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The first Pan-European Conference on Emergency Medical Services (PECEMS) was convened in Budapest, Hungary, 30 August through 3 September 1992, under the sponsorship of numerous international and national organizations with participants representing more than 40 countries.
Evidence placed before the conference identified serious deficiencies in the delivery of emergency health care in the overwhelming majority of participating countries.
In a single-tier, advanced-life-support (ALS) emergency medical service (EMS) system, ALS-trained staff in ALS-equipped vehicles respond to all ambulance calls. In some two-tier systems, basic life support (BLS) vehicles respond to calls which are determined initially to be non-emergency based on dispatcher triage. I emergency requiring ALS is discovered (or recognized) by BLS personnel, then a subsequent ALS response can be requested.
Purpose:
The purpose of this study was to determine the frequency of ALS care provided on ambulance calls initially dispatched as non-emergency.
Setting:
A single-tier, all-ALS provider, EMS system, serving an urban population of 475,000 with an annual response volume of 45,000 calls.
Methods:
A retrospective review of all prehospital transports initially dispatched as non-emergency from 1 January 1989 to 1 January 1990 that resulted in an ALS intervention being performed was conducted. An ALS intervention was defined as, “administration of a medication, endotracheal intubation, attempted IV insertion, and/or ECG monitoring.”
Results:
A total of 6,362 non-emergency calls were identified; of these 309 (5%) were upgraded to emergency while the responding unit was in route. Of 6,053 non-emergency calls remaining, 710 (11.7%) involved the provision of one or more ALS interventions. Of these, 296 (42%) received an IV, 24 (3%) a medication, and three (0.4%) were intubated. Calls that were upgraded by dispatchers required one or more interventions in 144/309 calls (46.6%). This was statistically significantly different than for the non-upgraded calls.
Conclusion:
Despite the use of strict dispatching protocols, 11.7% of patients prioritized as non-emergent unexpectedly received ALS care after evaluation by ALS personnel. These results add support for the use of a single-tier, ALS ambulance system.
Natural and man-made disasters continue to be a major cause of morbidity and mortality. Natural disasters include earthquakes, storms such as hurricanes, floods, fires, drought. Man-made disasters include fires, explosions, chemical and radioactive releases, major transportation accidents, terrorism, and war. The effects of disaster include injury, death, damage to infrastructure, environmental exposure, population movement, and increased incidence of communicable diseases.
The International Children's Center for Disaster Medicine is conceived as a non-governmental, non-profit institution. Its goal is to provide medical help to children during environmental and military disasters and their resulting circumstances, vnthout regard for their nationality, religion, or the political views of their parents.
The idea for an international children's center for disaster medicine grew out of the experiences of pediatricians active in disaster medicine, who were able to see at first-hand, the potential for assistance in such situations, but who also saw either overlapping services provided by well-intentioned organizations, or severe deficiencies in services because of a lack of communication and coordination between these organizations. Among the goals of this international children's center will be to provide volunteer medical help to children by the best specialists in pediatric care, including surgeons, pediatricians, traumatologists, orthopedists, neurosurgeons, intensive care and critical care specialists, experts in rehabilitation, and psychologists. A special training program will create a system of regional and inter-regional specialists, who can offer qualified help to children in catastrophic situations. This educational program will stress the preparation of local medical assets and simultaneously provide international support. The center will conduct scientific research devoted to the specific problems of assistance to children during catastrophic circumstances. A special surgical hospital will be built to care for children after catastrophes. Branches of this international center will be created to serve large regions of the world, allowing a reduction in mortality and morbidity of children, and leading to an improvement in the results of medical care.
This paper explores the interactional nexus surrounding the delivery of non-paying and/or uninsured patients by paramedics to hospital emergency departments (EDs).
Methods:
Interviews, direct observation, and participant observation were used as data-gathering techniques.
Results:
Twenty-four of 25 paramedics and 17 of 25 nurses in the sample responded affirmatively to a question which asked, “Does trouble ever arise regarding the ‘kind’ of patients …” brought to the emergency department. The majority of the respondents who said that trouble was produced by the kind of patient brought to the emergency department specifically mentioned that the poor financial or non-insured status of the patient produced trouble between paramedics and ED personnel.
Conclusion:
These circumstances present problematic situations in the United States especially within the context of recent COBRA and OBRA legislation.
Circumstances surrounding the prehospital management of trauma patients may mask clinical signs of inadequate oxygenation. Pulse oximetry (PO) may influence airway management prior to helicopter transport by helping to identify patients with occult hypoxemia.
Methods:
Patients were enrolled in a prospective study. Initially, the flight physician clinically decided how best to manage the patient's airway prior to helicopter transport. The patient's oxygenation saturation (O2at), was determined by PO. Then, the physician reassessed the initial airway management decision based on clinical assessment and knowledge of the O2Sat. All patients had an arterial blood gas (ABG) measurement taken after completion of transport.
