forum
1. Decreasing Blood Lactate Levels in EMS Patients
By T. Ryan Mayfield, MS, NREMT-P; & Mary Meyers, MHA, EMT-P
Introduction: Research has shown that clearance of blood lactate is associated with better outcomes in patients with severe sepsis and septic shock. One of the primary treatments of these patients is administration of IV fluids. This study looked at blood lactate levels before and after EMS treatment to determine if there was a significant change.
Hypothesis: There will be a change in blood lactate levels between EMS and hospital lactate levels.
Methods: Paramedics were provided with and given training on the Lactate Pro blood lactate meter by Arkray Inc. This meter is FDA-approved and CLIA waived, and has shown a good correlation to hospital lactate tests. Between May 1, 2009, and Sept. 15, 2010, 134 patients with suspected severe sepsis or septic shock underwent blood lactate readings by EMS. Patients with a lactate reading of ≥ 4.0 mg/dL were considered to be in shock regardless of their corresponding blood pressure. Treatment was not dictated by this study and was administered according to EMS protocols.
Results: Of the 134 patients, 120 had hospital lactate levels available for comparison. Overall, hospital lactate levels were lower after EMS treatment. EMS patients were divided into groups that received greater than 1000 mL of fluid between readings (Group A), and patients who received between 250 mL and 1000 mL (Group B). Group A had a median decrease of 2.25 mg/dL (p = 0.0003) while Group B had a decrease of 1.1 mg/dL (p < 0.0001). Analysis used the Wilcoxon-Rank Sum Test.
Conclusions: There was a significant decrease in lactate levels associated with EMS treatment. Further, the group that received greater amounts of IV fluids had an even larger drop in lactate levels. These results illustrate the importance of EMS treatment and how it might impact patient outcomes. Further research and training needs to be done to expand the role of lactate in EMS, as well as reinforcing the importance of fluid administration to these patients.
2. The Impact of Direct Transport of STEMI Patients to PCI Centers
By Michael Bachman, MHS, NREMT-P; Michael W. Hubble, PhD, MBA, NREMT-P; & Matthew Harmody, MD
Introduction: In the setting of ST elevation myocardial infarction (STEMI), the preferred treatment is percutaneous coronary intervention (PCI). In rural EMS settings, many local hospitals lack PCI facilities, requiring EMS to transport to the local hospital and later transfer the patient to a regional PCI center. As an alternative strategy, EMS may bypass the local hospital and transport directly to the PCI center. However, the impact of prolonged direct-to-PCI center transport times from rural areas is unknown. This study seeks to determine the impact on outcomes of this transport strategy.
Methods: Data were retrospectively abstracted from medical records of all confirmed STEMI patients transported by a rural EMS system. A protocol change in June 2006 required direct transport of all STEMI patients to a regional PCI center. These patients were compared against historical controls. Primary outcomes included in-hospital mortality, stroke and reinfarction post PCI intervention. Secondary outcomes include time saved from onset of symptoms until PCI, PCI center arrival until PCI intervention, and hospital length of stay.
Results: Sixty-four patients were transported directly to the PCI center, and 40 were transported to the local hospital and later transferred; of the total number of patients, one (<1.0%) received thrombolytics before transfer. Hospital mortality between the two groups was 7.8% vs. 15.0% (p=0.32), and reinfarction was 3.1% vs.7.5% (p=0.37) in the direct transport group compared to the local transport group respectively. There were no cases of post-intervention stroke. The symptom onset-to-PCI interval was 210.4 vs. 415.2 minutes (p = 0.00), the arrival-to-PCI interval was 84.2 vs. 107.7 minutes (p = 0.14), and the hospital LOS was 3.5 vs. 5.3 days (p=0.01) in the direct transport group compared to the local transport group respectively.
Conclusion: In this rural EMS system, direct transport to a regional PCI facility resulted in a 49% reduction in the symptom-onset-to-PCI interval, and a 51% reduction in hospital LOS. Improvements of similar magnitude were seen in hospital mortality and reinfarction rates, although these differences did not rise to statistical significance. In this rural EMS setting, transporting STEMI patients directly to regional PCI facilities offered considerable symptom-onset-to-PCI time savings, which translated into decreased hospital LOS.
