Last updated 10th July 2024: Online ordering is currently unavailable due to technical issues. We apologise for any delays responding to customers while we resolve this. For further updates please visit our website https://www.cambridge.org/news-and-insights/technical-incident
We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.
This journal utilises an Online Peer Review Service (OPRS) for submissions. By clicking "Continue" you will be taken to our partner site
https://mc.manuscriptcentral.com/pdm.
Please be aware that your Cambridge account is not valid for this OPRS and registration is required. We strongly advise you to read all "Author instructions" in the "Journal information" area prior to submitting.
To save this undefined to your undefined account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your undefined account.
Find out more about saving content to .
To save this article to your Kindle, first ensure coreplatform@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below.
Find out more about saving to your Kindle.
Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
Purpose: Difficulties with physical assessment inherent to the helicopter environment have led to suggestion that aeromedical crews may be unable to identify hemo- or pneumothorax (HTX/PTX) while in-flight. This study was conducted to determine the frequency of missed HTX/PTX in trauma patients undergoing air transport.
Methods: One year (1994) of an air medical service's trauma transports to a Level I trauma center were analyzed to identify patients undergoing tube thoracostomy (TT) within 2 hours of trauma center arrival. Patients who had received intra-transport needle thoracostomy were excluded. Records were reviewed to determine how HTX/PTX was diagnosed at the trauma center.
Results: Only 11 patients who had not received aeromedical needle decompression underwent TT at the receiving center. Two of the 11 were trauma arrests and received TT as part of thoracotomy, without air or blood return on TT. None of the remaining 9 patients had TT on clinical suspicion alone. Four had normal physical examination and underwent TT after chest X-ray (CXR). Remaining patients had no HTX/PTX clues on exam or CXR; one had a small HTX identified on chest computed tomography and the other four received intra-operative TT because of rib fractures in the setting of multisystem trauma.
Purpose: Criteria (T&R) have been proposed to identify hypoglycemic patients who may be treated in the field and released without transport to the hospital. We prospectively evaluated the validity of these criteria.
Methods: Patients presenting with hypoglycemia (blood glucose [BG] <80 mg/dL) to paramedics of 2 EMS systems were prospectively enrolled and the presence of T&R criteria determined. T&R criteria did not influence transport. Hospital records were reviewed to determine interventions and outcomes.
Results: A total of 151 patients were enrolled (58% male, age 56 years (range 12–94), BG 33 ±16 mg/dL) and 99 (66%) were transported to the hospital and used to test the T&R criteria. Fifty-six patients (57%) were discharged from the ED and 43 (43%) received additional medications, or were admitted. T&R criteria identified 28 (29%) patients as appropriate for treatment and release. Of these, 5/28 (18%) received additional dextrose 50% (D50) or admission; 3 received D50 (despite normal mental status and documented ED BG >100 mg/dL), and 2 were admitted (transient ischemic attack and 1 hospital day, hypoglycemia and gastroenteritis and 2 hospital days). Sensitivity, specificity, negative and positive predictive values for the T&R criteria were: 41%, 88%, 51%, and 82%, respectively, and 44%, 95%, 54%, and 93%, respectively, if the 3 cases receiving D50 despite BG>100 mg/dL are excluded.
Purpose: To determine how often house fires occur at addresses visited previously for emergency medical services (EMS) and were these visits missed opportunities for a point-of-contact fire safety intervention.
Method: Retrospective analysis of all Fire Department (FD) responses during 1994. Data studied with descriptive statistics: reason for response, property type, dollar loss estimate, injuries, fatalities, fire cause, smoke detector operation.
Results: The FD responded to 94,378 requests for service at 43,556 addresses. 27,406 addresses generated one response. However, 16,150 addresses had multiple requests, receiving 66,972 responses. For the multiple requests, 1,162 addresses had a fire condition of which 728 addresses requested EMS prior to the fire condition. 215 were one/two-family dwelling addresses receiving 489 responses; mean 2.3 EMS responses prior to the fire condition. 182/215 (85%) of these addresses had complete data, incurring a dollar loss estimate of [US]$2,017,470, 33 injuries and 0 fatalities. The top five causes for the fire condition were children playing with smoking materials, arson, suspicious, scorched food and undetermined. 87/182 (49%) of the one/two-family dwellings had a smoke detector present. However, only 31/182 (17%) of the dwellings had an operational smoke detector.
