Effect of gender on prehospital refusal of medical aid

Background

“Refusal of medical aid” (RMA) is the term commonly used by emergency medical technicians (EMTs) when someone calls 911 for care (usually the patient or a family member) but, after the initial encounter with the EMTs, the patient refuses emergency medical services transport to the hospital. Some intervention may have been performed, such as taking vital signs or an electrocardiogram, before the RMA. Although there have been multiple studies of the characteristics and outcomes of patients who RMA, little analysis has been done of the role of EMTs in these cases.

Objective

To analyze the association between EMT gender and the patient’s decision to refuse medical aid in the prehospital setting.

Methods

The study was performed using data from one hospital-based ambulance service in an urban setting that participates in the 911 system. This was a case control study that examined the data from consecutive patients who refused medical aid for a 1-year period compared to a control group of non-RMA patients.

Results

There was a significantly higher representation of all-male EMT teams in the RMA group (p < 0.0001). Using propensity score-matching methodology to control for other factors, all-male EMT teams were 4.75 times more likely to generate an RMA as compared to all-female and mixed-gender EMT teams (95% confidence interval 1.63–13.96, p = 0.0046).

Conclusion

We found that the gender of the EMTs was one of the most important factors associated with RMA, with a much higher frequency of RMAs occurring when both members of the team were male.     

Emergency medical technician treatment of hypoglycemia without transport

Objectives

We examine the safety and efficacy of emergency medical technicians (EMTs) providing treatment to stable hypoglycemic patients without transport or paramedic involvement, which is currently beyond their scope of practice.

Methods

All hypoglycemic patients treated in the field without transport for 12 months were included. We used a patient follow-up survey to compare the outcomes of EMT and paramedic-treated patients on the occurrence of repeat hypoglycemic episodes, 911 calls, and/or in-hospital reevaluation within 48 hours; patients' adhering to the provided instructions; and patient satisfaction.

Results

Of 402 cases identified, we were able to contact and survey 203 (51%). There were no statistically significant differences for any of the outcome measures studied. Patients treated by EMTs (110) and paramedics (93) had 8 (7%) and 7 (8%) episodes of repeat hypoglycemia, 3 (3%) and 5 (5%) repeat 911 calls, and 9 (8%) and 10 (11%) hospital evaluations, respectively.

Conclusions

Emergency medical technicians performed comparably with paramedics treating hypoglycemia without transport.     

Early Detection and Treatment of Patients with Severe Sepsis by Prehospital Personnel

Background

Severe sepsis is a condition with a high mortality rate, and the majority of patients are first seen by Emergency Medical Services (EMS) personnel.

Objective

This research sought to determine the feasibility of EMS providers recognizing a severe sepsis patient, thereby resulting in better patient outcomes if standard EMS treatments for medical shock were initiated.

Methods

We developed the Sepsis Alert Protocol that incorporates a screening tool using point-of-care venous lactate meters. If severe sepsis was identified by EMS personnel, standard medical shock therapy was initiated. A prospective cohort study was conducted for 1 year to determine if those trained EMS providers were able to identify 112 severe sepsis patients before arrival at the Emergency Department. Outcomes of the sample of severe sepsis patients were examined with a retrospective case control study.

Results

Trained EMS providers transported 67 severe sepsis patients. They identified 32 of the 67 severe sepsis patients correctly (47.8%). Overall mortality for the sample of 112 severe sepsis patients transported by EMS was 26.7%. Mortality for the sample of severe sepsis patients for whom the Sepsis Alert Protocol was initiated was 13.6% (5 of 37), crude odds ratio for survival until discharge was 3.19 (95% CI 1.14–8.88; p = 0.040).

Conclusions

This pilot study is the first to utilize EMS providers and venous lactate meters to identify patients in severe sepsis. Further research is needed to validate the Sepsis Alert Protocol and the potential associated decrease in mortality.     

