Airway management during cardiopulmonary resuscitation--a comparative study of bag-valve-mask, laryngeal mask airway and combitube in a bench model

Gastric inflation and subsequent regurgitation are a potential risk of ventilation during cardiopulmonary resuscitation (CPR). In respect of recent investigations, principal respiratory components such as respiratory system compliance, resistance and lower esophageal sphincter pressure were adapted according to CPR situations. The purpose of our study was to assess lung ventilation and gastric inflation when performing ventilation with bag-valve-mask, laryngeal mask airway, and combitube in a bench model simulating an unintubated cardiac arrest patient. Twenty-one student nurses, without any experience in basic life support measures, ventilated the bench model with all three devices. Mean ( +/- S.D.) gastric inflation with the laryngeal mask airway (seven cases) was significantly lower than with the bag-valve-mask (0.6 +/- 0.8 vs 3.0 +/- 2.11 min(-1), P < 0.01). There was no gastric inflation when ventilation was performed with the combitube. Only seven of 21 volunteers exceeded 1-min lung volumes of > 5 1 when using the bag-valve-mask, whereas mean (+/-S.D.) 1-min lung volumes with both laryngeal mask airway and combitube were significantly higher (laryngeal mask airway 15.0+/-6.61, combitube 16.6 +/- 6.81 vs bag-valve-mask 4.8 +/- 2.71, P < 0.01). The time for insertion was significantly faster with both bag-valve-mask and laryngeal mask airway compared with the combitube (median: bag valve mask 22 s, laryngeal mask airway 37 s vs combitube 70 s, P < 0.01). This may tip the scales towards using the laryngeal mask airway during basic life support airway management. In conclusion, our data suggests that both laryngeal mask airway and combitube may be appropriate alternatives for airway management in the first few minutes of CPR.

Clearing the cervical spine of adult victims of trauma

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The Spacebridge to Russia Project: internet-based telemedicine

The National Aeronautics and Space Administration (NASA) has been a pioneer in telemedicine since the beginning of the human spaceflight program in the early 1960s. With the rapid evolution in computer technology and equally rapid development of computer networks, NASA and the Department of Surgery in Yale University's School of Medicine created a telemedicine testbed with the Russia Space Agency, the Spacebridge to Russia Project, using multimedia computers connected via the Internet. Clinical consultations were evaluated in a store-and-forward mode using a variety of electronic media, packaged as digital files, and transmitted using Internet and World Wide Web tools. These systems allow real-time Internet video teleconferencing between remotely located users over computer systems. This report describes the project and the evaluation methods utilized for monitoring effectiveness of the communications. The Spacebridge to Russia Project is a testbed for Internet-based telemedicine. The Internet and current computer technologies (hardware and software) make telemedicine readily accessible and affordable for most health care providers. Internet-based telemedicine is a communication tool that should become integral to global health care.

Prehospital use of succinylcholine: a 20-year review

OBJECTIVE

To determine the safety and efficacy of succinylcholine, as an adjunct to endotracheal intubation, administered by paramedics trained in its use.

METHODS

Retrospective review of 1,657 consecutive patients, aged 16 years or older, receiving prehospital succinylcholine administered by paramedics. In this community of 175,000 people, trained paramedics intubated both medical and trauma patients with the assistance of succinylcholine. Main outcomes measured were success of intubations, complications of the procedure and/or the drug, and use of alternative methods of airway management.

RESULTS

Paramedics successfully intubated 95.5% (1,582) of all patients receiving succinylcholine, 94% (1,045) of trauma patients, and 98% (538) of medical patients. They were unable to intubate 4.5% (74) of the patients. All of these were successfully managed by alternative methods. Unrecognized esophageal intubation occurred in six (0.3%) patients. The addition of capnography and a tube aspiration device, in 1990, decreased the incidence of esophageal intubations.

CONCLUSION

Paramedics trained to use succinylcholine, to assist the process of endotracheal intubation, can safely intubate a high percentage of patients.

An evaluation of EMS educational programs in North Carolina. North Carolina Community College System Emergency Medical Science Curriculum Improvement Project Advisory and Steering Committees

OBJECTIVES

To determine whether EMS educational programs in North Carolina adequately prepare paramedics, and whether there is additional value to an associate of applied science (AAS) degree education in EMS when compared with traditional certificate training programs.

METHODS

Surveys were developed and distributed to EMS administrators, AAS paramedics, and certificate paramedics. The administrators were asked to rate the performance of both AAS and certificate paramedics in the areas of preemployment evaluation, patient-care skills, and non-patient-care duties. The paramedics were asked to rate their preparation for specific responsibilities within those three categories. All of the participants were asked to describe the requirements for employment within their EMS systems, and any preferences given to AAS paramedics.

RESULTS

The administrators rated both AAS and certificate paramedics as good or excellent in all three categories. The paramedics also rated their preparation for patient care as good or excellent. The certificate paramedics rated their preparation for eight non-patient-care duties significantly lower than did the AAS paramedics. The eight areas were: 1) verbal communication, 2) reading ability, 3) leadership, 4) conflict resolution, 5) computer skills, 6) teaching skills, 7) personal health/hygiene, and 8) Occupational Safety and Health Administration (OSHA) compliance. Fewer than half of the EMS administrators reported preferences in hiring (46.2%) or promotion (39.6%) for AAS paramedics, but at least half (50.0% and 54.2%) of the AAS paramedics worked in systems offering such preferences.

CONCLUSIONS

While administrators and paramedics believe the current EMS educational programs in North Carolina adequately prepare students to function as paramedics, there are identifiable areas that require additional emphasis. There appears to be additional value to an AAS education when compared with traditional certificate EMS educational programs.

Change the scope of practice of paramedics? An EMS/public health policy perspective

OBJECTIVE

To analyze the potential for expanding the scope of practice of paramedics from public health, health planning, and health policy perspectives, utilizing data covering more than 42,000 emergency patients.

METHODS

The authors conducted a retrospective study of 42,918 patients seen in two Baltimore emergency departments over a six-month period, 5,259 of whom were transported by emergency ambulance. The authors constructed epidemiologic profiles of in-hospital and prehospital patients, and merged ambulance data with discharge diagnoses.

