lifeline AUGUST 2017
A Comparison of Chest Compression Quality Delivered During On-Scene and Ground Transport Cardiopulmonary Resuscitation Page 12 TABLE OF CONTENTS |
4 6 4 PRESIDENT’S MESSAGE 6 ADVOCACY UPDATE
8 GUEST ARTICLE
12 ORIGINAL RESEARCH
20 ANNOUNCEMENTS THE ADVOCACY IN ACTION: SAVING 21 UPCOMING MEETINGS & DEADLINES Members Impacting SYSTEM Public Policy 22 CAREER OPPORTUNITIES
California ACEP AUGUST 2017 Index of Advertisers Board of Directors & Lifeline Editors Roster ADVANCED Page 18
2016-17 Board of Directors Lawrence Stock, MD, FACEP, President Advanced 2017 California ACEP Annual Assembly Page 19 Aimee Moulin, MD, FACEP, President-Elect Chi Perlroth, MD, FACEP, Vice President California ACEP – Member Renewal Page 10 Vikant Gulati, MD, Treasurer Vivian Reyes, MD, FACEP, Secretary California Hospitalists/ Emergency Physicians Medical Group, Inc Page 22 Marc Futernick, MD, FACEP, Immediate Past President John O. Anis, MD, FACEP John Coburn, MD Emergency Groups’ Office Page 5 Carrieann Drenten, MD Kevin Jones, DO Emergency Medical Management Associates Page 8 John Ludlow, MD, MBA Sujal Mandavia, MD, FACEP (At-Large) Valerie Norton, MD, FACEP Independent Emergency Physicians Consortium Page 8 Luke Palmisano, MD, MBA, FACEP Maria Raven, MD, MPH, FACEP Intercommunity Emergency Medical Group Page 22 Nicolas Sawyer, MD James C. Tse, DO, CAL/EMRA President Medelita Page 9 Lori Winston, MD, FACEP
Advocacy Fellowship Newport Emergency Medical Group Page 22 Aimee Moulin, MD, FACEP, Director
Lifeline Medical Editor Ohio ACEP Emergency Medicine Board Review Courses Page 11 Richard Obler, MD, FACEP, Medical Editor VA Long Beach Healthcare System Page 22 Lifeline Staff Editors Elena Lopez-Gusman, Executive Director Ryan P. Adame, MPA, CAE, Deputy Executive Director Ventura Emergency Physicians Page 22 Kelsey McQuaid, MPA, Director of Policy and Programs Lucia Romo, Education Coordinator
2 | LIFELINE a forum for emergency physicians in california WELCOME new members! Awista Ayuby Timothy Hong, MD Joseph Nelson, MD Anna Bilski, MD Thomas Hull, MD Sunny R. Patel, MD Nick Black, MD Meghan M. Hurley, MD Mark Portman Cindy Chang Ou Jin, MD Jon Risovas Aleksandra Degtyar Jessica G. Johnson, MD Paul E. Riuli Ranvir Dhillon, MD Erica R. Kiemele, MD Ignacio Salas David Dillon, MD Kim Kolibas Kyle M. Scozzafava Braxton Duncan, DO Christina M. Konecny Michael Self, MD Antonio Tomas Duran, MD Andrew C. Lavlyt, MD Suzanne S. Shah, MD Camille Enriquez, MD Nhu-Nguyen Le, MD Eileen Shi, MD Niklas Eriksson, MD Jung-Eun Lim, MD Joanna Maureen Sitzmann, DO Tom Fadial, MD Benjamin Liotta, MD Josey L. Strathe Allison Ferreira, MD Dennis Liu, MD Grace H. Taylor, MD Edward Grom, MD Ronald T. Luu Katherine Vuchkov, MD David Haase, Medical Student Neal P. Moehrle, MD Daena Watcha, MD Walid Hamud-Ahmed, MD Cameron Mozayen, MD Jake Wilson, MD Kevin Hanley, MD Andrew C. Navlyt, MD Mengqiao Xi, MD Zachary H. Hansen Emily Neill, MD Paul Hausknecht, MD Cole Nelson, MD
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AUGUST 2017 | 3 PRESIDENT’S MESSAGE |
By Larry Stock, MD, FACEP SAVING THE SYSTEM Dear Colleagues, I want to share a hopeful vision of emergency medicine's (EM) future. This spring, I wrote a three-part narrative to begin a discussion within our Chapter in which I argued: 1 There are no inappropriate emergency department (ED) visits 2 EM is an essential element of an integrated health care model 3 EM provides value Former California ACEP President Dr. Tom Sugarman wrote in 2013 about the need for EM providers and the health care system to further develop and implement strategies to improve the value of emergency care delivered to our patients (1). Former California ACEP President Dr. Wes Fields spoke at the 2017 ACEP Leadership and Advocacy Conference about our generational challenge to “save the system”. Echoing both of their views were a paper and accompanying editorial in the Annals of Emergency Medicine this June about value-based approaches for emergency care (2,3). These publications discuss a useful pathway forward for EM.
he US health care system is expensive and the rate of spending reward us for taking a value based approach to care (2). Value is quality growth is unsustainable (2). The current system lacks alignment divided by cost, balancing outcomes and the unit cost to achieve T of incentives among patients, providers, and payers to seek those outcomes (3). In a system with alignment of incentives-- safety, value. With a growing and aging US population, the federal government effectiveness, and efficiency can all be achieved in a patient centered has focused on Medicare payment reform as one method to address way. spending growth. The Merit-Based Incentive Payment System (MIPS) is the pathway within the Medicare Access and CHIP Reauthorization The vision explored by Medford-Davis and colleagues is one in which Act (MACRA) that most EM groups will take. A key concept is that MIPS emergency care provides a critical linkage and interface between creates a fee-for-service payment model, adjusted for value, to help outpatient longitudinal care and inpatient services. As opposed to
4 | LIFELINE a forum for emergency physicians in california fragmented episodic care or the ED solely as the place for critical care and coordination of care. Much of our work may well reside outside emergencies, this model visualizes the ED as the hub of unscheduled the ED, solving problems and creating linkages to provide value- acute care, where the ED integrates with primary care, hospital based care. The results will be a sustainable system and better health care, and post-discharge care through communication and care for our patients and communities. n coordination.(3) The four domains that form the composite MIPS score are 1) quality, 2) resource use (utilization), 3) clinical practice Thanks, improvement, and 4) advancing care information (information technology). Proposed measures in each of these domains provide a glimpse into the direction of future practice emphasis. Larry 1) Within the quality domain, outcomes of diagnostic accuracy, patient experience, and regional systems of care will be measured. Patient experience will measure meaningful areas, such as patient preferences for location of care (ED vs. primary care). REFERENCES: 2) The resource use domain will measure admission rates and 1. Western Journal of Emergency Medicine, Time to Focus on Improving Emergency De- testing rates, acknowledging that extra testing in the ED often partment Value Rather than Discouraging Emergency Department Visits, TJ Sugarman, results in the ability to find safe alternatives to hospital admission. November 2013. 2. Annals of Emergency Medicine, Value-Based Approaches for Emergency Care in a New Era, 3) The clinical practice improvement domain will measure an ED’s SA Farmer and A Brown, June 2017. safety net role (caring for uninsured and Medicaid patients), care coordination role (addressing the social determinants of health), 3. Annals of Emergency Medicine, Value-Based Approaches for Emergency Care in a New Era, and transfer coordination. L Medford-Davis, D Marcozzi, S Agrawal, et al, June 2017.
