Role of the physician in prehospital management of trauma: North American perspective

Nationwide status of aeromedical pre-hospital and retrieval medicine in Australia

OBJECTIVE

To survey the current structure, capability and operational scope of pre-hospital and retrieval aeromedical teams across Australia.

METHODS

The medical directors of all Australian civilian adult aeromedical retrieval organisations with pre-hospital teams and/or doctors for inter-hospital critical care patient transport were contacted in a survey to qualitatively assess capacity and team structure.

RESULTS

All 17 organisations contacted completed the survey. While there is diversity in team structure with the pairing of doctors, paramedics and nurses, capacity for patient care is generally homogenous. A doctor/paramedic model is the more common team structure for rotary-wing missions, and doctor/nurse for fixed-wing. Differences are mostly due to state government controlled aspects of their health services. An advanced degree of intensive patient care occurs outside of the hospital. Land and sea rescue is an important aspect of Australian aeromedical work.

CONCLUSION

Aeromedicine in Australia has many consistent elements, but variable contexts have resulted in a diversity of operational models.

Drive-thru continuing education to meet learners' needs

BACKGROUND

Continuing education is a requirement for emergency medical services practitioners in Ohio, and simulation-based learning has been effective for this purpose. Limitations to providing simulation for emergency medical services practitioners include a lack of simulation resources or equipment and a lack of trained simulationists to adequately use existing equipment, such as high-fidelity manikins. Here, we sought to provide simulation-based learning in the ambulance bays of our local hospitals to meet these needs.

METHODS

The OhioHealth simulation team, in conjunction with OhioHealth Emergency Medical Services, conducted simulation-based education sessions in ambulance bays scheduled in 2-h blocks for 3 consecutive days at 3 different hospitals in Columbus, Ohio. The outcomes of the education sessions were evaluated based on the ability to meet the educational objectives and the suitability of the environment for learning. In total, 171 learners completed educational sessions and evaluations.

RESULTS

Modified Likert scale surveys were completed by learners to assess their confidence in the learning objectives. For each session, the learners were able to meet the determined learning objectives after the education. Regarding the feasibility of using ambulance bays for education, 90% of learners (155/171) responded that they "Agree" or "Strongly Agree" that the environment was conducive to learning.

CONCLUSION

Using care site ambulance bays with simulation staff and content experts, we were able to effectively deliver simulation-based education. Based on learner perception and ability for education to meet its determined objectives, the ambulance bay provides a feasible way to address existing barriers (cost, access to equipment, and trained staff) to simulation-based education for emergency medical services practitioners.

Telemedical support for prehospital emergency medical service in severe emergencies: an open-label randomised non-inferiority clinical trial

BACKGROUND

A tele-emergency medical service with a remote emergency physician for severe prehospital emergencies may overcome the increasing number of emergency calls and shortage of emergency medical service providers. We analysed whether routine use of a tele-emergency medical service is non-inferior to a conventional physician-based one in the occurrence of intervention-related adverse events.

METHODS

This open-label, randomised, controlled, parallel-group, non-inferiority trial included all routine severe emergency patients aged ≥ 18 years within the ground-based ambulance service of Aachen, Germany. Patients were randomised in a 1:1 allocation ratio to receive either tele-emergency medical service (n = 1764) or conventional physician-based emergency medical service (n = 1767). The primary outcome was the occurrence of intervention-related adverse events with suspected causality to the group assignment. The trial was registered with ClinicalTrials.gov (NCT02617875) on 30 November 2015 and is reported in accordance with the CONSORT statement for non-inferiority trials.

RESULTS

Among 3531 randomised patients, 3220 were included in the primary analysis (mean age, 61.3 years; 53.8% female); 1676 were randomised to the conventional physician-based emergency medical service (control) group and 1544 to the tele-emergency medical service group. A physician was not deemed necessary in 108 of 1676 cases (6.4%) and 893 of 1544 cases (57.8%) in the control and tele-emergency medical service groups, respectively. The primary endpoint occurred only once in the tele-emergency medical service group. The Newcombe hybrid score method confirmed the non-inferiority of the tele-emergency medical service, as the non-inferiority margin of - 0.015 was not covered by the 97.5% confidence interval of - 0.0046 to 0.0025.

CONCLUSIONS

Among severe emergency cases, tele-emergency medical service was non-inferior to conventional physician-based emergency medical service in terms of the occurrence of adverse events.

Evaluating prehospital care of patients with potential traumatic spinal cord injury: scoping review

PURPOSE

To gain insight into current research regarding prehospital care (PHC) in patients with potential traumatic spinal cord injury (TSCI) and to disseminate the findings to the research community.