RESULTS

The 42,918 patients had a total of 2,118 different discharge diagnoses. The ten most frequent diagnoses of ambulance-transported patients were convulsions, injuries, asthma, congestive heart failure, chest pain, syncope and collapse, otitis media, abdominal pain, cardiac arrest, and respiratory abnormality. The ten most frequent diagnoses for all ED patients were otitis media, asthma, finger and nonspecific injuries, upper respiratory infections, chest pain, bronchitis, pharyngitis, gastroenteritis, nonspecific viral infections, and urinary tract infections. Infections accounted for 31.6% of the top 50% of diagnoses by volume, followed by injuries (24%) and cardiovascular cases (16.5%). However, 26.9% of ED patients received an assessment and diagnosis of general symptoms (no procedure).

CONCLUSIONS

The high number of diagnoses and the frequency of infections as a primary complaint in this patient sample reconfirm the primacy of the physician in prioritizing patients and assigning treatment pathways. The authors suggest a methodology that may allow properly trained medics to alter some of their role as physician extenders, but suggest that system planners must first ensure that any changes not reduce the public health benefits that each EMS system already provides.

A placebo-controlled experimental study of steroid inhalation therapy in ammonia-induced lung injury

BACKGROUND

The use of corticosteroids in toxic lung injury caused by exposure to an irritating gas such as ammonia has not been adequately studied.

OBJECTIVE

To evaluate the effects of budesonide inhalation in a rabbit model of toxic lung injury induced by ammonia.

DESIGN

Randomized, blind placebo-controlled laboratory investigation employing 16 New Zealand White rabbits. Lung injury was induced by inhalation of a defined amount of aerosolized ammonia. Thirty minutes later, the rabbits were randomized to receive either inhalation therapy with 0.5 mg budesonide or placebo. After another 2 hours, a second treatment inhalation, identical to the first one, was administered.

RESULTS

Airway pressures, hemodynamics, and gas exchange were measured at baseline, 5, and 15 minutes after ammonia administration and every 30 minutes during a 6-hour period after the first blind inhalation of corticosteroids or placebo. The ammonia inhalation resulted in an acute severe lung injury, detected after 15 minutes as a decrease in Pao2 from 23.3 (+/- 3.6) to 11.0 (+/- 3.6) kPa (p < 0.005) and an increase in peak airway pressure from 13 (+/- 2) to 17 (+/- 2) cm H2O (p < 0.005). During the 6-hour observation period, the blood gas parameters improved gradually in all rabbits. In comparison with placebo, budesonide did not result in improved gas exchange or reduced airway pressure levels during the observation period.

CONCLUSION

In this animal model corticosteroid inhalation therapy had no effect on ammonia-induced lung injury.

Accuracy of an enzymatic assay device for serum ethanol measurement

OBJECTIVE

To determine the accuracy of an enzymatic assay of serum to measure blood ethanol levels in the emergency department.

METHODS

A blinded, prospective study of emergency department patients for whom a blood ethanol was ordered and performed. After skin prep with betadine, two blood samples were drawn into separate sodium fluoride-containing vacutainers. One sample was sent to the hospital laboratory for blood ethanol analysis. The other was centrifuged for 5 minutes and the serum was then assayed using the QED A350 Saliva Alcohol Test. Values were then compared by kappa statistic and Pearson's correlation. Sensitivity and specificity calculations were determined for the QED device to detect a blood ethanol > 100 mg/dL.

RESULTS

Sixty-six patients were enrolled. The kappa value for QED compared to lab blood ethanol was 0.93. The Pearson's correlation coefficient was 0.94. The QED, in general, tended to overestimate blood ethanol slightly. The QED was 100% sensitive and 82% specific in detecting a blood ethanol > 100 mg/dL.

CONCLUSIONS

Analysis of serum using a QED A350' is a sensitive and accurate index of low to moderate increases in blood ethanol appropriate to emergency department, but not legal, interpretation.

Disturbing trends: the epidemiology of pediatric emergency medical services use

OBJECTIVE

To compare pediatric ambulance patients transported for chief complaints of suicide, assault, alcohol, and drug intoxication (SAAD) with pediatric patients transported for all other chief complaints.

METHODS

An out-of-hospital database for the primary transporting service in an urban area was analyzed for patients 0-20 years of age from 1992 to 1995. Chief complaints by age, gender, and billing status were analyzed.

RESULTS

There were 17,722 transports. The SAAD group comprised 14.9% of all transports (suicide attempt 1.6%, assault 5.9%, alcohol intoxication 3.2%, and drug abuse 4.2%). The proportion of transports due to SAAD increased with age: 0-11-year-olds (4.2%); 11-16-year-olds (17.5%); and 17-20-year-olds (20.3%) (p = 0.0001). Genders were equally represented in the overall group, while males comprised 52.6% of the SAAD transports (p = 0.032). In the SAAD group, the majority of transports for assaults (55.9%) and alcohol (58.8%) involved males, while females were the majority in transports for suicide (52.3%) and drug abuse (66%) (p = 0.0001). Reimbursement sources differed, with those in the SAAD group less likely to be reimbursed by private or public (Medicaid, government) insurance (p < 0.0001) compared with the overall group.

CONCLUSIONS

A substantial proportion of pediatric emergency medical services transports are for high-risk conditions. This patient population differs from the overall group by age distribution and reimbursement source.

Family-oriented care during pediatric inter-hospital transport

We evaluated the family-oriented care and counseling provided by the BC Children's Hospital Transport Team paramedies. One hundred families were asked to rate: (1) how they would like paramedies to communicate with them under ideal conditions; and (2) what they actually experienced during their child's transport. There were no significant differences in parents' preferences under ideal circumstances and what they actually experienced in five of nine behavioural areas studied. Nineteen paramedies also rated their use of elements of family-oriented communication and the strategies they would recommend other teams use when interacting with families. The elements that paramedies reported using most frequently were rated highly by parents and produced positive feelings in the majority of families. The study indicates that effective counseling can be achieved in 'critical', time-limited situations but improvements can be made; and it supports the value of appropriate selection and training of transport team personnel in family-oriented critical care.

