TARGET: A Randomized, Noninferiority Trial of a Pretest, Patient-Driven Genetic Education Webtool Versus Genetic Counseling for Prostate Cancer Germline Testing

PURPOSE

Germline genetic testing (GT) is important for prostate cancer (PCA) management, clinical trial eligibility, and hereditary cancer risk. However, GT is underutilized and there is a shortage of genetic counselors. To address these gaps, a patient-driven, pretest genetic education webtool was designed and studied compared with traditional genetic counseling (GC) to inform strategies for expanding access to genetic services.

METHODS

Technology-enhanced acceleration of germline evaluation for therapy (TARGET) was a multicenter, noninferiority, randomized trial (ClinicalTrials.gov identifier: NCT04447703) comparing a nine-module patient-driven genetic education webtool versus pretest GC. Participants completed surveys measuring decisional conflict, satisfaction, and attitudes toward GT at baseline, after pretest education/counseling, and after GT result disclosure. The primary end point was noninferiority in reducing decisional conflict between webtool and GC using the validated Decisional Conflict Scale. Mixed-effects regression modeling was used to compare decisional conflict between groups. Participants opting for GT received a 51-gene panel, with results delivered to participants and their providers.

RESULTS

The analytic data set includes primary outcome data from 315 participants (GC [n = 162] and webtool [n = 153]). Mean difference in decisional conflict score changes between groups was -0.04 (one-sided 95% CI, -∞ to 2.54; P = .01), suggesting the patient-driven webtool was noninferior to GC. Overall, 145 (89.5%) GC and 120 (78.4%) in the webtool arm underwent GT, with pathogenic variants in 15.8% (8.7% in PCA genes). Satisfaction did not differ significantly between arms; knowledge of cancer genetics was higher but attitudes toward GT were less favorable in the webtool arm.

CONCLUSION

The results of the TARGET study support the use of patient-driven digital webtools for expanding access to pretest genetic education for PCA GT. Further studies to optimize patient experience and evaluate them in diverse patient populations are warranted.

Technology-enhanced AcceleRation of Germline Evaluation for Therapy (TARGET): A randomized controlled trial of a pretest patient-driven webtool vs. genetic counseling for prostate cancer germline testing

BACKGROUND

Germline testing has an increasingly important role in prostate cancer care. However, a relative shortage of genetic counselors necessitates alternate strategies for delivery of pre-test education for germline testing. This study, funded by the Prostate Cancer Foundation, seeks to address the need for novel methods of delivery of pre-test germline education beyond traditional germline counseling to facilitate informed patient decision-making for germline testing.

METHODS

This is a two-armed randomized controlled trial (RCT) with a target enrollment of 173 participants with prostate cancer per study arm (total anticipated n = 346). Patients who meet criteria for germline testing based on tumor features, family history or Ashkenazi Jewish ancestry are being recruited from 5 US sites including academic, private practice and Veterans healthcare settings. Consenting participants are randomized to the interactive pretest webtool or germline counseling with assessment of key patient-reported outcomes involved in informed decision-making for germline germline testing.

RESULTS

Participants complete surveys at baseline, after pretest education/counseling, and following disclosure of germline germline results. The primary outcome of the study is decisional conflict for germline testing. Secondary outcomes include germline knowledge, satisfaction, uptake of germline testing, and understanding of results.

CONCLUSION

Our hypothesis is that the web-based germline education tool is non-inferior to traditional germline counseling regarding key patient-reported outcomes involved in informed decision-making for germline testing. If proven, the results would support deploying the webtool across various practice settings to facilitate pre-test germlines education for individuals with prostate cancer and developing collaborative care strategies with germline counseling.

CLINICALTRIALS

gov Identifier: NCT04447703.

The expression of positive and negative schizotypy in daily life: an experience sampling study

BACKGROUND

Psychometrically identified positive schizotypy and negative schizotypy are differentially related to psychopathology, personality and social functioning. However, little is known about the experience and expression of schizotypy in daily life and the psychological mechanisms that trigger psychotic-like experiences.

METHOD

The present study employed experience sampling methodology (ESM) to assess positive and negative schizotypy in daily life in a non-clinical sample of 412 young adults. ESM is a structured diary technique in which participants are prompted at random times during the day to complete assessments of their current experiences.

RESULTS

As hypothesized, positive schizotypy was associated with increased negative affect, thought impairment, suspiciousness, negative beliefs about current activities and feelings of rejection, but not with social disinterest or decreased positive affect. Negative schizotypy, on the other hand, was associated with decreased positive affect and pleasure in daily life, increased negative affect, and decreases in social contact and interest. Both positive schizotypy and negative schizotypy were associated with the desire to be alone when with others. However, this was moderated by anxiety in positive schizotypy and by diminished positive affect in negative schizotypy.

CONCLUSIONS

The results support the construct validity of a multidimensional model of schizotypy and the ecological validity of the positive and negative schizotypy dimensions. ESM appears to be a promising method for examining the daily life experiences of schizotypic individuals.

The effect of road improvements on motor vehicle crash injury and mortality in a developing country

The developing island-nation of Grenada undertook a major road improvement project between 1995 and 1998. In order to determine the effect of those improvements on crash injury and mortality, we reviewed the number of crash-related injuries and deaths for the years 1994 and 1999. After the road improvements, the proportion of crashes that resulted in injury decreased from 22% to 15%. The raw number of crashes (818 vs. 1233), deaths (4 vs. 12) and deaths per 100,000 population (4.1 vs. 11.9) increased, but the proportion of crashes that resulted in death (0.5% vs. 0.7%) remained effectively unchanged.