METHODS

In March 2019, we performed a literature search of publications from January 1990 to March 2019 indexed in PubMed, gray literature including professional websites; and reference sections of selected articles for other relevant literature. This review was performed according to Arksey and O'Malley's framework.

RESULTS

There were 42 studies selected based on the inclusion criteria for review; 18 articles regarding immobilization; 12 articles regarding movement, positioning and transport; four for spinal clearance; three for airway protection; and two for the role of PHC providers. There were some articles that covered two topics: one article was regarding movement, positioning and transport and airway protection, and two were regarding spinal clearance and the role of PHC providers.

CONCLUSION

There was no uniform opinion about spinal immobilization of patients with suspected TSCI. The novel lateral trauma position and one of two High Arm IN Endangered Spine (HAINES) methods are preferred methods for unconscious patients. Controlled self-extrication for patients with stable hemodynamic status is recommended. Early and proper identifying of potential TSCI by PHC providers can significantly improve patients' outcomes and can result in avoiding unwanted spinal immobilization. Future prospective studies with a large sample size in real-life settings are needed to provide clear and evidence-based data in PHC of patients with suspected TSCI.

Feasibility of prehospital delivery of remote ischemic conditioning by emergency medical services in chest pain patients: protocol for a pilot study

Background

Remote ischemic conditioning (RIC) is a non-invasive procedure with hypothesized therapeutic benefits for patients experiencing an acute ST-elevation myocardial infarction (STEMI). Further study of emergency medical services (EMS) delivery of RIC in the prehospital setting is needed to inform the design and methods for future clinical trials of RIC in STEMI patients. The main objective of this pilot study is to assess the feasibility of prehospital delivery of RIC by EMS providers in the United States.

Methods

We will conduct a single-arm study of the standard RIC procedure (i.e., up to 4 cycles of alternating 5-min inflation and 5-min deflation of an upper arm cuff) administered by EMS paramedics in 50 patients experiencing acute onset chest pain. The investigational autoRIC® device (CellAegis Devices, Inc., Toronto, Ontario) will be initiated by paramedics during ground ambulance transport. Automated RIC cycles will continue through emergency department arrival and stay. The primary endpoint will be the completion of all 4 cycles of RIC without interruption. We will also examine study procedures and collect qualitative data from study participants and paramedics.

Discussion

To our knowledge, this will be the first study in the United States to assess the feasibility of completing the 40-min RIC procedure when initiated during ground ambulance transport. Findings from this pilot study will be used to optimize the design and methods for a future efficacy trial of RIC in acute STEMI patients.

Trial registration

NCT03400579 (ClinicalTrials.gov). Registered on 17 January 2018.

Clinical leadership in paramedic services: a narrative synthesis

Purpose

In North America, delegated practice “medical direction” models are often used as a proxy for clinical quality and safety in paramedic services. Other developed countries favor a combination of professional regulatory boards and clinical governance frameworks that feature paramedics taking lead clinician roles. The purpose of this paper is to bring together the evidence for medical direction and clinical governance in paramedic services through the prism of paramedic self-regulation.

Design/methodology/approach

This narrative synthesis critically examines the long-established North American Emergency Medical Services medical direction model and makes some comparisons with the UK inspired clinical governance approaches that are used to monitor and manage the quality and safety in several other Anglo-American paramedic services. The databases searched were CINAHL and Medline, with Google Scholar used to capture further publications.

Findings

Synthesis of the peer-reviewed literature found little high quality evidence supporting the effectiveness of medical direction. The literature on clinical governance within paramedic services described a systems approach with shared responsibility for quality and safety. Contemporary paramedic clinical leadership papers in developed countries focus on paramedic professionalization and the self-regulation of paramedics.

Originality/value

The lack of strong evidence supporting medical direction of the paramedic profession in developed countries challenges the North American model of paramedics practicing as a companion profession to medicine under delegated practice model. This model is inconsistent with the international vision of paramedicine as an autonomous, self-regulated health profession.

Does the presence of an emergency physician influence pre-hospital time, pre-hospital interventions and the mortality of severely injured patients? A matched-pair analysis based on the trauma registry of the German Trauma Society (TraumaRegister DGU®)

PURPOSE

The role of emergency physicians in the pre-hospital management of severely injured patients remains controversial. In Germany and Austria, an emergency physician is present at the scene of an emergency situation or is called to such a scene in order to provide pre-hospital care to severely injured patients in approximately 95% of all cases. By contrast, in the United States and the United Kingdom, paramedics, i.e. non-physician teams, usually provide care to an injured person both at the scene of an incident and en route to an appropriate hospital. We investigated whether physician or non-physician care offers more benefits and what type of on-site care improves outcome.

