Prehospital management of trauma: A tale of three cities

The controversies that have surrounded the prehospital management of trauma stem not only from a lack of appropriate evaluation data, but also from a lack of medical accountability and "street-wise," academic physician involvement within emergency medical services (EMS) systems. As a result, the approach to EMS trauma care has often been over-generalized and debated in terms of simplistic, unidimensional concepts, such as "scoop and run" versus "field stabilization," without any regard for the type and anatomic location of injury involved, the efficiency and skill of rescuers, the proximity and actual capabilities of definitive care resources, and the logistics of the prehospital setting. The failure to understand and delineate these variables has led to conflicting studies and has confused the analysis of potential therapeutic modalities and management strategies. In view of this, a survey is provided of three major cities, each with intensive, academic physician involvement in their EMS systems, and the approach and rationale for their prehospital care strategies are summarized. In all three systems, patients generally are categorized according to three major injury types (penetrating, blunt, and thermal) and then further subcategorized with regard to anatomical involvement, specifically those involving potential (or known) internal truncal injuries versus those with isolated head trauma or isolated extremity injury. For all three, high-flow O2 delivery and aggressive, advanced airway management (by endotracheal intubation whenever feasible) are keystones of management. In cases of potential or known internal truncal injury, the priority is also expeditious transport to facilities with definitive surgical care with the establishment of IV access and rapid fluid infusions en route.(ABSTRACT TRUNCATED AT 250 WORDS)     

A computer-assisted quality assurance system for an emergency medical service

A busy urban emergency medical service answering more than 50,000 calls each year developed a plan for quality assurance using a computer-assisted model designed to employ a full-time quality assurance officer whose work was supplemented with computer evaluation of EMS field reports. The development of standardized reporting formats, protocols and computer programs enabled a significant improvement in detection of errors of documentation and patient care. Investigated cases rose dramatically in the month following implementation of the system, from five patient care errors per month to 35 (P less than .05), and from 50 documentation errors to 265 per month (P less than .05). Our experience indicates that computer-assisted evaluation of field performance, as judged by prehospital records, is a useful tool to ensure standards in patient care and EMS recordkeeping.     

The role of the emergency physician in emergency medical services for children

Emergency physicians have a duty to advance the care of pediatric patients in the emergency medical services (EMS) system. This policy resource and education paper, designed to support the American College of Emergency Physicians policy paper "The Role of the Emergency Physician in Emergency Medical Services for Children," describes the development of the federal EMS for Children Program, the importance of the integration of EMS for children into EMS systems, and the role of the emergency physician in EMS for children.     

Effect of standing orders on field times

Because of discontinuation of base hospital participation, paramedics in a large urban zone of a California emergency medical services (EMS) system serving 1.1 million persons went on emergency standing orders for nearly all calls requiring advanced life support. Subsequently, the base hospital resumed medical control function under limited standing orders. Standing orders were allowed for calls that required rapid intervention with little probability of morbidity. The EMS agency conducted a retrospective study to compare times at scene and total prehospital care times before (control group) and after institution of standing orders and limited standing orders. There were significant differences in total prehospital care times and at-scene times between the control group and the two standing order groups (P less than .01). There are important implications to EMS systems that use extensive base hospital contact.     

Prehospital DNR Orders: What Do Physicians in Washington Know?

OBJECTIVES: To assess whether physicians know of Washington State's prehospital do-not-resuscitate (DNR) policy, 6 years after its implementation. DESIGN: Cross-sectional survey. SETTING: Washington State, April 2001. PARTICIPANTS: Four hundred seventy-one practicing physicians. MEASUREMENTS: Multivariate logistic regression was used to determine relationships between physician and practice characteristics with knowledge of policies governing advance care planning. RESULTS: Among respondents, 60% did not know that Washington State requires an emergency medical service (EMS)-specific DNR order authored by a physician. Seventy-nine percent did not know that patient-authored advance directives apply only in hospitals and medical offices. CONCLUSION: The findings in this study suggest that most physicians in Washington State lack knowledge about the documentation needed for EMS personnel to forgo pre-hospital attempts at cardiopulmonary resuscitation. Further study is needed to determine whether physician education or legislative change is necessary.     

Medical command errors in an urban advanced life support system.

