Transient peroneal nerve palsies from injuries placed in traction splints

Two patients thought to have distal femur fractures presented to the emergency department (ED) of a level 1 trauma center with traction splints applied to their lower extremities. Both patients had varying degrees of peroneal nerve palsies. Neither patient sustained a fracture, but both had a lateral collateral ligament injury and one an associated anterior cruciate ligament tear. One patient had a sensory and motor block, while the other had loss of sensation on the dorsum of his foot. After removal of the traction splint both regained peroneal nerve function within 6 hours. Although assessment of ligamentous knee injuries are not a priority in the trauma setting, clinicians should be aware of this possible complication in a patient with a lateral soft tissue injury to the knee who is placed in a traction splint that is not indicated for immobilization of this type of injury.     

Ability of the Physiologic Criteria of the Field Triage Guidelines to Identify Children Who Need the Resources of a Trauma Center

Background: There is limited research on how well the American College of Surgeons/Center for Disease Control and Prevention Guidelines for Field Triage of Injured Patients assist EMS providers in identifying children who need the resources of a trauma center. Objective: To determine the accuracy of the Physiologic Criteria (Step 1) of the Field Triage Guidelines in identifying injured children who need the resources of a trauma center. Methods: EMS providers who transported injured children 15 years and younger to pediatric trauma centers in 3 mid-sized cities were interviewed regarding patient demographics and the presence or absence of each of the Field Triage Guidelines criteria. Children were considered to have needed a trauma center if they had non-orthopedic surgery within 24 hours, ICU admission, or died. This data was obtained through a structured hospital record review. The over- and under-triage rates and positive likelihood ratios (+LR) were calculated for the overall Physiologic Criteria and each individual criterion. Results: Interviews were conducted for 5,610 pediatric patients; outcome data were available for 5,594 (99.7%): 5% of all patients needed the resources of a trauma center and 19% met the physiologic criteria. Using the physiologic criteria alone, 51% of children who needed a trauma center would have been under-triaged and 18% would have been over-triaged (+LR 2.8, 95% CI 2.4–3.2). Glasgow Coma Score (GCS) < 14 had a +LR of 14.3 (95% CI 11.2–18.3), with EMS not obtaining a GCS in 4% of cases. 54% of those with an EMS GCS < 14 had an initial ED GCS < 14. Abnormal respiratory rate (RR) had a +LR of 2.2 (95% CI 1.8–2.6), with EMS not obtaining a RR in 5% of cases. 41% of those with an abnormal EMS RR had an abnormal initial ED RR. Systolic blood pressure (SBP) < 90 had a +LR of 3.5 (95% CI 2.5–5.1), with EMS not obtaining a SBP in 20% of cases. SBP was not obtained for 79% of children <1 year, 46% 1–4 years, 7% 5–9 years, and 2% 10–15 years. A total of 19% of those with an EMS SBP < 90 had an initial ED SBP < 90. Conclusions: The Physiologic Criteria are a moderate predictor of trauma center need for children. Missing or inaccurate vital signs may be limiting the predictive value of the Physiologic Criteria.     

Do EMS Providers Accurately Ascertain Anticoagulant and Antiplatelet Use in Older Adults with Head Trauma?