Teleconsultation in pre-hospital emergency medical services: real-time telemedical support in a prospective controlled simulation study

Background

Teleconsultation from the scene of an emergency to an experienced physician including real-time transmission of monitoring, audio and visual information seems to be feasible.In preparation for bringing such a system into practice within the research project “Med-on-@ix”, a simulation study has been conducted to investigate whether telemedical assistance (TMA) in Emergency Medical Services (EMS) has an impact on compatibility to guidelines and timing.

Material and methods

In a controlled simulation study 29 EMS teams (one EMS physician, two paramedics) ran through standardized scenarios (STEMI: ST-elevation myocardial infarction; MT: major trauma) on high-fidelity patient simulators with defined complications (treatable clearly following guidelines). Team assignments were randomized and each team had to complete one scenario with and another without TMA. Analysis was based on videotaped scenarios using pre-defined scoring items and measured time intervals for each scenario.

Results

Adherence to treatment algorithms improved using TMA. STEMI: cathlab informed (9/14 vs. 15/15; p = 0.0169); allergies checked prior to acetylsalicylic acid (5/14 vs. 13/15; p = 0.0078); analgosedation prior to cardioversion (10/14 vs. 15/15; p = 0.0421); synchronized shock (6/14 vs. 14/15; p = 0.0052). MT: adequate medication for intubation (3/15 vs. 10/14; p = 0.0092); mean time to inform trauma centre 547 vs. 189 s (p = 0.0001). No significant impairment of performance was detected in TMA groups.

Conclusions

In simulated setting TMA was able to improve treatment and safety without decline in timing. Nevertheless, further research is necessary to optimize the system for medical, organizational and technical reasons prior to the evaluation of this system in routine EMS.     

The effect of pulse oximetry on emergency medical technician decision making

Objective

Relatively little is known about the use of pulse oximetry in the prehospital setting. The purpose of this study was to determine how emergency medical technicians (EMTs) use pulse oximetry information to influence their decisions regarding the involvement of advanced life support (ALS) personnel in a two-tiered emergency medical services (EMS) system.

Methods

EMTs were trained and authorized to use pulse oximetry in predefined clinical situations. The EMTs completed a questionnaire describing the influence of the oximetry information on their decision making regarding the involvement of ALS units.

Results

The EMTs reported an influence on their decisions whether to involve ALS care in 35 (12%) of 302 cases. The addition of the pulse oximetry information caused the EMTs to request ALS dispatch in 11 cases, to cancel a previously dispatched ALS response in eight cases, and not to request an ALS response from the scene when they otherwise would have requested it in 16 cases.

Conclusion

Prehospital pulse oximetry has a measurable influence on EMT decisions concerning ALS involvement in a two-tiered EMS system. It improves system efficiency by helping to match patients to an appropriate level of care.     

A randomized trial of compression first or analyze first strategies in patients with out-of-hospital cardiac arrest: results from an Asian community

Background

It is still under debate whether a period of cardiopulmonary resuscitation should be performed prior to rhythm analysis for defibrillation for out of hospital cardiac arrests (OHCA). This study compared outcomes of OHCA treated by “compression first” (CF) versus “analyze first” (AF) strategies in an Asian community with low rates of shockable rhythms.

Methods

This randomized trial was conducted in Taipei City between February 2008 and December 2009. Dispatches of suspected OHCA that activated advanced life support teams were randomized into the CF and AF strategies. Patients assigned to CF strategy received 10 cycles of CPR prior to analysis by automatic external defibrillator. The primary outcome was sustained (>2 h) return of spontaneous circulation (ROSC) and secondary outcome was survival to hospital discharge.

Results

We included 289 cases in the final analysis after exclusion by pre-specified criteria, 141 were allocated to CF strategy and 148 to AF strategy. Baseline characteristics were similar. Thirty-seven (26.2%) of those receiving CF strategy and 49 (33.1%) of the AF strategy achieved sustained ROSC (p = 0.25). In a post-hoc analysis of patients who achieved ROSC, those that received CF strategy were more likely to be discharged alive from the hospital (16/37 = 43.2% vs. 11/49 = 22.4%, p = 0.02).