4) The advancing care information domain will measure bidirectional communication (between primary care and the ED) and use of the EMR and health information exchange to reduce testing and admission rates (3).
Far from a dystopia, the EM practice goals described are far more interesting and nuanced than currently acknowledged and incentivized. While ED length of stay is a key ED metric and a patient experience satisfier, in a value-based world the story is more complex. Time-sensitive conditions (STEMI, stroke, sepsis, trauma) require speed and proper sequence. However, for many conditions the test of time, coupled with aggressive treatment, may be needed to avoid a Clinically trained team hospital admission; understand and address the social determinants of health, coordinate care, and clearly communicate. This is a future Billing management services where clinical judgment and doctoring skills matter and our role as accountable stewards of resources is recognized. All of our clients are references Saving the system while improving the health of patients will require emergency physician leadership. California took a critical step towards R eimbu rsement coding by registered nurses universal insurance coverage by going all in with the Affordable Care Act. Coupled with our long history with managed care, we collectively practice EM in efficient ways that provide high value. California emergency physicians are leaders in social emergency medicine and research on special EM populations. As Dr. Fields has pointed out, we have created a blueprint of what a high value system looks like. Our C ONT A C T EM future will be tied to the relationships we form to ally with primary Andrea Brault M.D., MMM, FACEP (877)346-2211, ext. 278 | [email protected] care, hospital medicine, and post discharge care to create seamless 180 Via Verde Suite 100 | San Dimas, California 91773 transitions in the care continuum, with bidirectional communication
AUGUST 2017 | 5 ADVOCACY UPDATE |
2017 Legislative Leadership Conference attendees at the State Capitol in Sacramento in May 2017. ADVOCACY IN ACTION: Members Impacting Public Policy
Authors: Elena Lopez-Gusman & Kelsey McQuaid, MPA California ACEP takes pride in our advocacy efforts and the The Center will conduct research with a mission to provide the scientific evidence impact they have on the practice of emergency medicine. on which sound firearm violence preven- Our members are always the impetus for our advocacy ef- tion policies and programs can be based. forts, and sometimes it’s an individual member who takes Dr. Wintemute hopes the research done at the Firearm Violence Research Center up the charge on a specific public policy issue. will provide more insight into the nature of firearm violence; including the societal de- One such member is Dr. Garen Wintemute, In 2016, California ACEP supported an effort terminants of firearm violence, warning signs who has dedicated his career to under- by state Senator Lois Wolk and Dr. Wintemute of mass shootings, and the role of firearms in standing the causes of gun violence. He is a to create the University of California Firearm suicides, among others. professor of emergency medicine at UC Davis Violence Research Center. The Legislature cre- and, for over 30 years, Dr. Wintemute has re- ated the Center in the 2016-17 State Budget Up until days before the scheduled launch searched gun violence and has even paid for and allocated a five year grant of $5 million. date for the Center, it was unclear whether research out of his own pocket to the tune of Shortly thereafter, Dr. Wintemute was named it would become a reality. The University of $1 million. the head of the Center. California tried to control the funds and allo-
6 | LIFELINE a forum for emergency physicians in california cate them in a manner that is contrary to the ACEP Board in an effort to launch the project California ACEP on issues they are passionate legislation signed into law by the Governor. statewide. about, such as Dr. Andrew Fenton (POLST), After continued negotiations and advocacy Dr. Kevin Jones (ED violence), and Dr. Car- efforts by stakeholders, the Center launched California ACEP worked with Dr. Lev and a rieann Drenten (human trafficking), to name on July 1st. small work group to develop statewide safe a few. If there is an issue you’re passionate prescribing handouts and resources based about, we encourage you to reach out to us The Chapter has been committed to finding on the ones she had created for San Diego. and/or join a committee to help bring the is- solutions to reduce death and injury, whether Our handouts are now being used by over 70 sue to light. We’re here to help you improve it be caused by automobiles, drugs and al- coalition partners. your practice and the care your patients re- cohol, or firearms. That’s why we’re excited ceive. n about the UC Firearm Violence Research Cen- Another example is the work our Past-Presi- ter and why we’ve supported other public dent Dr. Marc Futernick has done to improve safety initiatives in the past. emergency psychiatric care. Dr. Futernick saw a problem that he wanted to help fix and One such public safety initiative was spear- ran for the California ACEP Board of headed by Dr. Larry Foreman. Dr. Foreman Directors with one goal in mind: worked at Arroyo Grande Community Hos- improving the way we care for pital, which was the closest hospital to the psychiatric patients in the ED. Oceano Dunes State Vehicular Recreation Area, a popular location to ride ATVs. He During Dr. Futernick’s time on treated a wide array of injuries due to ATV the Board, California ACEP has accidents in his emergency department (ED) supported numerous pieces of and took it upon himself to reduce the num- mental health legislation and has ber of ATV-related casualties. even sponsored 3 mental health bills in the last 3 years: AB 1300 (Ridley- California ACEP worked with Dr. Foreman to Thomas), AB 451 (Arambula), and AB sponsor SB 1228 (Maldonado) in 2008 to im- 1119 (Limόn). Dr. Futernick has been prove ATV safety by requiring and ATV rider a driving force behind this legislation education course for riders under the age of and there are many other members 16 and establishing guidelines for appropri- who have taken up the torch of im- ate ATV size based on the age of the rider. For proving emergency psychiatric nearly 10 years we’ve continued to work on care. improving ATV safety by taking positions on legislation. We have many mem- bers who have Similarly, California ACEP’s Past-President Dr. worked Roneet Lev became determined to reverse with the impact of opioid overdose and death in her county, San Diego. Dr. Lev built a coali- tion in San Diego and developed safe prescribing handouts to use in the ED. She then brought her work to the California
AUGUST 2017 | 7 GUEST ARTICLE | CONNECTED: Welcome to California ACEP’s New Online Member Community
Author: Kelsey McQuaid, MPA California ACEP is pleased to announce the launch of our new website and online member community called CONNECTED!.
