Paramedic intubation: patient position might matter.

OBJECTIVE: Paramedics often intubate in challenging environments. We evaluated whether patient position might affect prehospital intubation success rates utilizing a cadaver model. METHODS: The study was conducted in two phases: a cross-sectional survey and an experimental model in which paramedics were asked to demonstrate intubation skills on cadavers in three positions. New York State certified paid and volunteer paramedics and critical care emergency medical technicians were recruited from multiple agencies. To assess past experience, participants self-reported the number of patients they attempted to intubate in the previous 12 months and the patient positions in which they attempted those intubations. Participants attempted to intubate nonembalmed cadavers in a controlled environment in three positions: on the floor, on a low stretcher to simulate the patient care compartment of an ambulance, and on an elevated stretcher. Paramedics were allowed a maximum of three intubation attempts of one minute each per cadaver. Endotracheal tube placement was verified by a single attending emergency physician using direct visualization. RESULTS: Self-reports of intubation attempts in the previous 12 months indicated that participants had attempted to intubate a mean of 6.4 patients per paramedic. Self-reported positions of patient intubations were 57% on the floor, 33% in the ambulance, 7% on a stretcher of unspecified height, and 3% in some other position. During the study, 84 paramedics performed 251 intubations on 42 cadavers. First-attempt and cumulative first- and second-attempt success rates were 77.4 and 89.3% for the floor position, 74.7 and 94.0% for the low stretcher (ambulance) position, and 86.9 and 96.4% for the elevated stretcher position, respectively. First attempt success was higher in the elevated stretcher position compared to the low stretcher position (OR = 2.25, 95% CI 1.01-5.00). No other position contributed to greater odds of ETI success either on the first or second attempt. CONCLUSIONS: Endotracheal intubation success was higher with the cadaver positioned on an elevated stretcher compared to a low stretcher. Paramedics must be aware of patient position when performing prehospital intubation.

Emergency mental health: lessons learned from flight 3407.

Emergency mental health (EMH), a field that is often not well represented when considering emergency preparedness, is nonetheless a vital component to any disaster response. Emergency mental health issues must be considered not only for victims of disasters and their families, friends, and coworkers but also for both on-scene and off-scene responders and members of the community who may have witnessed the disaster. This article describes the EMH preparation for and response to the crash of Continental Airlines flight 3407 in western New York on February 12, 2009, killing all 49 crew and passengers on board and 1 person on the ground. It describes aspects of the response that went as planned and highlights areas for improvement. The lessons learned from this EMH preparation and response can be used to inform future planning for disaster response.

Cardiac arrest patients rarely receive chest compressions before ambulance arrival despite the availability of pre-arrival CPR instructions.

OBJECTIVES: To determine the proportion of out-of-hospital cardiac arrest (OOHCA) patients who received chest compressions, before EMS arrival, from bystanders who called the EMS emergency telephone number (9-1-1) at dispatch centers that provided telephone CPR instructions and to describe barriers to following instructions. METHODS: A retrospective case series was conducted in 2004 at three dispatch centers all of which provided sequential airway, breathing and chest compression pre-arrival instructions. All calls for which the call-taker established that the patient was in OOHCA were identified, and the recorded interaction was reviewed using a structured data collection tool. Data included whether the caller performed compressions, the sequence of instructions, whether there were barriers to performing CPR and characteristics of the caller, call taker and patient. Descriptive statistics were used to evaluate the data. RESULTS: 343 calls were reviewed. 3 were excluded because it was unclear whether compressions were provided. 172 calls were not eligible for pre-arrival instructions (e.g. obviously dead, already receiving CPR). Of the 168 calls eligible for CPR instructions, chest compressions were actually given to 25 patients (15%, 95% confidence interval 10-21%) before EMS arrival. Leading reasons for not following CPR instructions included: caller disconnected phone before directions were complete (19%), caller's refusal (18%), emotional state of the caller (14%), inability to listen to telephone instructions and care for patient at the same time (13%) and physical limitations of the caller (8%). Failure to complete airway and breathing steps prevented 8% of callers from providing compressions. CONCLUSIONS: Few 9-1-1 callers provided chest compressions following telephone CPR instructions that included airway and breathing steps. The majority of callers were unwilling or emotionally or physically unable to follow the instructions.

Linkages of acute care and EMS to state and local public health programs: application to public health programs.

Response to terrorism and mass casualty incidents has become a focal point for many public service agencies. Public health agencies and the emergency response community must work together to effectively and efficiently respond to any future incidents. Historically, collaboration has been a challenge since these agencies have functioned independently from one another, maintaining separate infrastructures that are not adequately interoperable. This article will summarize the consensus achieved during a meeting of multidisciplinary stakeholders held to discuss linkages between acute care, emergency medical services, and public health. The relevancy of these findings to public health, as well as the benefits from development of an interoperable infrastructure to public health, will be opined.

