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The First Access for Shock and Trauma (FAST 1) Sternal Intraosseous (IO) System is a vascular access device designed as an alternative to peripheral or central intravenous (IV) cannulation for the treatment of critically ill and injured adults. During the development of the device, key objectives included safety, speed of insertion, and ease of use with minimal training. This study evaluated these characteristics.
Ten experienced paramedics participated in a 90-minute training program for the use of the FAST 1 System at the Paramedic Academy of the Justice Institute of British Columbia. Then, the paramedics used thesystem in three simulated prehospital scenarios and evaluated the ease of use and compatibility of the training method with current practice using a 10-centimeter (cm) (3.94 inches (in)), visual analog scale.
The duration of the procedure from opening the package to initiation of fluid flow ranged 52–127 seconds (mean = 92 ±32 seconds). Placement accuracy was excellent, with a mean displacement of 2 mm (0.08 in) and 1 mm (0.04 in) in the vertical and horizontal planes, respectively. The paramedics rated the system highly in all areas. They considered the training “straight forward” and “comprehensive”. The possibility for interference between the IO system and cervical collars was reported, and several suggestions to remedy this and achieve other improvements were made.
Placement of the FAST 1 is fast, accurate, and easy to use. Paramedics had useful input concerning the design of the product.
Stress debriefing following exposure to a critical incident isbecoming more prevalent. Its aim is to prevent or minimize the development of excessive stress response symptoms that lead to loss of productivity or effectiveness in the workplace or at home. There is little evidence that any form of psychological debriefing is effective. This study evaluated the effectiveness of three intervention strategies, and attempted to correlate the symptoms with the severity of the incidentand level of intervention.
A randomized, controlled trial of three levels of critical stress intervention was conducted in the British Columbia Ambulance Service (BCAS), in British Columbia, Canada, among paramedics and emergency medical technicians (EMTs), reporting critical incident stress. Outcomes were measured at one week (Stanford Acute Stress Reaction Questionnaire (SASRQ), the Life Impact Score (LIS), and Schedule of Recent Events (SRE)), and at three months and six months following the intervention (Impact of Events (IE), Coping Mechanisms, LIS, and SRE).
Fifty calls were received during the 26-month study period (<1 per 10,000 BCAS response calls): 23 were by third parties, but the involved EMT did not call;nine were placed by crew unwilling to participate in the study; 18 subjects enrolled, but six completed no forms. No correlation was found between severity of the incident and scores on the SASRQ, IE, or LIS, or between any of these scores. There was no consistent pattern in the stress scores over time.
Requests for critical incident stress intervention were uncommon. The need for intervention may not be as great as generally is assumed. Further randomized trials, ideally multicenter studies, are indicated.
This study was conducted to determine whether point-of-care testing, using the iSTAT Portable Clinical Analyzer, would reduce time at the referring hospital required to stabilize ventilated pediatric patients prior to interfacility, air-medical transport.
The following data were collected prospectively: (1) When a blood gas analysis was ordered; (2) If it was necessary to call in a technician; (3) Waiting time for blood to be drawn; and (4) Waiting time for results. The cost-efficacy of point-of-care testing was calculated based on: (1) Three minutes for a transport team member to draw a sample and obtain a result using the iSTAT (unit cost $CDN8,000); (2) Lab technician call-back (minimum two hours at $90); (3) Paramedic overtime (by the minute at $49/hour); and (4) Cost of charter aircraft wait time ($200 per hour) for every hour beyond four hours.
Data were collected on 46 ventilated patients over a three month period. A blood gas analysis was ordered on 35 patients. Laboratory technicians were called in for 17 (49%). For 12 (34%) patients, there was a wait for the sample to be drawn, and for 23 (66%), there was a wait for results to become available. Total time waiting to obtain laboratory gases was 526 minutes compared with a calculated 105 minutes using point-of-care testing. An iSTAT cartridge cost of $420 would not have been different from laboratory costs. Cost-saving on technician callback ($1,530), paramedic overtime ($690) and aircraft time waiting charges ($2,000) would have totaled ($4,220). From this study, the cost of point-of-care equipment could be recouped in 101 patients if aircraft charges apply or 192 patients if no aircraft costs are involved. For 11 cases, ventilator adjustments were made subsequently during transport, and for six patients, point-of-care testing, if in place, would have been used to optimize transport care.
