Experience and mentoring requirements for competence in new/inexperienced paramedics.

A paramedic may be unprepared to practice alone or with an inexperienced partner immediately following completion of training. Emergency medical services systems have not generally set standards to ensure that a newly-licensed paramedic is competent to practice alone. Many other trades and professions, including health care providers, require many hours of mentoring or apprenticeship prior to working in an unsupervised environment. This paper summarizes mentoring requirements for other clinical professions and reviews studies from the out-of-hospital and hospital literature that demonstrate a positive correlation between experience and outcome and/or competence. The author recommends specific benchmarking and supervision by a training officer or an experienced paramedic to ensure competence in new and inexperienced paramedics.

Can paramedics using guidelines accurately triage patients?

STUDY OBJECTIVE: We determine whether paramedics, using written guidelines, can accurately triage patients in the field. METHODS: This prospective, descriptive study was conducted at an urban county emergency medical services (EMS) system and county hospital. Paramedics triaged patients, for study purposes only, according to 4 categories: (1) needing to come to the emergency department by advanced life support (ALS) transport, (2) needing to come to the ED by any transport, (3) needing to see a physician within 24 hours, or (4) not needing any further physician evaluation. Medical records that provided patient treatment information to the point of ED disposition were subsequently reviewed (blinded to the paramedic rating) to determine which of the categories was appropriate. The protocol of the EMS system of the study site dictates that all patients should be transported except for those who refuse care and leave against medical advice. Only transported patients were included in the present study. Fifty-four paramedics triaged 1,180 patients. RESULTS: Mean patient age was 43.4+/-17 years; 62.0% were male. Paramedics rated 1,000 (84.7%) of the patients as needing to come to the ED and 180 (15.3%) as not needing to come to the ED. Ratings according to triage category were as follows: 804 (68.1%) category 1, 196 (16.6%) category 2, 148 (12.5%) category 3, and 32 (2.7%) category 4. Seven hundred thirty-six (62.4%) patients were discharged, 298 (25.3%) were admitted, 90 (7.6%) were transferred, 36 (3.1%) left against medical advice, and 20 (1.7%) died. The review panel determined that 113 (9.6%) patients were undertriaged; 55 (48.7%) of these patients were misclassified because the paramedics misused the guidelines. Ninety-nine patients (8.4% of the total sample) were incorrectly classified as not needing to come to the ED. This represented 55% of the patients (99/180) categorized as 3 or 4 by the paramedics. Fourteen patients (1.2% of total) were incorrectly classified as category 4 instead of 3. Of the 113 undertriaged patients, 22 (19.6%) were admitted, 86 (76.1%) were discharged, and 4 (3.5%) were transferred. CONCLUSION: Paramedics using written guidelines fall short of an acceptable level of triage accuracy to determine disposition of patients in the field.

Prehospital communications during the Loma Prieta earthquake.

INTRODUCTION: On 17 October 1989, the Loma Prieta Earthquake shook the San Francisco Bay area, home to more than 6 million people. This study examined the effectiveness and function of emergency medical services (EMS) communications after this event. METHODS: The six Bay area counties most affected by the Loma Prieta Earthquake were surveyed using a 156-part questionnaire. This study examined the functioning of the primary 9-1-1 county dispatch centers. Paramedics involved in a set of defined activities during the period after the earthquake also were surveyed. Emergency medical services directors also were questioned by telephone using an interview tool developed for this purpose. All areas concerning disaster response were not queried. Ten specific areas were considered, including: 1) preparation for disaster; 2) the impact of the earthquake; 3) reconnaissance; 4) call volume; and 5) others. RESULTS: Coordination among the various agencies responsible for disaster response and mitigation needs more study. Uniform response plans for medical mutual aid need development. Government support similar to police and fire department arrangements for mutual aid are not in place. Additional planning and training for disasters at all levels need reassessment. The communication-center personnel indicated that they did not call for more resources, but instead accepted volunteers at dispatch centers and extra assistance. Once engaged, however, most communications centers (CCs) had great difficulty tracking and controlling all the units under their jurisdiction. In some large urban counties, some ambulances were idled awaiting calls but lost their communications centers, while other ambulance personnel were trying to handle multiple patients and requests for services. CONCLUSIONS: Significant help from a state or federal agency likely will be unavailable for a substantial period after a catastrophic regional event. Important coordination among EMS agencies for disaster response is poor or absent. Although fatalities and casualties were limited compared to what could have occurred, great confusion reigned for varying periods of time after the earthquake. Communications among local agencies, counties, and the state were problematic. Information flow to hospitals was cited frequently as a problem, making it difficult for hospitals to prepare adequately. Medical mutual-aid help was disorganized and inadequately controlled. The training of personnel and the method of recall for disaster response need to be examined.

