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The Metag triage label system was assessed during a major incident exercise at an international airport. The exercise simulated a crash of a plane carrying 40 passengers within the airport boundaries. A secondary incident also was staged involving an explosion resulting in a fire with three victims injured. The exercise involved the airport, fire, police, ambulance, and medical services of three counties—Leicestershire, Derbyshire, and Nottinghamshire. Use of the labels enabled evaluation of the triage process, early medical intervention for victims, and completion of the cards.
As evidenced in a number of recent disasters, there appears to be an increasing trend, for health care professionals to leave the confines of the hospital to provide on-scene care. This trend may be due to a number of recommendations from a variety of sources such as the National Disaster Medical System, the implementation of the United States Military Disaster Response, Federal Aviation Administration (FAA) recommended airport disaster plans, trends in community disaster planning, and Emergency Medical Services practice.
Ongoing monitoring of the availability of hospital critical care resources is necessary to assure patients in the emergency medical services (EMS) system reach appropriate care. In this densely populated area Multnomah County, Oregon, ambulances have been diverted by radio from several hospitals before finding one that would accept the patient. Dispatch centers and base-stations had no reliable method to monitor the availability of hospital resources. Data were not available for use in establishing policy.
In response, this community developed an on-line, computerized system known as Computerized Hospital On-Line Resources Allocation Link (CHORAL) that visually displays the resource status of all hospitals to the 911 center, base-station, and participating hospitals. A change of status requires simple keystrokes for entry into the computer which in turn is transmitted automatically to all other CHORAL computers.
Six patient care resources are monitored: Adult Ward (AW); Computerized Axial Tomography Scan (CT); Critical Care (CC); Labor and Delivery (LD); Pediatric (PEDS); and Psychiatric Secure Beds (PSB). Paramedics use protocol to determine if a particular patient fits one of these categories. Availability is relayed to paramedics by the 911 center and the base-station. During the first three months of system operation, there were 337 diversions representing 4,527 hours among 10 of the 12 participating hospitals. The most common resource resulting in diversion was PSB, which was unavailable for 2,195 hours (48.5%). Unavailability of CT resulted in the lowest number of diversions (1.3%, 60.3 hours). Using this system, the paramedics know the resource status of destination hospitals immediately, resource information monitored at base-stations and 911 centre is accurate, and data are available for use in establishing policy.
The purpose of this clinical study was to compare the prehospital use of fully automatic defibrillators versus semi-automatic defibrillators.
Methods:
Fully and semi-automatic defibrillator use by EMTs in neighboring communities was compared.
Results:
Both programs had similar response times, age and gender distribution, proportion of witnessed arrests, and proportion of patients found initially with ventricular fibrillation (VF). The time-to-shock from proper lead placement was shorter when the fully automatic defibrillator was used (16.6 vs. 44.3 seconds; p<.001) and the survival to hospital discharge rate was greater (26% vs. 0%; p=.O4). The semi-automatic defibrillators were more sensitive in detecting VF than were the fully automatic devices.
Conclusions:
These data support the need for further comparison of the efficacy and effectiveness of semi- and fully automatic, external defibrillators.
Prehospital care providers commonly indicate that they cannot wear seat belts owing to their need to be unrestrained while delivering care to the patient in the back of the ambulance. Each year, providers are injured in situations in which seat belts have been shown to be protective. Are ALS providers able to wear a seat belt and provide care in an ambulance?
Methods:
The ALS providers were asked to complete a form following calls during which they rode with a patient in the back of an ambulance. They indicated the amount of time which they felt they would have needed to have been unrestrained by seat belts and the reasons. There were no attempts to regulate or quantify seat belt usage. Additional information was gathered from the trip report.
Results:
The percentage of the time of each trip during which they felt they needed to be unrestrained was calculated for each trip. The mean was 41%. The mean transport time was 14.7 minutes. Sub-groupings by protocol type, showed that for cardiac arrest patients, providers felt they needed to be unrestrained for 82% of the duration of transport, for patients with “chest pain or cardiac dysrhythmia” 63%, for “shortness of breath” 38%, and for trauma patients 41%. Excluding cardiac arrest patients, the nine patients were assigned by the providers to have the most critical level of case severity required unrestrained time of 72%. Those nine patients with the lowest severity level requires that the provider by unrestrained only 18% of the time. Management of intravenous line and patient assessments most frequently were cited as reasons for needing to be unrestrained.
Conclusion:
Perceived need of ALS providers to be unrestrained varied with respect to the type of call, with cardiac arrest patient transports having the greatest need to be unrestrained. However, on the average, providers felt they needed to be unrestrained only 41% of the time; markedly less on some types of call, with cardiac arrest patient transports having the greatest need to be unrestrained. However, on the average, providers felt they needed to be unrestrained only 41% of the time; markedly less on some types of calls. The ALS providers should be able to wear seat belts for at least part of the time, on most ALS calls.
