Transition From Military Prehospital Medicine to Civilian EMS.

INTRODUCTION: Currently, there is a disconnection between veteran military medics and the civilian Emergency Medical Services (EMS) workforce. This project aimed to characterize the rate of civilian certification among military medics, both active duty and retired, and identify perceived barriers to continuing a career in EMS after military separation. MATERIALS AND METHODS: The National Association of Emergency Medical Technicians (EMTs) administered a 21-question online survey to participants. Individuals were recruited through the National Association of EMTs membership communications, Military Relations Committee members, and social media. All responses were anonymous and no identifiable information was collected. Survey questions were compiled and reported as a percentage of respondents. Free-text responses were categorized based on broad themes identified by the authors and are reported as a percentage of respondents. RESULTS: Results included 456 veteran and active duty respondents, of whom 304 (70.7%) had prehospital experience while in the military and 250 (58.1%) had emergency department experience. Over 60% of respondents participated in combat-related duty with 37% having at least 18 months of overseas deployment. Civilian EMT certification was held by 164 (36.7%) survey participants and 170 held paramedic certification (38.1%), while 65 (14.6%) held no EMS certification. There were 119 (28.1%) respondents who stated that they did not plan to work in civilian EMS. Top selected reasons for not pursuing civilian EMS careers included: pursuing a medical career that was not prehospital (28.5%), pay disparity (18.1%), and no interest in civilian prehospital medicine (16.4%). Write in responses indicated general frustration with maintaining certification and a desire for advanced certification (AEMT, paramedic) to be supplied by the military prior to transitioning to a civilian workforce as many respondents felt their military-endowed skills and experiences were better aligned with these advanced EMS licenses. CONCLUSION: The majority of survey respondents held an EMS certification of some kind and suggests that recent efforts to supply military medics with civilian certifications have been largely successful. However, there is still a large portion that remains noncertified or expresses disinterest with entering the civilian workforce. Generally, many of those certified feel their military scope of practice exceeded civilian EMT certification and requested AEMT or paramedic licensure opportunities while still active duty military.

Prehospital blunt traumatic arrest resuscitation augmented by whole blood: a case report.

BACKGROUND: Prehospital hemorrhagic shock accounts for approximately 25,000 civilian deaths annually in the United States. A balanced, blood-based resuscitation strategy is hypothesized to be the optimal treatment for these patients. Due to logistical constraints, delivering a balanced, blood-based resuscitation is difficult in the prehospital setting. A low titer O+ whole blood (LTO+ WB) ground ambulance initiative, may help alleviate this capability gap. CASE REPORT: A 37-year-old female was involved in a motor vehicle collision at approximately 16:30. While she was trapped inside the vehicle, her mental status deteriorated. The patient was successfully extricated at 17:04 and found to be in cardiac arrest. The paramedics and firefighters quickly secured her airway and applied a mechanical CPR device. The first responder team obtained return of spontaneous circulation, but the patient's blood pressure was 43/27 mmHg. The paramedics transfused one unit of LTO+ WB. Twenty-one minutes after the initial LTO+ WB transfusion, the air ambulance team transfused a second unit of LTO+ WB. Upon hospital arrival, the transfusion was completed, and the patient's shock index improved to 1.0. The trauma team identified a grade 5 splenic injury with active extravasation. Interventional radiology performed an angiogram and successfully embolized the tertiary branches of the inferior splenic pole. She was extubated on postinjury Day one and discharged to her home neurologically intact on postinjury Day 12. CONCLUSION: The prehospital availability of LTO+ WB may enhance the resuscitation of critically ill trauma patients.

Use of intrathoracic pressure regulation therapy in breathing patients for the treatment of hypotension secondary to trauma.

