Prehospital advanced life support (ALS) is provided by non-physicians under the supervision and the responsibility of a physician—the Emergency Medical Service Medical Director (EMSMD). In order to assess the time required of the EMSMD as well as the technical support provided and the medico-legal risks involved, a survey was distributed to physicians in attendance at the Annual Scientific Assemblies of the National Association of EMS Physicians in August 1986 and June 1987. The survey also was mailed to all EMSMDs in Michigan.

Of the 66 EMS medical director respondents, 69% were compensated, 62% were provided with malpractice coverage, and 22% had been involved in legal actions. Clerical support was provided for 89%, office space for 58%, and 60% had access to a computerized record database system. The average time consumed per week was 17±13 hours.

Differences were detected in the amount of support provided between services with an excess of 10,000 ALS responses per year and those with less than 10,000. The larger services more frequently provided office space and equipment (p<.02), malpractice coverage (p<.01), and access to a records database (p<.03) than did the smaller services. The EMSMDs for the larger services also were involved more frequently in legal actions (p<.03).

Legal actions involved 14 of the EMSMDs: paramedic malpractice (6); system failures (3); dispatch errors (2); inappropriate receiving facility (2); and paramedic licensure, equipment failure, union grievance, withdrawal of medical control, and trauma center designation (1 each). Four of the 14 involved had not been provided with malpractice coverage.

Medical direction of a prehospital EMS system requires a significant time commitment, incurs medico-legal risks, and in most communities receives clerical and data retrieval support, and the EMSMDs are compensated.

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.

We performed a retrospective review of the charts of 252 adult, non-traumatic, prehospital cardiac arrest patients treated over a one-year period in order to assess the effectiveness of intravenous (IV) and endotracheal (ET) administration of epinephrine (0.5–1.0 mg) (EPI) in assisting restoration of a spontaneous pulse. Patients initially receiving IV-EPI were more likely to develop a spontaneous pulse earlier than those receiving a similar dose ET (7.3% vs 0.9%; p<0.01. In those patients who received a second dose of EPI, six (2.9%) regained a spontaneous pulse; each had been treated previously with IV-EPI. None who required a third dose of EPI regained a spontaneous pulse. In total, only five (2%) patients survived to discharge. We conclude that, in our system, patients who receive the currently recommended dose of EPI to treat cardiac arrest have a poor prognosis, and that IV-EPI is associated with a higher incidence of return of a spontaneous pulse compared to those treated ET.

The ability to deliver large volumes of intravenous (IV) fluids may be critical to the successful prehospital resuscitation of hypovolemic patients. We compared the time required to deliver one liter of crystalloid solution, using an administration set-up consisting of a 16-guage (g), 1.25 inch, intravenous cannula, a pneumatic pressure bag, and either conventional intravenous tubing (3.2 mm internal diameter [ID]) or large bore (4.4 mm internal diameter [ID]) “shock” tubing. With the fluid bag positioned at 110cm (46 inches) above the level of the cannula, the mean elapsed time to deliver 1,000ml using the conventional tubing set-up was 6.0 minutes, while the same volume could be delivered in only 2.7 minutes with the shock tubing configuration. This time was reduced to 1.8 minutes when the intravenous cannula size was increased to 14g. By attaching a liter of fluid to each arm of the “Y” adapter of the shock tubing, virtually uninterrupted fluid flow may be maintained at this rate. We feel this intravenous configuration could enhance greatly the ability of paramedics to provide fluid resuscitation in the field setting. When such IVs are established en route to a receiving hospital, this technique may prove to be an important adjunct to improving patient outcome from hypovolemic shock.

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.

Obtaining and maintaining patient consent for treatment should be one of first considerations in every encounter between the health care practitioner and the patient. The emergency health care provider must be able to make rapid and correct assessments of the patient's consent to treatment before such treatment is commenced. The following paper will discuss the primary issues in this area.

