Naloxone Use in a Tiered-Response Emergency Medical Services System

Objective. To examine the delivery andeffect of naloxone for opioid overdose in a tiered-response emergency medical services (EMS) system andto ascertain how much time could be saved if the first arriving emergency medical technicians (EMTs) could have administered intranasal naloxone. Methods. This was case series of all EMS-treated overdose patients who received naloxone by paramedics in a two-tiered EMS system during 2004. The system dispatches basic life support–trained fire fighter–EMTs and/or advanced life support–trained paramedics depending on the severity of cases. Main outcomes were geographic distribution of naloxone-treated overdose, severity of cases, response to naloxone, andtime interval between arrival of EMTs andarrival of paramedics at the scene. Results. There were 164 patients who received naloxone for suspected overdose. There were 75 patients (46%) initially unresponsive to painful stimulus. Respiratory rate was <10 breaths/min in 79 (48%). Death occurred in 36 (22%) at the scene or during transport. A full or partial response to naloxone occurred in 119 (73%). Recognized adverse reactions were limited to agitation/combativeness in 25 (15%) andemesis in six (4%). Average EMT arrival time was 5.9 minutes. Average paramedic arrival time was 11.6 minutes in most cases and16.1 minutes in 46 cases (28%) in which paramedics were requested by EMTs at the scene. Conclusions. There is potential for significantly earlier delivery of naloxone to patients in opioid overdose if EMTs could deliver intranasal naloxone. A pilot study training andauthorizing EMTs to administer intranasal naloxone in suspected opioid overdose is warranted.     

Is Online Pediatric Continuing Education Effective in a Rural State?

Objective. This prospective study was designed to evaluate the effectiveness of online pediatric education for prehospital emergency medical technicians (EMTs). Methods. Online emergency medical services (EMS) continuing education modules, on various pediatric emergency topics, were developed for dissemination statewide. Pre- andposttest scores were compared by EMT level of training, rural versus urban location, andindividual module performance. Results. A total of 539 participants completed both the pre- andposttests. Of these, more than one-third (38.0%) reported Bernalillo County, the only urban county in the state, as the county in which they worked. Pretest scores ranged from 0 to 15 (mean = 8.5; 95% confidence interval [CI] = 8.2, 8.7), with a median of 8.0 anda mode of 8.0. Posttest scores were higher, ranging from 4 to 15 (mean = 11.6; 95% CI = 11.4, 11.7). For the posttest, the median score was 12.0 andthe mode was 13.0. Urban andrural EMTs improved in posttests comparably. EMT-Basic participants' scores improved (mean change in score = 3.4, 95% CI = 3.1, 3.7) more than those of EMT-Intermediates (mean = 2.9, 95% CI = 2.5, 3.2) or EMT-Paramedics (mean = 2.7, 95% CI = 2.2, 3.3). Conclusions. 1) The New Mexico EMS for Children (EMSC) online pediatric continuing education program increased EMTs' cognitive knowledge; 2) rural EMTs accessed the training more than urban EMTs; and3) although pre- andposttest results varied by EMT licensure level, improvements in scores also varied such that posttest scores were more similar than pretest scores.     

Factors Associated with Emergency Medical Services Scope of Practice for Acute Cardiovascular Events

