Field experience with prehospital advance directives.

STUDY OBJECTIVE: Some states have enacted legislation authorizing EMS providers to adhere to prehospital advance directives (ADs) in the terminally ill. This study was conducted to assess EMS providers' knowledge of and experience with prehospital ADs. METHODS: An anonymous survey was conducted of 142 EMS providers employed by a local, private ambulance service in the northeastern United States. The survey was administered during a 2-month period from January to March 1995. RESULTS: Of 142 participating providers, 106 (74.6%) completed questionnaires. Respondents included EMTs (61. 3%), paramedics (33.9%), and chair van operators (4.8%). The majority (58.6%) had at least 5 years of field experience. Almost all respondents (93.4%) were familiar with ADs, usually do-not-resuscitate orders. Most providers (78.3%) consider ADs before implementing extraordinary life support measures in terminally ill patients. Few (28.0%) have implemented prehospital ADs without medical control. The most commonly reported objections to withholding life support measures were fear of legal consequences, personal difficulty withholding care they are trained to provide, and ambiguity in the ADs received. Nearly all respondents (96.7%) support enactment of prehospital AD statutes. CONCLUSION: Most prehospital care providers recognize the need to withhold resuscitative care in terminally ill patients who have prepared ADs. However, a sizable minority fail to consider prehospital ADs as a routine part of their practice. The majority of our respondents support enactment of prehospital AD statutes to minimize confusion and provide legal authorization to limit resuscitation.

Causes and patterns of injury from ladder falls.

OBJECTIVES: To review all ladder fall injuries seen in a community ED and to identify patterns of injury, factors that contribute to falls, and what pre-event and event factors could have reduced the likelihood of a fall or a resulting injury. METHODS: This was a retrospective, observational study involving patients who presented to a community hospital ED from January 1993 through December 1995 with injuries from a ladder fall. The medical records of all patients were reviewed. Patients then underwent a structured telephone interview to provide additional information about the circumstances of the fall. RESULTS: There were 59 patients who sustained injuries relating to ladder falls. All were adults, aged > 18 years (mean 42.9 +/- 16.2 years), were predominantly male (93%), and had fallen a distance of 1-15 feet (mean 7.2 +/- 3.6 feet). Thirteen percent were admitted to the hospital, and there was 1 death. Fractures were observed in 21 patients (36%) and usually involved an extremity (77%). There was no relationship between the distance fallen and the occurrence of fracture. Other primary injuries included sprain (27%), contusion (24%), laceration (10%), abrasion (3%), and subdural hematoma (2%). Of the 59 patients, 42 (71%) were contacted directly. Most falls (79%) resulted from excessive reaching or incorrect ladder placement. Fifty percent of the described falls were occupationally related. CONCLUSIONS: Falls from ladders, both in the occupational and nonoccupational settings, often result in significant injury. Simple safety measures may have prevented the majority of falls in this study. Public health efforts should emphasize education on safe ladder practices and techniques to reduce the possibility of injury in the event of a fall.

Air bag safety.

STUDY OBJECTIVE: To describe injuries associated with deployment of air bag passive-restraint systems in use in the United States. DESIGN: Retrospective review of data collected by the National Highway Traffic Safety Administration (NHTSA) from 1980 to 1994. PARTICIPANTS: Occupants of air bag-equipped vehicles who were involved in crashes on US roads. RESULTS: Of 618 reported occupant injuries related to air bag deployment, an overwhelming majority were classified as minor (96.1%). Most occupants sustained abrasions, contusions, and lacerations. The face (42.0%), wrist (16.8%), forearm (16.3%) and chest (9.6%) were the most frequently injured body areas. CONCLUSION: Most injuries related to air bag deployment are minor and must be viewed in the context of the potentially life-threatening injuries they prevent.

Use of thrombolytic therapy in a heart transplant recipient with acute myocardial infarction.

We report the case of a 54-year-old long-term heart transplantation survivor who presented to the emergency department with acute myocardial infarction and was treated successfully with thrombolytic therapy. The case is discussed, and pertinent literature is reviewed.

Prehospital fluid therapy in pediatric trauma patients.

In order to evaluate the impact of prehospital intravenous fluid therapy on the outcome of pediatric trauma patients and to evaluate the effect of such therapy on the on-scene interval, we performed a retrospective chart review of 50 pediatric trauma patients less than 18 years old transported directly from the field by Emergency Medical Services personnel with an intravenous catheter in place and admitted to the Trauma Service of a level I urban pediatric trauma center. As judged by an expert panel using a new grading system, prehospital intravenous fluid therapy was inconsequential to outcome in 47 of 50 patients, possibly beneficial in two of 50 patients, and possibly detrimental in one of 50 patients. Patients who received their catheters at the scene had significantly longer on-scene intervals than those who received them in the ambulance (15.4 vs 11.4 minutes, P < 0.05). The mean volume of fluid administered was 4.4 ml/kg body weight. Placement of the catheter (at the scene vs in the ambulance) and prehospital fluid volume administered were independent of the Injury Severity Score. The role of prehospital fluid therapy in pediatric trauma patients in an urban setting requires reevaluation.