Prehospital guidelines that define the clinical indications for spine trauma also serve as the criteria for selective spinal immobilization in the field. Therefore, these criteria are important for avoiding further spinal cord damage. Because some spine injuries may occur without neurological deficits or other clinical signs, the recommended field guidelines extend beyond the signs and symptoms and include mechanisms of injury or other injuries commonly associated with a high risk of spine injury.
Purpose: The practice of helicopter emergency medical services is variable in its mission profile, crew configuration, and transport capabilities. We sought to describe the characteristics of physician air medical directors in the United States.
Methods: We surveyed medical directors concerning their education, training, transport experience, and roles/responsibilities in critical care air transport programs.
Results: Two page surveys were mailed to 281 air medical services. Three programs merged or were dissolved. Data from 122/278 (43.9%) air medical directors were analyzed. One-hundred eleven respondents reported residency training in: Emergency Medicine (EM) 44 (39.6%), Internal Medicine (IM) 18 (16.2%), General Surgery (GS) 18 (16.2%), Family Practice (FP) 12 (10.8%), dual-trained (EM/IM, EM/FP, IM/FP) 11 (9.9%) and others 8 (7.2%). Medical directors’ roles/responsibilities consist, most frequently of: drafting protocols 108 (88.5%), QA/CQI activities 104 (85.3%), crew training 98 (80.3%), and administrative negotiations 95 (77.7%).
Purpose: Determination of rapid blood glucose (RGB) by colorimetric stick test aids in the prehospital identification and treatment of hypoglycemia. The test may be applied unnecessarily to patients not at risk for, and in clinical situations not associated with hypoglycemia. We attempted to estimate the rate of over-utilization of RGB in a large urban EMS setting.
Methods: All run sheets during a one week period from 7 sites providing radio command to both city and private EMS units serving a large urban population were screened. Those runs including RGB determination were further classified for presence or absence of a test indication. RGB was considered indicated with history or finding of: altered mental status, decreased level of consciousness, seizure, syncope and near syncope, generalized weakness or dizziness, with or without a history of diabetes.
Results: 613 RGB determinations were identified during one week (annual rate = 31,876). 371 (61%) met indication criteria for test performance, and 242 (39%) failed to meet criteria. The patient complaint in cases not meeting criteria included; cardiac - 80, respiratory distress - 66, trauma - 38, abdominal pain -15, burns - 12, OB - 8, CVA - 6. Moreover, among these patients fewer than half had a history of diabetes. If this rate of over-utilization were maintained for one year, in excess of 12,500 extra tests would be performed in this system.
Statement of Purpose: Prehospital death pronouncement policies are common among ground ambulances. No previous report has addressed such policies among Air Medical (AM) programs.
Statement of Methods: Statement of Methods: Structured telephone interviews of 125 of 143 (87%) AM programs (14 fixed wing, 68 rotor wing, 43 both) were conducted by research staff from 6 to 8/95.
Summary of Results: Summary of Results: Only fifty percent of AM crews are permitted to pronounce death in the field. Of those AM programs which permit pronouncement, direct medical command physician contact is required in 35% of pronouncements while 25% of programs utilize protocols. Of those AM programs which permit pronouncement, 77% of flight nurses can pronounce while only 33% of paramedics. Most programs (95%) conduct QA reviews of all deaths.
Statement of Conclusions: Prehospital death pronouncement is permitted in only 50% of AM programs. Since prehospital death pronouncement may obviate the need for AM transport, AM programs may be transporting clinically dead but unpronounced patients wasting scarce medical resources. This differs greatly from ground EMS programs where death protocols are common. Particularly puzzling is the small percentage of flight paramedics who are allowed to pronounce when compared to flight nurses since ground EMS pronouncements are performed by paramedics. AM programs should review their prehospital pronouncement protocols since managed care initiatives will drive health care organizations to abandon the wasteful practice of transporting clinically dead, but unpronounced, patients.
Hypothesis: Assessments to rule out cervical spine injury performed by emergency medical services (EMS) personnel correlate well with assessments performed by emergency department (ED) physicians. Methods: EMS providers completed a data form based on their initial assessment of all immobilized adult patients. Data collected included the presence or absence of: neck pain/tenderness; altered mental status; history of loss of consciousness; drug/alcohol use; neurological deficit; and other painful/distracting injury. Immobilization was considered to be indicated if any one of the six physical findings was present. The ED physician caring for the patient completed an identical data form based on his/her assessment. Physicians and EMS providers were blinded to each other's assessments. The amount of discordance between the physician and EMS assessments was analyzed using McNemar's Chi-Square for matched pairs.