A comparison of first-responder automated external defibrillator (AED) application rates and characteristics of AED training.

OBJECTIVE: To determine whether there were associations between the characteristics of first-responder automated external defibrillator (AED) training and AED application rates. METHODS: This multicenter retrospective cohort study analyzed data from ten emergency medical services systems where first responders were trained and equipped with AEDs. Data were provided for all out-of-hospital cardiac arrests (OHCAs) occurring over two years, including whether the first-responder AED was applied (pads attached to patient). Systems were surveyed to determine the characteristics of their initial and continuing AED training. Data were analyzed using odds ratios (ORs) with 95% confidence intervals (95% CIs). RESULTS: Overall, the first-responder AED was applied to 53% of 2,181 OHCAs. First responders applied AEDs to 60% of OHCAs when a national AED training curriculum was used and to 49% of OHCAs when a locally created curriculum was used (OR=1.58; 95% CI=1.32-1.88). First responders applied AEDs to 61% of OHCAs when they were trained to the level of Certified First Responder or higher and to 28% of OHCAs when they were trained only in cardiopulmonary resuscitation (OR=3.97; 95% CI=3.20-4.93). First responders applied AEDs to 66% of OHCAs when they each had an opportunity to apply the AED during continuing training and to 17% of OHCAs when they did not have this opportunity (OR=9.04; 95% CI=7.15-11.42). First responders applied AEDs to 59% of OHCAs when they had not received continuing training within one year of their initial training and to 42% of OHCAs when they had received continuing training in the first year (OR=2.00; 95% CI=1.67-2.40). CONCLUSION: Use of a national AED training curriculum, training to the level of Certified First Responder or higher, and the ability for each first responder to apply the AED during continuing training were associated with higher AED application rates. Continuing training within the first year did not appear to be as important as actually using the AED during the training.

Is total out-of-hospital time a significant predictor of trauma patient mortality?

OBJECTIVE: To determine if there is an association between total out-of-hospital time and trauma patient mortality. METHODS: A retrospective review was performed of a convenience sample of consecutive medical records for all admitted patients transported by helicopter or ambulance from the scene of injury to the regional trauma center. Descriptive and univariate analyses were conducted to determine which variables were associated with patient mortality and total out-of-hospital time. Multiple predictors logistic regression was used to determine if total out-of-hospital time was associated with trauma patient outcome, while controlling for the variables associated with trauma patient mortality. RESULTS: Of the 2,925 patients who were transported from the scene, 1,877 met the inclusion criteria. Six percent (116) did not survive. The multiple predictors model included CUPS (critical, unstable, potentially unstable, stable) status, patient age, Injury Severity Score, Revised Trauma Score, and total out-of-hospital time as predictors of mortality. Total out-of-hospital time (odds ratio 0.987; p = 0.092) was the only variable not found to be a significant predictor of mortality. CONCLUSIONS: Provider-assigned CUPS status, patient age, Injury Severity Score, and Revised Trauma Score all were significant predictors of trauma patient mortality. Total out-of-hospital time was not associated with mortality.

The time first-response fire fighters have to initiate care in a midsize city.

The objective of this study was to determine whether simultaneously dispatched first-response firefighters (fire) arrive before transporting EMS providers (ambulance) and the amount of time fire has on scene to initiate care. Fire and ambulance dispatch records were obtained for all 9-1-1 responses from four 1-month intervals. Only incidents to which both agencies had been simultaneously dispatched were included. Response time for each agency was determined by subtracting the time of dispatch from the time of arrival. The difference between fire and ambulance response time was the time fire had to initiate care. Both agencies were simultaneously dispatched to 4752 incidents. Average response time for all incidents was 4.0 +/- 2.6 min for fire and 5.3 +/- 2.0 min for ambulance. Fire had 1.3 +/- 3.2 min on average to initiate care. Fire arrived before ambulance for 69% (3262) of requests and for these calls had 2.8 +/- 1.7 min on average to initiate care. Utilization of densely staged first-response fire apparatus in a midsize city may be appropriate because firefighters frequently arrive before ambulances and may have adequate time to initiate lifesaving interventions.

Can paramedics safely treat and discharge hypoglycemic patients in the field?

