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Objectives: Paramedic-initiated turndowns-to-BLS are a high-risk area for EMS. One non-clinical factor that might affect paramedics’ decision-making is a 24-hour work schedule. We attempted to determine the presence of circadian variation in the turndown rate from ALS to BLS when paramedics work 24-hour shifts.
Methods: Retrospective analysis of all 1994 ALS patient evaluations. Encounters were classified as: ALS transport; turndown-to-BLS; patient-initiated refusal of transport; other transport; field death. Analysis of variation in turndown rate by hour of ALS dispatch was performed using logistic regression to make paired comparisons for each hour.
Results: 17,877 patients were evaluated by ALS. Of these, 10,956 (61%) were ALS transports, 6,200 (35%) were not transported by ALS, and 721 (4%) were dead. Of the 6,200 alive non-ALS transports, 4,291 (69%) were turned down to BLS, 1,748 (28%) refused transport, and 161 (3%) were transported by others. One turndown-to-BLS was excluded due to missing dispatch time; for the remaining 4,290 the overall turndown rate was 25%. The turndown rates for 15 of 24 hours did not differ significantly (p >0.01) from any other hour. The rates at the following hours differed significantly: hour 3 < 13; hour 5 < 8,9,10,13,16,22; hour 9 > 20,22; hour 10 > 22; hour 13 > 20,22; hour 16 > 20,22.
Introduction: Monophasic defibrillation waveforms are presently the standard of care in clinical use for trans-thoracic defibrillation. Recently, there has been renewed interest in biphasic waveforms. This interest reflects the superior performance demonstrated with biphasic waveforms in implantable defibrillators (ICD). External defibrillation research on two biphasic truncated exponential waveforms has been reported in which the waveforms were compared clinically to a damped sine waveform. A limitation of these transthoracic waveforms is the insufficiency of fundamental design principles used to determine the waveform characteristics.
Methods: We developed design principles to determine the optimal waveform characteristics of an external biphasic truncated exponential waveform based on myocardial cell response model. The cell response model incorporates critical transthoracic elements into a recently published and experimentally validated intracardiac model used to design ICD waveforms. We determined the optimal leading-edge voltage (LEV), phase durations (in milliseconds, Ph1 D, Ph2 D), and delivered energies (ED) for the reported external biphasic waveforms (WF) using the model with 78 W for trans-chest resistance. We compared our results against those reported for the biphasic waveforms.
Triage of mass casualties in situations in which patients must remain on-scene for prolonged periods of lime, such as after a catastrophic earthquake, differs from traditional triage. Often there are multiple scenes (sectors), and the infrastructure is damaged. Available medical resources are limited, and the time to definitive care is uncertain. Early evacuation is not possible, and local initial responders cannot expect significant outside assistance for at least 49–72 hours. Current triage systems are based either on a shorter time to definitive care or on a longer time to initial triage.
The Medical Disaster Response (MDR) project deals with the scenario in which specially trained, local health-care providers evaluate patients immediately after the event, but cannot evacuate patients to definitive care. For this type of scenario, a dynamic triage methodology was developed that permits the triage process to evolve over hours or even days, thereby maximizing patient survival and resulting in a more efficient use of resources. This MDR system incorporates a modified version of “Simple Triage and Rapid Treatment” (START) that substitutes radial pulse for capillary refill, coupled with a system of secondary triage termed, “Secondary Assessment of Victim Endpoint” (SAVE).
The SAVE triage was developed to direct limited resources to the subgroup of patients expected to benefit most from their use. The SAVE assesses survivability of patients with various injuries and, on the basis of trauma statistics, uses this information to describe the relationship between expected benefits and resources consumed. Because early transport to an intact medical system is unavailable, this information guides treatment priorities in the field to a level beyond the scope of the START methodology.
Pre-existing disease and age are factored into the triage decisions. An elderly patient with burns to 70% of body surface area is unsalvageable under austere field conditions and would require the use of significant medical resources—both personnel and equipment—and would be triaged to an “expectant area.” Conversely, a young adult with a Glasgow Coma Scale score of 12 who requires only airway maintenance would use few resources and would have a reasonable chance for survival with the interventions available in the field, and would be triaged to a “treatment” area.
The START and SAVE triage techniques are used in situations in which triage is dynamic, occurs over many hours to days, and only limited, austere, field, advanced life support equipment is readily available. The MDR-SAVE methodology is the first systematic attempt to use triage as a tool to maximize patient benefit in the immediate aftermath of a catastrophic disaster.
Oral endotracheal intubation (ETI) is the preferred method of controlling the airway in critically ill or injured patients. It was postulated that time could be saved if intubation was performed in the ambulance en route to the hospital. This study was designed to determine whether the ambulance environment adversely affected the ability of emergency medical technicians at the advanced-intermediate level (EMT-AI) to perform oral ETI.
Hypothesis:
The restrictive environment of a moving ambulance would affect adversely the ability of EMT-AIs to perform ETI compared with a controlled setting. This would result in a significant increase in the time necessary to perform ETI in the ambulance compared with a controlled setting not complicated by restrictive space and motion.
Methods:
Twenty on-duty EMT-AIs were recruited to volunteer for this prospective, nonrandomized, nonblinded trial. All participants performed three consecutive oral ETIs on an airway mannequin in two settings: 1) in the back of a moving ambulance; and 2) on a table in the rescue squad station. Of the participants, 10 performed the intubations in the ambulance first; the remainder performed the intubations at the station first. Time for intubation with the mannequin was recorded by stopwatch. The mean times for intubation in both settings were compared by Student's t-test (p<0.05).
Results:
All intubation attempts were successful. The mean time for intubation in the station was 13.0±3.4 seconds. The mean time in the ambulance setting was 13.2±5.3 seconds. There was no significant difference between the intubation times in the two settings (p = 0.88).
Conclusion:
The environment of a moving ambulance does not appear to hinder the ability of EMT-AIs to perform oral ETI in a laboratory setting with a mannequin model.
The fall of the Berlin wall was a symbol of the failure of two systems to exist totally independent of each other. It also rendered obsolete the grand scenarios necessitated by the Cold War for dealing with a nuclear bombing attack. We hope and expect that these particular scenarios based on the premise of hostility between the world powers of the East and West never will need to be considered again. However, both sides gained a tremendous amount of experience in how nuclear and other weapons and industries operate, their health and environmental effects, and the extreme danger of these weapons. In the present time of peace among the world powers, it is important to develop disaster response scenarios that will be useful world-wide. We must contribute our collective wisdom and experience through working together as a world community. The recent cooperation between the United States and Russia in joint space program efforts is an example of the progress that can be made through close collaboration between countries that formerly were adversaries.
A more accurate estimate of the number of ambulances needed at disasters prevents vehicles from being withdrawn unnecessarily from their “normal” duties, thereby curtailing needless expense and helping to ensure that disaster sites are not overcrowded with emergency workers impeding each other's effectiveness. This article discusses a formula for determining the number of ambulances needed at a disaster.
Adenosine (Adenocard) is an endogenous purine nucleoside that has been approved recently for intravenous treatment of paroxysmal supraventricular tachycardia. With a serum half-life of 10 seconds, reported side effects including facial flushing, dyspnea, and chest pressure are common, but very transient. An elderly woman who received adenosine for paroxysmal supraventricular tachycardia had a prolonged anaphylactoid reaction that required pharmacological treatment. This is the first reported case of prolonged anaphylactoid reaction to adenosine.