Due to time constraints, most Emergency Medical Services (EMS) certification and continuing education programs offer no more than an overview of the principles of anatomy, physiology, and pathology. In an effort to strengthen the EMS professionals' knowledge of these concepts, an EMS Anatomical Workshop was developed. This workshop is a day-long program consisting of lectures and laboratory sessions covering anatomy, physiology, and pathology of major body systems. The workshop has been successful, and its fourth offering has been completed. This program could serve as a model for areas that desire to enhance the education of their EMS providers.
Since 1 August 1986, the [U.S.] Federal Aviation Administration (FAA) has required medical kits be carried on all aircraft with thirty or more seats. In addition, kits are commercially available, as are published suggestions for the composition of kits which can be used by physicians during wilderness, overseas, and shipboard travel. However, little data are available regarding medical kits to be carried in a physician's private automobile for use in prehospital emergencies. It was the goal of this study to design such a kit for use by the residents, graduates, and faculty of the Emergency Medicine Residency at Wright State University. This paper will discuss how and why the various items were chosen for inclusion in this kit.
Application of pressure infusion bags may increase intravenous (IV) flow rates three-fold. Commercially available pressure infusers, manual squeezing of the IV fluid bag, inflating a blood pressure (BP) cuff around the bag, and kneeling on the bag have been used by prehospital personnel attempting to augment fluid infusion rates. To test the efficacy of each these methods, seven experienced paramedics were asked to employ each method in turn trials using a 1-liter bag of saline though a 14-gauge, 5.7cm catheter and a standard administration set. Gravity flow from 80cm served as the control.
Pressure infusers generated flow rates of 257±54 ml/min and 296±53 ml/min when inflated to 300 mmHg and maximum pressure respectively. This rate was 2–2.5 times that of gravity flow (123±2 ml/min) and significantly greater than those rates obtained by any other method (p<.0005). Manually squeezing the bag also was significantly better than was gravity flow with flow rates of 184±6 ml/min and 173±40 ml/min achieved by each of two different squeezing methods (p<.01). Neither blood pressure (BP) cuff application and inflation (135±28 ml/min) nor kneeling on the bag (125±36 ml/min) was better than gravity alone.
These results indicate that pressure infusers should be used to the exclusion of other field methods of supplying infusion pressure. If pressure infusers are not available, manually squeezing the bag is the only alternative acceptable in the field.
Pediatric Emergency Air Transports (PEATs) at Massachusetts General Hospital, Boston, Massachusetts, were reviewed between November 1986 and December 1987. Severity of illness, complications, and outcome of PEATs were compared with ground transports. Factors associated with PEAT survival were identified.
Methods:
Severity of illness was measured using a modified Denver Patient Status Category (DPSC) method and the Therapeutic Intervention Scoring System (TISS). There were 35 PEATs (30 helicopter, five fixed-wing) and 96 ground transports.
Results:
Mean severity of illness for patients was greater in PEAT than for the ground transport (PEAT DPSC score=4.23±1.06 versus ground DPSC=3.57±0.89 [SD], p=.0005). The PEAT mortality was associated with a greater mean severity of illness (TISS survivors=19.1±11.4 versus non-survivors=44.3±9.5, p=.0001), but not with: the presence of an in-flight physician; transport delay; transport duration; age; sex; history of chronic illness; or intra-transport medical complication.
Conclusions:
Compared to ground transports, PEATs were used for higher risk patients.
A prior report demonstrated a five-minute decrement in scene and total prehospital times in the standing order and limited standing order intervals as compared to control.
Methods:
The Alameda County Emergency Medical Service (EMS) District studied the impact of standing orders on field times, comparison of paramedic assessments with emergency department diagnoses, field drug use and procedures, and hospital outcome. These variables were studied over three discrete, six-week, time-study intervals, which represented three different levels of base-hospital medical control (control, standing order, and limited standing order).
Results:
There were no statistically significant differences between the three time-study intervals for the following variables: 1) incidence of prehospital administration of three cardiac arrest drugs; 2) incidence of prehospital administration of no drugs; 3) incidence of performance of endotracheal intubation; 4) incidence of performance of defibrillation; 5) assessment comparison; and 6) hospital outcome. There were statistically significant differences between intervals for incidence of: 1) administration of naloxone; 2) administration of 50% dextrose; 3) intravenous (IV) starts; and 4) paramedic performance of no procedures.
Conclusion:
Although there are several potential flaws in method, the data suggest that standing orders result in decreased incidence of drug administration and IV starts in non-critical situations without a negative impact on paramedic assessments or hospital outcome.
Non-traumatic, sudden death in young patients has been described in several studies, but most of these studies have involved highly selected populations. This study examined consecutive cases of non-traumatic, prehospital, sudden death in young patients (age 2–35 years) in a six-year period in an urban EMS system. One-hundred-seven cases were identified; however, seven cases were excluded because of occult trauma or lack of documentation. Of the 100 cases studied, drug and/or toxin exposure was the most common etiology (32%), followed by cardiac (22%) and pulmonary (20%). This is the first study which describes all cases of non-traumatic, prehospital, sudden death in young patients presenting to an EMS system. Implications of these data for EMS personnel are discussed.