Beyond the basics: the art of critical thinking. Part 2

This two-part series has addressed the critical thinking process both through discussion and demonstration in the case studies presented here. Indeed, the process involves all of the decisions we make in assessment and treatment. It is not limited to advanced providers. With the exception of the ECG analysis mentioned earlier, all other decisions were based on history and physical exam and can be performed by any provider. Thinking is not limited to a particular license or certification level. We hope these articles have helped you cross a bridge into stronger critical decision-making and farther along the journey of being a true prehospital clinician at any level of certification.

Organizational description and emergency preparedness of Nationally Registered First Responders

INTRODUCTION

This study intended to describe the types of organizations and communities in which Nationally Registered First Responders (NRFR) perform their duties. Also, it aimed to estimate the number of NRFR who received disaster preparedness training. It was hypothesized that NRFR participation in disaster preparedness training was related to the types of organizations and communities in which they performed their duties.

METHODS

The NRFR re-registering in 2006 were asked to report the organization type and community size in which they work. They also were asked to report the amount and content of preparedness training received during the last 24 months. Multivariable logistic regression modeling was utilized to describe the relationship between NRFR organizational characteristics and the receipt of disaster preparedness training.

RESULTS

The analysis included 872 (59%) individuals who completed the survey and reported working for one or more emergency medical services (EMS) organizations. The majority of NRFR performed work in rural areas (75%) and more NRFR reported working for fire departments (61%) than for any other organization type. In all categories of service type, participants who reported working in urban areas had higher odds of receiving disaster preparedness training than those working in rural areas. Additionally, regardless of community size, individuals working in fire departments were more likely to receive disaster preparedness training.

CONCLUSIONS

This study indicated that the majority of NRFR perform EMS duties for fire departments and work in rural communities. In this sample of NRFR, more than one-quarter did not receive disaster preparedness training within a 24-month period. Finally, a statistical model was constructed that indicated a relationship between service type, community size, and the participation in disaster preparedness training.

Bariatric transport challenges: Part 2

In Part 1 in the April issue, we reviewed some basics of bariatric lifting and moving. This article examines some practical scenarios of showing how these skills can be put to use. Think about how you would handle each of these patients if you experienced a clinical encounter with them during duty hours.

Clinical experience and practical skills: results from Mexico City's paramedic registry

INTRODUCTION

Trauma is a leading cause of death and disability in Mexico. Unintentional injuries, along with diabetes and heart disease, contribute to > 35% of the country's total mortality. Effective and efficient prehospital care of the conditions may improve outcomes.

OBJECTIVE

The objective of this paper was to determine if prehospital field experience (PFE) correlated with higher passing rates among candidates for the paramedic registry in Mexico City.

METHODS

This was a retrospective, cohort study using data from the Voluntary Registry of Prehospital Care Professionals (VRPHP) in Mexico City.

RESULTS

The mean value for candidate age was 30.6 years and mean value for the years of PFE was 6.8 years (CI = 9-13 years). Most of the applicants were male and almost 90% were basic emergency medical services providers. Sixty-five percent of the candidates were from private, non-profit organizations, 73% were volunteers, and 19% had obtained a university degree. More than 57% had > 5 years of PFE, but the experience level did not correlate significantly with higher passing rates for the registry evaluation (chi2 = 1.66, p = 0.43). The results differed between the two years that the examination was offered (chi2 = 32.98, df = 1, p < 0.001, gamma = 0.54), regardless of gender, education, and years of experience.

CONCLUSIONS

Previous field experience showed no correlation with passing rates, although the correlations improved between examination periods. The results may be used to support appropriate implementation of future health policies for prehospital emergency services.

Backbreaking work. What you need to know about lifting and back safety in EMS

Geraldine did not look very heavy, but she was wedged between the toilet and bath-tub. She had slipped while getting out of the tub and was complaining of severe hip pain. The room was only big enough for me, my partner and Geraldine, who needed to be lifted up and out of the room to the cot in the hallway. The question at hand was how to keep Geraldine as pain-free as possible while protecting our own backs during the lift and move. Nearly every patient contact involves lifting and carrying equipment and patients, which applies forces that can potentially injure your back. In this article, we explore lifting and back safety for EMS providers.