National EMS Research Agenda

Now, more than ever before, the spirit of the emergency services professional is recognized by people everywhere. Individuals from every walk of life comprehend the reality of the job these professionals do each day. Placing the safety of others above their own is their acknowledged responsibility. Rescue and treatment of ill and injured patients are their purpose as well as their gratification. The men and women who provide prehospital care are well aware of the unpredictable nature of emergency medical services (EMS). Prehospital care is given when and where it is needed: in urban settings with vertical challenges and gridlock; in rural settings with limited access; in confined spaces; within entrapments; or simply in the street, exposed to the elements. Despite the challenges, EMS professionals rise to the occasion to do their best with the resources available. Despite more than 30 years of dedicated service by thousands of EMS professionals, academic researchers, and public policy makers, the nation's EMS system is treating victims of illness and injury with little or no evidence that the care they provide is optimal. A national investment in the EMS research infrastructure is necessary to overcome obstacles currently impeding the accumulation of essential evidence of the effectiveness of EMS practice. Funding is required to train new researchers and to help them establish their careers. Financial backing is needed to support the development of effective prehospital treatments for the diseases that drive the design of the EMS system, including injury and sudden cardiac arrest. Innovative strategies to make EMS research easier to accomplish in emergency situations must be implemented. Researchers must have access to patient outcome information in order to evaluate and improve prehospital care. New biomedical and technical advances must be evaluated using scientific methodology. Research is the key to maintaining focus on improving the overall health of the community in a competitive and cost-conscious health care market. Most importantly, research is essential to ensure that the best possible patient care is provided in the prehospital setting. The bravery and dedication of EMS professionals cannot be underestimated. Images of firefighters, EMS personnel, and others going into danger while others are evacuating will remain burned in our collective consciousness. These professionals deserve the benefit of research to assist them in providing the best possible care in the challenging circumstances they encounter. With this document, we are seeking support for elevating the science of EMS and prehospital care to the next level. It is essential that we examine innovative ways to deliver prehospital care. Strategies to protect the safety of both the patient and the public safety worker must be devised and tested. There are many questions that remain to be asked, many practices to be evaluated, and many procedures to be improved. Research is the key to obtaining the answers.

Pathological evaluation, clinical chemistry and plasma cholecystokinin in neonatal and young miniature swine fed soy trypsin inhibitor from 1 to 39 weeks of age

The potential toxicity of dietary soy trypsin inhibitor (TI) was evaluated in neonatal miniature swine. From 1 to 6 weeks of age, two groups of male piglets were artificially reared in an Autosow and automatically fed either TI or control liquid diet. From 6 to 39 weeks of age, these two groups were fed either TI or control chow diet. A third group, sow control (SC), suckled from birth to 6 weeks of age, were also weaned to control chow from 6 to 39 weeks of age. Clinical chemistry and plasma cholecystokinin (CCK) determined at 6, 18, 30 and 39 weeks of age, and serum amylase activity with gross and histopathological analyses of major organs at 6 and 39 weeks of age are reported. TI had no effect on plasma CCK, serum amylase activity, or numerous clinical chemistry values. TI-fed piglets had a larger relative liver weight at 6 weeks of age. Relative pancreas weight decreased with age but was not affected by TI. Gross and histopathological analyses of major organs, except the spleen, were within normal limits. Increased incidence of extramedullary hematopoiesis was noted in the spleen of the TI group at 6 but not at 39 weeks of age. There was no consistent pattern in immunohistochemical foci for secretin, gastrin releasing polypeptide or CCK, and no change in DNA, RNA, mitotic index or nuclear density of pancreatic cells. At 6 weeks of age, TI increased pancreatic protein and amylase activity but not trypsin or chymotrypsin activity. None of the effects suggested that this dose of TI was toxic to either the neonatal or sexually mature miniature male swine.

The Autosow raised miniature swine as a model for assessing the effects of dietary soy trypsin inhibitor

Toxicological effects of dietary soy trypsin inhibitor (TI) were assessed in male miniature swine, a model chosen for its similarities to human digestive physiology and anatomy. The TI preparation was extracted from defatted raw soy flour. From 1 through 5 weeks of age, piglets were automatically fed either a TI liquid diet [Autosow TI group (ASTI)] or a control liquid diet [Autosow control group (ASC)]. From 6 to 39 weeks of age, these animals received either swine chow and TI or swine chow and control article. The TI diets were formulated to contain a TI activity of approximately 500 mg TI/100 g dry matter. A sow control (SC) group suckled from birth to 6 weeks of age and then fed as the ASC group with swine chow plus control article from 6 to 39 weeks of age. The SC piglets grew faster than ASC piglets during postnatal weeks 1 and 2; however, the ASC piglets were significantly heavier than the SC piglets (P=0.001) at 6 weeks of age. Compared with the ASC group, TI caused a moderate decrease in feed consumption and a moderate but reversible decrease in growth from 2 to 5 weeks of age, but not thereafter. Some control and TI-fed Autosow-reared piglets had loose stools until 6 weeks of age; the effect was significantly greater in the TI-fed group. Otherwise, all swine were active and had normal appearance and behavior.

Are barrier creams actually effective?

This article reviews the current information surrounding the efficacy of barrier creams as a protective measure against contact dermatitis. The principles of the proposed effects of barrier creams on the skin and the experimental and clinical data regarding their efficacy in the prevention of irritant and allergic contact dermatitis are discussed.

Paramedic use of endotracheal tube introducers for the difficult airway

OBJECTIVE

To evaluate the ability of paramedics to learn and apply the skill of introducer-aided oral intubation in the setting of the simulated "difficult airway." The authors hypothesized that, following a brief introduction to the device, intubation success rates would not differ for traditional and introducer-aided intubations of an immobilized airway mannequin.

METHODS

During a paramedic recertification class, experienced paramedics were given a brief didactic introduction to the "bougie-like" Flex Guide endotracheal tube introducer (ETTI). The participants were then asked to intubate adult mannequins immobilized in the head-neutral position, with and without the ETTI. "Successful placement" was defined as completion of the procedure within 30 seconds and endotracheal tube position confirmed by the investigator with direct visualization.

RESULTS

For both traditional and ETTI intubations, 34 (97%) of the 35 paramedics successfully intubated within 30 seconds. The two unsuccessful intubation attempts were recognized by the paramedic as esophageal intubations, and correct tube placement was obtained within an additional 30 seconds.

CONCLUSION

In this study, use of the ETTI was mastered by the participants after only a brief didactic introduction to the device, with their ability to intubate an immobilized mannequin using the ETTI being equal to their ability to perform traditional intubation. These results suggest that use of the ETTI is easily learned, and may support the device's role in the prehospital management of the difficult airway.

Use of local climatic data to determine if weather precludes the operation of an air medical system

INTRODUCTION

Weather is one of many factors that affect safety in an air medical program. Syracuse, New York, has notoriously bad weather, and some have questioned whether an air medical service is practical given central New York's climate. This study was undertaken to determine the extent to which the area's climate could be expected to limit the availability of an air medical service.

METHODS

CAMTS weather minimums for rotor-wing programs were compared with 1996-1997 hourly weather observations from the Northeastern Regional Climate Center (NRCC) and sunrise/sunset data from the United States Naval Observatory to determine how frequently weather conditions could be expected to preclude an air medical response in the greater Syracuse area.