3. Prehospital Clopidogrel in the Presence Of Acute Myocardial Infarction: A Case Series
By Robert D. Smith, MHS, NREMT-P; Michael W. Hubble, PhD, NREMT-P; &
Jonathan R. Studnek, PhD, NREMT-P
Introduction: Clopidogrel (trade name: Plavix) is routinely administered to ST elevation myocardial infarction (STEMI) patients, and has been shown to improve infarct-related artery patency when given before thrombolysis or percutaneous coronary intervention (PCI). Some European EMS systems administer clopidogrel in the prehospital setting. However, these systems are typically staffed by physicians who also concurrently administer fibrinolysis prior to hospital arrival. Currently, there is limited research in the U.S. exploring the feasibility of administering clopidogrel. Our objective was to evaluate the feasibility of prehospital clopidogrel in a suburban EMS system using a case series design. We hypothesized there was minimal risk of bleeding events following the prehospital administration of clopidogrel.
Methods: Data were retrospectively abstracted from the records of all patients transported by EMS between November 2006 and June 2009 with a hospital discharge diagnosis of STEMI. All patients received 300 mg of clopidogrel in addition to the standard treatment of nitroglycerin, oxygen, morphine and a beta blocker. Primary outcomes were serious bleeding events and overall mortality. Secondary endpoints included in-hospital reinfarction and hospital length of stay. Data analysis was descriptive in nature utilizing frequencies, means, and standard deviations.
Results: Data were available for 55 patients. The mean age was 58.8 (SD = 11.4) years, and 46 patients (83.6%) were male. The infarct locations included inferior (45.5%), anterior (29.1%), inferolateral (16.4%), posterior (3.6%) and other (5.4%). Three patients (5.5%) experienced significant bleeding events that required transfusion. No patient experienced hemorrhagic stroke, and three (5.5%) suffered in-hospital reinfarction. One (1.8%) patient died before discharge, but the cause of death was unrelated to bleeding events. Average LOS was 5.6 (SD = 6.3) days. No patients received thrombolytics, and all received PCI.
Conclusion: This case series demonstrated that the prehospital administration of clopidogrel may be feasible, with few patients experiencing significant bleeding events. These results are similar to European studies in which clopidogrel is administered by physicians in conjunction with thrombolytics before hospital arrival. Additional research is needed to determine the impact on patient outcomes of late (in-hospital) vs. early (prehospital) administration of clopidogrel during transport to regional PCI centers.
4. Ambulances: Prehospital Reservoirs for Fomite-Mediated Bacterial Disease Transmission?
By Edward O’Connor, PhD, EMT-P; Jennifer Aldrich, EMT-P; & Christian Eggers, PhD
Background: Ambulances are an extension of the hospital and could be reservoirs for potential nosocomial, opportunistic and pathogenic agents. Given the nature of the many common invasive procedures performed in an ambulance, as well as the potentially compromised immune status of the patients being transported, any bacterial contamination in an ambulance might represent substantial risk of infection for both patients and emergency personnel.
Hypothesis: This study hypothesizes that common surfaces inside ambulances are fomites for disease transmission and that four surfaces (i.e., the left stretcher rails, fixed oxygen flow meter knobs, floor space between the bench seat, and stretcher and computer keyboards) represent areas where gross cross contamination is likely.
Methods: To investigate whether potentially pathogenic bacteria could be recovered from ambulances, investigators collected 60 samples from the above surfaces in the patient compartment of 14 different ambulances stationed throughout Connecticut. Additional samples were also collected from computer keyboards, microphones, sharps containers and biohazard trash can lids. Samples were collected using standard aseptic technique, with saline-moistened sterile cotton swabs. The samples were then submitted to a professional diagnostic laboratory for species identification and antibiotic resistance and susceptibility testing.
Results: Twenty-seven different species of bacteria that are known pathogenic, nosocomial and/or opportunistic infectious agents were identified. Among those identified are Acinetobacter baumanii, Staphylococcus aureus, Pseudomonas aeruginosa, Methicillin-resistant coagulase-negative Staphylococcus species, and a number of gram-negative enteric bacteria (including Klebsiella pneumoniae, Escherichia coli, and a Serratia species). Further, 11 of the species identified are multi-drug resistant.
Conclusions: Ambulances are reservoirs for nosocomial, opportunistic, potentially pathogenic multi-drug-resistant bacterial organisms. The surfaces inside the patient compartment demonstrate cross contamination and offer the potential for fomite disease transmission to emergency responders or patients, especially those who are immuno-compromised for medically or traumatic reasons.
