Saline locks in prehospital care.

OBJECTIVES: 1) To determine if paramedics could select appropriate patients for use of the saline lock; 2) to evaluate saline-lock patency upon arrival at the emergency department (ED); and 3) to define any cost-savings associated with the use of the saline lock. POPULATION: Patients in the prehospital setting who required intravenous (IV) access, but did not require fluid resuscitation. Patients with hypotension or multiple traumatic injuries were excluded. METHODS: Paramedics were given the option for the use of either the saline lock or a routine IV set-up. Initially, the reservoir was flushed with 1 ml 0.9 N saline solution and the flush was repeated only if medications subsequently were completed for each patient. Information collected included: 1) demographics; 2) reason for selection; 3) need for fluid infusion; 4) conversion of the lock to a routine IV set-up; and 5) administration of medications through the lock. Failures included inability to flush after arrival to the ED, or local infiltration detected on flush while in the ED. Costs associated with the use of the saline locks were compared with those associated with the use of traditional IV set-ups. Cost-savings were calculated as the cost of a traditional IV set-up minus costs of the lock set-up. RESULTS: A total of 58 male and 42 female patients was enrolled. All patients were assigned appropriately. The most commonly used indications included chest pain, possible stroke, and shortness of breath. Two locks were occluded, and two had infiltrated when flushed following arrival of the patient to the ED. Five patients had IV fluid loads initiated through the locks. Cumulative cost-saving were [U.S.]$130 to the hospitals and $1,710 to the patients or their carriers. Most paramedics were pleased with the performance and utility of the locks. CONCLUSIONS: The use of saline locks is an alternative to the use of traditional IVs in certain patients in the prehospital setting.

A proposed model for a residency experience in mass gathering medicine: the United States Air Show.

STUDY OBJECTIVE: Mass gathering medicine is an increasingly important responsibility for emergency physicians. A formal experience in mass gathering medicine can introduce emergency medicine residents to this aspect of community medicine. DESIGN: Educational model based on field experience and retrospective chart review from 1981 through 1991. SETTING: The US Air Show is a summer event that attracts an average of 223,000 spectators annually. Medical care is provided by physicians, nurses, and technicians operating within an organized system of care. Emergency medicine resident physicians (first-, second-, and third-year) evaluate and treat patients appropriate for the resident's level of responsibility. Residents provide immediate medical control and are integrated into the event disaster plan. On-site attending physician supervision is available at all times. Didactic instruction and event orientation are integrated into the residency curriculum. Residents participate in the planning stages of the event. RESULTS: During the study period, 2,091 patients were seen. The most common presenting problems were heat illness (28%), blisters and scrapes (25%), headaches (23%), fractures and lacerations (9%), and eye injuries (5%). One hundred forty-eight patients (7%) required transportation to the hospital. Approximately 16 residents participate each year and treat an average of 13.7 patients during their four-hour shift. A resident training model for a mass gathering experience is proposed to include adequate crowd size to generate useful patient volumes; a regularly scheduled event; organized medical and disaster preparations meeting local or published standards; didactic instruction on history, principles, and current issues; on-site attending supervision; degree of responsibility appropriate for training level; participation in planning and organizing the event; and postevent debriefing. CONCLUSION: A residency experience and training program in mass gathering medicine can introduce the principles of planning and providing care for crowds attending large public events.

Physician integration into mass gathering medical care. The United States Air Show.

INTRODUCTION: Limited information exists concerning physician staffing at mass gathering events. METHODS: A retrospective review of the preparation, planning, and provision of medical care for the United States Air Show was performed. Patient encounters from the air show for the years 1981-1991 also were evaluated. RESULTS: The frequency rate of overall encounters was 8.45 patients/10,000 spectators and hospital transport rate was 0.6/10,000 spectators. The majority of complaints were related to heat or minor injuries. During this period, emergency physicians played a vital role in both medical planning and on-site staffing. Emergency medicine residents also participated. A small patient population received direct benefit from on-site physician intervention. CONCLUSION: The on-site emergency physician is of benefit in event preplanning and reducing the burden on the EMS system during mass gathering events.

Surgical cricothyrotomy performed by air ambulance flight nurses: a 5-year experience.

Limited information exists in the current medical literature regarding the performance of surgical cricothyrotomy by flight nurse personnel. We undertook a retrospective review of all flight records from our regional air ambulance service. The flight team transported 2,188 patients during this time; 69 patients required surgical cricothyrotomy for airway access. In all cases, the procedure was performed by a flight nurse working under a predefined airway protocol. Indications for the procedure were predominantly for maxillofacial trauma. A secure airway was established in 98.5% of the cases (68/69). Acute complications involved hemorrhage (3) and placement (3) with a complication rate of 8.7%. We conclude that surgical cricothyrotomy can be performed by well-trained flight nurses with a high success rate and an acceptable complication rate.

Necrotizing myositis and toxic strep syndrome in a pediatric patient.

Group A beta hemolytic streptococcus (GABHS) is a common pathogen in infections of skin, soft tissue structures, and muscle. Most infections, when recognized and treated appropriately, result in a benign course. The development of more virulent forms of this organism have resulted in severe life-threatening infections. The following case of an immunocompetent host with necrotizing myositis and septic shock emphasizes the potential morbidity of GABHS infection. The spectrum of soft tissue and muscle infections is reviewed. The pathophysiology and emergency management of septic shock from GABHS is discussed.

Objectives to direct the training of emergency medicine residents on off-service rotations; radiologic imaging 1: Plain films.

Interpretation of radiologic images is an essential skill for the emergency physician. This is the first of two sets of objectives for an off-service rotation in radiology. It covers the interpretation of plain films. The second series will address commonly used, but more sophisticated, imaging modalities including the use of contrast materials, ultrasound, nuclear medicine, computed tomography, and magnetic resonance imaging. This set of objectives may be used to guide a one-month radiology rotation or serve as part of a teaching program integrated with didactic training and emergency department experience.

Objectives to direct the training of emergency medicine residents on off-service rotations: electrocardiology.

This is a continuing series of objectives to direct resident training in emergency medicine. Electrocardiography may not receive individual attention in many training programs. However, the importance, omnipresence, and medicolegal potential of electrocardiography in the practice of emergency medicine suggests its individual attention. Contents and specific learning objectives are presented to provide guidelines for resident mastery, following the format presented by preceding subjects.

Objectives to direct the training of emergency medicine residents on off-service rotations: emergency medical services.

Emergency Medical Services are an area of special interest in emergency medicine. Many emergency physicians are called upon to direct, train, or manage emergency medical services. Residents training in emergency medicine have a need for a defined curriculum in emergency medical services. Residency training should provide a basic foundation in EMS including on- and off-line medical control, medicolegal aspects, communications, disaster management, and EMS history, structure, and function. The resident must gain experience through on-scene observation, EMT/Paramedic education, medical direction, and quality assurance activities. This paper is one in a continuing series of goals and objectives to direct resident training in off-service rotations. Specific resources, learning objectives, and experiences are suggested.