RESULTS

Exactly 17,544 hourly observations were made. CAMTS weather minimums would have precluded local flights for 606 (3.5%) of these hours and cross-country flights for 1111 (6.3%) hours. Cross-country flights were more likely to be precluded than local flights (P = .001), and both local and cross-country flights were more likely to be precluded at nighttime than in the daytime (P = .001). All flights were more likely to be precluded during winter months than during summer months (P = .000).

CONCLUSION

The weather in central New York generally does not preclude the operation of an air medical services system.

Do warning lights and sirens reduce ambulance response times?

OBJECTIVE

To determine the time saving associated with lights and siren (L&S) use during emergency response in an urban EMS system.

METHODS

This prospective study evaluated ambulance response times from the location at time of dispatch to the scene of an emergency in an urban area. A control group of responses using L&S was compared with an experimental group that did not use L&S. An observer was assigned to ride along with ambulance crews and record actual times for all L&S responses. At a later date, an observer and an off-duty paramedic in an identical ambulance retraced the route--at the same time of day on the same day of the week--without using L&S and recorded the travel time. Response times for the two groups were compared using paired t-test.

RESULTS

The 32 responses with L&S averaged 105.8 seconds (1 minute, 46 seconds) faster than those without (95% confidence interval: 60.2 to 151.5 seconds, p = 0.0001). The time difference ranged from 425 seconds (7 minutes, 5 seconds) faster with L&S to 210 seconds (3 minutes, 30 seconds) slower with L&S.

CONCLUSION

In this urban EMS system, L&S reduce ambulance response times by an average of 1 minute, 46 seconds. Although statistically significant, this time saving is likely to be clinically relevant in only a very few cases. A large-scale multicenter L&S trial may help address this issue on a national level.

Rural vs urban motor vehicle crash death rates: 20 years of FARS data

OBJECTIVES

Historically, motor vehicle crash (MVC)-related mortality is higher in rural areas than in urban areas. The authors evaluated whether the difference in rural and urban MVC deaths is persisting, and whether the frequency of patients being found dead at the scene, particularly in rural areas, is increasing.

METHODS

Fatal Accident Reporting System (FARS) data for 1977 through 1996 were reviewed. The authors determined the frequency with which crash deaths occurred, and calculated population-based and vehicle-miles-traveled-based crash death rates. They compared rates for urban and rural areas.

RESULTS

A total of 875,405 crash deaths were included in the analysis. Both population-based and vehicle-miles-traveled-based MVC deaths have decreased over the last 20 years, but rural rates remain significantly higher than urban rates. Dead-at-scene rates may be increasing, and the rural dead-at-scene rate is higher than the urban rate.

CONCLUSION

While MVC death rates are declining, the rural MVC death rate is still higher than the urban rate. Although these data may indicate some positive movement in the area of MVC-related deaths, differences in the rural and urban rates and the number of patients found dead on-scene remain as issues that require attention.

Prehospital consideration of sildenafil-nitrate interactions

OBJECTIVE

To determine whether paramedics and on-line physicians screen patients for use of sildenafil citrate (Viagra) prior to prehospital administration of nitrates.

METHODS

A prospective, observational study was performed over a one-month period in three EMS systems. Consecutive radio communications between on-line physicians and paramedics concerning male patients with cardiac complaints were monitored. Investigators observed the frequency with which on-line physicians screened for sildenafil use prior to ordering nitrates. After observation of the radio communications was completed, a written survey was distributed to all paramedics in the three EMS systems.

RESULTS

Seventy-six physician-paramedic interactions were monitored. Nitrates were ordered by on-line physicians in 56 cases. No paramedic reported sildenafil use/nonuse, and no on-line physician inquired about the patient's potential use of the drug. Only half of the surveyed paramedics reported that they routinely screen for sildenafil use, and approximately a fourth reported that its use would not alter their management of chest pain patients.

CONCLUSION

In this study, on-line physicians in three EMS settings did not screen for sildenafil use prior to ordering nitrates. While some paramedics do screen for sildenafil use, practice patterns among paramedics in these three systems were inconsistent.

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.

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 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.

The readability of Prehospital Care Research Forum abstracts

OBJECTIVE

The Prehospital Care Research Forum sponsors both oral and poster presentations of emergency medical services (EMS) research in conjunction with JEMS Corporation's annual EMS Today Conference. Attendance at the research presentations, historically, has been poor. This descriptive study was designed to measure the readability of the Prehospital Care Research Forum abstracts in order to determine whether the abstracts are difficult to read, and thus are a deterrent to attendance at the oral and poster research presentations.

METHODS

The 31 abstracts published in the 1995 Prehospital Care Research Forum supplement to the Journal of Emergency Medical Services were analyzed using a computerized reading-level testing program. Six different reading-level tests were used to determine the readability of the abstracts.

RESULTS

The overall reading level for the 31 abstracts ranged from grade 7 to grade 20, with a mean grade level of 12.3. The mean Flesch reading ease score for the 31 abstracts ranged from 3.4 to 66.1, with a mean score of 36.0 +/- 14.4.

CONCLUSION

The abstracts for the Prehospital Care Research Forum presentations are not overly difficult to read. It is unlikely that readability of the abstracts is a factor in the interest, or lack of interest, in the proceedings of the Prehospital Care Research Forum.

EMT knowledge of ambulance traffic laws

OBJECTIVE

The safe operation of ambulances using warning lights and siren requires both the public and emergency medical technician (EMT) drivers to understand and obey relevant traffic laws. However, EMTs may be unfamiliar with these laws. The purpose of this study was to evaluate EMTs' knowledge of traffic laws related to the operation of ambulances with warning lights and sirens.

METHODS

North Carolina EMTs participating in a statewide EMS conference October 6-8, 1995, completed a five-question survey. Knowledge of ambulance speed limits, yielding at intersections, yielding in roadways, and following distances was assessed using a multiple-choice format. Demographic data pertaining to EMT age, years of experience, paid vs volunteer status, driver's education courses, and past accident involvement were also obtained. Proportions were compared using chi-square analysis, alpha = 0.05.

RESULTS

Two-hundred ninety-three of 308 (95%) EMTs attending the conference completed questionnaires. The median number of correct responses to the five knowledge questions was 1 (range 0-4). Thirty-three percent of the EMTs knew that other vehicles are required by law to yield while either approaching or being overtaken by an ambulance with warning lights and sirens; 2% knew that due regard for safety is the only requirement of an ambulance approaching a red light at an intersection; 14% knew that the minimum following distance behind an ambulance is one city block; and 28% knew that there is no speed limit on ambulances with warning lights and sirens. Respondents were more likely to score above the median if they had taken one or more emergency driver's education courses or had nine years or more of EMS experience.

