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To determine if intravenous (IV) glucose boluses cause significant alterations of serum potassium ([K+]) levels.
Methods:
A prospective, descriptive study of patients ≥18 years of age presenting with altered levels of consciousness (ALOC) to paramedics in the prehospital setting or to the emergency department (ED) of a community teaching hospital and who received 50% Dextrose (D50) intravenously (IV). At presentation, a blood sample (PRE) was obtained prior to D50 therapy. For patients treated by paramedics, a second blood sample (POST) was obtained upon arrival at the ED. For patients who initially were seen in the ED, the POST sample was obtained one hour after D50 therapy. Both samples were analyzed to determine [K+] and glucose levels.
Results:
Over a seven-month period, 40 patients met study criteria. The average age was 46±20 years. Sixty percent of patients (24/40) had PRE blood sugars (BS) <80 mg/dl (mean PRE BS = 37±12 mg/dl; mean POST BS = 140±45 mg/dl) and 40% (16/40) had a PRE BS >80 mg/dl, (mean PRE BS = 241±255 mg/dl; mean POST BS = 274±237 mg/dl). The mean PRE [K+] was 4.1±0.8 mEq/L and the mean POST [K+] was 4.2±0.7 mEq/L. Forty-two percent of patients (17/40) had a <5% change in [K+], 33% (13/40) had a >5% increase in [K+], and 25% (10/40) had a >5% decrease in [K+]. Ten percent of patients (4/40) had a >20% increase in [K+], and 3% (1/40) had a ≥20% decrease in [K+]. No patient was treated for symptoms of either hyperkalemia or hypokalemia.
Conclusion:
Boluses of IV glucose produce unpredictable changes in [K+]. The majority of these changes probably are insignificant clinically.
No randomized, prospective studies have been conducted that examine how standing orders for establishing intravenous (IV) lines in trauma patients affect prehospital time. The purpose of this randomized, prospective study was to determine if standing orders for IV lines in the field shorten prehospital time.
Design:
A prospective, randomized study was conducted.
Setting:
Trauma patients (n = 521) were randomized prospectively on an even-/odd-day basis over a one-year period from 1 April 1988 to 1 April 1989. Patients were sorted into an IV Standing Orders (SO) arm (n = 258) and a No Standing Orders (NO) arm (n = 263) in which On-Line [Direct] Medical Command (OLMC) was required before IV initiation.
Participants:
Trauma patients, paramedics in a high-volume, urban, EMS system, and medical-command physicians on the trauma team at a Level 1 trauma center.
Results:
No significant differences were found in demographics, prehospital vital signs, mechanism of injury, or trauma severity scores between the two treatment arms. Scene times were similar for the two groups (IV SO = 11.4 minutes, and NO = 10.6 minutes, p = .1675) as was IV success rate (92% vs. 88%, p = .1729).
Conclusion:
When compared to OLMC in this EMS system, IV standing orders did not affect scene time. This supports the concept that only spinal stabilization and airway management be performed at the scene and other ALS maneuvers (e.g., IVs) be performed in the ambulance, preferably en route to a Trauma Center. Since IV standing orders had no documented, adverse effects and led to focused, concise radio telemetry reports, this EMS system adopted their use on a permanent basis.
This study is an evaluation of the ability of medically trained and controlled emergency medical dispatchers to use telephone triage techniques to direct the appropriate prehospital unit to an emergency scene.
Methods:
Emergency dispatchers, educated in a formal emergency medical dispatch program, were assigned one of four triage priorities to incoming 9-1-1 calls. The actual field management delivered for each patient was compared with the dispatcher's triage to determine the appropriateness of triage.
Results:
A total of 1,045 consecutive calls were reviewed with 74.4% sorted as needing advanced life support (ALS) units on scene; 65.3% (95% CI, 61.9 to 68.6%) of these calls required ALS intervention. A total of 3.4% of the runs sorted to the non-ALS response groups were identified to have required ALS intervention. Comparing the need for ALS intervention, a significant difference was found between the triage groups.
Conclusion:
Emergency medical dispatchers, using a formal system for telephone triage, are able to direct appropriate prehospital resources to the emergency scene.
Emergency medical technicians (EMTs) find that the death of patients in their care is stressful.
Population:
Random sample of certified EMTs in one state (Levels I–IV).