Objective: Prehospital provider assessment of the use of anticoagulant or antiplatelet medications in older adults with head trauma is important. These patients are at increased risk for traumatic intracranial hemorrhage and therefore field triage guidelines recommend transporting these patients to centers capable of rapid evaluation and treatment. Our objective was to evaluate EMS ascertainment of anticoagulant and antiplatelet medication use in older adults with head trauma. Methods: A retrospective study of older adults with head trauma was conducted throughout Sacramento County. All 5 transporting EMS agencies and all 11 hospitals in the county were included in the study, which ran from January 2012 to December 2012. Patients ≥55 years who were transported to a hospital by EMS after head trauma were included. We excluded patients transferred between two facilities, patients with penetrating head trauma, prisoners, and patients with unmatched hospital data. Anticoagulant and antiplatelet use were categorized as: warfarin, direct oral anticoagulants (DOAC; dabigatran, rivaroxaban, and apixaban), aspirin, and other antiplatelet agents (e.g., clopidogrel and ticagrelor). We calculated the percent agreement and kappa statistic for binary variables between EMS and emergency department (ED)/hospital providers. A kappa statistic ≥0.60 was considered acceptable agreement. Results: After excluding 174 (7.6%) patients, 2,110 patients were included for analysis; median age was 73 years (interquartile range 62–85 years) and 1,259 (60%) were male. Per ED/hospital providers, the use of any anticoagulant or antiplatelet agent was identified in 595 (28.2%) patients. Kappa statistics between EMS and ED/hospital providers for the specific agents were: 0.76 (95% CI 0.71–0.82) for warfarin, 0.45 (95% CI 0.19–0.71) for DOAC agents, 0.33 (95% CI 0.28–0.39) for aspirin, and 0.51 (95% CI 0.42–0.60) for other antiplatelet agents. Conclusions: The use of antiplatelet or anticoagulant medications in older adults who are transported by EMS for head trauma is common. EMS and ED/hospital providers have acceptable agreement with preinjury warfarin use but not with DOAC, aspirin, and other antiplatelet use.     

Anterior spinal cord syndrome after initiation of treatment with atenolol

Anterior spinal cord syndrome is a rare condition with a variety of precipitating factors. Patients typically complain of weakness or paralysis of the extremities, often accompanied by pain, but frequently without a history of trauma. A 48-year-old man presented to the emergency department complaining of neck pain and inability to move his legs in the absence of trauma. Several hours prior he had seen his private physician and was given a dose of atenolol for elevated blood pressure. He had not previously been on medications for hypertension. His neurological examination revealed bilateral paralysis of the lower extremities. In the upper extremities he had weakness and sensory loss at the level of C6. Rectal tone was decreased and without sensation. Cervical and thoracic spine magnetic resonance imaging showed spondylotic disc disease, with disc herniation at C6-7 causing severe spinal canal stenosis. Despite i.v. methylprednisolone, pressors, and a prolonged intensive care unit course, the patient was discharged 5 weeks later with continued neurological deficits. Anterior spinal cord syndrome results from compression of the anterior spinal artery and often occurs in the absence of traumatic injury. The recognition, management, and prognosis of this condition are discussed.     

A Review of: “The Field Guide to Wilderness Medicine”

Objective. To develop guidelines allowing emergency medical services (EMS) dispatchers to safely match callers to an EMS response or, alternatively, to a nontraditional resource. Methods. This was a prospective cohort study of callers to an urban EMS dispatch center and an associated review of EMS patient care forms and emergency department (ED) patient care records. The following five “nature codes” (patient chief complaints) were included: back pain, fall, bleeding or laceration, sick, and trauma. Callers included in the study had been assigned the lowest severity level (Alpha), according to existing dispatch criteria. An a priori list of EMS and ED “important findings,” indicating need for an EMS response, was used as the outcome variable. Classification and regression tree (CART) analysis was used to develop a decision rule to further identify a low-risk subgroup of patients who could potentially be served by alternative resources. Results. From November 1, 1998, to May 31, 1999, 656 subjects were entered into the study, including 263 males (40%) and 389 females (59%). The mean age was 51 years (range, 0–101 years). One hundred twenty-five (19%) callers had an important EMS finding, including the administration of comfort medications, morphine, benzodiazepines, and droperidol. Forty-six subjects (7%) had an important ED finding. When EMS and ED findings were combined, 158 subjects (24%) had an “important finding.” Using CART analysis, having an age <12 years predicted a subset of patients who did not have an important finding suggesting the need for an EMS response. Using cross-validation, this decision rule had a 99% sensitivity, 13% specificity, and 98% negative predictive value. Conclusion. The authors were able to use a demographic variable (age) to predict a population of callers to a 911 dispatch center triaged to the lowest acuity category, who have a very low risk of having an EMS or ED important finding. The decision rule developed here is preliminary, requiring further validation.     