MATERIAL AND METHODS

In a matched-pair analysis using data from the trauma registry of the German Trauma Society, we retrospectively (2002-2011) analysed the pre-hospital management of severely injured patients (ISS ≥16) by physician and non-physician teams. Matching criteria were age, overall injury severity, the presence of relevant injuries to the head, chest, abdomen or extremities, the cause of trauma, the level of consciousness, and the presence of shock.

RESULTS

Each of the two groups, i.e. patients who were attended by an emergency physician and those who received non-physician care, consisted of 1235 subjects. There was no significant difference between the two groups in pre-hospital time (61.1 [SD 28.9] minutes for the physician group and 61.9 [SD 30.9] minutes for non-physician group). Significant differences were found in the number of pre-hospital procedures such as fluid administration, analgosedation and intubation. There was a highly significant difference (p<0.001) in the number of patients who received no intervention at all applying to 348 patients (28.2%) treated by non-physician teams and to only 31 patients (2.5%) in the physician-treated group. By contrast, there was no significant difference in mortality within the first 24h and in mortality during hospitalisation.

CONCLUSION

This retrospective analysis does not allow definitive conclusions to be drawn about the optimal model of pre-hospital care. It shows, however, that there was no significant difference in mortality although patients who were attended by non-physician teams received fewer pre-hospital interventions with similar scene times.

Use of prehospital ultrasound in North America: a survey of emergency medical services medical directors

Background

Advances in ultrasound imaging technology have made it more accessible to prehospital providers. Little is known about how ultrasound is being used in the prehospital environment and we suspect that it is not widely used in North America at this time. We believe that EMS system characteristics such as provider training, system size, population served, and type of transport will be associated with use or non-use of ultrasound. Our study objective was to describe the current use of prehospital ultrasound in North America.

Methods

This study was a cross-sectional survey distributed to EMS directors on the National Association of EMS Physicians (NAEMSP) mailing list. Respondents had the option to complete a paper or electronic survey.

Results

Of the 755 deliverable surveys we received 255 responses from across Canada and the United states for an overall response rate of 30%. Of respondents, 4.1% of EMS systems (95% CI 1.9, 6.3) reported currently using ultrasound and an additional 21.7% (95% CI 17, 26.4) are considering implementing ultrasound. EMS services using ultrasound have a higher proportion of physicians (p < 0.001) as their highest trained prehospital providers when compared to the survey group as a whole. The most commonly cited current and projected applications are Focused Abdominal Sonography for Trauma (FAST) and assessment of pulseless electrical activity (PEA) arrest. The cost of equipment and training are the most significant barriers to implementation of ultrasound. Most medical directors want evidence that prehospital ultrasound improves patient outcomes prior to implementation.

Conclusions

Prehospital ultrasound is infrequently used in North America and there are a number of barriers to its implementation, including costs of equipment and training and limited evidence demonstrating improved outcomes. A research agenda for prehospital ultrasound should focus on patient-important outcomes such as morbidity and mortality. Two commonly used indications that could be a focus of standardized training programs are the FAST exam, and assessment of PEA arrest.

Comparison of emergency medical services systems across Pan-Asian countries: a Web-based survey

BACKGROUND

There are great variations in out-of-hospital cardiac arrest (OHCA) survival outcomes among different countries and different emergency medical services (EMS) systems. The impact of different systems and their contribution to enhanced survival are poorly understood. This paper compares the EMS systems of several Asian sites making up the Pan-Asian Resuscitation Outcomes Study (PAROS) network. Some preliminary cardiac arrest outcomes are also reported.

METHODS

This is a cross-sectional descriptive survey study addressing population demographics, service levels, provider characteristics, system operations, budget and finance, medical direction (leadership), and oversight.

RESULTS

Most of the systems are single-tiered. Fire-based EMS systems are predominant. Bangkok and Kuala Lumpur have hospital-based systems. Service level is relatively low, from basic to intermediate in most of the communities. Korea, Japan, Singapore, and Bangkok have intermediate emergency medical technician (EMT) service levels, while Taiwan and Dubai have paramedic service levels. Medical direction and oversight have not been systemically established, except in some communities. Systems are mostly dependent on public funding. We found variations in available resources in terms of ambulances and providers. The number of ambulances is 0.3 to 3.2 per 100,000 population, and most ambulances are basic life support (BLS) vehicles. The number of human resources ranges from 4.0 per 100,000 population in Singapore to 55.7 per 100,000 population in Taipei. Average response times vary between 5.1 minutes (Tainan) and 22.5 minutes (Kuala Lumpur).

