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To assess the characteristics of rural emergency medical services providers involved in the prehospital care of victims of agricultural injuries and determine which aspects of an agricultural rescue course were perceived as most useful.
Design:
A questionnaire was sent to participants of a course designed for agricultural prehospital providers who had attended a farm accident rescue course between 1986 and 1993.
Setting:
A rural referral center in central Wisconsin.
Participants:
The questionnaire was sent to all persons who had participated in the course. Respondents to the questionnaire characterized their service experience and rated the topic areas in usefulness and whether the subject should be included in future courses.
Results:
A total of 459 surveys (44% of potential respondents) was returned. Of the respondents, 316 (74.4%) were men, and the mean age was 39.4 years. There were 247 (60.8%) who were volunteers, and an additional 126 (31%) were paid, on-call workers. There were 232 (56.4%) basic providers, and 365 (87.5%) were from a rural area. Many (n = 149; 36.9%) had not responded to farm accidents during the past year. Training course topics rated most useful were machinery extrication, tractor overturn, and enclosed-space rescue.
Conclusions:
Respondents to an evaluation of an agricultural rescue course primarily were rural, basic providers. Future development of courses for emergency medical technicians involved in agriculture rescue must account for this level of training. Such courses should be short and modular with an emphasis on continuing education, practice, and focus on the identified needs of the participants.
The purpose of this study was to determine current experience and training of emergency medical support personnel for special weapons and tactics (SWAT) teams in North America.
Methods:
This cross-sectional, epidemiologic survey was sent to SWAT unit commanders from the 200 largest metropolitan areas. Questions included basic demographics, specialized training of emergency medical services (EMS) personnel, and where such personnel are deployed during tactical operations. Unit commanders also were asked to estimate the number and type of injuries sustained during tactical operations and to list any recommendations to improve the EMS response.
Results:
A total of 150 surveys was completed, for a response rate of 75%. The most common medical support (69%) was a civilian ambulance on standby at a predesignated location. Ninety-four percent of these prehospital care providers had no specialized training, and could not enter an area that was not secured tactically. Police officers with first aid or EMT training comprised the next largest group of medical support. Overall, 31% of SWAT commanders depended on remote EMS dispatch by radio to the scene when injuries occurred. Thirty-eight percent of respondents reported a significant injury had occurred during their tactical operations within the past 24 months. Common injuries included gunshot wounds, chemical exposure, and fractures. However, 78% (117/150) of respondents did not have a medical director, and 23% (35/150) of teams did not have an EMS preplan or protocol.
Conclusion:
The results suggest a need for established EMS protocols, medical direction, and specialized tactical medical training, especially in large metropolitan areas.
Purpose: Standard prehospital practice includes frequent immobilization of blunt trauma patients, some based solely on mechanism. Unnecessary cervical spine (c-spine) immobilization does have disadvantages, including morbidity such as low back pain and splinting, increased scene time and costs, and patient-paramedic conflict. Emergency physicians (EPs) use clinical criteria to clear trauma patients of c-spine injury. If paramedics were able to apply clinical criteria in the out-of-hospital setting, then unnecessary c-spine immobilization could be safely avoided. We designed a prospective, randomized, simulated trial to determine the level of agreement between paramedic and EP assessment of clinical indicators of cervical spine injury. We hypothesized that there would be substantial agreement between paramedic and EP evaluation of standardized patients.
Methods: A convenience sample of ten paramedics and ten attending EPs participated. Ten standardized patients, with various combinations of positive and negative findings, were examined simultaneously by EP-paramedic pairs. Each pair evaluated five randomly assigned patients for six clinical criteria, which were: 1) alteration in consciousness, 2) evidence of intoxication, 3) complaint of neck pain, 4) cervical tenderness, 5) neurologic deficit or complaint, and 6) distracting injury. If any criterion was positive, that was considered an immobilization decision. The kappa statistic was utilized to determine level of agreement between the two groups for each individual criterion and for the immobilization decision. A kappa of 0.40 to 0.75 denotes good reproducibility and >0.75 denotes excellent reproducibility.
This paper describes the 1994 Northridge earthquake experience of the local emergency medical services (EMS) agency. Discussed are means that should improve future local agency disaster responses.
Methods:
Data reported are descriptive and were collected from multiple independent sources, and can be reviewed publicly and confirmed. Validated data collected during the disaster by the Local EMS Agency also are reported.
