Prehospital Active and Passive Warming in Trauma Patients.

OBJECTIVE: Hypothermia is common among trauma patients and can lead to a serious rise in morbidity and mortality. This study was performed to investigate the effect of active and passive warming measures implemented in the prehospital phase on the body temperature of trauma patients. METHODS: In a multicenter, multinational prospective observational design, the effect of active and passive warming measures on the incidence of hypothermia was investigated. Adult trauma patients who were transported by helicopter emergency medical services (HEMS) or ground emergency medical services with an HEMS physician directly from the scene of injury were included. Four HEMS/ground emergency medical services programs from Canada, the United States, and the Netherlands participated. RESULTS: A total of 80 patients (n = 20 per site) were included. Eleven percent had hypothermia on presentation, and the initial evaluation occurred predominantly within 60 minutes after injury. In-line fluid warmers and blankets were the most frequently used active and passive warming measures, respectively. Independent risk factors for a negative change in body temperature were transportation by ground ambulance (odds ratio = 3.20; 95% confidence interval, 1.06-11.49; P = .03) and being wet on initial presentation (odds ratio = 3.64; 95% confidence interval, 0.99-13.36; P = .05). CONCLUSION: For adult patients transported from the scene of injury to a trauma center, active and passive warming measures, most notably the removal of wet clothing, were associated with a favorable outcome, whereas wet patients and ground ambulance transport were associated with an unfavorable outcome with respect to temperature.

Bolus Vasopressor Use for Air Medical Rapid Sequence Intubation: The Vasopressor Intravenous Push to Enhance Resuscitation Trial.

BACKGROUND: Rapid sequence intubation (RSI) may compromise perfusion because of the use of sympatholytic medications as well as subsequent positive pressure ventilation. The use of bolus vasopressor agents may reverse hypotension and prevent arrest. METHODS: This was a prospective, observational study enrolling air medical patients with critical peri-RSI hypotension (systolic blood pressure [SBP] < 90 mm Hg) to receive either arginine vasopressin (aVP), 2 U intravenously every 5 minutes, for trauma patients or phenylephrine (PE), 200 µg intravenously every 5 minutes, for nontrauma patients. The main outcome measures included an increase in SBP, a reversal of hypotension, and the occurrence of dysrhythmia or hypertension (SBP > 160 mm Hg) within 20 minutes of vasopressor administration. RESULTS: A total of 523 patients (344 aVP and 179 PE) were enrolled over 2 years. An increase in SBP was observed in 326 aVP patients (95%), with reversal of hypotension in 272 patients (79%). An increase in SBP was observed in 171 PE patients (96%), with reversal of hypotension in 148 patients (83%). A low rate of rebound hypertension was observed for both aVP and PE patients. CONCLUSION: Both aVP and PE appear to be safe and effective for treating critical hypotension in the peri-RSI period.

A Continuous Quality Improvement Airway Program Results in Sustained Increases in Intubation Success.

INTRODUCTION: Airway management is a critical skill for air medical providers, including the use of rapid sequence intubation (RSI) medications. Mediocre success rates and a high incidence of complications has challenged air medical providers to improve training and performance improvement efforts to improve clinical performance. OBJECTIVES: The aim of this research was to describe the experience with a novel, integrated advanced airway management program across a large air medical company and explore the impact of the program on improvement in RSI success. METHODS: The Helicopter Advanced Resuscitation Training (HeART) program was implemented across 160 bases in 2015. The HeART program includes a novel conceptual framework based on thorough understanding of physiology, critical thinking using a novel algorithm, difficult airway predictive tools, training in the optimal use of specific airway techniques and devices, and integrated performance improvement efforts to address opportunities for improvement. The C-MAC video/direct laryngoscope and high-fidelity human patient simulation laboratories were implemented during the study period. Chi-square test for trend was used to evaluate for improvements in airway management and RSI success (overall intubation success, first-attempt success, first-attempt success without desaturation) over the 25-month study period following HeART implementation. RESULTS: A total of 5,132 patients underwent RSI during the study period. Improvements in first-attempt intubation success (85% to 95%, p < 0.01) and first-attempt success without desaturation (84% to 94%, p < 0.01) were observed. Overall intubation success increased from 95% to 99% over the study period, but the trend was not statistically significant (p = 0.311). CONCLUSIONS: An integrated advanced airway management program was successful in improving RSI intubation performance in a large air medical company.