We’ve been working hard on updating our look and feel and hope that you will find everything you need on our new member community. The community is similar to Facebook and LinkedIn; you’ll be able to connect with other California ACEP members, engage in discussions, join com- mittees, and read blog posts by fellow members. In the coming months we’ll be launching discussion groups on specific demographics and interests, such as: young physicians, women in emer- gency medicine, reimbursement, mass gathering medicine, and more. To log-in, you’ll want to click “Sign In” at the top-right of the website homepage. Once you’ve logged in, click on the manage profile link in order to edit your profile information and change your password. Please review all the information that was input into your record and make any changes, as necessary. Members were sent their login information in a July 14th email. If you have any questions about our new website or platform, please reach out to us. We welcome your feedback on ways to improve our resources and offerings. Visit the new website and online member community at www.californiaacep.org! n
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A Comparison of Chest Compression Quality Delivered During On-Scene and Ground Transport Cardiopulmonary Resuscitation
12 | LIFELINE a forum for emergency physicians in california Christopher S. Russi, DO* Lucas A. Myers, BAH‡ Logan J. Kolb, BS* Christine M. Lohse, MS† Erik P. Hess, MD, MSc*§ Roger D. White, MD¶
* Mayo Clinic, Department of Emergency Medicine, Rochester, Minnesota † Mayo Clinic, Division of Biomedical Statistics and Informatics, Rochester, Minnesota ‡ Mayo Clinic, Gold Cross, Rochester, Minnesota § Mayo Clinic, Division of Health Care Policy and Research, Rochester, Minnesota ¶ Mayo Clinic, Division of Cardiovascular and Thoracic Anesthesia, Division of Cardiovascular Diseases, Rochester, Minnesota
Section Editor: Mark I. Langdorf, MD, MHPE Submission history: Submitted February 2, 2016; Revision received May 11, 2016; Accepted June 4, 2016 Electronically published July 19, 2016 Full text available through open access at http://escholarship.org/uc/uciem_westjem DOI: 10.5811/westjem.2016.6.29949
INTRODUCTION: American Heart Association (AHA) guidelines recommend cardiopulmonary resuscitation (CPR) chest compressions 1.5 to 2 inches (3.75-5 cm) deep at 100 to 120 per minute. Recent studies demonstrated that manual CPR by emergency medical services (EMS) personnel is substandard. We hypothesized that transport CPR quality is significantly worse than on-scene CPR quality. METHODS: We analyzed adult patients receiving on-scene and transport chest compressions from nine EMS sites across Minnesota and Wisconsin from May 2008 to July 2010. Two periods were analyzed: before and after visual feedback. CPR data were collected and exported with the Zoll M series monitor and a sternally placed accelerometer measuring chest compression rate and depth. We compared compression data with 2010 AHA guidelines and Zoll RescueNet Code Review software. CPR depth and rate were “above (deep),” “in,” or “below (shallow)” the target range according to AHA guidelines. We paired on-scene and transport data for each patient; paired proportions were compared with the nonparametric Wilcoxon signed rank test. RESULTS: In the pre-feedback period, we analyzed 105 of 140 paired cases (75.0%); in the post-feedback period, 35 of 140 paired cases (25.0%) were analyzed. The proportion of correct depths during on-scene compressions (median, 41.9%; interquartile range [IQR], 16.1-73.1) was higher compared to the paired transport proportion (median, 8.7%; IQR, 2.7-48.9). Proportions of on-scene median correct rates and transport median correct depths did not improve in the post-feedback period. CONCLUSION: Transport chest compressions are significantly worse than on-scene compressions. Implementation of visual real- time feedback did not affect performance. [West J Emerg Med. 2016;17(5)634-639.]
AUGUST 2017 | 13 INTRODUCTION with a sternally positioned accelerometer to quantitatively measure the quality (rate and depth) of CPR. At all times during the study pe- The 2010 American Heart Association (AHA)/ International Liaison riod, prehospital providers were required to use a metronome during Committee on Resuscitation (ILCOR) Cardiopulmonary Resuscitation CPR, although verification of its use was not possible. (CPR) Guidelines call for a minimum chest compression rate of 100 to 120 compressions per minute and a minimum chest compression Correct CPR depth was defined as compressions of 1.5 to 2 inches depth of 1.5 to 2 inches (3.75-5 cm).1 Two clinical studies have reported (3.75-5 cm). Correct CPR rate was defined as 100 to 120 compressions the quality of chest compressions delivered before emergency medi- per minute. We calculated the proportions of correct CPR depths and cal services (EMS) transport and the quality of those delivered during rates as percentages of all compressions administered during each transport.2,3 Further evidence has suggested that visual, automated CPR episode. Hands-off time was not measured during this study. Only CPR feedback improves CPR quality.4,5 periods when compressions were done were analyzed. We analyzed all data with JMP Version 8.0 statistical software (SAS Institute, Inc). Research with the use of mannequins has shown that CPR quality is inferior on a moving stretcher6 and in a moving ambulance.7 We Outcomes hypothesized that the quality of CPR during ambulance transport The primary outcome was the proportional rate and depth of CPR is significantly worse than CPR delivered in a static situation (“on compressions delivered during on-scene resuscitation and during scene”—e.g., on the ground or in the street). The aim of this study was transport resuscitation. Secondary outcomes were survival to admis- to compare the quality of CPR delivered by paramedics on scene to sion and discharge. the quality of CPR delivered by paramedics during transport in two distinct periods: before the use of visual feedback (“pre-feedback”) and Statistical Analysis after the use of visual feedback (“post-feedback”). Visual feedback was For comparisons of proportional rate and depth of compressions be- deployed systemwide during the study period, and we thought that tween on-scene and transport resuscitations, we analyzed the cohort this was an important confounding variable that could not be ignored; in two groups: pre-feedback period (without visual feedback from the hence, we used two distinct periods with matched cases. Zoll monitor) and postfeedback period (with visual feedback from the Zoll monitor) because we considered this a substantial confounding METHODS variable. We used the Wilcoxon signed rank test for paired patient data in each group and the Kruskal-Wallis test for nonpaired data. We used Study Setting and Population simple descriptive statistics for measures of central tendency to de- Mayo Clinic Medical Transport (MCMT) is a ninesite EMS system with scribe demographic and time data. All probability tests were 2-tailed a public service area in Minnesota and Wisconsin. In October 2009, with an α level of .05. MCMT incorporated CPR feedback technology using a sternally po- sitioned accelerometer to quantitatively measure the quality (i.e., the RESULTS rate and depth) of CPR. We conducted this study with the nine EMS sites in Minnesota and Wisconsin where prehospital care is provided Participants by MCMT’s Gold Cross Ambulance Service. Resuscitation protocols A total of 140 adults had CPR performed on scene and were then trans- are identical at each site. This is an a