Results:
The experience of the Los Angeles County EMS Agency was similar to that of earthquake disasters previously reported. Communication systems, water, food, shelter, sanitation means, power sources, and medical supplies were resources needed early in the disaster. Urban Search and Rescue Teams and Disaster Medical Assistance Teams were important elements in the response to the Northridge earthquake. The acute phase of the disaster ended within 48 to 72 hours and public health then became the predominant health-care issue. Locating community food and water supplies near shelters, providing transportation to medical care, and public-health visits to shelter locations helped prevent the development of long-term park encampments. An incident command system for the field, hospitals, and government responders was necessary for an organized response to the disaster.
Conclusion:
Disaster preparedness, multiple forms of reliable communication, rapid mobilization of resources, and knowledge of available state and federal resources are necessary for a disaster response by a local EMS agency.
Purpose: The prevalence of asthma in the pediatric population is approximately 9% and the incidence of acute exacerbation in this population has been increasing. The purpose of this study was to determine if there has been a change in the pre-hospital presentation and treatment of pediatric asthma.
Methods: This observational study was a retrospective consecutive case series comparing pediatric (#18 yrs) asthmatics treated and transported by an inner city EMS system over two years. (1987, 1992). Data collected included patient demographics, prehospital treatment, and evaluated diagnostic criteria used by paramedics to initiate treatment. Students t test was performed for continuous data and contingency analysis (chisquare) for non-continuous data. A Wilks stepwise discriminant analysis was performed on 1987 and 1992 data to evaluate diagnostic factors.
Results: There were 407 transports in 1987 and 652 in 1992, representing a 60% increase. 237(56%) of patients received advanced life support (ALS) in 1987 and 344(53%) in 1992. Mean age of ALS patients in 1987 was 10.25 (±5.3) and was 8.03 (±2.8) in 1992 (p <0.001). Albuterol inhalation supplanted epinephrine (1987-205, 1992-1) and aminophylline (1987-15, 1992-1) as the treatment for asthma in our service system. The discriminant analysis revealed that in 1987, paramedics treatment decision making was influenced by age, cough, cold, and/or fever, home medications, accessory muscles, absence of wheezing, and normal respiratory rate. This changed in 1992 where only the presence or absence of wheezing and accessory muscle-use to be highly correlated with treatment decisions.
Prehospital 12-lead electrocardiographic (ECG) diagnostic strategies have been proven feasible and effective, provided they are designed and implemented properly. The authors of this communication have expended considerable time and effort in determining appropriate planning, implementation, and process monitoring necessary for successful implementation of a variety of prehospital diagnostic strategies. Many of these issues may not be obvious to an emergency medical services (EMS) director initiating a 12-lead ECG program. This level of attention to protocol development, education, training, inservice education, coordination of the health-care community, objective program assessment, monitoring and continuos quality improvement can serve as a model for other diagnostic EMS programs that may develop as an expanded role for EMS.
Purpose: Prehospital triage criteria (PTC) have been used to classify patients according to risk of serious injury. This study was conducted determine whether PTC could be used to identify serious injury, the need for intensive care (ICU), or immediate operative intervention (IOI).
Methods: Data for this observational study were gathered prospectively, at a level-I trauma center, from a patient cohort admitted to the trauma service from 01 February to 31 July 1995. Specific triage criteria, based on information given by EMS prior to arrival were used to categorize patients by severity. Patients classified as most serious (codes) had the following: shock, major anatomic injury or proximal penetrating trauma. Patients classified as more serious (alerts) had one of the following: abnormal vital signs, Glasgow Coma Scale <13, moderate anatomic injury, high-risk mechanism of injury, or co-morbid factors. Patients not meeting either set of criteria, but were admitted, served as controls (consults). Injury severity scores (ISS) and probability of survival (Probsurvival) were calculated for each patient. The percentage admitted to the ICU, operating room (OR), or requiring IOI, were tabulated. Statistical analysis was performed using ANOVA, Mest and chi-square.
Objective: Determine whether radio alerts to paramedics after 7 minutes of on-scene time reduces total on-scene time for trauma patients.
Methods: Paramedics radio base once they determine ACS criteria were met. Paramedics were informed by radio when 7 minutes lapsed on-scene. Dispatch times were recorded.
Results: The control group (Nov. 1-30, 1995) of 135 consecutive patients were reviewed without a radio alert. The test group (Dec. 1-31, 1995) of 103 consecutive patients, with a radio alert message 7 minutes after scene arrival were also reviewed. Groups were matched for extrication times, blunt versus penetrating trauma, age, etc. We analyzed both groups for the interval of time from announcement of “trauma alert,” (when paramedics determined the patient met ACS criteria or from the time extrication was complete (if applicable) to the time en route to the hospital. Average on-scene time for the control group was 13.7 minutes [range 4-35] versus test group 9.3 minutes [range 2-26] (p <0.001).
