Hypothesis: Do paramedics influence the outcome of out of hospital cardiac arrests in a rural setting?

Methods: Retrospective analysis of cardio-respiratory arrests of ALS-EMS system in rural Southeastern Alaska for 9 years. There were two patient groups treated by EMT-III or paramedics. EMT-III vs. paramedics differ in training/experience but not technical skills. Statistical analyses were done by chi square.

Results: Thirty-seven patients (52%) were treated by paramedics, thirty-four (48%) by EMT-III. Demographics/CPR variables for the groups were not significantly different. Comparing paramedics vs. EMT-III: successful ET placement (87% vs. 62%, p <0.02), successful IV placement (87% vs. 62%, p <0.02), return of spontaneous circulation (ROSC) 46% (17/37 pts.) vs. 18% (6/34 pts.) (p = 0.01), ICU admission 38% (14/37) vs. 15% (5/34) (p = 0.03), hospital discharge 20% (7/35) vs. 9% (3/34) (p = NS). There was no correlation between successful ET placement or IV insertion and outcome.

Purpose: To determine how often house fires occur at addresses visited previously for emergency medical services (EMS) and were these visits missed opportunities for a point-of-contact fire safety intervention.

Method: Retrospective analysis of all Fire Department (FD) responses during 1994. Data studied with descriptive statistics: reason for response, property type, dollar loss estimate, injuries, fatalities, fire cause, smoke detector operation.

Results: The FD responded to 94,378 requests for service at 43,556 addresses. 27,406 addresses generated one response. However, 16,150 addresses had multiple requests, receiving 66,972 responses. For the multiple requests, 1,162 addresses had a fire condition of which 728 addresses requested EMS prior to the fire condition. 215 were one/two-family dwelling addresses receiving 489 responses; mean 2.3 EMS responses prior to the fire condition. 182/215 (85%) of these addresses had complete data, incurring a dollar loss estimate of [US]$2,017,470, 33 injuries and 0 fatalities. The top five causes for the fire condition were children playing with smoking materials, arson, suspicious, scorched food and undetermined. 87/182 (49%) of the one/two-family dwellings had a smoke detector present. However, only 31/182 (17%) of the dwellings had an operational smoke detector.

Purpose: The use of automatic external defibrillators (AED) by emergency medical service (EMS) first responders (FR) is widely advocated based largely on reports from one metropolitan area, but widespread impact on survival remains unproven. We hypothesized that the addition of AEDs to an EMS system with short FR and prolonged paramedic response times (4 vs. 10 minutes) would improve survival from sudden cardiac death.

Methods: Prospective, controlled, crossover study (AED vs. no AED) of consecutive cardiac arrests managed by 24 FR fire companies from 1992–1995 in a city of 440,000. Patients were stratified by the Utstein criteria. Primary end-point was survival to hospital discharge among patients with bystander witnessed arrests of cardiac etiology. Power was set at 0.8 to detect a 10% difference in survival.

Results: A total of 627 patients were studied. Groups were comparable for age, gender, history of myocardial infarction, congestive heart failure or diabetes, arrest at home, bystander CPR, and ventricular fibrillation (VF) as initial rhythm.

Hypothesis: Assessments to rule out cervical spine injury performed by emergency medical services (EMS) personnel correlate well with assessments performed by emergency department (ED) physicians. Methods: EMS providers completed a data form based on their initial assessment of all immobilized adult patients. Data collected included the presence or absence of: neck pain/tenderness; altered mental status; history of loss of consciousness; drug/alcohol use; neurological deficit; and other painful/distracting injury. Immobilization was considered to be indicated if any one of the six physical findings was present. The ED physician caring for the patient completed an identical data form based on his/her assessment. Physicians and EMS providers were blinded to each other's assessments. The amount of discordance between the physician and EMS assessments was analyzed using McNemar's Chi-Square for matched pairs.

