Expert Witness Qualifications and Ethical Guidelines for Emergency Medical Services Litigation: Resource Document for the National Association of EMS Physicians Position Statement

Abstract

The clinical provision of medical care by emergency medical services (EMS) providers in the out-of-hospital environment and the operation of EMS systems to provide that care are unique in the medical arena. There is a substantive difference in the experience of individuals who provide medical care in the out-of-hospital setting and the experience of those who provide similar care in the hospital or other clinical settings. Furthermore, physicians who provide medical direction for EMS personnel have a clinical and oversight relationship with EMS personnel. This relationship uniquely qualifies EMS medical directors to provide expert opinions related to care provided by nonphysician EMS personnel. Physicians without specific EMS oversight experience are not uniformly qualified to provide expert opinion regarding the provision of EMS. This resource document reviews the current issues in expert witness testimony in cases involving EMS as these issues relate to the unique qualifications of the expert witness, the standard of care, and the ethical expectations.     

Emergency Incident Rehabilitation: Resource Document to the Position Statement of the National Association of EMS Physicians

Position Statement: Emergency Incident Rehabilitation

The National Association of EMS Physicians® believes that:

• Emergency operations and training conducted while wearing protective clothing and respirators is physiologically and cognitively demanding.

• The heat stress and fatigue created by working in protective clothing and respirators creates additional risk of illness/injury for the public safety provider.

• Emergency incident rehabilitation provides a structured rest period for rehydration and correction of abnormal body core temperature following work in protective clothing and respirators.

• Emergency incident rehab should be conducted at incidents (e.g. fireground, hazardous materials, and heavy rescue emergencies) and trainings involving activities that may lead to exceeding safe levels of physical and mental exertion.

• Emergency incident rehabilitation is incident care, not fitness for duty, and meant to reduce physiologic strain and prepare the responder to return to duty at the current incident and for the remainder of the shift.

• EMS should play a role in emergency incident rehabilitation with providers trained to understand the physiologic response of healthy individuals to environmental, exertional, and cognitive stress and implement appropriate mitigation strategies.

• An appropriately qualified physician should have oversight over the creation and implementation of emergency incident rehabilitation protocols and may be separate from the roles and responsibilities of the occupational medicine physician.

• There are no peer-reviewed data related to cold weather rehabilitation. Future studies should address this limitation to the literature.

     

Mass Gathering Medical Care: Resource Document for the National Association of EMS Physicians Position Statement

Abstract

Mass gatherings are heterogeneous in terms of size, duration, type of event, crowd behavior, demographics of the participants and spectators, use of recreational substances, weather, and environment. The goals of health and medical services should be the provision of care for participants and spectators consistent with local standards of care, protection of continuing medical service to the populations surrounding the event venue, and preparation for surge to respond to extraordinary events. Pre–event planning among jurisdictional public health and EMS, acute care hospitals, and event EMS is essential, but should also include, at a minimum, event security services, public relations, facility maintenance, communications technicians, and the event planners and organizers. Previous documented experience with similar events has been shown to most accurately predict future needs. Future work in and guidance for mass gathering medical care should include the consistent use and further development of universally accepted consistent metrics, such as Patient Presentation Rate and Transfer to Hospital Rate. Only by standardizing data collection can evaluations be performed that link interventions with outcomes to enhance evidence-based EMS services at mass gatherings. Research is needed to evaluate the skills and interventions required by EMS providers to achieve desired outcomes. The event-dedicated EMS Medical Director is integral to acceptable quality medical care provided at mass gatherings; hence, he/she must be included in all aspects of mass gathering medical care planning, preparations, response, and recovery. Incorporation of jurisdictional EMS and community hospital medical leadership, and emergency practitioners into these processes will ensure that on-site care, transport, and transition to acute care at appropriate receiving facilities is consistent with, and fully integrated into the community's medical care system, while fulfilling the needs of event participants.     

Ambulance Diversion and Emergency Department Offload Delay: Resource Document for the National Association of EMS Physicians Position Statement

Abstract

The emergency medical services (EMS) system is a component of a larger health care safety net and a key component of an integrated emergency health care system. EMS systems, and their patients, are significantly impacted by emergency department (ED) crowding. While protocols designed to limit ambulance diversion may be effective at limiting time on divert status, without correcting overall hospital throughput these protocols may have a negative effect on ED crowding and the EMS system. Ambulance offload delay, the time it takes to transfer a patient to an ED stretcher and for the ED staff to assume the responsibility of the care of the patient, may have more impact on ambulance turnaround time than ambulance diversion. EMS administrators and medical directors should work with hospital administrators, ED staff, and ED administrators to improve the overall efficiency of the system, focusing on the time it takes to get ambulances back into service, and therefore must monitor and address both ambulance diversions and ambulance offload delay. This paper is the resource document for the National Association of EMS Physicians position statement on ambulance diversion and ED offload time.     

