Psychological Comfort of Paramedics with Field Death Pronouncement: A National Asian Study to Prepare Paramedics for Field Termination of Resuscitation

Objectives: Paramedics' decision to terminate field resuscitation without a physician present may depend on personal and external factors. This study investigates factors associated with paramedic psychological comfort with termination of resuscitation (TOR) to inform future training. Methods: We administered an anonymous survey to all practicing paramedics in a large urban Asian Emergency Medical Services system where formal TOR training had not yet been conducted and field TOR was not routinely applied. The survey assessed psychological comfort using the validated Psychological Comfort Total (PCT) scale (summed score of 28 items, with higher scores representing greater comfort). We examined scores associated with four personal (prior resolution of personal loss, knowledge of survival probability, religious affiliation and experience with death pronouncements) and two external (location of patient and perceived trust of family) factors. Data were entered into Excel and analyzed by t-tests and ANOVA. Results: Response rate was 73.6% (254/345). Respondents were 30.3 years (mean, SD 7.1) with 7.2 years (mean, SD 5.54) of practice experience. Over 60% had been involved in 6 or more field death pronouncements in the prior 12 months. Higher PCT scores were associated with prior resolution of personal loss and knowledge of survival probability. Lower PCT scores were associated with patient location in a public place and perceived family lack of trust. PCT scores were not associated with paramedic religious affiliation or number of prior death pronouncements. Conclusions: Paramedic psychological comfort with field death pronouncement is associated with personal and external factors. Since paramedic comfort is important for protocol adoption, TOR education should target not only knowledge, but also public arena management, communication skills for engaging with families, and help paramedics resolve prior personal loss.     

Correlation Between Paramedic Disaster Triage Accuracy in Screen-Based Simulations and Immersive Simulations

Background: Disaster triage is an infrequent, high-stakes skill set used by emergency medical services (EMS) personnel. Screen-based simulation (SBS) provides easy access to asynchronous disaster triage education. However, it is unclear if the performance during a SBS correlates with immersive simulation performance. Methods: This was a nested cohort study within a randomized controlled trial (RCT). The RCT compared triage accuracy of paramedics and emergency medical technicians (EMTs) who completed an immersive simulation of a school shooting, interacted with an SBS for 13 weeks, and then completed the immersive simulation again. The participants were divided into two groups: those exposed vs. those not exposed to 60?Seconds to Survival^© (60S), a disaster triage SBS. The aim of the study was to measure the correlation between SBS triage accuracy and immersive simulation triage accuracy. Improvements in triage accuracy were compared among participants in the nested study before and after interacting with 60S, and with improvements in triage accuracy in a previous study in which immersive simulations were used as an educational intervention. Results: Thirty-nine participants completed the SBS; 26 (67%) completed at least three game plays and were included in the evaluation of outcomes of interest. The mean number of plays was 8.5 (SD =7.4). Subjects correctly triaged 12.4% more patients in the immersive simulation at study completion (73.1% before, 85.8% after, P?=?0.004). There was no correlation between the amount of improvement in overall SBS triage accuracy, instances of overtriage (P?=?0.101), instances of undertriage (P?=?0.523), and improvement in the second immersive simulation. A comparison of the pooled data from a previous immersive simulation study with the nested cohort data showed similar improvement in triage accuracy (P?=?0.079). Conclusions: SBS education was associated with a significant increase in triage accuracy in an immersive simulation, although triage accuracy demonstrated in the SBS did not correlate with the performance in the immersive simulation. This improvement in accuracy was similar to the improvement seen when immersive simulation was used as the educational intervention in a previous study.     

Pulseless Electrical Activity:

Abstract

Objectives. The primary aims of this study were to compare paramedic success rates and complications of two different video laryngoscopes in a prehospital clinical study. Methods. This study was a multi-agency, prospective, non-randomized, cross over clinical trial involving paramedics from four different EMS agencies. Following completion of training sessions, six Storz CMAC? video laryngoscopes and six King Vision? (KV) video laryngoscopes were divided between agencies and placed into service for 6 months. Paramedics were instructed to use the video laryngoscope for all patients estimated to be ≥ 18 years old who required advanced airway management per standard operating procedure. After 6 months, the devices were crossed over for the final 6 months of the study period. Data collection was completed using a telephone data collection system with a member of the research team (available 24/7). First attempt success, overall success, and success by attempt, were compared between treatment groups using exact logistic regression adjusted for call type and user experience. Results. Over a 12-month period, 107 patients (66 CMAC, 41 KV) were treated with a study device. The CMAC had a significantly higher likelihood of first attempt success (OR = 1.85; 95% CI 0.74, 4.62; p = 0.188), overall success (OR = 7.37; 95% CI 1.73, 11.1; p = 0.002), and success by attempt (OR = 3.38; 95% CI 1.67, 6.8; p = 0.007) compared to KV. Providers reverted to direct laryngoscopy in 80% (27/34) of the video laryngoscope failure cases, with the remaining patients having their airways successfully managed with a supraglottic airway in 3 cases and bag-valve mask in 4 cases. The provider-reported complications were similar and none were statistically different between treatment groups. Complication rates were not statistically different between devices. Conclusion. The CMAC had a higher likelihood of successful intubation compared to the King Vision. Complication rates were not statistically different between groups. Video laryngoscope placement success rates were not higher than our historical direct laryngoscopy success rates.     