The data from the present study indicate significant cost-efficacy from use of this technology to reduce stabilization times, and support the potential to improve quality of care during air medical interfacility transport.
To evaluate three prototype versions of semi-quantitative end-tidal CO2 monitors with different alarm features during prehospital or inter-facility use.
Subjects were 43 adult, non-pregnant patients requiring intubation, or who already were intubated and required transport. Teams at one AirEvac and seven Advanced Life Support (ALS) paramedic stations were trained in the use of the monitors. Team members at each station evaluated each model for eight days. Participants completed questionnaires following each use.
The monitors performed properly in all cases, but in one case, vomit in the airway adapter tube prevented obtaining a readout. The monitors aided management in 40 of 43 cases (93%); in one, the monitor reading was reported as variable (between 20 and 30 mmHg) although the teams knew the monitors were semi-quantitative; in another, the monitor was not required, but performed properly; and the third was the one in which vomit in the tube prevented a reading. In 26 of 43 cases (60.4%), the monitor was used to confirm endotracheal tube placement (there were no instances of incorrect placement). In all cases, the devices were used to monitor respiration and oxygen saturation. Alarms were audible in the environment, but only preferred in the AirEvac situation. The “breath beep” feature was useful, particularly in patients in whom chest movements during respiration were difficult to observe.
“Breath beeps” were clearly audible and were a useful feature in all prehospital and transport environments, while audible alarms were desired only in the AirEvac situation. Semi-quantitative CO2 detection is valuable in the ALS/AirEvac environment, even for teams with high intubation success rates.
Pulse-oximetry has proven clinical value in Emergency Departments and Intensive Care Units. In the prehospital environment, oxygen is given routinely in many situations. It was hypothesized that the use of pulse oximeters in the prehospital setting would provide a measurable cost-benefit by reducing the amount of oxygen used.
This was a prospective study conducted at 12 ambulance stations (average transport times >20 minutes). Standard care protocols and paramedic assessments were used to determine which patients received oxygen and the initial flow rate used. Pulse-oximetry measurements (oxygen-saturation measured by pulse oximetry) were then taken. If oxygen-saturation measured by pulse oximetry fell below 92% or rose above 96% (except in patients with chest pain), oxygen (O2) flow rates were adjusted. Costs of oxygen use were calculated: volume that would have been used based on initial flow rate; and volume actually used based on actual flow rates and transport time.
A total of 1,907 patients were recruited. Oximetry and complete data were obtained on 1,787 (94%). Of these, 1,329 (74%) received O2 by standard protocol: 389 (27.5%) had the O2 flow decreased; 52 had it discontinued. Eighty-seven patients (6%) not requiring O2 standard protocol were hypoxemic (oxygen-saturation measured by pulse oximetry < 92%) by oximetry, and 71 patients (5%) receiving oxygen required flow rate increases. Overall, O2 consumption was reduced by 26% resulting in a cost-savings of $0.20 / patient. Prehospital pulse-oximetry allows unncessary or excessive oxygen therapy to be avoided in up to 55% of patients transported by ambulance and can help to identify suboptimally oxygenated patients (11%).
Rationalizing the O2 administration using pulse-oximetry reduced O2 consumption. Other health care savings likely would result from a reduced incidence of suboptimal oxygenation. Oxygen cost-saving justifies oximeter purchase for each ambulance annually where patient volume exceeds 1,750, less frequently for lower call volumes, or in those services where the mean transport time is less than the 23 minute average noted in this study.
Following an air ambulance crash with five fatalities, critical incident stress debriefing (CISD) was provided for involved paramedics, physicians, and nurses. A study was conducted to evaluate the long-term effects of a critical incident with critical incident stress debriefing according to the Mitchell model.
