The role of the base-hospital and on-line medical control in a disaster has not been investigated previously. This study assesses the roles of base-hospitals and the value and feasibility of on-line medical control during the 1989 Loma Prieta earthquake.

The researchers studied five Bay Area counties most affected by the earthquake: San Francisco, Alameda, San Mateo, Santa Clara, and Santa Cruz. Researchers sent questionnaires to all 1,498 registered EMTs and paramedics in these counties; 620 were returned (41.4%). Respondents answered questions about activities performed, contacts with base-hospitals and other agencies, and problems encountered the night of the earthquake. Researchers selected 63 paramedics for in-depth interviews based on their performance of significant advanced life support (ALS) activities performed during the disaster. The coordinators of the 13 base-hospitals (BHCs) in the region also received and returned questionnaires about medical control, base-hospital roles during the disaster, and problems encountered. Researchers interviewed all five county emergency medical services (EMS) agency directors.

The surveys of EMS directors, base-hospital coordinators, and paramedics indicate that confusion existed over the status of medical control after the earthquake. There was general agreement among base-hospital coordinators (BHCs) that suspension of medical control is appropriate in a major disaster.

Three bases had appropriate equipment to function as back-up dispatch centers. Eight bases had adequate personnel, but only one BHC felt his personnel had adequate training to function in a dispatch capacity. Nine paramedics did not start or continue resuscitation on patients whom they ordinarily would have begun resuscitation.

Emergency medical services should suspend medical control immediately following a major disaster and ensure that all prehospital and base personnel are notified. Disrupted communications protocols for prehospital personnel should reflect the skill and knowledge level of paramedics and the need for rapid, advanced practice in a disaster. Disaster planners should consider other roles for base hospitals in major disasters.

Direct physician observation of advanced life support (ALS) personnel is rare in a demographically diverse state.

Twenty ALS agencies from throughout Arizona.

A board-certified emergency physician performed on-site interviews with the emergency medical services (EMS) supervisor of each agency to approximate the number of days per year that physicians observe ALS personnel in the field.

Only 11 agencies (55%) reported that physicians ever observed ALS personnel. Among all agencies, an estimated total of 84 observer-days occurred per year. The agencies staffed a total of 86 ALS units, resulting in an estimated 0.98 observer-days/unit/year (84/86). On the average, it took 3.4 ALS personnel to staff a given unit over time and the probability that an ALS provider would be on a unit on any given day was 0.29 (1/3.4). The probability of a given provider being observed during one year was approximately 0.29 (0.98 x 0.29). Thus, on the average, an ALS provider would be observed by a physician approximately once every 3.5 years (1/0.29). Among urban agencies, the “average” ALS provider would be observed once every 2.9 years. This compared to a likelihood of in-field observation of only once every 6.7 years for non-urban providers (p = .036).

The skills of ALS providers in Arizona are observed by a physician in the field very infrequently. Although an uncommon occurrence in urban agencies, observation of non-urban ALS personnel occurs even less frequently. In addition, nearly one-half of the agencies surveyed never had a physician-observer. Although a variety of skills evaluation methods exist, it remains unclear whether any method is as useful as direct observation. Future investigations are needed to evaluate whether in-field physician observation impacts skills, patient care, or outcome in EMS systems.

The need for quality assurance (QA) systems for review of prehospital advanced life support (ALS) care has long been recognized. However, there only have been limited published studies on the operation and cost of QA systems for prehospital care. A number of different systems currently are in use, and the relative effectiveness of different QA systems has not been well determined.

The aim of this study was to compare the personnel work-time and costs of two different systems of QA for prehospital ALS services, and thereby determine which type of system was more cost-effective in the generation of QA reports.

The quality assurance program (System 1) for three independent ALS services in a rural/suburban area and the QA program (System 2) for a nearby urban ALS service were compared. Data recorded included the training level and number of hours per year devoted exclusively to QA activities by different personnel. The annual costs for other aspects of the QA systems and apportioned salary costs for time spent on QA work were recorded.