Conclusion

In this study population of low rates of shockable rhythms, there was no difference in ROSC for CF or AF strategies. Considering the EMS operation situations, a period of paramedic-administered CPR for up to 10 cycles prior to rhythm analysis could be a feasible strategy in this community.     

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.     

Agreement between emergency medical services and expert blood pressure measurements

Background

Emergency Medical Services (EMS)-measured blood pressures (BPs) are utilized for administering medications in the field and for triage decisions. Retrospective work has demonstrated poor agreement between EMS and Emergency Department (ED) BP but has lacked a valid, reliable reference standard.

Study Objectives

To compare EMS BP measurements with those of trained research assistants (RA) and observe measurement technique for sources of error.

Methods

A prospective study was performed with a large urban EMS. BP measurements were made by RA within 5 min of patients presenting to the ED. EMS personnel were asked about technique. EMS personnel were then observed while RA simultaneously measured BP. Analysis was performed using methods outlined by Bland and Altman.

Results

There were 100 patients enrolled for each phase. In the first phase, the mean difference in systolic BP was −3.8 ± 18.6 mm Hg (95% confidence interval [CI] −8.3 to 0.59), and the mean difference in diastolic BP was 0.42 ± 13.8 mm Hg (95% CI −3.3 to 4.1). In the second phase, the mean difference in systolic BP was −4.6 ± 10.1 mm Hg (95% CI −6.6 to −2.6) and the mean difference in diastolic BP was −3.6 ± 10.6 mm Hg (95% CI −3.6 to −0.2). EMS personnel failed to properly place the cuff or deflate it 2–3 mm Hg/s in over 90% of the readings. They failed to properly inflate the cuff in 74% of the patients, and failed to properly place the stethoscope in 40%. EMS personnel demonstrated a significant preference for the terminal digit of “0” (p < 0.0001).

Conclusions

EMS and expert BP measurements showed smaller discrepancies than those previously noted, especially with simultaneous measurements. However, EMS demonstrated poor adherence to American Heart Association recommendations for measuring BP. EMS also showed terminal digit preference.     

Traumatic out-of-hospital cardiac arrests in Melbourne, Australia

Introduction

Many consider attempted resuscitation for traumatic out-of-hospital cardiac arrest (OHCA) futile. This study aims to describe the characteristics and profile of adult traumatic OHCA.

Methods

The Victorian Ambulance Cardiac Arrest Registry (VACAR) was used to identify all trauma related cases of OHCA in patients aged ≥16 years.

Results

Between 2000 and 2009, EMS attended 33,178 OHCAs of which 2187 (6.6%) had a traumatic aetiology. The median age (IQR) of traumatic OHCA cases was 36 (25–55) years and 1612 were male (77.5%). Bystander CPR was performed in 201 cases (10.2%) with median (IQR) EMS response time 8 (6–11) min. The first recorded rhythm by EMS was asystole seen in 1650 (75.4%), PEA in 294 (13.4%) cases and VF in 35 cases (1.6%). Cardiac output was present in 208 (9.5%) cases who subsequently had an EMS witnessed OHCA. EMS attempted resuscitation in 545 (24.9%) patients of whom 84 (15.4%) achieved ROSC and were transported, and 27 (5.1%) survived to hospital discharge; 107 were transported with CPR of whom 8 (7.4%) survived to hospital discharge. Where EMS attempted resuscitation in traumatic OHCAs, survival for VF was 11.8% (n = 4), PEA 5.1% (n = 10) and asystole 2.4% (n = 3). In EMS witnessed traumatic OHCA, resuscitation was attempted in 175 cases (84.1%), 35 (16.8%) patients achieved sustained ROSC before transport of whom 5 (14%) survived to leave hospital and 60 (28.8%) were transported with CPR of whom 6 (10%) survived to leave hospital. Compared to OHCA cases with ‘presumed cardiac’ aetiology traumatic OHCAs were younger [median years (IQR): 36 (25–55) vs 74 (61–82)], had resuscitation attempted less (25% vs 48%), were less likely to have a shockable rhythm (1.6% vs 17.1%), were more likely to be witnessed (62.8% vs 38.1%) and were less likely to receive bystander CPR (10.2% vs 25.5%) (p < 0.001, respectively). Multivariate logistic regression identified factors associated with EMS decision to attempt resuscitation. The odds ratio [OR (95% CI)] for ‘presence of bystander CPR’ was 5.94 (4.11–8.58) and for ‘witnessed arrest’ was 2.60 (1.86–3.63).