The authors, who served as anesthesiologists for 15 months at an International Committee of the Red Cross (ICRC) surgical field hospital in a Cambodian refugee camp, report their anesthesiologic experience with 2,906 patients. In spite of preferential use of regional anesthetic techniques, general anesthesia was required in 68% of the cases. Local infiltration anesthesia was applied in 21% of the cases, conduction anesthesia in 3%, and spinal anesthesia in 8%.

The purpose of this study was to measure the contributions of a physician crew member in a helicopter emergency medical service (HEMS) and to develop a method to utilize physician services more efficiently. A two-part study utilizing two independent sets of measurements of physician necessity was conducted. A post-flight questionnaire and the success rate for endotracheal intubation were used as measurement tools.

With the passage of time, the fight nurses perceived the physician crew member' contribution to clinical judgment decreased from 21% to 1% of the flights and that the physician's contribution of technical skills (intubation) declined from 11% to 3%. The contribution to clinical decisions seemed more important on interhospital transports than on scene responses. The technical skills (judged by the tracheal intubation success rates) of a physician seemed more cogent on responses to the scene. When in the capacity of a second crew member with an experienced flight nurse, the endotracheal intubation success rate increased from 71% to 90%. Therefore, it seems that physician services could be restricted primarily to scene response flights. This limited utilization of flight physicians should make these physicians available for other duties.

Disasters are defined as events caused either by natural or technological occurrences, that overwhelm the resources that are immediately available to manage or mitigate the impact of the event. Disasters, by their very nature, are newsmakers. With the improvement in telecommunications, the barriers of distance are reduced to the extent that the people of the world all are members of what Marshall MacLuhan called the “global village.” It now is a common practice to watch the effects of a disaster on the other side of the world, from the safety and comfort of the living room, live on television. The capacity to empathize with the victims, and to feel almost a part of the incident, results in tremendous public attention and an urging of governments, not directly affected by the event, to get involved and “do something!”

There are several unique aspects of aeromedical transportation that render it vital to the overall management of disaster emergencies. Valuable time can be saved in moving medical expertise, supplies, and equipment into the disaster area as well as in moving victims out of the hazardous area quickly and in large numbers. Chaotic ground traffic at and near the disaster scene as well as environmental obstacles en route often may be avoided. Large numbers of disaster victims can be cared for efficiently en route by proportionately fewer health care personnel than is possible using traditional land carriers due to the concentration of many patients in one aircraft. Patients with similar injuries (e.g., burns) can be routed to and concentrated in centralized institutions that specialize in the care of those specific injuries. The plans for execution of the foregoing should include the use of military troop-transport aircraft that may be converted easily for patient transport. Also, military personnel should be involved, as they are part of a highly organized structure that can be mobilized more easily and swiftly than can most civilian organizations. The United States Air Force aeromedical evacuation policies and management structure is reviewed with attention directed toward additions and adaptations of this system needed to allow it to serve global disaster response. Such a highly evolved system will require a governing body with global reach for purposes of coordination and management. The resources for such a system currently exist but such an organization has yet to be formed.

The Basic Trauma Life Support (BTLS) course was developed to teach prehospital providers a rapid, prioritized approach to assess and manage the trauma victim. Little data currently are available relative to the retention of the cognitive and psychomotor skilk taught in the course. To examine this question, thirteen paramedics were retested on identically moulaged trauma scenarios and written examinations 14–16 months after initial training in BTLS. No advanced notification of the re-test was given. Written test scores decreased from an initial mean of 93.0±6.6 to a mean of 64.9±11.8 (p<0.001) 14–16 months later. Similarly, the trauma scenario test scores declined from 71.6±10.4 to 61.3±16.2 (p<0.05). The results suggest that there is significant loss of both didactic information and practical skills from the BTLS course 14–16 months after training. Frequent BTLS refresher training in the form of supplemental readings, lectures, and repeated exposures to trauma simulations is needed.