To determine whether paramedics can safely treat and discharge insulin-dependent diabetic patients experiencing uncomplicated hypoglycemic events, we conducted a prospective, observational study with a convenience sample of diabetic patients whose hypoglycemia resolved after intravenous administration of dextrose and before they were transported by paramedics. On-line medical control was contacted to obtain approval and informed consent for participation from interested patients who met all eligibility criteria for the study. Participating patients were given instructions upon discharge from the study and were contacted by telephone 24 hours later to ascertain their medical outcomes and their opinions of the study protocol. We enrolled a total of 36 patients with 38 incidents of hypoglycemia. Of these, 91% reported no complications after discharge. Two patients developed recurrent hypoglycemia but treated themselves and did not require further emergency care. One further patient was found unresponsive on the morning following discharge and was subsequently admitted to a long-term care facility with hypoglycemic encephalopathy. Of the study participants, 85% were very satisfied with not being transported to an emergency department (ED) and 91% were very satisfied with the care they had received. All (100%) of the patients surveyed favored a permanent protocol allowing discharge of hypoglycemic patients without admission to an ED. We conclude that paramedics successfully treated, without complication, most of the patients with uncomplicated hypoglycemic events who were examined in our study. These patients generally preferred discharge without transportation to an ED.

A survey of first-responder firefighters' attitudes, opinions, and concerns about their automated external defibrillator program.

OBJECTIVE: To identify barriers to first-responder automated external defibrillator (AED) use by determining firefighter attitudes, opinions, and concerns about their AED program. METHODS: An anonymous survey was mailed to all firefighters in a municipal department that had had first-responder defibrillation for more than two years. A follow-up survey was mailed to all nonrespondents. The survey requested firefighter demographics, comfort and experience with AED, definition of DOA (dead on arrival), and opinion of the program. RESULTS: Of 749 firefighters surveyed, 686 responded (92%). The respondents had an average of 12 +/- 8 years of experience; 66% felt very comfortable using the AED and 3% felt very uncomfortable. The respondents had applied an AED to a patient a median of 2 times (range 0-30); 24% had never applied an AED. Eighty-three percent reported they had been on the scene of an out-of-hospital cardiac arrest when their AED was not used for at least one patient. Predominant reasons for not applying an AED included the ambulance arrived "soon enough" (72%), the ambulance arrived first (63%), the patient was DOA (61%), and the patient had a do-not-resuscitate (DNR) order (32%). Eighty-one percent of the respondents correctly listed at least one clinical finding that defines DOA. Ninety-nine percent felt they should continue the AED program. The respondents gave numerous suggestions for improving the program, including being able to visualize the rhythm, increasing their level of care, and improved AED training. CONCLUSIONS: Municipal first response firefighters view their AED program favorably despite infrequently applying an AED. The appropriateness of withholding defibrillation because a secondary response unit will arrive "soon enough" should be reviewed. The definition of DOA should be reviewed to ensure that viable patients are not denied defibrillation.

Electronic patient registration and tracking at mass vaccination clinics: a clinical study.

To protect the citizens of the United States from the use of dangerous biological agents, the Center for Disease Control and Prevention (CDC) has been actively preparing to deal with the consequences of such an attack. Their plans include the deployment of mass immunization clinics to handle postevent vaccinations. As part of the planning efforts by the Western New York Public Health Alliance, a Web-based electronic patient registration and tracking system was developed and tested at a recent trial smallpox vaccination clinic. Initial goals were to determine what the pitfalls and benefits of using such a system might be in comparison to other methods of data collection. This exercise proved that use of an electronic system capable of scanning two-dimensional bar codes was superior to both paper-based and optical character recognition (OCR) methods of data collection and management. Major improvements in speed and/or accuracy were evident in all areas of the clinic, especially in patient registration, vaccine tracking and postclinic data analysis.

Regional emergency preparedness efforts by local health departments in Western New York.

Public health agencies at all levels are now under increasing pressure to prepare for and respond to emerging natural and manmade threats to the health and wellness of those they serve. In particular, local health departments must be prepared to provide front-line defense and first response as threats of terrorism have become increasingly real. Success in meeting this monumental task will be highly dependent on funding as well as the availability of other resources. Although local health departments serving smaller counties may have fewer resources and receive less preparedness funding, they must still develop similar plans, surveillance systems, and response capabilities as local health departments serving larger counties (albeit on a smaller scale). Although local health departments serving larger counties may have more resources and receive more preparedness funding, they may face a greater chance of an intentional terrorist act and could benefit from support from local health departments serving smaller counties. Regional planning and response solutions to this challenge will allow partnerships of small and large local health departments to pool their resources and cooperatively provide more services with less duplication using whatever funding is available. This article describes that process as it is occurring in western New York among eight local county health departments.

Out-of-hospital do-not-resuscitate orders by primary care physicians.