Can ems providers adequately assess trauma patients for cervical spinal injury?

Objective. To determine whether EMS providers can accurately apply the clinical criteria for clearing cervical spines in trauma patients. Methods. EMS providers completed a data form based on their initial assessments of all adult trauma patients for whom the mechanism of injury indicated immobilization. Data collected included the presence or absence of neck pain/tenderness; altered mental status; history of loss of consciousness; drug/alcohol use; neurologic deficit; and other painful/distracting injury. After transport to the ED, emergency physicians (EPs) completed an identical data form based on their assessments. Immobilization was considered to be indicated if any one of the six criteria was present. The El's and EMS providers were blinded to each other's assessments. Agreement between the EP and EMS assessments was analyzed using the kappa statistic. Results. Five-hundred seventy-three patients were included in the study. The El' and EMS assessments matched in 78.7% (n = 451) of the cases. There were 44 (7.7%) patients for whom EP assessment indicated immobilization, but the EMS assessment did not. The kappa for the individual components of the assessments ranged from 0.35 to 0.81, with the kappa for the decision to immobilize being 0.48. The EMS providers' assessments were generally more conservative than the EPs'. Conclusion. EMS and EP assessments to rule out cervical spinal injury have moderate to substantial agreement. However, the authors recommend that systems allowing EMS providers to decide whether to immobilize patients should follow those patients closely to ensure appropriate care and to provide immediate feedback to the EMS providers.     

To have and to hold, until competence do us part!

By using the EMS "tools" discussed here, your exposure to mismanagement of patients who refuse treatment/transport can be greatly mitigated, but probably not completely eliminated. Remember, an EMS provider may be the last medical professional to see a patient alive before he refused transportation. It is suggested that EMS providers research their own local and state laws concerning patient refusal, as these laws vary from state to state. At a bare minimum, your refusal policy must address the high-risk refusals that trigger medical oversight, some method for determining patient competence, and a documentation policy with post-review that supports a well-constructed account of the refusal. As for the chest pain patient discussed earlier. If this patient can be determined "competent" regardless of his cardiac stability and etiology, he can refuse treatment and transportation. The EMS provider's protocols should address the use of MMSE and OLMC consultation. The OLMC consult should involve a conversation with both the patient and his wife, who would add credibility to her husband's competence and could possibly be used as a source of support for EMS. If determined competent, the risks of refusing treatment and transportation would be discussed on the radio, including the patient's possible death. The patient would be advised of the benefits of transportation, including the proposed EMS care and ensuing treatment at the hospital. If not convinced, the patient could sign an informed refusal, witnessed by his wife or another third party. The patient and his wife would be advised to call 9-1-1 if the chest pain returns.     

Inappropriate Use of Emergency Medical Services Transport: Comparison of Provider and Patient Perspectives

Objectives: To determine the extent of inappropriate ambulance use from the perspectives of both emergency medical services (EMS) providers and patients utilizing EMS transport, assess level of agreement, and identify variables associated with inappropriate ambulance use. Methods: A prospective cross-sectional study was done of a consecutive sample of patients arriving by ambulance during the month of February 1997 at an urban university hospital ED. EMS providers and patients completed a survey with questions regarding their perceptions of whether the need for ambulance transport was an emergency or a nonemergency. Patient demographic information and availability of alternate means of transportation to the hospital were also evaluated. Results: Eight hundred eighty-seven patients were included in the study. EMS providers thought that 501 patient transports were appropriate and represented true emergencies, whereas 689 patients believed their medical problems were true emergencies. A significant number of patients (n = 415, 47%) had access to alternative transportation to the hospital. Blunt traumatic injury and altered mental status were the most common reasons for EMS transport. Patient characteristics significantly associated with EMS provider perception of a true emergency were male gender, age >51 years, higher education, chest pain/cardiac complaints, shortness of breath/respiratory complaints, and Medicare insurance. Characteristics significantly associated with patients who perceived themselves to have true emergencies were black ethnicity, higher education, shortness of breath/respiratory complaints, and Medicare insurance. There was 75% agreement between EMS providers and patients on appropriateness of ambulance transport (kappa = 0.84). Conclusion: Inappropriate ambulance use is a significant problem from both EMS provider and patient perspectives. Certain patient characteristics are associated with a higher probability of appropriate and inappropriate uses of EMS transport. A large number of patients transported by ambulance have alternative means of transportation but elect not to use them.     