Conclusion

In this paramedic delivered EMS attempted resuscitation was not always futile in traumatic OHCA with a survival of 5.1%. The quality of survival needs further study.     

A pilot study of emergency medical technicians' field assessment of intoxicated patients' need for ED care

Objective

Alcohol–intoxicated individuals account for a significant proportion of emergency department care and may be eligible for care at alternative sobering facilities. This pilot study sought to examine intermediate-level emergency medical technician (EMT) ability to identify intoxicated individuals who may be eligible for diversion to an alternative sobering facility.

Methods

Intermediate-level EMTs in an urban fire department completed patient assessment surveys for individual intoxicated patients between May and August 2010. Corresponding patient medical records were retrospectively reviewed for diagnosis, disposition, and blood alcohol content. Statistical analysis was conducted to determine correlates of survey response, diagnosis, and disposition; and survey sensitivity and specificity were calculated.

Results

One hundred ninety-seven patient transports and medical records were analyzed. Emergency medical technicians indicated 139 patients (71%) needed hospital-based care, and 155 patients (79%) had a primary ethanol diagnosis. Fourteen patients (7%) were admitted to the hospital, and EMTs identified 93% of admitted patients as requiring hospital-based care. Overall sensitivity and specificity of the survey were 93% (95% confidence interval, 66.1-99.8) and 40% (95% confidence interval, 33.3-47.9), respectively.

Conclusion

Intermediate-level EMTs may be able to play an important role in facilitating triage of intoxicated patients to alternate sobering facilities.     

Paediatric traumatic out-of-hospital cardiac arrests in Melbourne, Australia

Introduction

Many consider attempted resuscitation for traumatic out-of-hospital cardiac arrest (OHCA) futile. This study aims to describe the characteristics and profile of paediatric traumatic OHCA.

Methods

The Victorian Ambulance Cardiac Arrest Registry (VACAR) was used to identify all trauma related cases of OHCA in patients aged less than 16 years of age. Cases were linked with their coronial findings.

Results

Between 2000 and 2009, EMS attended 33,722 OHCAs including 2187 adult traumatic OHCAs. There were 538 (1.6%) OHCAs in children less than 16 years of age of which n = 64 were due to trauma. The median age (IQR) of paediatric traumatic OHCA was 7 (4.5–13) years and 44 were male (69%). Bystander CPR was performed in 22 cases (34.4%). The first recorded rhythm by EMS was asystole seen in 42 (66%), PEA in 14 (22%) cases and VF in 2 cases (3%). Cardiac output was present in 7 (11%) cases who subsequently had an EMS witnessed OHCA. EMS attempted resuscitation in 35 (55%) patients of whom 7 (20%) achieved ROSC and were transported, and 1 (3%) survived to hospital discharge with severe neurological sequelae; 14(40%) were transported with CPR of whom none survived. Coronial cause of death was multiple injuries in 35%, head injury in 33%, head and neck injury in 10%, chest injuries in 10% and other causes (12%).

Conclusions

Traumatic aetiology of OHCA when compared to the incidence of adult traumatic OHCAs is uncommon. Resuscitation efforts are seldom effective and associated with poor neurological outcome.     

Transfusion of Packed Red Blood Cells is Not Associated with Improved Central Venous Oxygen Saturation or Organ Function in Patients with Septic Shock

Background

The exact role of packed red blood cell (PRBC) transfusion in the setting of early resuscitation in septic shock is unknown.

Study Objective

To evaluate whether PRBC transfusion is associated with improved central venous oxygen saturation (ScvO₂) or organ function in patients with severe sepsis and septic shock receiving early goal-directed therapy (EGDT).

Methods

Retrospective cohort study (n = 93) of patients presenting with severe sepsis or septic shock treated with EGDT.