Emergency medical services collisions (EMVCs) are a largely unexplored area of emergency medical services (EMS) research. Factors that might contribute to an EMVC are numerous and include use of warning lights and siren (WL&S). Few of these factors have been evaluated scientifically. Similarly, the incidence and severity of EMVCs is poorly documented in the literature. This study sought to define the incidence and severity of, and where possible, identify any contributing factors to EMVCs in a large urban system.
Methods:
Retrospective study of all collisions involving vehicles assigned to the EMS Division of the Houston Fire Department in calendar year 1993. Fifty-one ambulances were operational 24 hours per day during calendar year 1993. Houston EMS received 150,000 requests for assistance, made 180,000 vehicular responses, and accrued 2,651,760 miles in 1993.
Results:
Eighty-six EMVCs were identified during the study period. The gross incidence rate was therefore 3.2 EMVC/100,000 miles driven or 4.8 collisions/10,000 responses. Of the 86 EMVCs, 74 (86%) files were complete and available for evaluation. Major collisions, determined according to injuries or vehicular damage, accounted for 10.8% of all EMVCs. There were 17 persons transported to hospitals from EMS collisions, yielding an injury incidence of 0.64 injuries/100,000 miles driven or 0.94 injuries/10,000 responses. There were no fatalities. The majority of collisions (85.1%) occurred at some site other than an intersection. There was no statistical association between occurrence at an intersection and severity, day versus night, weekend versus weekday, presence or absence of precipitation, or use of WL&S versus severity of collision. Drivers with a history of previous EMVCs were involved in 33% of all collisions. The presence of prior EMVCs was associated (p < 0.001) with the number of persons transported from the collision to a local hospital. Five drivers, all with previous EMVCs, accounted for 88.2% (15/17) of all injuries.
Conclusions:
A few drivers with previous EMVCs account for a disproportionate number of EMVCs and nearly 90% of all injuries. This risk factor—history of previous EMVC—has not been reported in the EMS literature. It is postulated that this factor ultimately will prove to be the major determinant of EMVCs. Data collection of EMS collisions needs to be standardized and a proposed collection tool is provided.
To determine the effectiveness of a prototype esophageal detection device (EDD) during use in the prehospital setting.
Design/Setting:
Prospective convenience sample in a prehospital setting.
Population:
Intubated adult patients.
Interventions:
The study device was used to determine esophageal or endotracheal placement of endotracheal tubes in intubated patients. Clinical means were used to confirm tube location. A data sheet was completed for each patient.
Results:
Of 105 uses of the device, 17 of 17 esophageal tubes were identified correctly (100% sensitivity). Sixty-five of 88 tracheal tubes were correctly identified (78% specificity). There was intermediate reinflation of the device on 13 of the 65 tracheal tubes. Five tests were indeterminate. There were no false negatives (negative predictive value 100%), but 18 false positives (positive predictive value 48%).
Conclusion:
This prototype EDD adequately identifies esophageally placed endotracheal tubes. Correct identification of endotracheally placed tubes was less sensitive. Much work needs to be done regarding the use of negative aspiration devices to identify placement of endotracheal tubes.
While large cities typically staff ambulances with two emergency medical services (EMS) professionals, some EMS agencies use three people for ambulance crews. The Greenville, North Carolina, EMS agency converted from three-person to two-person EMS crews in July 1993. There are no published reports investigating the best crew size for out-of-hospital emergency care.
Hypothesis:
Two-person EMS crews perform the same number and types of interventions as three-person EMS crews. Two-person EMS crews do not have longer on-scene times than do three-person EMS crews.
Methods:
Data for the two most common advanced life support calls in this system—seizures and chest pains—were collected for the months of June and August 1993. Three-person EMS crews responded to both types of calls in June. In August, two-person EMS crews responded to seizure calls; two-person EMS crews accompanied by a fire department engine (pumper) with additional manpower responded to chest pain calk. The frequency of specific interventions, number of total interventions, and scene times for the August calls were compared to their historical control groups, the June calls.
Results:
One hundred twenty-six patient contacts were included in the study. There were no significant differences in total number or types of procedures performed for the two patient groups. Mean on-scene time for patients with seizures was 11.0±4.2 minutes for three-person crews and 19.4±8.3 minutes for two-person crews (p <0.001). Mean on-scene time for patients with chest pain was 13.6±4.9 minutes for three-person crews, and 15.4±3.2 minutes for two-person crews assisted by fire department personnel (p >0.05).
Conclusion:
Two-person EMS crews perform the same number of procedures as do three-person EMS crews. However, without the assistance of additional responders, two-person EMS crews may have statistically significantly longer onscene times than three-person EMS crews.
