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.

A 48-year-old man with severe shortness of breath.

A 48-year-old man was found by his neighbor unconscious on the floor at his residence. Earlier in the day, his neighbor reported noticing the patient was becoming more short of breath and having some trouble speaking. The neighbor alerted EMS. Upon EMS arrival, the patient was tachypneic with a room air O2 saturation in the 60s. A LifeFlight helicopter responded to transfer this patient to a tertiary care center from his home in a rural farming community.

Metastatic epidural spinal cord compression.

Metastatic epidural spinal cord compression (MESCC) occurs when cancer metastasises to the spine or epidural space and causes secondary compression of the spinal cord. MESCC is a common complication of malignancy that affects almost 5% of patients with cancer. The most common symptom is back pain. MESCC is a medical emergency that needs rapid diagnosis and treatment if permanent paralysis is to be prevented: the diagnosis of MESCC is best made with MRI; and corticosteroids, radiation therapy, and surgery are all established treatments. Future research will focus on prevention, improving detection, and the development of new treatments.

King airway use by air medical providers.

BACKGROUND: In cases of difficult or failed endotracheal intubation (ETI), alternate airways are designed to provide adequate oxygenation and ventilation until a definitive airway can be established. The King Laryngeal Tube Disposable (LTD) is a new superglottic alternate airway. OBJECTIVE: To describe the use, rates of success, and outcomes of the King airway by highly skilled prehospital providers. METHOD: In this retrospective analysis, we examined prehospital King airway use by a large regional air medical service for the period from March 2006 to December 2006. Rescuers used alternate airways after three unsuccessful ETI attempts or in situations of anticipated ETI difficulty. We identified clinical characteristics, described airway difficulties, and determined the success of airway placement. Where available, we evaluated the hospital course and outcomes. RESULTS: Of 575 ETI, alternate airways were used in 27 cases, including 26 King airway placements (4.5%, 95% CI: 3.0-6.6%). All were successfully placed; 24 required one attempt, and two required more than one attempt. No immediate complications were observed. No prehospital surgical airways were performed. Follow-up data were available for 15 of 26 patients. Five patients were in cardiac arrest and did not survive to hospital admission. Many of the patients required specialized efforts from anesthesia or surgery for definitive airway management with 40% (4/10) requiring emergent tracheostomy. CONCLUSION: In this series of critically ill patients, air medical providers successfully used the King airway as an alternate airway device. Definitive airway management was complicated and required specialized efforts from surgery and anesthesia.

Minimally invasive lumbar discectomy in obese patients.

OBJECTIVE: To assess patient outcomes and complication rates after minimally invasive lumbar microdiscectomy in an obese patient population. METHODS: A retrospective clinical review of 32 patients with a body mass index of 30 kg/m or greater undergoing lumbar minimally invasive discectomy was performed. The initial chart review was followed by phone interview if all information could not be obtained from chart review. Demographic and pertinent pre-, peri-, and postoperative data were obtained. RESULTS: Favorable clinical outcomes were obtained in all patients except one, indicating that they would undergo operative intervention again. Most patients reported minimal or no leg or back pain. Twenty-five of the patients did not require any chronic analgesia. The overall complication rate was 12.5%. Two patients had recurrent disc herniations requiring reoperation and one patient required fusion for a pars defect and subsequent subluxation. CONCLUSION: Lumbar minimally invasive discectomy is our preferred surgical technique for symptomatic disc herniations in this patient population. Decreased incision length and a trend toward reduced infectious complications are the primary reasons. We feel that, given the comorbidities often found in this patient population, a minimally invasive technique will supplant open approaches in the near future.

EMS and emergency department physician triage: injury severity in trauma patients transported by helicopter.

BACKGROUND: Many trauma patients who are not severely injured arrive at trauma centers via helicopter emergency medical services (HEMS). OBJECTIVE: To compare the injury severity of patients sent to trauma centers by HEMS from community emergency departments (EDs) with the injury severity of those triaged by prehospital providers to HEMS directly from accident scenes. METHODS: All records were reviewed from trauma-related missions during 1997for a single HEMS system, extracting information on location, time of day, patient age and gender, mechanism of injury, initial vital signs, Revised Trauma Score (RTS), and the extent of care required during transport. These records were then matched with outcome information routinely supplied to the HEMS system by affiliated trauma centers. Information from patients flown directly from scenes was then compared with that for patients flown from community EDs. RESULTS: Information was obtained for 658 patients flown from scenes and 345 flown from community EDs. There were similar proportions of patients in the two groups, with Injury Severity Scale (ISS) scores less than 6 (11.0% vs. 13.5%), between 6 and 14 (47.0% vs. 49.3%), and greater than 15 (42.0% vs. 37.1%); these were not statistically different (p > 0.05). There was also no significant difference between the groups in the RTS, mean ISS score, intensive care unit length of stay, hospital length of stay, or disposition. CONCLUSIONS: Scene and interhospital HEMS trauma missions in this system involve patients of similar injury severities. Prehospital providers may triage trauma patients to HEMS transport with proficiency similar to that of community ED physicians.