A comparison of adenosine and verapamil for the treatment of supraventricular tachycardia in the prehospital setting.

STUDY OBJECTIVE: To compare the efficacy and base hospital physician use of adenosine with that of verapamil in the prehospital treatment of supraventricular tachycardia (SVT). DESIGN: A 12-month prospective chart review of adenosine administration and a 12-month retrospective chart review of verapamil administration. SETTING: A single-tier advanced life support emergency medical service system. PARTICIPANTS: Prehospital adult patients presenting with narrow-complex SVT. INTERVENTIONS: Field paramedics identified SVT. They then administered verapamil or adenosine under on-line physician medical control. Paramedics administered up to two i.v. doses of verapamil, 2.5 mg and 5 mg, or up to two i.v. doses of adenosine, 6 mg and 12 mg. They recorded ECG readings; blood pressure; pulse; respirations; and symptoms before, during, and after drug administration. RESULTS: During the verapamil period, paramedics identified 102 cases of SVT and administered verapamil to 17 patients. Review by a cardiologist revealed 6 of the 17 patients to have been in atrial fibrillation, atrial tachycardia, or sinus tachycardia. Of the remaining 11 patients, 7 (64%) converted from SVT to sinus rhythm. During the adenosine period, paramedics identified 89 cases of SVT, and they administered adenosine to 64 patients. Eight patients had no review because prehospital rhythm strips were lost. Of the remaining 56 patients, 24 were later determined to have been in atrial fibrillation, atrial tachycardia, sinus tachycardia, atrial flutter, or ventricular tachycardia. Of the remaining 32 patients who were in SVT, adenosine converted 25 (78%) to sinus rhythm. An important incidental finding was the misinterpretation of tachydysrhythmias in 30 of 73 patients by paramedics and base hospital physicians. CONCLUSION: Our study showed no difference in conversion rates between verapamil and adenosine. Base hospital physicians were more likely to order adenosine than verapamil. Paramedics and base hospital physicians often misinterpret tachydysrhythmias.

Hospital disaster operations during the 1989 Loma Prieta earthquake.

OBJECTIVE: To study hospital disaster operations following a major United States disaster. DESIGN: Researchers interviewed all 51 hospital administrators and 49 of 51 emergency department (ED) charge nurses and emergency physicians who were on duty at the study hospitals during the 13-hour period immediately following the 1989 Loma Prieta earthquake. SETTING: The 51 acute-care hospitals in the six northern California counties most affected by the Loma Prieta earthquake. MEASUREMENTS: Questionnaires and in-person interviews. RESULTS: The most frequently noted problem was lack of communications within and among organizations. Hospitals received inadequate information about the disaster from local governmental agencies. Forty-three percent of hospitals had inadequate back-up power configurations, and five hospitals sustained total back-up generator failures. Twenty hospitals performed partial evacuations. CONCLUSIONS: The Loma Prieta earthquake did not cause total disruption of hospital services. Hospitals need to work with local governmental agencies and internal hospital departments to improve disaster communications.

The 1989 Loma Prieta earthquake: issues in medical control.