Abstract

Objectives. To examine prehospital emergency medical services (EMS) scope of practice for acute cardiovascular events and characteristics that may affect scope of practice; and to describe variations in EMS scope of practice for these events and the characteristics associated with that variability. Methods. In 2008, we conducted a telephone survey of 1,939 eligible EMS providers in nine states to measure EMS agency characteristics, medical director involvement, and 18 interventions authorized for prehospital care of acute cardiovascular events by three levels of emergency medical technician (EMT) personnel. Results. A total of 1,292 providers responded to the survey, for a response rate of 67%. EMS scope of practice interventions varied by EMT personnel level, with the proportion of authorized interventions increasing as expected from EMT-Basic to EMT-Paramedic. Seven of eight statistically significant associations indicated that EMS agencies in urban settings were less likely to authorize interventions (odds ratios <0.7) for any level of EMS personnel. Based on the subset of six statistically significant associations, fire department–based EMS agencies were two to three times more likely to authorize interventions for EMT-Intermediate personnel. Volunteer EMS agencies were more than twice as likely as nonvolunteer agencies to authorize interventions for EMT-Basic and EMT-Intermediate personnel but were less likely to authorize any one of the 11 interventions for EMT-Paramedics. Greater medical director involvement was associated with greater likelihood of authorization of seven of the 18 interventions for EMT-Basic and EMT-Paramedic personnel but had no association with EMT-Intermediate personnel. Conclusions. We noted statistically significant variations in scope of practice by rural vs. urban setting, medical director involvement, and type of EMS service (fire department–based/non–fire department–based; volunteer/paid). These variations highlight local differences in the composition and capacity of EMS providers and offer important information for the transition towards the implementation of a national scope of practice model.     

Legislative and regulatory description of ems medical direction: A survey of states

Objective. To assess regulatory trends in EMS medical direction by examining state EMS legislation and regulations, and legal qualifications for medical direction.

Methods. A two-page survey was mailed to all 50 state EMS directors, with a repeat mailing to nonresponders and telephone follow-up as needed. Copies of EMS legislation and regulations were requested to assist in the interpretation of answers to survey questions. The questions focused on two physician roles in the oversight of the practice of paramedics: off-line ALS service medical director (ASMD) and on-line medical command (OLMC).

Results. Thirty-nine surveys were returned (78%). Only one state (IL) requires that ASMDs be board-certified in emergency medicine. Thirteen others (33%) permit physicians with primary care specialization or various ACLS/ATLS certifications to serve as ASMDs. Twenty-two states (56%) require only that the ASMD be a physician; three states (8%) have no requirements at all. Eight states (21%) have no requirements for personnel providing OLMC, and another 25 (64%) require only physician licensure. Six states (15%) require various ACLS/ATLS certifications. Several states do not differentiate between the two physician roles. Twenty-four states (62%) provide some type of Good Samaritan protection for medical direction, but in two of these only unpaid medical directors are protected.

Conclusions. There is tremendous variation in regulatory requirements for physician participation in EMS medical direction activities at the ALS level. Few states have specific training or background requirements for the provision of OLMC, and a requirement for board certification in emergency medicine is the exception, not the rule.     

Reasons 9-1-1 Is Called for Cardiac Arrest Cases in Which No Resuscitation Is Attempted

Objective. The goal of this investigation was to describe the reasons emergency medical services (EMS) is activated when resuscitation is not desired or when patients show signs of irreversible death. Methods. All medical incident report forms (MIRFs) indicating a cardiac arrest for which resuscitation was withheld were obtained from five participating fire departments. For each eligible case (N = 196), one of the emergency medical technicians (EMTs) present at the scene was interviewed and the dispatch tape of the 9-1-1 call was reviewed. Patient and caller characteristics were abstracted from the MIRFs and dispatch tapes. The EMTs were asked about the reasons for the call, whether the family expected this death, and the caller's emotional state when EMS arrived at the scene. In addition, EMS providers were asked open-ended questions about the services they provided for the patient and patient's family. Using chi-square statistics and t-tests, we compared two groups: 1) patients for whom resuscitation was not desired as indicated by a do-not-resuscitate (DNR) order, terminal illness, or hospice (n = 66) and 2) patients for whom resuscitation was not started because of signs of irreversible death (n = 130). Results. Compared with callers for patients with signs of irreversible death, callers for patients for whom resuscitation was not desired were less likely to access EMS because they needed medical assistance (11% versus 30%) and more likely to call 9-1-1 because they thought it was “required by law” (30% versus 8%). Other common reasons in both groups for activating 9-1-1 were confusion regarding what to do and a request to confirm death. The most frequently reported service provided by EMTs for both groups was to “offer to contact a chaplain.” Conclusion. In a third of patients for whom EMS did not initiate resuscitation, resuscitation was withheld primarily because it was not desired rather than because there was evidence of irreversible death. Efforts to improve education may prevent EMS activation in these cases. An alternative EMS response could also help ensure patient autonomy and decrease costs to the EMS system.     