Results: Five-hundred-seventy-three patients were included in the study. Physician and EMS assessments matched in 78.7% (n = 451) of the cases. In 13.6% (n = 78) of the cases, the EMS assessment indicated immobilization, but the physician assessment did not. In 7.7% (n = 44) of the patients, the physician assessment indicated immobilization, but the EMS assessment did not. The discordance between assessments was statistically significant (p <0.001). The presence of neck pain or tenderness accounted for the most discordance.

Purpose: The new Emergency Medical Technician (EMT) basic curriculum includes an optional session on intubation. Unfortunately little data is available regarding retention of endotracheal intubation skills by basic EMTs. The objective of this study was to examine endotracheal intubation skills by basic EMTs, and compare skills retention for a transillumination (TI) versus a direct visualization (DV) technique.

Methods: A prospective, randomized trial was conducted over a five week period during a basic EMT class. EMT classes were randomized to train students to perform endotracheal intubation using either a transillumination or a direct visualization technique. Initial education was performed using an airway mannequin during a modified, accelerated three hour course, consisting of both a didactic and skills session. To assess performance, participants were tested using an airway mannequin and checklist currently implemented by our flight nurse program. Without further education or practice, students were then tested one week and five weeks later to assess short and long term retention.

Purpose: Headache is a very common complaint in emergency medicine. Its causes are myriad, ranging from benign to life-threatening. Patients who access emergency medical services (EMS), often do so after self-assessment has indicated high acuity. We conducted this study to determine if patients transported by EMS with a chief complaint of headache have a higher rate of serious etiology.

Methods: This observational, retrospective study, was conducted by consecutive review of charts on all patients presenting to the emergency department (ED) from December 1994 through May 1995 with a chief complaint of headache. Patients presenting with other manifestations of intracranial pathology (ICP), such as altered mental status or seizures, were excluded. Mode of arrival was determined to be either via emergency medical services (EMS) or other means. Patients were categorized as having serious (meningitis, hemorrhage, tumor) or benign (migraine, etc.) ICP, based final diagnosis. It was noted whether or not diagnostic studies (DS), such as CT scan and lumbar puncture, were performed. Statistical analysis was performed using the Yates corrected chi-square test.

Objective: To determine the frequency and nature of patient complaints in a large urban Fire Rescue system.

Methods: A two year retrospective review of all unsolicited patient complaints received from any source either internal or external, through our full-time customer service personnel. All customer complaints, concerns and interactions are documented on an interaction form which we reviewed. All complaints were resolved with disposition related to the customer prior to our retrospective study inclusion.

Results: During the study period our Fire Rescue system responded to a total of 169,651 calls for medical assistance. Our division customer service personnel received a total of 87 unsolicited customer complaints (n = 87) regarding the service encounter with Fire Rescue/EMS. This accounts for a 0.0005% rate of customer complaints captured in correlation to total incidents during the study period. The majority of complaints, 27% were related to lost or missing goods. Service that was perceived as uncourteous or inconsiderate after calling 911, accounted for 25% of complaints. Complaints regarding not being transported after calling 911 accounted for 18%. Uncourteous driving or noise of sirens accounted for 7% of complaints. 7% of complaints resulted from not being transported to the hospital of their choice. Actual care received concerns were only 3% of total. Leaving medical objects behind was 2% of the total volume and 4% fit no specific trend.

Purpose: To determine the prevalence of gastric trauma and pulmonary aspiration after cardiopulmonary resuscitation (CPR) and to examine factors which may be associated with increased prevalence of these complications.

Methods: Retrospective review of 1,928 consecutive autopsy reports in a suburban teaching hospital from January 1, 1977 – June 1, 1986 of which 860 received CPR and 1,037 did not. Of the 860 who received CPR, 527 received prehospital CPR and 333 arrested in hospital and received only hospital CPR. Thirty-one cases were excluded because of inability to accurately examine the stomach.

