E MERGENCY M EDICAL S ERVICES AND C ULTURAL D ETERMINANTS OF AN E MERGENCY IN K ARACHI,P AKISTAN

Objectives. The study was conducted to understand the prehospital system in Karachi, the mode of transport that adult inpatients use to reach the emergency departments (EDs), and the barriers to the use of ambulances. Methods. The study consisted of two parts. The first part involved interviewing the administrators of major ambulance services in Karachi. The second part consisted of a structured interview of randomly selected adult inpatients admitted to one government and one private hospital. Results. Seven ambulance service administrators were interviewed. The interviews revealed that ambulances in Karachi are mainly involved in transporting patients from hospital to hospital or to home. A large number of calls are for transporting dead bodies. A total of 92 patients were interviewed (58 male, 34 female). Admission complaints included abdominal pain (22), blunt trauma (11), penetrating trauma (3), chest pain (6), shortness of breath (4), hematemesis (3), acute focal weakness (4), high fever (4), and other (32). The most common mode of transport to the ED was taxi (53, 58%), followed by private car (21, 23%). Specific reasons for not using ambulances included a perception that the patient was not sick enough (34, 45%), slow response of the ambulance services (17, 23%), not knowing how to find one (8, 11%), and the high cost (6, 8%). Conclusion. In case of a medical emergency, most people in Karachi do not use ambulances. The reasons for this low usage include not only poor accessibility, but also cultural barriers and lack of education in recognition of danger signs.     

P REDICTED U TILIZATION OF E MERGENCY M EDICAL S ERVICES T ELEMEDICINE IN D ECREASING A MBULANCE T RANSPORTS

Objective. To determine predicted utilization, decrease in ambulance transports, and target population for emergency medical services (EMS) if telemedicine capabilities were available to the medic units in the field. Methods. A retrospective chart review of 345 consecutive ambulance transports to four hospitals (Level I urban trauma center, urban tertiary care center, children's hospital, and suburban community hospital) was performed by a panel of three board-certified emergency medicine physicians experienced and credentialed in emergency telemedicine. They independently reviewed the emergency department (ED) and EMS records and were asked to determine whether patients required ambulance transport for evaluation or whether disposition could be made following paramedic and emergency physician assessment via telemedicine. A five-point Likert scale was used to grade feasibility of telemedicine disposition (definitely yes, probably yes, maybe, probably no, definitely no). Other variables analyzed included age, sex, race, chief complaint, phone, private medical doctor, and call location by patient zip code, call site, and receiving hospital. Results. In 14.7% of cases (6% definitely yes and 8.7% probably yes), disposition could be made without transport using telemedicine. The age range for eliminating transport was 2 weeks through 92 years, with mean age of 26.6 years. Under the age of 50 years, 46 out of 238 patients (19.3%) could have possibly been managed by telemedicine. Conclusion. Use of EMS telemedicine could result in an approximately 15% decrease in ambulance transports when it alone is added to the prehospital care provider's armamentarium. Emphasis for implementation should be placed on younger patients and an identified subset of chief complaints conducive to management using telemedicine.     

E MERGING C OMMUNICATION T ECHNOLOGIES IN E MERGENCY M EDICAL S ERVICES

Advances in communication technologies are changing the face of emergency medical services (EMS). Two communication technologies in particular—cellular-enhanced 9-1-1 service and automatic crash notification (ACN)—will have a considerable impact on EMS. Although enhanced 9-1-1 service from land-line phones is now available in nearly every EMS system across the country, enhanced 9-1-1 service from cell phones currently does not exist. With more and more emergency calls made from cell phones, the implementation of this service is a clear priority. Automatic crash notification, a quickly emerging technology, can potentially provide EMS systems with invaluable data within seconds of when a collision occurs. However, many issues with regard to ACN systems need to be addressed, including liability concerns, access to ACN data, ability of drivers to understand the ACN system, and ACN system architecture. The potential interfaces between ACN systems and EMS systems create significant opportunities to enhance EMS resource management and care of patients involved in motor vehicle crashes. With both cellular-enhanced 9-1-1 and ACN in their infancy, EMS physicians and administrators have a valuable opportunity to provide leadership in the development of these services.     

