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Without a well-functioning, prehospital, do-not-resuscitate (DNR) system in place, emergency medical service (EMS) providers must resuscitate all patients who access the system, regardless of the patients' wishes and regardless of what makes ethical or economic sense. In lieu of valid documentation, it is not appropriate to withhold resuscitative measures in this critical, time-dependent situation. In order to help EMS systems implement functional prehospital DNR protocols, this paper reviews the state-of-the-art of prehospital DNR including the issues to consider when designing such a system and a discussion of the features of some of the existing systems. This review includes: 1) the basis and requirements of a DNR system; 2) legal and physical forms for DNR orders; 3) eligibility for DNR status; 4) reversal of DNR orders; and 5) inappropriate use of EMS systems for DNR patients. Finally, a more general discussion of overall resource utilization in prehospital resuscitations is presented to emphasize that implementing prehospital DNR systems is only one piece of a larger issue.
The urban prehospital setting is one of the best venues in which to examine life-saving resuscitation interventions. When the entire catchment of the urban emergency medical services (EMS) system is used, large-population patient studies can be generated. Certain unique features give several urban centers the ability to conduct clinical trials in the out-of-hospital setting. Without resuscitation at the scene, it is rare for cardiac arrest patients to survive. In the case of trauma resuscitation, prehospital care can impact outcome significantly. Since coronary artery disease and trauma kill nearly one-million persons annually in the United States, prehospital care research is a worthwhile endeavor. This rationale for prehospital care research is strengthened by the relatively high potential for full recovery.
A panel session on undergraduate education in Emergency Medicine from a worldwide perspective was conducted at the Seventh World Congress of Emergency and Disaster Medicine in Montreal, in May, 1991. Desmond Colohan MD, of the University of Toronto (Canada) was the panel moderator. Panel speakers were: Louis Binder MD, Texas Tech University Health Services Center (USA); Wolfgang Dick MD, University of Mainz (Germany); Bernard Nemitz MD, Faculty de Medicine d'Ameins (France); Yoel Donchin MD, Hadassa Medical Organization (Israel); and Noriyoshi Ohashi MD, Tsukuba Medical Center (Japan).
Prehospital care experienced a “honeymoon” from the early 1970s until recently. Treatments usually were extrapolated directly from the hospital setting, even though the prehospital environment is markedly different. That honeymoon is over and emergency medical services (EMS) providers must prove what is beneficial. Additionally, academic prehospital care physicians interested in professional advancement, must show the same ability as do the more traditional medical academicians to expand the knowledge base of their chosen field.
This manuscript will highlight the basic features and identify the potential benefits and pitfalls of prehospital research. This chapter is not a cookbook for EMS research, nor will it obviate the need for accessing other sources on research design. Other manuscripts within this series will focus on more specific topics; yet, it will be obvious that many of the points made here will be re-emphasized in the following papers. That simply is a reflection of the importance of these commonly overlooked perils and pitfalls.
Prehospital (EMS) personnel routinely enter patient's homes and often are the first trained persons to evaluate an ill or injured child. Therefore, it is vital for these individuals to recognize child abuse (CA), and to understand the proper procedures for reporting suspected cases.
Methods:
A questionnaire was administered to prehospital care-givers participating in a seminar on pediatric emergencies. Questions were designed to test factual knowledge of CA and the correct reporting procedures, as well as to evaluate attitudes toward CA.
Results:
There were 48 responses to the questionnaire; 34 (71%) were paramedics, the remainder were emergency medical technicians (EMTs) and/or registered nurses (RNs). Thirty-three (69%) practiced either in a rural or suburban setting. Subjects had an average of 10.8 years of prehospital emergency-care experience. Twenty-eight (58%) reported no previous training in CA. All participants understood the nature of CA, were able to identify the various forms of CA, and believed CA to be a significant problem. However, 33 (69%) did not understand the legislation that mandates reporter status, and while 27 (56%) claimed to have reported CA, only 16 (33%) had made a report either to police or to children's services workers. Of the 21 who never had reported a case of CA, 14 (67%) believed that they never had encountered an abused child. The remainder were not certain, and therefore, did not report, or thought that the hospital staff would report.
Conclusions:
While this subject deserves further study, it seems that many EMTs and paramedics lack a complete understanding of their role in the identification and reporting of CA. This information should be emphasized further in EMT and paramedic education, and should be reinforced through continuing education.
Emergency Medical Services (EMS) researchers face a variety of obstacles when conducting out-of-hospital investigations. This paper reviews some common problems and discusses practical solutions to facilitate the process and help avoid traps. This discussion focuses on prospective prehospital research.