Results: Five-hundred-seventy-three patients were included in the study. Physician and EMS assessments matched in 78.7% (n = 451) of the cases. In 13.6% (n = 78) of the cases, the EMS assessment indicated immobilization, but the physician assessment did not. In 7.7% (n = 44) of the patients, the physician assessment indicated immobilization, but the EMS assessment did not. The discordance between assessments was statistically significant (p <0.001). The presence of neck pain or tenderness accounted for the most discordance.
Objective: In our community the majority of patients presenting to the ED with acute chest pain come by car and do not recall their MD suggesting EMS. How do private MD's (our customers) view EMS?
Methods: Single mailing survey to all 238 physicians with admitting privileges in Medicine at an urban, tertiary care hospital (722 beds). EMS services provided by 2 private ALS systems and 35 volunteer ALS services operating under one physician medical director and identical protocols. Survey consisted of a scenario with a cardiac patient in the home of the MD, followed by opinions regarding EMS.
Results: 50% return. Respondents were 79% male, mean age 44 ±14yr, 68% internal medicine, 11% cardiologists. Given a patient with acute chest pain at the MD's home, 90% would call EMS, 10% would drive patient. 16% chose to drive for safety concerns, 83% because it was faster. Of those who chose EMS, 10% made negative comments regarding paramedics “playing doctor”. The following perceptions were noted: 3% of respondents indicated paramedics take “too long” to respond to calls, 26% indicated paramedics delay patient arrival to the hospital, and 6% indicated patients get too nervous if told to take an ambulance. On the other hand, 59% indicated EMS prevents cardiac arrests, 83% indicated paramedics can appropriately treat cardiac arrest, and 13% agreed paramedics can provide similar treatment for chest pain patients as hospitals.
Objective: To determine the accuracy of ambulance (AR), emergency department (EDR) and police (PR) records in describing motor vehicle crash (MVC) characteristics when compared to a standard - an in-depth motor vehicle crash investigation record (CIR).
Methods: Fifty-six MVC patients transported to a suburban, university hospital emergency department via ambulance and included in a crash investigation were identified. The time period was January 1993 through December 1995. Data sources were the AR, EDR, PR and CIR. The CIR was abstracted to a standard form. The other data sources were abstracted to a standard form using a retrospective, blinded review. Variables included occupant position, restraint use, air bag deployment, type of impact, ejection, and external cause of injury code. Accuracy was measured by determining percent agreement and Kappa for each data source compared to the CIR.
Results: Forty-six cases (82%) had one or more episodes of discordance. The mean percent agreement for the sources studied was AR 0.813, EDR 0.893 and PR 0.932. Mean values for Kappa were AR 0.712, EDR 0.831 and PR 0.885. Among variables, restraint use was determined with the least accuracy with means for percent agreement and Kappa of 0.792 and 0.674, respectively. For the AR, discordance was due to missing information almost 50% of the time.
Purpose: The wide spread use of orotracheal intubation with rapid sequence induction has made it difficult for EMS professionals to gain experience in nasotracheal intubation (NTI) in a controlled supervised setting. The purpose of this study was to determine if a training session on NTI with a breathing manikin can be used to improve skill and comfort of EMS professionals.
Methods: A prospective trial was conducted with a convenience sample of 16 emergency medical service professionals, previously trained in nasotracheal intubation techniques. For the training session a Laerdal airway manikin was modified by replacing the lungs with a bag-valve mask device, to simulate breathing with an inspiratory and expiratory phase. Following verbal instruction, and with direct supervision, each participant practiced NTI using the breathing manikin. Each participant completed a questionnaire, both before and after the training session, to determine self assessed comfort and skill level for both oral and nasal intubations (0 = lowest, 10 = highest). The pre and post intervention scores were compared using the Wilcoxon signed-rank test, £ = 0.01.
Objectives: To determine the accuracy of sphygmomanometers (SPHYGs) from a metropolitan EMS system and quantitate the mis-triage of adult blunt trauma patients based on erroneous systolic blood pressure (SBP) readings.
Methods-A: A cross-sectional, convenient sample of 150 SPHYGs was checked for accuracy using industry standards. Mean high and low deviations were calculated at 90 mmHg.
