Defining the Core Content for Transport Physician Training Programs.

In many parts of the world, emergency medical services (EMS) clinical care is traditionally delivered by different levels or types of EMS clinicians, such as emergency medical technicians and paramedics. In some areas, physicians are also included among the cadre of professionals administering EMS-based care. This is especially true in the interfacility transport (IFT) setting. Though there is significant overlap between the knowledge and skills necessary to safely and effectively provide care in the IFT and prehospital settings, the IFT care environment requires physicians to develop several additional competencies beyond those that are expected of traditional EMS clinicians. NAEMSP first published recommendations regarding what some of these competencies should be in 1983 and subsequently updated those recommendations in 2002. This document is an updated work, given the evolution of the field.

Prehospital Echocardiogram Use in Identifying Massive Pulmonary Embolism in Unidentified Respiratory Failure.

Medical transport teams often handle cases of complex, critically ill patients and are in need of rapid, bedside assessments to guide clinical decision making. The use of point-of-care ultrasound (POCUS) as a diagnostic indicator has gained increased acceptance in emergency medicine. Ultrasound devices have become increasingly portable, and numerous studies have demonstrated that use in the prehospital setting is feasible, accurate, and can have a dramatic impact on the care of patients. In this case report, we highlight the use of handheld ultrasound in the identification of right heart dilation in an unstable patient with respiratory failure in a rural emergency department, concerning for massive pulmonary embolism. The patient was given thrombolytic therapy with dramatic clinical improvement, ultimately surviving transport to the intensive care unit at a nearby tertiary care center.

Tranexamic Acid Use in Pediatric Hemorrhagic Shock From Farm-Related Trauma: A Case Report.

This case describes the use of tranexamic acid as an adjunctive treatment in the management of a pediatric patient in hemorrhagic shock. The case also highlights other components of current best practices for hemorrhagic shock in children, including bleeding source control and prompt resuscitation with blood products. A 20-month old male suffered an agricultural accident with significant injury to the right upper extremity. This led to subsequent extremity hemorrhage and clinical evidence of hemorrhagic shock. As a result of interventions performed by emergency medical services as well as the helicopter emergency medical services team, including the application of a tourniquet, prehospital blood product administration, and tranexamic acid administration, the patient had hemodynamically stabilized by arrival at the level 1 pediatric trauma center and was neurologically intact when discharged from the hospital.

A Model Curriculum for a Helicopter Emergency Medicine Services (HEMS) Rotation for Resident Physicians.

Audience: This curriculum is designed for resident physicians at all levels of training who have an interest in HEMS. Length of Curriculum: This curriculum is designed to run over a 28-day period. Introduction: Helicopter emergency medicine services play a critical role in patient transport, and resident physicians may often encounter patients transported by HEMS programs. Residents, and emergency medicine residents in particular, are being offered more opportunities to gain flight experience with HEMS programs; however, these experiences may be highly variable. These inconsistencies in training experiences may lead to incomplete understanding of HEMS systems and patient care performed during flight. Educational Goals: The primary objective of this course is to present a standardized curriculum which allows learners to gain understanding of HEMS systems and retrieval medicine while practicing safety in the aviation environment. Educational Methods: The educational strategies used in this curriculum include hands-on training with senior flight staff, asynchronous learning via access to a curated reading "library," and in-person learning via ride-along experience on the aircraft and program operational meeting attendance. Research Methods: This curriculum was introduced at the authors' institution and was completed by 11 rotating resident physicians, primarily PGY-2 and PGY-3 emergency medicine residents. Learners completed free-form feedback forms as well as a numerically graded post rotation survey. Learner feedback was used to identify areas where additional instruction was necessary and make changes to optimize learner flight experience. Results: The curriculum was graded by learners on a 5-point Likert scale. The statement of "My overall educational experience during the rotation met my expectations and the learning objectives outlined at the beginning of the rotation" received an average score of 4.7 based on 1-Disagree to 5-Completely agree. The statement "The longitudinal curriculum contributed to my learning" averaged 4.5. A score of 4.9 was given for the statement "I found the rotation to be of use in my emergency medicine training." Free-form feedback was also solicited by learners and included comments such as "It was helpful for me to spend some time in the airway [and procedure] lab and go through the shift topics." Discussion: As evidenced by the learner feedback and survey results, the curriculum was effective in meeting the designed educational objectives, and learner feedback was largely positive in nature. Utilizing dedicated daily teaching topics was key to providing a standardized learning experience and ensuring that education progressed without reliance on flight call volumes. Topics: Helicopter aviation safety, HEMS crew member operations, retrieval medicine, advanced trauma care, advanced airway management, ventilator management, HEMS program operations.

Three Airway Management Techniques for Airway Decontamination in Massive Emesis: A Manikin Study.