Results: There were 3 cases of stomach mucosal laceration and 4 cases of through and through laceration of the stomach in the CPR group and only one occurred in the non-CPR group (p <0.03). All gastric trauma in the CPR group occurred in the prehospital group (p <0.05). Pulmonary aspiration occurred in 31% of prehospital CPR patients and only 10% of hospital CPR patients (p <0.0001). The prehospital group differed from the hospital group in the following factors: longer basic life support times without intubation, 14.0 minutes vs. 2.0 minutes (p <0.0001) and longer total resuscitation time 46.9 minutes vs. 34.6 minutes (p <0.0001).

Purpose: To determine the degree of concordance between thrombolytic checklists completed by emergency medical technicians (EMTs) in the field and corresponding checklists completed by emergency physicians in the emergency department (ED).

Methods: This was a comparative analysis of matched pairs of thrombolytic checklists. Subjects included patients 35 years or older with clinical signs or symptoms of cardiac origin who were transported to the ED by ambulance. The checklist contained 12 items and was completed by EMTs during transport of eligible patients. An identical checklist was completed in the ED by an emergency physician upon arrival of the patient. The main outcome measurement was concordance between the matched pairs.

Objective: To determine the accuracy of ambulance (AR), emergency department (EDR) and police (PR) records in describing motor vehicle crash (MVC) characteristics when compared to a standard - an in-depth motor vehicle crash investigation record (CIR).

Methods: Fifty-six MVC patients transported to a suburban, university hospital emergency department via ambulance and included in a crash investigation were identified. The time period was January 1993 through December 1995. Data sources were the AR, EDR, PR and CIR. The CIR was abstracted to a standard form. The other data sources were abstracted to a standard form using a retrospective, blinded review. Variables included occupant position, restraint use, air bag deployment, type of impact, ejection, and external cause of injury code. Accuracy was measured by determining percent agreement and Kappa for each data source compared to the CIR.

Results: Forty-six cases (82%) had one or more episodes of discordance. The mean percent agreement for the sources studied was AR 0.813, EDR 0.893 and PR 0.932. Mean values for Kappa were AR 0.712, EDR 0.831 and PR 0.885. Among variables, restraint use was determined with the least accuracy with means for percent agreement and Kappa of 0.792 and 0.674, respectively. For the AR, discordance was due to missing information almost 50% of the time.

Introduction: Previous studies of motorcycle injuries show that helmet use is associated with a decrease in head trauma. Understanding patterns of helmet use is important in selecting and assessing injury prevention strategies.

Methods: All 470 motorcyclists presenting to either of two regional Level I trauma centers from 7/93 through 12/95 comprise this case series. Thirty-three patients were excluded due to unknown helmet use or outcome, and 50 due to age under 18 years (for whom helmet use was required by state law).

Results: Of 386 patients, 42% wore helmets, and 58% did not, with no difference in the mean ages of the groups. 13% of patients were women (n = 50), and 10% were passengers (n = 38). Women were 25 times more likely than men to be passengers (95% CI: 11 to 50), and passengers were 5 times more likely than drivers to not wear a helmet (95% CI: 2 to 16). Helmet use was not related to sex, even when the data were controlled for driver vs. passenger. Of 265 patients assayed for ethanol, 30% had >100 mg/dL, 7% had <100 mg/dL, and 63% had none. Non-helmeted patients were 3.6 more likely than helmeted ones to have detectable ethanol (95% CI: 2.0 to 6.5), but there was no association with sex or age. The mean ethanol level was 80 mg/dL in non-helmet users, and 24 mg/dL in helmet users (p <0.001). 39% of non-helmeted patients were legally intoxicated (ethanol > 100 mg/dL), compared to 11% of helmeted ones.

Purpose: Prehospital triage criteria (PTC) have been used to classify patients according to risk of serious injury. This study was conducted determine whether PTC could be used to identify serious injury, the need for intensive care (ICU), or immediate operative intervention (IOI).