Characterizing Strokes and Stroke Mimics Transported by Helicopter Emergency Medical Services

Objective: Stroke is the leading cause of disability in the United States with most of these patients being transported by emergency medical services. These providers are the first medical point of contact and must be able to rapidly and accurately identify stroke and transport these patients to the appropriate facilities for treatment. There are many conditions that have similar presentations to stroke and can be mistakenly identified as potential strokes, thereby affecting the initial prehospital triage. Methods: A retrospective observational study examined patients with suspected strokes transported to a single comprehensive stroke center (CSC) by a helicopter emergency medical service (HEMS) agency from 2007 through 2013. Final diagnosis was extracted from the Get with the Guidelines (GWTG) database and hospital discharge diagnosis for those not included in the database. Frequencies of discharge diagnosis were calculated and then stratified into interfacility vs. scene transfers. Results: In this study 6,243 patients were transported: 3,376 patients were screened as potential strokes, of which 2,527 had a final diagnosis of stroke (2,242 ischemic stroke and 285 transient ischemic attack), 166 had intracranial hemorrhage, and 655 were stroke mimics. Stroke mimics were more common among scene transfers (223, 32%) than among interfacility transfers (432, 16%). Conclusions: In our study approximately 20% of potential stroke patients transported via HEMS were mimics. Identifying the need for CSC resources can be an important factor in creating a prehospital triage tool to facilitate patient transport to an appropriate health care facility.     

Predictors of Emergency Medical Services Utilization by Elders

OBJECTIVE: Elders (age > or = 65 years) frequently use emergency medical services (EMS) for care. Understanding reasons for EMS use by elders may allow better management of EMS demand. To the best of the authors' knowledge, no studies have identified patient characteristics associated with EMS use by elders. This study aimed to identify patient attributes associated with elder EMS users. METHODS: This was a prospective cohort study of non-institutionalized elders presenting to an urban university hospital emergency department. Nine hundred thirty elder patients completed the survey. The authors asked patients about access to care, health beliefs, and reasons for requesting EMS assistance. Univariate and logistic regression were used to identify predictors of EMS use. RESULTS: The sample had a mean age of 76 years; 37% were male; 79% were African American. Thirty percent arrived via EMS. Sixty-five percent of those transported and 46% of those not transported by EMS were admitted to the hospital (p < 0.001). Reported reasons for using EMS transport included immobility (33%), illness (22%), request by others (21%), instruction from health care providers (10%), and lack of transportation (10%). Logistic regression identified symptom onset within four hours of seeking care (OR = 3.1), age > or = 85 years (OR = 1.63), increased deficiencies in activities of daily living (OR = 1.40 per deficiency), worse physical functioning (OR = 1.14/10 points), and worse social functioning (OR = 1.06/10 points) as factors associated with EMS use. CONCLUSIONS: Elders report using EMS because of immobility, perceived medical needs, or requests by others. Similarly, the presence of acute illness symptoms, older age, and poor social and physical function, rather than health beliefs, predict EMS use among elders. These factors must be considered when managing the demand for EMS services.     

Landing Sites and Intubation May Influence Helicopter Emergency Medical Services On-scene Time

Background

Reduced transport time of patients from the scene of an accident to definitive surgical treatment is one important reason to employ ambulance helicopters on trauma missions. However, if the helicopter is unable to land close to the scene, the transport time may be increased compared to transport with ground ambulance, due to time-consuming transfer of the patient between vehicles.

Objective

The objective of this study was to evaluate how the landing site, as determined by distance from the scene, and rapid sequence intubation (RSI) affected on-scene time (OST).

Methods

This was a prospective observational study performed during a 12-month period in a mixed urban and rural anesthesiologist-staffed Helicopter Emergency Medical Service in Norway. Data regarding the landing sites, the accident, and patient treatment were recorded.

Results

A total of 252 primary trauma missions were included in the study. In 75% of the missions, the aircraft landed < 50 meters from the scene, and in 7% the distance exceeded 200 meters. Mean OST when the patient was not intubated was 14.5 min (median 14 min). When an RSI was performed, the mean OST was significantly higher (22.7 min, median 20 min; p < 0.001).

Conclusion

Usually, a helicopter can land close to the accident scene and the location of the landing site does not contribute to a delay in arrival of the patient at the hospital. The OST is significantly higher, however, in those patients who receive endotracheal intubation before take-off. This reflects the time needed for intubation, as well as the increased complexity and workload when the patient is severely injured.     