CONCLUSION

In this sample, EMT knowledge of basic traffic laws pertaining to ambulance operation is poor. Emergency driver's education courses and increased experience appear to be related to increased knowledge scores. Increased training for EMTs about traffic laws may improve the safe operation of ambulances.

Can quantitative capnometry differentiate between cardiac and obstructive causes of respiratory distress?

STUDY OBJECTIVE

To determine whether quantitative measurement of end-tidal carbon dioxide (ETCO2) can differentiate between cardiac and obstructive causes of respiratory distress.

DESIGN

Prospective observational study.

SETTING

Emergency department (ED) of a tertiary care hospital.

PATIENTS

Adult patients who presented to the ED with moderate-to-severe dyspnea. Patients were excluded if they were unable to cooperate with the performance of peak expiratory flow rate (PEFR) or ETCO2 tests, were younger than 18 years of age, or had received prehospital intervention for their respiratory distress.

INTERVENTIONS

Physicians obtained an ETCO2 level and PEFR prior to ED pharmacologic intervention. A hand-held capnometer with digital read-out was used to obtain the ETCO2 level. The patient's age, sex, initial vital signs, breath sounds and medication history, the presence or absence of diaphoresis and/or orthopnea, the duration of symptoms, the chest radiograph interpretation, and final diagnosis were also recorded.

MEASUREMENTS AND RESULTS

Forty-two patients were eligible for inclusion in the analysis. The mean ETCO2 level was 31.1+/-9.4 mm Hg; the mean PEFR was 161.3+/-53.1 L/min. The ETCO2 levels for pulmonary edema/congestive heart failure (CHF) patients differed significantly from those of asthma/COPD patients (27.1+/-7.8 mm Hg vs 33.4+/-9.6 mm Hg; p=0.0375). However, no single ETCO2 level was found to be a reliable predictor of diagnosis.

CONCLUSION

ETCO2 levels for pulmonary edema/CHF patients differ significantly from those of asthma/COPD patients. However, no single ETCO2 level reliably differentiates between the two disease processes.

Can EMS providers adequately assess trauma patients for cervical spinal injury?

OBJECTIVE

To determine whether EMS providers can accurately apply the clinical criteria for clearing cervical spines in trauma patients.

METHODS

EMS providers completed a data form based on their initial assessments of all adult trauma patients for whom the mechanism of injury indicated immobilization. Data collected included the presence or absence of: neck pain/tenderness; altered mental status; history of loss of consciousness; drug/alcohol use; neurologic deficit; and other painful/distracting injury. After transport to the ED, emergency physicians (EPs) completed an identical data form based on their assessments. Immobilization was considered to be indicated if any one of the six criteria was present. The EPs and EMS providers were blinded to each other's assessments. Agreement between the EP and EMS assessments was analyzed using the kappa statistic.

RESULTS

Five-hundred seventy-three patients were included in the study. The EP and EMS assessments matched in 78.7% (n = 451) of the cases. There were 44 (7.7%) patients for whom EP assessment indicated immobilization, but the EMS assessment did not. The kappa for the individual components of the assessments ranged from 0.35 to 0.81, with the kappa for the decision to immobilize being 0.48. The EMS providers' assessments were generally more conservative than the EPs'.

CONCLUSION

EMS and EP assessments to rule out cervical spinal injury have moderate to substantial agreement. However, the authors recommend that systems allowing EMS providers to decide whether to immobilize patients should follow those patients closely to ensure appropriate care and to provide immediate feedback to the EMS providers.

A comparison of oxygen administration practices of EMTs and emergency physicians

This study examined whether emergency medical technicians (EMTs) withhold oxygen from hypothetical patients whom emergency physicians would treat with high-flow oxygen, particularly chronic obstructive pulmonary disease (COPD) patients. A survey describing 12 hypothetical patients was distributed to 33 emergency physicians, 30 newly trained EMTs, and 27 experienced EMTs. For each patient, the respondents were asked to identify the most appropriate prehospital oxygen administration rate as "low flow" or "high flow". Using an alpha value of .05, chi 2 analysis was used to compare the frequency of high-flow oxygen administration for the three groups. Newly trained EMTs were significantly more likely than physicians to administer high-flow oxygen to patients with COPD who were not receiving home oxygen. Otherwise, the oxygen administration practices of EMTs were not inconsistent with those of emergency physicians.

The perceived importance of paramedic skills and the emphasis they receive during EMS education programs

OBJECTIVE

The National Standard Curriculum for paramedics is currently being revised. There is little scientific evidence of what does and what does not work in prehospital care, and of whether the National Standard Curriculum prepares paramedics for the field. To provide some basis for the current revisions to the National Standard Curriculum, the authors determined which prehospital skills are perceived by paramedics to be the most important, and whether the emphasis placed on those skills during initial and continuing education programs corresponds with the perceived importance.

METHODS

Surveys listing 21 paramedic skills were mailed to the directors of 41 EMS agencies who agreed to participate in the study. The directors distributed the surveys to 1,364 paramedics affiliated with their organizations. The participants were asked to rate the importance of each skill, and the emphasis placed on each skill during their initial and continuing education. Skills were ranked on a scale of 0 to 4, with 0 representing no importance or emphasis, and 4 representing the most possible importance or emphasis.

RESULTS

Six-hundred of the 1,364 (44%) surveys were returned. Respondents had a mean of 9.9 +/- 5.6 years of EMS experience, and 5.4 +/- 4.0 years of experience as paramedics. The three skills ranked highest in importance were: 1) endotracheal intubation; 2) defibrillation; and 3) assessment. Importance in prehospital care was ranked equal to or higher than emphasis in both initial and continuing education for all skills except splinting and urinary catheterization, which received higher rankings for emphasis in initial education. Emphasis in initial education equaled or exceeded the emphasis in continuing education for all skills except intraosseous infusion.

CONCLUSION

The perceived importance of most prehospital skills is very high, and exceeds the emphasis placed on those skills during both initial and continuing education programs. These findings have implications for medical directors, EMS instructors, and persons involved with the revision of the National Standard Curriculum.

Accuracy of rural EMS provider interpretation of three-lead ECG rhythm strips

OBJECTIVE

To measure the accuracy of lead II rhythm strip interpretations performed by advanced life support (ALS) emergency medical technicians (EMTs) in a rural emergency medical services (EMS) system.

METHODS

An electronic rhythm simulator was used to produce 24 three-lead electrocardiogram (ECG) rhythm strips. The rhythms were shown to 57 ALS EMTs participating in regularly scheduled continuing education classes. The participants were asked to identify the rhythms.

