By Jim Sideras
RN, MSN, CFO, CMO, MIFireE
EMS-related calls now account for up to 80 percent of the total received by many fire departments. With a range of EMS supplies available on the market today, here's three areas you can focus on — stethoscopes, suction units and bags — and some tips to aid your purchasing decision.
For every EMT and fire-paramedic, listening to both heart and lung sounds are a daily part of the job. Stethoscopes are important for listening and recording blood pressures. The decisions for buying stethoscopes are important since the paramedics are using them in noisy environments where hearing and differentiating sounds can be difficult. Here are some tips to help in your purchase of a stethoscope.
1. Tubing Design
There are two basic designs for tubing that goes from the chest piece of the stethoscope to the ear pieces. The original design uses two separate tubes, which is known as a Sprague design. The two tubes offer excellent hearing compared to a single tube. However, one significant problem is that the tubes often rub together and create more noise — or artifact — that can compromise what the paramedic is listening for.
Another style uses a single tube, rather than the dual tubes. These were designed to help eliminate some of the artifact. These models vary greatly in quality — lower quality models have narrow tubing that can make it difficult for the transmission of sounds. Lower end models are often found in clinics where they are used for taking blood pressures.
Bilumen tubing incorporates the best of both worlds. It uses a single tube that has a split lumen which goes to each earpiece. Basically, it has two tubes inside a single tube. This offers improved hearing without the artifact. This design was made very popular with the 3M Littman stethoscopes, started with their Cardiology series. As a personal preference, I have found the bilumen models to offer better sound quality and decreased artifact.
2. Chest piece design
There are two different designs for the chest piece of a stethoscope — combination or single design.
The combination chest piece has two heads that can be rotated to select from either a diaphragm or a bell. The diaphragm is used to listen to high frequency sounds, while the bell side is used to hear lower frequencies.
The single head chest piece uses a unique design. To hear low frequency sounds, one rests the chest piece in place with light pressure. To hear high frequency sounds, one applies firm fingertip pressure on the chest piece. This pressure alters the frequency response by changing the contact points. There are some newly designed single head chest pieces that use a lightweight acrylic design. This is intended to increase the amplification significantly.
The price of a stethoscope can vary greatly by the quality and design. The cheapest stethoscopes can cost as little as $5. On the other end of the spectrum, a 3M Littman Cardiology III can cost well over $160. A good quality stethoscope will cost around $50. If you are purchasing them in bulk quantities, there may be some negotiation of pricing leading to a significant savings in cost.
4. Test run
Before you purchase stethoscopes for your organization, get input from your people. Test various models on the market to determine what they feel works best in their working environment.
If you expect your paramedics to be able to differentiate lung and heart sounds in the back of an ambulance, you need to purchase a good quality stethoscope. It is one of the essential tools needed to provide the best level of patient care. Their input is valuable and it offers them ownership in the decision process.
5. Other considerations
Adult stethoscopes do not work well with pediatric patients. There are stethoscopes for pediatric, infant and newborn patients on the market. Those should be placed with other pediatric equipment.
Stethoscopes often disappear if they are set down. Members need to be aware of the cost stethoscopes, and how it impacts the organizational budget to replace them. Stethoscopes can be a status symbol in healthcare settings. I have seen med students, paramedics, and physicians ask to borrow expensive stethoscopes and "accidentally" walk off with them. This often happens during a busy or chaotic situation. If members are aware of the price, the loss of stethoscopes rarely happens.
Keeping a patient's airway clear is critical to patient survival. Suction units are vital to complete this task and maintain an open airway. There are many types and styles of suction units on the market. Here are some key points to consider before purchasing suction units.
1. Battery powered
Suction units are either battery or manually powered. Battery powered devices allow for continuous suction. They are easier to use comparing to having to manually pump while also manipulating a manual unit. When discussing battery powered devices, there are some other considerations.