Methods: Data for this observational study were gathered prospectively, at a level-I trauma center, from a patient cohort admitted to the trauma service from 01 February to 31 July 1995. Specific triage criteria, based on information given by EMS prior to arrival were used to categorize patients by severity. Patients classified as most serious (codes) had the following: shock, major anatomic injury or proximal penetrating trauma. Patients classified as more serious (alerts) had one of the following: abnormal vital signs, Glasgow Coma Scale <13, moderate anatomic injury, high-risk mechanism of injury, or co-morbid factors. Patients not meeting either set of criteria, but were admitted, served as controls (consults). Injury severity scores (ISS) and probability of survival (Probsurvival) were calculated for each patient. The percentage admitted to the ICU, operating room (OR), or requiring IOI, were tabulated. Statistical analysis was performed using ANOVA, Mest and chi-square.

Purpose: To identify calls “under-triaged” by priority medical dispatch and determine causes and pre-hospital outcomes.

Methods: 6 month retrospective analysis identified calls dispatched “low priority” to which medics assigned “high acuity” transports (acute status or requiring ALS meds; not just IV/O2/monitor). CAD data, paramedic run-sheets, and audiotapes were reviewed to determine optimal dispatch levels and transport codes. “Under-triage” was defined as calls warranting “high priority” dispatch based on evidence from the run-sheet. Dispatcher, calling party, and patient data influencing “undertriage” were assessed.

Results: In 1995, 11,178/70,887 (16%) medical aid requests were dispatched “low priority”. 201(1.8%) were subsequently assigned “high acuity” transport codes by paramedics. 105/5,737 such consecutive patients were analyzed from July-December 1995. 6 were excluded due to incomplete data. After review, 42/99 actually warranted “high priority” dispatch. 7 had potential life/limb threatening injuries; 35 required ALS intervention. None had adverse prehospital outcome. Undertriage was associated with dispatcher error, information relayed from law enforcement officers (OR =3.4, CI: 1.2-10) calls involving alcohol (OR = 2.8, CI: 0.9-9.2) or patients with ALOC(OR= 3.4, CI: 1.2-10).

Objectives: To determine the accuracy of sphygmomanometers (SPHYGs) from a metropolitan EMS system and quantitate the mis-triage of adult blunt trauma patients based on erroneous systolic blood pressure (SBP) readings.

Methods-A: A cross-sectional, convenient sample of 150 SPHYGs was checked for accuracy using industry standards. Mean high and low deviations were calculated at 90 mmHg.

Methods-B: Retrospectively, a frequency distribution of the initial SBPs of all blunt trauma patients, age ≥21, seen in 1994 was plotted to characterize our study population. The numbers of patients potentially over- or under-triaged were identified when their reported SBP was corrected for using the mean high and low deviation plus 2 SDs.

Results-A: Overall, 25.3% of the SPHYGs were inaccurate. At 90 mmHg, 28.0% (42/150) were inaccurate with 16.7% (7/42) high by 4.6±1.5 mmHg and 81.0% (34/42) low by 6.2±4.2 mmHg; one was inoperable.

Results-B: 1,005 adult blunt trauma patients were evaluated; 61 were eliminated: 35 had initial SBPs of 0 mmHg and 26 had no SBP recorded (n = 944). The mean initial SBP was 138 ±30mmHg, and 3.8% (36/944) of the patients had SBPs <90 mmHg. Potentially, 2.0% (19/944) of the patients were undertriaged (initial erroneously high SBP reading 90–98 mmHg) and 2.5% (24/944) over-triaged (initial erroneously low SBP reading 74–90 mmHg).

Purpose: The accessibility of emergency medical services (EMS) for enrollees of managed care organizations (MCOs) is currently a topic of national debate. The mechanisms by which enrollees currently enter the EMS system have not been well described. The purpose of this study was to determine how these patients enter our EMS system.

Methods: All enrollees who belong to the region's largest MCO and who were transported to hospital EDs by the paramedic level municipal EMS department were identified from billing records. Members of the MCO are mandated to call the MCO prior to seeking any emergency care. Dispatch logs were then examined to determine the time and origin of the call to the 911 communications center. Patient care records were used to obtain patient age, the level of care (ALS vs. BLS), and whether the ALS patient received medications (ALS Meds).