RESULTS

The three-lead ECG interpretations were generally accurate, although there was some difficulty in distinguishing between specific types of tachydysrhythmia and atrioventricular (AV) block. The overall accuracy of the rhythm interpretations was 79.2%, ranging from 45.6% (second-degree type II heart block) to 98.2% (sinus bradycardia). The sensitivity for specific tachydysrhythmias ranged from 68.4% (supraventricular tachycardia) to 86.0% (atrial fibrillation); the sensitivity for specific types of AV block ranged from 45.6% (second-degree, type II) to 71.9% (third-degree).

CONCLUSION

In this EMS system, ECG interpretations are generally accurate, with tachydysrhythmias and AV blocks being the source of most discrepancies.

A breathing manikin model for teaching nasotracheal intubation to EMS professionals

OBJECTIVE

The widespread use of orotracheal intubation with rapid-sequence induction has made it difficult for emergency medical services (EMS) professionals to gain experience in nasotracheal intubation (NTI) in a controlled and supervised setting. The purpose of this study was to determine whether a training session on NTI with a breathing manikin can be used to improve the self-assessed skill level and comfort of EMS professionals.

METHODS

A prospective trial was conducted with a convenience sample of 33 EMS professionals, previously trained in NTI techniques. For the training session, a Laerdal airway manikin was modified by replacing the lungs with self-inflating resuscitation bag. The bag could then be squeezed to simulate breathing, with an inspiratory and expiratory phase. Following didactic instruction, and with direct supervision, each participant practiced NTI using this breathing manikin. Each participant completed a questionnaire, both before and after the training session, to determine self-assessed comfort and skill level for both oral and nasal intubations (0 = lowest, 10 = highest). The pre- and postintervention scores were compared using the Wilcoxon signed-rank test, alpha = 0.01.

RESULTS

Following the training session, the comfort level for NTI by the participants increased significantly from a median value of 2 to 7 (p = 0.001). Furthermore, the self-assessed skill level for NTI following the training session increased significantly from a median value of 4 to 8 (p = 0.0001). As expected, there were no significant differences noted in self-assessed skill level for orotracheal intubation following the training session. However, there was statistically significant improvement in self-assessed comfort levels for orotracheal intubation after the skills laboratory, p = 0.0001.

CONCLUSION

For EMS professionals, a training session for NTI using a relatively inexpensive and easily assembled breathing manikin model increases both comfort and self-assessed skill level.

Effect of vital signs on advanced life support interventions for prehospital patients

OBJECTIVE

Routine vital signs assessment is considered a fundamental component of patient assessment. This study was undertaken to determine whether advanced life support (ALS) emergency medical services (EMS) providers depend on vital signs information in managing their patients.

METHODS

Emergency medical technician-paramedics (EMT-Ps) and EMT-Intermediates (EMT-Is) were presented with 20 randomized patient scenarios that did not included vital signs information. The participants were asked to identify all of the interventions they would perform for each hypothetical patient. At least six weeks later the same scenarios were presented in a new order, with vital signs information, and the participants again identified the interventions they would perform. The participants' estimations of the patients' blood pressures, as well as the frequencies with which 18 specific interventions were performed, were compared for the no-vital signs and the vital signs groups using chi-square of Fisher's exact test, with an alpha value of 0.05 considered significant.

RESULTS

Fourteen EMT-Ps and 16 EMT-Is completed both the no-vital signs and vital signs portions of the study, for a total of 1,160 hypothetical patient encounters. When vital signs were given, the EMT-Is were more likely to apply a cardiac monitor (65.2% vs 80.1%, p = 0.000), more likely to start at least one intravenous (i.v.) line (82.1% vs 87.8%, p = 0.038), and more likely to administer a medication (1.3% vs 5.6%, p = 0.003). The EMT-Ps were also more likely to apply a cardiac monitor (84.4% vs 90.3%, p = 0.041), more likely to run an i.v. at a "wide open" rate (9.5% vs 19.0%, p = 0.004), and less likely to identify patients as being hypotensive (39.9% vs 26.4%, p = 0.004).

CONCLUSION

The presence or absence of vital signs information does influence some of the patient care decisions of EMS providers; however, the clinical implications of these decisions are unclear. Further studies are needed to determine whether ALS providers can adequately manage actual patients without obtaining vital signs.

Potential time savings by prehospital administration of activated charcoal

OBJECTIVE

Activated charcoal (AC) has been proven useful in many toxic ingestions. Theoretically, administration of AC in the prehospital environment could save valuable time in the treatment of patients who have sustained potentially toxic oral ingestions. The purpose of this study was to determine the frequency of prehospital AC administration and to identify time savings that could potentially result from field AC administration.

METHODS

Adult patients with a chief complaint of toxic ingestion who had complete emergency medical services (EMS) and emergency department (ED) records and no medical treatment (gastric emptying, AC administration) prior to EMS arrival were eligible for inclusion. Data obtained from EMS and ED records included time of EMS departure from the scene, time of EMS arrival at the ED, and time of administration of AC in the ED. Since most EMS agencies in this system do not insert gastric tubes, patients requiring gastric tube placement for administration of AC were excluded.

RESULTS

Twenty-nine of 117 (24.8%) adult patients received oral AC with no other intervention. None of the 117 patients received AC in the prehospital setting. The EMS transport time for these patients ranged from 5 to 43 minutes (mean 16.2 +/- 9.7 minutes). The delay from ED arrival to AC administration ranged from 5 to 94 minutes (mean 48.8 +/- 24.1 minutes), and was more than 60 minutes for 14 (48.2%) of the patients. The total time interval from scene departure to ED AC administration ranged from 17 to 111 minutes (mean 65.0 +/- 25.9 minutes).

CONCLUSIONS

In a selected subset of patients who tolerate oral AC, prehospital administration of AC could result in earlier and potentially more efficacious AC therapy. Prospective study of the benefits and feasibility of prehospital AC administration is indicated.

Assessment of breath sounds during ambulance transport

STUDY OBJECTIVE

To determine whether the environment of a moving ambulance affects the ability of our-of-hospital care providers to auscultate breath sounds.

METHODS

Out-of-hospital care providers assessed breath sounds with a previously described breath-sounds model in a quiet environment (control) and in a moving ambulance. The setting was a nonurban emergency medical services system and an interhospital transport agency based at a 600-plus-bed tertiary care center. The participants were physicians, transport nurses, and advanced life support EMS providers routinely involved in the emergency out-of-hospital treatment and transportation of the ill and injured. The accuracy with which participants identified the presence or absence of breath sounds in the two environments was compared with the use of the chi 2 test, with the alpha-value set at .05.