A P EDIATRIC S URVEY FOR THE N ATIONAL H IGHWAY T RAFFIC S AFETY A DMINISTRATION : E MERGENCY M EDICAL S ERVICES S YSTEM R E-ASSESSMENTS

Emergency medical services for children, or EMSC, is still a relatively underdeveloped component of most state and local EMS systems. Advocacy and funding for EMSC from the federal EMSC Program, availability of many useful EMSC products, and the rapidly enlarging literature in EMSC have created heightened awareness and interest in improving systems for pediatric emergency, trauma, and critical care. The new National Highway Traffic Safety Administration (NHTSA) EMS Technical Assistance (TA) re-assessment program, the second version of the successful original TA Program from 1988 to 1996, provides an ideal opportunity for state EMS professionals to evaluate EMSC capabilities and to integrate new EMSC products and services. The history of the TA Program reflects the evolution of EMS itself and indicates a historical inattention to children's issues, but re-assessment TA teams now have much useful intervening EMSC history to draw upon and a clear philosophical mandate to integrate children more fully in EMS system planning and management. In order to facilitate state-of-the-art reviews of EMSC within state EMS systems, a pediatric survey for the NHTSA re-assessments is presented. The survey, developed with the input of EMS administrators and physicians and approved by the National Association of State EMS Directors, follows the original ten-component model for EMS system review. It is intended for optional use within the overall EMS review process.     

P NEUMOCOCCAL V ACCINATION : A N O PPORTUNITY FOR E MERGENCY M EDICAL S ERVICES

This report examines the literature regarding pneumococcal disease and the current state of pneumococcal vaccination. Improvements in medical care have reduced the number of deaths from pneumococcal disease. However, vaccination is still the most effective measure. The U.S. Department of Health and Human Services, through the Healthy People 2000 and Healthy People 2010 reports, have recommended widespread pneumococcal vaccination practices. In spite of this, vaccination rates remain low among all segments of the population, with minorities and groups at risk for pneumococcal disease the most neglected. The authors propose implementation of emergency medical services (EMS)-delivered vaccination against pneumococcal disease. The epidemiology of pneumococcal disease is presented. The efficacy, availability, and use recommendations for the vaccine are described within this report. Finally, the benefits and possible implementation strategies for EMS delivery are detailed.     

A N E MERGENCY M EDICAL S ERVICES P ROGRAM OF A LTERNATE D ESTINATION OF P ATIENT C ARE

Objective: The emergency department (ED) is ideally reserved for urgent health needs. The ED, however, is often the site of care for nonurgent conditions. The authors investigated whether emergency medical technicians could decrease ED use by patients with nonurgent concerns who use 911 by appropriately identifying and triaging them to alternate care destinations. Methods: From August 2000 through January 2001, two King County fire-based emergency medical services (EMS) agencies participated in an alternate care destination program for patients with specific low-acuity diagnosis codes (intervention group). Eligible patients were offered care at a clinic-based destination as an alternate to the ED (n = 1,016). The frequency of the destination of care (ED, clinic, or home) for the intervention group was compared with a matched control group that was comprised of a preintervention historical cohort of EMS encounters from the same two fire-based agencies and with the same acuity and diagnosis criteria and seasonal interval (n = 2,617). Results: Compared with the preintervention group, a smaller proportion of patients in the intervention group received care in the ED (44.6% vs. 51.8%, p = 0.001), while a greater proportion of patients in the intervention group received clinic care (8.0% vs. 4.5%, p = 0.001) or home care (no transport) (47.4 vs. 43.7%, p = 0.043). Results were comparable when adjusted for other patient characteristics. Similar relationships were not evident among nonparticipating King County EMS agencies. Based on physician review and patient interview, the alternate care intervention appeared to be safe and satisfactory. Conclusion: An EMS-based program may represent one approach to limiting nonurgent ED use.     

R EIMBURSEMENT IN E MERGENCY M EDICAL S ERVICES : H OW TO A DAPT IN A C HANGING E NVIRONMENT

The proposed Medicare fee schedule for medically necessary ambulance transportation will have a profound impact on emergency medical services (EMS) systems throughout the country. When the new Medicare rules are implemented, reimbursement for Medicare patients will be largely based on national relative value units that vary depending on the level of service provided, from basic life support to advanced life support emergency. Under the new fee schedule, nearly all EMS systems will lose money when compared with the actual cost of providing the service, particularly advanced life support services, rural services, efficient systems, and those that bill for services. To adapt to these impending changes, EMS administrators and medical directors must work together to diversify and solidify their revenue sources and to seek out ways to make their systems even more efficient while maintaining a high quality of clinical care.     