Morbidity and mortality of hospitalized patients after the 1995 Hanshin-Awaji earthquake

The objective of this study was to provide an overview of the morbidity and mortality of hospitalized patients during the Hanshin-Awaji earthquake. Medical records of 6,107 patients admitted to 95 hospitals (48 affected hospitals within the disaster area and 47 back-up hospitals in the surrounding area) during the initial 15 days after the earthquake were analyzed retrospectively. Patient census data, diagnoses, dispositions, and prognoses were considered. A total of 2,718 patients with earthquake-related injuries were admitted to the 95 hospitals included in our survey, including 372 patients with crush syndrome and 2,346 with other injuries. There were 3,389 patients admitted with illnesses. Seventy-five percent of the injured were hospitalized during the first 3 days. In contrast, the number of patients with illnesses continued to increase over the entire 15-day period after the earthquake. The mortality rates were 13.4% (50/372), 5.5% (128/2,346), and 10.3% (349/3,389) associated with crush syndrome, other injuries, and illness, respectively. The overall mortality rate was 8.6% (527/6,107 patients). Morbidity as well as mortality rates increased with age in patients with both injuries and illnesses. In the initial 15-day period, there was an unprecedented number of patients suffering from trauma, and they converged upon the affected hospitals. Subsequently an increased incidence of illness was observed. This survey underscores the need for adequate disaster response in such an urban situation.

Emergency medical services in China

The objective of this article is to identify and describe Chinese emergency medical services (EMS) components. Chinese EMS system development began in the 1980s with "importing" of EMS principles from other systems. China is now attempting to unify these principles. Chinese EMS systems are absent in most rural areas. Urban ambulance dispatch or "rescue" centers provide both transport and inpatient care. Ambulances are staffed with either a physician or a driver. There is not extensive overlap between hospital emergency physicians and ambulance physicians and no out-of-hospital providers at the paramedic or emergency medical technician level exist. Access to EMS is accomplished by dialing 1-2-0. Emergency calls go directly to the rescue center and a physician is dispatched. No on-line radio communication between hospitals and ambulances typically takes place. China has assimilated both traditional and unique EMS components and is undergoing development. It remains unclear whether a systematized EMS structure will emerge.

Factors to consider when buying a mobile health unit

Purchasing a mobile unit to deliver healthcare services can be an expensive undertaking, and there is little information in the literature on planning or designing these vehicles. The authors discuss guidelines to help nurse administrators make better decisions regarding the purchase of mobile health units (MHUs). The guidelines resulted from a synthesis of the literature, correspondence with the chief executive officers of firms that manufacture MHUs, and onsite visits to agencies with an MHU.

Proposed fellowship training program in international emergency medicine

Interest in international emergency medicine (EM) has grown steadily over the last ten years. This growth has been fueled by increased demand for emergency services abroad and the proliferation of emergency physicians (EPs) working in international relief and development. As a response, several academic EM programs have developed international EM fellowships for the purpose of providing formal training to EPs interested in international health. Although there have been preliminary articles describing fellowship curricula, to the authors' knowledge no recommendations have been proposed by national consensus that suggest emphasis or required components of a fellowship program. Therefore, a group of EPs interested in fellowship training convened for the purpose of developing goals and objectives for a postgraduate training program in international EM. To that end, this article proposes guidelines for a fellowship training program for international EM.

Predicting regional variations in mortality from motor vehicle crashes

OBJECTIVE

To show that the previously-observed inverse relationship between population density and per-capita mortality from motor vehicle crashes can be derived from a simple mathematical model that can be used for prediction.

METHODS

The authors proposed models in which the number of fatal crashes in an area was directly proportional to the population and also to some power of the mean distance between hospitals. Alternatively, these can be parameterized as Weibull survival models. Using county and state data from the U.S. Census, the authors fitted linear regression equations on a logarithmic scale to test the validity of these models.

RESULTS

The southern states conformed to a different model from the other states. If an indicator variable was used to distinguish these groups, the resulting model accounted for 74% of the variation from state to state (Alaska excepted). After controlling for mean inter-hospital distance, the southern states had a per-capita mortality 1.37 times that of the other states.

CONCLUSIONS

Simply knowing the mean distance between hospitals in a region allows a fiarly accurate estimate of its per-capita mortality from vehicle crashes. After controlling for this factor, vehicle crash mortality per capita is higher in the southern states, for reasons yet to be explained.

Compliance with prehospital triage protocols for major trauma patients

BACKGROUND

The extent to which severely injured patients receive definitive care at trauma centers is determined by the accuracy of prehospital major trauma criteria in predicting severe injuries and by the level of compliance with these triage instructions by prehospital providers. This study was conducted to evaluate the level of compliance with triage criteria in an established trauma system.

METHODS

The study involved a retrospective analysis of the 1995 Maryland statewide prehospital ambulance data. Prehospital providers in Maryland are instructed to consider transporting patients meeting any of the three nonexclusive major trauma criteria-physiology, injury, and mechanism-to designated trauma centers. Compliance with these criteria was defined as the proportion of patients transported to designated trauma centers among those meeting prehospital triage criteria as documented on the ambulance trip report. Special emphasis was placed on differences in the levels of compliance by age of the trauma patients.

RESULTS

A total of 32,950 transports were analyzed. Patients meeting injury criteria were most likely to be transported to trauma centers (86%), followed by those meeting mechanism criteria (46%), and physiology criteria (34%). When the level of compliance was stratified by age, there was no age difference in the level of compliance for patients meeting injury criteria (90.5% for patients aged 0-54 years vs. 88.7% for patients aged 55+ years; p = 0.197). For older patients meeting physiology criteria only or for those meeting mechanism criteria only, however, compliance was differentially low. For patients meeting physiology criteria only, the compliance was 40.3% for patients aged 0 to 54 years and 23.9% for patients aged 55 years and older (p = 0.0001); for patients meeting mechanism criteria only, compliance was 47.0% for patients aged 0 to 54 years and 39.7% for patients aged 55+ years (p = 0.002).

CONCLUSION

The majority of patients meeting prehospital major trauma criteria were transported to designated trauma centers. Patients meeting only physiology criteria, however, were much less likely to be transported to trauma centers, and there was a differentially low compliance for elderly trauma patients meeting physiology criteria alone. The causes and consequences of lower compliance with triage instructions for the elderly population deserve further investigation.

