The A to E (ABCDE) Pit Crew Model: A Novel Approach to Team Based Care of Critical Patients in the Prehospital Setting.

Background: This study aimed to evaluate the effectiveness of a Pit Crew intervention to improve team dynamics and time to performance of critical actions in a prehospital critical care scenario. The primary outcome was successful completion of critical actions and time to completion of these critical actions. Secondary outcomes included effectiveness of communication and overall team functioning. Methods: The study was conducted with a fire-based Emergency Medical Services (EMS) system with 233 paramedics and 115 Emergency Medical Technicians (EMT). Eight EMS crews comprised of five members each were randomly selected and assigned to either the intervention or the control group. The intervention group (n=20) watched a thirty-minute video prior to the training describing the "Pit Crew Approach;" the control group (n=20) did not watch the video. Each crew was given the same simulation scenario of a pediatric patient that had overdosed on a beta-blocker. Completion of predetermined critical tasks were noted and timestamped. A survey was administered to the participants following the training to assess team dynamics and level of confidence. Results: Three outcomes were statistically significant between the two arms: The interventional group felt they themselves had a more defined role in the resuscitation in comparison to the non-interventional group (p= 0.021). The interventional group also felt that their team members had a clearer and more defined role than the nonintervention group (p= 0.018). The interventional group also felt more confident managing a beta blocker overdose than the nonintervention group (p.007). The only statistically significant secondary outcome finding was in scene departure decision: the interventional arm spent more time on-scene (p=0.031). Of note, the non-intervention group missed performing tasks more often than the interventional group and team leaders of these groups often performed task(s) while also directing the patient care. Conclusion: The Pit Crew model was developed to optimize communication and team function. Our data identified that a formal instruction of the pit crew approach to a critical care scenario improved comfort in patient care. Future studies are needed evaluate other methods of training and the effects of continued formal pit-crew training over time.

Evaluation of Glial and Neuronal Blood Biomarkers Compared With Clinical Decision Rules in Assessing the Need for Computed Tomography in Patients With Mild Traumatic Brain Injury.

Importance: In 2018, the combination of glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase (UCH-L1) levels became the first US Food and Drug Administration-approved blood test to detect intracranial lesions after mild to moderate traumatic brain injury (MTBI). How this blood test compares with validated clinical decision rules remains unknown. Objectives: To compare the performance of GFAP and UCH-L1 levels vs 3 validated clinical decision rules for detecting traumatic intracranial lesions on computed tomography (CT) in patients with MTBI and to evaluate combining biomarkers with clinical decision rules. Design, Setting, and Participants: This prospective cohort study from a level I trauma center enrolled adults with suspected MTBI presenting within 4 hours of injury. The clinical decision rules included the Canadian CT Head Rule (CCHR), New Orleans Criteria (NOC), and National Emergency X-Radiography Utilization Study II (NEXUS II) criteria. Emergency physicians prospectively completed data forms for each clinical decision rule before the patients' CT scans. Blood samples for measuring GFAP and UCH-L1 levels were drawn, but laboratory personnel were blinded to clinical results. Of 2274 potential patients screened, 697 met eligibility criteria, 320 declined to participate, and 377 were enrolled. Data were collected from March 16, 2010, to March 5, 2014, and analyzed on August 11, 2021. Main Outcomes and Measures: The presence of acute traumatic intracranial lesions on head CT scan (positive CT finding). Results: Among enrolled patients, 349 (93%) had a CT scan performed and were included in the analysis. The mean (SD) age was 40 (16) years; 230 patients (66%) were men, 314 (90%) had a Glasgow Coma Scale score of 15, and 23 (7%) had positive CT findings. For the CCHR, sensitivity was 100% (95% CI, 82%-100%), specificity was 33% (95% CI, 28%-39%), and negative predictive value (NPV) was 100% (95% CI, 96%-100%). For the NOC, sensitivity was 100% (95% CI, 82%-100%), specificity was 16% (95% CI, 12%-20%), and NPV was 100% (95% CI, 91%-100%). For NEXUS II, sensitivity was 83% (95% CI, 60%-94%), specificity was 52% (95% CI, 47%-58%), and NPV was 98% (95% CI, 94%-99%). For GFAP and UCH-L1 levels combined with cutoffs at 67 and 189 pg/mL, respectively, sensitivity was 100% (95% CI, 82%-100%), specificity was 25% (95% CI, 20%-30%), and NPV was 100%; with cutoffs at 30 and 327 pg/mL, respectively, sensitivity was 91% (95% CI, 70%-98%), specificity was 20% (95% CI, 16%-24%), and NPV was 97%. The area under the receiver operating characteristic curve (AUROC) for GFAP alone was 0.83; for GFAP plus NEXUS II, 0.83; for GFAP plus NOC, 0.85; and for GFAP plus CCHR, 0.88. The AUROC for UCH-L1 alone was 0.72; for UCH-L1 plus NEXUS II, 0.77; for UCH-L1 plus NOC, 0.77; and for UCH-L1 plus CCHR, 0.79. The GFAP biomarker alone (without UCH-L1) contributed the most improvement to the clinical decision rules. Conclusions and Relevance: In this cohort study, the CCHR, the NOC, and GFAP plus UCH-L1 biomarkers had equally high sensitivities, and the CCHR had the highest specificity. However, using different cutoff values reduced both sensitivity and specificity of GFAP plus UCH-L1. Use of GFAP significantly improved the performance of the clinical decision rules, independently of UCH-L1. Together, the CCHR and GFAP had the highest diagnostic performance.

