Can basic life support personnel safely determine that advanced life support is not needed?

OBJECTIVE: To determine whether firefighter/emergency medical technicians-basic (FF/EMT-Bs) staffing basic life support (BLS) ambulances in a two-tiered emergency medical services (EMS) system can safely determine when advanced life support (ALS) is not needed. METHODS: This was a prospective, observational study conducted in two academic emergency departments (EDs) receiving patients from a large urban fire-based EMS system. Runs were studied to which ALS and BLS ambulances were simultaneously dispatched, with the patient transported by the BLS unit. Prospectively established criteria for potential need for ALS were used to determine whether the FF/EMT-B's decision to cancel the ALS unit was safe, and simple outcomes (admission rate, length of stay, mortality) were examined. In the system studied, BLS crews may cancel responding ALS units at their discretion; there are no protocols or medical criteria for cancellation. RESULTS: A convenience sample of 69 cases was collected. In 52 cases (75%), the BLS providers indicated that they cancelled the responding ALS unit because they did not feel ALS was needed. Of these, 40 (77%) met study criteria for ALS: 39 had potentially serious chief complaints, nine had abnormal vital signs, and ten had physical exam findings that warranted ALS. Forty-five (87%) received an intervention immediately upon ED arrival that could have been provided in the field by an ALS unit, and 16 (31%) were admitted, with a median length of stay of 3.3 days (range 1.1-73.4 days). One patient died. CONCLUSION: Firefighter/EMT-Bs, working without protocols or medical criteria, cannot always safely determine which patients may require ALS intervention.

Emergency medical services and cultural determinants of an emergency in Karachi, Pakistan.

OBJECTIVES: The study was conducted to understand the prehospital system in Karachi, the mode of transport that adult inpatients use to reach the emergency departments (EDs), and the barriers to the use of ambulances. METHODS: The study consisted of two parts. The first part involved interviewing the administrators of major ambulance services in Karachi. The second part consisted of a structured interview of randomly selected adult inpatients admitted to one government and one private hospital. RESULTS: Seven ambulance service administrators were interviewed. The interviews revealed that ambulances in Karachi are mainly involved in transporting patients from hospital to hospital or to home. A large number of calls are for transporting dead bodies. A total of 92 patients were interviewed (58 male, 34 female). Admission complaints included abdominal pain (22), blunt trauma (11), penetrating trauma (3), chest pain (6), shortness of breath (4), hematemesis (3), acute focal weakness (4), high fever (4), and other (32). The most common mode of transport to the ED was taxi (53, 58%), followed by private car (21, 23%). Specific reasons for not using ambulances included a perception that the patient was not sick enough (34, 45%), slow response of the ambulance services (17, 23%), not knowing how to find one (8, 11%), and the high cost (6, 8%). CONCLUSION: In case of a medical emergency, most people in Karachi do not use ambulances. The reasons for this low usage include not only poor accessibility, but also cultural barriers and lack of education in recognition of danger signs.

Subcutaneous epinephrine in the prehospital setting.

OBJECTIVES: To outline current practice regarding the prehospital use of subcutaneous epinephrine, and systematically review the existing literature to determine the level of support for its use in the elderly. Many health care personnel are reluctant to administer subcutaneous epinephrine for potentially life-threatening conditions such as asthma and anaphylaxis in older patients. This sytematic review examined the following focused question: "For older patients not known to have coronary artery disease, does administration of subcutaneous epinephrine carry a significant enough risk of cardiovascular side effects to mandate age as a relative contraindication to self-administration or emergency medical services administration in the prehospital setting?" METHODS: The MEDLINE and Health Star databases were searched to identify studies evaluating the use of subcutaneous epinephrine in the treatment of asthma and anaphylaxis. Bibliographies from included studies, known reviews, and textbooks were examined to identify additional studies. The strength of evidence presented in each study was assessed in accordance with the classification system proposed by the American Heart Association's Emergency Cardiovascular Care Committee. RESULTS: The review of the literature revealed only three case reports (level VII evidence) that record adverse reactions of epinephrine when used for anaphylaxis and allergy, while several level III and V studies found no adverse effects when used for asthma. No controlled trials documenting adverse effects were found. CONCLUSIONS: The authors did not find significant evidence to contraindicate the use of subcutaneous epinephrine in older patients who are not known to have coronary artery disease, who present with either asthma or allergic reactions.

Emergency medical services equipment hygiene practices.