One concern is how the units will be recharged. Outlets will need to be in place on the vehicles for that process. If carried on fire apparatus, chargers may need to be fitted into compartments.
Some battery powered units can also run on both DC and AC power. This can be a valuable option if the unit cannot be recharged in the event the battery goes dead between calls.
Battery powered units weigh more than manual units. This weight can vary with different models. The lightest units weigh around 3 pounds, with heavier units weighing over 10 pounds. However, lighter may not always be better since some of the weight can be in the battery and that can impact run time.
Prices range from $500 to $1,000.
2. Manually powered
There are also manually powered units that require the user to manually squeeze or pull a handle to generate suction. The suction in some units can match the battery powered units.
One major advantage is that there is no external power. This can be advantageous when the units are stored in vehicles without power outlets.
One disadvantage is that these units can be more difficult to operate depending on the presentation of the patient. The canisters for manually powered units are usually smaller in capacity. To compensate for this, some models have overflow ports that allow for emesis to be vented out the side when the canister is filled. This can create a problem regarding infection control and safety issues.
Prices range from $50 to $100.
3. Resupply / canisters
One expense that is often overlooked is associated with putting the units back into service. The costs will include the tubing, suction tip and canister. The cost that is specific to the suction unit is the canister. Some units have a specific canister that must be used with that particular model. Remember, crews should always be using disposable canisters.
When considering any suction unit, the resupply costs can be a hidden expense especially if you run a high volume of EMS incidents. Some suction units use a generic 1200cc canister with a cost of $4. These containers are large and inexpensive. If your organization has differing units and they all use generic canisters, your supply and restocking issues will decrease.
Other suction units will need a specific container that will only work in a particular suction unit. These can range in price up to $25 per canister. If used just once a week, these expensive canisters can add up to $1,300 per year. In addition, many of these specific canisters may only hold 300cc, and may need to be changed during an incident, which can also increase operational costs.
4. Try before you buy
Get demonstration units of the models that are being considered. Have your paramedics test them and see what they like. I suggest using Campbell’s Manhandler Soup to test your units. Add a little water and then test the units. Determine how well the units operate, how quickly the canisters will be filled, changed and battery life.
5. Other concerns
Some organizations carry both battery and manually powered units. This allows the ability to treat multiple patients. Also, in the event of a failure in the battery unit the crew will always have a backup unit.
When changing suction units, it is important to consider additional training for the new units. Each style of unit has its own particular controls and training prevents crew failure during high stress situations.
By Dan White
In my early years few departments used bags, as everything was in some kind of hard box. But the boxes were all heavy and hard to carry. I can remember one ambulance company that manufactured a wheeled cart to carry them and the monster defibrillator of that era. So in the early 80s, EMS providers started switching over to soft cases. The first of these were pretty cheaply constructed, but then along came Thomas Packs and Pacific Packs. People began to appreciate the ease of use and those wonderful shoulder straps. It wasn’t long before most EMS agencies were using soft cases. A good bag, properly engineered to the mission, can help you deliver better care more quickly. But a poorly designed bag can slow you down and create enormous frustration. Here are the top five considerations when selecting a new Trauma Bag or Medical Kit.
1. Consider the context. You must examine each new bag purchase in the context of how everything else is carried. The idea is to balance loads so that "no hand carries more than another." If you can more equally balance what gets carried, you will have a lot less fatigue and I believe have reduced injuries. This is not always possible; often one item will outweigh the rest.
Examples are when you are forced to carry steel E tanks, or perhaps a full-featured 12-lead defibrillator that will outweigh the other components. But don't make this situation worse. Some agencies insist on trying to combine everything in one huge bag.
2. Try them on. Buying a bag in a picture book or the internet for the first time is like getting a mail order wife. I highly recommend you get a sample and put your equipment in the bag. Stock it just as you plan to use it, and see how everything lays out. Then think about how you use these items. I’ve found what works best is to look at two specific but very different considerations.