5. Effect of Crew Configuration on Routine Measures of Clinical Performance
By Bryan Edwards, BS; & Michael Hubble, PhD
Introduction: Among the EMS systems of the most populous cities in the United States, only 40% routinely staff ambulances with two paramedics. A recent report indicates that many systems with dual-paramedic crews are transitioning to one paramedic and one EMT crews as a cost-saving measure or in response to a shortage of paramedics in their areas. Despite the substantial proportion of EMS systems opting for the single-paramedic crew, the impact of this crew configuration on patient care is poorly quantified. Consequently, this study seeks to determine the impact of single vs. dual-paramedic crew configuration on routine measures of clinical performance.
Methods: The study reviewed critical patients transported by a high-performance, urban EMS system between June 2008 and December 2009. Data were retrospectively abstracted from the medical records of patients requiring emergent transport to the hospital with a chief complaint of major trauma, cardiac complaint, confirmed ST elevation myocardial infarction (STEMI), cardiac arrest or stroke. The on-scene times and scene arrival to key treatment time intervals (measured in seconds) were compared between patients treated by single vs. dual-paramedic crews.
Results: A total of 3,532 patients were included, of which 2,715 (76.9%) were treated by single-paramedic crews and 817 (23.1%) by dual-paramedics crews. There was no significant difference in on-scene times (687.4 vs. 696.9, p=0.40) or the time intervals of scene arrival to intraosseous access (527.9 vs. 467.5, p=0.28), intravenous access (443.3 vs. 455.6, p=0.43), oxygen administration (246.9 vs. 319.3, p=0.33), EKG (391.4 vs. 395.9, p=0.93), defibrillation (209.9 vs. 193.7, p=0.75), advanced airway (419.5 vs. 398.8, p=0.46), or first drug administration (520.8 vs. 383.9, p=0.41) for single vs. dual-paramedic crews respectively. Similar trends were evident when stratifying by chief complaint.
Conclusion: In this high-performance, urban EMS system, there were no significant differences in on-scene times or the scene arrival to key treatment time intervals between single and dual-paramedic crews for select critical patients. Although other clinically relevant reasons might exist for dual-paramedic crew configurations, this study found no advantage in on-scene or treatment times.
6. Utilization of Capnography among Nationally Certified Paramedics
By Melissa A. Bentley, BS, NREMT-P; & Antonio R. Fernandez, MS, NREMT-P
Introduction: Capnography has been recognized as an important tool in the maintenance of proper endotracheal tube placement. Failure to utilize capnography has also been associated with unrecognized misplacement of the endotracheal tube in the prehospital setting.
Hypothesis: The objective of this study was to quantify use of capnography among nationally certified paramedics and to determine significant associations between demographic/work-life characteristics and capnography utilization. It was hypothesized that utilization of capnography would be associated with demographic/work-life characteristics.
Methods: As part of the 2009 Practice Analysis conducted by the National Registry of EMTs, paramedics were asked to report their use of capnography in the last year. Capnography utilization was assessed among nationally certified paramedics who reported performing adult endotracheal tube intubation. Demographic variables collected and assessed included community size, years of experience, service type, call type, number of calls per week and frequency of ETI. Statistical analysis was conducted using chi-square analysis (p= 0.05).
Results: Of the 2,689 paramedics who received surveys, 669 (24.9%) responses were obtained. Of those 601 (89.8%) who performed ETI, 85 (14.1%) reported never utilizing capnography. None of the demographic variables assessed revealed statistically significant associations with the utilization of capnography. Frequency of intubation was the only work-life characteristic variable assessed which revealed a significant association with the report of utilization of capnography. Specifically, there was a stepwise increase in the frequency of ETI and the percentage of paramedics reporting using capnography once per year: 69.7%, between once per year and once per month: 85.1% once per month: 95.5%; (p<0.001).
Conclusion: When used appropriately, capnography can assist in ETI being a lifesaving intervention; however, when omitted, ETI might be hazardous to the patient. This study revealed a measurable number of nationally certified paramedics who are not utilizing capnography. If paramedics are to “do no harm” when performing ETI, capnography should be universally mandated.
7. 12-lead ECG Obtainment and Interpretation among Nationally Certified Paramedics
By Melissa A. Bentley, BS, NREMT-P; & Antonio R. Fernandez, MS, NREMT-P
Introduction: Early recognition of ST-elevated myocardial infarction (STEMI) is essential for positive patient outcomes. However, it is unknown how often paramedics obtain and interpret 12-lead ECGs. Likewise, paramedic’s competence regarding 12- lead ECG placement and interpretation is not assessed on the national certification examination.