EMS blood collection from patients with acute chest pain reduces emergency department length of stay

BackgroundExpediting the measurement of serum troponin by leveraging EMS blood collection could reduce the diagnostic time for patients with acute chest pain and help address Emergency Department (ED) overcrowding. However, this practice has not been examined among an ED chest pain patient population in the United States.MethodsA prospective observational cohort study of adults with non-traumatic chest pain without ST-segment elevation myocardial infarction was conducted in three EMS agencies between 12/2016–4/2018. During transport, paramedics obtained a patient blood sample that was sent directly to the hospital core lab for troponin measurement. On ED arrival HEART Pathway assessments were completed by ED providers as part of standard care. ED providers were blinded to troponin results from EMS blood samples. To evaluate the potential impact on length of stay (LOS), the time difference between EMS blood draw and first clinical ED draw was calculated. To determine the safety of using troponin measures from EMS blood samples, the diagnostic performance of the HEART Pathway for 30-day major adverse cardiac events (MACE: composite of cardiac death, myocardial infarction (MI), coronary revascularization) was determined using EMS troponin plus arrival ED troponin and EMS troponin plus a serial 3-h ED troponin.ResultsThe use of EMS blood samples for troponin measures among 401 patients presenting with acute chest pain resulted in a mean potential reduction in LOS of 72.5 ± SD 35.7 min. MACE at 30 days occurred in 21.0% (84/401), with 1 cardiac death, 78 MIs, and 5 revascularizations without MI. Use of the HEART Pathway with EMS and ED arrival troponin measures yielded a NPV of 98.0% (95% CI: 89.6–100). NPV improved to 100% (95% CI: 92.9–100) when using the EMS and 3-h ED troponin measures.ConclusionsEMS blood collection used for core lab ED troponin measures could significantly reduce ED LOS and appears safe when integrated into the HEART Pathway.     

Paramedic and Emergency Medical Technicians Views on Opportunities and Challenges When Forgoing and Halting Resuscitation in the Field

Objectives:  The objective was to assess paramedic and emergency medical technicians (EMT) perspectives and decision-making after a policy change that allows forgoing or halting resuscitation in prehospital atraumatic cardiac arrest.
Methods:  Five semistructured focus groups were conducted with 34 paramedics and 2 EMTs from emergency medical services (EMS) agencies within Los Angeles County (LAC), 6 months after a policy change that allowed paramedics to forgo or halt resuscitation in the field under certain circumstances.
Results:  Participants had an overwhelmingly positive view of the policy; felt it empowered their decision-making abilities; and thought the benefits to patients, family, EMS, and the public outweighed the risks. Except under certain circumstances, such as when the body was in public view or when family members did not appear emotionally prepared to have the body left on scene, they felt the policy improved care. Assuming that certain patient characteristics were present, decisions by paramedics about implementing the policy in the field involve many factors, including knowledge and comfort with the new policy, family characteristics (e.g., agreement), and logistics regarding the place of arrest (e.g., size of space). Paramedic and EMT experiences with and attitudes toward forgoing resuscitation, as well as group dynamics among EMS leadership, providers, police, and ED staff, also play a role.
Conclusions:  Participants view the ability to forgo or halt resuscitation in the field as empowering and do not believe it presents harm to patients or families under most circumstances. Factors other than patient clinical characteristics, such as knowledge and attitudes toward the policy, family emotional preparedness, and location of arrest, affect whether paramedics will implement it.     

