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Seizures are a common pediatric problem encountered by prehospital personnel. Status epilepticus is defined as seizure activity lasting longer than 15 minutes, or recurrent seizures that occur close together without a period of consciousness between ictal periods. It is estimated that 60,000 to 160,000 cases of status epilepticus occur each year within the United States. Prior to 1960, status epilepticus carried a 50% morbidity rate. However, improved anticonvulsive medications, aggressive airway management, and the spread of EMS Systems throughout the nation have reduced the morbidity rate to a range of 8% to 12%.
Prompt and vigorous treatment is paramount in the successful management of status epilepticus because delays can result in neuronal damage and death. Although intravenous diazepam currently is the drug of choice to terminate seizure activity, it may be difficult to rapidly establish a patent intravenous (IV) line during status epilepticus in young children with vigorous motor activity. Alternate routes, such as intramuscular injections, are unreliable due to unpredictable absorption. Rectal administration of diazepam may provide an useful alternate route for delivery of the drug during status epilepticus when IV attempts fail.
In this review, the authors discuss a case of status epilepticus wherein intravenous access could not be established rapidly and the patient was given diazepam rectally with favorable results.
Transcutaneous cardiac pacing (TCP) is a promisingprehospital intervention, but there are little data available regarding protocols to improve patient tolerance to TCP. A 50:50 nitrous oxide:oxygen analgesic mixture aho is a commonly employed prehospital intervention. In this randomized, prospective study, we compared the discomfort experienced by 18 healthy subjects when paced in two triah at the capture threshold: one following breathing of a 50:50 nitrous oxide:oxygen mixture; and the second breathing only room air. Discomfort was rated on an analog scale from 1 (minimal discomfort) to 10 (severe pain). Of the 18 subjects, 15 (83%) reported that nitrous oxide improved the tolerance to pacing at capture threshold. The median pain scores at capture threshold in the nitrous oxide and room air group were 3.8 and 5.0 respectively (P<.05). Nine of the subjects tolerated TCP for the maximum allotted time of 30 seconds in each trial; six tolerated TCP for a longer time period in the nitrous oxide trial; three tolerated TCP longer in the room air trial. These data suggest that inhalation of a 50:50 nitrous oxide:oxygen mixture may improve tolerance to TCP in the conscious patient.
Terrorism can be considered a form of low-intensity conflict. It results from extreme reactions to sociopolitical conditions. These reactions, through a variety of intellectual and emotional processes, are manifest as overt acts of violence. Terrorism includes acts by individuals or organizations which seek to change political or social conditions, make political or ideological statements, or obtain funds for sustaining ongoing terrorist or revolutionary campaigns. Terrorist incidents are increasingly prevalent. Often, they involve loss of lives and mass casualties and have special medical dimensions. As such, the role of EMS in terrorist incidents needs to be defined clearly.
Verification of endotracheal tube (ETT) location in prehospital setting and the emergency department (ED) is a challenging task. Unrecognized esophageal intubations with potentially dangerous consequences may occur more frequently in these environments than in less hectic settings. To evaluate the capabilities of a portable, non-directable, fiberoptic bronchoscope (Visicath; Saratoga Medical, Saratoga, Calif., USA) to detect appropriate ETT placement, a prospective series of 22 intubated prehospital, air-medical, or ED patients underwent fiberoptic verification (FOV) of a newly placed ETT. Each patient was intubated under urgent circumstances. The time required for FOV, ETT location, the relative difficulty of intubation, and the changes in management as a result of FOV were recorded. A total of 24 FOVs were performed, twenty-one tracheal (88%), and two esophageal (8%) intubations were identified. Position could not be identified in one case (4%). FOV confirmed placement in 23 intubations (96%) in less than 25 seconds. Seven intubations (29%) were judged to be “difficult.” FOV resulted in five minor changes in management (22%) and was the sole confirmation method for five intubations. We conclude that fiberoptic verification is a promising method of ETT position in air-medical and ED intubations.
This study describes a series of mechanisms to alleviate overcrowding of hospital emergency departments by distributing critically ill patients among facilities with available resources. The initial mechanism, which was based on the availability of critical care beds, was used successfully between 1982 and 1986, but had to be abandoned when several new factors caused the availability of emergency department resources to become the limiting factor. A second approach, based on the availability of critical care and emergency department resources, produced limited success over a one-year period. The system currently in use, implemented in 1989, includes a distribution system based on the availability of emergency department resources and critical care beds, as well as a mechanism for diversion of ambulances to hospitals in neighboring counties at times of extremely high utilization. This experience demonstrates that mechanisms for planning the distribution of emergency and critically ill patients have universal applicability.
Prehospital health-care providers regularly are called upon to assist terminally ill patients in residential or institutional, non-hospital settings such as nursing homes or hospices. Among the most crucial issues regarding such patients is whether they should be resuscitated. With alarming frequency, EMS providers are encountering vigorous and sometimes violent refusals of examination, treatment, and/or transportation from the terminally ill patient, members of the patient's family, or third persons ostensibly acting on the patient's behalf. Today, the prehospital emergency health-care provider repeatedly is faced with the legal and ethical questions that surround the issue of resuscitation and advanced life support.
The prehospital care provider has been limited in his or her initial assessment of patients due to having available only a limited number of simple diagnostic tests. There has not been an accurate field test available to rule out significant ethanol intoxication. We designed a prospective trial for the prehospital setting to test the utility of a rapid, semi-quantitative, saliva alcohol reagent strip for patients with an altered level of consciousness. We found that these strips were useful in ruling out significant ethanol intoxication as a cause of an altered level of consciousness with a sensitivity of 85.7% and a specificity of 94.4%, but were not useful in accurately predicting the blood alcohol level. We conclude that these reagent strips are useful in the prehospital setting to provide information about patients with an altered level of consciousness.
There has been limited organizational research applied to EMS, especially in the area of job satisfaction. In the midst of a general shortage of health care workers, effective recruitment and retention of a qualified and satisfied work force is a critical issue. The purpose of this study was to examine the factors and elements in the structure or “design” of the work of emergency medical technicians (EMTs) and paramedics that can create conditions for high levels of work motivation, satisfaction, and performance.
A modified Job Diagnostic Survey was administered to a cross section of 102 paid and volunteer EMS personnel in Pennsylvania. The relationships between measured job characteristics, experienced psychological states, and job longevity on overall job satisfaction was examined.
Significant positive relationships (p<.05) exist between a number of the job characteristic variables (such as task significance, autonomy, and job feedback) and job satisfaction. Job longevity did not have a significant relationship to job satisfaction. Volunteer EMS personnel experienced higher levels of job satisfaction than did paid providers.
The results indicate that the EMT and paramedic perform complex jobs that have high levels of the characteristics that cause internal work motivation. Methods to increase the amount of these core job characteristics to improve overall job satisfaction are discussed.