RESULTS

The accuracy of breath-sounds assessment in the control environment was 96% (251 of 260); the sensitivity was 96% and the specificity 97%. The accuracy of breath-sounds assessment in the experimental environment was 54% (140 of 260); the sensitivity was .09% and the specificity 98%. Participants were significantly less likely to hear breath sounds in the moving ambulance than in the quiet room (P < .001).

CONCLUSION

Assessment of breath sounds is hampered by the environment of a moving ambulance.

Do pulse checks cause a significant delay in the initial defibrillation sequence?

This study was undertaken to determine if checking for a pulse between initial defibrillations causes a clinically significant delay in the administration of the defibrillations. Ten emergency department nurses and 10 emergency medicine resident physicians were timed delivering three successive defibrillations (200, 300 and 360 J) to a manikin under three randomly assigned scenarios: (1) without pulse checks; (2) with pulse checks performed by an assistant; and (3) with pulse checks performed by the participant. All participants performed the three defibrillation scenarios using three different models of defibrillators. Repeated measures analysis of variance was used to compare mean defibrillation times for the three scenarios. The mean time was 20.4 +/- 1.0 s for defibrillation without pulse checks; 20.2 +/- 1.2 s with pulse checks by an assistant and 22.0 +/- 2.0 s with pulse checks by the participant. There was a statistically significant difference between no pulse checks and pulse checks by the participant. No statistically significant difference was noted between no pulse checks and pulse checks by an assistant. We conclude that checking for a pulse does cause a statistically significant delay in the administration of defibrillations. This difference, however, is not likely to be clinically relevant.

Comparison of staples vs suturing for securing central venous catheters

OBJECTIVE

To determine whether skin staples can be used to secure central venous catheters as effectively as does suturing.

METHODS

A prospective, randomized trial of techniques to secure a central venous catheter was performed in a medical school human anatomy laboratory using human cadavers. Central lines were secured to the upper left thorax using either standard suture material (000 silk) or skin staples (5.7 mm x 3.8 mm). Once secured, an upward force was applied to the hub of the catheter perpendicular to the skin. The amount of force needed to break the catheter hub free of the skin was measured in kg. A total of 10 measurements were made for each of 3 methods for securing the catheters (2 sutures, 2 staples, 4 staples). In addition, the site of catheter breakage was recorded.

RESULTS

Those catheter hubs secured by 2 sutures required a mean force of 3.1 +/- 0.5 kg to cause breakage, and the break always occurred at the suture. Those hubs secured by 2 staples gave way at 3.0 +/- 0.3 kg (p = NS), while those secured with 4 staples gave way at 4.5 +/- 1.4 kg (p < 0.05). Although 1 hub did break, in all other stapled cases, the break occurred at the staple.

CONCLUSIONS

Based on this cadaver model, use of staples appears to be as effective as suturing for securing central venous catheters. Further studies of safety and time for placement are needed.

EMS knowledge and skills in rural North Carolina: a comparison with the National EMS Education and Practice Blueprint

INTRODUCTION

Many state and local emergency medical services (EMS) systems may wish to modify provider levels and their scope of practice to align their systems with the recommendations of the National Emergency Medical Services Education and Practice Blueprint. To determine any changes that may be needed in a typical EMS system, the knowledge and skills of EMS providers in one rural area of North Carolina were compared with the knowledge and skills recommended in the National Emergency Medical Services Education and Practice Blueprint.

METHODS

A survey listing 175 items of patient care-oriented knowledge and skills described in the National Emergency Medical Services Education and Practice Blueprint was developed. EMS providers from five rural eastern North Carolina counties were asked to identify on the survey those items of knowledge and skills they believed they possessed. The skills and knowledge selected by the respondents at the five different North Carolina levels of certification were compared with the knowledge and skills listed for comparable provider levels delineated by the National Emergency Medical Services Education and Practice Blueprint. The proportions of the recommended skills reported to be possessed by the respondents were compared to determine which North Carolina certification levels best correlate with the Blueprint.

RESULTS

One hundred forty-five EMS providers completed the survey. The proportion of recommended skills and knowledge reported to be possessed by Emergency Medical Technicians (EMTs) ranked significantly lower than did the skills and knowledge reported to be possessed by respondents at other levels in five of the 10 Blueprint elements. The proportion of recommended skills and knowledge reported to be possessed by EMT-Defibrillator-level personnel ranked lower than did those reported to be possessed by respondents at other levels in seven of the 10 Blueprint elements. The proportion of recommended skills and knowledge reported to be possessed by EMT-Intermediates ranked lower than did those reported to be possessed by respondents at other levels in nine of the 10 Blueprint elements. The proportion of recommended skills and knowledge reported to be possessed by EMT-Advanced Intermediates ranked lower than were the skills and knowledge reported to be possessed by respondents at other levels in two of the 10 Blueprint elements. Finally, the proportion of recommended skills and knowledge reported to be possessed by EMT-Paramedics ranked lower than were those reported to be possessed by respondents at other levels in one of the 10 Blueprint elements.

CONCLUSION

In North Carolina, combining the EMT and EMT-Defibrillator levels and eliminating the EMT-Intermediate level would create three levels of certification, which would be more consistent with levels recommended by the Blueprint. The results of this study should be considered in any effort to revise the levels of EMS certification in North Carolina and in planning the training curricula for bridging those levels. Other states may require similar action to align with the National Emergency Medical Services Education and Practice Blueprint.

Does basic life support in a rural EMS system influence the outcome of patients with respiratory distress?

PURPOSE

The purpose of this study was to determine whether basic life support, prehospital emergency medical care in a rural area affects the hospital course of patients with respiratory distress.

METHODS

Medical records for patients admitted from the emergency department with a discharge diagnosis related to respiratory disease were reviewed. Data collected included: 1) mode of arrival; 2) initial symptom; 3) vital signs; 4) prehospital interventions applied; 5) hospital days; 6) discharge status; and 7) principal diagnosis. Multiple logistic regression analysis was used to predict length of hospital stay.

RESULTS

Charts for 603 patients were reviewed. Complete data for all variables included in the logistic regression analysis were available for 471 patients (78.1%). Because 55 patients died, only 416 (69.0%) were included in the multiple regression analysis conducted to predict length of hospital stay. Logistic regression analysis demonstrated that patients who arrived by ambulance and older patients were more likely to die; patients with higher systolic blood pressures were more likely to survive. Only patient age predicted length of hospital stay, with older patients having longer stays.