Methods-B: Retrospectively, a frequency distribution of the initial SBPs of all blunt trauma patients, age ≥21, seen in 1994 was plotted to characterize our study population. The numbers of patients potentially over- or under-triaged were identified when their reported SBP was corrected for using the mean high and low deviation plus 2 SDs.
Results-A: Overall, 25.3% of the SPHYGs were inaccurate. At 90 mmHg, 28.0% (42/150) were inaccurate with 16.7% (7/42) high by 4.6±1.5 mmHg and 81.0% (34/42) low by 6.2±4.2 mmHg; one was inoperable.
Results-B: 1,005 adult blunt trauma patients were evaluated; 61 were eliminated: 35 had initial SBPs of 0 mmHg and 26 had no SBP recorded (n = 944). The mean initial SBP was 138 ±30mmHg, and 3.8% (36/944) of the patients had SBPs <90 mmHg. Potentially, 2.0% (19/944) of the patients were undertriaged (initial erroneously high SBP reading 90–98 mmHg) and 2.5% (24/944) over-triaged (initial erroneously low SBP reading 74–90 mmHg).
Purpose: To determine what types of EMS systems (public vs. private) are contributing to the peer reviewed field research in EMS and what type of research is being done by these agencies.
Methods: A Medline literature search was conducted of all peer reviewed journals using the search terms: EMS, emergency medical services, EMT, paramedic, and ambulance. Studies published between 1976 and 1995 meeting these criteria were reviewed and classified as field or non-field studies. Studies were classified as field studies if they evaluated clinical outcomes or overall EMS system structure and performance. The type of EMS system in which the study was conducted was classified as: public (PB), private (PR), or a mixture of public and private agencies (PP). If the type of system was not evident in the paper, the primary author or EMS agency was contacted by phone. The primary affiliation of the first author was classified as being with: an educational institution, hospital, government agency, or EMS agency. Each study was also classified as being primarily clinical or evaluating EMS system structure. Review articles, editorials, and meta-analyses were excluded as were studies in which critical data elements could not be verified. Fischer's exact test was used for statistical analysis.
Results: A total of 365 studies were evaluated with 66 non-field studies being excluded from analysis. 75 studies did not meet inclusionary criteria. This left 224 studies for analysis. PB systems accounted for 167 (74.5%) of field studies, with PP 44 (19.6%) and PR 13 (5.8%). Clinical studies were more commonly done by PB systems (72.5%) when compared to PR systems (38.5%), p = 0.02. System structure studies accounted for the majority of studies done by PR systems (61.5%). An affiliation with an educational institution such as a university occurred in 61.2% of the studies. The number of field studies done by PB systems has increased steadily over the last 10 years while field studies published by PR and PP systems has remained at a low level, with none published from 1992–1994.
Objective: The scope of practice (SOP) for flight paramedics (FPs) remains a controversial issue for air medical directors. This study's objective was to determine the current level and breadth of FPs'SOP.
Methods: A 6-item survey of lead FPs in all 158 air medical programs throughout the U.S. The survey addressed five issues: 1)Certifications required of FPs above state certification; 2) Procedures included in SOP; 3) Medications FPs are allowed to administer; and 4) Requirements needed to expand FPs’ SOP. Views on establishing a National FP certification (NFPC) to alter their current SOP.
Results: Survey response was 57% (90/158). Ten responding programs (11%) did not utilize FPs. Of the 80 programs (89%) that utilize FPs, 76 programs (95%) required certification in ACLS, 65 (81%) in PALS, and 50 (63%) in BCLS. Paramedics were allowed to perform cricothyroidotomy in 68 programs (85%), pericardiocentesis in 24 programs (30%), and tube thoracostomy in 23 programs (29%). A wide spectrum of medications were approved for administration by FPs, including streptokinase in 37 programs (46%), r-TPA in 51 (64%), and succinylcholine in 50 (63%). In 61 programs (76%), the SOP was determined solely by the air medical director. Eighteen respondents (23%) believed that the development of a NFPC program would alter their SOP.
There is conflicting research regarding the extent to which patient care is a source of stress for emergency medical technicians (EMTs). Some research indicates that it is important, whereas other studies suggest that it takes a “back seat” to administrative and organizational problems. This study sought to explore this issue further by investigating the relationship between caring for patients, daily workday stress, and daily nonworkday stress among EMTs.