OBJECTIVE: To determine whether emergency medical services (EMS) systems adhere to accepted equipment hygiene standards. METHODS: Mail surveys were sent to the physician medical directors of the EMS systems of the 125 most populous cities in the United States. RESULTS: Eighty-five surveys (68%) were returned. Seventy-three (86%) of the responding services have a policy addressing equipment decontamination, and 32 of these (44%) have an accompanying quality assurance program. Seventy-nine (93%) utilize either alcohol or a commercial disinfectant (A/CD) on noncritical items when visibly contaminated with blood. However, only 32 of those agencies (41%) use soap and water in addition to A/CD. Another nine (11%) exchange contaminated items at the hospital, one (1%) uses other methods, and two (2%) respondents did not know. Seventy-six (89%) of the responding agencies perform endotracheal intubation. Of the 54 that decontaminate their own blades, 20 (37%) use soap and water in addition to A/CD, 32 (59%) use A/CD alone, and two (4%) use soap and water alone. CONCLUSION: Adherence to accepted hygiene standards among EMS systems in our most populous cities is poor. Many systems do not use soap and water prior to A/CD. Failure to do so may minimize the effectiveness of disinfection. Several systems use A/CD or soap and water alone, neither of which meets current standards for high-level disinfection recommended for items that will come in contact with mucous membranes, such as laryngoscope blades.

Physician field response: a national survey.

OBJECTIVE: To assess the availability, scope of practice, and training of physician field response (PFR) units for emergency medical services (EMS) systems in the United States. METHODS: The physician medical directors of EMS systems in the 125 most populous U.S. cities were surveyed by mail, with a second mailing and phone follow-up to nonresponders. In cities that listed multiple services, a survey was sent to each. RESULTS: One hundred sixty-eight surveys were mailed, and 121 responses were received (72%), representing 109 of the 125 cities (87%). Seventy-seven cities (71%) reported having no PFR capability. Of the 32 (29%) with some type of PFR, two reported having a dedicated field response unit, while 30 had an "on-call" system from the hospital or home. Staffing patterns were highly variable, with no dominant pattern. The number of annual PFR responses ranged from 0 to 10,000 (median 15, IQR 3-200). All systems reported that their PFR unit was well accepted by EMS providers. The following scope-of-practice items were reported (n = 30): physician triage, 30 teams (94%); on-scene medical direction, 14 (47%); amputation, six (20%); tube thoracostomy, 12 (40%); and blood administration, 29 (97%). The following training requirements for physician team members were reported (n = 32): incident command system, 15 (47%); emergency vehicle operations, 12 (38%); hazardous materials, 13 (41%); vehicle rescue/extrication, seven (22%); confined space medicine, four (13%); and none 12 (38%). CONCLUSION: There is a wide variability in the availability, training, and scope of practice of PFR units across the country. No standardization or trends could be detected.

Cancellation of responding ALS units by BLS providers: a national survey.

OBJECTIVE: In many emergency medical services (EMS) systems, personnel without advanced life support (ALS) training are authorized to cancel responding ALS units before the ALS personnel arrive and examine the patient. This study was conducted to examine these cancellations in major U.S. cities. METHODS: A survey was mailed to the physician medical directors of the EMS services of the 125 largest U.S. cities, with telephone follow-up of nonresponders. The survey requested information on system structure, and on policies governing cancellation of responding ALS units by non-ALS personnel. RESULTS: Ninety-four cities responded (75%), from 35 states. Nineteen systems (20%) are all-ALS with no basic life support (BLS) tier, and these were eliminated. Of the remaining 75 systems, eight (11%) use BLS ambulances (BLS-A), 35 (47%) use BLS first responders (BLS-FR), and 32 (43%) use both. Of these 75 systems, 60 (80%) allow cancellation of responding ALS units by BLS personnel. Only 24 of these (40%) have written protocols for such cancellations, and only 12 of those (50%) involve specific medical criteria, with two (8%) relying on the best judgment of the BLS personnel with no medical criteria, and another eight (33%) allowing cancellation only for logistic reasons. Of the 60 systems that permit cancellation, 13 (22%) perform some type of medical oversight review of all such calls, 26 (43%) review some such calls (median 10%, range 2-80% for the 19 systems specifying a percentage), 15 (25%) do not review any, and six did not specify. CONCLUSIONS: Fewer than half of the surveyed EMS systems that permit non-ALS personnel to cancel responding ALS units use written protocols to guide these decisions, and only half of those protocols utilize specific medical criteria. Medical oversight review of these calls is highly variable, with many systems reviewing few or none of these cancellations.