A MIODARONE AND R URAL E MERGENCY M EDICAL S ERVICES C ARDIAC A RREST P ATIENTS : A C OST A NALYSIS

Objective: Recent American Heart Association guidelines suggest amiodarone as an antiarrhythmic in refractory ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT). The authors sought to assess the impact of amiodarone use on outcomes and cost associated with this practice in a rural emergency medical services (EMS) state. Methods: Statewide EMS records were reviewed for the calendar year 1999. Data reviewed included prehospital diagnosis, medications given by prehospital providers to patients with cardiac arrest, and procedures performed, including cardiopulmonary resuscitation (CPR) and defibrillation. Cost-benefit analysis assumed the cost of amiodarone treatment to be $137.65 per patient encounter. Absolute risk reduction (ARR) and number needed to treat (NNT) analysis utilized resuscitation rates published in the ARREST and ALIVE trials. Results: During the study period, EMS providers diagnosed 2,189 patients as having cardiac arrest. Five hundred thirty-five (24.4%) cardiac arrest patients were defibrillated. One hundred sixty patients (7.3%), including 15 who did not receive defibrillation, were given lidocaine during resuscitation efforts. The annual cost increase from current practice for a statewide amiodarone VF/VT protocol was $21,822.40 (10,572.87%). The initial cost to stock EMS vehicles for this protocol would be $50,115.52. The cost-benefit analysis yielded a potential for one additional patient survival to hospital discharge in Maine per 3.125 years of system-wide practice at a cost of $68,840.00. Conclusion: Based on current data, instituting amiodarone treatment for refractory VF and pulseless VT in a rural EMS setting requires the investment of substantial resources, relative to current treatment strategies, for any potential survival benefit.     

E MERGENCY M EDICAL S ERVICES I NFORMATION S YSTEMS AND A F UTURE EMS N ATIONAL D ATABASE

Since the early 1970s, various publications and legislation have contributed to the development of emergency medical services (EMS) information systems and databases. Yet, even today, EMS systems vary in their ability to collect patient and systems data and to put these data to use. In addition, no means currently exists to easily link disparate EMS databases to allow analysis at local, state, and national levels. For this reason, the National Association of State EMS Directors is working with its federal partners at the National Highway Traffic Safety Administration (NHTSA) and the Trauma and EMS program of the Health Resources and Services Administration's (HRSA's) Maternal and Child Health Bureau to develop a national EMS database. Such a database would be useful in developing nationwide EMS training curricula, evaluating patient and EMS system outcomes, facilitating research efforts, determining national fee schedules and reimbursement rates, and providing valuable information on other issues related to EMS care.     

M EDICAL D IRECTION AND M EDICAL C ONTROL OF A IR M EDICAL S ERVICES Position statement of the Air Medical Physician Association

Abstract

Introduction. Traumatic injury is a leading cause of morbidity and mortality, but these can be minimized by timely transport to definite care. Helicopter emergency medical services (HEMS) provide timely transport and can influence survival. However, accident analyses indicate that landing at an unsecured landing zone (LZ), particularly at night, increases the risk of aviation accidents. To ensure safety, some HEMS operations land only at designated, secured LZs. Objective. This study utilized geographic information systems (GISs) to compare locations of scene call requests and secure LZs. The goal was to determine the optimal placement of new helipads as a strategy to improve access while mitigating the risk of aviation accidents. Methods. Call request data from a large air medical transport service were used to determine the geographic locations of all requests for scene responses in 2006. Request locations were compared with the locations of existing helipads, and straight-line distances between scene and helipad were determined using the GIS application. The application was then used to determine potential locations for new helipads. Results. During the study period, 748 requests for scene calls and 269 helipads were available. There were 476 (52.4%) requests at least 10 kilometers from a helipad and 356 (36.6%) requests at least 15 kilometers from a helipad. One particular region, Southwestern Ontario, was identified as having the highest number of requests >15 kilometers from the closest helipad. Conclusion. GISs can be used to determine potential locations for new helipad construction using historical call request data. This evidence-based approach can improve HEMS access while mitigating operational risk.     

