Effectiveness of and Adherence to Triage Algorithms During Prehospital Response to Mass Casualty Incidents.

Mass casualty incidents (MCIs) can rapidly exhaust available resources and demand the prioritization of medical response efforts and materials. Principles of triage (i.e., sorting) from the 18th century have evolved into a number of modern-day triage algorithms designed to systematically train responders managing these chaotic events. We reviewed reports and studies of MCIs to determine the use and efficacy of triage algorithms. Despite efforts to standardize MCI responses and improve the triage process, studies and recent experience demonstrate that these methods have limited accuracy and are infrequently used.

Paramedic Pain Management Practice with Introduction of a Non-opiate Treatment Protocol.

INTRODUCTION: There is concern about the initiation of opiates in healthcare settings due to the risk of future misuse. Although opiate medications have historically been at the core of prehospital pain management, several states are introducing non-opiate alternatives to prehospital care. Prior studies suggest that non-opiate analgesics are non-inferior to opiates for many acute complaints, yet there is little literature describing practice patterns of pain management in prehospital care. Our goal was to describe the practice patterns and attitudes of paramedics toward pain management after the introduction of non-opiates to a statewide protocol. METHODS: This study was two-armed. The first arm employed a pre/post retrospective chart review model examining medication administrations reported to the Massachusetts Ambulance Trip Information System between January 1, 2017-December 31, 2018. We abstracted instances of opiate and non-opiate utilizations along with patients' clinical course. The second arm consisted of a survey administered to paramedics one year after implementation of non-opiates in the state protocol, which used binary questions and Likert scales to describe beliefs pertaining to prehospital analgesia. RESULTS: Pain medications were administered in 1.6% of emergency medical services incidents in 2017 and 1.7% of incidents in 2018. The rate of opiate analgesic use was reduced by 9.4% in 2018 compared to 2017 (90.6% vs 100.0%). The absolute reduction in opiate use in 2018 was 3.6%. Women were less likely (odds ratio [OR] = 0.78, 95% confidence interval [CI], 0.69-0.89) and trauma patients were more likely to receive opiates (OR = 2.36, CI, 1.96-2.84). Mean transport times were longer in opiate administration incidents (36.97 vs 29.35 minutes, t = 17.34, p<0.0001). We surveyed 100 paramedics (mean age 41.98, 84% male). Compositely, 85% of paramedics planned to use non-opiates and 35% reported having done so. Participants planning to use non-opiates were younger and less experienced. Participants indicated that concern about adverse effects, efficacy, and time to effect impacted their practice patterns. CONCLUSION: The introduction of non-opiate pain medication to state protocols led to reduced opiate administration. Men and trauma patients were more likely to receive opiates. Paramedics reported enthusiasm for non-opiate medications. Beliefs about non-opioid analgesics pertaining to adverse effects, onset time, and efficacy may influence their utilization.

Characteristics of Patients with Recurrent Emergency Medical Services Utilization for Symptomatic Hypoglycemia in an Urban Setting.

Background: Symptomatic hypoglycemia frequently results in utilization of emergency medical services (EMS). Understanding the characteristics of hypoglycemic patients with high EMS utilization may help providers optimize resource allocation. Objective: To describe characteristics of patients utilizing EMS for hypoglycemia and to determine if any factors identifiable in the prehospital setting are associated with recurrent EMS utilization. Methods: A retrospective chart review of prehospital care records from an urban EMS system was performed. Patients who received oral glucose, parenteral glucose, or intramuscular glucagon for hypoglycemia over a one-year period were identified. Extracted information included demographics, prehospital treatment, disposition, zip code median income, and the number of subsequent EMS utilizations within 365 days. Results: We identified 549 subjects, mean age 55 years (range 5 to 104, 65% male). The mean glucose level for all patients was 44 mg/dl with standard deviation (SD) of 15. In total, 69% of patients received oral glucose, 26% received parenteral glucose, 3% received glucagon, and 2% received more than one medication. At the index visit, 81% of patients accepted hospital transportation. The rate of recurrent EMS utilization for hypoglycemia was 10%, and 3% of patients had 3 or more repeat utilizations within 365 days. The mean finger-stick glucose at index visit was 39 mg/dL (SD 15) for patients with multiple EMS utilizations and 44 mg/dL (SD 14) for those with one EMS visit (P = 0.006). Repeat utilizers were more likely to have received medications other than oral glucose at index visit, 51% vs. 28% (P < 0.001). Age, gender, median zip code income, and disposition were not associated with recurrent EMS utilization. The overall annual rate of hypoglycemia requiring EMS treatment per estimated diabetic population was 0.84%. Conclusion: A low proportion of patients utilizing EMS for hypoglycemia had subsequent EMS visits within 365 days. Those who did had lower initial blood glucose at the index visit and were more likely to have received prehospital treatment with medications other than oral glucose. Demographic characteristics did not yield any patterns predictive of repeat utilization. Refusing transport to the hospital after EMS treatment for hypoglycemia did not increase the risk of recurrent utilization.