Results

Thirty-four of 93 patients received at least one PRBC transfusion. The ScvO₂ goal > 70% was achieved in 71.9% of the PRBC group and 66.1% of the no-PRBC group (p = 0.30). There was no difference in the change in Sequential Organ Failure Assessment (SOFA) score within the first 24 h in the PRBC group vs. the no-PRBC group (8.6–8.3 vs. 5.8–5.6, p = 0.85), time to achievement of central venous pressure > 8 mm Hg (732 min vs. 465 min, p = 0.14), or the use of norepinephrine to maintain mean arterial pressure > 65 mm Hg (81.3% vs. 83.8%, p = 0.77).

Conclusions

In this study, the transfusion of PRBC was not associated with improved cellular oxygenation, as demonstrated by a lack of improved achievement of ScvO₂ > 70%. Also, the transfusion of PRBC was not associated with improved organ function or improved achievement of the other goals of EGDT. Further studies are needed to determine the impact of transfusion of PRBC within the context of early resuscitation of patients with septic shock.     

The early phase of human sepsis is characterized by a combination of apoptosis and proliferation of T cells

Purpose

T cell activation as well as unresponsiveness has been described in separate studies in sepsis. Our aim was to establish the coexistence of both T cell fate in human sepsis.

Patients and Methods

This is a cross-sectional study of 48 patients presenting with severe sepsis or septic shock and 15 healthy controls. Cytofluorometric techniques were used to quantify T cell activation, apoptosis, proliferation, expression of costimulatory molecules, and cytokine secretion.

Results

Patients with sepsis were characterized by a significant increase in the percentage of activated T cell subsets, as measured using CD69 marker, compared with healthy controls (P < .05). T cell proliferation as measured through Ki67 expression was obvious in infected patients for both CD4 and CD8 T cell subsets compared with controls (P ≤ .006). T cell subset apoptosis as measured using Hoechst dye was also increased in infected patients compared with controls (P ≤ .002). CD4 T cell proliferation was correlated with interleukin 2 secretion (R² = 0.84, P < .001), whereas up-regulation of CD4 T cell apoptosis was correlated with CTLA-4 expression (R² = 0.24, P = .001). No such similar relationship was observed for CD8⁺ T cells.

Conclusions

Concomitant T cell proliferation and T cell apoptosis are observed in human sepsis, being related to a different pathway.     

The relationship between paramedics' level of education and degree of commitment

Introduction

Emergency medical services (EMS) personnel attrition is a serious concern. Two fundamental psychological constructs linked to attrition are organizational and occupational commitment.

Objective

To determine if there is a relationship between a paramedic's degree of occupational/organizational commitment and the following: (1) levels of education and (2) type of employment.

Methods

This was a cross-sectional study of paramedics in 6 states that require continued paramedic national registration. The data collection instrument consisted of demographic and occupational and organizational commitment sections. For level of education, the primary independent variable, each subject was placed into 1 of 3 groups: (1) certificate, (2) associate's or bachelor's degree in EMS (degree), and (3) paramedic certificate or degree with a non-EMS postbaccalaureate degree. Type of employment (fire based vs non–fire based) was also used as an independent variable. Organizational and occupational commitment was measured using validated scales for each. Analysis of variance was used for the comparisons between levels of each of the independent variables. A P < .05 was considered significant.

Results

For occupational commitment, the participants with certificate level of education had a significantly higher score (88.9) than did those with either the degree (83.6) or postbaccalaureate (80.9) level of education. There were no significant differences for total organizational commitment. There were also no overall differences in occupational and organizational commitment between fire- and non–fire-based employees.

Conclusion

Paramedic occupational commitment shows a statistically significant decrease with increased level of education. Factors associated with commitment of more highly educated paramedics need to be explored.     