Emergency Medical Services Provider Experiences of Hospice Care

Background: Growing numbers of emergency medical services (EMS) providers respond to patients who receive hospice care. The objective of this investigation was to assess the knowledge, attitudes, and experiences of EMS providers in the care of patients enrolled in hospice care. Methods: We conducted a survey study of EMS providers regarding hospice care. We collected quantitative and qualitative data on EMS provider's knowledge, attitudes, and experiences in responding to the care needs of patients in hospice care. We used Chi-squared tests to compare EMS provider's responses by credential (Emergency Medical Technician [EMT] vs. Paramedic) and years of experience (0–5 vs. 5+). We conducted a thematic analysis to examine open-ended responses to qualitative questions. Results: Of the 182 EMS providers who completed the survey (100% response rate), 84.1% had cared for a hospice patient one or more times. Respondents included 86 (47.3%) EMTs with Intermediate and Advanced training and 96 (52.7%) Paramedics. Respondent's years of experience ranged from 0–10+ years, with 99 (54.3%) providers having 0–5 years of experience and 83 (45.7%) providers having 5+ years of experience. There were no significant differences between EMTs and Paramedics in their knowledge of the care of these patients, nor were there significant differences (p < 0.05) between those with 0–5 and 5+ years of experience. Furthermore, 53 (29.1%) EMS providers reported receiving formal education on the care of hospice patients. A total of 36% respondents felt that patients in hospice care required a DNR order. In EMS providers' open-ended responses on challenges in responding to the care needs of hospice patients, common themes were family-related challenges, and the need for more education. Conclusion: While the majority of EMS providers have responded to patients enrolled in hospice care, few providers received formal training on how to care for this population. EMS providers have expressed a need for a formal curriculum on the care of the patient receiving hospice.     

The Resuscitation Outcomes Consortium Epistry-Trauma: design, development, and implementation of a North American epidemiologic prehospital trauma registry

Injury is a major public health problem generating substantial morbidity, mortality, and economic burden on society. The majority of seriously injured persons are initially evaluated and cared for by prehospital providers, however the effect of emergency medical services (EMS) systems, EMS clinical care, and EMS interventions on trauma patient outcomes is largely unknown. Outcome-based information to guide future EMS care has been hampered by the lack of comprehensive, standardized, multi-center prehospital data resources that include meaningful patient outcomes. In this paper, we describe the background, design, development, implementation, content, and potential uses of the first North American comprehensive epidemiologic prehospital data registry for injured persons. This data registry samples patients from 264 EMS agencies transporting to 287 acute care hospitals in both the United States and Canada.     

Emergency medical service providers' experience with family presence during cardiopulmonary resuscitation

OBJECTIVE: To describe emergency medical service providers' experiences with family member presence during resuscitation, and to determine whether those experiences are similar within urban and suburban settings. METHODS: We conducted a personally distributed survey of a convenience sample of urban and suburban emergency medical service (EMS) providers presenting to two Midwestern Emergency Departments. Providers were questioned as to their experiences with resuscitating patients in the presence of family members. RESULTS: There were 128 respondents to the survey (59 urban and 69 suburban), of which 70.1% were EMT-Paramedics. No provider who was approached refused participation. Nearly all (122) had performed CPR in the presence of family members, with most (77%) performing greater than 20. Subjects averaged 12.3 years of experience. The majority of urban and suburban providers felt it was inappropriate for family to witness resuscitations (75.9% versus 60.3%, respectively; p=0.068). Many providers reported feeling uncomfortable with family presence (31.5% urban versus 44.8% suburban; p=0.136), and few preferred that family witness the resuscitation (13.2% urban versus 15.4 suburban; p=0.738). A minority of providers believed that family were better prepared to accept the death of the patient (37.0% urban versus 37.6% suburban; p=0.939). Approximately half felt comfortable providing emotional support (66.0% urban versus 53.7% suburban; p=0.173). Many felt that family caused a negative impact during resuscitation (53.7% urban and 36.8% suburban; p=0.061). Urban providers more often reported feeling threatened by family members during resuscitation (66.7% versus 39.7%; p=0.003), and felt that family often interfered with their ability to perform resuscitations (35.6% versus 16.4%, p=0.014). CONCLUSIONS: EMS providers have substantial experience with family witnessed resuscitations, are uncomfortable about their presence, and often must provide support for families. While urban providers tended to report more negative experiences and perceptions, there were minimal differences between the two groups.     