U SE OF E MERGENCY M EDICAL S ERVICES FOR S USPECTED A CUTE C ARDIAC I SCHEMIA AMONG D EMOGRAPHIC AND C LINICAL P ATIENT S UBGROUPS : T HE REACT T RIAL

Objective. Barriers to the use of emergency medical services (EMS) and patient delay in seeking care can limit the receipt or effectiveness of reperfusion therapies and the availability of prehospital emergency cardiac care. The Rapid Early Action for Coronary Treatment (REACT) trial was designed to determine the impact of a community intervention on use of EMS among demographic and clinical subgroups of patients with suspected acute cardiac ischemia. Methods. A randomized controlled community trial was conducted in 20 pair-matched communities in the United States. One community from each pair received an 18-month, multicomponent community education program. Data were collected at 44 participating hospitals during a four-month baseline period and throughout the 18-month trial, using medical record abstracts to collect information on mode of transport to the hospital and other sociodemographic and clinical variables. Eligible patients were persons aged ≥30 years presenting with chest pain or discomfort to emergency departments (EDs) who were admitted and discharged with a cardiac-related diagnoses (ICD 410-414, 427-429, 440, 786.9). Results. The net change in the odds of EMS use was an increase of 34% in intervention compared with control communities [adjusted odds ratio (OR) 1.34, 95% CI 1.07–1.67]. We observed greater increases in the odds of EMS use among patients who had chronic or other cardiac diagnoses (adjusted OR 1.53, 95% CI 1.18–1.99, and adjusted OR 1.52, 95% CI 1.17–1.97, respectively) than in those diagnosed as having acute ischemia (adjusted OR 1.14, 95% CI 0.91-1.44). We observed greater increases in odds of EMS use in those who were retired (adjusted OR 1.62, 95% CI 1.29–2.04) or had systolic blood pressure (SBP) at or below 160?mm Hg upon presentation to the ED (adjusted OR 1.55, 95% CI 1.26–1.91 for SBP 100-160 mm Hg; 1.61, 95% CI 0.88–2.97 for SBP <100?mm Hg). Conclusions. The REACT trial demonstrated a significant impact on the use of EMS among patients admitted to the hospital for suspected acute myocardial infarction, with greater increases among patients with chronic or other cardiac ICD-9 discharge diagnoses, those presenting with lower SBP, and retired persons.     

U SE OF E MERGENCY M EDICAL S ERVICES BY C HILDREN WITH S PECIAL H EALTH C ARE N EEDS

Objective. This study describes emergency medical services (EMS) responses for children with special health care needs (CSHCN) in an urban area over a one-year period. Methods. A prospective surveillance system was established to identify EMS responses for children, 21 years of age or younger, with a congenital or acquired condition or a chronic physical or mental illness. Responses related to the special health care needs of the child were compared with unrelated responses. Results. During a one-year period, 924 responses were identified. Fewer than half of the responses were related to the child's special health care need. Younger children were significantly more likely to have a response related to their special needs than older children. Among related responses, seizure disorder was the most common diagnosis, while asthma was more common for unrelated responses. Almost 58% of the responses resulted in transport of the child to a hospital. Conclusions. Emergency medical services responses related to a child's special health care needs differ from unrelated responses. The most common special health care needs of children did not require treatment beyond the prehospital care provider's usual standard of care. These results are relevant for communities providing EMS services for CSHCN.     

T RAINING M ILITARY M EDICS AS C IVILIAN P REHOSPITAL C ARE P ROVIDERS IN S OUTHERN S UDAN

Objective. To describe and evaluate a training program to teach civilian prehospital care to military medics in the Sudan People's Liberation Army (SPLA). Methods. Forty-one SPLA military personnel with variable prior medical experience participated in the course. Pre- and postintervention tests were used to evaluate participant knowledge and skill level, and test results were compared using paired t-tests. Results. An intensive 40-hour course consisting of didactic teaching sessions, small-group discussions, and practical skill stations was completed during November 1997. Thirty-seven participants successfully completed the program. Four medics with significant prior experience were trained as teaching assistants. The pretest scores for the other 33 participants ranged from 25.0% to 75.0% (SD 12.4). The posttest scores ranged from 25.0% to 87.5% (SD 15.2), with a mean improvement in test scores of 35.0% (p < 0.0005). The most striking improvements were noted in the knowledge of subjects related to wound care, hemorrhage, and head trauma. Conclusions. A field medic training program in Southern Sudan was conducted utilizing an interactive training curriculum. This program may serve as an educational model to teach prehospital care principles in other areas of international conflict.     