Hypothesis: First responder organizations with automated external defibrillators (AEDs) can have a larger impact on survival of out-of-hospital cardiac arrest than placing AEDs in large buildings.
Methods: To evaluate the impact, all cardiac arrests handled by a large urban fire department for 1994 were analyzed. Each 5.6 square mile area of the city was defined as business (Bus), high (HilRes), middle (MilRes), or low income (LoIRes) residential. For each area, the CPR rates were calculated for the number of arrests/100 ambulance dispatches, and were stratified by percent of adults over age 65.
Results: Of the 1,222 cardiac arrests, only 85 occurred in business and industrial areas, 1,041 occurred in residential areas. The downtown business district had only 77 arrests with half of those being outside of buildings or in shelters.
Objective: Traditional EMS teaching identifies mechanism of injury as an important predictor of spine injury. Clinical criteria to select patients for immobilization are being studied in Michigan and have been implemented in Maine. Maine requires automatic immobilization of patients with “a positive mechanism” clearly capable of producing spine injury. The purpose of this study is to determine if mechanism of injury effects the ability of clinical criteria to select patients with spine injury.
Design: Multicenter Prospective Cohort.
Methods: EMS personnel completed a check-off data sheet on out-of-hospital spine immobilized patients. Data included mechanism of injury and yes/no determinations of the clinical criteria: altered mental status, neurologic deficit, evidence of intoxication, spinal pain or tenderness, and suspected extremity fracture. Hospital outcome data included confirmation of spine injury and treatment required. Mechanisms of injury were tabulated and rates of spine injury for each mechanism was calculated. The patients were divided into high-risk and low-risk groups.
Results: Data was collected on 6,500 patients. There were 213 (3.3%) patients with spine injuries identified. There were 1,065 patients with 100 (9.4%) injuries in the high-risk mechanism group, and 5435 patients with 113 (2%) injuries in the low-risk group. Clinical criteria identified 96 of 100 (96%) injuries in the high risk mechanism group and 106 of 113 (94%) in the low-risk group.
Objective: To determine the prevalence and outcome of out-of-hospital ventricular tachycardia (VT) cardiac arrest with a prolonged QT interval and to identify the subset with torsades de pointes (TdP).
Methods: Design: Retrospective review. Setting: Fire department-based paramedic system. Participants: Non-traumatic VT cardiac arrest (1/91-12/94) with a supraventricular perfusing rhythm (SVPR) and a measurable QT interval. Interventions: QT interval was measured from a SVPR and corrected QT interval (QTc) was calculated (prolonged if ≥0.45 sec). VT was classified as polymorphic or monomorphic.
Results: 190 patients met inclusion criteria. 51% of patients had a prolonged QTc (PQTc). The overall hospital discharge rate was 28.4%. No difference with respect to paramedic-witnessed arrests in each QTc group was found (25.8% normal QTc [NQTc] vs. 27.8% PQTc; p = 0.752). Patients with PQTc were less likely to be discharged from the hospital (19.6% vs. 37.6%; p = 0.01). Patients with PQTc were not more likely to have PVT (37% vs. 40%; p = 0.705). 16 (8.4%) patients had TdP. 27.8% of TdP and 26.8% of non-TdP patients were discharged (p = 0.912).
Predicting paramedic candidate performance on the written Iicensure examination is of considerable importance to educators, students, employers, and state regulators. There has been little investigation of the available statistical data regarding examinee pass rate and examination score. No studies have measured an examinee's sequential success pattern on the basic emergency medical technician (EMT) or paramedic examinations. There has been no analysis of the relationship between the number of examinations required for successful paramedic Iicensure and examination score.
Objective:
The purpose of this study was to determine the frequency with which paramedic Iicensure examinees successfully pass the State of Michigan written examination on the first or subsequent attempts; to determine the frequency with which the paramedic examinees pass the prerequisite basic EMT Iicensure examination; to determine whether the frequency of paramedic examination attempts is related to examination score; and to determine whether there is a relationship between successfully passing the basic EMT examination and successfully passing the paramedic examination.
Methods:
A retrospective study of Michigan paramedic Iicensure examination results for 1994 was done on the basis of a review of reports prepared for Michigan Department of Public Health Emergency Medical Services (MDPH-EMS) by Professional Examination Services. Analysis of paramedic examination score and the number of examination attempts is correlated to EMT score and number of attempts required to pass. Success in the first or subsequent paramedic examinations is correlated to paramedic score, and success in passing the first or subsequent EMT examination is then related to success in passing the paramedic examination.
