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Current prehospital protocols for the management of patients with altered mental status include the empiric administration of hypertonic glucose, naloxone, and thiamine. The injudicious use of 50% dextrose (D50W) may result in hyperosmolarity, a worsening of hypokalemia, and unwarranted additional health-care costs for the patient. The administration of D50W also may worsen the neurological outcome of patients with local or generalized ischemia.
To evaluate the ExacTech blood glucose meter's ability to estimate blood glucose levels accurately and rapidly.
Emergency medical technicians (EMTs) from selected advanced life support (ALS) units in the Portland, Ore., metropolitan area participated in a prospective clinical trial of the ExacTech blood glucose meter. A convenience sample, was drawn from emergency medical services (EMS) patients with suspected diabetic emergencies, altered mental status, and other neurological deficits. Venous blood samples were drawn from these populations at the same time as the ExacTech readings were obtained. The venous blood was submitted to the receiving hospitals for laboratory analysis of blood glucose levels, and a comparison was made between the results of the two methods.
A total of 80 matched sets of data were obtained from 1 April 1990 through 6 May 1991. The hospital blood glucose values ranged from 8 to 1233 mg/dl. Sixteen (20%) of the patients were hypoglycemic (<60 mg/dl) and 23 (28.8%) were hyperglycemic (>180 mg/dl). The ExacTech device sensitivity and specificity for hypoglycemia using venous samples were 94.6% and 89.2%, respectively. For hyperglycemia, these same parameters were 87.5% and 97.1%. Pearson's r over the range of the instrument (40–450 mg/dl) was 0.8656 (p <.001). If the prehospital “definition” of hypoglycemia (for threshold-to-treat) is raised to 65 mg/dl, the device has 100% sensitivity in the sample population.
The device functioned accurately and consistently in the prehospital environment over a wide range of temperatures, and in the hands of many different individuals.
Emergency medical technicians (EMTs) find that the death of patients in their care is stressful.
Random sample of certified EMTs in one state (Levels I–IV).
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.
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.
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.
Paramedics accurately estimate the closest trauma hospital for ground transport.
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.
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.
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).
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.
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