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Several hypotheses may explain the association between substance use, posttraumatic stress disorder (PTSD), and depression. However, few studies have utilized a large multisite dataset to understand this complex relationship. Our study assessed the relationship between alcohol and cannabis use trajectories and PTSD and depression symptoms across 3 months in recently trauma-exposed civilians.
In total, 1618 (1037 female) participants provided self-report data on past 30-day alcohol and cannabis use and PTSD and depression symptoms during their emergency department (baseline) visit. We reassessed participant's substance use and clinical symptoms 2, 8, and 12 weeks posttrauma. Latent class mixture modeling determined alcohol and cannabis use trajectories in the sample. Changes in PTSD and depression symptoms were assessed across alcohol and cannabis use trajectories via a mixed-model repeated-measures analysis of variance.
Three trajectory classes (low, high, increasing use) provided the best model fit for alcohol and cannabis use. The low alcohol use class exhibited lower PTSD symptoms at baseline than the high use class; the low cannabis use class exhibited lower PTSD and depression symptoms at baseline than the high and increasing use classes; these symptoms greatly increased at week 8 and declined at week 12. Participants who already use alcohol and cannabis exhibited greater PTSD and depression symptoms at baseline that increased at week 8 with a decrease in symptoms at week 12.
Our findings suggest that alcohol and cannabis use trajectories are associated with the intensity of posttrauma psychopathology. These findings could potentially inform the timing of therapeutic strategies.
Posttraumatic stress symptoms (PTSS) are common following traumatic stress exposure (TSE). Identification of individuals with PTSS risk in the early aftermath of TSE is important to enable targeted administration of preventive interventions. In this study, we used baseline survey data from two prospective cohort studies to identify the most influential predictors of substantial PTSS.
Self-identifying black and white American women and men (n = 1546) presenting to one of 16 emergency departments (EDs) within 24 h of motor vehicle collision (MVC) TSE were enrolled. Individuals with substantial PTSS (⩾33, Impact of Events Scale – Revised) 6 months after MVC were identified via follow-up questionnaire. Sociodemographic, pain, general health, event, and psychological/cognitive characteristics were collected in the ED and used in prediction modeling. Ensemble learning methods and Monte Carlo cross-validation were used for feature selection and to determine prediction accuracy. External validation was performed on a hold-out sample (30% of total sample).
Twenty-five percent (n = 394) of individuals reported PTSS 6 months following MVC. Regularized linear regression was the top performing learning method. The top 30 factors together showed good reliability in predicting PTSS in the external sample (Area under the curve = 0.79 ± 0.002). Top predictors included acute pain severity, recovery expectations, socioeconomic status, self-reported race, and psychological symptoms.
These analyses add to a growing literature indicating that influential predictors of PTSS can be identified and risk for future PTSS estimated from characteristics easily available/assessable at the time of ED presentation following TSE.
This chapter overviews the importance of analgesia as an important endpoint in prehospital care. Analgesia's importance is magnified by the frequency with which EMS providers interact with injured patients in significant pain. The chapter focuses on prehospital medication administration, with the understanding that not all medications will be available in all EMS systems. The perceived problem with out-of-hospital analgesia administration is that the drugs incur risk of hemodynamic or respiratory compromise. Examination-related issues other than the neurological evaluation are also prominent reasons for physicians not to administer prehospital analgesia. The opioids are the primary analgesic approach available to most EMS services. The prototypical opioid for use in prehospital care is morphine, which is demonstrated to be useful for a variety of adult and pediatric conditions encountered in EMS. Regional nerve blocks with local anesthetic injection are efficacious for field use in settings where physician prehospital providers are available.
Objective: Traditional EMS teaching identifies mechanism of injury as an important predictor of spine injury. Clinical criteria to select patients for immobilization are being studied in Michigan and have been implemented in Maine. Maine requires automatic immobilization of patients with “a positive mechanism” clearly capable of producing spine injury. The purpose of this study is to determine if mechanism of injury effects the ability of clinical criteria to select patients with spine injury.
Design: Multicenter Prospective Cohort.
Methods: EMS personnel completed a check-off data sheet on out-of-hospital spine immobilized patients. Data included mechanism of injury and yes/no determinations of the clinical criteria: altered mental status, neurologic deficit, evidence of intoxication, spinal pain or tenderness, and suspected extremity fracture. Hospital outcome data included confirmation of spine injury and treatment required. Mechanisms of injury were tabulated and rates of spine injury for each mechanism was calculated. The patients were divided into high-risk and low-risk groups.
Results: Data was collected on 6,500 patients. There were 213 (3.3%) patients with spine injuries identified. There were 1,065 patients with 100 (9.4%) injuries in the high-risk mechanism group, and 5435 patients with 113 (2%) injuries in the low-risk group. Clinical criteria identified 96 of 100 (96%) injuries in the high risk mechanism group and 106 of 113 (94%) in the low-risk group.
Recent studies have documented decreased time to emergency department (ED) thrombolytic therapy with the use of prehospital electrocardiography.
Is the time to ED diagnosis and treatment of acute myocardial infarction (AMI) patients with thrombolytic agents decreased by emergency medical services (EMS) transport when compared with those transported by other means (non-EMS)?
Retrospective, case-control study
The AMI patients treated with thrombolytic agents at a 34,000-visit, community hospital ED during 1992.