Results:
Paramedic examinees (n = 869) generated a 72.1% pass rate in 1994 (mean score = 82.2%). The minimum passing score is 80%. The average score for examinees who passed (n = 627) was 86.2 % (95% confidence interval [CI] = 85.8–86.6%); those who failed (n = 242) averaged 71.9% (95% CI = 71.1–72.6%). Paramedic examinees successful on the first attempt (n = 500) had higher average scores (mean = 87.1%; 95% CI = 86.7–87.5%) than did those who required multiple attempts (mean = 82.8%; 95% CI = 82.3–83.3%; n = 127).
A total of 702 (90.5%) paramedic examinees passed the EMT examination on the first attempt. Examinees who passed the EMT examination the first time averaged fewer attempts on the paramedic examination (mean 1.5; 95% CI = 1.4–1.6) than did those who required multiple EMT examinations (mean 2.3; 95% CI = 2.0–2.6). Paramedic examinees passing the EMT examination in one attempt had higher average paramedic scores (82.6%; 95% CI = 82.1–83.2%) than those needing multiple EMT attempts (75.5%; 95% CI = 73.4–77.5%).
Conclusion:
Paramedic examinees who pass their EMT Iicensure examination on the first attempt have a significantly better chance of passing the paramedic Iicensure examination. Paramedic Iicensure examinees who pass the paramedic examination on the first attempt score significantly higher than do examinees who require additional attempts. Paramedic programs should incorporate EMT examination performance into their student selection criteria. Further study of variables predictive of success is needed.
To describe the epidemiology of pediatric emergency medical services (EMS) practice in a large patient population from several geographic areas.
Design:
Retrospective computer analysis of EMS databases from four states using a common data set and analysis system.
Setting:
Pennsylvania, Tennessee, Mississippi, and Nevada (except Clark County), 1990 through 1992.
Methods:
All patient-care reports of patients 14 years old and younger were extracted from the EMS databases and analyzed for the following factors: age, gender, date, elapsed pre-hospital times, incident type, mechanism of injury, call disposition, illness or injuries encountered, severity of illness/injury (by abnormal vital signs), and basic life support (BLS) and advanced life support (ALS) treatment delivered.
Results:
A total of 1,512,907 patient care reports were reviewed. Those of 61,132 children were extracted for analysis. These children comprised about 4% of prehospital responses. Male subjects predominated (56%), and children aged 7 through 14 years represented 46% of cases. Most calls occurred in the evening and daylight hours. Children were transported by ambulance in 89% of cases, and care was refused in 7.7%. Mean response time was 9±16 minutes, mean scene time 12±14 minutes, and mean transport time 14±20 minutes. Traumatic incidents predominated at 42%, with motor vehicle accidents and falls the most common mechanisms. Blunt injuries accounted for 94% of trauma, whereas respiratory problems, seizures, and poisoning/overdose were the most common medical problems. Vital signs were obtained in 56% of cases. Abnormal vital signs were noted in 21% of these, and the presumptive causes were similar in distribution to those of the general population, with the addition of cardiac arrest. The most commonly used treatments were spinal immobilization, oxygen administration, intravenous access and several ALS medications. An ALS capability was available in more than half the runs, but ALS treatment was delivered in only 14% of those cases. Outcome data were not available.
Conclusion:
This multistate analysis of pediatric EMS epidemiology confirms findings reported in smaller regional studies, with several exceptions. Excessive scene times were not noted. Few children had serious disorders as evidenced by abnormal vital signs. An ALS treatment, when available, was used infrequently. These findings have implications for EMS planners and educators.
Aeromedical navigation to the scene of an accident using navigational assistance computer mapping software (NACM) can be difficult in rural areas due to the lack of topographic landmarks. In these instances, navigation is made easier using the Global Positioning Satellite (GPS) system to determine latitude and longitude.
Purpose: To determine the reliability and feasibility of portable GPS receivers compared with our current system of NACM (MAP EXPERT®) in the navigation of aeromedical transport flights.
Design: A non-randomized prospective trial comparing flights using either GPS or NACM. Setting: Flight program at a Level I trauma center.
Methods: GPS receivers (for transmitting location) were carried by half the helicopters and ground EMS units. The NACM system was used to transmit the location of the accident to the other flights. Data on flight time, distance, and accident location were collected. Pilots and EMS personnel using the portable GPS system completed a questionnaire regarding accuracy, reliability, and ease of use.
Results: This study included 51 flights; GPS (n = 26) and NACM (n = 25). There was no difference in the miles flown per minute in the NACM group (1.69 miles/minute) compared with the GPS group (1.70 miles/minute). Pilots and EMS personnel rated the GPS reliable, accurate, and easy to use for navigation.