Twelve Years,Five Thousand Pages

Abstract

Medical oversight is a fundamental component of every emergency medical services (EMS) system. The quality of physician medical direction has a significant impact upon the system and patient outcome. The lead agency for the state EMS system is a principal facet of our emergency care system, and the state EMS medical director is a vital component within this comprehensive network. The selection of an experienced, qualified physician for the provision of state EMS medical direction is a critical decision. This resource document provides a snapshot of the status of state EMS medical direction in our nation in 2007 and a projection of the achievable benchmarks for the role of the state EMS medical director in the future. As an informational resource, this tool will assist state EMS officials, legislators, laypersons, and partners within the emergency care system to comprehend, create or improve, and support the state EMS medical director position within their jurisdictions.     

Educational Outreach to Improve Emergency Medical Services Systems of Care for Stroke in Montana

Abstract

Objective. To improve stroke knowledge, identification, and acute care among first responders (FRs) and emergency medical technicians (EMTs) through educational outreach and support. Methods. Beginning in 2006, the Montana Stroke Initiative implemented outreach to FRs and EMTs and emergency medical services (EMS) statewide. Cross-sectional telephone surveys of FRs and EMTs were used to evaluate changes in stroke knowledge and practice in 2006 (n == 988) and 2009 (n == 944), overall and in rural and urban counties. Results. The respondents to the 2009 survey were more likely to report the availability of a stroke protocol in their service (69%% vs. 61%%, p == 0.001), training in the use of a stroke screening tool (62%% vs. 42%%, p < 0.001), use of a stroke screening tool (62%% vs. 40%%, p < 0.001), and an adequate level of knowledge about stroke (81%% vs. 66%%, p < 0.001) compared with the respondents to the 2006 survey. Significant improvements in each of these areas were achieved for both rural and urban FRs and EMTs. Conclusions. Educational outreach to FRs and EMTs was associated with marked improvement in selected components of the EMS system of stroke care.     

Emt knowledge of ambulance traffic laws

Objective. The safe operation of ambulances using warning lights and siren requires both the public and emergency medical technician (EMT) drivers to understand and obey relevant traffic laws. However, EMTs may be unfamiliar with these laws. The purpose of this study was to evaluate EMTs' knowledge of traffic laws related to the operation of ambulances with warning lights and sirens. Methods. North Carolina EMTs participating in a statewide EMS conference October 6–8, 1995, completed a five-question survey. Knowledge of ambulance speed limits, yielding at intersections, yielding in roadways, and following distances was assessed using a multiple-choice format. Demographic data pertaining to EMT age, years of experience, paid vs volunteer status, driver's education courses, and past accident involvement were also obtained. Proportions were compared using chi-square analysis, alpha = 0.05. Results. Two-hundred ninety-three of 308 (95%) EMTs attending the conference completed questionnaires. The median number of correct responses to the five knowledge questions was 1 (range 0–4). Thirty-three percent of the EMTs knew that other vehicles are required by law to yield while either approaching or being overtaken by an ambulance with warning lights and sirens; 2% knew that due regard for safety is the only requirement of an ambulance approaching a red light at an intersection; 14% knew that the minimum following distance behind an ambulance is one city block; and 28% knew that there is no speed limit on ambulances with warning lights and sirens. Respondents were more likely to score above the median if they had taken one or more emergency driver's education courses or had nine years or more of EMS experience. Conclusion. In this sample, EMT knowledge of basic traffic laws pertaining to ambulance operation is poor. Emergency driver's education courses and increased experience appear to be related to increased knowledge scores. Increased training for EMTs about traffic laws may improve the safe operation of ambulances.     