Review of records of patients who received thrombolytic therapy for AMI. Statistical analysis was performed using “Student's” t-test and Yates corrected Chi-square (X2).
Eighty-seven patients received thrombolytic agents for AMI during 1992; 33 arrived by ambulance, 54 arrived by other methods. There were no differences in age, gender, or time of ED arrival among these groups. Ambulance patients received standard advanced life support (ALS) care, but not a 12-lead electrocardiogram (ECG) or thrombolytic agents. Ambulance patients experienced a significantly shorter time to first ECG (12.9 ±9.1 min. versus 20.8 ±25.3 win.; p = .028) and received thrombolytic therapy sooner than did controls (56.0 ±31.5 min. versus 78.0 ±63.4 min.; p = .018). There was no difference in time from diagnosis to treatment between these groups.
Emergency medical services transport of AMI patients in this study decreased time to diagnosis and treatment and may be a confounder in studies that assess the value of field EMS interventions. Non-EMS AMI patients did not receive as rapid diagnosis and treatment, and emergency physicians should evaluate and address this issue in their departments.
To analyze the characteristics of fatal ambulance crashes to assist emergency medical services (EMS) directors in objectively developing their EMS system's policy governing ambulance operations.
No difference exists between the characteristics of fatal ambulance crashes during emergency and nonemergency use.
Retrospective, cross-sectional, comparative analysis of ambulance crashes resulting in fatalities reported to the Fatal Accident Reporting System (FARS) from 1987 to 1990.
Twenty variables, representing characteristics of fatal ambulance crashes, were selected from the National Highway Traffic Administration FARS Codebook and were evaluated using tests of significance for categorical data grouped by emergency use and nonemergency use. Crash variable categories examined included demographics, accident configuration, accident severity, vehicle description, and ambulance operator action.
During the four-year study period, 109 fatal ambulance crashes occurred producing 126 deaths. Four states, New York, Michigan, California, and North Carolina, accounted for 37.5% of all fatal crashes. Seventy-five fatal crashes (69%) occurred during emergency use (EU) and 34 fatal crashes (31%) occurred during nonemergency use (NEU). The total number of fatal crashes varied in a downward trend (1987:32; 1988:24; 1989:28; 1990:25). The number of fatal EU crashes also varied in a downward trend (1987:28; 1988:16; 1989:19; 1990:12), while the number of fatal NEU crashes increased each year [1987:4; 1988:8; 1989:9; 1990:13](p = .016). Most EU fatal crashes occurred between 1200 h and 1800 h (p = .009). Most NEU fatal crashes occurred during times when light conditions were poor (p = .003). When a violation was charged to the ambulance driver (17 cited), the vehicle was more likely to be in EU (p = .056). No statistically significant differences between EU and NEU were identified by: 1) day of week; 2) season; 3) atmospheric conditions; 4) roadway surface type; 5) roadway surface condition; 6) speed limit; 7) roadway alignment; 8) relationship to junction; 9) manner of collision; 10) year manufactured; 11) vehicle role; 12) vehicle maneuver; 13) manner leaving scene; 14) extent of deformation; 15) violations charged; or 16) number of persons killed in accident.
Few characteristics differentiate between fatal ambulance crashes during EU and NEU. The difference between EU and NEU were statistically significant in only three out of the 20 variables examined: 1) year occurred; 2) time of day; and 3) light condition. These data provide few objective measures that may be used to develop ambulance operation policies to decrease fatal ambulance crashes.
The developments of emergency medicine and emergency medical services (EMS) have occurred simultaneously although at times on parallel paths. The recognition of EMS providers as physician surrogates and emergency care resources as an extension of emergency department care has mandated close physician involvement. This intimate physician involvement in EMS activities is now well accepted. It has, however, pointed out the need for in-depth training of physicians in the subspecialty of EMS.
The purpose of this clinical study was to compare the prehospital use of fully automatic defibrillators versus semi-automatic defibrillators.
Fully and semi-automatic defibrillator use by EMTs in neighboring communities was compared.
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.
These data support the need for further comparison of the efficacy and effectiveness of semi- and fully automatic, external defibrillators.
A daily EMS audit was performed to assess whether a paramedic peer review audit would improve the quality of documentation and radio communications in cases transported to a single receiving facility.
Prehospital EMS run sheets and run tapes were reviewed for adherence to standards developed for the county EMS system. Items evaluated were run sheet documentation of care and paramedic radio presentation. Checklists were used and multiple parameters evaluated for each case. Two periods, 1987–88 and 1989 were compared to evaluate the effectiveness of this system. Care rendered by a total of 106 paramedics was evaluated. Confidence intervals of 0.95 were calculated on the differences between groups. Practicing paramedics audited 63% of the days in 1987–88 and 80% in 1989. Data from each case were tabulated and a profile, average deficiencies per run calculated for each paramedic.
A total of 4175 run sheets and tapes were audited for the period 1987–88 with an average of deficiencies/run of 0.27, and for 1989 a total of 1872 run sheets and tapes were reviewed with a deficiency/run rate of 0.21, indicating a statistically significant improvement (0.95 CI= 0.02, 0.08). Twelve paramedics were not auditors in 1987–88, but audited in 1989. Their deficiencies/run decreased from 0.13 to 0.08
A peer review audit in this system appears to be effective in improving documentation and radio performance. Performance also improved when paramedics served as auditors.
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.
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