STUDY OBJECTIVE: The aim of this study was to assist in focusing educational efforts for command physicians by identifying the most common types of errors made by on-line medical command. DESIGN: Retrospective survey of prehospital advanced life support (ALS) trip sheets. SETTING: An urban ALS paramedic service with on-line physician medical command rotating on a monthly basis among three hospitals. PARTICIPANTS: From September 1988 through December 1990, all ALS run sheets were reviewed as part of an ongoing quality assurance program. Cases were identified as deviating from regional emergency medical services protocols as judged by agreement of three physician reviewers. Cases were excluded if all three reviewers did not agree that the command rendered was inappropriate. INTERVENTIONS: Command errors were identified from the prehospital ALS run sheets and categorized. RESULTS: One hundred ninety-four command errors in 167 cases were identified from 3,839 runs (4.4% of all runs). Six types of errors accounted for 80% of the total errors, with the most common error (34%) being failure to address the possibility of hypoglycemia with altered level of consciousness. Error rate decreased from 7.9% to 2.6% of total runs during the study period. CONCLUSION: To reduce the medical command error rate, physician education should be directed at the six problem areas identified. Ongoing quality assurance review of medical command may result in a decrease of the command error rate.     

Clinical trials of the pneumatic antishock garment in the urban prehospital setting

As a result of experimental data and favorable clinical impressions, the pneumatic antishock garment (PASG) has gained widespread acceptance as a reasonable standard of care in emergency medical services (EMS) systems. It is currently legislated as required equipment for medical rescue vehicles in two-thirds of the United States. But despite a decade of widespread use, prospective, randomized, controlled trials that demonstrate the efficacy of the PASG have not been published. Furthermore, certain complications have been reported and concerns have been raised about the use of the PASG under certain circumstances, such as penetrating thoracic injury. In the fall of 1983, the City of Houston EMS system embarked on a long-term prospective evaluation of PASG use in hypotensive victims of injury in the urban prehospital setting. All victims of injury whose systolic blood pressure was 90 mm Hg or less when they initially presented to paramedics in the field were entered into the study. All patients received the identical treatment protocol, with the sole exception of PASG application and inflation to full pressure prior to intravenous catheterization on an alternate day basis. Prospectively collected demographic data have demonstrated that the two resulting groups of PASG and no-PASG patients are well matched in terms of age, sex, injury type, anatomic location of the injury, initial field trauma score, injury severity score and probabilities of survival, as well as the amounts of IV fluids infused in the prehospital setting and the response, scene, and transport times.(ABSTRACT TRUNCATED AT 250 WORDS)     

An emergency medical services curriculum for emergency medicine residencies

Knowledge and experience in emergency medical services (EMS) are essential objectives for residency training in emergency medicine (EM). Although a need exists for competent physician EMS leaders, opportunities for educating emergency physicians in this aspect of emergency care have been few. We describe a curriculum for training EM residents in EMS. The purpose of this training is to assure competency in both on-line and off-line medical control. The former requires a working knowledge of the local system policies and the ability to respond appropriately to paramedic radio calls. Additional education prepares the resident for a much broader role in EMS, including off-line medical control.     

Evaluation of EMS management training offered during emergency medicine residency training

Physician involvement in the provision of both direct and indirect medical control to emergency medical providers is critical to the effective operation of an emergency medical services (EMS) system. We conducted a survey of all accredited emergency medicine residency programs in the United States to determine the content of EMS instruction provided to these physicians-in-training. The majority of programs provide an introduction to direct medical control, to EMS organizational structure, and the opportunity to participate in EMS-related research. Less than 65%, however, provide formal instruction in EMS risk management or quality assurance or the opportunity to observe policy-making bodies related to EMS. The importance placed on EMS during residency training is variable. EMS is the domain of emergency medicine, and adequate training of residents for these responsibilities is imperative.     

Primary care delivery is associated with greater physician experience and improved survival among persons with AIDS

OBJECTIVE: It has been shown that greater physician experience in the care of persons with AIDS prolongs survival, but how more experienced primary care physicians achieve better outcomes is not known. DESIGN/SETTING/PATIENTS: Retrospective cohort study of HIV-infected patients enrolled in a large staff-model health maintenance organization from 1990 through 1999. MEASUREMENTS: Adjusted odds of medical service delivery and adjusted hazard ratio of death by physician experience level (least, moderate, most) and service utilization. MAIN RESULTS: Primary care delivery by physicians with greater AIDS experience was associated with improved survival. After controlling for disease severity, patients cared for by the most experienced physicians were twice as likely to receive a primary care visit in a given month compared with patients of the least and moderately experienced physicians (P <.01). Patients of the least experienced physicians received the lowest level of outpatient pharmacy and laboratory services (P <.001) and were half as likely to have a specialty care visit compared with patients of the most and moderately experienced physicians (P <.05). Patients who received infrequent primary care visits by the least experienced physicians were 15.3 times more likely to die than patients of the most experienced physicians (P =.02). There was a significant increase in primary care services delivered to the population of HIV-infected patients receiving care in 1999, when highly active antiretroviral therapy (HAART) was in general use, compared with the time period prior to the introduction of HAART. CONCLUSIONS: Primary care delivery by physicians with greater HIV experience contributes to improved patient outcomes.     