Methods:
A blinded, self-administered survey was sent to a random sample of 2,500 EMTs. Demographic data obtained were: level of training; hours worked each month; population of area served; age; gender; number of deaths per year; training for coping prehospital deaths; and availability of protocols and on-line medical advice for out-of-hospital deaths. A five-point, Likert scale was used to rate the frequency of perceived stress experienced by EMTs in specific situations and the routine practice for notification of survivors. Univariable analysis was performed using Spearman's Rank correlation, Kruskal-Wallis test, and Mann-Whitney U-test. Multivariable correlations were performed using forward and backward step-wise logistic regression analysis. A significance level of 0.05 was used throughout.
Results:
There were 654 respondents with a mean age of 35.5±8.3 yr; 83% were men. Their highest level of training was: 4% EMT-I, 43% EMT-II, 18% EMT-III, 33% EMT-IV. They saw an average of 9.6 deaths/year and spent an average of 20±17 minutes with survivors. 62 % found treatment of a patient that was dying or died in their care was commonly a stressful experience. Factors that made notification of the family about the prehospital death emotionally difficult included: fewer hours worked/month; working in a smaller community; lower level of EMT training; female gender; and fewer deaths seen during the previous year. The same factors were associated with general emotional difficulty in treatment of a patient who died during prehospital care. Online [direct] medical direction by physicians was common (73%), but did not lessen the difficulty of notification. It did reduce the emotional difficulty for specific clinical situations. Written protocols for not attempting resuscitation were common (66%), but only 44% had protocols for termination of resuscitation. Resuscitation of the clearly dead for the benefit of the family (10%) or for the EMT (5%) was practiced infrequently. Most (67%) respondents had some formal training in dealing with death and the dying patient. Such training did not correlate with less difficulty in notification of survivors or in coping with the deaths of patients in their care.
Conclusion:
EMTs perceive they have emotional difficulty when prehospital deaths occur and survivors must be notified. Less experience and a lower level of EMT training correlate with more difficulty in coping with patient death. Protocols and on-line [direct] medical control can provide support for the EMT in coping with out-of-hospital deaths. Most notification of survivors is handled by EMTs with formal training to cope with patients that are dying or who die during prehospital care.
Emergency physician interpretation of prehospital, paramedic-acquired, electrocardiograms (ECG) is accurate judged by comparison with that of a reference cardiologist.
Methods:
Twelve-lead ECGs were obtained by paramedics in the field from 150 patients with acute chest pain. The ECGs were transmitted by cellular telephone to a central location. Each ECG was assessed for evidence of acute myocardial infarction (AMI) by: 1) a third-year, emergency medicine resident (EMP-R); 2) a residency-trained, board-certified, emergency physician (EMP-RT); 3) an emergency physician board certified under the practice option (EMP-PT); and 4) a board-certified cardiologist. Agreement between each emergency physician and the cardiologist was assessed by the kappa statistic. Hospital records were reviewed for final diagnosis of each patient.
Results:
Sixteen of 150 (10.7%) patients received a hospital discharge diagnosis of AMI. Sensitivity of physician interpretation ranged from 0.31 to 0.56. All physicians achieved specificity of 0.99. False-positive rates for the physicians ranged from 0.18–0.29. The mean positive predictive value for the four physicians was 0.77±0.05; the mean negative predictive value was 0.94±0.01. The total agreements between the EMP-R, EMP-RT, and EMP-PT and the cardiologists were 0.97, 0.96, and 0.97, respectively. Kappa values for agreement between the emergency physicians and the cardiologist ranged from 0.65–0.79.
Conclusions:
Residency-trained or board-certified emergency physician interpretations of prehospital, paramedic-acquired 12-lead ECGs show a high degree of agreement with reference cardiologist interpretations.
Paramedics accurately estimate the closest trauma hospital for ground transport.
Population:
Ground ambulance scene transports of trauma system patients to six participating trauma hospitals in Multnomah County, Oregon from 1 January 1986 to 1 January 1987 were studied. Transports involving multiple patients or pediatric patients were excluded.
Methods:
A retrospective analysis was performed on consecutive patient transports to be taken to the closest trauma hospital as required by protocol. The availability of each hospital to receive trauma patients was monitored continuously by a central communications facility. Paramedics were provided hospital availability data at the time of patient system entry. When several hospitals were available, the paramedics were required by protocol to select the “closest” hospital. Subsequently, the vector distance from the trauma site to each of the available hospitals was measured using a grid map. This method was validated by odometer measurement (r2 = 0.924). Chisquare analysis was used to analyze hospital bypasses to specific hospitals.