The objective of this study was to determine the knowledge, utilization, and experience of primary care physicians (PCPs) with nonhospital do-not-resuscitate (NH-DNR) orders. An anonymous survey was sent to all PCPs in a single northeastern county. Up to two surveys were mailed to each PCP. Descriptive statistics were used to report provider responses. The main variable of interest was issuance of NH-DNR orders. Surveys were mailed to 820 PCPs; 348 (42%) were returned. Respondents had practiced an average 17 +/- 11 years, and cared for an average of 720 patients per month, 7 of whom were terminally ill. Seventy percent issued NH-DNR orders. Twenty-five percent reported resuscitation had been attempted for at least one patient with a NH-DNR order; 64% reported this had happened more than once. Of respondents who had a NH-DNR order ignored, 14% had instructed family members to call police, fire, or EMS following death of the patient. Of the PCPs who did not issue NH-DNR orders, 71% reported not caring for any appropriate patients, yet 41% reported caring for at least 1 terminally ill patient per month. Seventy-nine percent disagreed that intubation and mechanical ventilation were appropriate treatment for DNR patients in severe respiratory distress, and 71% disagreed that cardioversion was appropriate treatment for an unconscious DNR patient with unstable ventricular tachycardia. In conclusion, a majority of respondents issued NH-DNR orders and one quarter reported these orders had not been followed. A majority felt intubation, mechanical ventilation, and cardioversion should not be performed for noncardiac arrest DNR patients with an indication, but not in cardiac arrest.

Automated external defibrillator (AED) utilization rates and reasons fire and police first responders did not apply AEDs.

OBJECTIVES: To determine the rate at which fire and police first responders (FRs) apply automated external defibrillators (AEDs) and to ascertain reasons for not applying them. METHODS: Twenty-one emergency medical services (EMS) systems whose FRs had been supplied with AEDs by a philanthropic foundation provided data for all out-of-hospital cardiac arrest (OHCA) patients. Data including the incidence of AED application and explanations for not applying AEDs were analyzed using descriptive statistics. RESULTS: A total of 2,456 OHCAs were reported. AED application information was available for 2,439 patients and revealed that FRs had not applied AEDs to 1,025 patients (42%). Fire FRs were more likely than police FRs to have applied AEDs (relative risk 1.87, 95% confidence interval 1.65-2.12). Reasons for not applying AEDs were listed for 664 (65%) of the OHCA patients to whom AEDs had not been applied. The predominant reason the FRs did not apply an AED was that the transporting ambulance defibrillator had already been applied (74%). However, when response times for FRs and the transporting ambulances were compared for these OHCA patients, it was found that the transporting ambulances arrived after the FRs 23% the time, simultaneously with the FRs 45% of the time, and before the FRs only 32% of the time. CONCLUSION: Fire and police FRs did not apply AEDs to a significant number of OHCA patients. Use of the transport ambulance defibrillator was the primary reason given for not applying the FR AED. Given low AED application rates by FRs, future studies are needed to determine the characteristics of communities in which equipping FRs with AEDs is the most beneficial deployment strategy, and how to increase AED application by FRs in communities with FR AED programs.

Assessment of emergency department health care professionals' behaviors regarding HIV testing and referral for patients with STDs.

The objective of this study was to evaluate human immunodeficiency virus (HIV) counseling, testing, and referral practices of emergency department health care professionals (i.e., medical doctors [MD], physician assistants [PA], nurse practitioners [NP], and registered nurses [RN]) for patients presenting with other sexually transmitted diseases (STD). All health care professionals from 10 emergency departments in a northeastern county were asked to complete an anonymous survey. The surveys were returned by 154 (41%) health care professionals (RN = 99, NP = 5, PA = 7, MD = 39, other = 4). The average years in practice were 11. Only 7% of respondents were certified to provide state mandated HIV pretest counseling (certification not required for MD). Respondents reported caring for an average of 13 patients per week with suspected STD. Fifty-five percent of respondents reported that they always or usually warn STD patients of their HIV risk, yet only 10% always or usually encouraged these patients to consent to HIV testing in their emergency department (RN = 7%, NP = 25%, PA = 0%, MD = 16%). Reasons for not offering HIV testing in their emergency department were follow-up concerns (51%), not certified to provide pretest/posttest counseling (45%), and too time consuming (19%). Twenty-seven percent of respondents indicated HIV testing was not available in their emergency department despite all hospital laboratories reporting HIV testing capability. Ninety-three percent of respondents were aware that confidential testing sites were available, but only 35% always or usually referred patients not tested in the emergency department elsewhere for testing. Emergency department health care professionals frequently fail to provide HIV counseling, testing, and/or referral for patients with suspected STD.