An evidence-based evaluation of EMS protocols

OBJECTIVE

To determine the extent to which prehospital patient care protocols incorporate the findings of the peer-reviewed scientific EMS literature.

METHODS

Using a computerized literature search, articles published from eight institutions known to be active in prehospital care research were identified and obtained from the local health sciences library. Animal or bench research, analysis of administrative practices, evaluation of educational or quality assurance techniques, collective reviews, and air medical articles were excluded. We compared the findings of each article with the guidelines contained in 12 sets of prehospital care protocols, ranking them as: 1) consistent; 2) partially consistent; 3) not discussed; or 4) not consistent. The rankings for the article-protocol comparisons for each EMS system were compared using the Kruskal-Wallis test.

RESULTS

Forty-nine papers were compared with 12 sets of protocols, resulting in 588 comparisons. More than half (53.1%, n = 312) of the comparisons were ranked as "consistent." Only 28 (4.8%) of the comparisons were found to be "not consistent." There was no significant difference in the rankings assigned to the comparisons for protocols from each individual system, nor in the rankings for protocols from the EMS system associated with the source of the article, from other systems with academic affiliations, and from systems without academic affiliations.

CONCLUSION

Most EMS protocols are consistent with the published peer-reviewed research. There is no difference in the level of consistency when comparing protocols from EMS systems associated with the source of the articles, those associated with other academic institutions, and those without strong academic affiliations.

A death education curriculum for emergency physicians, paramedics, and other emergency personnel

Although death education is a standard component in most medical schools and nursing programs, few include instruction on dealing with sudden death. Typically, death education courses overlook instruction in areas germane to emergency medicine, e.g., making death notifications, interacting with survivors during the immediate grief period, and reducing professional stress innate to working with newly bereaved persons. This curriculum was developed to address the paucity of existing death education materials for emergency professionals. Topics include death perspectives and awareness, death typology, cultural and religious considerations, communicating with bereaved persons, making death notifications, and dealing with initial grief reactions. Units of instruction are outlined, including educational goals, descriptions of units, teaching strategies, and supplemental readings.

A descriptive analysis of air medical directors in the United States

INTRODUCTION

The purpose of this study was to describe the characteristics and functions of U.S. physician air medical directors.

METHODS

This descriptive study included physician directors of U.S. rotor-wing and fixed-wing air medical services. Data were obtained using a standardized survey in regard to the training, education, and roles/responsibilities of directors of critical care air medical services (AMSs).

RESULTS

Data from 153 of 276 surveys (55.4%) were analyzed and reported in this study. Air medical directors' residency training varied, but emergency medicine was the most frequently reported training type (38.0%). Most directors reported less than 5 years of job experience in AMS (57.3%), had neither residency/fellowship-based flight experience (63.9%) nor practical flight experience (60.5%), and performed director functions on a part-time basis (93.2%). The six most commonly reported medical director activities were medical protocol development (87.6%), quality improvement activities (86.3%), medical crew training (80.4%), administrative negotiations (79.1%), on-line medical control (71.9%), and personnel hiring (59.5%). The three most common sources of continuing education for medical directors were literature review (95.8%), attendance at medical conferences (79.2%), and participation in professional organizations (59.7%).

CONCLUSION

These data describe the characteristics of U.S. air medical directors and identify physician contributions to patient care in the aviation environment.

Paramedic use of a spinal injury clearance algorithm reduces spinal immobilization in the out-of-hospital setting

OBJECTIVE

To determine whether paramedics can safely use a spinal clearance algorithm to reduce unnecessary spinal immobilization (SI) in the out-of-hospital setting.

METHODS

Paramedics were instructed in the use of a spinal clearance algorithm that prompted assessment of the trauma patient's 1) level of consciousness, 2) drug and/or alcohol use, 3) loss of consciousness during the event, 4) presence of spinal pain/tenderness, 5) presence of neurologic deficit, 6) concomitant serious injury, or 7) presence of pain with range of motion. The algorithm indicated that if any of the above were present, the patient should receive full SI, and if all of the above were negative, then SI could be withheld. Paramedics completed a tracking form that included the above and followed the patient to the emergency department (ED). Data were then gathered to determine the presence of spinal fracture, neurologic deficit, or a combination of the two. To compare the trends for SI, a retrospective medical incident report (MIR) review was conducted from the previous year. MIRs were selected based on the same criteria as those used for study inclusion.

RESULTS

Two hundred eighty-one patients were included in the study, with 65% (n = 183) of them receiving SI. Two hundred ninety-three MIRs were included in the retrospective sample, with SI being provided 95% (n = 288) of the time. Comparison of these samples shows a 33% reduction in utilization of SI (95% confidence interval: 27.2%- 38.8%).

CONCLUSION

An out-of-hospital spinal clearance algorithm administered by paramedics can reduce SI by one-third. Any application of a spinal clearance algorithm should be accompanied by rigorous medical supervision.

EMS systems: foundations for the future

Emergency medical services (EMS) occupy a unique position in the continuum of emergency health care delivery. The role of EMS personnel is expanding beyond their traditional identity as out-of-hospital care providers, to include participation and active leadership in EMS administration, education, and research. With these roles come new challenges, as well as new responsibilities. This paper was developed by the SAEM EMS Task Force and provides a discussion of these new concepts as well as recommendations for the specialty of emergency medicine to foster the continued development of all of the potentials of EMS.

Current practice in clinical cervical spinal clearance: implication for EMS

OBJECTIVES

To examine the practice of clinically "clearing" the cervical spine (c-spine) of trauma patients brought to the ED by EMS with cervical immobilization in place, and to examine developing trends in prehospital c-spine clearance.

METHODS

A 12-question survey form was mailed to the physician medical directors of 300 randomly selected EDs. Questions examined ED clinical clearance practices, EMS clearance protocols and research, and attitudes toward prehospital clearance. Estimated clinical clearance rates were requested.