Termination of resuscitation in the prehospital setting for adult patients suffering nontraumatic cardiac arrest. National Association of EMS Physicians Standards and Clinical Practice Committee.

The National Association of EMS Physicians (NAEMSP) supports out-of-hospital termination of resuscitation for adult, nontraumatic cardiac arrest patients who have not responded to full resuscitative efforts. The following factors should be considered in establishing termination of resuscitation protocols: 1) Termination of resuscitation may be considered for any adult patient who suffers sudden cardiac death that is likely to be medical. 2) Unwitnessed cardiac arrest with delayed initiation of cardiopulmonary resuscitation (CPR) beyond 6 minutes and delayed defibrillation beyond 8 minutes has a poor prognosis. 3) In the absence of "do not resuscitate" or advanced directives, a full resuscitative effort including CPR, definitive airway management, medication administration, defibrillation if necessary, and at least 20 minutes of treatment following Advanced Cardiac Life Support (ACLS) guidelines should be performed prior to declaring the patient dead. 4) A patient whose rhythm changes to, or remains in, ventricular fibrillation or ventricular tachycardia should have continued resuscitative efforts. Patients in asystole or pulseless electrical activity should be strongly considered for out-of-hospital termination of resuscitation. 5) Logistic factors should be considered, such as collapse in a public place, family wishes, and safety of the crew and public. 6) Online medical direction should be established prior to termination of resuscitation. The decision to terminate efforts should be a consensus between the on-scene paramedic and the online physician. 7) The on-scene providers and family should have access to resources, such as clergy, crisis workers, and social workers. 8) Quality review is necessary to ensure appropriate application of the termination protocol, law enforcement notification, medical examiner or coroner involvement, and family counseling.

Now that we have the Utstein style, are we using it?

OBJECTIVES: To examine the extent to which the Utstein style has been used for out-of-hospital cardiac arrest (OOHCA) research since its publication in 1991. The style was developed in an effort to standardize OOHCA research and reporting. METHODS: To locate all OOHCA research papers published between 1992 and 1997, all issues of six emergency medicine/emergency medical services (EM/ EMS) journals were examined manually, and papers from other journals were located using computerized searches. All located articles were examined by the first author to determine whether use of the Utstein style was indicated and if so, whether it had actually been used. When either of these was uncertain, all three authors reviewed the paper, and a consensus was reached. The Pearson chi-square test was used to compare rates of use from U.S. and non-U.S. institutions, and from the EM/EMS and non-EM/EMS literature, with significance set at p < 0.05. RESULTS: All 143 OOHCA research articles identified by the search were examined. The Utstein style was found to be not applicable to 41 (29%), and these were eliminated. The Utstein style was indicated for the remaining 102 studies. Of these, 41 (40%) used the Utstein style, and 61 (60%) did not. There was no difference in rates between papers from sites in the United States (18/48, 38%) and elsewhere (23/54, 43%), or between papers from the EM/EMS literature (17/44, 39%) and non-EM/EMS literature (25/59, 42%). Despite an upward trend in the use of the Utstein style seen from 1992 to 1994, use leveled off from 1994 to 1997, and has not exceeded 60% in any given calendar year studied. CONCLUSIONS: Six years after the release of the Utstein style for OOHCA research, fewer than 60% of OOHCA research articles actually use the style.

EMS systems: foundations for the future.

Emergency medical services (EMS) occupy a unique position in the continuum of emergency health care delivery. The role of EMS personnel is expanding beyond their traditional identity as out-of-hospital care providers, to include participation and active leadership in EMS administration, education, and research. With these roles come new challenges, as well as new responsibilities. This paper was developed by the SAEM EMS Task Force and provides a discussion of these new concepts as well as recommendations for the specialty of emergency medicine to foster the continued development of all of the potentials of EMS.

Current practice in clinical cervical spinal clearance: implication for EMS.