INTRODUCTION: Emesis occurs during airway management and results in pulmonary aspiration at rates of 0.01% - 0.11% in fasted patients undergoing general anesthesia and 0% - 22% in non-fasted emergency department patients. Suction-assisted laryngoscopy and airway decontamination (SALAD) involves maneuvering a suction catheter into the hypopharynx, while performing laryngoscopy and endotracheal intubation. Intentional esophageal intubation (IEI) involves blindly intubating the esophagus to control emesis before endotracheal intubation. Both are previously described techniques for endotracheal intubation in the setting of massive emesis. This study compares the SALAD and IEI techniques with the traditional approach of ad hoc, rigid suction catheter airway decontamination and endotracheal intubation in the setting of massive simulated emesis. METHODS: Senior anesthesiology and emergency medicine (EM) residents were randomized into three trial arms: the traditional, IEI, or SALAD. Each resident watched an instructional video on the assigned technique, performed the technique on a manikin, and completed the trial simulation with the SALAD simulation manikin. The primary trial outcome was aspirate volume collected in the manikin's lower airway. Secondary outcomes included successful intubation, intubation attempts, and time to successful intubation. We also collected pre- and post-simulation demographics and confidence questionnaire data. RESULTS: Thirty-one residents (21 anesthesiology and 10 EM residents) were randomized. Baseline group characteristics were similar. The mean aspirate volumes collected in the lower airway (standard deviation [SD]) in the traditional, IEI, and SALAD arms were 72 (45) milliliters per liter (mL), 100 (45) mL, and 83 (42) mL, respectively (p = 0.392). Intubation success was 100% in all groups. Times (SD) to successful intubation in the traditional, IEI, and SALAD groups were 1.69 (1.31) minutes, 1.74 (1.09) minutes, and 1.74 (0.93) minutes, respectively (p = 0.805). Overall, residents reported increased confidence (1.0 [0.0-1.0]; P = 0.002) and skill (1.0 [0.0-1.0]; P < 0.001) in airway management after completion of the study. CONCLUSION: The intubation techniques provided similar performance results in our study, suggesting any one of the three can be employed in the setting of massive emesis; although this conclusion deserves further study. Residents reported increased confidence and skill in airway management following the experience, suggesting use of the manikin provides a learning impact.

Troubleshooting Hypoxemia After Placement of an Extraglottic Airway.

The case presented here highlights the feasibility of using an extraglottic airway device as a conduit for delivering high levels of lifesaving positive end expiratory pressure (PEEP), as well as other means of combating recalcitrant hypoxia. The case also highlights the merit of an approach to the hypoxic patient with an in-situ extraglottic airway device based not only on deciding if the device is functioning to maintain a patent airway, but also, simultaneously considering the patient's physiology. A 71 year old male suffered an out-of-hospital cardiac arrest. Part of his resuscitation included placement of a dual-balloon extraglottic airway device by EMS. He was hypoxic, but the device seemed to be providing for a patent airway without an air leak. There was also a favorable end-tidal carbon dioxide waveform. The flight team chose to the leave the device in place. PEEP was up-titrated to 17 cmH20 without issue. Sigh breaths, as well as breath holds, were also able to be delivered. The patient's hypoxia improved over the course of the patient's transport, and he ultimately did well.

The Impact of Video Laryngoscopy on the Clinical Learning Environment of Emergency Medicine Residents: A Report of 14,313 Intubations.

BACKGROUND: The introduction of video laryngoscopy (VL) may impact emergency medicine (EM) residents' intubation practices. METHODS: We analyzed 14,313 intubations from 11 EM training sites, July 1, 2002, to December 31, 2012, assessing the likelihood of first-attempt success and likelihood of having a second attempt, by rank and device. We determined whether direct laryngoscopy (DL) first-attempt success decreased as VL became more prevalent using a logistic regression model with proportion of encounters initiated with VL at that center in the prior 90 and 365 days as predictors of DL first-attempt success. RESULTS: First-attempt success by PGY-1s was 71% (95% confidence interval [CI] = 63% to 78%); PGY-2s, 82% (95% CI = 78% to 86%); and PGY-3+, 89% (95% CI = 85% to 92%). Residents' first-attempt success rate was higher with the C-MAC video laryngoscope (C-MAC) versus DL, 92% versus 84% (risk difference [RD] = 8%, 95% CI = 4% to 11%), but there was no statistical difference between the GlideScope video laryngoscope (GVL) and DL, 80% versus 84% (RD = -4%, 95% CI = -10% to 1%). PGY-1s were more likely to have a second intubation attempt after first-attempt failure with VL versus DL: 32% versus 18% (RD = 14%, 95% CI = 5% to 23%). DL first-attempt success rates did not decrease as VL became more prevalent. CONCLUSIONS: First-attempt success increases with training. Interns are more likely to have a second attempt when using VL. The C-MAC may be associated with increased first-attempt success for EM residents compared with DL or GVL. The increasing prevalence of VL is not accompanied by a decrease in DL success.

