Although general discussions of legal claims against emergency medical services (EMS) have been published, there is no literature that examines legal claims that specifically have involved base-station contact for direct medical control.

A review of case law through July 1994 was conducted to identify cases that involved radio communications between a prehospital provider and a physician or nurse under the direction of a physician.

Only eight cases could be identified. Each case is described in terms of the event, selected pertinent legal issues, and the opinions rendered by the court.

These few cases illustrate some important observations that indicate that there will occur an increase in the detail, role delineation, and clarification of the prehospital providers, medical directors, base-station physicians, and others who provide direct medical control to prehospital EMS providers. These findings have important implications for EMS medical directors.

Although many emergency medical services (EMS) providers are concerned about liability litigation, no comprehensive, national studies of EMS appelate cases have been published. Information about these cases and the use of liability immunity (sovereign immunity, emergency medical care immunity, or Good Samaritan immunity) as a defense could be used for EMS risk management and better patient care.

To review recent EMS system civil litigation cases to determine their common characteristics and the number that used liability immunity as a legal defense.

An observational study of the WESTLAW computerized database of legal cases from all state and federal appellate courts. All legal cases that named a member of the EMS system as a defendant, involved either a patient-care incident or ambulance collision, and received an appellate court opinion from 1987 through 1992, were studied.

Eighty-six cases were identified and analyzed. Most cases (85%) were related to a patient-care incident, and 71 % of the cases involved a death or significant physical injury. More than 49% of the patient cases alleged inadequate assessment or treatment, and 27% alleged delay in ambulance arrival or no ambulance arrival. There were 11 cases (15%) that alleged no transport of the patient to the hospital. Liability immunity was used as a defense in 53% of the cases. The appellate courts ruled in favor of 68% of the defendants that did not use an immunity defense and in favor of 72% of those that did use liability immunity.

There have been a large number of recent appellate cases involving EMS systems. The common characteristics of many of these cases demonstrate the need for providing rapid ambulance arrival, proper assessment and treatment, and rapid patient transportation to a hospital. Although liability immunity was used as a legal defense by most EMS system defendants, the appellate court outcome was similar regardless of its use.

The purpose of the study was to document the occurrence and causes of disagreements between paramedics in a tiered-response emergency medical services (EMS) system.

This cohort analysis of disagreements between paramedics sampled 63 male public agency, 90 male private agency, and 41 female private agency paramedics. Paramedics responded to Likert-type items and one open-ended item concerning the occurrence of conflict between paramedics.

On-scene conflict between EMS personnel from public and private agencies was reported by 70% of the respondents. Conflicts that interfered with patient care were reported to occur more frequently between paramedics from different types of agencies. The most commonly mentioned subject of disagreement was patient treatment, followed by patient transport, interpersonal and interagency conflicts, and patient assessment.

A majority of paramedics have experienced on-scene disagreements with other paramedics. Disagreements occur more frequently between paramedics from different agencies and encompass a wide range of issues concerning patient care and interpersonal relationships.

Prehospital emergency medical services (EMS) personnel, as initial responders to calls for assistance, are in an ideal position to identify abused or neglected elderly. A survey of prehospital personnel in Michigan was conducted to determine the scope of this problem, levels of awareness, and willingness to report cases of elder abuse.

The study population was a random sample of 500 prehospital personnel throughout one state. A blinded, self-administered survey was completed by emergency medical technicians (EMTs) and paramedics outlining their practice characteristics, prevalence of abuse in their community, and training available specific to elder abuse. Attitudes concerning the understanding and reporting of geriatric abuse were measured using a Likert-type scale.