State/University Collaboration to Strengthen Children's Residential and Placement Services

This article presents a model of collaboration between a state child welfare licensing division and a public university to develop and administer online examinations for persons seeking licensure as administrators of residential child care facilities or child placing agencies. The exams assess knowledge of state standards and various practice domains. The article presents the project's underpinnings in child welfare history, contingency theory, and literature on contracting and collaboration. The article examines other states' practices and details the evolution of this project since 2003. It concludes with discussion of the project's usefulness as a model for other states and jurisdictions.     

Quality Assessment of Expired Naloxone Products from First-Responders’ Supplies

Objective: Naloxone is an opioid receptor antagonist that reverses life-threatening effects of opioid overdose. Since the 1970s, naloxone products have been developed as injectable solutions, and more recently as nasal sprays. Naloxone products have saved many lives in emergency settings. These products are routinely carried by public safety first-responders including fire fighters (FF), law enforcement officers (LEO), and emergency medical services (EMS). Now, they are also distributed through community access programs to the public. While public safety medications are monitored, those publically distributed are not, so expired products can be possibly found on-hand in an emergency. This study analyzed the quality and stability of expired Naloxone HCl Solutions for Injection, to assess their remaining efficacies and potential risks. Methods: The samples were collected from EMS or law enforcement training supplies and expired returns, with expiration dates ranging from 1990 to 2018. Using standardized techniques, the remaining naloxone was quantified, and the main degradation products, nornaloxone (also known as noroxymorphone) and other possible species, were monitored and quantified systematically. Results: Most tested samples were found containing more than 90% of labeled naloxone, including those stored for nearly 30 years. The naloxone degradation was slow, but generally correlated with storage time length. There was no significant amount of degradation products detected across all samples. Nornaloxone was detected from some older samples, but all less than 1%. Therefore, although it is an opioid agonist, the risk caused by nornaloxone should be low. Conclusion: This quality assessment demonstrates that expired naloxone products may still meet USP standards, even after many years. Further pharmaceutical, clinical, and regulatory investigation should be conducted to confirm our findings, especially for new naloxone products with different formulations and routes of administration. Extending the shelf-life of naloxone products may have important financial and public health consequences in addressing future drug shortages and meeting the needs for this critical drug.     

Prehospital do-not-resuscitate orders: a survey of state policies in the United States

INTRODUCTION: Many states in the United States have developed policies that enable prehospital emergency medical services (EMS) providers to withhold cardiopulmonary resuscitation (CPR) in the terminally ill. Several states also have policies that enable the implementation of do-not-resuscitate (DNR) orders. OBJECTIVES: 1) assess which states have statutes governing DNR orders for the prehospital setting; 2) determine which states authorize DNR orders in ways other than by specific state statue; and 3) define those states that had regional protocols which address prehospital DNR orders. METHODS: Survey of the state EMS directors in each of the 50 U.S. states, the District of Columbia, and Puerto Rico. RESULTS: As of 1992, specific legislation authorizing the implementation of DNR orders was in place in 11 states. In addition, six others have a legal opinion or policy allowing the implementation of DNR orders. Fourteen additional states have either working groups or legislation pending that address prehospital DNR orders. In only five were there no existing regional protocols for implementation of DNR orders in the prehospital setting. CONCLUSIONS: There exists great variation in legal authorization by states for implementation of DNR orders in the prehospital setting. Despite the existence of enabling legislation, many state, regional, or local EMS systems have implemented policies dealing with DNR orders.     

Accuracy of rural ems provider interpretation of three-lead ecg rhythm strips

Objective. To measure the accuracy of lead II rhythm strip interpretations performed by advanced life support (ALS) emergency medical technicians (EMTs) in a rural emergency medical services (EMS) system.

Methods. An electronic rhythm simulator was used to produce 24 three-lead electrocardiogram (ECG) rhythm strips. The rhythms were shown to 57 ALS EMTs participating in regularly scheduled continuing education classes. The participants were asked to identify the rhythms.