Prehospital endotracheal intubation: rationale for training emergency medical personnel

Endotracheal intubation by emergency medical services (EMS) personnel in the prehospital setting decreases morbidity and helps to improve the outcome of critically ill patients, especially those with cardiac or respiratory arrest, multiple injuries, or severe head trauma. The endotracheal tube facilitates better oxygenation and ventilation because it enhances lung inflation and protects the lungs from aspiration. No other alternative modality is as efficacious. Compared to physicians in general, properly instructed, well-supervised paramedics can be trained to perform this procedure safely and more efficiently in the emergency setting. The use of the endotracheal tube in the prehospital setting should be strongly encouraged and the training of EMS personnel in this skill should be given high priority.     

Session 8: Logistical considerations

The challenges of EMS trauma care that emergency physicians face revolve around the role of the physician in the trauma care chain and the ability of the physician to effect changes in a system that may not meet the needs of the patient. Coupled with this is documentation of the influence of field care and transport systems on patient outcome. Data are accumulating that demonstrate the benefits of medically accountable ALS systems. Our future will be determined by our ability to prove what we do, change what does not work, and contribute to medical science and the trauma literature.     

To Transmit or Not to Transmit: How Good Are Emergency Medical Personnel in Detecting STEMI in Patients With Chest Pain?

Background

There is growing use of prehospital electrocardiograms (ECGs) in establishing early diagnosis of ST segment myocardial infarction (STEMI) to facilitate early reperfusion. This study aimed to determine the predictive value of prehospital ECGs interpreted by nonphysician emergency medical services (EMS) in chest pain presentations.

Methods

In our city of 658,700 people, EMS/paramedics received 21 hours of instruction on STEMI management, ECG acquisition, and interpretation. Suspected STEMI ECGs were wirelessly transmitted to and discussed with a physician for possible therapy. ECGs deemed negative for STEMI by EMS were not transmitted; patients were transported to the closest hospital without prehospital physician involvement.

Results

From July 21, 2008 to July 21, 2010, there were 5426 chest pain calls to EMS, 380 were suspected STEMI cases. The remaining ECGs were deemed negative for STEMI by EMS. To audit the nontransmitted ECGs we analyzed 323 consecutive patients over 2 selected months (January and June 2010) for comparison. Of nontransmitted cases there was 1 missed and 2 STEMIs that developed subsequently. Based on 380 transmitted and 323 nontransmitted cases, the sensitivity and specificity of EMS detecting STEMI were 99.6% and 67.6%, respectively. The positive and negative predictive values for STEMI were 59.5% and 99.7%, respectively.

Conclusions

Our findings demonstrate nonphysician EMS interpretation of STEMI on prehospital ECG has excellent sensitivity and high negative predictive value. This finding supports the use of prehospital ECGs interpreted by EMS to help identify and facilitate treatment of STEMI. These results may have broad implications on staffing models for first responder/EMS units.     

Patient characteristics affecting stroke identification by emergency medical service providers in Brooklyn,New York

Early identification of stroke should begin in the prehospital phase because the benefits of thrombolysis and clot extraction are time dependent. This study aims to identify patient characteristics that affect prehospital identification of stroke by Long Island college hospital (LICH) emergency medical services (EMS). All suspected strokes brought to LICH by LICH ambulances from January 1, 2010 to December 31, 2011 were included in the study. We compared prehospital care report-based diagnosis against the get with the guidelines (GWTG) database. Age-adjusted logistic regression models were used to study that the effect of individual patient characteristics have on EMS providers’ diagnosis. Included in the study were 10,384 patients with mean age 43.9 years. Of whom, 75 had a GWTG cerebrovascular diagnosis: 53 were ischemic strokes, 7 transient ischemic attacks, 3 subarachnoid hemorrhage, and 12 intercerebral bleeds. LICH EMS correctly identified 44 of 75 GWTG strokes. Fifty-one patients were overcalled as stroke by the EMS. Overall EMS sensitivity was 58.7 % and specificity was 99.5 %. Dispatcher call type of altered mental status, stroke, unconsciousness, and increasing prehospital blood pressure quartile were found to be significantly predictive of a true stroke diagnosis. Patients with a past medical history and EMS providers’ impression of seizures were more likely to be overcalled as a stroke in the field. More than a third of actual stroke patients were missed in the field in our study. Our results show that the patients’ past medical history, dispatcher collected information and prehospital vital sign measurements are associated with a true diagnosis of stroke.     

