Results of a 4-hour endotracheal intubation class for EMT-basics.

STUDY OBJECTIVE: In 1994, the Department of Transportation made endotracheal intubation an optional EMT-Basic skill. To data, there have been no studies addressing the ability of this group to learn or perform this skill. We used a standarized mannequin test to perform a prospective evaluation of this intubation skills of basic EMTs immediately after a 4-hour course on endotracheal intubation. We hypothesized that the intubation success rates would be comparable with those of other types of providers newly trained in this skill. METHODS: Eighty-three EMTS were selected/recruited from four EMS provider agencies. Ninety-six percent of the EMTs were men, and the average age was 38 years; average length of EMT experience was 9.4 years. Training was provided in classes of 6 to 14 persons and included 1 hour of didactic instruction, a 1-hour demonstration of intubation techniques, and 90 minutes of supervised practice with the mannequins in groups of 2 to 4 persons. Testing followed American Heart Association guidelines. Interrater reliability of test criteria was assessed. RESULTS: Ninety-four percent (95% confidence interval 86% to 98%) of the EMTs passed the examination by intubating the mannequin within 35 seconds within 3 attempts. Of the successful EMTs, 94% succeeded on their first attempt, 3% on their second attempt, and 3% on their third. There were three esophageal intubations; all were detected immediately. Interrater agreement was 100% on the pass/fail decision. CONCLUSION: This 4-hour class trained basic EMTs to perform endotracheal intubation on mannequins with a success rate of 94%. Further research should confirm the ability of EMT-Basics to detect esophageal intubation and address the retention of intubation skills, the applicability of these skills to the field, and the components of this course that were responsible for its success.

Differential front and back seat safety belt use by prehospital care providers.

The object of the study was to assess the habits and attitudes of prehospital care personnel regarding safety belt use in the front and rear ambulance compartments. Therefore, a cross-sectional descriptive survey was administered at emergency medical service conferences and through provider agencies throughout the United States and Canada. Approximately 900 public, private, and volunteer prehospital care providers participated. Demographic information, traffic collision history, percent of time safety belts were used, belief in safety belt use, and reasons for nonuse in the rear compartment of the ambulance were measured. The results showed that safety belt use was highest in the front seat during emergency runs (median, 100%) and rarest in the back compartment during emergency runs (median, 0%). Respondents cited the following reasons for non-use in the rear compartment: inhibited patient care (67.9%), restricted movement (34.7%) inconvenience (15.1%), or lack of efficacy (5.3%). Prehospital care personnel typically wear safety belts when in the front seat, but not while in the rear compartment of the ambulance. More intensive efforts at educating prehospital care providers about the importance of safety restraints in the rear compartment, enumerating patient care activities that can be performed while wearing a safety belt, and design of a functional restraint system for the rear compartment may increase ambulance safety.

Spinal immobilization on a flat backboard: does it result in neutral position of the cervical spine?

STUDY OBJECTIVES: To determine the amount of occipital padding required to achieve neutral position of the cervical spine when a patient is immobilized on a flat backboard. Neutral position was defined as the normal anatomic position of the head and torso that one assumes when standing looking straight ahead. DESIGN: Descriptive with hypothesis testing of selected descriptive elements. SETTING: University campus and hospital. SUBJECTS: One hundred healthy young adults with no history of back disease. INTERVENTIONS: Volunteers were measured in standing and supine positions. MEASUREMENTS: Occipital offset; height; weight; and head, neck, and chest circumferences were measured for each subject. MAIN RESULTS: The amount of occipital offset required to achieve neutral position varied from 0 to 3.75 in. (mean, 1.5 in.). Mean occipital offset for men (1.67 in.) was significantly greater than that for women (1.31 in.) Easily obtained body measurements did not accurately predict occipital offset. CONCLUSION: Immobilization on a flat backboard would place 98% of our study subjects in relative cervical extension. Occipital padding would place a greater percentage of patients in neutral position and increase patient comfort during transport.

Rapid volume infusion in prehospital care.

The ability to deliver large volumes of intravenous (IV) fluids may be critical to the successful prehospital resuscitation of hypovolemic patients. We compared the time required to deliver one liter of crystalloid solution, using an administration set-up consisting of a 16-gauge (g), 1.25 inch, intravenous cannula, a pneumatic pressure bag, and either conventional intravenous tubing (3.2 mm internal diameter [ID]) or large bore (4.4 mm internal diameter [ID]) "shock" tubing. With the fluid bag positioned at 110cm (46 inches) above the level of the cannula, the mean elapsed time to deliver 1,000ml using the conventional tubing set-up was 6.0 minutes, while the same volume could be delivered in only 2.7 minutes with the shock tubing configuration. This time was reduced to 1.8 minutes when the intravenous cannula size was increased to 14g. By attaching a liter of fluid to each arm of the "Y" adapter of the shock tubing, virtually uninterrupted fluid flow may be maintained at this rate. We feel this intravenous configuration could enhance greatly the ability of paramedics to provide fluid resuscitation in the field setting. When such IVs are established en route to a receiving hospital, this technique may prove to be an important adjunct to improving patient outcome from hypovolemic shock.

Impact of urban disaster on a university trauma center.

On the eve of the 1984 Summer Olympics, a deranged man drove his car at high speed onto a pedestriancrowded sidewalk in a suburb of Los Angeles. The UCLA Medical Center, located two blocks from the scene, received 17 of 51 casualties. One patient arrived in full cardiac arrest and could not be resuscitated. Six had minor injuries or temporary hysteria and did not require admission to hospital. The mean injury severity score of the 10 patients who were admitted was 13.6 (range 3 to 48). Three patients required immediate surgical procedures, and two had delayed orthopedic operations. Specialty consultations were needed in orthopedics, neurosurgery, plastic surgery, otolaryngology, pediatric surgery, and pediatric intensive care. There were no subsequent deaths, although two patients had substantial residual neurologic disability. This episode of unexpected urban violence underscores the need for dedicated trauma services in university centers. Functions of such services include disaster planning, deploying surgical personnel, managing injured patients, and analyzing outcomes.

Efficacy of cervical spine immobilization methods.

Cervical spine immobilization devices are widely used to stabilize the cervical spine and prevent neurologic deficits associated with unstable fractures. In order to quantitate their efficacy we measured controlled cervical spine motion in three axes, using six different immobilization methods in 25 volunteers instructed to actively move their necks as much as possible in the directions of flexion, extension, rotation, and lateral bending while lying supine. Control measurements were made with no device and measurements were repeated following immobilization with: soft collar (SC), hard collar (HC), extrication collar (EC), Philadelphia collar (PC), bilateral sandbags joined with 3-inch cloth tape across the forehead (ST), and the combination of sandbags, tape, and the Philadelphia collar (ST/PC). Neck movements were reported in degrees recorded on a hand-held goniometer. There were no significant differences between control and SC measurements except in rotary movement. PC was not significantly better than the other two types of hard collars, except in limiting extension. ST immobilization was significantly better than any of the other four methods used alone, for all four movements. The addition of PC to ST was significantly more effective in reducing extension only.