Bystander CPR occurrences in out of hospital cardiac arrest between sexes.

BACKGROUND: Bystander CPR (B-CPR) is known to be a critical action in treating out-of-hospital cardiac arrest (OHCA). Immediate CPR may double a patient's chance of survival. Only 40% of OHCA patients receive B-CPR (Cardiac Arrest Registry to Enhance Survival1). Civilians may be more comfortable performing CPR on male than female victims based on stereotyped training and the culture of cardiac disease treatment. OBJECTIVE: We hypothesize that of OHCA patients receiving B-CPR, there is a gender disparity favoring males. METHODS: This is a retrospective analysis of the National Emergency Medical Services Information System (NEMSIS) dataset. 149,734 cases were included in this analysis. Primary outcome was frequency of B-CPR between genders. Secondary analysis included gender disparity in AED pad placement, and subsets divided by type of bystander. RESULTS: Among 149,734 OHCA, 78,738 received B-CPR. 28,485 of 55,215 females (51.59%) received B-CPR, compared to 50,253 of 94,519 males (53.17%, p < 0.001). Of OHCA with bystander AED pad placement, 22.9% of females had AED pads applied, compared to 24.6% of males (p < 0.001). In OHCA witnessed by family member, 57.80% of females versus 61.70% of males received B-CPR (p < 0.001). In OHCA witnessed by layperson, 62.50% of females versus 69.00% of males received B-CPR (p < 0.001). CONCLUSION: There was a significantly lower rate of B-CPR in women experiencing OCHA in the population sample analyzed. Continued education and research are needed on the topic to address gender-specific differences in OHCA.

Unnecessary emergency medical services transport associated with alcohol intoxication.

Objective This study investigated medically unnecessary emergency medical services (EMS) transportation by comparing non-intoxicated versus intoxicated patients who did not receive emergency department (ED) treatment but utilized EMS transport. Methods Patients who used EMS but did not receive ED treatment were classified into non-intoxicated and intoxicated groups. Reasons for not receiving ED treatment were categorized according to whether the decision was made by the patient against medical advice or if the decision was based on a physician's evaluation and their recommendations. Results There were 212 patients reviewed; 120 in the non-intoxicated group and 92 in the intoxicated group. The intoxicated group had a higher proportion of males than the non-intoxicated group. The most common cause of non-disease symptoms in the intoxicated group was assault. In the non-intoxicated group, the most common reason for the lack of ED treatment was that treatment could take place on an outpatient basis, while in the intoxicated group, the reason was lack of patient cooperation. Conclusions The intoxicated group was older, male and more likely to present with symptoms not related to a disease process than those in the non-intoxicated group when using unnecessary EMS transport.

Association between EMS Question Bank Completion and Passing Rates on the EMS Certification Examination.

INTRODUCTION: A board review question bank was created to assist candidates in their preparation for the 2015 EMS certification examination. We aimed to describe the development of this question bank and evaluate its successes in preparing candidates to obtain EMS subspecialty board certification. METHODS: An online question bank was developed by 13 subject matter experts who participated as item writers, representing eight different EMS fellowship programs. The online question bank consisted of four practice tests, with each of the tests comprised of 100 questions. The number of candidates who participated in and completed the question bank was calculated. The passing rate among candidates who completed the question bank was calculated and compared to the publicly reported statistics for all candidates. The relationship between candidates' performance on the question bank and subspecialty exam pass rates was determined. RESULTS: A total of 252 candidates took at least one practice test and, of those, 225 candidates completed all four 100-question practice tests. The pass rate on the 2015 EMS certification exam was 79% (95%CI 74-85%) among candidates who completed the question bank, which is 12% higher than the overall pass rate (p = 0.003). Candidates' performance on the question bank was positively associated with overall success on the exam (X2 = 75.8, p < 0.0001). Achieving a score of ≥ 70% on the question bank was associated with a higher likelihood of passing the exam (OR = 17.8; 95% CI: 8.0-39.6). CONCLUSION: Completing the question bank program was associated with improved pass rates on the EMS certification exam. Strong performance on the question bank correlated with success on the exam.

Trauma Simulation Training Increases Confidence Levels in Prehospital Personnel Performing Life-Saving Interventions in Trauma Patients.

