Pediatric Outcomes of Emergency Medical Services Non-Transport Before and During the COVID-19 Pandemic.

Introduction: Pediatric patients account for 6-10% of emergency medical services (EMS) activations in the United States. Approximately 30% of these children are not transported to an emergency department (ED). Adult data in the literature reports higher hospitalization and complications following non-transport. Few studies discuss epidemiology and characteristics of pediatric non-transport; however, data on outcome is limited. Our primary aim was to determine outcomes of non-transported children within our urban EMS system before and during the COVID-19 pandemic. Our secondary objective was to explore reasons for non-transport. Methods: This was a prospective, descriptive pilot study. We compared EMS data for September 2019 (pre-COVID-19) to September 2020 (pandemic). Included were children aged 0-17 years who activated EMS and did not receive transport to the primary hospital for the EMS capture area. We defined outcomes as repeat EMS activation, ED visits, and hospital admissions, all within 72 hours. Data was obtained via electronic capture. We used descriptive statistics to analyze our data, chi square for categorical data, stepwise logistic regression, and univariate logistic regression to test for association of covariates with non-transport. Results: There were 1,089 pediatric EMS activations in September 2019 and 780 in September 2020. Non-transport occurred in 633 (58%) in September 2019 and 412 (53%) in September 2020. Emergency medical services was reactivated within 72 hours in the following: 9/633 (1.4%) in 2019; and 5/412 (1.2%) in 2020 (P = 0.77). Visits to the ED occurred in 57/633 (9%) in 2019 and 42/412 (10%) in 2020 (P = 0.53). Hospital admissions occurred in 10/633 (1.5%) in 2019 and 4/412 (0.97%) in 2020 (P = 0.19). One non-transported patient was admitted to the intensive care unit in September 2020 (<1%) and survived. Hispanic ethnicity, age >12 years, and fever were associated with repeat EMS activation. The most common reason for non-transport in both study periods was that the parent felt an ambulance was not necessary (47%). Conclusion: In our system, non-transport of pediatric patients occurred in >50% of EMS activations with no significant adverse outcome. Age >12 years, fever, and Hispanic ethnicity were more common in repeated EMS activations. The most common reason for non-transport was parents feeling it was not necessary. Future studies are needed to develop reliable EMS guidelines for pediatric non-transport.

Using Trauma Video Review to Assess EMS Handoff and Trauma Team Non-Technical Skills.

OBJECTIVE: Handoffs by emergency medical services (EMS) personnel suffer from poor structure, inattention, and interruptions. The relationship between the quality of EMS communication and the non-technical performance of trauma teams remains unknown. METHODS: We analyzed 3 months of trauma resuscitation videos (highest acuity activations or patients with an Injury Severity Score [ISS] of ≥15). Handoffs were scored using the mechanism-injury-signs-treatment (MIST) framework for completeness (0-20), efficiency (category jumps), interruptions, and timeliness. Trauma team non-technical performance was scored using the Trauma Non-Technical Skills (T-NOTECHS) scale (5-15). RESULTS: We analyzed 99 videos. Handoffs lasted a median of 62 seconds [IQR: 43-74], scored 11 [10-13] for completeness, and had 2 [1-3] interruptions. Most interruptions were verbal (85.2%) and caused by the trauma team (64.9%). Most handoffs (92%) were efficient with 2 or fewer jumps. Patient transfer during handoff occurred in 53.5% of the videos; EMS providers giving handoff helped transfer in 69.8% of the Primary surveys began during handoff in 42.4% of the videos. Resuscitation teams who scored in the top-quartile on the T-NOTECHS (>11) had higher MIST scores than teams in lower quartiles (13 [11.25-14.75] vs. 11 [10-13]; p < .01). There were no significant differences in ISS, efficiency, timeliness, or interruptions between top- and lower-quartile groups. CONCLUSIONS: There is a relationship between EMS MIST completeness and high performance of non-technical skill by trauma teams. Trauma video review (TVR) can help identify modifiable behaviors to improve EMS handoff and resuscitation efforts and therefore trauma team performance.

Should a Physician Ever Violate SWAT or TEMS Protocol in a Mass Casualty Incident?

Mass casualty incidents involving active shooters are becoming more common, and many involve special weapons and tactics team responses. Standard of care is to have tactical emergency medical services paramedics or physicians direct triage and administer immediate interventions. In these situations, a clinical and ethical value is to do the greatest good for the greatest number of people. Cases in which beneficence and justice are at odds are particularly complex. This commentary on such a case argues that directing resources to patients most likely to survive accords triage principles and explores ethical complexity in resource allocation decisions.

Los incidentes con múltiples víctimas abatidas por un tirador activo son cada vez más comunes y muchos involucran armas especiales y una respuesta de los equipos tácticos. El estándar de atención es que los paramédicos o médicos de los servicios médicos de emergencia táctica dirijan el triaje y administren las intervenciones inmediatas. En estas situaciones, un valor clínico y ético es hacer el mayor bien para el mayor número de personas. Los casos en los que la beneficencia y la justicia están en conflicto son particularmente complejos. Este comentario sobre un caso de este tipo sostiene que dirigir los recursos a los pacientes con más probabilidades de sobrevivir concuerda con los principios de triaje y explora la complejidad ética al tomar decisiones de asignación de recursos.

Dallas MegaShelter Medical Operations Response to Hurricane Harvey.

On August 25, 2017, Hurricane Harvey made landfall near Corpus Christi, Texas. The ensuing unprecedented flooding throughout the Texas coastal region affected millions of individuals.1 The statewide response in Texas included the sheltering of thousands of individuals at considerable distances from their homes. The Dallas area established large-scale general population sheltering as the number of evacuees to the area began to amass. Historically, the Dallas area is one familiar with "mega-sheltering," beginning with the response to Hurricane Katrina in 2005.2 Through continued efforts and development, the Dallas area had been readying a plan for the largest general population shelter in Texas. (Disaster Med Public Health Preparedness. 2019;13:33-37).