INTRODUCTION: The role of the base-hospital and on-line medical control in a disaster has not been investigated previously. This study assesses the roles of base-hospitals and the value and feasibility of on-line medical control during the 1989 Loma Prieta earthquake. METHODS: The researchers studied five Bay Area counties most affected by the earthquake: San Francisco, Alameda, San Mateo, Santa Clara, and Santa Cruz. Researchers sent questionnaires to all 1,498 registered EMTs and paramedics in these counties; 620 were returned (41.4%). Respondents answered questions about activities performed, contacts with base-hospitals and other agencies, and problems encountered the night of the earthquake. Researchers selected 63 paramedics for in-depth interviews based on their performance of significant advanced life support (ALS) activities performed during the disaster. The coordinators of the 13 base-hospitals (BHCs) in the region also received and returned questionnaires about medical control, base-hospital roles during the disaster, and problems encountered. Researchers interviewed all five county emergency medical services (EMS) agency directors. RESULTS: The surveys of EMS directors, base-hospital coordinators, and paramedics indicate that confusion existed over the status of medical control after the earthquake. There was general agreement among base-hospital coordinators (BHCs) that suspension of medical control is appropriate in a major disaster. Three bases had appropriate equipment to function as back-up dispatch centers. Eight bases had adequate personnel, but only one BHC felt his personnel had adequate training to function in a dispatch capacity. Nine paramedics did not start or continue resuscitation on patients whom they ordinarily would have begun resuscitation. CONCLUSION: Emergency medical services should suspend medical control immediately following a major disaster and ensure that all prehospital and base personnel are notified. Disrupted communications protocols for prehospital personnel should reflect the skill and knowledge level of paramedics and the need for rapid, advanced practice in a disaster. Disaster planners should consider other roles for base hospitals in major disasters.

The 1989 Loma Prieta earthquake: impact on hospital patient care.

STUDY OBJECTIVE: To provide an overview of the Loma Prieta earthquake regarding patient care in affected hospitals. DESIGN: A retrospective review of medical records using International Classification of Disease, ninth revision (ICD-9) codes and a personal interview questionnaire. SETTING: Fifty-one hospitals in the six-county area most affected by the earthquake. TYPE OF PARTICIPANTS: Patients seeking care in emergency departments of study hospitals and supervising emergency physicians and ED nurses at the time of the earthquake. MEASUREMENTS: ED census data, complaint and diagnosis, disposition, and operative procedures for patients seen during the study period. MAIN RESULTS: Affected hospitals experienced a 15% increase in ED census during the study period. Minor trauma was the most common patient complaint. Open wound (870-897), contusion (920-924), and fracture (800-829) were the most common ICD-9 diagnostic categories. The percentage of patients presenting to EDs during the study period who were hospitalized increased slightly compared with baseline. Seventy-five percent of operative procedures were earthquake related; 63.7% of these were for fracture reduction. Physicians and nurses had somewhat conflicting opinions on adequacy of ED staffing. A small number of emergency physicians had difficulty in obtaining diagnostic tests on the night of the earthquake. Physicians noted no differences in diagnosis or treatment resulting from the earthquake. CONCLUSION: The Loma Prieta earthquake resulted in minimal negative impact on patient care in hospitals in the study area. The use of the ICD-9 classification deserves further consideration and study to improve the predictive value of disaster illness and injury reporting. The event has provided the stimulus for Bay Area hospitals to further improve plans for patient care during a disaster.

Effect of standing orders on field times.

Because of discontinuation of base hospital participation, paramedics in a large urban zone of a California emergency medical services (EMS) system serving 1.1 million persons went on emergency standing orders for nearly all calls requiring advanced life support. Subsequently, the base hospital resumed medical control function under limited standing orders. Standing orders were allowed for calls that required rapid intervention with little probability of morbidity. The EMS agency conducted a retrospective study to compare times at scene and total prehospital care times before (control group) and after institution of standing orders and limited standing orders. There were significant differences in total prehospital care times and at-scene times between the control group and the two standing order groups (P less than .01). There are important implications to EMS systems that use extensive base hospital contact.

Clinical characteristics of paramedics' performance of pediatric endotracheal intubation.

There are little data available on success rates, complications, and efficacy of intubation in the pediatric age group by prehospital personnel. In a 12-month period, paramedics successfully intubated 32 of 36 (88.9%) patients for various indications, with a total of 67 attempts. Seventeen of 36 (47.2%) patients survived to hospital admission. Patient age ranged from newborn to 14 years. Paramedics used the straight blade in 21 of 37 patients (56.8%). The study demonstrates that paramedics can intubate pediatric patients with the same success rate as in adult patients. The data support the inclusion of pediatric endotracheal intubation in the scope of paramedic practice.