One challenge to EMS research is to find new methods of improving the quality of care delivered in the field. There has been an emphasis placed on “exciting” topics, such as cardiac arrest and trauma resuscitation. Other events dominate the daily practice of prehospital medicine, but have not been well-studied. For example, what is the best way to immobilize the spine? What should be done for a patient with a suspected C-spine injury who is wearing a motorcycle helmet? No one has a scientifically proven approach to solve these common prehospital problems. There is a need to look at problems such as immobilization, asthma, overdose, and congestive heart failure to see what can be done differently in the field.
Investigate Emergency Physicians' knowledge about the Superfund Amendments and Reauthorization Act (SARA) Title III legislation, passed by the United States Congress in 1986, and to determine the factors contributing to their level of preparedness in dealing with patients exposed to toxic chemicals.
Methods:
A 115-item questionnaire was mailed to the medical directors of all emergency departments (EDs) in the State of New York. The results of the cross-sectional survey were analyzed using standard statistical methods.
Results:
One hundred and eighty-seven (72%) of the directors of EDs in New York State responded to the survey. Three years after SARA was enacted, only 33% of the directors had heard about this legislation. Only 18% had been invited to attend the meetings of the Local Emergency Planning Committees (LEPC). Sixty percent of the directors knew whether or not the LEPC had devised plans that defined a role for their EDs in responding to environmental emergencies. This knowledge about community planning mainly had an effect on preparedness of the EDs. Preparedness also was predicted by how recently the EDs had treated patients exposed to toxic chemicals, the perception that emergency physicians had a legitimate role in planning for and responding to chemical emergencies, and how often emergency physicians had attended continuing education courses about hazardous materials.
Conclusion:
Despite the finding that some emergency physicians are involved in community preparations, two main problems persist in planning a medical response to environmental emergencies. First, the ED directors generally are unaware of the legislation that mandates these preparations and are not interacting with community planners. Second, there is not full involvement by the local EDs in the LEPC planning efforts.
Recommendations:
A procedure is needed to disseminate information about legislation which affects emergency physicians, such as SARA, and about regional planning for environmental emergencies. Dissemination should include education about the professions' role in planning for and providing care for patients exposed to toxic chemicals.
A reported in-field, prospective evaluation of 227 prehospital patient assessments by advanced life support (ALS) emergency medical technicians (EMTs) found a frequent failure to measure vital signs. The objective of this retrospective review was to report the omission frequency of vital signs found in a centralized emergency medical services (EMS) data collection system.
Methods:
The EMS database contained information from 90,480 optically scanned, prehospital patient encounter forms. Each record identified EMT skill levels, response times, dispatch type, vital signs, medical and trauma information, treatment, and patient disposition. Records for 1989 and 1990 were collected from 92 rural EMS providers who responded to emergency medical and trauma events.
Results:
Of 90,480 emergency responses, 14,129 (15.6%) were false alarms, deceased, or canceled without vital patient contact. Valid encounters were documented for 76,351 (84.4%) patient contacts. Systolic blood pressure measurements were not recorded for 13,262 (17.4%) patients. Diastolic blood pressure was not recorded for 14,272 (18.7%) patients. A pulse record was not recorded for 12,125 (15.9%) patients. A ventilatory rate was absent in 12,958 (17.0%) patient records.
Conclusion:
This study found a frequent failure by non-metropolitan basic life support (BLS) and advanced life support (ALS) EMTs to record vital signs on prehospital emergency patient encounter forms. It supports a previous report of direct in-field observations of ALS EMTs failing to measure vital signs during patient assessment. The impact of vital sign omissions upon individual patient care can be assessed only by receiving medical control physicians. In the absence of effective emergency physician networking, the statewide magnitude of the problem among BLS and ALS EMTs has not been recognized as a system issue.
Determining the variables that influence survival in the treatment of cardiac arrest is important as both a research and a quality assurance tool. Out-of-hospital cardiac arrest remains the only medical condition in which it has been determined rigorously that prehospital care affects survival. Thus, it uniquely is suited to outcome-based research and quality assurance studies. After approximately 20 years of study, the determinants of survival after cardiac arrest are well-known; however, a plethora of fascinating research questions remain to be addressed.
The prevalence of out-of-hospital cardiac arrest seems to be decreasing. In the Seattle area, there are 30% fewer cases than there were ten years ago. This parallels the overall decline in mortality from ischemic heart disease in the United States in the last thirty years. There also has been a change in the profile of cardiac arrest victims, with today's arrestee several years older than the victim of fifteen years ago. Thus, when one performs comparative clinical trials, the control group of today is very different from the historical control of ten or fifteen years ago.