Insufficient quality of research on prehospital medical emergency care--where are the major problems and solutions?

It is still unclear today whether a few minutes more or less spent in prehospital medical emergency care have a positive effect on a range of outcome variables. Modern emergency medical services (EMS) systems are expensive and have been introduced all over the industrialized world. Yet their effectiveness and efficiency are supported by scant scientific evidence. This is why research into EMS systems is urgently needed. There are significant differences between the approach to EMS research and traditional clinical research. New methodological approaches, such as system-orientated research and risk-adjustment measurements, must be further developed. The implementation of randomized controlled trials (RCTs) in the prehospital setting is often very difficult and not always possible or suitable. Valid alternatives to RCTs exist and should be further developed. Epidemiologists would be of assistance here. Agreement on clear definitions, standard data elements and validated severity scoring for trauma and non-trauma conditions, as well as their validation and routine use throughout the world are urgently needed. Clarifying many questions with regard to EMS systems cannot be left to chance. An internationally recognized research agenda with prioritisation and adaptation to regional requirements would be of great assistance here. Finally, reliable research in Switzerland into EMS enabling relevant decisions will hardly be possible without financial support from the Swiss National Fund and other institutions. Furthermore, it would be inappropriate to decrease the current standard of prehospital care we offer in the short term in order to save money as long as we have no reliable results that indicate that we should. This would also render impossible the very research into this sector that is urgently needed.     

Palliative Care and Prehospital Emergency Medicine: Analysis of a Case Series

Palliative care, which is intended to keep patients at home as long as possible, is increasingly proposed for patients who live at home, with their family, or in retirement homes. Although their condition is expected to have a lethal evolution, the patients—or more often their families or entourages—are sometimes confronted with sudden situations of respiratory distress, convulsions, hemorrhage, coma, anxiety, or pain. Prehospital emergency services are therefore often confronted with palliative care situations, situations in which medical teams are not skilled and therefore frequently feel awkward.We conducted a retrospective study about cases of palliative care situations that were managed by prehospital emergency physicians (EPs) over a period of 8 months in 2012, in the urban region of Lausanne in the State of Vaud, Switzerland.The prehospital EPs managed 1586 prehospital emergencies during the study period. We report 4 situations of respiratory distress or neurological disorders in advanced cancer patients, highlighting end-of-life and palliative care situations that may be encountered by prehospital emergency services.The similarity of the cases, the reasons leading to the involvement of prehospital EPs, and the ethical dilemma illustrated by these situations are discussed. These situations highlight the need for more formal education in palliative care for EPs and prehospital emergency teams, and the need to fully communicate the planning and implementation of palliative care with patients and patients’ family members.     

Cardiac Outcomes Through Digital Evaluation (CODE) STEMI project: prehospital digitally-assisted reperfusion strategies

Background

Guidelines for reperfusion in ST-elevation myocardial infarction (STEMI) were recently adopted by the Canadian Cardiovascular Society. We have developed a blended model of prehospital thrombolytic (PHL) therapy or primary percutaneous coronary intervention (PPCI) activation, in order to achieve guideline times.

Methods

In our urban centre of 658,700 people, emergency medical services (EMS) were trained to perform and screen electrocardiograms (ECGs) for suspected STEMI. Suspected ECGs were transmitted to a physician's hand-held device. If the physician confirmed the diagnosis they coordinated initiation of either PHL or PPCI. In cases where physicians found the prehospital ECG negative for STEMI (PHENST), patients were transported to the closest emergency room.

Results

From July 21, 2008 to July 21, 2010, the Cardiac Outcomes Through Digital Evaluation (CODE) STEMI project received 380 transmitted calls. There were 226 confirmed STEMI by the on-call physician, 158 (70%) received PPCI, 48 (21%) received PHL, and 20 (9%) had angiography but no revascularization. The PPCI, median time from first medical contact to reperfusion was 76 minutes (interquartile range [IQR], 64-93). For PHL, median time from first medical contact to needle was 32 minutes (IQR, 29-39). The overall mortality rate for the STEMI patients was 8% (PHL = 4 [8.3%], PPCI = 8 [5%], medical therapy = 7 [35%]). There were 154 PHENST patients, 44% later diagnosed with acute coronary syndrome. The mortality rate for PHENST was 14%.

Conclusions

Through a model of EMS prehospital ECG interpretation, digital transmission, direct communication with a physician, and rapid coordinated service, we demonstrate that benchmark reperfusion times in STEMI can be achieved.     