Results:
Sixty patients were enrolled. Knowledge of the O2Sat, as determined by pulse oximetry, did not influence airway management. No patients with occult hypoxemia were identified.
Conclusion:
The use of PO in the initial evaluation of trauma patients prior to helicopter transport did not influence the flight physician's initial management of the airway.
Emergency cardiopulmonary resuscitation (CPR) instruction via telephone (ETCPR) is cost-effective compared to prehospital, emergency medical technician (EMT)/paramedic treatment alone of witnessed, ventricular fibrillation (VF) in adult patients.
Methods:
A total of 118 patients, age >18 years, with prehospital, witnessed ventricular fibrillation were studied. Patient data were extracted from hospital records, monitor-defibrillator recordings, paramedic reports, dispatching records, and telephone interviews with bystanders. No ETCPR was available during this period. The costs of ETCPR implementation were estimated retrospectively. Marginal cost of the paramedic service attributable to treatment of VF was calculated from fire department records. Years-of-life saved were estimated from age, gender, and race matched norms.
Results:
Of the 53 patients receiving bystander CPR (BCPR), 14 (26%) survived to hospital discharge versus 4/65 patients (6%) lacking BCPR, These groups did not differ significantly (p>.05) in age, EMS response times, or time from collapse to defibrillation. The mean time interval from collapse to CPR was significantly less for patients with BCPR (1.8 min) than for patients without BCPR (7.1 min). Had all patients received BCPR and survived at the rate of 0.26, 13 additional patients would have survived to hospital discharge. The cost per year-of-life saved by the EMS system with ETCPR would have been [US]$2,834 versus $4,881 without ETCPR. The cost per additional year-of-life saved by ETCPR was estimated to be $560 in patients experiencing out-of-hospital ventricular fibrillation.
Conclusion:
The use of ETCPR instruction of callers by 9-1-1 dispatchers potentially is a cost-effective addition to a two-tier, EMS system for treatment of prehospital ventricular fibrillation.
The emphasis of training for paramedics that function in the civilian sector in the United States has focused on the management of blunt trauma. The personal risks they face generally are the result of accidents or public health threats. The management of penetrating trauma under the threat of intentional personal harm is a different matter.
Law enforcement agencies have responded to the threat of apprehending heavily armed felons by forming special units highly trained in military-style, small-unit tactics. To provide care in this special environment, and support a special weapons and tactics (SWAT) team in fulfilling its mission, there is a requirment for a unique body of knowledge and special skills. (Prehospital care providers with at least emergency medical technician [EMT] skills and SWAT training will be referred to as tactical medics.)
Helicopter emergency medical service (HEMS) systems typically are described in terms of their role in the care and transport of trauma victims, while their function(s) in the care of patients with medical illness goes unrecognized.
Methods:
Review of 575 prehospital HEMS missions by a flight program located in rural, north-central Florida over a five-year period, was performed to define demographics regarding the nature of the call.
Results:
Scene responses for trauma victims comprised 63% of these missions, while patients with medical illnesses comprised 37%. The incidence of medical scene responses is significantly higher in this review than has been noted in previous reports.
Conclusion:
1) In rural settings, patients with medical illnesses comprise a major share of prehospital HEMS responses; 2) HEMS flight crews should be competent in treatment of prehospital medical patients, and their protocols reflect the needs of these patients; and 3) EMS providers must be aware of the role of HEMS in the transport of the medical patient.
To determine the clinical efficacy, patient volume, and program costs that justify pediatric intraosseous (IO) infusion as a routine skill for the treatment of patients with cardiac arrest in a prehospital system.
Methods:
A decision analytic model was constructed to include patient outcomes and costs to society. Critical variables for the analysis were: 1) time to vascular access; 2) success of vascular access; 3) clinical efficacy (i.e., the percentage of lives saved by early vascular access); 4) number of patients requiring IO annually; and 5) the cost of an IO program. Program costs included training and equipment expenses. Sensitivity analysis, which repeatedly evaluates the model using different values for the critical variables, identified those values at which IO would be cost-effective.
Results:
With an estimated 80% success rate for IO access within five minutes, the cost-per-life-saved would be [US] $161,000. This cost-effectiveness ratio assumed annual program expenses of $2,000 and one patient per year needing IO. The cost-effectiveness ratio also required a clinical efficacy of 2% for vascular access. To prove that the clinical efficacy of vascular access is in fact 2%, epidemiologic studies would require a sample of nearly 9,000 patients.
Conclusions:
This analysis suggests IO probably is cost-effective given a clinical efficacy above 2%. While the true efficacy may be below this value, clinical studies are unlikely to have sufficient size to prove it. Therefore, emergency medical services (EMS) medical directors must make the decision to utilize IO based on their own beliefs about its clinical efficacy. Further, it must be considered in the context of other prehospital programs which may be more cost-effective. Such analyses permit establishment of rational priorities to rank programs in prehospital systems.