CONCLUSION

We found substantial variation in 11 communities across the PAROS EMS systems. This study will provide the foundation for understanding subsequent studies arising from the PAROS effort.

Medical direction of wilderness and other operational emergency medical services programs

Within a healthcare system, operational emergency medical services (EMS) programs provide prehospital emergency care to patients in austere and resource-limited settings. Some of these programs are additionally considered to be wilderness EMS programs, a specialized type of operational EMS program, as they primarily function in a wilderness setting (eg, wilderness search and rescue, ski patrols, water rescue, beach patrols, and cave rescue). Other operational EMS programs include urban search and rescue, air medical support, and tactical law enforcement response. The medical director will help to ensure that the care provided follows protocols that are in accordance with local and state prehospital standards, while accounting for the unique demands and needs of the environment. The operational EMS medical director should be as qualified as possible for the specific team that is being supervised. The medical director should train and operate with the team frequently to be effective. Adequate provision for compensation, liability, and equipment needs to be addressed for an optimal relationship between the medical director and the team.

Evolution of the Literature Identifying Physicians' Roles in Leadership, Clinical Development, and Practice of the Subspecialty of Emergency Medical Services

Purpose: The 2007 Institute of Medicine report entitled Emergency Medical Services at the Crossroads identified a need for the establishment of physician subspecialty certification in emergency medical services (EMS). The purpose of this study was to identify and explore the evolution of publications that define the role of the physician in EMS systems in the United States.

Methods: Three comprehensive searches were undertaken to identify articles that define the physician's role in the leadership, clinical development, and practice of EMS. Independent reviewers then evaluated these articles to further determine whether the articles identified the physician's role in EMS. Then, identified articles were classified by the type of publication in order to evaluate the transition from a non-peer reviewed to peer-reviewed literature base and an analysis was performed on the differences in the growth between these two groups. In addition, for the peer-reviewed articles, an analysis was performed to identify the proportion of articles that were quantitative versus qualitative in nature.

Results: The comprehensive review identified 1,504 articles. Ninety articles were excluded due to lack of relevance to the US. The remaining 1,414 articles were reviewed, and 194 papers that address the physician's role within EMS systems were identified; 72 additional articles were identified by hand search of references for a total of 266 articles. The percentage of peer-reviewed articles has increased steadily over the past three decades. In addition, the percentage of quantitative articles increased from the first decade to the second and third decades.

Conclusions: This comprehensive review demonstrates that over the past 30 years an evidence base addressing the role of the physician in EMS has developed. This evidence base has steadily evolved to include a greater proportion of peer-reviewed, quantitative literature.

The association of mobile medical team involvement on on-scene times and mortality in trauma patients

OBJECTIVES

Mobile medical teams (MMTs) provide specialized care on-scene with the purpose to improve outcome. However, this additional care could prolong the on-scene time (OST), which is related to mortality. The purpose of this study was to assess the effects of MMT involvement on the mortality rate and on the OST, in a Dutch consecutive cohort of Level I trauma patients.

METHODS

All patients who required presentation in the trauma resuscitation room in an urban Level I trauma center were included in this prospective study during the period of November 2005 till November 2007. For data collection, we used both pre- and in-hospital registration systems. Outcome measures were 30-day mortality and OST.

RESULTS

In total, 1,054 patients were analyzed. In 172 (16%) patients, the MMT was involved. Mortality was significantly higher in the MMT group compared with patients treated without MMT involvement; 9.9% versus 2.7%, respectively (p < 0.001). Significantly higher Injury Severity Scores, intervention rates, and a significantly lower Triage Revised Trauma Score were found in patients treated by MMT. After adjustment for patient and injury characteristics, no association could be found between MMT involvement and higher mortality (95% CI, 0.581-3.979; p = 0.394). In patients with severe traumatic brain injury (GCS score ≤ 8) in whom a MMT was involved, the mortality was 25.5%, compared with 32.7% in those without MMT involvement (p = 0.442). The mean OST was prolonged (2.7 minutes) when MMT was involved (26.1 vs. 23.4 minutes; p = 0.003).