priori secondary analysis of data ported and required CPR at some time during transport. obtained from a large recently published prospective multicenter Descriptive Data clinical trial on adult patients treated with CPR in the prehospital envi- ronment.8 We included adults (age ≥18 years) who had nontraumatic Table 1 summarizes cohort demographic features, including age, sex, out-of-hospital cardiac arrest, received CPR on scene, and were sub- and on-scene and transport times and distances. There were no signifi- sequently transported with ongoing CPR in an ambulance. The null cant differences between groups when compared by visual feedback hypothesis was that there is no difference in proportional delivery of period (Table 2). correct CPR depth and rate between on-scene CPR and transport CPR. Main Results Data Collection and Processing In the pre-feedback period, we analyzed 105 of 140 paired cases We obtained institutional review board approval from the hospitals (75.0%); in the post-feedback period, 35 of 140 paired cases (25.0%) that received patients. were analyzed (Figure). Demographic data and transport times were collected with the use Pre-feedback Period (n=105) of Zoll RescueNet Code Review data and documentation software The proportion of correct depths during on-scene compressions (Zoll Medical Corp). CPR quality indicators (rate and depth) were ab- (median, 41.9%; interquartile range [IQR], 16.1%-73.1%) was higher stracted with the use of Zoll M series CPR accelerometer technology compared to the paired transport proportion (median, 8.7%; IQR, and entered into an Excel database (Microsoft Corp). We categorized [2.7%-48.9%]). Paired analysis with the Wilcoxon signed rank test CPR depth and rate as “above (deep),” “in,” or “below (shallow)” the target showed that the difference was significant (p<0.0001). The proportion range according to AHA guidelines. of correct compression rates during on-scene CPR (median, 45.5%; IQR, Classification of Time Periods and Quality of CPR [9.9%-60.7%]) was higher compared to the paired transport proportion (median, 11.1%; IQR, [5.8%- 34.5%]). Paired analysis with the Wilcoxon In October 2009, MCMT and Gold Cross Ambulance Service incorpo- signed rank test showed that the difference was significant (p<0.0001) rated visual CPR feedback technology (Zoll Medical Corp) in all sites Post-feedback Period (n=35)
14 | LIFELINE a forum for emergency physicians in california TABLE 1. Cohort demographic and clinical features.
FEATURE VALUE
Age, mean (95% CI), y 65.6 (62.9-68.2) Male, % of patients (95% CI) 67.4 (58.9-74.9) First rhythm, median (%)a Ventricular fibrillation 39 (30.2) Ventricular tachycardia 1 (0.8) Nonshockable (pulseless electrical activity and asystole) 86 (66.7) Not documented 3 (2.3) On-scene care time, median (IQR), min 18.7 (11.2) Estimated patient weight, mean (95% CI), kg 91.2 (86.3-96.1) Distance from scene to hospital, median (IQR), km 5 (10) CPR duration, median (IQR), min On-scene 7.7 (10.1) Transport 2.2 (3.3) Correct rate, median (IQR), % On-scene 45.8 (49.8) Transport 11.5 (39.3) Correct depth, median (IQR), % On-scene 48.3 (61.0) Transport 9.8 (54.8) Disposition, No. of patients (%) Died as inpatient 67 (51.9) Discharged alive 33 (25.6) Hospitalized at end of study 29 (22.5)
CPR, cardiopulmonary resuscitation; IQR, interquartile range; CI, confidence intervala , Documented by Gold Cross Ambulance personnel
TABLE 2. Cohort descriptive features by visual feedback period.
FEATURE PRE-FEEDBACK (N=105) POST-FEEDBACK (N=35) P a
Age, median (IQR), y 66.0 (22.0) 66.5 (23.5) .86 Male, % 67.4 67.6 .98 Time, median (IQR), min On-scene 19.2 (10.4) 18.3 (12.8) .62 Transport 6.0 (5.0) 6.0 (6.1) .78 Destination, median (IQR), km To scene 5.0 (6.7) 5.0 (8.3) .40 To hospital 5.0 (10.0) 4.0 (11.7) .21
IQR, interquartile range a ,Comparison of medians with use of nonparametric tests (Wilcoxon signed rank test)
AUGUST 2017 | 15 FIGURE. Patient flowchart. Cardiopulmonary Despite our expectation that visual feedback technology during CPR would assist in providing the correct rate and depth of compression, resuscitation (CPR) was administered without regardless of location, we showed that compression depth was statis- automated visual feedback to 105 patients; CPR tically worse for patients receiving CPR while being transported in an ambulance compared to patients receiving on-scene CPR. The correct was administered with automated visual feed- rate during transport compared to on-scene CPR was not significantly back to 35 patients. different; however, despite the study not having the power to detect a difference, the median absolute percentage difference of 29.2% is concerning. That is, the CPR rate during transport was nearly one-third worse than the rate during on-scene resuscitation despite its lack of 384 Screened for both on-scene and transport CPR statistical significance. May 2008 to July 2010 Further, a subgroup analysis was done on the 71.4% of patients for whom full mortality data existed. Visual feedback provided no statisti- cally significant improvement in mortality as measured by discharge from the hospital. 140 (36.5%) 244 (63.5%) Strengths and Limitations of the Study Met inclusion criteria Excluded This project had several important limitations. First, we did not ac- count for provider fatigue as a factor in poor CPR performance. Data for this confounder are impossible to collect from transport records. Our suspicion is that on-scene fatigue was not a factor because our 35 (25.0%) CPR with 105 (75.0%) CPR without practice is to change providers every two minutes, but it could con- automated visual feedback automated visual feedback found the transport phase results because often only one provider is in the patient compartment. However, this effect is likely small given that the median transport time was six minutes. We did not account for the provider type and aerobic health of the The proportion of correct depths during on-scene compressions (me- provider. Our providers, as is likely true in most systems, include dian, 75.7%; IQR, [36.3%-95.1%]) was higher compared to the paired EMTs, paramedics, and firefighters who have a broad range of physi- transport proportion (median, 14.0%; IQR, [4.8%-90.8%]). The difference cal abilities. was significant (p<0.0001). The proportion of correct compression rates during on-scene CPR (median, 48.2%; IQR, [14.7%-62.4%]) was Our study did not account or measure hands-off time as has been higher compared to the paired transport proportion (median, 19.0%; done in previous studies. Our analysis quantified only the periods IQR, [9.5%-60.2%]). The difference was not significant (p=0.079). when compressions were done in each respective resuscitation phase (on scene vs transport). Handsoff time has been clearly associated Other Analyses with increased mortality; however, our aim was to show the quality of Effect of Visual Feedback on On-Scene and Transport CPR what was delivered rather than the amount. Proportions of on-scene median correct rates and transport. median To our knowledge, the Zoll accelerometer has not been prospectively correct depths did not improve after the initiation of visual feedback validated with outcomes assessment (i.e., survival) in moving ambu- (Kruskal-Wallis test; p=0.28 and 0.07, respectively). However, propor- lances. tions of on-scene median correct depths and transport median correct Comparison with Other Published Studies rates improved significantly (p=0.0006 and p=0.03, respectively). To our knowledge, this study is the third showing how transport af- Effect of Visual Feedback on Mortality fects the quality of CPR