Results:
Of the 1193 eligible patients entered into the trauma system, 160 (13%; 95% CI = 11–15%) transports bypassed the closest available hospital for a receiving hospital ≥1 mile more distant. There were 11 (1%; 0–2%) patients transported to a hospital more than five miles more distant. Of the 132 patients with a trauma score (TS) <12, 15 (11%; 6–18%) were taken to a hospital one mile or further beyond the closest hospital. None (0%; 0–2%) were transported more than five miles past the closest hospital. Of the six hospitals, three were bypassed more than one mile significantly more often then they received bypass patients. One hospital received such patients four times more than it was bypassed (p <.001).
Conclusion:
While paramedics generally can identify the closest hospital for trauma patient transport, some systematic hospital bypass errors occur. If a community wants assurance of an equitable patient distribution among participating trauma hospitals and assignment of the closest geographic hospital for injured patients, then map vector distance determination to identify the closest available hospital should supplement paramedic dispatching.
The effectiveness of using supplemental teaching sessions with animals and cadavers on the acquisition of technical skills of endotracheal intubation was studied.
Methods:
Paramedic students were evaluated for early endotracheal skill acquisition in the operating room and by questionnaire.
Results:
Supplemental practice skills using either sheep or cadavers did not produce a statistically significant improvement in the percentage of successful clinical operating room intubations as compared to a group trained solely using intubation mannequins. More paramedics, certified and in practice, reported a statistically significant psychological benefit to supplemental cadaver training compared to supplemental animal (p<.05) and mannequin (p<.05) training.
Conclusion:
Adjunctive teaching sessions using animals or cadavers do not improve the acquisition of initial technical success in clinical intubation over the use of the mannequin alone.
This article presents the concepts of a computerized information system and its potential applications to Emergency Medical Services (EMS). It is an informational article intended to provide administrators clear concepts of how computers may be best used to provide information in integrated networked systems for EMS needs. It addresses the function of a system, processes of computerizing a department, planning, and provides an overview of computer hardware.
Suicidal patients who refuse prehospital transport pose a difficult problem for emergency medical services. A survey was conducted in an attempt to assess the current strategies for involuntary transport of such patients.
Methods:
The medical directors of 135 of the largest EMS systems in the United States were mailed a questionnaire requesting descriptions of the operating procedures for dealing with suicidal patients who refuse transport.
Results:
Fifty-nine of 130 questionnaires (45%) were returned. Seventeen emergency medical services (EMS) systems (29%) serve populations of less the 250,000, while 41 (69%) serve populations greater than 250,000. Cumulatively, respondents represent an excess of 2.1-million EMS responses per year, of which 0.5%-10.0% involve behavioral emergencies. Eleven of the 59 responding systems (19%) have urritten, explicit policies guiding the management of suicidal patients who refuse to be transported. Involuntary commitment proceedings are initiated in the prehospital setting in 25 of the 59 services (42%). Of these 25, the initiation of commitment proceedings is performed by the following (more than one may apply to a given system): 11 (44%) by base-station physicians, six (24%) by the emergency medical technician (EMT), 23 (92%) by a police officer, and five (20%) by family or friends. Ten of the 59 systems (17%) require a mental health delegate to authorize commitment. Two physicians can mandate involuntary commitment in one of the responding systems. Of the 25 systems that actually perform involuntary commitment in the prehospital setting, seven (28%) have established policies. Of the 34 systems which do not perform involuntary prehospital commitment, four (12%) have policies to guide the care of suicidal patients who refuse care.
Conclusion:
Suicidal patients commonly confront emergency medical services, yet many systems lack explicit policies for dealing with such patients. Widely varied strategies are used to authorize transport of patients who are suicidal and refuse to be transported.
The growth and development of emergency medical services (EMS) has been both impressive and extensive since the late 1960s. Since that time, there has been much discussion and debate regarding the level and quality of care that patients receive from the EMS system. In the United States, this has resulted in a wide variety of emergency medical technician (EMT) certification levels that determine which personnel administer an extensive range of medications, procedures, and medical protocols. Because of these differences, the care a patient receives varies not only from state to state but from community to community. Even though there are many different EMS system configurations, EMS professionals generally believe die level of care they provide in their local community is effective. It is unfortunate that very often, opinions about EMS system effectiveness are not based on studies of EMS system performance or patient outcome data, but upon subjective assessments of ongoing activities by those individuals providing the services.