Results. The three-lead ECG interpretations were generally accurate, although there was some difficulty in distinguishing between specific types of tachydysrhythmias and atrioventricular (AV) block. The overall accuracy of the rhythm interpretations was 79.2%, ranging from 45.6% (second-degree type II heart block) to 98.2% (sinus bradycardia). The sensitivity for specific tachydysrhythmias ranged from 68.4% (supraventricular tachycardia) to 86.0% (atrial fibrillation); the sensitivity for specific types of AV block ranged from 45.6% (second-degree, type II) to 71.9% (third-degree).

Conclusion. In this EMS system, ECG interpretations are generally accurate, with tachydysrhythmias and AV blocks being the source of most discrepancies.     

The Use of Epinephrine for Out-Of-Hospital Treatment of Anaphylaxis

Abstract

The National Association of EMS Physicians (NAEMSP) believes that all levels of emergency medical services (EMS) providers should be allowed to carry and administer epinephrine for the treatment of anaphylaxis. This document is the official position of the NAEMSP.     

Challenges in Statewide Implementation of a Prehospital Evidence-Based Guideline: An Assessment of Barriers and Enablers in Five States

Background: Individual states, regions, and local emergency medical service (EMS) agencies are responsible for the development and implementation of prehospital patient care protocols. Many states lack model prehospital guidelines for managing common conditions. Recently developed national evidence-based guidelines (EBGs) may address this gap. Barriers to statewide dissemination and implementation of model guidelines have not been studied. The objective of this study was to examine barriers and enablers to dissemination and implementation of an evidence-based guideline for traumatic pain management across 5 states. Methods: This study used mixed methods to evaluate the statewide dissemination and implementation of a prehospital EBG. The guideline provided pain assessment tools, recommended opiate medication dosing, and indications and contraindications for analgesia. Participating states were provided an implementation toolkit, standardized training materials, and a state-specific implementation plan. Outcomes were assessed via an electronic self-assessment tool in which states reported barriers and enablers to dissemination and implementation and information about changes in pain management practices in their states after implementation of the EBG. Results: Of the 5 participating states, 3 reported dissemination of the guideline, one through a state model guideline process and 2 through regional EMS systems. Two states did not disseminate or implement the guideline. Of these, one state chose to utilize a locally developed guideline, and the other state did not perform guideline dissemination at the state level. Barriers to state implementation were the lack of authority at the state level to mandate protocols, technical challenges with learning management systems, and inability to track and monitor training and implementation at the agency level. Enablers included having a state/regional EMS office champion and the availability of an implementation toolkit. No participating states demonstrated an increase in opioid delivery to patients during the study period. Conclusion: Statewide dissemination and implementation of an EBG is complex with many challenges. Future efforts should consider the advantages of having statewide model or mandatory guidelines and the value of local champions and be aware of the challenges of a statewide learning management system and of tracking the success of implementation efforts.     

A comparison of oxygen administration practices of EMTs and emergency physicians

This study examined whether emergency medical technicians (EMTs) withhold oxygen from hypothetical patients whom emergency physicians would treat with high-flow oxygen, particularly chronic obstructive pulmonary disease (COPD) patients. A survey describing 12 hypothetical patients was distributed to 33 emergency physicians, 30 newly trained EMTs, and 27 experienced EMTs. For each patient, the respondents were asked to identify the most appropriate prehospital oxygen administration rate as “low flow” or “high flow.” Using an alpha value of .05, χ² analysis was used to compare the frequency of high-flow oxygen administration for the three groups. Newly trained EMTs were significantly more likely than physicians to administer high-flow oxygen to patients with COPD who were not receiving home oxygen. Otherwise, the oxygen administration practices of EMTs were not inconsistent with those of emergency physicians.     