RESULTS

A total of 173 surveys were returned (58%). At 21 hospitals (12%), c-spine films are obtained for all immobilized trauma patients; clinical clearance is never attempted. Of the remaining 151 hospitals, on average, clinical clearance is attempted for 65.5% of these patients (range 3-100%, interquartile range 50-100%) and is successful (films are not obtained) for 53.7% of attempts (range 0-100%, interquartile range 35-75%). No differences exist in either attempt rate or success rate between trauma centers and non-trauma centers, or between academic/university hospitals, community teaching hospitals, and community non-teaching hospitals (t-test or ANOVA, p > 0.05). Seventy-two respondents (42%) reported significant variation in clinical clearance practice patterns among their ED physicians. Seventy-three respondents (42%) feel that EMS providers should immobilize all trauma patients, while 99 (57%) feel it is reasonable for trained EMS providers to attempt clinical clearance on low-risk trauma patients.

CONCLUSIONS

There is tremendous variation in the ED practice of clinically clearing cervical spines. This, and a lack of support from many ED directors, may hinder attempts at development of research and standardized protocols for pre-hospital c-spine clearance.

Applications of telemedicine and telecommunications to disaster medicine: historical and future perspectives

Disaster management utilizes diverse technologies to accomplish a complex set of tasks. Despite a decade of experience, few published reports have reviewed application of telemedicine (clinical care at a distance enabled by telecommunication) in disaster situations. Appropriate new telemedicine applications can improve future disaster medicine outcomes, based on lessons learned from a decade of civilian and military disaster (wide-area) telemedicine deployments. This manuscript reviews the history of telemedicine activities in actual disasters and similar scenarios as well as ongoing telemedicine innovations that may be applicable to disaster situations. Emergency care providers must begin to plan effectively to utilize disaster-specific telemedicine applications to improve future outcomes.

Survey of state EMS-DNR laws and protocols

Author presents the results of a survey of state emergency medical services do-not-resuscitate laws and protocols that have been implemented statewide and describes their structural and operational characteristics, as well as responses from key state contacts on program challenges and issues.

Inappropriate use of emergency medical services transport: comparison of provider and patient perspectives

OBJECTIVES

To determine the extent of inappropriate ambulance use from the perspectives of both emergency medical services (EMS) providers and patients utilizing EMS transport, assess level of agreement, and identify variables associated with inappropriate ambulance use.

METHODS

A prospective cross-sectional study was done of a consecutive sample of patients arriving by ambulance during the month of February 1997 at an urban university hospital ED. EMS providers and patients completed a survey with questions regarding their perceptions of whether the need for ambulance transport was an emergency or a nonemergency. Patient demographic information and availability of alternate means of transportation to the hospital were also evaluated.

RESULTS

Eight hundred eighty-seven patients were included in the study. EMS providers thought that 501 patient transports were appropriate and represented true emergencies, whereas 689 patients believed their medical problems were true emergencies. A significant number of patients (n=415, 47%) had access to alternative transportation to the hospital. Blunt traumatic injury and altered mental status were the most common reasons for EMS transport. Patient characteristics significantly associated with EMS provider perception of a true emergency were male gender, age >51 years, higher education, chest pain/cardiac complaints, shortness of breath/respiratory complaints, and Medicare insurance. Characteristics significantly associated with patients who perceived themselves to have true emergencies were black ethnicity, higher education, shortness of breath/respiratory complaints, and Medicare insurance. There was 75% agreement between EMS providers and patients on appropriateness of ambulance transport (kappa=0.84).

CONCLUSION

Inappropriate ambulance use is a significant problem from both EMS provider and patient perspectives. Certain patient characteristics are associated with a higher probability of appropriate and inappropriate uses of EMS transport. A large number of patients transported by ambulance have alternative means of transportation but elect not to use them.

Out-of-hospital cervical spine clearance: agreement between emergency medical technicians and emergency physicians

OBJECTIVE

Determine the level of agreement between emergency medical technicians (EMTs) and emergency physicians (EPs) when applying an existing emergency medical services/fire department protocol for out-of-hospital clinical cervical spine injury (CSI) clearance in blunt trauma patients.

METHODS

Prospective observational study of consecutive blunt trauma patients transported by emergency medical services/fire department during a 3-month study period. The setting was an urban Level I trauma center. Measurement of interrater agreement (kappa) was determined.

RESULTS

Mean age of the 190 patients was 34+/-19 years (range, 6 -98 years). Fifty-nine percent of the patients were male. One hundred forty-six patients (77%) were immobilized by EMTs; 17 of these patients were clinically cleared by EPs. Forty-four patients (23%) were clinically cleared by EMTs and presented without CSI precautions; of these, 61% (27 of 44) were immobilized by EPs and 57% (25 of 44) had cervical spine radiographs obtained. Overall, 141 patients (74%) required radiographic clearance. CSI were detected in five patients (2.6%); all five were immobilized in the out-of-hospital setting. Overall disagreement between EMTs and EPs regarding out-of-hospital CSI clearance occurred in 44 patients (23%) (kappa=0.29; 95% confidence interval, 0.15-0.43; p < 0.01).

CONCLUSION

Significant disagreement in clinical CSI clearance exists between EMTs and EPs. Further research and education is recommended before widespread implementation of this practice.

The recent development of emergency medicine in South Korea

Emergency medicine has developed rapidly in South Korea in the past decade, giving Korea one of the most advanced systems of emergency medical care in Asia. This article reviews the overall health care system and medical climate in Korea, as well as the great progress made in establishing emergency medicine as a specialty. It also describes the many improvements implemented in academic emergency medicine, emergency patient care, and emergency medicine management systems. Although the current economic crisis offers new challenges, much optimism remains about the future of this new Korean specialty.

Evaluation of a weight-adjusted single-bolus plasminogen activator in patients with myocardial infarction: a double-blind, randomized angiographic trial of lanoteplase versus alteplase

BACKGROUND

Lanoteplase (nPA) is a rationally designed variant of tissue plasminogen activator with greater fibrinolytic potency and slower plasma clearance than alteplase.