The Effect of a Quality Improvement Program on Paramedic On-scene Times for Patients with Penetrating Trauma

OBJECTIVE: To decrease paramedic on-scene times (OSTs) for major trauma patients through a focused quality improvement (QI) program. METHODS: A prospective study was conducted from 1993 through 1997 to determine the impact of a QI program on paramedic OSTs. All penetrating trauma patients transported by paramedics to Los Angeles County/USC Medical Center, a Level-1 trauma center, were included, and all cases with OSTs > 20 minutes were reviewed in detail for extenuating circumstances. Cases including multiple victims or unsecured scenes were considered "acceptable deviations." All others were considered "fallouts," which prompted extensive review with the paramedics and their field supervisors. RESULTS: Prior to the inception of the QI project there was a 4.1% fallout rate of penetrating trauma patients with OSTs > 20 minutes. This fallout rate fell to 1.5% in 1997 (p < 0.01). Mortality rates among these fallouts decreased from 5.1% to 0.8% during the study period (p < 0.01). CONCLUSIONS: An intensive QI program can have a significant, positive impact on paramedic OSTs among patients with penetrating trauma.     

Transcutaneous Electrical Nerve Stimulation Reduces Acute Low Back Pain during Emergency Transport

Background: Patients with acute low back pain may require emergency transport because of pain and immobilization. Transcutaneous electrical nerve stimulation (TENS) is a nonpharmaceutical therapy for patients with low back pain. Objective: To evaluate the efficacy of paramedic‐administered TENS in patients with acute low back pain during emergency transport. Methods: This was a prospective, randomized study involving 74 patients transported to hospital. The patients were randomly assigned to two groups: group 1 (n= 36) was treated with true TENS, while group 2 (n= 36) was treated with sham TENS. The authors recorded pain and anxiety as the main outcome variables using a visual analog scale (VAS). Results: The authors recorded a significant (p < 0.01) pain reduction (mean ± standard deviation) during transport in group 1 (79.2 ± 6.5 mm VAS to 48.9 ± 8.2 mm VAS), whereas pain scores remained unchanged in group 2 (75.9 ± 16.4 mm VAS and 77.1 ± 11.2 mm VAS). Similarly, the scores for anxiety were significantly reduced (p < 0.01) in group 1 (81.7 ± 7.9 mm VAS to 69.2 ± 12.1 mm VAS) after treatment. No significant change was noted (84.5 ± 5.8 mm VAS and 83.5 ± 8.9 mm VAS, respectively) in group 2. Conclusions: TENS was found to be effective and rapid in reducing pain during emergency transport of patients with acute low back pain and should be considered due to its ease of use and lack of side effects in the study population.     

New paradigm for protection:: The emergency ambulance services in the time of severe acute respiratory syndrome

Severe acute respiratory syndrome (SARS) is a newly emerging and highly infectious form of atypical pneumonia with a high rate of transmission, especially among health care workers. With SARS, certain policies had to be implemented rapidly by the emergency ambulance services and the Ministry of Health to support and protect all personnel adequately. The authors discuss the changes in policies and personnel behavior, the training and education that had to be disseminated widely, and certain alternatives in policies such as transportation. The authors hope to share their experience in the implementation of these strategies by the Singapore Civil Defence Force and stress the importance of the psychological preparedness of the paramedics and prehospital care providers worldwide in this era of SARS.     

Successful Resuscitation: Novel Partnership between Paramedics and U.S. Coast Guard

In this article, we present a notable case that illustrates a novel partnership between a United States Coast Guard small boat station and a civilian paramedic response unit. Patients who experience medical emergencies in remote environments are at particularly high risk for morbidity and mortality. For the most serious conditions, delayed contact with Advanced Life Support (ALS) has grave results. Typically, these circumstances involve small groups of individuals and cannot be easily predicted. The waters off the coasts of Maui, Hawaii, however, host millions of residents and visitors annually, with activities including swimming, snorkeling, diving, parasailing, and other types of ocean recreation. As a result, medical and rescue emergencies are not uncommon, many with poor outcomes. Prior to October of 2013, a Coast Guard response boat crew with limited medical training and equipment responded to most off shore cases. Since October 2013, a paramedic from Maui County EMS co-responds aboard the Coast Guard boat with a full complement of ALS equipment. This partnership has resulted in some significant improvements in patient outcome, and strengthened a collaborative emergency services system. The experience has also indicated the need for continued improvement in early activation and communication, as well as reinforcing the importance of primary prevention.