Spirituality of EMTs: a study of the spiritual nature of EMS workers and its effects on perceived happiness and prayers for patients

INTRODUCTION: There is reason to believe that traumatic events experienced on the job make emergency medical services (EMS) workers more skeptical about their spiritual beliefs. Little is known about the spiritual lives and experiences of emergency medical technicians (EMTs). No studies have measured the responses of EMTs to the spiritual needs of their patients. PURPOSE: This study investigates whether EMS workers are less spiritual than the average U.S. citizen, and what effect this has on prayer for patients and perceived happiness. METHODS: Data were collected in a major metropolitan EMS system from 125 EMTs and paramedics through a questionnaire about their beliefs and behaviors regarding their spirituality. Pearson product-moment correlation coefficients (r) were used to analyze variables. The religious attitudes of EMTs were compared with those of the general population as defined in the Gallup studies. RESULTS: Ninety-one percent of the EMS workers interviewed and 94% of Gallup's sample of the general population said they believe in God. The findings on other measures in the EMT sample also were very similar to those defined in the general population. Of the EMTs, 60% said they never have doubted the existence of God. Eighty-four percent believe God still works miracles, and 80% of the EMTs believe in life after death. Eighty-seven percent of EMS workers pray; 62% pray for their patients, and 54% pray for their coworkers. Frequency of church or synagogue attendance is positively and significantly correlated with the degree of perceived life happiness (r = 0.226, p < 0.025 > 0.005). Frequency of prayer also is correlated positively to perceived life happiness (r = 0.182, p < 0.025 > 0.005). CONCLUSION: Emergency medical services workers are interested and willing to talk about their spiritual lives. They do have more doubts about the existence of God than does the average civilian, but are just as spiritual. Those EMTs with more active spiritual lives perceive themselves as happier. The majority of EMS workers pray for their patients.     

Mistaken identity: the effect of badges on EMT recognition

INTRODUCTION: Many emergency medical services (EMS) providers wear badges with their uniforms. This study was undertaken to determine whether emergency medical technicians (EMTs) who wear badges with their uniforms are more likely to be mistaken for law enforcement personnel than are those who do not wear badges. HYPOTHESIS: Emergency medical services providers who wear badges are more likely to be mistaken for law enforcement personnel than are those who do not wear badges. METHODS: High school students, college students, civic organizations, and church groups were shown slides of different uniforms and badges/insignia and asked to identify the person portrayed. Responses were categorized as "EMS," "law enforcement," or "other." Frequency of responses for each uniform and insignia were compared with chi-square analysis. RESULTS: Fifty-nine percent of the uniforms with badges were identified as law enforcement personnel. Only 5.5% of the uniforms with badges were identified as "EMS," compared with 74% of the uniforms with a Star of Life (p < 0.001). CONCLUSION: Individuals wearing uniforms with badges are more likely to be identified as law enforcement personnel than are EMS personnel. Emergency medical services providers who do not wish to be mistaken for law enforcement personnel should wear the Star of Life, not a badge, with their uniform.     

Feasibility of Bystander Administration of Public-Access Naloxone for Opioid Overdose

Objective: Pre-stationing naloxone, a competitive antagonist that can reverse the effects of opioid overdose, in public spaces may expedite antidote delivery. Our study aimed to determine the feasibility of bystander-assisted overdose treatment using pre-stationed naloxone. Methods: Convenience sample of bystanders in Cambridge, Massachusetts in April 2017. Subjects assisted a simulated patient described as unconscious. Subjects interacted with simulated EMS dispatch to locate a nearby box, unlock it, and administer naloxone. Results: Fifty participants completed the simulation. Median time from simulated ambulance dispatch to naloxone administration was 189 seconds, and from arrival at patient side to administration 61 seconds. All but one participant (98.0%) correctly administered naloxone. Subjects' comfort with administration and willingness to provide medical care increased from before to after the trial. Comfort in administering naloxone varied significantly with level of previous training prior to, but not following, study participation. Conclusions: Bystanders are willing and able to access pre-stationed naloxone and administer it to a simulated patient in a public space. Public access naloxone stations may be a useful tool to reduce time to naloxone administration, particularly in areas where opioid overdoses are clustered.