delivered. Olasveengen et al2 demonstrated Mortality data were complete for 100 of the 140 patients (71.4%). We similar findings with a focus on the rate and the compression ratio. A categorized mortality as either “discharged alive” or “died as inpatient.” recent study found that patients achieving out-of-hospital return of In this subgroup, the Fisher exact test showed no statistically signifi- spontaneous circulation (ROSC) experienced another cardiac arrest cant difference in survival after implementation of visual feedback 38% of the time.9 These high rates of rearrest in patients with ROSC (p=0.28, odds ratio, 0.48; 95% CI, [0.15-1.58]). show the need to not only anticipate the high potential for rearrest in those transported but the need to improve CPR quality during DISCUSSION transport. Summary of Major Findings Inappropriate compression depth has been associated with worse 5,10 Our study showed that, without visual feedback technology, the depth outcomes. In the present study, the difference between the propor- and rate of compressions during CPR while transporting a patient were tion of correct depths during on-scene compressions (median, 75.7%) significantly worse than during on-scene resuscitation. However, both and the proportion of correct depths during transport (median, 14.0%) depth and rate were suboptimal, regardless of the environment where was 61.7%. the resuscitation occurred. Debate about CPR devices and marketing of mechanical CPR devices
16 | LIFELINE a forum for emergency physicians in california has grown along with evidence of their potential efficacy.11,12 The key Address for Correspondence: Christopher S. Russi, DO, Mayo Clinic, element in the present study is that the on-scene environment is a rel- Department of Emergency Medicine, 200 First St SW, Rochester, MN atively static environment in which to perform CPR compared to the 55905. Email: [email protected]. more dynamic environment of the patient compartment in an ambu- lance. Although on-scene CPR may occur in challenging and austere Conflicts of Interest: By the WestJEM article submission agreement, all locations, the on-scene environment does not include the types of ex- authors are required to disclose all affiliations, funding sources and ternal acceleration forces experienced in a moving ambulance. financial or management relationships that could be perceived as po- An additional factor likely contributing to poor CPR performance in tential sources of bias. The authors disclosed none. an ambulance is the change in rescuer posture. In the on-scene en- Copyright: © 2016 Russi et al. This is an open access article distributed vironment, the patient is often on the floor or on the ground, so that in accordance with the terms of the Creative Commons Attribution the rescuer can kneel beside the patient. In an ambulance, the rescuer (CC BY 4.0) License. See: http://creativecommons.org/ licenses/by/4.0/ must stand and lean because the patient is on a cot, fairly low to the floor. Studies have determined the ideal bed height for optimal com- pression quality and have shown that a rescuer’s performance is worse in a standing position than in a kneeling.13 However, secured ambu- lance cots are not adjustable. REFERENCES We believe that future research needs to address how to create a more 1. Sayre MR, Koster RW, Botha M, et al; Adult Basic Life Support Chapter Collaborators. Part 5: static environment for performing quality CPR during transport. Most Adult basic life support: 2010 International Consensus on Cardiopulmonary Resuscitation patients in the present study had ROSC before transport and were and Emergency Cardiovascular Care Science With Treatment Recommendations. Circula- presumed to have a much higher likelihood of survival. However, a tion. 2010;122(16):S298-324. Erratum in: Circulation. 2013;128(19):e393. concerted effort should always be made to stabilize a patient’s condi- tion before transport, but if rearrest occurs during transport, CPR must 2. Olasveengen TM, Wik L, Steen PA. Quality of cardiopulmonary resuscitation before and be resumed in the ambulance. If quality CPR cannot be provided dur- during transport in out-of-hospital cardiac arrest. Resuscitation. 2008;76(2):185-90. ing transport arrest, several questions need to be considered: 3. Odegaard S, Olasveengen T, Steen PA, et al. The effect of transport on quality of cardiopul- monary resuscitation in out-of-hospital cardiac arrest. Resuscitation. 2009;80(8):843-8. 1. Should protocols mandate that EMS providers stop the ambu- lance if CPR resumption is necessary? 4. Dine CJ, Gersh RE, Leary M, et al. Improving cardiopulmonary resuscitation quality and resuscitation training by combining audiovisual feedback and debriefing. Crit Care Med. 2. Should EMS providers have mechanical CPR devices at their 2008;36(10):2817-22. disposal in anticipation of the need for CPR during transport? 5. Wik L, Kramer-Johansen J, Myklebust H, et al. Quality of cardiopulmonary resuscitation 3. Should the monitors be placed in an optimal visual position during out-of-hospital cardiac arrest. JAMA. 2005;293(3):299-304. in the ambulance to take full advantage of the visual feedback 6. Kim JA, Vogel D, Guimond G, et al. A randomized, controlled comparison of cardiopulmo- markers? nary resuscitation performed on the floor and on a moving ambulance stretcher. Prehosp Emerg Care. 2006;10(1):68-70. 4. Should clear audio feedback be provided at all times, aug- menting the visual feedback? 7. Stone CK and Thomas SH. Can correct closed-chest compressions be performed during prehospital transport? Prehosp Disaster Med. 1995;10(2):121-3. 5. Should extra crew members be in the patient compartment of 8. Hess EP, Agarwal D, Myers LA, et al. Performance of a rectilinear biphasic waveform in the ambulance to serve as coaches? defibrillation of presenting and recurrent ventricular fibrillation: a prospective multicenter Our study showed several interesting results. Clearly, the transport pe- study. Resuscitation. 2011;82(6):685-9. riod, regardless of visual feedback, had a significantly worse quality of 9. Salcido DD, Stephenson AM, Condle JP, et al. Incidence of rearrest after return of spontane- CPR rate and depth during compressions. On-scene administration of ous circulation in out-of-hospital cardiac arrest. Prehosp Emerg Care. 2010;14(4):413-8. compressions of the correct depth improved significantly after imple- menting visual feedback; however, the other quality markers showed 10. Bohn A, Weber TP, Wecker S, et al. The addition of voice prompts to audiovisual feedback and debriefing does not modify CPR quality or outcomes in out of hospital cardiac arrest: a no improvement or marginal benefit. prospective, randomized trial. Resuscitation. 2011;82(3):257-62. CONCLUSION 11. Casner M, Andersen D, Isaacs SM. The impact of a new CPR assist device on rate of re- turn of spontaneous circulation in out-of-hospital cardiac arrest. Prehosp Emerg Care. Despite the presence or absence of a visual feedback tool during car- 2005;9(1):61-7. diopulmonary arrest, in a comparison with on-scene CPR, the quality of CPR delivered during transport was significantly worse. Further work 12. Liao Q, Sjoberg T, Paskevicius A, et al. Manual versus mechanical cardiopulmonary resusci- should assess the effects of ambulance monitor locations, ambulance tation: an experimental study in pigs. BMC Cardiovasc Disord. 2010;10:53. configurations to improve rescuer position, audio feedback systems or 13. Cho J, Oh JH, Park YS, et al. Effects of bed height on the performance of chest compres- coaches, and mechanical CPR devices. n sions. Emerg Med J. 2009;26(11):807-10.