Paramedic specialization: a strategy for better out-of-hospital care.

Demographic, economic, and political forces are driving significant change in the US health care system. Paramedics are a health profession currently providing advanced emergency care and medical transportation throughout the United States. As the health care system demands more team-based care in nonacute, community, interfacility, and tactical response settings, specialized paramedic practitioners could be a valuable and well-positioned resource to meet these needs. Currently, there is limited support for specialty certifications that demand appropriate education, training, or experience standards before specialized practice by paramedics. A fragmented approach to specialty paramedic practice currently exists across our country in which states, regulators, nonprofit organizations, and other health care professions influence and regulate the practice of paramedicine. Multiple other medical professions, however, have already developed effective systems over the last century that can be easily adapted to the practice of paramedicine. Paramedicine practitioners need to organize a profession-based specialty board to organize and standardize a specialty certification system that can be used on a national level.

Prednisone for emergency department low back pain: a randomized controlled trial.

BACKGROUND: Although oral corticosteroids are commonly given to emergency department (ED) patients with musculoskeletal low back pain (LBP), there is little evidence of benefit. OBJECTIVE: To determine if a short course of oral corticosteroids benefits LBP ED patients. DESIGN: Randomized, double-blind, placebo-controlled trial. SETTING: Suburban New Jersey ED with 80,000 annual visits. PARTICIPANTS: 18-55-year-olds with moderately severe musculoskeletal LBP from a bending or twisting injury ≤ 2 days prior to presentation. Exclusion criteria were suspected nonmusculoskeletal etiology, direct trauma, motor deficits, and local occupational medicine program visits. PROTOCOL: At ED discharge, patients were randomized to either 50 mg prednisone daily for 5 days or identical-appearing placebo. Patients were contacted after 5 days to assess pain on a 0-3 scale (none, mild, moderate, severe) as well as functional status. RESULTS: The prednisone and placebo groups had similar demographics and initial and discharge ED pain scales. Of the 79 patients enrolled, 12 (15%) were lost to follow-up, leaving 32 and 35 patients in the prednisone and placebo arms, respectively. At follow-up, the two arms had similar pain on the 0-3 scale (absolute difference 0.2, 95% confidence interval [CI] -0.2, 0.6) and no statistically significant differences in resuming normal activities, returning to work, or days lost from work. More patients in the prednisone than in the placebo group sought additional medical treatment (40% vs. 18%, respectively, difference 22%, 95% CI 0, 43%). CONCLUSION: We detected no benefit from oral corticosteroids in our ED patients with musculoskeletal LBP.

Critical care transportation by paramedics: a cross-sectional survey.

OBJECTIVE: The purpose of this study was to gather data from paramedics practicing in the critical care transport setting to guide development of the education, training, and clinical practices for certification as a critical care paramedic. METHODS: A paper survey of 1991 randomly selected nationally registered (NREMT) paramedics was conducted. Nine paramedics with residences in small US Pacific Island territories were not included in the survey. RESULTS: We received 610 responses (30.6%). Respondents that stated that they provided critical care transport services reported using pediatric skills and equipment the most and intracranial pressure monitoring the least. Paramedics served as the primary provider for pediatric patients (72.5%), 12-lead electrocardiogram (66.3%), intravenous infusion pump (76.7%), mechanical ventilator (66.9%), central line management (63.1%), and chest tube management (63.3%). Paramedics served in a team member capacity most often with neonatal isolette (71.8%), intra-aortic balloon pump (79.2%), and ICP monitoring (64.9%). The majority provided ground critical care transport (249) compared to 44 rotor-wing and 6 fixed-wing. Sixteen respondents reported serving as primary providers on combinations of ground, rotor-, and fixed-wing services. CONCLUSIONS: Paramedics reported being the primary provider on the critical care transport team and performing skills while using equipment and administering medications that exceeded their education and training as paramedic and, at times, without the benefit of any additional education or training. National appreciation of this reality should spur development of standardized education, licensing or certification, and continuing education to prepare paramedics for their role as critical care medical providers.