BACKGROUND: Intrathoracic pressure regulation (IPR) therapy has been shown to increase blood pressure in hypotensive patients. The potential value of this therapy in patients with hypotension secondary to trauma with bleeding is not well understood. We hypothesized that IPR would non-invasively and safely enhance blood pressure in spontaneously breathing patients with trauma-induced hypotension. METHODS: This prospective observational cohort study assessed vital signs from hypotensive patients with a systolic blood pressure (SBP) ≤90 mmHg secondary to trauma treated with IPR (ResQGARD™, ZOLL Medical) by pre-hospital emergency medical personnel in three large US metropolitan areas. Upon determination of hypotension, facemask-based IPR was initiated as long as bleeding was controlled. Vital signs were recorded before, during, and after IPR. An increased SBP with IPR use was the primary study endpoint. Device tolerance and ease of use were also reported. RESULTS: A total of 54 patients with hypotension secondary to trauma were treated from 2009 to 2016. The mean ± SD SBP increased from 80.9 ± 12.2 mmHg to 106.6 ± 19.2 mmHg with IPR (p < 0.001) and mean arterial pressures (MAP) increased from 62.2 ± 10.5 mmHg to 81.9 ± 16.6 mmHg (p < 0.001). There were no significant changes in mean heart rate or oxygen saturation. Approximately 75% of patients reported moderate to easy tolerance of the device. There were no safety concerns or reported adverse events. CONCLUSIONS: These findings support the use of IPR to treat trauma-induced hypotension as long as bleeding has been controlled.

A randomized control hands-on defibrillation study-Barrier use evaluation.

INTRODUCTION: Chest compressions and defibrillation are the only therapies proven to increase survival in cardiac arrest. Historically, rescuers must remove hands to shock, thereby interrupting chest compressions. This hands-off time results in a zero blood flow state. Pauses have been associated with poorer neurological recovery. METHODS: This was a blinded randomized control cadaver study evaluating the detection of defibrillation during manual chest compressions. An active defibrillator was connected to the cadaver in the sternum-apex configuration. The sham defibrillator was not connected to the cadaver. Subjects performed chest compressions using 6 barrier types: barehand, single and double layer nitrile gloves, firefighter gloves, neoprene pad, and a manual chest compression/decompression device. Randomized defibrillations (10 per barrier type) were delivered at 30 joules (J) for bare hand and 360J for all other barriers. After each shock, the subject indicated degree of sensation on a VAS scale. RESULTS: Ten subjects participated. All subjects detected 30j shocks during barehand compressions, with only 1 undetected real shock. All barriers combined totaled 500 shocks delivered. Five (1%) active shocks were detected, 1(0.2%) single layer of Nitrile, 3(0.6%) with double layer nitrile, and 1(0.2%) with the neoprene barrier. One sham shock was reported with the single layer nitrile glove. No shocks were detected with fire gloves or compression decompression device. All shocks detected barely perceptible (0.25(±0.05)cm on 10cm VAS scale). CONCLUSIONS: Nitrile gloves and neoprene pad prevent (99%) responder's detection of defibrillation of a cadaver. Fire gloves and compression decompression device prevented detection.

Use of an impedance threshold device in spontaneously breathing patients with hypotension secondary to trauma: an observational cohort feasibility study.

BACKGROUND: An impedance threshold device (ITD) intended for use in the spontaneously breathing patient has been shown to raise blood pressure in hypotensive patients. This device has not been evaluated in patients with hypotension secondary to trauma. This study focused on changes in key vital signs when the ITD was added to the paramedic treatment protocol for hypotensive patients with prehospital traumatic injury. METHODS: A 6-month prospective nonrandomized observational cohort study was conducted of 200 spontaneously breathing symptomatic adult patients with prehospital hypotension due to multiple causes; the patients of primary interest experienced a traumatic injury. Upon determination of hypotension (systolic blood pressure of approximately ≤90 mm Hg), standard therapy was initiated by application of the mask-style ITD. Vital signs were documented every 2 minutes to 5 minutes after intervention. A change in mean arterial pressure (MAP) with ITD use was the primary study endpoint. RESULTS: Of the 200 hypotensive subjects treated, 29 (3 were excluded because of incomplete data sets and 3 patients treated with the ITD were excluded because their blood pressure did not meet inclusion criterion) were hypotensive secondary to trauma. Their MAP increased from 60 mm Hg (SD, 11 mm Hg; 95% confidence interval [CI], 8.17-15.432) to 78 mm Hg (16 mm Hg; 95% CI, 12.43-23.46) (p = 0.001), without significant change in mean heart rate. Approximately 75% of the patients reported moderate to easy tolerance. Similar increases in MAP were observed in the nontraumatic patients, from 60 mm Hg (10 mm Hg; 95% CI, 9.4-11.5) to 70 (15; 95% CI, 13.4-16.7) (p = 0.0001). CONCLUSION: In this observational cohort study of patients with hypotension secondary to trauma, the ITD was well tolerated, and MAP as well as systolic and diastolic blood pressure were improved. The patients were not overresuscitated with this intervention. On the basis of these findings, additional studies in patients with hypotension secondary to traumatic injury should be performed to better define the need and benefit of additional fluid resuscitation when the ITD is used. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Capnography for the nonintubated patient in the emergency setting.