CONCLUSIONS

In this study, OSTs were long compared with PHTLS recommendations. MMT involvement slightly prolonged the OST. Trauma patients with MMT involvement had a high mortality, but after correction for patient and injury characteristics, the mortality rate did not significantly differ from patients without MMT involvement.

Physician medical direction and clinical performance at an established emergency medical services system

OBJECTIVE

Few developed emergency medical services (EMS) systems operate without dedicated medical direction. We describe the experience of Hamad Medical Corporation (HMC) EMS, which in 2007 first engaged an EMS medical director to develop and implement medical direction and quality assurance programs. We report subsequent changes to system performance over time.

METHODS

Over one year, changes to the service's clinical infrastructure were made: Policies were revised, paramedic scopes of practice were adjusted, evidence-based clinical protocols were developed, and skills maintenance and education programs were implemented. Credentialing, physician chart auditing, clinical remediation, and online medical command/hospital notification systems were introduced.

RESULTS

Following these interventions, we report associated improvements to key indicators: Chart reviews revealed significant improvements in clinical quality. A comparison of pre- and post-intervention audited charts reveals a decrease in cases requiring remediation (11% to 5%, odds ratio [OR] 0.43 [95% confidence interval (CI) 0.20-0.85], p = 0.01). The proportion of charts rated as clinically acceptable rose from 48% to 84% (OR 6 [95% CI 3.9-9.1], p < 0.001). The proportion of misplaced endotracheal tubes fell (3.8% baseline to 0.6%, OR 0.16 [95% CI 0.004-1.06], (exact) p = 0.05), corresponding to improved adherence to an airway placement policy mandating use of airway confirmation devices and securing devices (0.7% compliance to 98%, OR 714 [95% CI 64-29,334], (exact) p < 0.001). Intravenous catheter insertion in unstable cases increased from 67% of cases to 92% (OR 1.31 [95% CI 1.09-1.71], p = 0.004). EMS administration of aspirin to patients with suspected ischemic chest pain improved from 2% to 77% (OR 178 [95% CI 35-1,604], p < 0.001).

CONCLUSIONS

We suggest that implementation of a physician medical direction is associated with improved clinical indicators and overall quality of care at an established EMS system.

Prehospital withholding and withdrawal of life-sustaining treatments. The French LATASAMU Survey

OBJECTIVE

To investigate the end-of-life decision process in patients managed by emergency physicians in the prehospital setting.

DESIGN

A 40-item retrospective study about most recent end-of-life decision in the prehospital setting.

PATIENTS AND PARTICIPANTS

1069 physicians (44.9%) from 192 French emergency mobile units.

MEASUREMENTS AND RESULTS

A total of 816 (76.3%) physicians reported at least one prehospital end-of-life decision. Conscious patients were involved in 30.7% (54/176) and families in 63.6% of cases. The physician discussed the end-of-life decision with at least one other physician in 56.5% of cases. Perceived imminent death was the most frequently reported criterion (90.1%). Nearly four fifths of patients died before arrival at the hospital (78.8%). Factors independently associated with prehospital withdrawal decision included multiple trauma [odds ratio (OR) 5.7, 95% confidence interval (CI) 1.6-19.7], intubation (OR 3.9, 95% CI 2.3-6.5), chronic disease with severe heart failure (OR 2.8, 95% CI 1.5-5.2), acute event with postanoxic coma (OR 2.2, 95% CI 1.3-4.0), emergency physician from a teaching hospital (OR 2.1, 95% CI, 1.3-3.5), male patient (OR 1.9, 95% CI 1.1-3.3), and no sedation (OR 1.9, 95% CI 1.2-3.1). Prehospital withholding decisions were taken for 684 (88%) patients and withdrawing decisions for 12%.

CONCLUSIONS

Treatment withholding and withdrawal is common in the prehospital setting in France. These decisions remain highly questionable in this emergency context, in the absence of knowledge of the patient's medical history and of patients' and relatives' clear wishes concerning end-of-life decisions.

The epidemiology and modern management of traumatic hemorrhage: US and international perspectives

Trauma is a worldwide problem, with severe and wide ranging consequences for individuals and society as a whole. Hemorrhage is a major contributor to the dilemma of traumatic injury and its care. In this article we describe the international epidemiology of traumatic injury, its causes and its consequences, and closely examine the role played by hemorrhage in producing traumatic morbidity and mortality. Emphasis is placed on defining situations in which traditional methods of hemorrhage control often fail. We then outline and discuss modern principles in the management of traumatic hemorrhage and explore developing changes in these areas. We conclude with a discussion of outcome measures for the injured patient within the context of the epidemiology of traumatic injury.