System 1, a computer-based system, utilized 1,116 hours per year of personnel time and required [US]$17,662 in total costs per year (average cost per run reviewed of $4.38). System 2 (a manual system) utilized 569 hours per year of personnel time and had an annual cost of [US]$8,361 (or $2.15 per run reviewed). System 1 generated 852 reports per year (21 % of runs) about non-compliance with protocols or charting deficiencies. System 2 generated 284 reports per year (7.3% of runs) for similar events.

Either a computer-based or “manual” system for QA of prehospital ALS services can be utilized. A computer-based system requires more personnel time and is more expensive, but generates more reports per year than does the manual system. A computer-based system more readily can retrieve run report data for further review.

To examine the effects of age, race, gender, and insurance status on utilization and times-to-transport (TTT) for interhospital air medical transfers from rural hospitals to tertiary care centers.

A retrospective review of interhospital transport records. The TTT was examined as a function of age, gender, race, and insurance status using the Student's t-test for unpaired samples. The Exact Binomial Test (alpha error at 0.05) was used to compare the observed versus expected transport rates for non-whites.

A total of 268 patient transfers from hospitals within a two-county region in central Pennsylvania to tertiary care centers was analyzed. All records with sufficient demographic, TTT, or insurance data were included. Absence of data was the only exclusion.

The TTT (mean ± SD) was longer (2666 ± 3940 minutes (min.) versus 619 ± 909 min., respectively) for adult than pediatric patients (p <O1), and (2588 ± 4041 min. versus 640 ± 1301 min., respectively) for insured versus uninsured patients (p <.O1). The observed proportion of non-whites transported was less than expected (.41% versus 2.1 %) based on the proportion of non-whites in the region (p <.O5).

The TTT was longer for adults than for children and for the insured than the uninsured. Non-whites were transported less frequently than predicted.

Many states in the United States ‘have developed policies that enable prehospital emergency medical services (EMS) providers to withhold cardiopulmonary resuscitation (CPR) in the terminally ill. Several states also have policies that enable the implementation of do-not-resuscitate (DNR) orders.

1) assess which states have statutes governing DNR orders for the prehospital setting; 2) determine which states authorize DNR orders in ways other than by specific state statue; and 3) define those states that had regional protocols which address prehospital DNR orders.

Survey of the state EMS directors in each of the 50 U.S. states, the District of Columbia, and Puerto Rico.

As of 1992, specific legislation authorizing the implementation of DNR orders was in place in 11 states. In addition, six others have a legal opinion or policy allowing the implementation of DNR orders. Fourteen additional states have either working groups or legislation pending that address prehospital DNR orders. In only five were there no existing regional protocols for implementation of DNR orders in the prehospital setting.

There exists great variation in legal authorization by states for implementation of DNR orders in the prehospital setting. Despite the existence of enabling legislation, many state, regional, or local EMS systems have implemented policies dealing with DNR orders.

The standard of practice and teaching for prehospital pediatric endotracheal intubation (PETI) in the United States currently is unknown. The accepted practice of prehospital PETI is of interest because it has contradictory support in the medical literature.

PETI is an accepted method of prehospital airway control in the United States.

Nationwide mail survey (June 1991 to March 1992) of each state emergency medical service (EMS) agency and all known paramedic training sites.

The use of PETI is supported by 100% of state EMS agencies and the American Virgin Islands. Ninety-seven percent (339 of 349) of the responding (349 of 523) paramedic training sites reported that PETI was taught in their programs. The results of the survey did not identify a predominate method for instructing paramedics in PETI. Lectures, mannequins, operating room demonstration, animal models, and cadavers were used in various ways for teaching the skill.

Endotracheal intubation is an accepted standard in prehospital pediatric care. This standard exists with marginal support in published literature and study of prehospital PETI is needed to define the benefits, risks, and optimal instruction methods for the procedure.

Evaluate the experience of paramedic personnel at mass gatherings in the absence of on-site physicians.

Retrospective review of patients evaluated by paramedics with emergency medical services (EMS) medical control.