[How is out-of-hospital cardiac arrest dispatched?]

INTRODUCTION

In Denmark any person needing urgent medical help can dial 112 and get in contact with an alarm centre where a non-health educated operator assesses what kind of help is needed. A specific dispatch report (DR) is used if an ambulance is dispatched. We assessed which DRs were used for the Copenhagen Mobile Emergency Care Unit (MECU) in the case of out-of-hospital cardiac arrest.

MATERIALS AND METHOD

All DRs for the MECU during 2000 to 2006 were analyzed and compared with the diagnosis recorded by the dispatched specialist in anaesthesiology after every case. We divided the DRs into five categories: ''cardiac arrest'', ''possible death'', ''unconscious'', ''heart attack'', and ''miscellaneous'' (consisting of 40 different DR categories).

RESULTS

We found 52088 DRs, 2902 of which were diagnosed as cardiac arrest. 32% of these cardiac arrests were dispatched in accordance with this, while the DRs were different from cardiac arrest in 68%. ''Unconscious'' accounted for 21%. 41% of the cases with DR cardiac arrest could not be verified upon the arrival of the dispatched medical doctor.

CONCLUSION

Only 32% of the cases with cardiac arrest had a correct DR. We suspect that some of the patients had an unrecognized cardiac arrest at the time of contact to the alarm centre. The current alarm system can presumably be improved. The alarm centre has a central role in such a quality improvement.

[Use of skills among ambulance crews assessed by ambulance on-line record-keeping system]

INTRODUCTION

To fulfil the increasing requirements for documentation and quality assurance, amPHI, an ambulance on-line record-keeping system has been developed. We present the data from the pilot study to access how often ambulance crews use their skills.

MATERIALS AND METHODS

As a pilot study amPHI was installed and tested in an emergency ambulance for 21 months. Data was entered using a computer with touch-enabled screen. Communication between the ambulance and the hospital was established through a special secured network based on the GSM mobile telephone network.

RESULTS

The ambulance was dispatched for 830 high-priority services and amPHI was used in 674 cases (81%) during the pilot study. A total of 26 out of 31 skills were used less than ten times a year per EMT (Emergency Medical Technician). Three of these skills--mask-ventilation, CPR (Cardio Pulmonary Resuscitation) and suction are technically difficult and require routine.

CONCLUSION

The initial treatment is of prime importance for the outcome of the patient. It is therefore necessary to ensure that the ambulance crew is able to maintain their skills. In this connection amPHI can be very useful. Important and sometimes life-saving skills such as mask-ventilation, CPR and suction were used to a very limited extent. It is of great importance for the EMT to keep up these skills in another way. The ambulance crews are satisfied with the amPHI system and find it easy to use.

Effectiveness of paramedic practitioners in attending 999 calls from elderly people in the community: cluster randomised controlled trial

OBJECTIVE

To evaluate the benefits of paramedic practitioners assessing and, when possible, treating older people in the community after minor injury or illness. Paramedic practitioners have been trained with extended skills to assess, treat, and discharge older patients with minor acute conditions in the community.

DESIGN

Cluster randomised controlled trial involving 56 clusters. Weeks were randomised to the paramedic practitioner service being active (intervention) or inactive (control) when the standard 999 service was available.

SETTING

A large urban area in England.

PARTICIPANTS

3018 patients aged over 60 who called the emergency services (n=1549 intervention, n=1469 control).

MAIN OUTCOME MEASURES

Emergency department attendance or hospital admission between 0 and 28 days; interval from time of call to time of discharge; patients' satisfaction with the service received.

RESULTS

Overall, patients in the intervention group were less likely to attend an emergency department (relative risk 0.72, 95% confidence interval 0.68 to 0.75) or require hospital admission within 28 days (0.87, 0.81 to 0.94) and experienced a shorter total episode time (235 v 278 minutes, 95% confidence interval for difference -60 minutes to -25 minutes). Patients in the intervention group were more likely to report being highly satisfied with their healthcare episode (relative risk 1.16, 1.09 to 1.23). There was no significant difference in 28 day mortality (0.87, 0.63 to 1.21).

CONCLUSIONS

Paramedics with extended skills can provide a clinically effective alternative to standard ambulance transfer and treatment in an emergency department for elderly patients with acute minor conditions.