1. Are the things you use the most often easily accessible?
2. Are the things you want instantly when you do need them (like an OPA) only one zipper-pull away?
When I design a bag I often use yellow post it notes to mark all the supplies first. I assign each item that will go inside the bag a score in two categories, for Frequency and Urgency. I use numbers to grade how many zippers I can use to organize the specific item. For example, an Oral Airway is not something I use very often. But when I do use it I want it right now. So I need to make it available with only one zipper between the rescuer and the airway.
A portable oxygen tank is something you use on almost every call. So it too needs to be immediately accessible. The oxygen supplies for it need to be right next to it. If you had to open yet another zipper to get the mask out for it, it would really slow you down.
3. Look at the details. Look carefully at the side and corner seams for signs of irregularity or puckering. A bag that isn’t cut correctly won’t assemble correctly.
Look at the handle attachments and shoulder strap mounts. Will they hold up to the weight you plan to load in it?
Look at the inside of the bag where the main zipper attaches. Is it single or double stitched, and how straight do the sew lines run? This is one spot on most bags where shoddy construction will be revealed most easily, particularly around the corners.
Check the impact liner. Is it cheap open cell foam they goes "pop" between your fingers and soon stops providing protection? Or is it high-density foam that will take years of abuse?
Is the bottom double-layered or reinforced in some manner? This is a primary wear point on many kits. It should also be constructed to resist fluid penetration.
4. Don't put a pig in a thimble. I've long suspected that the Hepatitis B vaccine is strangely contaminated. I have no other explanation for the apparent pathogen. It seems like all EMS people and only EMS people will always try to put 15 percent more stuff in the bag than it was designed to hold. It must be a virus. I've seen oxygen bags with 15 oxygen masks. This is ridiculous, but I think I know why some do it. It's because they don’t want to restock promptly after each call.
I worked at a station where if I was gone for a few days, the bag would inexplicably grow. So did the weight and also my frustration level when later on that shift I was trying to find something. If you overstuff your kits you make them harder to use and they also wear out sooner. Periodically go through your kits to look for items you never use. If you have not used it once in years, maybe it can stay on the truck.
5. Get everyone onboard. This is one purchase that you would be well advised to seek consensus on. EMS providers are deeply affected by changes in deployment systems. I suggest you leave the stocked "new" bag in the kitchen or somewhere for a few days. Give everybody a chance to see his or her stuff in the bag before you buy.
If you take a little extra time making a new bag purchase, you will potentially be rewarded with happier staff and a better-controlled budget. Failing to do a little homework can turn an organization into a simmering cauldron of discontent. A bag is used on every single call every single day. It's a personal extension of what we do and our principle means of affecting it. I can think of few purchases that can more deeply affect your daily work life.
- Any other suggestions? Anything we missed in the list above? Leave a comment below or e-mail firstname.lastname@example.org with your feedback.
James Sideras is a Division Chief for Sioux Falls Fire Rescue and has received both the Chief Fire Officer (CFO) and Chief Medical Officer (CMO) designations. He is a 25-year veteran of SFFR and a registered nurse with a Master of Science degree in nursing as a Clinical Nurse Specialist.
He received the Harvard University Fire Executive Fellowship, completed a Human Resources program through Cornell University, and the National Fire Academy's Executive Fire Officer program. He has spoken on various topics concerning fire and EMS at national and international conferences, including the World Conference on Disaster Management. He has written more than 20 articles on the fire service and EMS.
Jim is a member of the National Association of EMS Physicians, International Association of Fire Chiefs, the South Dakota Nurses Association, and the South Dakota EMT Association.
He can be contacted at: Sideras@post.harvard.edu.
Dan White, EMT-P, is the National Sales & Marketing Director for Truphatek, Inc., and was previously the director of Corporate Planning & Product Development for AllMed®. He has been continuously certified as an emergency paramedic since 1977, and a certified EMT, paramedic, and ACLS instructor since 1981.