AUGUST 2017 | 17
California ACEP Annual Assembly
SATURDAY, SEPTEMBER 23, 2017
Westin Pasadena 191 N Los Robles Ave., Pasadena, California 91101 | Phone: (626) 792-2727
ADVANCED 2017 is California ACEP’s annual conference. Medical Student Registration Price: $49 This one-day conference will empower members through Phisician Registration Regularly: $159 Early Bird Price: $129 diverse lectures on topics from clinical to policy to wellness and leadership. Resident Registration Price: $49
GENERAL SESSION MATCHED: Medical Student Track
8:00 am - 9:00 am Continental Breakfast/ Early AM Networking 10:00 am - 11:00 am Ask the Experts -EM Program Directors Panel Discussion 9:00 am - 9:10 am Introduction & Overview PRESENTER: Tomer Begaz, MD, Caitlin Bailey, MD PRESENTERS: Jorge Fernandez, MD and Lawrence Stock, MD, FACEP 11:00 am - 11:15 am Lightning Lecture: Myths and Truths about EM Residency 9:10 am - 9:40 am Talk 1: Keynote PRESENTER: Linda Herman, MD, FACEP PRESENTER: Paul Kivela, MD, MBA, FACEP 11:15 am - 11:30 am Lightning Lecture: Emergency Medical Services and Mass Casualty Response 9:40 am - 10:00 am Lightning Series: Take 1 PRESENTER: Melody Glenn, MD PRESENTERS: John Costumbrado, MD; Moosa Azadian, MD; and Jessica Rainey, MD 11:30 am - 11:45 am Lightning Lecture: Community EMergency Medicine from an Academic EM Perspective 12:00 pm - 1:20 pm Lunch and Awards PRESENTER: Al’Ai Alvarez, MD PRESENTERS: Vivia Reyes, MD, FACEP and Lawrence Stock, MD, FACEP 3:20 pm - 3:40 pm Talk 10: Human Trafficking and Being A Leader 11:45 am - 12:00 pm Lightning Lecture: So you think you are interested in global health? PRESENTER: Carrieann Drenten, MD PRESENTER: Matthew Waxman, MD, DTMH 3:40 pm - 4:00 pm Lightning Series: Take 4 12:00 pm - 1:20 pm Break, Awards & Lunch PRESENTERS: Allen Chang, MD; Kevin Jones, DO; and Fred Dennis, MD, MBA, FACEP 1:30 pm - 2:30 pm “Low Stress” Mock Interviews 4:00 pm - 5:30 pm Farewell and Happy Hour with Live Band PRESENTERS: Tomer Begaz, MD and Caitlin Bailey, MD 2:30 pm - 3:30 pm Residency & Fellowship Fair PRESENTERS: Tomer Begaz, MD and Caitlin Bailey, MD EMPOWERED: Attending Physician Track 10:00 am - 10:20 am Talk 2: Turning Off the Faucet: Bleeding & New Anticoagulants SIMULATED: Resident Track PRESENTER: Tarlan Hedayati, MD, FACEP 10:20 am - 10:40 am Break 10:00 am - 12:00 pm SIMULATED: Morning Rounds PRESENTERS: Ian Julie, MD, FACEP; Joshua Hui, MD, MSCR, FACEP; and Leslie Oyama, MD, FACEP 10:40 am - 11:00 am Talk 3: 5150 Remixed: Psych Boarding & Ways to Fix It PRESENTER: Marc Futernick, MD, FACEP 1:20 pm - 3:20 pm SIMULATED: Final Rounds and Awards PRESENTERS: Ian Julie, MD, FACEP; Joshua Hui, MD, MSCR, FACEP; and Leslie Oyama, MD, FACEP 11:00 am - 11:20 am Talk 4: Antibiotic Stewardship; Why EM Should Be Leading PRESENTER: Larissa May, MD, FACEP 11:20 am - 11:40 am Talk 5: “Why Wait? File A Complaint!” CA Medical Board PRESENTER: Greg Guldner, MD, FACEP This activity has been planned and implemented in accordance with the accreditation 11:40 am - 12:00 pm Lightning Series: Take 2 requirements and policies of the Accreditation Council for Continuing Medical Education PRESENTERS: Kimberly Schertzer, MD, FACEP; Susanne Spano, MD, FACEP; and Ryan Pedigo, MD (ACCME) through the joint providership of the American College of Emergency Physicians 1:20 pm - 1:40 pm Lightning Series: Take 3 and California ACEP. The American College of Emergency Physicians is accredited by the PRESENTERS: Melody Glenn, MD; Viveta Lobo, MD; and Linda Herman, MD, FACEP ACCME to provide continuing medical education for physicians. 1:40 pm - 2:00 pm Talk 6: Tweaking the EMR in A Disaster: A Case Study PRESENTER: Ian P. Brown, MD, FACEP The American College of Emergency Physicians designates this live activity for a maximum of 2:00 pm - 2:20 pm Talk 7: Mindfulness Matters: Using mindfulness to relieve pain 4.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate and anxiety with patients with the extent of their participation in the activity. PRESENTER: Paula Whiteman, MD, FACEP 2:20 pm - 2:40 pm Talk 8: Hot Stuff: Single Payer, EM, and California ACEP ADVANCED 2017 has been approved by the American College of Emergency Physicians for a PRESENTERS: Lawrence Stock, MD, FACEP and Wesley Fields, MD, FACEP maximum of 4.25 hour(s) of ACEP Category I credit 2:40 pm - 3:00 pm Break BRN: California ACEP is approved by the California Board of Registered Nursing for 4.25 3:00 pm - 3:20 pm Talk 9: Cutting Edge Tech & 21st Century Learning contact hours, Provider Number 15059. PRESENTERS: Paul Juhn and Tarlan Hedayati, MD, FACEP
For more information Contact: [email protected] | 916.325.5455 CEMAF ANNOUNCEMENTS |