BACKGROUND: Multiple studies illustrate the benefits of waveform capnography in the nonintubated patient. This type of monitoring is routinely used by anesthesia providers to recognize ventilation issues. Its role in the administration of deep sedation is well defined. Prehospital providers embrace the ease and benefit of monitoring capnography. Currently, few community-based emergency physicians utilize capnography with the nonintubated patient. OBJECTIVE: This article will identify clinical areas where monitoring end-tidal carbon dioxide is beneficial to the emergency provider and patient. DISCUSSION: Capnography provides real-time data to aid in the diagnosis and patient monitoring for patient states beyond procedural sedation and bronchospasm. Capnographic changes provide valuable information in such processes as diabetic ketoacidosis, seizures, pulmonary embolism, and malignant hyperthermia. CONCLUSIONS: Capnography is a quick, low-cost method of enhancing patient safety with the potential to improve the clinician's diagnostic power.

Promoting early diagnosis of hemodynamic instability during simulated hemorrhage with the use of a real-time decision-assist algorithm.

BACKGROUND: This study aimed to test the hypothesis that the addition of a real-time decision-assist machine learning algorithm by emergency medical system personnel could shorten the time needed to identify an unstable patient during a hemorrhage profile as compared with vital sign information alone. METHODS: Fifty emergency medical team-paramedics from a large, urban fire department participated as subjects. Subjects viewed a monitor screen on two occasions as follows: (1) display of standard vital signs alone and (2) with the addition of an index (Compensatory Reserve Index) associated with estimated central blood volume status. The subjects were asked to push a computer key at any point in the sequence they believed the patient had become unstable based on information provided by the monitor screen. The average difference in time to identify hemodynamic instability between experimental and control groups was assessed by paired, two-tailed t test and reported with 95% confidence intervals (95% CI). RESULTS: The mean (SD) amount of time required to identify an unstable patient was 18.3 (4.1) minutes (95% CI, 17.2-19.4 minutes) without the algorithm and 10.7 (4.2) minutes (95% CI, 9.5-11.9 minutes) with the algorithm (p < 0.001). CONCLUSION: In a simulated patient encounter involving uncontrolled hemorrhage, the use of a monitor that estimates central blood volume loss was associated with early identification of impending hemodynamic instability. Physiologic monitors capable of early identification and estimation of the physiologic capacity to compensate for blood loss during hemorrhage may enable optimal guidance for hypotensive resuscitation. They may also help identify casualties benefitting from forward administration of plasma, antifibrinolytics and procoagulants in a remote damage-control resuscitation model.

Cardiac arrest survival is rare without prehospital return of spontaneous circulation.

BACKGROUND: Emergency medical services (EMS) are crucial in the management of out-of-hospital cardiac arrest (OHCA). Despite accepted termination-of-resuscitation criteria, many patients are transported to the hospital without achieving field return of spontaneous circulation (ROSC). OBJECTIVE: We examine field ROSC influence on OHCA survival to hospital discharge in two large urban EMS systems. METHODS: A retrospective analysis of prospectively collected data was conducted. Data collection is a component of San Antonio Fire Department's comprehensive quality assurance/quality improvement program and Cincinnati Fire Department's participation in the Cardiac Arrest Registry to Enhance Survival (CARES) project. Attempted resuscitations of medical OHCA and cardiac OHCA for San Antonio and Cincinnati, respectively, from 2008 to 2010 were analyzed by city and in aggregate. RESULTS: A total of 2,483 resuscitation attempts were evaluated. Age and gender distributions were similar between cities, but ethnic profiles differed. Cincinnati had 17% (p = 0.002) more patients with an initial shockable rhythm and was more likely to initiate transport before field ROSC. Overall survival to hospital discharge was 165 of 2,483 (6.6%). More than one-third (894 of 2,483, 36%) achieved field ROSC. Survival with field ROSC was 17.2% (154 of 894) and without field ROSC was 0.69% (11 of 1,589). Of the 11 survivors transported prior to field ROSC, nine received defibrillation by EMS. No asystolic patient survived to hospital discharge without field ROSC. CONCLUSION: Survival to hospital discharge after OHCA is rare without field ROSC. Resuscitation efforts should focus on achieving field ROSC. Transport should be reserved for patients with field ROSC or a shockable rhythm.