Prehospital Trauma Triage Decision-making: A Model of What Happens between the 9-1-1 Call and the Hospital

We describe the decision-making process used by emergency medical services (EMS) providers in order to understand how 1) injured patients are evaluated in the prehospital setting; 2) field triage criteria are applied in-practice; and 3) selection of a destination hospital is determined. We conducted separate focus groups with advanced and basic life support providers from rural and urban/suburban regions. Four exploratory focus groups were conducted to identify overarching themes and five additional confirmatory focus groups were conducted to verify initial focus group findings and provide additional detail regarding trauma triage decision-making and application of field triage criteria. All focus groups were conducted by a public health researcher with formal training in qualitative research. A standardized question guide was used to facilitate discussion at all focus groups. All focus groups were audio-recorded and transcribed. Responses were coded and categorized into larger domains to describe how EMS providers approach trauma triage and apply the Field Triage Decision Scheme. We conducted 9 focus groups with 50 EMS providers. Participants highlighted that trauma triage is complex and there is often limited time to make destination decisions. Four overarching domains were identified within the context of trauma triage decision-making: 1) initial assessment; 2) importance of speed versus accuracy; 3) usability of current field triage criteria; and 4) consideration of patient and emergency care system-level factors. Field triage is a complex decision-making process which involves consideration of many patient and system-level factors. The decision model presented in this study suggests that EMS providers place significant emphasis on speed of decisions, relying on initial impressions and immediately observable information, rather than precise measurement of vital signs or systematic application of field triage criteria.     

Everyone dies

It's not unusual to be dispatched to one problem and discover something completely different when you arrive. Patients and family members will tell dispatch what they feel is the problem, and dispatch, without the benefit of being on scene, can only pass along the complaint as it was given to them. Upon arrival back at base, the attending paramedic in this case was asking himself questions like, "What if I had done this differently?" and "Did I miss something?" At the conclusion of every patient interaction, there is an opportunity for EMS to review its actions and [table: see text] change its approach to similar cases in the future. The benefit of public-safety agencies providing service in nonemergent situations is the opportunity to "practice" for true crisis incidents. This case, however, did not present many opportunities to improve care or change the outcome. The paramedic's assessment identified the need for the patient to be transported immediately. Immediate packaging of the patient, intubation and pacing were performed on scene--you known this crew was moving. The ED physician concurred that this was a "load and go" situation. The crew is to be commended for taking charge of a critical situation and performing in an expeditious manner. Oxygen, pacing, i.v. and meds were all given in a timely fashion. Unfortunately, this patient's cancer had progressed to a critical point, and the patient was not going to survive even with optimal care. This EMS crew unfortunately walked into an end-of-life event. Despite their best efforts (a total on-scene time of seven minutes and a five-minute transport) and performing every function flawlessly, this patient still died. This patient was given excellent medical service, but perhaps more important, at his critical moment, was in the presence of people who cared. One of the first things we learn in EMS is that people die. Sometimes our job is simply to provide comfort, relieve suffering and communicate with the survivors. Since all humans must die, it is just as important for us to service their needs at that moment in time. From there, we move on to the next call.