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A multitude of life-threatening and nonlife-threatening processes cause chest pain and shortness of breath. Prehospital therapy for these patients may be lifesaving and includes pharmacologic interventions, as well as invasive procedures. Appropriate therapy depends on the diagnostic skills of the paramedic.
Objective:
This study was undertaken to determine the accuracy of the paramedic diagnosis in patients transported with a chief complaint of pain or shortness of breath.
Setting:
Multihospital, one large municipal hospital, one community hospital.
Design:
Prospective, cross-sectional study. Paramedics evaluated the patient and then completed a standard form indicating the diagnosis. The paramedic's and final emergency physician's diagnoses were compared to assess the accuracy of the paramedic diagnosis.
Population:
All patients who complained of chest pain or shortness of breath, transported to the study centers by the city of Denver paramedia, were eligible for the study. Ninety-nine of the 102 patients enrolled had complete records for analysis and were entered into the study.
Results:
Diagnostic concordance data were analyzed by organ system (e.g., cardiac, pulmonary, etc.) and for specific diagnoses using the kappa statistic and McNemar's chi-square analysis for discordant pairs. Using the kappa statistic, there was statistically significant concordance between the paramedic and emergency-physician diagnosis for cardiac (p = 0.0001; kappa value = 0.54) and pulmonary organ systems (p = 0.0001; kappa value = 0.61). Overall, for organ system diagnosis, the paramedics had an 82% accuracy (p = 0.05) rating. For specific cardiac and pulmonary diagnosis, paramedics had good concordance with emergency physicians.
Conclusions:
Overall, paramedia have excellent diagnosis by organ system. They retained good agreement on specific cardiac diagnoses and pulmonary diagnosis.
Although major sequelae of carbon-monoxide (CO) poisoning and its treatment with hyperbaric oxygen (HBO) are well-documented, a syndrome of low-level CO poisoning has received relatively little attention. Subtle symptoms of poor concentration, language difficulty, problems with calculations, and memory loss were noted after an acute exposure of 131 dormitory residents to low levels of CO. The CO Neuropsychological Screening Battery (CONSB), a series of tests reported by others as useful to identify victims of CO poisoning, was performed on a subset of 46 victims. It was hypothesized that their test scores would improve after treatment with HBO.
Methods:
Testing was performed both before and after HBO on 35 CO-exposed victims. A control group of 20 students residing on the same college campus, but not involved with the CO incident, also were tested on two separate occasions to assess the ability of the test to identify selectively victims of low-level CO poisoning, as well as to evaluate its validity when administered serially.
Results:
Both CO-exposed and control subjects demonstrated significant performance improvement when completing the testing for the second time. In addition, the baseline test scores were not significantly different for either the CO-exposed or the control groups. Nonetheless, all CO-exposed victims reported immediate subjective improvement of their symptoms after HBO therapy.
Conclusion:
These observations and a review of the literature suggest that there might exist a syndrome of subtle neurological disturbances in victims of low-level CO poisoning. Whether this is permanent or might regress spontaneously over time is unknown. As a diagnostic adjunct, the CONSB does not appear to be as useful in low-level CO poisoning.
To explore the determinants influencing oral/nasal endotracheal intubation (OETI/NETI) and determine which cognitive, therapeutic, and technical interventions may assist prehospital airway management.
Design, Setting, and Participants:
Prospective review of run reports and structured interviews of paramedics involved in OETI/NETI attempts were conducted in a high-volume, inner-city, advanced life support (ALS) system during an eight-month period (July 1991 to February 1992). Data were abstracted from run reports, and paramedics were asked in structured interviews to describe difficulties in OETI/NETI attempts.
Results:
Of 236 patients studied, 88% (208) were intubated successfully. Success/failure rate was not related statistically to patients' ages (p = 0. 78), medical or trauma complaint (89% vs 85%, p = 0.35), oral versus nasal route (88% vs 85%, p = 0.38), care time (scene + transport times: success, 18 minutes; failure, 20 minutes, p = 0.30), paramedic seniority (p = 0.13), or number of attempts per paramedic (p >0.05). Increased level of consciousness (LOC) was associated with decreased success rate (p = 0.04). Paramedics reported difficulties in endotracheal intubation (ETI) attempts in 110 (46.6%) of patients. Factors reported to increase ETI difficulty were: 1) technical problems (35.6%); 2) mechanical problems (15.6%); and 3) combative patients (12.7%).
Conclusions:
Oral endotracheal intubation and NETI success rates identified in this study are similar to those described in the literature, although innovative strategies could be used to facilitate prehospital airway management. Many of the factors found to increase ETI difficulty could be ameliorated by the administration of paralytic agents, that is, for combative patients. Focused training in cadaver and animal labs coupled with recurrence training in the operating suites should be used on a regular basis to decrease difficulties in visualization. Interventions directed at alleviating mechanical difficulties that should be explored include new-to-the-field techniques, such as retrograde intubation, fiber-optic technology, and surgical tracheal access.
The need for search and rescue and medical care following a sudden impact disaster is immediate and often overwhelming. In the past, governments and international organizations have relied on external assistance for these efforts. Because the life expectancy of severely injured and trapped victims is limited, the response must come first from the impact area itself. The preponderance of disaster research demonstrates that the local populace overwhelmingly is responsible for search-and-rescue efforts. Emergency medical care, e.g., that delivered in the first 24 hours to 48 hours after a disaster, also is overwhelmingly from local or regional resources. Outside and, perhaps, even international assistance is required for medium- and long-term response, but is of limited benefit for the “emergency phase.”
On 17 October 1989, the Loma Prieta Earthquake shook the San Francisco Bay area, home to more than 6 million people. This study examined the effectiveness and function of emergency medical services (EMS) communications after this event.
Methods:
The six Bay area counties most affected by the Loma Prieta Earthquake were surveyed using a 156-part questionnaire. This study examined the functioning of the primary 9-1-1 county dispatch centers. Paramedics involved in a set of defined activities during the period after the earthquake also were surveyed. Emergency medical services directors also were questioned by telephone using an interview tool developed for this purpose. All areas concerning disaster response were not queried. Ten specific areas were considered, including: 1) preparation for disaster; 2) the impact of the earthquake; 3) reconnaissance; 4) call volume; and 5) others.
Results:
Coordination among the various agencies responsible for disaster response and mitigation needs more study. Uniform response plans for medical mutual aid need development. Government support similar to police and fire department arrangements for mutual aid are not in place. Additional planning and training for disasters at all levels need reassessment. The communication-center personnel indicated that they did not call for more resources, but instead accepted volunteers at dispatch centers and extra assistance. Once engaged, however, most communications centers (CCs) had great difficulty tracking and controlling all the units under their jurisdiction. In some large urban counties, some ambulances were idled awaiting calls but lost their communications centers, while other ambulance personnel were trying to handle multiple patients and requests for services.
Conclusions:
Significant help from a state or federal agency likely will be unavailable for a substantial period after a catastrophic regional event. Important coordination among EMS agencies for disaster response is poor or absent. Although fatalities and casualties were limited compared to what could have occurred, great confusion reigned for varying periods of time after the earthquake. Communications among local agencies, counties, and the state were problematic. Information flow to hospitals was cited frequently as a problem, making it difficult for hospitals to prepare adequately. Medical mutual-aid help was disorganized and inadequately controlled. The training of personnel and the method of recall for disaster response need to be examined.