There is a growing interest in cases in which emergency medical services (EMS) providers evaluate a patient, but do not transport the patient to a hospital. A subset of these cases, the patient-initiated refusal (PIR) in which the patient refused care and transport, was studied and evaluated. The objectives of the study were to examine the adequacy of ambulance call report documentation in PIR, to examine the clinical outcome of these patients in one hospital-based, suburban EMS system, and to assess the potential impact of on-line medical command (OLMC) on cases of PIR.

The system studied is a hospital-based, transport-capable, advanced life support service in a suburban EMS system, with an annual call volume of 4,200 runs. During the 6-month study period, all ambulance call reports completed by the paramedics and medical command control forms completed by medical command physicians were examined, and cases of PIR collected. Each ambulance call report was examined for adequacy of documentation. Patient outcome was determined from emergency department records and telephone follow-up.

Eighty-five PIRs were documented during the study period. Four cases were excluded because of a missing ambulance call reports and/or medical command control forms, leaving 81 PIRs for analysis. Despite policy requiring OLMC in cases of PIR, OLMC was established in only 23 PIRs (28%). Of these, two (9%) had inadequate ambulance call report documentation. Of the 58 PIR in which OLMC was not established, 25 (43%) had inadequate ambulance call report documentation (p <0.001, Fisher's exact test). Follow-up was obtained for 54 (67%) PIR. Of these, 37 (68%) did not subsequently see a physician, and all needed no further medical care. Seven (13%) saw their own physicians within a few days of the initial refusal of prehospital care, and had no further problems. Ten patients were seen in an emergency department within a few days. Three (6%) were discharged, and did well. Seven (13%) were admitted to the hospital, with four (7%) admitted to monitored beds, and three (6%) to unmonitored beds. There were no deaths.

Ambulance call report documentation is better with OLMC than without. Patients who initially refuse care may be ill, and some ultimately will be hospitalized. Further research may elucidate a role for OLMC in preventing refusals by incompetent patients, convincing patients who are competent but appear ill to accept transport, and assisting paramedics with other difficult or unusual circumstances.

Prehospital providers regularly encounter patients with obstetrical emergencies. This study determined the frequency and outcome of out-of-hospital deliveries in an urban, all advanced life support (ALS) emergency medical services (EMS) system.

Retrospective review of all out-of-hospital records that involved women delivering babies in the care of prehospital providers from 1984–1988. The EMS system answered an average of 62,000 calls during the study period. The records of these patients were identified through a computer database.

A total of 81 out-of-hospital deliveries (1.4/month) occurred during the study years. The average age of the mothers was 24 years, and the average gestation period was 30 weeks. The women had an average of three previous pregnancies and two previous deliveries, and 10 were primagravida. Seventy-two (89%) of the deliveries occurred in the home. The paramedia encountered a variety of obstetrical and neonatal complications in 34% of the patient encounters. Nine neonates were delivered prior to the arrival of the paramedic team. Twenty-four neonates had Apgar scores calculated, and the one- and five-minute scores averaged eight and nine respectively. Five of the mothers had no prenatal care. Maternal complications included four patients noted to be hypertensive with the delivery, nine patients had some degree of vaginal bleeding, and in 33 patients, the prehospital providers did not deliver the placenta in the field. An EMS physician was in attendance for only two of the out-of-hospital deliveries.

In this urban EMS system, out-of-hospital deliveries, especially pre-term deliveries, are a common event. There appears to be a significant number of neonatal complications that confront paramedics. Generally, the paramedics were deficient in their documentation of the neonatal assessment. Continuing educational programs for paramedics should include reviewing normal and complicated vaginal deliveries as well as ALS measures for neonates. Protocols for obstetrical emergencies need to be developed and subjected to quality improvement measures.

Paramedics, especially those in urban settings, are likely to encounter obstetrical and neonatal emergencies and a significant number of associated complications. Emergency medical services systems and medical directors should have in place continuing educational programs, patient-care protocols, and continuous quality improvement measures to evaluate the care rendered to patients having out-of-hospital deliveries.

To characterize the types of occupational exposures and injuries reported by emergency medical service (EMS) workers.

A blinded review of accidents/exposures among EMS workers employed by a Baltimore County fire department was conducted. Medical records for 1992 were reviewed.

Two hundred and twenty-six reports were filed by EMS workers (n = 197) employed by a large, urban fire department in 1992. The most commonly reported injuries were sprains (23%), strains (20%), and exposure to blood and body fluids (15%). The body site most commonly injured was the back (20%) followed by the respiratory system (10%). Most incidents were treated at the employee health clinic, and 13% of the incidents resulted in a hospital visit. Fifteen percent of the injuries resulted in more than seven lost work days. Most incidents were caused by stretcher mishaps, especially during transport of heavy patients. Walkway impediments (e.g., icy steps, wet leaves, broken and uneven pathways) also played an important role in creating slipping and tripping hazards.

These results suggest a variety of prevention strategies aimed at reducing accidents and exposures among EMS workers.

Pediatric mortality is predicted by age, presence of head trauma, head trauma with a low Glasgow Coma Scale (GCS) score, a low Pediatric Trauma Score (PTS), and transport directly to a pediatric trauma center.

Studied were 1,429 patients younger than 16 years old admitted to or declared dead on arrival (DOA) in a pediatric trauma center from January through October, 1988. The trauma system, which served 3-million persons, included six pediatric trauma centers.

Data were obtained by a retrospective review of summary statistics provided to the Chicago Department of Health by the pediatric trauma centers.