Preliminary Report: Comparing Aspiration Rates between Prehospital Patients Managed with Extraglottic Airway Devices and Endotracheal Intubation.

INTRODUCTION: There has been a shift from endotracheal intubation (ETI) toward extraglottic devices (EGDs) for prehospital airway management. A concern exists that this may lead to more frequent cases of aspiration. METHODS: This was a retrospective study using a prehospital quality assurance database. Patients were assigned to groups based on the method that ultimately managed their airways (EGD or ETI). Cases with documented blood/emesis obscuring the airway were considered inevitable aspiration cases and excluded. Aspiration was defined by the radiology report within 48 hours. RESULTS: A total of 104 EGD and 152 ETI patients were identified. Aspiration data were available for 67 EGD and 94 ETI cases. Of those, 8 EGD and 3 ETI cases had blood/emesis obscuring the airway and were excluded as planned. After exclusions, there were 5 EGD and 11 ETI cases in which aspiration was later diagnosed (EGD aspiration rate = 8%, ETI aspiration rate = 12%; χ2: P = .359; relative risk = .841; 95% confidence interval, .329-2.152). CONCLUSION: In this small quality assurance database, aspiration rates were not significantly different for prehospital patients managed with an EGD versus ETI.

Administration of CroFab Antivenom by a Helicopter Emergency Medical Service Team.

The case presented here highlights an unconventional use of a helicopter emergency medical service (HEMS) to provide a specialized medication to a critically ill patient when definitive transport was delayed. A 39-year-old man presented to a rural hospital 1 hour after sustaining a copperhead envenomation. He developed severe symptoms and was intubated. Arrangements were made for transfer to a tertiary referral center by HEMS, but because of incoming weather conditions, the team would not be able to make the return flight safely. The decision was made for the HEMS team to fly antivenom to the patient, administer the medication, and then transport the patient by ground to the tertiary medical center. This plan was executed, and the patient was safely transported to the accepting facility. Antivenom is most effective when administered early because this will halt the progression of edema and may reverse the systemic effects of envenomation. In this case, HEMS transport of antivenom to the patient with severe toxicity prevented a delay to administration and likely improved the patient's outcome. Although the traditional role of HEMS is to provide rapid transport to critically ill patients, HEMS teams can also function to deliver specialized medications to remote settings.

Endotracheal intubation versus supraglottic airway placement in out-of-hospital cardiac arrest: A meta-analysis.

OBJECTIVE: Overall survival from out-of-hospital cardiac arrest (OHCA) is less than 10%. After initial bag-valve mask ventilation, 80% of patients receive an advanced airway, either by endotracheal intubation (ETI) or placement of a supraglottic airway (SGA). The objective of this meta-analysis was to compare patient outcomes for these two advanced airway methods in OHCA patients treated by Emergency Medical Services (EMS). METHODS: A dual-reviewer search was conducted in PubMed, Scopus, and the Cochrane Database to identify all relevant peer-reviewed articles for inclusion in the meta-analysis. Exclusion criteria were traumatic arrests, pediatric patients, physician/nurse intubators, rapid sequence intubation, video devices, and older airway devices. Outcomes were (1) return of spontaneous circulation (ROSC), (2) survival to hospital admission, (3) survival to hospital discharge, and (4) neurologically intact survival to hospital discharge. Results were adjusted for covariates when available and combined using the random effects model. RESULTS: From 3,454 titles, 10 observational studies fulfilled all criteria, representing 34,533 ETI patients and 41,116 SGA patients. Important covariates were similar between groups. Patients who received ETI had statistically significant higher odds of ROSC (odds ratio [OR] 1.28, 95% confidence interval [CI] 1.05-1.55), survival to hospital admission (OR 1.34, CI 1.03-1.75), and neurologically intact survival (OR 1.33, CI 1.09-1.61) compared to SGA. Survival to hospital discharge was not statistically different (OR 1.15, CI 0.97-1.37). CONCLUSIONS: Patients with OHCA who receive ETI by EMS are more likely to obtain ROSC, survive to hospital admission, and survive neurologically intact when compared to SGA.

Prospective evaluation of real-time use of the pulmonary embolism rule-out criteria in an academic emergency department.

