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Many states are implementing prehospital do-not-resuscitate (DNR) programs through legislation or by state or local protocol. There are no outcome studies in the literature regarding the utilization of, access to, or barriers to prehospital DNR programs, nor are there studies that evaluated whether they meet the patients' needs.
Study Objective:
To explore physicians' perceptions of the utilization of, access to, and barriers to a southeastern state's prehospital DNR program, and to identify key professional groups needing information about prehospital DNR issues.
Methods:
A convenience sample survey and a descriptive review using retrospective, self-report questionnaires sent to all physicians who requested and obtained a supply of the state's out-of-facility DNR forms in 1993.
Results:
Respondents reported that the most common terminal conditions for patients with prehospital DNR orders are cancer and multiple chronic diseases in elderly patients. More than half of the physicians recalled that enrolled patients had engaged the services of emergency medical services (EMS), most often because the patients' conditions worsened, and the families were uncertain about what to do. Most of the enrolled patients have at least one other DNR order in another health-care setting, and are at home with hospice care or home-health care at the time of the prehospital DNR order implementation. The most frequent barrier to honoring dying patients' wishes in the prehospital environment is a lack of knowledge of prehospital issues by patients, families, primary care physicians, and nursing home staff. Ninety-eight percent of the respondents support a single, universal DNR order that would apply across all health-care settings.
Conclusions:
Patients, families, and key health-care professional groups need to be targeted with educational programs regarding prehospital DNR issues. Primary care physicians, using the current prehospital DNR program, support more comprehensive approaches to DNR orders across health-care settings.
A misprint occurred in “Early Predictors of Sepsis in the Motor-Vehicle Crash Trauma Victim” by Jeanette K. Previdi, RN, BSN, MPH, CEN, C. Gene Cayten, MD, MPH, Daniel W. Bryne, MS, published in Vol. 11, No. 1.
To provide a descriptive analysis of the prehospital emergency medical transportation system operating in and around a major Bosnian city, and to discuss the effect of the war on that transportation system.
Design:
A prospective, consecutive sample study.
Setting:
The largest tertiary-care referral hospital currently operating in central Bosnia.
Participants:
158 consecutive patients who sought care in the trauma and medical receiving rooms at Zenica Hospital.
Method and Measurements:
Patients were surveyed as to time of transportation to the site of first medical care and to Zenica Hospital, and modes of transportation used.
Results:
Time to transport to first care within the city of Zenica is 30±21 minutes. Time to transport to Zenica Hospital from within Zenica is 51±39 minutes. Time to transport to first care outside of Zenica is 77±56 minutes. Time to transport to Zenica Hospital from outside the city of Zenica is 178±94 minutes. The prehospital emergency medical service was used in 11.7% of cases reviewed.
Conclusion:
The majority of patients with major injury and illness are unable to obtain prehospital transportation and medical care through informal modes of transportation. The existing prehospital emergency medical services system is inadequate for the numbers of patients requiring such services, and transportation time from outside the city of study is especially prolonged.
Burnout in firefighter/paramedics (FF/EMT-Ps) is widely believed to exist, but few empirical data support its existence, symptomatology, or intervention. Understanding the extent, nature, and cause of burnout is crucial to improving employee morale and performance.
Study Population:
Ninety-one FF/EMT-Ps employed by Salt Lake County Fire Department.
Hypotheses:
Three specific hypotheses were tested: 1) FF/EMT-Ps who score high on burnout also will score high on authoritarianism; 2) FF/EMT-Ps who score high on burnout also will score high on inner-directedness; and 3) FF/EMT-Ps who score high on burnout also will score high on sensation seeking.
Methods:
In this descriptive study, FF/EMT-Ps computed four standardized instruments measuring authoritarianism, burnout, inner-directedness versus other-directedness and sensation seeking.
Results:
Firefighters who scored high on burnout also scored high on authoritarianism and on the sensation-seeking subscale of boredom. Burnout did not correlate with the overall sensation-seeking scale or with its other subscales (thrill, experience, and disinhibition), or inner-directedness versus other-directedness.