Overall mortality was 4.8% (68 of 1429); 32 of the patients who died (47.1%) were DOA. The in-hospital mortality rate was 2.6%. Head injury was the principal diagnosis in 46.2% of admissions and was a factor in 72.2% of hospital deaths. The mortality rate was 20.3% in children with a GCS≤10 and 0.4% when the GCS was >10 (odds ratio [OR] = 67.0, 95% CI = 15.0–417.4). When the PTS was ≤ 5, mortality was 25.6%; with a PTS > 5, the mortality was 0.2% (OR = 420.7, 95% CI = 99.3–2,520). Although transfers to a pediatric trauma center accounted for 73.6% of admissions, direct field triage to a pediatric trauma center was associated with a 3.2 times greater mortality risk (95% CI = 1.58–6.59). Mortality rates were equal for all age groups. Pediatric trauma center volume did not influence mortality rates.

Head injury and death occur in all age groups, suggesting the need for broad prevention strategies. Specific GCS and PTS values that predict mortality can be used in emergency medical services (EMS) triage protocols. Although the high proportion of transfers mandates systemwide transfer protocols, the lower mortality in these patients suggests appropriate EMS field triage. These factors should be considered as states develop pediatric trauma systems.

To test the hypothesis that a prehospital time threshold (PhTT) exists that when exceeded, significantly increases the mortality of trauma patients transported directly from the scene of injury to a trauma center rather than to the closest hospital.

Review of data contained within the Illinois Trauma Registry encompassing the period from fall 1989 through spring 1991.

A total of 5,215 injured persons with an Injury Severity Score (ISS) >10, cared for in an Illinois level-I or -II trauma center outside of the city of Chicago.

Injury severity expressed as ISS, scene time (ST), transport time (TrT), total emergency medical services time (TEMST), and outcome were determined for each patient. Patients were stratified into groups on the basis of ISS.

Patient outcomes were significantly different statistically between ISS groups (p <0.001, X2). Mean ST and TEMST, but not TrT, were significantly different statistically between ISS groups (p <0.001, analysis of variance). Lower ISS was associated with longer times. Mean ST, TrT, and TEMST were significantly different statistically between survivors and nonsurvivors (p <0.001, two-sample t-tests). Survival was associated with longer times. Each of the mean times remained significantly different between survivors and nonsurvivors after controlling for severity of injury (p <0.001, two-way analysis of variance).

No PhTT beyond which time patient transport to the closest hospital would have decreased mortality was identifiable, because no prehospital time <90 minutes exerted a significant adverse effect upon survival.

Sixteen percent of all motor-vehicle fatalities are pedestrian, and accidents involving pedestrians are associated with the highest morbidity and mortality rates. Classic pedestrian injury patterns have been described. However, it has been suggested that the pattern may differ if the pedestrian is intoxicated. The role of pedestrian intoxication on motor-vehicle accident injury patterns has not been well-delineated.

Intoxicated pedestrian traffic victims have an injury pattern that is more serious and more rapidly fatal than is the pattern for nondrinking victims.

Autopsies of 223 consecutive pedestrian victims were reviewed and grouped according to the presence of alcohol in the blood: Group I, Negative (n = 165); Group II, Positive (n = 58). Gender, age, anatomic injuries, survival time, time of day, and year also were examined.

Results indicated that there were more males in Group II (79%) than in Group I (64%); younger victims, younger than 40 years old, in Group II (70%) than in Group I (34%); fewer victims older than 60 years old in Group II (8%) than in Group I (38%). Group II sustained more frequent and more severe injuries—two times the frequency of the cervical spine, liver, upper and lower extremity, pelvic and rib fractures and thoracolumbar spine injuries; three times more aortic injuries; five times more heart injuries. Death occurred within 24 hours in 95% of those in Group II and in 67% of those in Group I. Accidents occurred from 1500h to 2300h in 67% of Group II and in 53% of Group I victims.

Intoxicated pedestrian accident victims are predominantly young men, struck between 1500h and 0700h; they have an injury pattern that is two to five times more serious than is the pattern for the sober victims.

The civil war in Somalia has destroyed the medical system and left hundreds of thousands of people without access to medical care. Samaritan's Purse and World Medical Missions, two relief organizations, developed mobile medical teams to provide health care to urban and rural Somalia. Gastroenteritis with severe dehydration was encountered frequently, and difficult intravenous (TV) access presented a challenging dilemma for patients who were unable to tolerate oral or nasogastric fluid administration.

Intraperitoneal (IV) fluid infusion may be used to treat dehydration in patients with poor venous access and ongoing fluid losses.

Two mobile medical teams treated patients from 1 January to 1 April 1993. Intraperitoneal fluid infusions were given to 16 patients with severe dehydration in whom IV access was unobtainable. Children received approximately 80 ml/kg of 0.45% normal saline, and adults received 40 ml/kg of 0.9% normal saline. Patients were reexamined at one and seven days.

A total of 25,659 patients were seen in the mobile medical clinics during a 3-month period. Dehydration was diagnosed in 1,833 (7.1%) patients, and 1,203 (4.7%) patients were found to be malnourished. Sixteen patients were treated with IP fluid infusions, 14 patients (87.5%) survived, and two patients (12.5%) died, both within 24 hours. In one patient (6.3%), subcutaneous infiltration occurred without subsequent adverse effects.

This case series found that in the mobile clinic setting in Somalia, IP fluid administration improved the hydration status in patients with significant dehydration. Although IV infusion remains the treatment of choice when oral or nasogastric fluid administration is not possible, IP infusion is easily performed and may be an important alternative in disaster setting.