OBJECTIVES: The pulmonary embolism rule-out criteria (PERC rule) is a nine-component decision rule derived to exclude pulmonary embolism (PE) without the use of formal diagnostic testing (D-dimer, computed tomography pulmonary angiography, ventilation-perfusion lung scanning, or venous ultrasonography) when all nine components are negative ("PERC negative"). This study examined whether clinicians who document PERC negative also document results of all nine components of the PERC rule. METHODS: This was a pilot study at a single-center, urban teaching emergency department (ED) with a residency program in emergency medicine. Patients were over 17 years of age with at least one of nine predefined chief complaints. Clinicians were asked three questions regarding suspicion for PE, intent to use the PERC rule, and the result. Charts were independently reviewed by two authors for fidelity of the nine PERC components. Patients were followed for PE outcome at 14 days. RESULTS: The study examined 526 patients cared for by 82 clinicians, who indicated suspicion for PE in 183 of 526 (35%) and intent to use the PERC rule in 115 of 526 (22%) cases, of whom 65 of 115 were documented as PERC negative. No formal test for PE was ordered in 49 of 65 (75%), and 46 of 49 had incomplete documentation to support PERC negative. The most common deficiency was omission of two risk factors for PE in the rule (prior venous thromboembolism or recent surgery). Six patients had PE diagnosed within 14 days, but none of these had been deemed PERC negative. CONCLUSIONS: Clinicians seldom document all nine data elements of the PERC rule in patients they deem PERC negative. These data suggest the need for paper or electronic aids to support use of the PERC rule.

One year mortality of patients treated with an emergency department based early goal directed therapy protocol for severe sepsis and septic shock: a before and after study.

INTRODUCTION: Early structured resuscitation of severe sepsis has been suggested to improve short term mortality; however, no previous study has examined the long-term effect of this therapy. We sought to determine one year outcomes associated with implementation of early goal directed therapy (EGDT) in the emergency department (ED) care of sepsis. METHODS: We performed a longitudinal analysis of a prospective before and after study conducted at a large urban ED. Adult patients were enrolled if they had suspected infection, 2 or more systemic inflammatory response criteria, and either systolic blood pressure (SBP) <90 mmHg after a fluid bolus or lactate >4 mM. Exclusion criteria were: age <18 years, no aggressive care desired, or need for immediate surgery. Clinical and outcomes data were prospectively collected on consecutive eligible patients for 1 year before and 2 years after implementing EGDT. Patients in the pre-implementation phase received non-protocolized care at attending physician discretion. The primary outcome was mortality at one year. RESULTS: 285 subjects, 79 in the pre- and 206 in the post-implementation phases, were enrolled. Compared to pre-implementation, post-implementation subjects had a significantly lower ED SBP (72 vs. 85 mm Hg, P < 0.001) and higher sequential organ failure assessment score (7 vs. 5, P = 0.0004). The primary outcome of 1 year mortality was observed in 39/79 (49%) pre-implementation subjects and 77/206 (37%) post-implementation subjects (difference 12%; P = 0.04). CONCLUSIONS: Implementation of EGDT for the treatment of ED patients with severe sepsis and septic shock was associated with significantly lower mortality at one year.

Prospective evaluation of right ventricular function and functional status 6 months after acute submassive pulmonary embolism: frequency of persistent or subsequent elevation in estimated pulmonary artery pressure.

BACKGROUND: No published data have systematically documented pulmonary artery pressure over an intermediate time period after submassive pulmonary embolism (PE). The aim of this work was to document the rate of pulmonary hypertension, as assessed noninvasively by estimated right ventricular systolic pressure (RVSP) of >or= 40 mm Hg 6 months after the diagnosis of submassive PE. METHODS: We enrolled 200 normotensive patients with CT angiography-proven PE and a baseline echocardiogram to estimate RVSP. All patients received therapy with unfractionated heparin initially, but 21 patients later received alteplase in response to circulatory shock or respiratory failure. Patients returned at 6 months for repeat RVSP measurement, and assessments of the New York Heart Association (NYHA) score and 6-min walk distance (6MWD). RESULTS: Six months after receiving a diagnosis, 162 of 180 survivors (90%) returned for follow-up, including 144 patients who had been treated with heparin (heparin-only group) and 18 patients who had been treated with heparin plus alteplase (heparin-plus-alteplase group). Among the heparin-only patients, the RVSP at diagnosis was >or= 40 mm Hg in 50 of 144 patients (35%; 95% CI, 27% to 43%), compared with 10 of 144 patients at follow-up (7%; 95% CI, 3% to 12%). However, the RVSP at follow-up was higher than the baseline RVSP in 39 of 144 patients (27%; 95% CI, 9% to 35%), and 18 of these 39 patients had a NYHA score of >or= 3 or exercise intolerance (6MWD, < 330 m). Among heparin-plus-alteplase patients, the RVSP was >or= 40 mm Hg in 11 of 18 patients at diagnosis (61%; 95% CI, 36% to 83%), compared with 2 of 18 patients at follow-up (11%; 95% CI, 1% to 35%). The RVSP at follow-up was not higher than at the time of diagnosis in any of the heparin-plus-alteplase patients (95% CI, 0% to 18%). CONCLUSIONS: Six months after experiencing submassive PE, a significant proportion of patients had echocardiographic and functional evidence of pulmonary hypertension.