METHODS AND RESULTS

InTIME (Intravenous nPA for Treatment of Infarcting Myocardium Early), a multicenter, double-blind, randomized, double-placebo angiographic trial, evaluated the dose-response relationship and safety of single-bolus, weight-adjusted lanoteplase. Patients (n=602) presenting within 6 hours of acute myocardial infarction were randomized and treated with either a single-bolus injection of lanoteplase (15, 30, 60, or 120 kU/kg) or accelerated alteplase. The primary objective was to determine TIMI grade flow at 60 minutes. Angiographic assessments were also performed at 90 minutes and on days 3 to 5. Follow-up was continued for 30 days. Lanoteplase achieved its primary objective, demonstrating a dose-response in TIMI grade 3 flow at 60 minutes (23.6% to 47.1% of subjects, P<0. 001). Similar results were observed at 90 minutes (26.1% to 57.1%, P<0.001). At 90 minutes, coronary patency (TIMI 2 or 3) increased across the dose range up to 83% of subjects at 120 kU/kg lanoteplase compared with 71.4% with alteplase. Thus, at this dose, lanoteplase was superior to alteplase in restoring coronary patency (difference, 12%; 95% CI, 1% to 23%). The early safety experience in this study suggests that lanoteplase was well tolerated at all doses with safety comparable to that of alteplase.

CONCLUSIONS

Lanoteplase, a single-bolus, weight-adjusted agent, increased coronary patency at 60 and 90 minutes in a dose-dependent fashion. Coronary patency at 90 minutes was achieved more frequently with 120 kU/kg lanoteplase than alteplase. In this study, safety with lanoteplase and alteplase was comparable. InTIME-II, a worldwide mortality trial, will evaluate efficacy and safety with this promising new agent.

Out-of-hospital treatment of hypoglycemia: refusal of transport and patient outcome

OBJECTIVES

Patient refusal of transport after treatment of hypoglycemia is common in urban emergency medical services (EMS) systems. The rate of relapse is unknown. The goal of this study was to compare the outcomes of diabetic patients initially refusing transport (refusers) and those transported to an ED.

METHODS

All paramedic runs from January to July 1995 were retrospectively reviewed. Inclusion criteria were adult patients with a field assessment of hypoglycemic signs/symptoms, and a fingerstick glucose <80 mg/dL. Data for analysis included paramedic run duration, patient demographics, and refusal or acceptance of transport. Patient outcome was obtained from a review of hospital and medical examiner records. Relapse was defined as hypoglycemia necessitating EMS activation or an ED visit within 48 hours of the initial episode. Student's t-test and chi2 analysis were used to compare means and rates, respectively.

RESULTS

Over the 7 months, 374 patients made 571 calls to 9-1-1 that met inclusion criteria (5.2% of all paramedic runs). Of these, 412 were refusers (72.2%) and 159 were transported patients (27.8%). The hospital records of 4 transported patients were unavailable. Sixty-three transported patients were admitted (11.2%), with 1 death from prolonged hypoglycemia. The rates of relapse did not differ between the refusers and the transported patients (p > 0.05). Twenty-five relapses occurred among the refusers (6.1%), with 14 repeat refusals, 11 transports, 5 admissions, and no deaths. There were 7 relapses among the transported patients (4.4%), with 2 refusals, 5 transports, 2 admissions, and no deaths. The paramedic run time was significantly shorter for the refusers than for the transported patients (p < 0.05).

CONCLUSIONS

The out-of-hospital treatment of hypoglycemic diabetic patients appears to be effective and efficient. Independent of the patient's refusal or acceptance of transport, the out-of-hospital treatment of hypoglycemic patients in this system appears to be safe.

Effect of a comprehensive quality management process on compliance with protocol in an emergency medical dispatch center

STUDY OBJECTIVE

Modern emergency medical dispatch provides appropriate resource responses with the use of an emergency medical dispatch priority reference system (EMDPRS). The EMDPRS is a systematic protocol for all aspects of the dispatch process, including interrogating the caller, matching responses with severity, and providing pre-arrival care. We tested the hypothesis that appropriate performance feedback would increase dispatcher compliance with the protocol.

METHODS

We examined how emergency medical dispatchers complied with the protocols contained in the Advanced Medical Priority Dispatch System, a commercially available EMDPRS. Six key areas and overall compliance were studied. Dispatchers performed for 2 months without feedback and for a further 2 months with performance feedback. We used statistical methods to compare the dispatchers' compliance with the protocols each month.

RESULTS

The mean overall compliance score improved from 76.4%+/-10.2% (mean+/-SD) in the absence of performance feedback to 96.2%+/-4.0% (n=217; P <.001) when performance feedback was provided. Five of 6 key areas showed similar improvements.

CONCLUSION

Providing emergency medical dispatchers with regular and objective feedback regarding their performance dramatically improves how rigorously they follow a systematized dispatch protocol.

The impact of paramedics on out-of-hospital cardiac arrests in a rural community

OBJECTIVE

To determine whether paramedics influence the outcome of cardiac arrest patients in a rural area.

METHODS

Retrospective analysis of cardiorespiratory arrest patients in rural southeast Alaska from 1987 to 1996.

RESULTS

Paramedics treated 37 patients and advanced life support emergency medical technicians (EMT-IIIs) treated 34 patients. Demographics/CPR variables of the two groups were similar. Return of spontaneous circulation (ROSC) was 46% (17/37) for the paramedic-treated patients and 18% (6/34) for the EMT-III-treated patients (p = 0.01). Intensive care unit (ICU) admission was 38% (14/37) for the paramedic-treated patients and 15% (5/34) for the EMT-III-treated patients (p < 0.03). Discharge from the hospital neurologically intact was 20% (7/35) for the paramedic-treated patients and 9% (3/34) for the EMT-III-treated patients (p = NS). Two patients in the paramedic-treated group had ROSC and survived in the local hospital ICU for several days before being transferred to a tertiary care hospital in another state and were lost to follow-up for the discharge-from-hospital-neurologically-intact category but were included in the ROSC and ICU admission analysis.

CONCLUSION

In this rural setting, a paramedic on the scene significantly improved the ROSC (paramedics = 46% vs 18% for EMT-III, p = 0.01) and survival to ICU admission (38% vs 15%, p = 0.03). The presence of a paramedic on the scene increased survival to hospital discharge neurologically intact (20% vs 9%), although this was not statistically significant.

Survey of out-of-hospital emergency intubations in the French prehospital medical system: a multicenter study

STUDY OBJECTIVE

To determine the clinical characteristics of endotracheal intubation in the French emergency prehospital medical system and compare these data with those of other systems.