Paramedics successfully perform humeral EZ-IO intraosseous access in adult out-of-hospital cardiac arrest patients.

OBJECTIVE: Studies on humeral placement of the EZ-IO (Vidacare, Shavano Park, TX, USA) have shown mixed results. We performed a study to determine the first-attempt success rate at humeral placement of the EZ-IO by paramedics among prehospital adult cardiac arrest patients. METHODS: A retrospective cohort analysis of data prospectively collected over a 9-month period. Data are a subset extracted from a prehospital cardiac arrest study. The cohort consisted of adult cardiac arrest patients in whom the EZ-IO placement was attempted in the humerus by paramedics. Choice of vascular access was at the discretion of the paramedic; options included tibial or humeral EZ-IO and intravenous. Primary outcome is the percentage of successful placements (stable, flow, without extravasation) on first attempt. Secondary outcomes are overall successful placement, complications, and reason for failure. Data were collected during a post-cardiac arrest interview. RESULTS: Humeral intraosseous (IO) access was attempted in 61% (n = 247) of 405 cardiac arrests evaluated with mean age of 63 (±16) years, 58% male. First-attempt successful placement was 91%. Successful placement was 94%, considering the second attempts. In the unsuccessful attempts, 2% reported obesity as the cause, 1% reported stable placement without flow, and 2% reported undocumented causes for failure. There were also 2% reports of successful placement with subsequent dislodgement. CONCLUSIONS: The results of this study suggest a high degree of paramedic proficiency in establishment of IO access in the proximal humerus of the out-of-hospital cardiac arrest. Few complications suggest that proximal humeral IO access is a reliable method for vascular access in this patient population.

No deaths associated with patient refusal of transport after naloxone-reversed opioid overdose.

INTRODUCTION: Naloxone is widely used in the treatment and reversal of opioid overdose. Most emergency medical services (EMS) systems administer naloxone by standing order, and titrate only to reverse respiratory depression without fully reversing sedation. Some EMS systems routinely administer sufficient naloxone to fully reverse the effects of opioid overdose. Frequently patients refuse further medical evaluation or intervention, including transport. OBJECTIVES: The purpose of this study was to evaluate the safety of this practice and determine whether increased mortality is associated with full reversal of opioids. As a component of a comprehensive quality assurance initiative, we assessed mortality during the 48 hours after patients received naloxone to reverse opioid overdose followed by patient-initiated refusal of transportation. METHODS: The setting was a large urban fire-based EMS system. Investigators provided the Bexar County Medical Examiner's Office (MEO) with a list of patients who were treated by the San Antonio Fire Department with naloxone, and not transported. Inclusion criteria were administration of naloxone and patient-initiated refusal. Patient dispositions also included aid only, referral to the MEO, or referral to law enforcement. The list was then compared with the MEO database. A chart review was completed on all patients treated and subsequently presented to the MEO within two days. A secondary time period of 30 days was also assessed. RESULTS: The list identified 592 patients treated with naloxone and not transported to the emergency department. Five-hundred fifty-two patients received naloxone and refused transport or were not transported. The remaining 40 patients all presented to EMS in cardiac arrest, naloxone was administered during the course of resuscitation, and subsequent efforts were terminated in the field. None of the patients receiving naloxone with a subsequent patient-initiated refusal were examined at the MEO within the two-day end point. The 30-day assessment revealed that nine individuals were treated with naloxone and subsequently died, but the shortest time interval between date of service and date of death was four days. CONCLUSION: The primary outcome was that no patients who were treated with naloxone for opioid overdose and then refused care were examined by the MEO within a 48-hour time frame.