F EW E MERGENCY M EDICAL S ERVICES P ATIENTS WITH L OWER-EXTREMITY F RACTURES R ECEIVE P REHOSPITAL A NALGESIA

Previous literature has identified prehospital pain management as an important emergency medical services (EMS) function, and few patients transported by EMS with musculoskeletal injuries receive prehospital analgesia (PA). Objectives. 1) To describe the frequency with which EMS patients with lower-extremity and hip fracture receive prehospital and emergency department (ED) analgesia; 2) to describe EMS and patient factors that may affect administration of PA to these patients; and 3) to describe the time interval between EMS and ED medication administrations. Methods. This was a four-month (April to July 2000) retrospective study of patients with a final hospital diagnosis of hip or lower-extremity fracture who were transported by EMS to a single suburban community hospital. Data including patient demographics, fracture type, EMS response, and treatment characteristics were abstracted from review of EMS and ED records. Patients who had ankle fractures, had multiple traumatic injuries, were under the age of 18 years, or did not have fractures were excluded. Results. One hundred twenty-four patients met inclusion criteria. A basic life support (BLS)-only response was provided to 20 (16.0%). Another 38 (38.4%) received an advanced life support (ALS) response and were triaged to BLS transport. Of all the patients, 22 (18.3%) received PA. Patients who received PA were younger (64.0 vs. 77.3 years, p < 0.001) and more likely to have a lower-extremity fracture other than a hip fracture (31.8% vs. 10.7%, p < 0.004). Of all patients, 113 (91.1%) received ED analgesia. Patients received analgesia from EMS almost 2.0 hours sooner that in the ED (mean 28.4 ± 36 min vs. 146 ± 74 min after EMS scene arrival, p < 0.001). Conclusion. A minority of the study group received PA. Older patients and patients with hip fracture are less likely to receive PA. It is unclear whether current EMS system design may adversely impact administration of PA. Further work is needed to clarify whether patient need or EMS practice patterns result in low rates of PA.     

H OSPITAL F OLLOW - UP OF P ATIENTS C ATEGORIZED AS N OT N EEDING AN A MBULANCE U SING A S ET OF E MERGENCY M EDICAL T ECHNICIAN P ROTOCOLS

Objective. Using hospital outcomes, this study evaluated emergency medical technicians' (EMTs') ability to safely apply protocols to assign transport options. Methods. Protocols were developed that categorized patients as: 1) needs ambulance; 2) may go to emergency department (ED) by alternative means; 3) contact primary care provider (PCP); or 4) treat and release. After education on application of the protocols, EMTs categorized patients at the scene prior to transport but did not change current practice. Hospital charts were reviewed to determine outcome of patients whom EMTs categorized as not needing an ambulance. Category 2 patients were assumed to need the ambulance if they were admitted to a monitored bed or intensive care unit. Category 3 and 4 patients were assumed to need the ED if they were admitted. Results. The EMTs categorized 1,300 study patients: 1,023 (79%) ambulance transport, 200 (15%) alternative means, 63 (5%) contact PCP, and 14 (1%) treat and release. Hospital data were obtained for 140 (51%) patients categorized as not needing ambulance transport. Thirteen of 140 (9%) patients who transporting EMTs determined did not need the ambulance were considered to be undertriaged: five in category 2, six in category 3, and one in category 4. Six of 13 (46%) undertriaged patients had dementia or a psychiatric disorder as one of their presenting complaints. Conclusion. These protocols led to a 9% undertriage rate. Patients with psychiatric complaints and dementia were at high risk for undertriage.     

N ONTRAUMA H ELICOPTER E MERGENCY M EDICAL S ERVICES T RANSPORT : A NNOTATED R EVIEW OF S ELECTED O UTCOMES - RELATED L ITERATURE

While helicopter emergency medical services (HEMS) has its roots in military transport of wounded soldiers, rotor-wing transport is also used for a wide variety of nontrauma indications. Despite this common use of HEMS for noninjured patients, a Medline search found little systematic review of the literature pertinent to HEMS use for nontrauma. With HEMS utilization subject to appropriately increased scrutiny, those seeking to research HEMS utility in noninjured patients could benefit from existence of a collection of the topical literature. This paper aims to provide such a review, in the form of an annotated bibliography of Index Medicus journal studies assessing potential medical risks and benefits of HEMS transport for noninjured patients. The paper's goal is to provide a useful resource for those interested in pursuing more focused review of various sectors of the nontrauma HEMS literature. As such, the main objective of the article summaries is to provide a brief outline of study design and results; there is also limited editorial comment included after each summary.