Appropriate and safe utilization of helicopter emergency medical services: a joint position statement with resource document.

This position statement with accompanying resource document is the result of a collaborative effort of a writing group comprised of members of the Air Medical Physician Association (AMPA), the American College of Emergency Physicians (ACEP), the National Association of EMS Physicians (NAEMSP), and the American Academy of Emergency Medicine (AAEM). This document has been jointly approved by the boards of all four organizations. Patients benefit from the appropriate utilization of helicopter emergency medical services (HEMS). EMS and regional health care systems must have and follow guidelines for HEMS utilization to facilitate proper patient selection and ensure clinical benefit. Clinical benefit can be provided by Meaningfully shortening the time to delivery of definitive care to patients with time-sensitive medical conditions Providing necessary specialized medical expertise or equipment to patients before and/or during transport Providing transport to patients inaccessible by other means of transport The decision to use HEMS is a medical decision, separate from the aviation determination whether a transport can be completed safely. Physicians with specialized training and experience in EMS and air medical transport must be integral to HEMS utilization decisions, including guideline development and quality improvement activities. Safety management systems must be developed, adopted, and adhered to by air medical operators when making decisions to accept and continue every HEMS transport. HEMS must be fully integrated within the local, regional, and state emergency health care systems. HEMS programs cannot operate independently of the surrounding health care environment. The EMS and health care systems must be involved in the determination of the number of HEMS assets necessary to provide appropriate coverage for their region. Excessive resources may lead to competitive practices that can affect utilization and negatively impact safety. Inadequate resources will delay receipt of definitive care. National guidelines for appropriate utilization of HEMS must be developed. These guidelines should be national in scope yet allow local, regional, and state implementation. A National HEMS Agenda for the Future should be developed to address HEMS utilization and availability and to identify and support a research strategy for ongoing, evidence-based refinement of utilization guidelines.

Music reduces patient anxiety during interfacility ground critical care transport.

INTRODUCTION: Interfacility ground critical care transport (CCT) of patients by ambulance may be stressful. This study evaluated whether playing music during CCT reduces patient anxiety and whether objective evidence is manifested by a change in vital signs. SETTING: Urban teaching hospital. METHODS: In this prospective cohort study, music was played for eligible adult patients during CCT while recording vital signs. A questionnaire was subsequently mailed to patients to rate whether the ambulance transport was stressful, the impact music had on transport, whether music changed their anxiety, whether music made them comfortable and relaxed, and whether they would prefer music to be played on future transports. Vital signs were compared between respondents who perceived transport as stressful and those who did not. RESULTS: One hundred two patients were enrolled; 23 respondents (22.5%) constituted the study group. Four patients (17.4%) reported CCT as stressful (average response, 4.75). Nineteen (82.6%) rated CCT as not stressful (average response, 1.63). Subjectively, patients reported a positive impact of music on transport, with improved comfort and relaxation but only a minimal decrease in anxiety. No statistically significant change in vital signs was observed between cohorts; too few patients were enrolled to generate power to detect any difference. CONCLUSIONS: Music therapy is a simple adjunct for use during CCT that may increase patient comfort and alleviate anxiety. The small number of patients in this preliminary report limits the strength of any conclusions. Larger studies are needed.

The relation of stroke admissions to recent weather, airborne allergens, air pollution, seasons, upper respiratory infections, and asthma incidence, September 11, 2001, and day of the week.