Noninvasive Positive Pressure Ventilation: Resource Document for the National Association of EMS Physicians Position Statement

Abstract

The National Association of EMS Physicians (NAEMSP) believes that noninvasive positive pressure ventilation (NIPPV) is an important treatment modality for the prehospital management of acute dyspnea. This document serves as a resource to the NAEMSP position on prehospital NIPPV.     

Role of Pilot Instrument Proficiency in the Safety of Helicopter Emergency Medical Services

Objectives : To determine whether instrument-proficient pilots would more safely manage a flight into unplanned instrument meteorologic conditions (IMC) than would nonproficient pilots.
Methods : A controlled experimental study was performed using a full-motion helicopter simulator. Participants were emergency medical services (EMS) pilots with commercial licenses and previous simulator experience who were blinded to the study design and hypothesis. During a simulated EMS mission, cloud ceiling and visibility were decreased until IMC prevailed, and pilot actions were recorded. Data included the altitude at which the aircraft entered IMC, and whether the pilots maintained control of the aircraft, flew within aviation standards (i.e., bank angle, airspeed), and safely landed.
Results : Twenty-eight pilots (13 instrument-proficient, 15 nonproficient) participated; they had a median of 6,300 hours of helicopter experience. Two pilots crashed, both from the nonproficient group. The instrument-proficient pilots lost control less often (15% vs 67%, p < 0.05), maintained instrument standards more often (77% vs 40%, p < 0.05), and entered IMC at a higher altitude (689 feet vs 517 feet, p < 0.05) compared with the nonproficient pilots. Instructor comments indicated that the nonproficient pilots made more errors than did the instrument-proficient pilots.
Conclusions : Instrument-proficient pilots more safely manage an unexpected encounter with IMC. Helicopter EMS programs should strongly consider maintaining instrument proficiency to enhance safety.     

Ethics of Emergency Department Triage: SAEM Position Statement

Emergency department overcrowding, the growth of managed care, and the high cost of emergency care are creating pressures to triage patients away from US. EDs. Paradoxically. this pressure to limit patient access to EDs has increased in spite of federal laws that restrict patient triage and transfer The latter regulations view EDs as the safety net for the US health care system. The SAEM Ethics Committee evaluated the ethical implications of policies that triage patients nut of the ED prior to complete evaluation and treatment. The committee used these implications to develop practical guidelines, which are reported.     

Termination of Resuscitation of Nontraumatic Cardiopulmonary Arrest: Resource Document for the National Association of EMS Physicians Position Statement

Abstract

In the development of an emergency medical services (EMS) system, medical directors should consider the implementation of protocols for the termination of resuscitation (TOR) of nontraumatic cardiopulmonary arrest. Such protocols have the potential to decrease unnecessary use of warning lights and sirens and save valuable public health resources. Termination-of-resuscitation protocols for nontraumatic cardiopulmonary arrest should be based on the determination that an EMS provider did not witness the arrest, there is no shockable rhythm identified, and there is no return of spontaneous circulation (ROSC) prior to EMS transport. Further research is needed to determine the need for direct medical oversight in TOR protocols and the duration of resuscitation prior to EMS providers’ determining that ROSC will not be achieved. This paper is the resource document to the National Association of EMS Physicians position statement on the termination of resuscitation for nontraumatic cardiopulmonary arrest.     

The Oregon Physician Orders for Life-Sustaining Treatment Registry: A Preliminary Study of Emergency Medical Services Utilization

Background

The Physician Orders for Life-Sustaining Treatment (POLST) form translates patient treatment preferences into medical orders. The Oregon POLST Registry provides emergency personnel 24-h access to POLST forms.

Objective

To determine if Emergency Medical Technicians (EMTs) can use the Oregon POLST Registry to honor patient preferences.

Methods

Two telephone surveys were developed: one for the EMT who made a call to the Registry and one for the patient or the surrogate. The EMT survey was designed to determine if the POLST form accessed through the Registry changed the care of the patient. The patient/surrogate survey was designed to determine if the care provided matched the preferences on the POLST. When feasible, the Emergency Medical Services (EMS) record was reviewed to determine whether or not treatment was provided.

Results

During the study period there were 34 EMS calls with matches to patients' POLST forms, and 23 interviews were completed with EMS callers, for a response rate of 68%. In seven cases (30%) the patient was in cardiopulmonary arrest; one patient had a respiratory arrest with a pulse. Eight respondents (35%) reported that the patient was conscious and apparently able to make decisions about preferences. For 10 cases (44%) the POLST orders changed treatment, and in six instances (26%) they affected the decision to transport the patient. For the 10/11 patients or surrogates interviewed, the care reportedly matched their wishes.