Tourniquet Use in a Civilian Emergency Medical Services Setting: A Descriptive Analysis of the Boston EMS Experience.

INTRODUCTION: Despite the resurgence of early tourniquet use for control of exsanguinating limb hemorrhage in the military setting, its appropriate role in civilian emergency medical services (EMS) has been less clear. OBJECTIVE: To describe the experience of prehospital tourniquet use in an urban, civilian EMS setting. METHODS: A retrospective review of EMS prehospital care reports was performed from January 1, 2005 to December 1, 2012. Data, including the time duration of prehospital tourniquet placement, EMS scene time, mechanisms of injury, and patient demographics, underwent descriptive analysis. Outcomes data for participating receiving hospitals were also reviewed. RESULTS: Ninety-eight cases of prehospital tourniquet use were identified. The most common causes of injury were penetrating gunshot or stabbing wounds (67.4%, 66/98); 7.1% (7/98) of cases were due to blunt trauma; 23.5% (23/98) of cases were from nontraumatic hemorrhage related to uncontrolled hemodialysis shunt or wound bleeding; 45.4% (44/97) of cases were placed on a lower extremity; 54.6% (53/97) were placed on an upper extremity. Placement was successful in hemorrhage control in 91% (87/95, 95%CI: 85.9-97.3%) of cases. The average prehospital tourniquet placement time was 14.9 minutes. Half of all tourniquet placements were performed by basic life support providers. Hospital follow-up was available for 96.9% (95/98) of cases. Of these, the tourniquet was removed by EMS in 3.2% (3/95), the emergency department in 54.7% (52/95), or in the operating room (OR) in 31.6% (30/95) of the time; 46.7% (14/30) of these OR cases had a documented vascular injury needing repair. Ten deaths with hospital follow-up data were identified, none of which were due to tourniquet use. There was one case of forearm numbness potentially due to nerve injury and one case with potential vascular complication, representing an overall complication rate of 2.1% (2/95). CONCLUSION: The early use of tourniquets for extremity hemorrhage in an urban civilian EMS setting appears to be safe, with complications occurring infrequently.

The impact of heat waves on transport volumes in an urban emergency medical services system: a retrospective review.

INTRODUCTION: Heat waves pose a serious public health risk to particular patient populations, especially in urban areas. Emergency Medical Services (EMS) in many urban areas constitute the first line of regional preparation and response to major heat wave events; however, little is known on heat wave operational impact to the EMS system, such as call volume or demand. OBJECTIVE: To examine the effect of heat wave periods on overall urban EMS system call volume and transport volume as well as the nature of the call types. METHODS: Retrospective review of all emergency medical calls to an urban, two-tiered EMS system performed over a 5-year period from 2006-2010. Heat wave days (HWD) defined as two or more consecutive days of hot weather >32.2°C (90°F) were compared with similar non-heat wave days (nHWD) of the previous year to also include two calendar days prior to and after the heat wave. National Weather Service (NWS) temperature data, daily EMS call volume data, and call type codes were collected and underwent descriptive analysis. RESULTS: Thirty-one HWD were identified and compared with 93 nHWD. The mean maximum temperature for HWD was 34°C (93.2°F) compared with 25.3°C (77.6°F) for nHWD (P < .001). Average daily medical emergency calls (318.4 vs 296.3, P < .001) and actual patients transported per day (247.5 vs 198.3, P < .001) were significantly higher during HWD. There was no difference in daily medical emergency call volume or EMS transports between weekdays or weekend days. No significant differences on various call types were observed between HWD and nHWD except for "heat" related calls (7.7 vs 0.5, P < .001). CONCLUSION: Emergency Medical Services call volumes were significantly increased during heat waves, however there was minimal change in the types of calls received.