Do neurologists and primary care physicians agree on the extent of specialty involvement of patients referred to neurologists?

OBJECTIVE: Understanding the roles and responsibilities of physicians who manage mutual patients is important for assuring good patient care. Among physicians expressing a preference to involve a neurologist in the care of a patient, we evaluated agreement between neurologists and primary care physicians for the extent of specialty involvement in the evaluation and management of the patient, and the factors influencing those preferences. DESIGN AND SETTING: A self-administered survey containing 3 clinical scenarios was developed with the assistance of a multispecialty advisory board and mailed to a stratified probability sample of physicians. PARTICIPANTS: Six hundred and eight family physicians, 624 general internists, and 492 neurologists in 9 U.S. states. INTERVENTIONS: For each scenario, those respondents who preferred involvement of a specialist were asked about the preferred extent of that involvement: one-time consultation with and without test/medication ordering, consultation and limited follow-up, or taking over ongoing care of the specialty problem as long as it persists. MAIN RESULTS: Survey response rate was 60%. For all 3 scenarios, neurologists preferred a greater extent of specialty involvement compared to primary care physicians (all P <.05). Other physician and practice characteristic factors, including financial incentives, had lesser or no influence on the extent of specialty involvement preferred. CONCLUSIONS: The disagreement between primary care physicians and specialists regarding the preferred extent of specialist involvement in the care of patients with neurological conditions should raise serious concerns among health care providers, policy makers, and educators about whether mutual patient care is coordinated and appropriate.     

The impact of injury severity and prehospital procedures on scene time in victims of major trauma.

STUDY OBJECTIVE: To evaluate the relationship among injury severity, prehospital procedures, and time spent at the scene by paramedics for victims of major trauma. DESIGN: Retrospective study of 98 consecutive patients with an Injury Severity Score of more than 15 who were brought to a trauma center by fire department paramedics. SETTING: A medium-sized metropolitan emergency medical services (EMS) system and a Level I trauma center. RESULTS: There were 66 male and 32 female patients with a mean age of 34 years. Thirty-two patients (32.6%) died. Blunt and penetrating trauma accounted for 68.4% and 31.6% of cases, respectively. Thirty-three patients (33.7%) had successful advanced airway procedures, and 81 (82.7%) had at least one IV line started in the field. Analysis of scene time, prehospital procedures, and injury severity parameters revealed that more procedures were performed in the field on the more severely injured cases; that despite this, there was a trend toward shorter scene time for more severely injured patients; and that there was a mean scene time of 8.1 minutes. This is the shortest scene time reported to date for prehospital trauma care in an EMS system. CONCLUSION: Extremely short scene times can be attained without foregoing potentially life-saving advanced life support interventions in an urban EMS system with strong medical control. In such a system, the most severely injured victims may spend less time at the scene although more procedures are performed on them.     

Effect of Adenosine on the Management of Supraventricular Tachycardia by Urban Paramedics

Study objective: To determine the effect of the addition of adenosine, as a standing-order medication, on the prehospital management of supraventricular tachycardia (SVT) in a large urban emergency medical services (EMS) system. Design: Prospective observational case series with historical controls. Setting: Large urban municipal EMS system staffed by paramedics and emergency medical technicians trained to operate automatic or semiautomatic defibrillators (EMT-Ds). Participants: We observed a consecutive sample of prehospital patients who presented with an initial ECG rhythm of SVT, as interpreted by the treating paramedics, between July 1 and December 31, 1993. We used patients from the same 6-month period in 1992 as our control group. Indications for treatment were chest pain, evidence of myocardial ischemia, or shock. Adenosine had been introduced as a first-line medication to be used under standing orders in cases of unstable SVT before a physician was contacted for medical control options. Results: We studied 239 cases and 228 controls. Acceptable call reports with pretreatment and posttreatment ECGs were available for 140 (59%) of the study cases and 104 (46%) of the controls. The two groups were similar in terms of age, sex, and initial vital signs. In the control group, 75 patients had indications for treatment, and 16 were treated (21%). In the study group, 127 had indications for treatment and 103 (81.1%) were treated (odds ratio, 15.83; 95% confidence interval, 7.38-34.4). Conclusion: The introduction of adenosine as a standing-order medication into an urban EMS system increased the proportion of patients who received advanced life support treatment. Paramedics were able to accurately diagnose and begin treatment of SVT with adenosine without direct medical supervision. [Lozano M Jr, McIntosh BA, Giordano LM: Effect of adenosine on the management of supraventricular tachycardia by urban paramedics. Ann Emerg Med December 1995;26:691-696.]