A total of 156 surveys (31%) was completed; 68% of the respondents were paramedics. Respondents had an average of 8.7 years (range: 9 months-30 years) of prehospital emergency-care experience, and evaluated an average of 11 patients (range: 1–59) older than 65 years of age each week. Seventy-eight percent had seen a suspected case of elder abuse or negligence during their careers; 68% had seen a case during the past 12 months (mean: 2.3 cases/yr; range: 0–24 cases/yr). However, surveyed personnel reported only 27% of suspected cases to authorities last year (mean: 0.62 cases/yr). Reasons for not reporting included 1) unsure which authorities take reports; 2) unclear definitions; 3) unaware of mandatory reporting laws; and 4) lack of anonymity. Ninety-five percent of respondents stated that training related to elder abuse was not available through their EMS agency.

Paramedics and EMTs lack complete understanding of their role in the identification and reporting of elder abuse. This information should be emphasized during EMS training and reinforced through continuing education.

Mask ventilation is a procedure routinely used in emergency medicine. Potential hazards are inadequate alveolar ventilation and inflation of the stomach with air, leading to subsequent regurgitation and aspiration. The aim of this study was to measure lung function and gastric inflation pressures during mask ventilation.

For this purpose, 31 patients scheduled for routine urological procedures were studied during induction of anesthesia. Lung function was assessed by recording respiratory flow and pressure directly at the face mask. Gastric inflation was observed with a microphone taped to the epigastric area.

Gastric inflation occurred in 22 of the 31 patients. Mean gastric inflation pressure was 27.5 ±6.55 cm H2O, mean compliance was 67 ±24.1 ml/cm H2O, mean resistance was 17.4 ±6.41 cm H2O/L/sec, and the mean respiratory time constant was 1.1 ±0.26 seconds.

These data suggest that inspiratory pressure be limited to 20 cm H2O, and that an inspiratory time of at least four times the respiratory time constant be allowed. Monitoring airway pressure and gastric inflation is a simple technique that may improve the safe-ty of patients during mask ventilation.

Alcohol use is associated with many motor-vehicle crashes and may increase the severity of injury. Because alcohol use also may mask injury, prehospital emergency care providers (PHECPs) may make inaccurate assessments. To assess and triage crash victims accurately, PHECPs must identify recent alcohol use.

This study examines the accuracy of PHECPs in identifying motor-vehicle crash victims who had positive serum alcohol concentrations.

Retrospective cohort study.

Included in the study were motor-vehicle crash victims more than 17 years of age who were conveyed directly to a university medical center emergency department by ground ambulance (n = 372).

15 July 1990 to 15 July 1991.

Data sources included ambulance report forms and hospital records. Variables that were abstracted included the Revised Trauma Score (RTS), the PHECPs' impression of alcohol use, and serum alcohol concentrations. Sensitivity, specificity, predictive-value positive, predictive-value negative, and 0.95 confidence intervals (0.95 CI) were calculated for the PHECPs' ability to identify patients with a serum alcohol concentration >0. The relationship between the RTS and the impressions of alcohol use was analyzed with chi-square testing: a p-value of <0.05 was considered statistically significant.

This study suggests that tims with positive serum alcohol concentrations. Selection bias and retrospective design are significant limitations of this study. Future studies should develop and evaluate methods to improve PHECPs' accuracy in assessing alcohol use in motor-vehicle crash victims.

Little information exists concerning special medical needs at the athletes' residence (as distinct from the sport venues) at major international sporting events. During the summer of 1993, Buffalo, New York became the first city in the United States to host the World University Games. Approximately 6,000 athletes and accompanying staff from 118 countries attended. This report seeks to characterize emergency medical care use and the degree of language difficulty encountered at the athletes' village medical center (AVMC) set up at the athletes' residence for this event.

Demographic data were collected prospectively for each athlete or staff member housed in the athletes' village who presented to AVMC for medical evaluation rather than being cared for by a team physician or at one of the venues. Difficulty in medical treatment secondary to language differences was assessed, by the treating physician on a scale of 0–3.