Needle thoracostomy: implications of computed tomography chest wall thickness.

OBJECTIVES: To determine the length of catheter required to perform a needle thoracostomy, as determined by chest wall thickness, to treat the majority of patients presenting to the emergency department (ED) with a potential tension pneumothorax. METHODS: A convenience sample of 111 computed tomography (CT) scans of the chest in trauma and medical resuscitation patients at a military Level 1 trauma center in San Antonio, Texas, was pooled, and the chest wall thickness was measured at the second intercostal space, midclavicular line, to the nearest 0.1 cm. RESULTS: The mean chest wall thickness in the patients studied averaged 4.24 cm (95% confidence interval [CI] = 3.97 to 4.52). Nearly one fourth (25) of the study patients had a chest wall thicker than 5 cm. Women, on average, have thicker chest walls than men (4.90 for women; 4.16 for men; p = 0.022). CONCLUSIONS: In this study, a catheter length of 5 cm would reliably penetrate the pleural space of only 75% of patients. A longer catheter should be considered, especially in women.

A randomized, controlled trial comparing arteriovenous to venovenous rewarming of severe hypothermia in a porcine model.

BACKGROUND: The purpose of this study was to evaluate active rewarming using continuous arteriovenous rewarming (CAVR) and continuous venovenous rewarming (CVVR) methods during severe hypothermia using an electromagnetic fluid warmer. Rapid rewarming using these techniques is superior to passive rewarming and is possible with commercially available equipment. METHODS: Eighteen swine (55-65 kg) were assigned to CAVR, CVVR, or control. Vascular access was obtained via central lines (8.5-French) in all subjects. Subjects were cooled to 27 degrees C (80.6 degrees F) in an ice bath, and then dried, covered, and connected to the rewarming device. The carotid artery (CAVR) or internal jugular vein (CVVR) was used for circuit inflow. Warmed 39 degrees C (102.2 degrees F) blood was returned via the femoral vein. Hemodynamic parameters and temperatures (pulmonary artery and rectal) were recorded until reaching an endpoint of a pulmonary artery temperature of 37 degrees C (98.6 degrees F). RESULTS: Mean rewarming time in the CAVR group was 2 hours 14 minutes, with a mean rewarming rate of 4.5 degrees C/h (8.1 degrees F/h, 0.034 degrees C/kg/h). Total circulating volume averaged 65 L. CVVR averaged 3 hours 8 minutes, with a mean rewarming rate of 3.2 degrees C/h (5.8 degrees F/h, 0.024 degrees C/kg/h). Total circulating volume averaged 67 L. Controls averaged 10 hours 42 minutes, with a mean rate of 0.9 degrees C/h (1.7 degrees F/h, 0.007 degrees C/kg/h). The CAVR group was faster than the CVVR group in both the rewarming rate and total time to rewarming (p = 0.034 and p = 0.040, respectively). Both experimental groups were significantly different from controls in rewarming rate and total time to rewarming (p < 0.001). CONCLUSION: CAVR offers the most rapid rate of rewarming. CVVR offers a rapid rate using less invasive procedures. Both techniques are markedly superior to passive rewarming methods typically used during early resuscitation.

360-degree feedback: possibilities for assessment of the ACGME core competencies for emergency medicine residents.

The Accreditation Council for Graduate Medical Education (ACGME) has challenged residency programs to provide documentation via outcomes assessment that all residents have successfully mastered the six core competencies. A variety of assessment "tools" has been identified by the ACGME for outcomes assessment determination. Although rarely cited in the medical literature, 360-degree feedback is currently in widespread use in the business sector. This tool provides timely, consolidated feedback from sources in the resident's sphere of influence (emergency medicine faculty, emergency medicine residents, off-service residents and faculty, nurses, ancillary personnel, patients, out-of-hospital care providers, and a self-assessment). This is a significant deviation from both the peer review process and the resident review process that almost exclusively use physicians as raters. Because of its relative lack of development, utilization, and validation as a method of resident assessment in graduate medical education, a great opportunity exists to develop the 360-degree feedback tool for resident assessment.