Results: Over a six month period 195 enrollees were transported to EDs, Three modes of system entry were identified: Group I—enrollees who called 911 directly; Group II—enrollees who called the MCO triage center who then called 911 for the patient; and Group III—enrollees who were sent to the MCO center for evaluation and subsequently the MCO called 911 to transport the patient to the hospital.

Purpose: To determine whether melatonin (N-acetyl-5-methoxytryptamine) is effective in helping prehospital personnel working consecutive night shifts reset their biological clock and minimize circadian rhythm disruption.

Methods: A double-blinded, randomized, cross-over study was performed using 12 paramedic volunteers. Paramedics were working a span of consecutive night (2300-0700) shifts and received either a melatonin capsule (6 mg) or placebo to be taken prior to each of the consecutive day sleeps. Each participants completed a total of four spans of consecutive night shifts (2-melatonin, 2-placebo). Collected data included daily sleep diaries, quantification of alcohol/caffeine consumed, and possible drug side-effects. Assessment of job performance, mood and alertness were measured every day using 10-cm visual analog scales (VAS).

Results: Analysis of sleep diaries demonstrated no significant difference (p >0.05) between the two treatments in respect to mean sleep latency (melatonin = 15.4 min. vs. placebo = 14.6 min), mean sleep duration (melatonin = 6.7 hrs. vs. placebo = 6.9 hrs), or subjectively rated sleep quality (melatonin = 5.8 VAS vs placebo = 5.6 VAS). Similarly, no significant benefits were noted between the mean VAS scores for daily job performance, mood and alertness. Adverse effects were rare, one patient taking melatonin reported a prolonged sedative effect.

Conclusion: Despite widespread belief in the benefits of melatonin as a hypnotic agent, no clinical benefits were noted in terms of daytime sleep or job performance in paramedics working consecutive night shifts.

Purpose: The prevalence of asthma in the pediatric population is approximately 9% and the incidence of acute exacerbation in this population has been increasing. The purpose of this study was to determine if there has been a change in the pre-hospital presentation and treatment of pediatric asthma.

Methods: This observational study was a retrospective consecutive case series comparing pediatric (#18 yrs) asthmatics treated and transported by an inner city EMS system over two years. (1987, 1992). Data collected included patient demographics, prehospital treatment, and evaluated diagnostic criteria used by paramedics to initiate treatment. Students t test was performed for continuous data and contingency analysis (chisquare) for non-continuous data. A Wilks stepwise discriminant analysis was performed on 1987 and 1992 data to evaluate diagnostic factors.

Results: There were 407 transports in 1987 and 652 in 1992, representing a 60% increase. 237(56%) of patients received advanced life support (ALS) in 1987 and 344(53%) in 1992. Mean age of ALS patients in 1987 was 10.25 (±5.3) and was 8.03 (±2.8) in 1992 (p <0.001). Albuterol inhalation supplanted epinephrine (1987-205, 1992-1) and aminophylline (1987-15, 1992-1) as the treatment for asthma in our service system. The discriminant analysis revealed that in 1987, paramedics treatment decision making was influenced by age, cough, cold, and/or fever, home medications, accessory muscles, absence of wheezing, and normal respiratory rate. This changed in 1992 where only the presence or absence of wheezing and accessory muscle-use to be highly correlated with treatment decisions.

Objectives: Paramedic-initiated turndowns-to-BLS are a high-risk area for EMS. One non-clinical factor that might affect paramedics’ decision-making is a 24-hour work schedule. We attempted to determine the presence of circadian variation in the turndown rate from ALS to BLS when paramedics work 24-hour shifts.