Hypothesis: The objectives of this study were to quantify how often nationally certified paramedics obtain and interpret 12-lead ECGs and identify work-life characteristics associated with obtaining and interpreting 12-lead ECGs. It was hypothesized that work-life characteristics would be associated with obtaining and interpreting a 12-lead ECG.
Methods: As part of the National Registry of EMTs 2009 Practice Analysis, paramedics reported their frequency of obtaining and interpreting 12-lead ECGs. Work-life variables (community size, years of experience, service type, call type and number of calls per week) were analyzed to determine if significant associations were present. Analysis was conducted using Chi-Square (x2= 0.05).
Results: There were 2,689 nationally certified paramedics who received the survey and 669 (24.9%) responded. Although 5.2% (35) of nationally certified paramedics reported never obtaining a 12-lead ECG, the majority of paramedics reported obtaining a 12-lead ECG more than once per week to once per month (83.1%). Similarly, 6.8% (45) reported never interpreting a 12-lead ECG while 81.9% (548) interpreted a 12-lead more than once per week and to once per month. None of the work-life variables assessed were significantly associated with obtaining or interpreting 12-lead ECGs.
Conclusion: An overwhelming majority of nationally certified paramedics are playing an integral part in the early recognition of STEMIs. Therefore, demonstration of 12-lead ECG entry level competence should be part of the national certification process.
8. Missing the Mark: An Assessment of Paramedics’ Ability to Correctly Perform Drug Calculations
By Christopher Shane Henderson, BS, EMT-P; Anne Clouatre, MHS, EMT-P; T. Ryan Mayfield, MS, NREMT-P; Clancy Meyers, MHA, EMT-P; & David Sanko, BA, EMT-P
Introduction: Paramedics are often required to perform medication calculations in the management of their patients. The prehospital work environment is dynamic and offers a number of special challenges that could impact medication delivery. Appropriate medication delivery is critical to patient outcome. However, there are few safeguards in place to ensure proper field delivery in an emergent setting.
Hypthosis: The objective of this study was to improve education programs by identifying commonalities among providers who accurately perform calculations.
Methods: A demographic survey and a 10-item medication calculation assessment were administered to a nonrandom convenience sample of 47 field paramedics from two sites in the United States. Participants were evaluated on their response to seven intravenous bolus and three infusion calculations, with a time limit of 20 minutes. Each calculation was separated into its components in an effort to recognize where providers had the most difficulty.
Results: The overall mean score was 31.0% (SD 24.4), with three (6.4%) participants scoring >70%. The assessment resulted in 29 (61.7%) participants scoring <50% on both the bolus and infusion calculations. Participants achieved greater results with intravenous bolus calculations than with infusions, but each individual component outcome was < 50%. Although disproportional to the results, 91.5% of the participants expressed they were comfortable performing drug calculation in a nonemergency setting.
Conclusions: The ability to identify commonalities among participants that perform drug calculations well was inhibited by the poor overall performance. This study coupled with results of similar research suggests there is a significant need for improving the mathematical competency skills of field paramedics. The calculations utilized in the assessment were fundamental in paramedic practice. Therefore, it is imperative that the mathematical competency of paramedic students is solid before becoming an entry-level practitioner. Also, continuing education programs should include modules to ensure accurate, timely delivery of medications. Further research is needed to identify effective educational, quality assurance and quality improvement methods, as related to medication calculations.
9. Evaluation of Vital Signs and Saturation of Peripheral Oxygen (SpO2) in Patients Experiencing Shortness of Breath and Treated with Continuous Positive Airway Pressure (CPAP)
By Jodi Navandro, MSN; Baxter Larmon, PhD, MICP; Taryn Hoffman, BS, EMT-B; Todd LeGassick, MPH; Steve Rottman, MD, FACEP; & Jeff Furrows, EMT-P
Introduction: Few studies evaluate the changes in vital signs in shortness of breath patients treated with continuous positive airway pressure (CPAP) in EMS.
Methods: This was a retrospective nonrandomized study that looks at all patients complaining of shortness of breath in an urban community of 84,000 people for a one-year period. Measurements of systolic blood pressure, pulse, respiratory rate, and pulse oximetry (SPO2) were gathered before and after CPAP treatment. One research assistant retrieved data from patient care records and entered them into a database. IRB was obtained with expedited review. A confidence interval (CI) of 95% (CI 95%) was used to determine statistical significance.