Introduction. Limited evidence is available on simulation training of prehospital care providers, specifically the use of tourniquets and needle decompression. This study focused on whether the confidence level of prehospital personnel performing these skills improved through simulation training. Methods. Prehospital personnel from Alachua County Fire Rescue were enrolled in the study over a 2- to 3-week period based on their availability. Two scenarios were presented to them: a motorcycle crash resulting in a leg amputation requiring a tourniquet and an intoxicated patient with a stab wound, who experienced tension pneumothorax requiring needle decompression. Crews were asked to rate their confidence levels before and after exposure to the scenarios. Timing of the simulation interventions was compared with actual scene times to determine applicability of simulation in measuring the efficiency of prehospital personnel. Results. Results were collected from 129 participants. Pre- and postexposure scores increased by a mean of 1.15 (SD 1.32; 95% CI, 0.88-1.42; P < 0.001). Comparison of actual scene times with simulated scene times yielded a 1.39-fold difference (95% CI, 1.25-1.55) for Scenario 1 and 1.59 times longer for Scenario 2 (95% CI, 1.43-1.77). Conclusion. Simulation training improved prehospital care providers' confidence level in performing two life-saving procedures.

Evaluation of an off-the-shelf mobile telemedicine model in emergency department wound assessment and management.

We examined the agreement between a videoconference-based evaluation and a bedside evaluation in the management of acute traumatic wounds in an emergency department. Adult and paediatric patients with acute wounds of various severities to the face, trunk and/or extremities presenting to the emergency department within 24 hours of injury were enrolled. Research assistants transmitted video images of the wound to an emergency physician using a laptop computer. The physician completed a standard wound assessment form before conducting a bedside evaluation and then completing a second assessment form. The primary outcome measure was wound length and depth. We also assessed management decision-making. A total of 173 wounds were evaluated. The correlation coefficient between video and bedside assessments was 0.96 for wound length. The mean difference between the lengths was 0.02 cm (SD 0.91). Management of the wound would have been the same in 94% of cases. The agreement on wound characteristics and wound management ranged from 84-100%. The highest correlation was 0.92 in suture material used and the lowest correlation was 0.64 in wound type. The ability of video images to distinguish between a minor and non-minor wound, and predicting the need for hospital management, had high degrees of sensitivity and specificity. The study showed that wound characteristics and management decisions appear to correlate well between video and bedside evaluations.

A comparison of tele-education versus conventional lectures in wound care knowledge and skill acquisition.

We conducted a randomized controlled study to compare conventional lectures with tele-education for delivering wound care education. Education was delivered by the two methods simultaneously to two classes. Forty-eight paramedics received a live didactic presentation and 41 paramedics received the same lecture via videoconferencing. The participants were evaluated by a multiple-choice examination and a practical test of their wound closure skills. There were no significant differences in any category of the practical skills test, and no difference in the results of the written examination: the mean total score was was 109.0 (95% CI 105.7-112.4) in the conventional lecture group and 110.3 (95% CI 106.2-114.3) in the video group (P = 0.63). In a survey at the end of the study the live lecture group rated the overall effectiveness of teaching significantly higher than the video-based group: the median scores for effectiveness of teaching were 6.0 (IQR 5.5-6.0) in the live lecture group and 4.0 (IQR 3.0-5.0) in the video group (P < 0.001). Videoconferencing was at least as effective as live didactic presentation.

Effects on cytokines and histology by treatment with the ACE inhibitor captopril and the antioxidant retinoic acid in the monocrotaline model of experimentally induced lung fibrosis.

Monocrotaline (MCT), a pyrrolizidine alkaloid extracted from the shrub Crotalaria spectabilis, induces in the lungs of many mammalian species severe hypertension and fibrosis. Previous work with MCT-induced lung disease in rats has shown that some of the steps to progressive fibrosis can be interrupted or decreased by intervention with retinoic acid (RA) or with the angiotensin converting enzyme inhibitor, captopril. This report emphasizes the pathology and cytokines present in lungs of rats in the MCT model of hypertension and fibrosis in 8 treatment groups, six per group: (1) controls, not treated; (2) captopril; (3) RA; (4) combined captopril and RA. Groups 5-8 replicated groups 1-4 and also received MCT subcutaneously. Tissues were harvested at 28 days for histopathology and measurement of cytokines TGFbeta, TNFalpha, interleukin 6, and IFN_. TGFbeta was depressed at 28 days by MCT, an effect reversed by a combination of captopril and RA. RA influences production of an important Th1 cytokine, IFN_, and demonstrated the greatest limitation of MCT-induced TNFalpha. The MCT-induced lung pathology of vasculitis, interstitial pneumonia and fibrosis was limited by captopril. Smooth muscle actin was overexpressed in MCT treated animals receiving RA, an effect reduced with captopril. Overall, the study confirmed the existence of a protective effect for both captopril and RA from MCT-induced lung damage at 30 days. No synergistic or antagonistic activity was observed when the two drugs were administered together. Each of the drugs exerts different and particular effects on serum and tissue levels of various cytokines, suggesting that each drug is efficient at different points of attack in the control of lung fibrosis.