OBJECTIVES: To examine the practice of clinically "clearing" the cervical spine (c-spine) of trauma patients brought to the ED by EMS with cervical immobilization in place, and to examine developing trends in prehospital c-spine clearance. METHODS: A 12-question survey form was mailed to the physician medical directors of 300 randomly selected EDs. Questions examined ED clinical clearance practices, EMS clearance protocols and research, and attitudes toward prehospital clearance. Estimated clinical clearance rates were requested. RESULTS: A total of 173 surveys were returned (58%). At 21 hospitals (12%), c-spine films are obtained for all immobilized trauma patients; clinical clearance is never attempted. Of the remaining 151 hospitals, on average, clinical clearance is attempted for 65.5% of these patients (range 3-100%, interquartile range 50-100%) and is successful (films are not obtained) for 53.7% of attempts (range 0-100%, interquartile range 35-75%). No differences exist in either attempt rate or success rate between trauma centers and non-trauma centers, or between academic/university hospitals, community teaching hospitals, and community non-teaching hospitals (t-test or ANOVA, p > 0.05). Seventy-two respondents (42%) reported significant variation in clinical clearance practice patterns among their ED physicians. Seventy-three respondents (42%) feel that EMS providers should immobilize all trauma patients, while 99 (57%) feel it is reasonable for trained EMS providers to attempt clinical clearance on low-risk trauma patients. CONCLUSIONS: There is tremendous variation in the ED practice of clinically clearing cervical spines. This, and a lack of support from many ED directors, may hinder attempts at development of research and standardized protocols for pre-hospital c-spine clearance.

Injuries to emergency medicine residents on EMS rotations.

OBJECTIVES: To study the incidence and nature of injuries sustained by emergency medicine (EM) residents during EMS rotations, and steps taken at EM residency programs to increase resident safety during field activities. METHODS: An eight-question survey form was mailed to all 114 U.S. EM residency directors, with a second mailing to nonresponders eight weeks after the initial mailing. RESULTS: A total of 105 surveys were returned (92%). Six surveys were from new programs whose residents have not yet rotated on EMS. These were excluded from further analysis, leaving 99 programs. Of these, 91 (92%) reported no injuries. One EM resident died in a helicopter crash in 1985. Seven other injury events were reported: 1) facial lacerations, rib fractures, and a shoulder injury in an ambulance accident; 2) an open finger fracture (crushed by a backboard); 3) contusions and a concussion when an ambulance was struck by a fire engine; 4) a groin pull sustained while entering a helicopter; 5) bilateral metatarsal fractures in a fall; 6) rib fractures, a pneumothorax, and a concussion in an ambulance accident; and 7) "minor injuries" sustained in a crash while responding to a scene in a program-owned response vehicle. Actions taken at residency programs to reduce the risk of injury include the use of ballistic vests (four programs), requiring helmets on flights (five programs), and changing flight experience from mandatory to optional (two programs). Ten programs (10%) reported using ground scene safety lectures, and nine programs (15% of those offering flights) reported various types of flight safety instruction. Sixty-nine programs (70%) reported no formal field safety training or other active steps to increase resident safety on EMS rotations. CONCLUSIONS: Injuries sustained by EM residents during EMS rotations are uncommon but nontrivial, with several serious injuries and one fatality reported. The majority of EM residency programs have no formal safety training programs for EMS rotations.

A time-motion study of the emergency medical services turnaround interval.

STUDY OBJECTIVE: Because overall EMS system response depends on ambulance availability, we conducted a prospective study of the EMS turnaround interval. This interval represents the time elapsed from ambulance arrival at the hospital until the ambulance reports back in service. METHODS: An on-site observer, while monitoring EMS radio traffic, recorded the delivery and recovery activities of personnel from a large urban EMS system at a university hospital emergency department. System policy permitted a maximum turnaround interval of 30 minutes. Prospectively defined subintervals were analyzed. RESULTS: A convenience sample of 122 patient deliveries was collected. Observed and radio-reported times of arrival at the hospital differed by -1'24" to +11'08". In 18.9% of cases, arrival was reported on radio more than 5 minutes after the observed arrival. Time from arrival to removal of the patient from the ambulance averaged 59" (range, 13" to 2'53"), and time from patient removal to emergency department entry averaged 42" (range, 10" to 5'22"). Time from ED entry to placement of the patient on an ED bed averaged 2'11" (range, 33" to 9'35"). Although the mean interval for the verbal report to ED staff was 33" (range, 13" to 2'53"). it was 15" or less in 36% of cases. Writing the ambulance call report took an average of 17'12" (range, 5'20" to 52'11"). The mean time off radio was 29'51" (range, 11'43" to 53'37"), and the mean time the ambulance was actually at the ED was 30'01" (range, 11'25" to 1 degree 17'53"). Observed and radio-reported ambulance departure times differed by -4'31" to +23'32". In 22% of cases, departure times differed by -4'31" to +23'32". In 22% of cases, departure was reported by radio more than 5' after actual departure. CONCLUSION: In this system, ambulance call report documentation required the greatest subinterval of turnaround interval. The turnaround interval and its subintervals varied widely, and radio contact times correlated poorly with observed times at the ED. Attempts at improvement of overall system response through active management of the turnaround interval may be frustrated by reliance on radio-reported availability.