Results: Ninety-eight patients were entered into the study; a complete set of vital signs or SPO2 was not available for all encounters. Pulse (n=59 of the 98 records; 60.2%) was the only vital sign that did not show a statistically significantly difference before and after CPAP. Respiratory rate (n=56; 57.1%) had mean decrease of 3 (CI -4.43 to 1.74). Systolic blood pressure (n=57; 58.2%) had a mean decrease of 11 (CI -18.77–3.80). Both respiratory rate and systolic blood pressure were statistically significant. SPO2 (n=89; 90.1%) was also found to be significant with a mean increase of 15 (CI 12.67–17.08). A subset of patients with pulse greater than 110, systolic blood pressure greater than 140, respiratory rate > 24 and a SPO2 below 94% were evaluated (n=14; 14.3%). In this group pulse and respiratory rate did not show a significant change. There was a statistical difference for systolic blood pressure and SAO2, with a mean decrease of systolic blood pressure of 17.85 (CI -32.21to -3.50) and a mean increase in SPO2 of 20.21 (CI 14.67 to 25.76).
Conclusion: This study found a statically significant drop in respiratory rate, systolic blood pressure and SPO2 in shortness of breath patients when treated with CPAP in the prehospital care setting. No difference was found in pulse rate. In patients with significant clinical signs of respiratory distress, both systolic blood pressure and SPO2 showed clinically more improvement when treated with CPAP. In general, these findings are associated with clinical improvement of patients with shortness of breath.
10. Are Levels of EMS Involvement with ECG Interpretation and Catheterization Lab Activation Associated with Success in Achieving a
Door-to-Balloon Time of 90 Minutes or Less?
By Philip Beckley, PhD; Anna Ek, RN, BSN, CNOR, RNFA; Jill Clutter, PhD, CHES; Kay Styer Holmes, MSA, RN, BSN; Darcie Allard, RN, MSA, FABC, CNOR; &
Timothy LaBarge, BS
Introduction: The 2004 ACC/AHA Guidelines for the management of patients with ST elevated myocardial infarction (STEMI) state that primary percutaeous coronary intervention should be performed as quickly as possible, with a goal of a door-to-balloon time within 90 minutes (Class 1B recommendation). It is assumed that delays in the door-to-balloon time can be minimized by involving the EMS in the interpretation and transmission of the ECG and activation of the catheterization lab from the field.
Objective: To determine if levels of EMS involvement are related to percent compliance with a door-to-balloon time of 90 minutes or less as well as various facility/EMS characteristics.
Methods: A retrospective review of Facility Information Booklets from facilities applying for Cycle 3 Chest Pain Center Accreditation was conducted. Three levels of EMS involvement were studied: 1) EMS activates the catheterization lab from the field, 2) catherization lab is activated after ECG transmission and review by the physician, and 3) catherization lab is activated after arrival to the facility. These levels were compared to the door-to-balloon time over the year before application. The levels were also compared to other characteristics related to facility size, setting and EMS coverage.
Results: Level 1 facilities met the 90-minute goal 93.1% of the time, level 2 met the goal 88.5% of the time, and level 3 met the goal 82.9% of the time. Although success trended with the level of EMS involvement the differences were not significant (p = .070). There were no significant differences between levels of involvement with respect to facility setting, number of licensed beds, number of ED visits per year, number of primary PCIs performed per year, number of EMS jurisdictions and patient transport time.
Conclusion: Success in achieving a door-to-balloon time of 90 minutes or less is associated with EMS involvement in ECG interpretation and CL activation. Study results further indicate that facilities of any size and setting can have success in approaching this goal.
11. Gender Bias in Prehospital ChestPain Management
By Nabil El Sanadi, MD, MBA, FACEP; & Todd LeDuc, MS, CFO, CEM
Introduction: Patients with possible coronary insufficiency should undergo aggressive treatment to minimize the pain, as chest pain is a correlate of myocardial ischemia and injury. Patient gender should not affect intensity of therapy.
Methods: A retrospective run-sheet review from a large prehospital system (684 paramedics and 17,000 EMS runs per year) was done to determine the gender of the lead paramedic, the gender of the patient and the chest pain score difference pre- and post-treatment. Treatment included standards therapy of oxygen, nitroglycerin and morphine. A pain score of 0–10 was used, All runs with “chest pain” as the chief complaint were reviewed from April 2007 to August 2008, and 225 cases were found. A two-sample Poisson test was used to analyze the data.