METHODS

This study was performed in lle de France (Paris Region) in mobile ICUs staffed by physicians. This prospective, descriptive study involved completion of a questionnaire by the operator just after endotracheal intubation was performed.

RESULTS

Six hundred eighty-five (99.1%) of 691 consecutive prehospital intubations were performed successfully in the field. The orotracheal route was used in 96.0%, and no surgical approaches such as cricothyroidotomy were used. Mechanical complications occurred in 84 patients, at a rate of 15.9% for nonarrest patients and 8.1% for arrest patients. A wide variety of sedation protocols were used. Difficult intubations (10.8%) were comparable in incidence to the number seen in US emergency departments, not US prehospital systems. By the same token, intubation success rates (99.1%) were comparable to US EDs and much higher than US prehospital results.

CONCLUSION

The characteristics of French prehospital airway management differ significantly from those of other countries. These differences may be explained by differences in approach to prehospital management rather than differences of skill.

Prehospital advanced life support for major trauma: critical need for clinical trials

A widely diverse body of information exists on the use of Advanced Life Support procedures by prehospital personnel. We compared and contrasted the literature that currently exists on this topic. We examined methodologies, results, and conclusions for each article. We also stress the need for critical clinical evaluations in this arena.

Unexpected return of spontaneous circulation after cessation of resuscitation (Lazarus phenomenon)

Since 1982, more than 20 patients with return of spontaneous circulation after cessation of cardiopulmonary resuscitation (Lazarus phenomenon) have been published. We report on another case here. Such cases are probably underreported due to medicolegal concerns. After cessation of resuscitation, each patient should be further monitored for at least 10 min to detect a possible Lazarus phenomenon.

A comparison of demand-valve and bag-valve ventilations in a swine pneumothorax model

OBJECTIVE

Two means of delivering artificial ventilation readily available to out-of-hospital personnel are the bag-valve (BV) and the O2-powered demand-valve (OPDV). However, use of the OPDV has been limited because of concerns that it may worsen an underlying pneumothorax. This study compared the changes in size of pneumothorax in swine ventilated with the 2 devices.

METHODS

Three swine were anesthetized, intubated, and instrumented with a femoral arterial line and a pediatric Swan-Ganz catheter. A chest tube was placed, the chest was opened, and the lung parenchyma was visualized. The lung was disrupted by a single stab with a #10 scalpel; the chest was then sealed; and a pneumothorax was created by injecting 30 mL of air through the chest tube. The animals were ventilated by 12 emergency medical technicians using either BV or OPDV. After 10 minutes of ventilation, the pneumothorax volume was measured.

RESULTS

When comparing final pneumothorax volumes after 10 minutes of ventilation with the 2 devices, there was no significant difference (mean +/- SD = 40.8 +/- 28.2 mL vs 52.3 +/- 23.1 mL, p = 0.286).

CONCLUSION

There is no difference in final pneumothorax volumes after OPDV or BV ventilation.

Out-of-hospital intravenous access: unnecessary procedures and excessive cost

OBJECTIVE

To evaluate the concordance with criteria developed by the study investigators and supply costs associated with placement of i.v. lines and saline locks by paramedics in the out-of-hospital setting.

METHODS

This was a retrospective consecutive case series at an urban base hospital. Patients were treated by paramedics using one base hospital for medical control during December 1995. Base hospital written records and taped patient calls were reviewed to determine actual i.v. access method used by paramedics, chief complaint, and whether fluid administration was ordered. Indicated method of i.v. access was determined for each patient based on predetermined criteria developed by the investigators. i.v. access methods were ranked by cost of supplies as follows: i.v. line (i.v.) > saline lock (SL) > no i.v. line (No i.v.). An assignment of concordant treatment was made when actual = indicated method, discordant-overtreatment when actual > indicated, and discordant-undertreatment when actual < indicated.

RESULTS

452 patients were treated via radio by the base hospital during the study period. 380 of 452 (84%) received an i.v.. 28 of 380 (7%) received fluid resuscitation in the field. 166 of 452 (37%) received concordant treatment; 253 (56%) discordant-overtreatment; and 33 (7%) discordant-undertreatment. Pediatric patients (< or =14 years of age) were more likely to be undertreated as compared with adults, 33% vs 3% (p < 0.001). Patients who had medical chief complaints were more likely to receive discordant-overtreatment as compared with patients who had trauma chief complaints, 61% vs 32% (p < 0.001). 73% of chest pain patients received discordant-overtreatment. Based on these data, the yearly cost of supplies used in i.v. access discordant-overtreatment was $13,735 for this base hospital and $560,000 for the Los Angeles County emergency medical services (EMS) system. 91% of the excess supply cost is due to patients' receiving an i.v. instead of a SL.

CONCLUSION

Based on study criteria for utilization of i.v. lines vs SLs in the field, paramedics and base hospital personnel often provide discordant-overtreatment of patients by placement of an i.v. when a SL or No i.v. would suffice, resulting in unnecessary costs for EMS systems.

Accuracy of reagent strips in detecting hypoglycemia in the emergency department

STUDY OBJECTIVE

Although reagent strips are commonly used, their reliability to estimate blood glucose concentration and guide administration of dextrose solutions in the emergency department environment has not been proved. We determined the accuracy of visually interpreted reagent strips (Chemstrip bG, Boehringer Mannheim Corp, Indianapolis, IN) and their ability to identify hypoglycemic patients in the ED.

METHODS

We conducted a prospective, nonrandomized blinded clinical study of the visual estimation of blood glucose values by ED personnel using Chemstrip bG reagent strips during a 4-month period. Simultaneously obtained blood samples sent for laboratory glucose determination served as controls. The study was conducted at a large university hospital ED with an urban patient population. A convenience sample of 215 adult ED patients underwent serum glucose determination with data form completion. No study intervention was tested, although timing of administration of dextrose solutions, if given, was recorded.