Conclusion:
A focus on control issues needs to be an integral part of programs for decreasing employee burnout among FF/EMT-Ps. Specific components of such programs should include stress management and counseling. In addition, management personnel need to be taught not only to assist direct-service staff, but also to recognize and deal with their own control issues as they affect job performance.
Local military conflicts continue in many areas of the world. These conflicts produce multiple casualties to military personnel and civilians. This paper describes one aspect of the medical care required for victims of the civil conflict in the Republic of Georgia.
Methods:
Interviews with patients and their accompanying persons and abstraction of medical records.
Results:
Data were acquired on 108 victims admitted to the Center for Critical Medicine in Tbilisi. Three stages in the care of these victims are described: 1) battlefield and transportation; 2) regional, front-line hospitals; and 3) the Central Hospital. The performance of each stage is described. Distribution of injuries and procedures performed in the third stage of treatment are described and survivors are defined. For illustration, two cases are reviewed in detail.
Conclusions:
The results are encouraging. Major problems existed in the treatment and evacuation of the wounded. Furthermore, many of the victims were injured because of their carelessness and lack of experience on the battlefield.
The use of direct medical control (DMC) in the out-of-hospital setting often is beneficial, but has the disadvantage of consuming emergency medical services (EMS) resources.
Hypothesis:
Uncomplicated, nontrauma, adult patients with chest pain can be treated safely and transported by paramedics without DMC.
Methods:
Retrospective chart review of all nontrauma, adult patients with chest pain treated in a combined rural and suburban EMS system during a 2-year period (December 1990 through November 1992) was conducted. Before November 1991, DMC was mandatory for all patients with chest pain. Beginning 01 November 1991, if a patient had resolution of pain either spontaneously, with administration of oxygen, or after a single dose of nitroglycerin, DMC was at the discretion of the paramedic. Using the above criteria for inclusion, three study groups were defined: Group 1, before protocol change; Group 2, after protocol change without DMC; and Group 3, after protocol change when physician contact was obtained, but not required. These groups were compared for the following parameters: 1) scene time; 2) time to administration of first dose of nitroglycerin; 3) time interval between measurement of vital signs; 4) oxygen use; 5) intravenous access; and 6) electrocardiographic monitoring. Continuous and categorical variables were analyzed by multivariate and univariate analysis of variance and chi-square tests, respectively.
Results:
Of 308 nontrauma, adult patients with chest pain, 71 met inclusion criteria in Group 1, 40 in Group 2, and 34 in Group 3. No statistically significant differences were identified in any of the study parameters.
Conclusion:
Adult patients with chest pain who have no other symptoms or complicating conditions can be treated appropriately by paramedics without DMC.
An estimated 110 million land mines scattered in 64 countries continue to terrorize people and destroy human lives long after wars and fighting have ceased. Despite efforts to clear these devices, their numbers continue to increase and their presence, constitutes a substantial threat to public health in the affected countries. Direct consequences include both the physical and emotional injuries from the impact, flying debris, and structural collapse associated with their detonation. Indirect consequences include increases in the incidence of waterborne diseases, diarrhea, malnutrition, infectious diseases, and spread of the human immunodeficiency virus associated with the increased use of blood. Those at highest risk of these latter consequences are mostly the disadvantaged poor, especially children. Psychiatric disorders, such as post-traumatic stress disorder, occur in those not directly injured as well as those physically wounded by the explosion.
Besides efforts to ban production, stockpiling and export of land mines, a comprehensive and integrated health program aimed at the prevention, treatment, and rehabilitation of those injured directly or indirectly by land mines is needed urgently. Strategies should include mine-awareness programs, enhanced transport of those directly injured, training the villagers in first aid, augmenting the capacity and quality of treatment facilities, improving the psychological support and treatment capabilities, development of rehabilitation programs, and the institution and enhancement of public-health programs directed at the indirect consequences associated with the presence of land mines.
Land mines constitute a major public-health problem in the world that must be addressed.