Six months following the incident, empirically designed questionnaires were mailed to all transport paramedics and directly involved medical staff, and a random sample of both nurses from the dispatch/receiving institution and paramedics from around the province. Twenty-four months post-incident, all members of the transport paramedics completed the Impact of Events Scale and the General Health Questionnaires.
There were no differences between groups on any scores, except for disturbed sleep patterns, bad dreams, and the need for personal counseling being greater among transport paramedics at one day. There was no correlation between how well the deceased individuals were known, amount of debriefing, and symptom severity. A trend was seen for those with pre-existing stress management routines to have less severe symptoms at six months (p = 0.07). At two years, 16% of transport paramedics still had significant abnormal behavior.
CISD did not appear to affect the severity of stress symptoms, whereas having pre-existing stress management strategies may. These findings give justification for proceeding to a randomized, controlled trial of different levels of critical incident stress intervention.
The key element of your training should be a progressive increase in the level of independent action in all aspects of patient care while still in a situation where you can receive guidance from more experiencd physician peers. This process inevitably involves elements of supervision and direction and relies, for its successful completion, on your motivation and effective involvement. Ultimately, you are the one who determines how well you are trained. The program can only provide the structure on which you build your clinical experience and knowledge. A sense of responsibility for your education and your role in patient care is a key element. Taking appropriate responsibility enhances self-esteem, and your self–esteem has a considerable bearing on how good or bad you decide each day has been. Whatever you feel about your postgraduate training, you will inevitably have moments of extreme doubts. Be reassured that this time is a finite “rite of passage” and with thoughtful management, it can be both a rich and rewarding experience.
No human being, including the best physician, can get on well with everyone. Though some communication skills are innate, many others can be learned. Residents and fellows with good communication skills are more likely to thrive during training. Clear communication, both spoken and written, improves relationships with other physicians, nurses, children and parents as well as with family and significant others. Communicating the key details of a child's hospitalization to the family physician and/or referring pediatrician is an essential component of good care, particularly at the time of discharge and following emergency transfer.
In most sections of this book, death is not mentioned, although terminal illness can and does occur in many of the conditions described. In the Intensive Care Unit (ICU), 6% of the patients die, and this is likely the highest proportion within the hospital. However, transfer to ICU is not obligatory prior to death nor for that matter is being in hospital. If everything appropriate has been done in an attempt to diagnose and treat the child, it may well be that (s)he and the family will be more than happy for death to occur at home, provided all appropriate support measures are in place.
Hopefully, when a child dies, the possibility has been anticipated and there has been time for those close to the child to discuss the prospect of death with the patient and with members of the immediate family. As with the grieving process, an individual's concept of death and the approach and reactions to it will vary with age, culture and upbringing. However, it is safe to say that in the majority of cases, the opportunity to talk about the likelihood of death is welcomed, providing the moment is appropriate and the words are well chosen. It is often a good technique to encourage the child to ask you questions. Your perception of his or her fears may be considerably off mark, and it may well be that some reassurance that the child will not be alone and will not be allowed to be in pain is what they most want to hear.
Advances in technology and the delivery of medical care for critically ill neonates and children have resulted in reduced morbidity and mortality and necessitated the development of regionalized neonatal and pediatric intensive care units. Regionalization and rationalization of specialized services have resulted in the need for transfer of the growing number of patients from the institutions where they first received care to these specialised units. Increasingly, this interfacility transfer of patients is managed by transport teams because of the recognition that critically ill and injured children can be extremely vulnerable during interhospital transfers. Transport programs vary considerably, depending on local geography, logistics, and population. However, the priorities for transport teams in different locations are often similar and standard of care has been established to enable the majority of these infants and children to be transported without harm from the inherent risks of the transport process itself.
The safe transport of a child is complicated and requires good communication between the referring and receiving physicians. Stabilization at the referring hospital is important so that the condition of the patient remains as stable as possible during the transfer and no preventable deterioration occurs. Each transport should be coordinated by a transport team director who is experienced in all aspects of transport and responsible for all major decisions regarding interfacility transport.
For continuity of care and safe transfer between one hospital and another, a clear cut sequence of events must occur.
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