TRIAL REGISTRATION

ISRCTN27796329 [controlled-trials.com].

Use of the Airtraq laryngoscope in a model of difficult intubation by prehospital providers not previously trained in laryngoscopy

This study evaluated the ability of prehospital providers who had no previous training in intubation, to use an Airtraq laryngoscope to intubate a manikin model of a Cormack and Lehane grade III/IV view. Volunteers attending the Australian College of Ambulance Professionals conference, Adelaide, in November 2006 received approximately 5 min of Airtraq training. First-time intubation success rate was 26/33 (79%) (95% CI 61-91%); oesophageal intubation rate was 0/33 (0%) (95% CI 0-11%); median time to intubation was 17 s (IQR 10-25 s (range 5-30 s)); and median subject-rated difficulty of use score was 21 out of a maximum of 100 (IQR 7.5-35.5 (range 1-65)). Pre-hospital providers without previous laryngoscopy training achieved high first-time intubation success rates when managing a model of a grade III/IV difficult intubation with an Airtraq laryngoscope. Users evaluated it as easy to use and achieved intubation within an acceptable breath-to-breath interval.

International comparison of prehospital trauma care systems

OBJECTIVE

Given the recent emphasis on developing prehospital trauma care globally, we embarked upon a multicentre study to compare trauma patients' outcome within and between countries with technician-operated advanced life support (ALS) and physician-operated (Doc-ALS) emergency medical service (EMS) systems. These environments represent the continuum of prehospital care in high income countries with more advanced prehospital trauma care systems.

METHODS

Five countries with ALS-EMS system and four countries with Doc-ALS EMS system provided us with de-identified patient-level data from their national or local trauma registries. Generalised linear latent and mixed models was used in order to compare emergency department (ED) shock rate (systolic blood pressure (SBP) <90mmHg) and early trauma fatality rate (i.e. death during the first 24h after hospital arrival) between ALS and Doc-ALS EMS systems. Logistic regression was used to compare outcomes of interest among different countries, accounting for within-system correlation in patient outcomes.

RESULTS

After adjustment for patient age, sex, type and mechanism of injury, injury severity score and SBP at scene, the ED shock rate did not vary significantly between Doc-ALS and ALS systems (OR: 1.16, 95% CI: 0.73-1.91). However, the early trauma fatality rate was significantly lower in Doc-ALS EMS systems compared with ALS EMS systems (OR: 0.70, 95% CI: 0.54-0.91). Furthermore, we found a considerable heterogeneity in patient outcomes among countries even with similar type of EMS systems.

CONCLUSION

These findings suggest that prehospital trauma care systems that dispatch a physician to the scene may be associated with lower early trauma fatality rates, but not necessarily with significantly better outcomes on other clinical measures. The reasons for these findings deserve further studies.

An approach to shorten time to infarct artery patency in patients with ST-segment elevation myocardial infarction

We developed a regional strategy to decrease the time to percutaneous coronary intervention (PCI) for patients with acute ST-segment elevation myocardial infarction (STEMI). Protocols were created for paramedics and referring hospitals to identify and directly triage all patients with STEMI to a single PCI center. Time to PCI reperfusion and in-hospital mortality were assessed in 233 consecutive patients with STEMI. Ninety-minute initial hospital door-to-patent infarct artery was achieved in 58.3% of paramedic-diagnosed and directly triaged patients compared with 37.5% of "walk-ins" to the PCI hospital and with only 5.2% of those transferred from another hospital emergency department (ED; p <0.001). Overall in-hospital mortality was 2.1%, 0% in paramedic identified patients, and 0% in those walk-ins to the PCI hospital ED compared with 4.3% for those transferred from a referring hospital ED (p = 0.007). Paramedic diagnosis of STEMI and direct triage to a prealerted interventional hospital for primary PCI was associated with a high percentage of patients achieving <90-minute infarct artery patency. Substantial delays remained for those who presented initially to a non-PCI hospital ED despite the expedited protocol. In conclusion, this observational study suggests that wider use of paramedic electrocardiographic STEMI diagnosis and direct triage to a prealerted PCI hospital catheterization team may help improve outcomes of patients with STEMI.