Methods:
All EMTs employed by East Baton Rouge Parish Emergency Medical Services were eligible for participation. After the study was described, subjects completed a demographic information sheet and informed consent was obtained. Participants then completed 30 days of monitoring with a standardized measure of daily stress (the Daily Stress Inventory) and a measure of patient-care stress designed for use in this study (Emergency Call Questionnaire).
Results:
A very large portion of the variance in the EMTs' overall daily workday stress was associated with patient care (r = 0.677, p <0.001). Additionally, patient care stress on workdays significantly predicted overall daily stress on the following nonworkday (i.e., post-workday) (r = 0.633, p <0.001). Finally, EMTs who had stressful pre-workdays rated their patient care as more stressful on the following workday (r = 0.512, p <0.01).
Conclusions:
Results suggest that patient care is a critical factor in daily stress among EMTs, both on workdays and post-workdays, providing preliminary evidence for a carryover effect. Evidence also suggests that stress on the day before work may influence EMTs' perceptions of their patients on workdays.
Purpose: The accessibility of emergency medical services (EMS) for enrollees of managed care organizations (MCOs) is currently a topic of national debate. The mechanisms by which enrollees currently enter the EMS system have not been well described. The purpose of this study was to determine how these patients enter our EMS system.
Methods: All enrollees who belong to the region's largest MCO and who were transported to hospital EDs by the paramedic level municipal EMS department were identified from billing records. Members of the MCO are mandated to call the MCO prior to seeking any emergency care. Dispatch logs were then examined to determine the time and origin of the call to the 911 communications center. Patient care records were used to obtain patient age, the level of care (ALS vs. BLS), and whether the ALS patient received medications (ALS Meds).
Results: Over a six month period 195 enrollees were transported to EDs, Three modes of system entry were identified: Group I—enrollees who called 911 directly; Group II—enrollees who called the MCO triage center who then called 911 for the patient; and Group III—enrollees who were sent to the MCO center for evaluation and subsequently the MCO called 911 to transport the patient to the hospital.
Purpose: Treatment and prevention strategies regarding people who jump from medium height bridges over water could be optimized by an improved understanding of patient demographics and injury spectra. Currently, little is known about this EMS patient population. We sought to describe the demographics and injuries sustained by those who jumped or fell from medium height bridges.
Methods: We searched the River Rescue and EMS reports of a medium size city for the ten year period 1986–1995 to identify cases involving a person who jumped/fell from a bridge into water. Additional cases were identified by searching coroner and trauma center registries. For each case, we reviewed applicable EMS, hospital, and coroner records to determine patient demographics, treatment provided, and injuries sustained.
Results: We identified 76 cases of individuals who jumped/fell from bridges into water. Eighteen of the region's 24 bridges (40 to 100 feet high) were involved. Average patient age was 34.8 years, 87% were male, and 29% jumped during July. These jumps/falls resulted in 25 (33%) deaths and 22 (29%) uninjured persons. Of those who died, 18 (72%) drowned, sustaining no other detectable injuries. Hospitalized survivors and injured coroner cases suffered predominantly extremity and rib fractures, pneumo/hemothoraces, and closed head injuries. No neck injuries were identified. No patient whose advanced level EMS treatment exceeded basic monitoring and IV access survived.
Purpose: To identify calls “under-triaged” by priority medical dispatch and determine causes and pre-hospital outcomes.
Methods: 6 month retrospective analysis identified calls dispatched “low priority” to which medics assigned “high acuity” transports (acute status or requiring ALS meds; not just IV/O2/monitor). CAD data, paramedic run-sheets, and audiotapes were reviewed to determine optimal dispatch levels and transport codes. “Under-triage” was defined as calls warranting “high priority” dispatch based on evidence from the run-sheet. Dispatcher, calling party, and patient data influencing “undertriage” were assessed.
Results: In 1995, 11,178/70,887 (16%) medical aid requests were dispatched “low priority”. 201(1.8%) were subsequently assigned “high acuity” transport codes by paramedics. 105/5,737 such consecutive patients were analyzed from July-December 1995. 6 were excluded due to incomplete data. After review, 42/99 actually warranted “high priority” dispatch. 7 had potential life/limb threatening injuries; 35 required ALS intervention. None had adverse prehospital outcome. Undertriage was associated with dispatcher error, information relayed from law enforcement officers (OR =3.4, CI: 1.2-10) calls involving alcohol (OR = 2.8, CI: 0.9-9.2) or patients with ALOC(OR= 3.4, CI: 1.2-10).