Over the 14 days that the AVMC was in operation, for 24 hours a day, a total of 362 athletes (mean age: 22.9 ±2.9 years, 257 males, 105 females) and 149 accompanying staff (mean age: 39.8 ±11.6 years, 110 males, 39 females) were treated. More than 90 % of the patients were seen between the hours of 0800 and 2400. A broad spectrum of minor medical problems occurred, with musculoskeletal injuries accounting for most of the visits for both athletes (54 %) and staff (27%). Nonsteroidal anti-inflammatory agents and oral antibiotics were the most commonly prescribed medications. On-site radiographic facilities were used for 22% of the athletes and 11% of the staff treated. The majority of patients (92% of athletes, 91% of staff) were discharged from the AVMC. Four of the 12 patients that were transferred to a hospital-based emergency department were admitted to the hospital. Language problems, as assessed by the treating physician, were mostly minor; 25% of the patients had accompanying interpreters. One volunteer Physician, and two to three nurses adequately staffed each shift.

The AVMC provided medical care for a large variety of medical problems that could, be treated on-site without transfer to a higher-level facility, thereby providing directed medical care for this special population in a secure environment. Language differences were perceived as a minor problem. This report should be valuable in the planning of medical care at the athletes' residences for similarly large sporting events.

Mobile medical clinics were established by an international medical relief organization to provide health care to victims of the war in Somalia. The study's purpose was to examine the prevalence of diseases seen and the effectiveness of mobile medical clinics, and to evaluate military support in security and care provisions.

This is a descriptive case series conducted over a 6-month period. Physicians determined clinical diagnoses, and clinic personnel assigned security scores (one to five) based on: 1) crowd control; 2) the incidence of looting; and 3) threats of violence by individuals demanding treatment.

Mobile medical teams that provided health care to regions in urban and rural Somalia assisted by United States and Italian military forces.

At 149 mobile clinics, 25,265 patients were treated.

Medical treatment included dispensing medications, intravenous rehydration, and minor surgical procedures. The effectiveness of security measures was scored based on: 1) effective crowd control; 2) the lack of theft or threats of violence; and 3) the unimpaired operation of the clinic.

Medical teams treated 25,265 patients. The most common medical problems encountered were skin infections (19.5%), upper and lower respiratory tract infections (16.1%), and gastroenteritis with dehydration (7.1%). Malnutrition was seen in 4.7% of cases, and trauma accounted for only 0.7% of complaints. When military escorts were provided, the mean security score was 43% higher (4.85 ±0.46) as compared to the absence of a military escort (3.40 ±0.60) (p <0.001).

Mobile medical clinics were found to be effective in this setting despite difficult conditions, limited therapeutic modalities, and few in-patient facilities. Infectious diseases were most common, while malnutrition and trauma were less commonly seen. The cooperation of United States and Italian military forces facilitated relief efforts by maintaining security, particularly in unstable areas.

The resuscitation rate from out-of-hospital cardiac arrest is low. There are many factors to be considered as contributing to this phenomenon. One factor not previously considered is the impact of a moving ambulance environment on the ability to perform closed-chest compressions.

Proper closed-chest compressions can be performed in a moving ambulance.

A cardiopulmonary resuscitation (CPR) training mannequin with an attached skill meter (Skillmeter ResusciAnnie®, Laerdal, Armonk, N. Y., USA) that measures each chest compression for proper depth and hand placement was used. Ten emergency medical technician-basic (EMT-B) certified prehospital providers were assigned into one of five teams. Each team performed a total of four sessions of five minutes of continuous closed-chest compressions on the mannequin. Two sessions were done by each team: one in the control environment with the mannequin placed on the floor, and the other in the experimental environment with the mannequin placed in the back of a moving ambulance. The ambulance was operated without warning lights and siren, and all traffic rules were obeyed. The percentage of correct closed-chest compressions was recorded for each session, and the mean values were compared using Student's t-test with alpha set at 0.01 for statistical significance.

Ten sessions of compressions were done in both environments. The mean percentage of correct compressions was 77.6 ±15.6 for the control group and 45.6 ±18.3 for the ambulance group (p = 0.0005).

A moving ambulance environment appears to impair the ability to perform closed-chest compressions.