BACKGROUND AND PURPOSE: Some previous research links stroke incidence to weather, some links strokes to air pollution, and some report seasonal effects. Alveolar inflammation was proposed as the mechanistic link. We present a unified model of time, weather, pollution, and upper respiratory infection (URI) incidence. METHODS: We combined existing databases: US Environmental Protection Agency pollution levels, National Weather Service data, counts of airborne allergens, and New York City Health and Hospitals Corporation counts of stroke, asthma, and URI patients. We used autoregressive integrated moving average modeling (a statistical time series modeling technique) with stroke admissions as the response variable and day of week, holidays, September 11th, and other counts and levels as explanatory variables. RESULTS: Using a broad definition of stroke, there were 5.1+/-2.3 stroke admissions per day: narrowly defined, 4.2+/-2.1 strokes per day. There are relatively fewer strokes on Sundays (0.50 strokes; P=0.0011), Saturdays (0.62; P<0.0001), Fridays (0.38; P=0.0009) and holidays (0.875; P=0.0016). We found relatively small, independent exacerbating effects of higher air temperature (P=0.0211), dry air (P=0.0187), URIs, (P<0.0001), grass pollen (P=0.0341), sulfur dioxide (SO2; P=0.0471), and suspended particles <10 microm in size (P=0.0404). These effects are modest: < or =0.6, 0.6, 2.4, 1, 0.9, and 0.7 strokes per day, respectively. We did not find statistically significant exacerbating effects of other variables. CONCLUSIONS: We found statistically significant, independent exacerbating effects of warmer, drier air, URIs, grass pollen, SO2, and particulate air pollution. The model supports the theory that links pulmonary inflammation to stroke.

Adequacy of online medical command communication and emergency medical services documentation of informed refusals.

BACKGROUND: In the out-of-hospital setting, when emergency medical services (EMS) providers respond to a 9-1-1 call and encounter a patient who wishes to refuse medical treatment and/or transport to the hospital, the EMS providers must ensure the patient possesses medical decision-making capacity and obtain an informed refusal. In the city of Cleveland, Ohio, Cleveland EMS completes a nontransport worksheet that prompts the paramedics to evaluate specific patient characteristics that can influence medical decision-making capacity and then discuss the risks of refusing with the patient. Cleveland EMS then contacts an online medical command (OLMC) physician to authorize the refusal. OLMC calls are recorded for review. OBJECTIVES: To assess the ability of EMS to determine medical decision-making capacity and obtain an informed refusal of transport. METHODS: This study was a retrospective review of a cohort of recorded OLMC refusal calls and of the accompanying written documentation by Cleveland EMS. The completeness of the verbal communication between the paramedic and OLMC physician and the written documentation on the nontransport worksheet were measured as surrogate markers of the adequacy of determining medical decision-making capacity and obtaining an informed refusal. RESULTS: One hundred thirty-seven OLMC calls for patient-initiated refusals were reviewed. Vital signs and alertness/orientation were verbally communicated more than 83% of the time. The presence of head injury, presence of alcohol or drug intoxication, and presence of hypoglycemia were verbally communicated less than 31% of the time. Verbal communication stating that the risks of refusing had been discussed with the patient occurred 44.5% of the time. The written documentation of the refusal encounter was more complete, exceeding 95% for vital signs and alertness/orientation, and exceeding 80% for the remaining patient characteristics. The rate of written documentation that the risks of refusing had been discussed with the patient was 48.7%. Discrepancies between the verbal and written paramedic reports were clinically insignificant. CONCLUSIONS: Paramedic and OLMC physician communication for patients refusing out-of-hospital medical treatment and/or transport is inadequate in the Cleveland EMS system. A written nontransport worksheet improves documentation of the refusal encounter but does not ensure that every patient who refuses possesses medical decision-making capacity and the capacity to provide an informed refusal.