Methods: Retrospective analysis of all 1994 ALS patient evaluations. Encounters were classified as: ALS transport; turndown-to-BLS; patient-initiated refusal of transport; other transport; field death. Analysis of variation in turndown rate by hour of ALS dispatch was performed using logistic regression to make paired comparisons for each hour.

Results: 17,877 patients were evaluated by ALS. Of these, 10,956 (61%) were ALS transports, 6,200 (35%) were not transported by ALS, and 721 (4%) were dead. Of the 6,200 alive non-ALS transports, 4,291 (69%) were turned down to BLS, 1,748 (28%) refused transport, and 161 (3%) were transported by others. One turndown-to-BLS was excluded due to missing dispatch time; for the remaining 4,290 the overall turndown rate was 25%. The turndown rates for 15 of 24 hours did not differ significantly (p >0.01) from any other hour. The rates at the following hours differed significantly: hour 3 < 13; hour 5 < 8,9,10,13,16,22; hour 9 > 20,22; hour 10 > 22; hour 13 > 20,22; hour 16 > 20,22.

Purpose: To determine what types of EMS systems (public vs. private) are contributing to the peer reviewed field research in EMS and what type of research is being done by these agencies.

Methods: A Medline literature search was conducted of all peer reviewed journals using the search terms: EMS, emergency medical services, EMT, paramedic, and ambulance. Studies published between 1976 and 1995 meeting these criteria were reviewed and classified as field or non-field studies. Studies were classified as field studies if they evaluated clinical outcomes or overall EMS system structure and performance. The type of EMS system in which the study was conducted was classified as: public (PB), private (PR), or a mixture of public and private agencies (PP). If the type of system was not evident in the paper, the primary author or EMS agency was contacted by phone. The primary affiliation of the first author was classified as being with: an educational institution, hospital, government agency, or EMS agency. Each study was also classified as being primarily clinical or evaluating EMS system structure. Review articles, editorials, and meta-analyses were excluded as were studies in which critical data elements could not be verified. Fischer's exact test was used for statistical analysis.

Results: A total of 365 studies were evaluated with 66 non-field studies being excluded from analysis. 75 studies did not meet inclusionary criteria. This left 224 studies for analysis. PB systems accounted for 167 (74.5%) of field studies, with PP 44 (19.6%) and PR 13 (5.8%). Clinical studies were more commonly done by PB systems (72.5%) when compared to PR systems (38.5%), p = 0.02. System structure studies accounted for the majority of studies done by PR systems (61.5%). An affiliation with an educational institution such as a university occurred in 61.2% of the studies. The number of field studies done by PB systems has increased steadily over the last 10 years while field studies published by PR and PP systems has remained at a low level, with none published from 1992–1994.

Purpose: Criteria (T&R) have been proposed to identify hypoglycemic patients who may be treated in the field and released without transport to the hospital. We prospectively evaluated the validity of these criteria.

Methods: Patients presenting with hypoglycemia (blood glucose [BG] <80 mg/dL) to paramedics of 2 EMS systems were prospectively enrolled and the presence of T&R criteria determined. T&R criteria did not influence transport. Hospital records were reviewed to determine interventions and outcomes.

Results: A total of 151 patients were enrolled (58% male, age 56 years (range 12–94), BG 33 ±16 mg/dL) and 99 (66%) were transported to the hospital and used to test the T&R criteria. Fifty-six patients (57%) were discharged from the ED and 43 (43%) received additional medications, or were admitted. T&R criteria identified 28 (29%) patients as appropriate for treatment and release. Of these, 5/28 (18%) received additional dextrose 50% (D50) or admission; 3 received D50 (despite normal mental status and documented ED BG >100 mg/dL), and 2 were admitted (transient ischemic attack and 1 hospital day, hypoglycemia and gastroenteritis and 2 hospital days). Sensitivity, specificity, negative and positive predictive values for the T&R criteria were: 41%, 88%, 51%, and 82%, respectively, and 44%, 95%, 54%, and 93%, respectively, if the 3 cases receiving D50 despite BG>100 mg/dL are excluded.