The California Emergency Medicine Advocacy Fund (CEMAF) has transformed California ACEP’s advocacy efforts from primarily legislative to robust efforts in the legislative, regulatory, legal, and through the Emergency Medical Political Action Committee, political arenas. Few, if any, organization of our size can boast of an advocacy program like California ACEP’s; a program that has helped block Medi-Cal provider rate cuts, lock in $500 million for the Maddy EMS Fund over the next 10 years, and fight for ED overcrowding solutions! The efforts could not be sustained without the generous CALIFORNIA ACEP PRESENTS ADVANCED 2017 support from the groups listed below, some of whom have September 23, 2017, The Westin Pasadena, Pasadena, CA http://californiaacep.site-ym.com/events/EventDetails.aspx?id=980933 donated as much as $0.25 per chart to ensure that California ACEP can fight on your behalf. Thank you to our 2015-16 CALIFORNIA ACEP CO-SPONSORED CONFERENCES contributors (in alphabetical order): 40th Annual Emergency Medicine in Yosemite • Alvarado Emergency Medical Associates January 10-13, 2018 • Antelope Valley Emergency Medical Associates Yosemite, CA http://www.yosemitemef.org/ • Beach Emergency Medical Associates Ohio ACEP Emergency Medicine Board Review Course • Berkeley Emergency Medical Group February 1-5, 2018 • Centinela Freeman Emergency Medical Associates San Diego Marriott La Jolla http://www.ohacep.org/aws/OACEP/pt/sp/cme_oralboard • CEP America • Chino Emergency Medical Associates CALIFORNIA ACEP IS DELIGHTED TO ANNOUNCE THE • Coastline Emergency Physicians Medical Group RESULTS FROM THE 2017 BOARD ELECTION, CONDUCTED • Culver Emergency Medical Group FROM MAY 15 TO MAY 31. • Eden Emergency Medical Group Directors Re-Elected: • Vikant Gulati, MD, FACEP • Hollywood Presbyterian Emergency Medical Associates • John T. Ludlow, MD, MBA • Mills Peninsula Emergency Medical Group • Sujal Mandavia, MD, FRCP(C), FACEP • Vivian Reyes, MD, FACEP • Montclair Emergency Medical Associates Newly-Elected Directors: • Napa Valley Emergency Medical Group • Kapil Dhingra, MD, MBA, FACEP • Orange County Emergency Medical Associates • Douglas E. Gibson, MD, FACEP • Karen Murrell, MD, MBA, FACEP • Pacific Coast Emergency Medical Associates • Pacific Emergency Providers WELCOME TO OUR NEW BOARD MEMBER • Pacifica Emergency Medical Associates California ACEP would also like to acknowledge Dr. Luke Palmisano, who • Riverside Emergency Physicians was appointed to fill the remainder of Dr. Rodney Borger's term (ending • San Dimas Emergency Medical Associates in 2018) on the Chapter Board. Dr. Palmisano is from LAC+USC. • Sherman Oaks Emergency Medical Associates Congratulations to all of the new and returning Board members! • South Coast Emergency Medical Group, Inc. • Tarzana Emergency Medical Associates • TeamHealth • Temecula Valley Emergency Physicians, Inc. • US Acute Care Solutions • Valley Emergency Medical Associates • VEP Healthcare, Inc. • Valley Presbyterian Emergency Medical Associates • West Hills Emergency Medical Associates
20 | LIFELINE a forum for emergency physicians in california | CALIFORNIA ACEP UPCOMING MEETINGS & DEADLINES
For more information on upcoming meetings, please e-mail us at [email protected]; unless otherwise noted, all meetings are held via conference call.
AUGUST 2017 AUGUST 2017
SUN MON TUES WED THURS FRI SAT Chapter Board of Directors Retreat 16th - 17th Sacramento, CA 1 2 3 4 5
21st Legislature Reconvenes 6 7 8 9 10 11 12
13 14 15 16 17 18 19
20 21 22 23 24 25 26 SEPTEMBER 2017 27 28 29 30 31
1st Legislation Fiscal Deadline
Labor Day Holiday 4th Chapter Office Closed SEPTEMBER 2017 Reimbursement Committee 12th Conference Call SUN MON TUES WED THURS FRI SAT
15th End of 2017 Legislative Session 1 2
3 4 5 6 7 8 9 18th Legislative Interim Recess Begins 10 11 12 13 14 15 16 Chapter Board of Directors Meeting 22nd Pasadena, CA 17 18 19 20 21 22 23
ADVANCED 2017: California ACEP Annual Assembly 24 25 26 27 28 29 30 23rd The Westin Pasadena, Pasadena, CA
OCTOBER 2017 OCTOBER 2017
SUN MON TUES WED THURS FRI SAT Government Affairs Committee (GAC) 19th Conference Call 1 2 3 4 5 6 7 ACEP Council 27th-28th 8 9 10 11 12 13 14 Washington, DC
ACEP17 15 16 17 18 19 20 21 29th-November 1 Washington, DC 22 23 24 25 26 27 28
29 30 31
AUGUST 2017 | 21 CAREER OPPORTUNITIES |
DOWNTOWN LOS ANGELES: Emergency Physician needed. $350,000 + SOUTHERN CALIFORNIA OPPORTUNITIES: incentive per year, malpractice paid, half days, half nights. ABEM ABOEM with experience. Present core group average 23 yrs tenure. 36,000 annual visits, • Tustin, CA - Orange County - 73-bed community hospital, 8-bed ER, paramedic receiving (no peds) STEMI Stroke, physician coverage 36-40 hrs/day, paramedic receiving, low volume. 10 x 24hr = $240,000/yr + incentive NP & PA coverage 12-20 hrs/day • East Los Angeles - 120-bed community hospital urgent care (non FAX CV to 213 482 0577 or call 213 482 0588 or [email protected] paramedic receiving) volume 700/mo. Guarantee $100/hr. • Norwalk, CA - 60-bed hospital. 500-600 patient/mo. Paramedic receiving. LONG BEACH, CALIFORNIA: VAMC in beautiful Long Beach, CA seeks EM $110/hr. physicians along with FP and IM with EM experience. Low acuity, flexible FAX CV to 213 482 0577 or call 213 482 0588 or email [email protected] schedule, day and night shifts available. Contact Tammy Spruill at 314-744-4246 [email protected] or visit www.spectrumhealth.com. VENTURA CALIFORNIA: New hospital under construction and scheduled to open in the fall of 2017. Central coast of California and 70 miles from LAX. Positions available in two facilities for BC/BE emergency physician. STEMI NEWPORT BEACH, CALIFORNIA: Newport Emergency Medical Group is Center, Stroke Center with on-call coverage of all specialties. Teaching facility accepting applications from Board Certified or eligible Emergency Physicians for with residents in Family Practice, Surgery, Orthopedics and Internal Medicine. a Full Time position. Newport Emergency is a democratic, independent group Admitting hospital teams for Medicine and Pediatrics. Twenty-four hour OB associated with Hoag Hospital since 1981. The Hoag Irvine