CONCLUSIONS

Basic life support prehospital care in this rural emergency medical services system does not result in a lower mortality rate or a shorter hospital stay for a broad group of patients with respiratory distress who require hospital admission. Although this study is limited to a single population and a single emergency medical services system, it is one of only a few studies of outcome in basic life support systems.

Serum estradiol in the differential diagnosis of ectopic pregnancy

In a prospective study using a cutoff value of 140 pg/mL, serum estradiol 17-beta assay had a sensitivity of 83% and a specificity of 100% in differentiating ectopic pregnancy (6 patients) from normal pregnancy with threatened abortion proceeding to viability (7 patients). In differentiating threatened abortion from spontaneous abortion (9 patients), the estradiol assay had a sensitivity of 88.9% and a specificity of 100%. All but one of the patients with ectopic pregnancy had estradiol levels below the cutoff value of 140 pg/mL, as did all but one of the patients who had spontaneous abortion. All the patients who had threatened abortion that progressed to viability had values well above the cutoff level. The mean estradiol values for the viable pregnancy group were significantly different from those of the other two groups. These data suggest that, at the institution where this study was done, serum estradiol determinations may be of value in the differentiation of both ectopic pregnancy and spontaneous abortion from threatened abortion but appears to be of very limited usefulness in distinguishing ectopic pregnancy from spontaneous abortion. The validity of these conclusions is limited by the small number of subjects. Further studies comprising greater numbers of subjects are needed.

Does ambulance crew size affect on-scene time or number of prehospital interventions?

INTRODUCTION

While large cities typically staff ambulances with two emergency medical services (EMS) professionals, some EMS agencies use three people for ambulance crews. The Greenville, North Carolina, EMS agency converted from three-person to two-person EMS crews in July 1993. There are no published reports investigating the best crew size for out-of-hospital emergency care.

HYPOTHESIS

Two-person EMS crews perform the same number and types of interventions as three-person EMS crews. Two-person EMS crews do not have longer on-scene times than do three-person EMS crews.

METHODS

Data for the two most common advanced life support calls in this system--seizures and chest pains--were collected for the months of June and August 1993. Three-person EMS crews responded to both types of calls in June. In August, two-person EMS crews responded to seizure calls; two-person EMS crews accompanied by a fire department engine (pumper) with additional manpower responded to chest pain calls. The frequency of specific interventions, number of total interventions, and scene times for the August calls were compared to their historical control groups, the June calls.

RESULTS

One hundred twenty-six patient contacts were included in the study. There were no significant differences in total number or types of procedures performed for the two patient groups. Mean on-scene time for patients with seizures was 11.0 +/- 4.2 minutes for three-person crews and 19.4 +/- 8.3 minutes for two-person crews (p < 0.001). Mean on-scene time for patients with chest pain was 13.6 +/- 4.9 minutes for three-person crews, and 15.4 +/- 3.2 minutes for two-person crews assisted by fire department personnel (p > 0.05).

CONCLUSION

Two-person EMS crews perform the same number of procedures as do three-person EMS crews. However, without the assistance of additional responders, two-person EMS crews may have statistically significantly longer on-scene times than three-person EMS crews.

Does the ambulance environment adversely affect the ability to perform oral endotracheal intubation?

OBJECTIVE

Oral endotracheal intubation (ETI) is the preferred method of controlling the airway in critically ill or injured patients. It was postulated that time could be saved if intubation was performed in the ambulance en route to the hospital. This study was designed to determine whether the ambulance environment adversely affected the ability of emergency medical technicians at the advanced-intermediate level (EMT-AI) to perform oral ETI.

HYPOTHESIS

The restrictive environment of a moving ambulance would affect adversely the ability of EMT-AIs to perform ETI compared with a controlled setting. This would result in a significant increase in the time necessary to perform ETI in the ambulance compared with a controlled setting not complicated by restrictive space and motion.

METHODS

Twenty on-duty EMT-AIs were recruited to volunteer for this prospective, nonrandomized, nonblinded trial. All participants performed three consecutive oral ETIs on an airway mannequin in two settings: 1) in the back of a moving ambulance; and 2) on a table in the rescue squad station. Of the participants, 10 performed the intubations in the ambulance first; the remainder performed the intubations at the station first. Time for intubation with the mannequin was recorded by stopwatch. The mean times for intubation in both settings were compared by Student's t-test (p < 0.05).

RESULTS

All intubation attempts were successful. The mean time for intubation in the station was 13.0 +/- 3.4 seconds. The mean time in the ambulance setting was 13.2 +/- 5.3 seconds. There was no significant difference between the intubation times in the two settings (p = 0.88).

CONCLUSION

The environment of a moving ambulance does not appear to hinder the ability of EMT-AIs to perform oral ETI in a laboratory setting with a mannequin model.

Can prehospital personnel detect hypoxemia without the aid of pulse oximeters?

Although pulse oximeters have been proven accurate in the prehospital environment, they have not been proven to be necessary. This study was undertaken to determine if emergency medical services (EMS) providers can identify hypoxemia without pulse oximetry. An oximeter was placed at the ambulance entrance to the emergency department (ED), and EMS personnel obtained saturation levels on all patients on arrival. Hypoxemia was defined as a saturation level of 95% or less. The hypoxemia was classified as "recognized" if the patient received aggressive intervention and "unrecognized" if the patient did not. One hundred eighty patients were enrolled in the study; 30 had a saturation level of 95% or less. Twenty-seven (90%) of those patients had "unrecognized" hypoxemia. Twenty-three (85.2%) of the 27 patients with "unrecognized" hypoxemia did not complain of respiratory distress. Thus, there are patients whose hypoxemia is unrecognized by EMS providers, and this occurs most frequently in patients who do not complain of respiratory distress.

Mistaken identity: the effect of badges on EMT recognition

INTRODUCTION

Many emergency medical services (EMS) providers wear badges with their uniforms. This study was undertaken to determine whether emergency medical technicians (EMTs) who wear badges with their uniforms are more likely to be mistaken for law enforcement personnel than are those who do not wear badges.

HYPOTHESIS

Emergency medical services providers who wear badges are more likely to be mistaken for law enforcement personnel than are those who do not wear badges.

METHODS

High school students, college students, civic organizations, and church groups were shown slides of different uniforms and badges/insignia and asked to identify the person portrayed. Responses were categorized as "EMS," "law enforcement," or "other." Frequency of responses for each uniform and insignia were compared with chi-square analysis.