RESULTS

Hypoglycemia was defined as a glucose concentration less than 60 mg/dL on standard laboratory analysis. Reagent strips identified 28 of 29 of these patients (sensitivity=97%), and 171 of 182 patients without hypoglycemia (specificity=94%, negative predictive value=99%) compared with control samples. The 1 false-negative reagent strip reading of 80 mg/dL was obtained from blood stored in a serum separator tube and had a laboratory glucose value of 39 mg/dL. Eighty-seven percent of the reagent strips were within +/-60 mg/dL of the control value for the laboratory glucose reference range less than 350 mg/dL.

CONCLUSION

Visually interpreted Chemstrip bG reagent strips provide an acceptable estimation of blood glucose concentration in the ED and are highly sensitive in detecting hypoglycemia.

Evaluation of Institutional Review Board review and informed consent in publications of human research in critical care medicine

OBJECTIVE

To examine the frequency of obtaining Institutional Review Board (IRB) approval and informed consent in critical care research.

DATA SOURCES AND DATA EXTRACTION

One-year retrospective review of original critical care research in humans published in seven journals, including American Journal of Respiratory and Critical Care Medicine, Chest, Critical Care Medicine, Intensive Care Medicine, The Journal of the American Medical Association, Lancet, and The New England Journal of Medicine. Studies were examined for general information (country/state where the research was performed, affiliation of the hospital to a medical school, and whether the work was supported by a grant and specifically by a pharmaceutical company), approval by IRB, method of consent, design of research, and interventions involved in the study.

DATA SYNTHESIS

Two hundred seventy-nine studies were reviewed, 124 (44%) of which were conducted in the United States. Two hundred forty-three (87%) studies were performed in a university institution, 96 (34%) studies were supported by a grant, and 23 (24%) studies were supported by a pharmaceutical company. In 66 (24%) studies, there was no evidence of IRB review and informed consent approval. IRB approval was obtained but the method of consent was not specified in 36 (13%) studies. No significant differences were found in obtaining IRB approval and informed consent between research conducted in the United States (n=71, 57%) or outside the United States (n=92, 59%). Grant support was obtained in ten (9%) of the 116 studies not fully approved, compared with 70 (50%) of the 140 studies that obtained full approval (p < .05). All studies (23) supported by the pharmaceutical industry were fully approved.

CONCLUSIONS

Many published studies in critical care lack IRB approval and/or informed consent. All research supported by the pharmaceutical industry was fully approved. The findings raise ethical concerns about critical care research.

The short-term outcome of hypoglycemic diabetic patients who refuse ambulance transport after out-of-hospital therapy

OBJECTIVE

To determine the short-term medical outcome of hypoglycemic insulin-dependent diabetic patients who refuse transport after out-of-hospital therapy and return to baseline mental status.

METHODS

Prospective, descriptive, short-term medical outcome data for adult patients were collected between May 1996 and December 1996. Paramedics responding to the aid of hypoglycemic insulin-dependent diabetic patients who refused transport after administration of dextrose solution (D50W) contacted a medical command physician at the University of Pennsylvania. The patients' medical histories, names, addresses, and telephone numbers were recorded. Three days after their hypoglycemic episodes, these patients were contacted by telephone by a registered nurse to determine their medical conditions.

RESULTS

Of 132 patients enrolled in the study, 103 (78%) could be contacted by telephone follow-up. Ninety-four (91%) of these patients had no recurrence of symptoms. Nine patients (9%) had recurrence of hypoglycemia and recontacted 911. Eight of these (8%) were transported to a hospital via ambulance and 3 (3%) were admitted, 1 (1%) for a cancer-related illness and 2 (2%) for hypoglycemia, 1 of whom died (1%). The remaining patient refused transport a second time after being treated, despite having the risks of refusal explained to him by a medical command physician.

CONCLUSIONS

The practice of treating and releasing most hypoglycemic insulin-dependent diabetic patients who return to normal mental status after D50W administration appears in general to be safe. Patients should be advised of the risks of recurrent hypoglycemia.

Respiratory system compliance decreases after cardiopulmonary resuscitation and stomach inflation: impact of large and small tidal volumes on calculated peak airway pressure

The purpose of the present study was to evaluate respiratory system compliance after cardiopulmonary resuscitation (CPR) and subsequent stomach inflation. Further, we calculated peak airway pressure according to the different tidal volume recommendations of the European Resuscitation Council (7.5 ml/kg) and the American Heart Association (15 ml/kg) for ventilation of an unintubated cardiac arrest victim. After 4 min of ventricular fibrillation, and 6 min of CPR, return of spontaneous circulation (ROSC) after defibrillation occurred in seven pigs. Respiratory system compliance was measured at prearrest, after ROSC, and after 2 and 4 l of stomach inflation in the postresuscitation phase; peak airway pressure was subsequently calculated. Before cardiac arrest the mean (+/- S.D.) respiratory system compliance was 30 +/- 3 ml/cm H2O, and decreased significantly (P < 0.05) after ROSC to 24 +/- 5 ml/cm H2O, and further declined significantly to 18 +/- 4 ml/cm H2O after 2 l, and to 13 +/- 3 ml/cm H2O after 4 l of stomach inflation. At prearrest, the mean +/- S.D. calculated peak airway pressure according to European versus American guidelines was 9 +/- 1 versus 18 +/- 3 cm H2O, after ROSC 12 +/- 2 versus 23 +/- 4 cm H2O, and 15 +/- 2 versus 30 +/- 5 cm H2O after 2 l, and 22 +/- 6 versus 44 +/- 12 cm H2O after 4 l of stomach inflation. In conclusion, respiratory system compliance decreased significantly after CPR and subsequent induction of stomach inflation in an animal model with a wide open airway. This may have a significant impact on peak airway pressure and distribution of gas during ventilation of an unintubated patient with cardiac arrest.

The Ontario Prehospital Advanced Life Support (OPALS) Study: rationale and methodology for cardiac arrest patients

The Ontario Prehospital Advanced Life Support Study represents the largest prehospital study yet conducted, worldwide. This study will involve more than 25,000 cardiac arrest, trauma, and critically ill patients over an 8-year period. The study will evaluate the incremental benefit of rapid defibrillation and prehospital Advanced Cardiac Life Support measures for cardiac arrest survival and the benefit of Advanced Life Support for patients with traumatic injuries and other critically ill prehospital patients. This article describes the OPALS study with regard to the rationale and methodology for cardiac arrest patients.