Expertise in prehospital endotracheal intubation by emergency medicine physicians-Comparing 'proficient performers' and 'experts'

Background

Training requirements to perform safe prehospital endotracheal intubation (ETI) are not clearly known. This study aimed to determine differences in ETI performance between ‘proficient performers’ and ‘experts’ according to the Dreyfus &; Dreyfus framework of expertise. As a model for ‘proficient performers’ EMS physicians with a clinical background in internal medicine were compared to EMS physicians with a background in anaesthesiology as a model for ‘experts’.

Methods

Over a one-year period all ETIs performed by the EMS physicians of our institution were prospectively evaluated. ‘Proficient performers’ and ‘experts’ were compared regarding incidence of difficult ETI, ability to predict difficult ETI, and decision for ETI.

Results

Mean years of professional experience were similar between the physician groups, but the median ETI experience differed significantly with 18/year for ‘proficients’ and 304/year for ‘experts’ (p < 0.001). ‘Proficient performers’ intubated 130 of their 2170 treated patients (6.0%), while ‘experts’ did so in 146 of 1809 cases (8.1%, p = 0.01 for difference). The incidence of difficult ETI was 17.7% for ‘proficient performers’, and 8.9% for ‘experts’ (p < 0.05). In 4 cases ETI was impossible, all managed by ‘proficient performers’, but all patients could be ventilated sufficiently. Unexpected difficult ETI occurred in 6.1% for ‘proficient performers’, and 2.0% for ‘experts’ (p = 0.08).

Conclusions

In a prehospital setting ‘expert’ status was associated with a significantly lower incidence of ‘difficult ETI’ and a higher proportion of ETI decisions. In addition, ability to predict difficult ETI was higher, although non-significant. There was no difference in the incidence of impossible ventilation.     

Does the time of onset of severe sepsis in a surgical intensive care unit influence mortality rates: a single-center retrospective analysis

Purpose

The purpose of this study was to investigate possible differences in characteristics and mortality rates between early- and late-onset severe sepsis in surgical intensive care unit (ICU) patients.

Materials and Methods

Prospectively collected data from all adult patients (>18 years) admitted to our 50-bed surgical ICU between 1st March 2004 and 30th July 2006 were analyzed retrospectively.

Results

Of 5925 patients admitted during the study period, 234 patients (3.9%) had severe sepsis: 74 (31.6%) early onset and 160 (68.4%) late onset. Respiratory infections (48.1 versus 27.0%, P = .002) and infections of unknown origin (21.9 versus 12.2%, P = .005) were recorded more frequently in patients with late-onset than in those with early-onset severe sepsis; abdominal infections were more frequent in early-onset than in late-onset severe sepsis (20.3% versus 7.5%, P = .005). Gram-positive infections were more frequent in late-onset than in early-onset severe sepsis (63.1 versus 51.4%, P = .036). The time of onset of severe sepsis was not independently associated with an increased risk of ICU (early versus late: odds ratio, 1.1; confidence interval, 0.78-0.59; P = .786) or in-hospital (early versus late: odds ratio, 0.68; 95% confidence interval, 0.36-1.29; P = .689) death.

Conclusions

Patterns of infection are different in patients with early-onset and those with late-onset severe sepsis. The time of onset of severe sepsis in surgical ICU patients has no impact on mortality. These data may be important in risk stratification and may be useful in resource allocation in the ICU.     

Emergency Medical Services as a Strategy for Improving ST-Elevation Myocardial Infarction System Treatment Times

Background

Reducing delays in time to treatment is a key goal of ST-elevation myocardial infarction (STEMI) emergency care. Emergency medical services (EMS) are a critical component of the STEMI chain of survival.

Study Objective

We sought to assess the impact of the careful integration of EMS as a strategy for improving systemic treatment times for STEMI.

Methods

We conducted a study of all 747 nontransfer STEMI patients who underwent primary percutaneous coronary intervention (PCI) in Dallas County, Texas from October 1, 2010 through December 31, 2011. EMS leaders from 24 agencies and 15 major PCI receiving hospitals collected and shared common, de-identified patient data. We used 15 months of data to develop a generalized linear regression to assess the impact of EMS on two treatment metrics—hospital door to balloon (D2B) time, and symptom onset to arterial reperfusion (SOAR) time, a new metric we developed to assess total treatment times.