RESULTS

Fifty-nine percent of the uniforms with badges were identified as law enforcement personnel. Only 5.5% of the uniforms with badges were identified as "EMS," compared with 74% of the uniforms with a Star of Life (p < 0.001).

CONCLUSION

Individuals wearing uniforms with badges are more likely to be identified as law enforcement personnel than are EMS personnel. Emergency medical services providers who do not wish to be mistaken for law enforcement personnel should wear the Star of Life, not a badge, with their uniform.

Do pulse checks delay semiautomatic defibrillation by EMT-defibrillators?

Advanced cardiac life support (ACLS) guidelines from the American Heart Association (AHA) now recommend not checking for a pulse between the initial three defibrillations for pulseless patients in ventricular tachycardia or fibrillation. The AHA asserts that checking for a pulse needlessly delays defibrillation. This study was undertaken to determine if pulse checks delay defibrillation by EMT-Defibrillators (EMT-Ds) using a semiautomatic defibrillator (SAED). Twenty-seven EMT-Ds demonstrated delivery of three successive defibrillations during two test scenarios: once with and once without pulse checks after the first and second defibrillations. The time from the first to third defibrillation was recorded. The mean time to deliver the defibrillations was 60.2 +/- 6.2 seconds with pulse checks and 57.5 +/- 4.6 seconds without pulse checks. The difference, 2.7 +/- 5.9 seconds, was statistically significant (P = 0.026). Pulse checks by EMT-Ds do delay administration of defibrillations, but consideration should be given to reinstating pulse checks as a part of the AHA guidelines, since this delay is of questionable clinical significance.

Is ambulance transport time with lights and siren faster than that without?

STUDY OBJECTIVE

To determine whether ambulance transport time from the scene to the emergency department is faster with warning lights and siren than that without.

DESIGN

In a convenience sample, transport times and routes of ambulances using lights and sirens were recorded by an observer. The time also was recorded by a paramedic who drove an ambulance without lights and siren over identical routes during simulated transports at the same time of day and on the same day of the week as the corresponding lights-and-siren transport.

SETTING

An emergency medical service system in a city with a population of 46,000.

PARTICIPANTS

Emergency medical technicians and paramedics.

RESULTS

Fifty transport times with lights and siren averaged 43.5 seconds faster than the transport times without lights and siren [t = 4.21, P = .0001].

CONCLUSION

In this setting, the 43.5-second mean time savings does not warrant the use of lights and siren during ambulance transport, except in rare situations or clinical circumstances.

Prehospital blood pressures: inaccuracies caused by ambulance noise?

Blood pressure measurements in a moving ambulance can be difficult to obtain. Sirens, engine noise, and road noise can all interfere with the accurate detection of a patient's blood pressure. This study was undertaken to determine the influence of ambulance noise and vibration on auscultated blood pressures. A model was developed that used dynamic pressures to simulate systolic Korotkoff sounds. Forty-nine emergency personnel were asked to obtain blood pressures using the model in both a quiet environment and in a moving ambulance. A total of 485 blood pressure measurements were obtained. Systolic pressures were randomized to two settings: 76 mm Hg and 138 mm Hg. Stationary readings were compared with moving readings using analysis of variance for repeated measures. Systolic blood pressure measurements obtained in the quiet environment averaged 133 +/- 5 mm Hg at the high setting, and 45 +/- 6 mm Hg at the low setting. Systolic blood pressure measurements obtained in a moving ambulance averaged 86 +/- 7 mm Hg at the high setting, and 41 +/- 7 mm Hg at the low setting. The average differences between quiet and moving measurements were 47 mm Hg at the "high" setting (P < .01) and 4 mm Hg at the "low" setting (P > .01). At physiological levels, blood pressures obtained in moving ambulances differ significantly from those obtained in a quiet environment, which may be caused by road noise and ambulance motion.

Public perceptions of a rural emergency medical services system

INTRODUCTION

To determine the awareness of citizens and physicians concerning the capabilities of a rural emergency medical services (EMS) system.

HYPOTHESIS

Citizens and physicians are unaware of the capabilities of the EMS system.

METHODS

Residents were selected randomly from the local telephone directory and asked a series of structured questions about their EMS agency. A written survey was distributed to area physicians. Chi-square analysis was used to compare the proportion of respondents who knew the available interventions in their community with the proportion of those who did not. Statistical significance was inferred at p < 0.01.

RESULTS

A total of 49% of the citizens were able to identify available skills, and 41.4% of the physicians were able to identify available skills. Physicians were less likely than were the citizens to be able to identify the skills performed by each provider (p < 0.001).

CONCLUSION

This study indicates that both physicians and the lay public have little understanding of the capabilities of their EMS system.

Adverse lighting condition effects on the assessment of capillary refill

In 1989, Champion et al recommended revising the Trauma Score to exclude capillary refill because it is "difficult to assess at night. . . ." However, a literature search produced no studies evaluating the effect of lighting conditions on the assessment of capillary refill. This study was undertaken to determine if any such effect exists. Three hundred nine participants at an emergency medical services (EMS) seminar were asked to assess each others' capillary refill in both light and dark environments. The participants were nurses, emergency medical technicians (EMTs), and paramedics who had been instructed in the assessment of capillary refill. In daylight conditions (partly cloudy day, lux meter = 15 to 16), capillary refill was reported as normal in 94.2% of the participants, delayed in 1.9% of the participants, and undetected in 3.9% of the participants. In dark conditions (moonlight or street lamp, lux meter = 4 to 6), capillary refill was reported as normal in 31.7% of the participants, delayed in 1.6% of the participants, and undetected in 66.7% of the participants. chi 2 analysis demonstrated a statistically significant difference between capillary refill assessment in light versus dark environments (P < .001).

Study of the teratogenic potential of FD & C Yellow No. 5 when given by gavage to rats

FD & C Yellow No. 5 (tartrazine) was given to Osborne-Mendel rats by gavage at dose levels of 0, 60, 100, 200, 400, 600 or 1000 mg/kg body weight/day on days 0-19 of gestation. No maternal or developmental toxicity was observed when the rats were killed on day 20. The mean daily food consumption for the entire period of gestation was significantly greater in the females given 1000 mg/kg body weight/day than in the controls, but maternal body-weight gain was not affected. No dose-related effects were observed in implantations, foetal viability or external foetal development. Foetal skeletal and visceral development was similar among foetuses from all groups. At the doses given, FD & C Yellow No. 5 was neither toxic nor teratogenic.