Conclusion

This small study suggests that an electronic registry of POLST forms can be used by EMTs to enhance their ability to locate and honor patient preferences regarding life-sustaining treatments.     

The Role of Intraosseous Vascular Access in the Out-of-Hospital Environment (Resource Document to NAEMSP Position Statement)

Thousands of critically ill emergency patients are treated in the out-of-hospital setting in the United States every year. In many patients intravenous (IV) therapy cannot be initiated because of inadequate access to peripheral veins. In some cases, this lack of vascular access may limit benefit of medications because of late administration.[[]] Both speed andoverall success of vascular access are important when evaluating potential methodologies for their use in the out-of-hospital environment. Insertion of an IV cannula has been reported to require substantial time in the prehospital environment, with a recent study reporting an average successful intravenous line placement time of 4.4 ± 2.8 minutes.[[]] In critically ill pediatric patients, vascular access may present substantial difficulties to the provide.[[]] Intraosseous access may provide a significant time saving which may benefit many critically ill patients, both by decreasing the time to achieve access andby decreasing the time to administration of indicated medications.[[]] Achieving rapid administration of medications may facilitate the care of critically ill patients.[[]] Devices are now available that permit rapid, accurate access to the intraosseous space. Recent changes in the American Heart Association's resuscitation guidelines state that the intraosseous route should be the first alternative to difficult or delayed intravenous access.[[]] With these considerations, the role of intraosseous vascular access in the out-of-hospital environment should be reemphasized.     

Emergency Medical Services Education in Emergency Medicine Residency Programs: A National Survey

Objectives: Emergency medical services (EMS) was recently approved as a subspecialty by the American Board of Medical Specialties, highlighting the core content of knowledge that encompasses prehospital emergency patient care. This study aimed to describe the current state of EMS education at emergency medicine (EM) residency programs in the United States. Methods: The authors distributed an online survey containing multiple‐choice and free‐response questions pertaining to resident EMS education to the directors of EM residency programs in the United States between July 21 and September 10, 2010. Results: Of 154 programs, 117 (75%) responded to the survey, and 108 (70%) completed the survey by answering all required questions. Of completed surveys, 82 programs (76%) reported the cumulative time devoted to EMS didactic education during the course of residency training, a median of 20 hours (range = 3 to 300 hours; interquartile range [IQR] = 12 to 36 hours). There is a designated EMS rotation in 89% of programs, with a median duration of 3 weeks (range = 1 to 9 weeks; IQR = 2 to 4 weeks). Most programs involve residents on EMS rotations strictly as in‐field observers (63%), some as in‐field providers (20%), and the rest with some combination of the two roles. Ground ride‐along is required in 94% of programs, while air ride‐along is mandatory in 4% and optional in 81% of programs. Direct medical oversight (DMO) certification is required in 41% of residency programs, but not available in 26% of program jurisdictions. Residents in 92% of programs provide DMO. In those programs, most residents (77%) provide DMO primarily while working in the emergency department (ED), 13% during dedicated EMS or medical oversight shifts, and 4% during a combination of these shifts. Disaster‐preparedness was most frequently listed as the component programs would like to add to their EMS curricula. Conclusions: There is a wide range in the didactic, online, and in‐field EMS educational experiences provided as part of EM training. Most residents participate in ground ride‐along activities, provide DMO, and have a dedicated EMS rotation. Disaster‐preparedness is the most common desired addition to existing EMS rotations. ACADEMIC EMERGENCY MEDICINE 2012; 19:1–6 © 2012 by the Society for Academic Emergency Medicine     

The Use of Epinephrine for Out-of-Hospital Treatment of Anaphylaxis: Resource Document for the National Association of EMS Physicians Position Statement

Abstract

Anaphylaxis is a potentially life-threatening condition that requires both prompt recognition and treatment with epinephrine. All levels of emergency medical services (EMS) providers, with appropriate physician oversight, should be able to carry and properly administer epinephrine safely when caring for patients with anaphylaxis. EMS systems and EMS medical directors should develop a mechanism to review the charts of patients who received epinephrine and were not in cardiac arrest. This will help to ensure the safe and appropriate use of epinephrine in order to provide continued quality improvement. Despite the safety of epinephrine, EMS systems that carry epinephrine autoinjectors should establish protocols to deal with patients or emergency responders who have an unintentional injection of epinephrine into the hand or digit. Continued research is needed to better define the role that EMS plays in the management of anaphylaxis. This paper serves as a resource document to the National Association of EMS Physician position on the use of epinephrine for the out-of-hospital treatment of anaphylaxis.