Clinical characteristics of paramedics' performance of endotracheal intubation.

Paramedics intubated 358 of 383 (93.5%) patients over a nine-month period. There were 85 survivors. The intubators used the curved-blade laryngoscope in 304 patients (79.5%). Two of 25 (8.0%) patients who were not successfully intubated lived; 83 of 358 (23.2%) successfully intubated patients survived. Clinically significant complications occurred in 32 patients (8.9%) who were successfully intubated. Paramedics encountered adverse conditions in 126 patients (32.9%). Presenting cardiac rhythm was recorded. There were no significant differences in intubation success rate between survivors and nonsurvivors or as a function of cardiac rhythm. This retrospective study further documents the ability of paramedics to successfully perform endotracheal intubation. The high success rate supports training with live subjects. Further studies of cause and impact of complications, correlation of success with increased survival, and alternative techniques are essential for effective EMS system medical control.

Evaluation of a pulse oximeter in the prehospital setting.

Paramedics field-tested a portable, battery-powered pulse oximeter to determine its applicability and usefulness as an adjunct to prehospital care. The pulse oximeter was attached to 62 consecutive patients who met local criteria for mandatory advanced life support base hospital contact. Arterial hemoglobin saturation (SaO2) levels and changes over time were documented by the pulse oximeter's integral printer and prehospital care reports prepared by paramedics. The pulse oximeter performed reliably in 60 patients (96.7%) by providing continuous SaO2 levels. Fifteen patients (24.2%) had saturations below 91%, and the pulse oximeter detected two (3.2%) otherwise undetected saturations below 80%. In each case, field intervention improved saturation. Pulse oximetry quantifies SaO2 changes correlated with many prehospital interventions: medications, suctioning, precarious gurney transport, oxygen therapy, and ventilatory assistance. The pulse oximeter performs reliably in the field and can be invaluable as an adjunct to patient care. Further prehospital studies are needed to evaluate specific field treatments and techniques, to assess the pulse oximeter's effect on morbidity and mortality, and to analyze the determination of severe hypoxemia in the field.

EMS quality assurance: a computerized incident reporting system.

Incident reports are an extremely valuable quality assurance vehicle in Emergency Medical Services (EMS) Systems. Appropriate identification, analysis, and followup of incidents can identify trends and recurrent problems, and change system policy. An urban EMS System utilized a computerized data base program to expedite its handling of a large number of incident reports.

The advanced life support base hospital audit for medical control in an emergency medical services system.

A large California county uses an audit of its advanced life support (ALS) base hospitals to maintain medical control of prehospital care and to improve the county emergency medical services. The audit is a rigorous, semi-annual evaluation of ALS base hospital performance using objective, written criteria. The county emergency medical service district and the base hospitals have benefited from the data that have resulted from the audits. The base hospital audit is an excellent method of assessing medical control in an emergency medical services system.

Glucose analysis: indications for ordering and alternatives to the laboratory.

Cost considerations mandate that the emergency physician consider the use of test strips for glucose analysis. Presented are medical criteria for glucose analysis, a description of available test strips and reflectance meters, and data from studies which compare performance and cost of the strips with laboratory methods. Emergency physicians should study the test strips and their indications more comprehensively. In general, glucose test strips provide a clinically acceptable means for blood glucose determinations.

Emergency physicians' duty to warn and protect: a critique and guidelines.

For ten years, psychotherapists in California have practiced under a court decision which imposed a duty to warn intended victims of violent crimes. Other cases extended the scope of the psychotherapists' duty to warn to an alarming degree. Although there have been no court cases involving emergency physicians, it is reasonable to assume that, under certain circumstances, the duty to warn could be extended to primary care physicians. Emergency physicians should familiarize themselves with applicable case law and should be aware of measures to use to avoid potential civil liability.

The emergency physician and medical control in advanced life support.

A large urban emergency medical services district (EMSD) in California set certification, recertification, and continuing education standards for advanced life support physician medical radio operators. The EMSD attempted to encourage physician participation and to maintain a high level of medical control. The standards have been well received. There is enthusiastic physician support and widespread physician involvement in the advanced life support system.