Results: Female paramedics treating female patients vs. treating male patients had a difference of 1.77 (p=0.010). Male paramedics treating male patients vs. female patients had a difference of 0.57 (p=0.063).
N mean decrease in chest pain score
Female EMT-P Treating Female Patients 16 4.88
Female EMT-P Treating Male Patients 19 3.16
Male EMT-P Treating Male Patients 102 4.02
Male EMT-P Treating Female Patients 88 4.59
Conclusion: Female paramedics treat female patients more aggressively for chest pain than male patients. This might be due to gender bias and expectation of pain tolerance by male patients. Male paramedics treat male and female patients with the same intensity.
12. Paramedic Self-Perception of Medication Calculation Ability
By Christopher Shane Henderson, BS, EMT-P; Anne Clouatre, MHS, EMT-P; T. Ryan Mayfield, MS, NREMT-P; Clancy Meyers, MHA, EMT-P; & David Sanko, BA, EMT-P
Introduction: Medication calculation and administration is a large part of the initial paramedic curriculum as well as normal practice for field paramedics. However, it is unknown how this skill is maintained after initial education, with additional training being given by paramedic request only.
Methods: A demographic survey as well as a 10-question medication calculation test was given to a nonrandom sample of 47 paramedics at two U.S. sites. Participants were given 20 minutes to complete the seven intravenous bolus and three infusion calculations. Included in the demographic survey were questions dealing with the paramedic’s comfort level with performing medication calculations.
Results: Of the 47 paramedics who participated, 43 (91.5%) reported they were comfortable performing medical calculations in a nonemergent setting. In contrast to their response, only 3 respondents (6.4%) scored above 70%.
Conclusions: In the sample, the overwhelming majority of paramedics stated they were comfortable performing medication calculations. However, most were unable to achieve a passing score. This presents an area of concern for quality assurance if actual dosage of medication, not just the correctness of the medication, is not regularly reviewed. Increased training must be done to strengthen paramedics’ ability to correctly perform medication calculations. Further studies need to be completed to determine if these results are representative of the entire population of paramedics. JEMS
UCLA Center for Prehospital Care
ZOLL Medical Corp.
National Association of EMS Educators
National Association of EMTs
BOARD OF ADVISORS
Lawrence H. Brown, EMT-P
Edward Dickinson, MD, FACEP, EMT-P
William J. Koenig, MD, FACEP
Todd LeGassick, MPH
Mark Marchetta, BS, RN, NREMT-P
Gregg Margolis, MS, NREMT-P
David Page, MS, NREMT-P
Marv Birnbaum, MD, PhD
Elizabeth Criss, RN, MEd
Baxter Larmon, PHD, MICP
EMS RESEARCH FELLOWS
Melissa Bentley, BS, NREMT-P
Terry Abrams, MS, EMT-P
Paul Bishop, MPA, EMT-P
Scott Bourn, PhD, NREMT-P
Joseph Corley, BSHS, EMT-P
Megan Corry, MA, EMT-P
Twink Dalton, RN, NREMT-P, MS
Robert De Lorenzo, MD, FACEP
Robert Delagi, MA, NREMT-P
Phillip Dickinson, NREMT-P
Thomas Dunn, PhD, EMT-B
Antonio R. Fernandez, BS, NREMT-P
Greg Gibson, PhD, PRC, NREMT-B
David Harrawood, RN, NREMT-P
Nancy Hays, MPH
David Hostler, PhD, NREMT-P, CSCS
Billy James, PhD, EMT-P
Todd LeDuc, MS, CFO, CEM, EMT-P
Thomas LeMaster, RN, NREMT-P
Jeffrey Lindsey, PhD, MS, EMT-P
Mary Kay Margolis, MHA, MPH
Richard Narad, DPA
Madeleine O’Donnell, BNg, BEd, MedS
Robert J. Philip, MPH, NREMT-P
Thomas Raithby, BS, EMT-P
Chris Thos. Ryther, MS, NREMT-P
Andrew W. Stern, MPA, MA, NREMT-P
Walt Alan Stoy, PhD, EMT-P, CCEMT-P
Jonathan R. Studnek, BS, NREMT-P
Mike Taigman, EMT-P
William F. Toon, MEd, NREMT-P
Atilla Üner, MD, MPH, FAAEM
Donald Walsh, PhD, EMT-P
Paul A. Werfel, NREMT-P
Matthew Zavarella, RN, NREMT-P
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