ED averages 100 coverage in house and a well established NICU. Physician’s shifts are 9 hrs and patients per day and is staffed with 4 overlapping EDMD shifts and 3 PA shifts 12 hours of PA/NP coverage. All shifts and providers have scribe services 24/7. per day. Scribes assist each provider. SCM EMR will transition to EPIC over the Affiliated hospital is a smaller rural facility 20 minutes from Ventura in Ojai. next year. A partnership track is available. The ED is being expanded to double Malpractice and tail coverage is provided. New hires will work days, nights, capacity to 36 beds with completion scheduled for 8/18. Acceptable applicants weekends and weekdays. will be contacted to discuss the position in detail. Send resume to Alex Kowblansky MD FACEP at [email protected] Send indication of interest and CV to [email protected]
SOUTHERN CALIFORNIA: LA/OC area single hospital democratic group 40+ year contract holder with low turnover seeks BC/BE Emergency Physician for FT/PT position. We are a STEMI/Stroke Receiving Center with an 80K/year census. We have 24/7 in-house hospitalist and intensivist coverage along with To advertise with Lifeline and to take advantage of our circulation of over a NICU and FP residency. The ED has 60 beds including Fast Track with PA/NP 3,000 readers, including Emergency Physicians, Groups, and Administrators coverage, provider in triage, Scribes, and triple physician coverage during peak throughout California who are eager to learn about what your business has hours. Competitive compensation with night differential, paid malpractice, and to offer them, please contact us at [email protected] or give us a call educational support. at (916) 325-5455. Email CV to [email protected] or Fax to 562-945-5283
22 | LIFELINE a forum for emergency physicians in california Looking forwing California an providersITLS list: course? EMREF offers the follo Riggs Ambulance Service Greg Petersen, EMT-P, Clinical Care Coordinator 100 Riggs Ave, Merced, CA 95340 Loma Linda University Medical Center Phone: (209) 725-7010 Lyne Jones, Administrativ e Assistant Fax: (209) 725-7044 Department of Emergency Medicine Email: [email protected] Web: www.riggsambulance.com American Health Education, Inc 11234 Anderson St., A108, Loma Linda, CA 92354 Perry Hookey, EMT-P Phone: (909) 558-4344 x 0 Rocklin Fire Department 7300B Amador Plaza Road, Dublin, CA 94568 Fax: (909) 558-0102 Chris Wade, Firefighter/Paramedic Phone: (800) 483-3615 Email: [email protected] 3401 Crest Drive, Rocklin, CA 95765 Email: [email protected] Web: www.llu.edu Phone: (916) 625-5311 Web: www.americanhealtheducation.com Medic Ambulance Fax: (209) 725-7044 James Pierson, EMT-P Email: [email protected] American Medical Response (AMR) 506 Couch Street, Vallejo, CA 94590-2408 Web: www.rocklin.ca.us Ken Bradford, Operations Phone: (707) 644-1761 Rural Metro Ambulance 841 Latour Court, Ste D, Napa, CA 94558-6259 Fax: (707) 644-1784 Brian Green, EMT-P Phone: (707) 953-5795 Email: [email protected] 1345 Vander Way, San Jose, CA 95112 Email: [email protected] Web: www.medicambulance.net Phone: (408) 645-7345 Compliance Training Napa Valley College Fax: (408) 275-6744 Jason Manning, EMS Course Coordinator Gregory Rose, EMS Co-Director Email: [email protected] 3188 Verde Robles Drive, Camino, CA 95709 2277 Napa Highway, Napa CA 94558 Web: www.rmetro.com Phone: (916) 429-5895 Phone: (707) 256-4596 Santa Rosa Junior College Public Safety Fax: (916) 256-4301 Email: [email protected] Training Center Email: [email protected] Web: www.winecountrycpr.com Bryan Smith, EMT-P, Course Coordinator 5743 Skylane Blvd, Windsor, CA 95492 CSUS Prehospital Education Program NCTI – National College of Technical Instruction Phone: (707) 836-2907 Derek Parker, Program Director Lena Rohrabaugh, Course Manager Fax: (707) 836-2948 3000 State University Drive East, Napa Hall, Sacramento, CA 333 Sunrise Ave Suite 500, Roseville, CA 95661 Email: [email protected] 95819-6103 Phone: (916) 960-6284 x 105 Web: www.santarosa.edu Office: (916) 278-4846 Fax: (916) 960-6296 Mobile: (916) 316-7388 Email: [email protected] WestMed College Email: [email protected] Web: www.ncti-online.com Brian Green, EMT-P Web: www.cce.csus.edu Oakland Fire Department 5300 Stevens Creek Blvd., Suite 200, San Jose, CA 95129-1000 Sheehan Gillis, EMT-P, EMS Coordinator Phone: (408) 977-0723 EMS Academy 47 Clay Street, Oakland, CA 74607 Email: [email protected] Nancy Black, RN, Course Coordinator Phone: (510) 238-6957 Web: www.westmedcollege.com 1170 Foster City Blvd #107, Foster City, CA 94404 Fax: (510) 238-6959 Phone: (866) 577-9197 Verihealth/Falck Northern California Email: [email protected] Fax: (650) 701-1968 Ken Bradford, Training Coordinator Web: http://www.oaklandnet.com/fire/ Email: [email protected] 2190 South McDowell Blvd, Petaluma, CA 94954 Web: www.caems-academy.com PHI Air Medical, California Phone: (707) 766-2400 Graham Pierce, Course Coordinator Email: [email protected] ETS – Emergency Training Services 801 D Airport Way, Modesto, CA 95354 Web: www.verihealth.com Mike Thomas, Course Coordinator Phone: (209) 550-0884 3050 Paul Sweet Road, Santa Cruz, CA 95065 Fax: (209) 550-0885 Phone: (831) 476-8813 Email: [email protected] Toll-Free: (800) 700-8444 Web: http://www.phiairmedical.com/ Fax: (831) 477-4914 Email: [email protected] Web: www.emergencytraining.com
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