Results

We found statistically significant reductions in median D2B (11.1-min reduction) and SOAR (63.5-min reduction) treatment times when EMS transported patients to the receiving facility, compared to self-transport. In addition, when trained EMS paramedics field-activated the cardiac catheterization laboratory using predefined specified protocols, D2B times were reduced by 38% (43 min) after controlling for confounding variables, and field activation was associated with a 21.9% reduction (73 min) in the mean SOAR time (both with p < 0.001).

Conclusion

Active EMS engagement in STEMI treatment was associated with significantly lower D2B and total coronary reperfusion times.     

Gender differences in scene time, transport time, and total scene to hospital arrival time determined by the use of a prehospital electrocardiogram in patients with complaint of chest pain

Background

Recent studies have described a gender bias against women in the setting of acute coronary syndrome (ACS).

Objectives

We sought to measure the impact that a prehospital electrocardiogram (PH ECG) has on prehospital total scene time to hospital arrival time, comparing men and women with the complaint of chest pain (cCP).

Methods

This study retrospectively analyzed San Diego Emergency Medical Services (EMS) runsheets of patients with cCP before and after implementation of the PH ECG protocol. The average scene time (ST), transport time (TT), and total scene-to-arrival-at-hospital time (STH) were compared. After stratification by gender, times were compared in patients with ST-elevation myocardial infarction (STEMI) to those without STEMI.

Results

Of 21,742 EMS activations for patients with cCP, there were no significant differences overall. When stratified by gender, there was a significant reduction of ST (00:19:16 min vs. 00:20:48 min, p < 0.001, 95% CI 00:01:17–00:01:48) and STH (00:33:22 min vs. 00:35:44 min, p < 0.001, 95% CI 00:01:21–00:02:24) favoring men in cases without STEMI. In cases of STEMI, men had a significant reduction in ST (00:17:27 min vs. 00:20:29 min, p < 0.001, 95% CI 00:01:24–00:04:40) and STH (00:30:30 min vs. 00:34:25 min, p < 0.01, 95% CI 00:01:23–00:06:26) times compared to women.

Conclusion

Prehospital ECG implementation led to no significant differences in pre- and post-implementation times. In cases of STEMI, men had significantly reduced scene time and scene-to-hospital time when compared to women. The precise reason for these disparities remains unknown.     

A Pilot Study Examining the Viability of a Prehospital Assessment with UltraSound for Emergencies (PAUSE) Protocol

Background

Prehospital ultrasound has been shown to aid in the diagnosis of multiple conditions that do not generally change prehospital management. On the other hand, the diagnoses of cardiac tamponade, tension pneumothorax, or cardiac standstill may directly impact patient resuscitation in the field.

Study Objective

To determine if prehospital care providers can learn to acquire and recognize ultrasound images for several life-threatening conditions using the Prehospital Assessment with UltraSound for Emergencies (PAUSE) protocol.

Methods

This is a prospective, educational intervention pilot study at an urban fire department with integrated emergency medical services (EMS). We enrolled 20 emergency medical technicians – paramedic with no prior ultrasonography training. Subjects underwent a 2-h training session on basic ultrasonography of the lungs and heart to evaluate for pneumothorax, pericardial effusion, and cardiac activity. Subjects were tested on image interpretation as well as image acquisition skills. Two bedside ultrasound-trained emergency physicians scored images for adequacy. Image interpretation testing was performed using pre-obtained ultrasound clips containing normal and abnormal images.

Results

All subjects appropriately identified the pleural line, and 19 of 20 paramedics achieved a Cardiac Ultrasound Structural Assessment Scale score of ≥4. For the image interpretation phase, the mean PAUSE protocol video test score was 9.1 out of a possible 10 (95% confidence interval 8.6–9.6).

Conclusion

Paramedics were able to perform the PAUSE protocol and recognize the presence of pneumothorax, pericardial effusion, and cardiac standstill. The PAUSE protocol may potentially be useful in rapidly detecting specific life-threatening pathology in the prehospital environment, and warrants further study in existing EMS systems.