First-aid facility operated by paramedics at an outdoor amphitheater involving 32 (predominantly rock music) concerts in accordance with the Chicago EMS System, June through September 1990.

A total of 438 patients (≤0.1% on-site population) were evaluated.

Presentations to the first-aid facility were viewed as if the patient was presenting to an ambulance. Transportation to an emergency department was strongly recommended for all encounters. Time from presentation to the first-aid facility until disposition was limited to 30 minutes in the absence of on-line [direct] medical control. Refusal of care was accepted. On-line [direct] medical control with the EMS resource hospital was initiated as needed. Off-line [indirect] medical control consisted of weekly reviews of all patient records and periodic site visits.

Of the 438 patients, 366 (84%) refused further care, including 31 patients (7%) who refused advanced life support (ALS) level care. Seventy-two patients (16%) were transported; 37 by ALS and 35 by basic life support (BLS) units. On-line [direct] medical control was initiated in all ALS patients that were transported as well as for those who refused care. No known deaths or adverse outcomes occurred, based on lack of inquiries or complaints from the local EMS system, emergency departments receiving transported patients, law enforcement agencies, 9-1-1 emergency response providers, venue management, or security. No request for medical records from law firms have occurred. Problems noted initially were poor documentation and a tendency not to document all encounters (e.g., dispensing band-aids, tampons, earplugs, etc.). Concerns noted included: initial and subsequent vital signs, times of arrival, interventions, dispositions, and patient conditions of refusal. Specific problems with documentation of refusals at disposition included: appropriate mental status, speech, and gait; release with an accompanying family member or friend; and parental notification and approval of care for minors. There also was an initial tendency not to establish on-line [direct] medical control for ALS refusal or BLS medicolegal issues.

The medical system configuration modeled after practices of prehospital care, demonstrates physicians did not need to be onsite when adequate EMS medical control existed with less than 30 minutes on-scene time.

Concern for possible disease transmission during mouth-to-mouth resuscitation has decreased the incidence of bystander cardiopulmonary resuscitation (CPR). Barrier masks have become available that may be effective in CPR as well as protective against cross-contamination.

A silicone rubber barrier mask incorporating a one-way-valved airway (Kiss of Life [KOL]) designed to prevent contamination of the rescuer, permits satisfactory mouth-to-mouth ventilation of victims of cardiopulmonary arrest.

Ten adult patients who did not survive non-traumatic cardiac arrest were ventilated with exhaled room air using a KOL barrier mask while external cardiac massage continued. Arterial blood gases were obtained every two minutes for a maximum of 10 minutes. The operator was blinded to the results of these blood tests.

Eight men and two women with ages from 55 to 99 years were studied. Four patients were edentulous and two of these had marked mandibular atrophy. The two patients with mandibular atrophy were poorly ventilated with the barrier mask. One other patient was not ventilated successfully. This patient had undergone multiple attempts at endotracheal intubation and had transtracheal needle ventilation performed prior to use of the barrier mask. One patient had elevated PaCO2 despite being well-ventilated clinically. Six patients were ventilated well clinically and had satisfactory PaCO2 and PaO2 values.

The barrier mask studied appears to be an effective aid to ventilation in CPR Patients without facial support, as in edentulous patients with mandibular atrophy, are not ventilated well with this device.

To examine the level of interest in paramedic upgrade education among a sample of intermediate-level emergency medical technicians, referred to as cardiac rescue technicians (CRT), to obtain education to upgrade to the paramedic level.

The design of this study was a descriptive, cross-sectional study utilizing a mailed survey instrument.

Most of the CRTs reported interest in advancement to the paramedic level with the most active CRTs significantly more interested in upgrading than were those with lower grade of activity. Preference was for the upgrade training to be offered as a single course, two nights per week. Respondents also indicated an interest in receiving college credits for the course.

Active volunteer, intermediate-level emergency medical technicians (EMTs) in Maryland are interested in participating in the education necessary to advance them to the paramedic level.