C. Crawford Mechem

Injuries from assaults on paramedics and firefighters in an urban emergency medical services system

Objective. To determine the nature and frequency of injuries resulting from assaults on paramedics and firefighters in a large, fire department-based emergency medical services (EMS) system. Methods. This was a descriptive study involving retrospective analysis of an occupational injury database. All injury reports involving assaults from 1996 to 1998 were reviewed. Variables examined included the employees age, sex, work assignment, and activity being performed when assaulted, the time of day and day of the week of the assault, the nature of the injury, whether medical care was sought, and whether time was lost from work. Assaults were classified as “intentional,” if the perpetrator intended to harm the victim, or “unintentional,” if the injury resulted from a patients inadvertently striking the victim due to an acute medical condition. Results. There were 1,100 injury reports submitted during the study period, of which 44 (4.0%, 95% CI 0-10.9%) involved an assault. Paramedics were assaulted in 35 (79.5%) of these incidents and firefighters in nine (20.5%). Forty-one assaults (93.2%) occurred during patient care activities. Medical attention was sought in 36 incidents (81.8%), and in 14 (31.8%) the employee lost time from work. Twenty-six assaults (59.1%) were classified as intentional and 17 (38.6%) as unintentional. One (2.3%) could not be classified. Conclusions. In this EMS system, injuries resulting from assaults were uncommon. However, due to their potential impact on the victims and the EMS system as a whole, policies and procedures should be developed to minimize these incidents.

Effect of Time of Day on Prehospital Care and Outcomes After Out-of-Hospital Cardiac Arrest

Background— More than 300 000 out-of-hospital cardiac arrests (OHCA) occur each year in the United States. The relationship between time of day and OHCA outcomes in the prehospital setting is unknown. Any such association may have important implications for emergency medical services resource allocation. Methods and Results— We performed a retrospective review of cardiac arrest data from a large, urban emergency medical services system. Included were OHCA occurring in adults from January 2008 to February 2012. Excluded were traumatic arrests and cases in which resuscitation measures were not performed. Day was defined as 8 AM to 7:59 PM; night, as 8 PM to 7:59 AM. A relative risk regression model was used to evaluate the association between time of day and prehospital return of spontaneous circulation and 30-day survival, with adjustment for clinically relevant predictors of survival. Among the 4789 included cases, 1962 (41.0%) occurred at night. Mean age was 63.8 years (SD, 17.4 years); 54.5% were male. Patients with an OHCA occurring at night did not have significantly lower rates of prehospital return of spontaneous circulation compared with patients having daytime arrests (11.6% versus 12.8%; P=0.20). However, rates of 30-day survival were significantly lower at night (8.56% versus 10.9%; P=0.02). After adjustment for demographics, presenting rhythm, field termination, duration of call, dispatch-to-scene interval, automated external defibrillator application, bystander cardiopulmonary resuscitation, and location, 30-day survival remained significantly higher after daytime OHCA, with a relative risk of 1.10 (95% confidence interval, 1.02–1.18). Conclusion— Rates of 30-day survival were significantly higher for OHCA occurring during the day compared with at night, even after adjustment for patient, event, and prehospital care differences.

Derivation andInternal Validation of a Rule to Predict Hospital Admission in Prehospital Patients

Objective. To derive andinternally validate a simple prediction rule, using routinely collected prehospital patient data, that discriminates between hospital admission andemergency department (ED) discharge for adult patients who arrive by ambulance. Methods. We performed a retrospective cohort study of consecutive adult nontrauma patients transported to two separate EDs over two months by a city-run emergency medical services (EMS) system. We tested whether specific prehospital variables could predict hospital admission using chi-square tests, logistic regression, andreceiver-operating characteristic curves. We created a rule to predict the probabilities of hospital admission for individual patients. Results. Of 401 patients, the mean age was 47 years; 60% were black and32% were white; 51% were female; and33% were admitted to an inpatient service after evaluation in the ED. Independent predictors of admission were dyspnea (adjusted odds ratio [OR] 6.8; awarded 3 points), chest pain (OR 5.2; 3 points), anddizziness, weakness, or syncope (OR 3.5; 2 points). Also predictive were age ≥60 years (OR 5.5; 3 points) andthe prehospital identification of a history of diabetes (OR 1.9; 1 point) or cancer (OR 3.9; 2 points). Patients who had a score of 5 or higher had a greater than 69% chance of being admitted to an inpatient unit. Conclusion. Routinely collected EMS patient information can help predict hospital admission for certain ED patients.

Resuscitation Center Designation: Recommendations for Emergency Medical Services Practices

Abstract Regionalization of medical resources by designating specialty receiving centers, such as trauma and stroke centers, within emergency medical services (EMS) systems is intended to ensure the highest-quality patient care in the most efficient and fiscally responsible fashion. Significant advances in the past decade such as induction of therapeutic hypothermia following resuscitation from cardiac arrest and a time-driven, algorithmic approach to management of septic patients have created compelling arguments for similar designation for specialized resuscitative interventions. Resuscitation of critically ill patients is both labor- and resource-intensive. It can significantly interrupt emergency department (ED) patient throughput. In addition, clinical progress in developing resuscitation techniques is often dependent on the presence of a strong research infrastructure to generate and validate new therapies. It is not feasible for many hospitals to make the commitment to care for large numbers of critically ill patients and the accompanying investigational activities, whether in the prehospital, ED, or inpatient arena. Because of this, the question of whether EMS systems should designate specific hospitals as “resuscitation centers” has now come center stage. Just as EMS systems currently delineate criteria and monitor compliance for trauma, ST-elevation myocardial infarction (STEMI), and stroke centers, strong logic now exists to develop similar standards for resuscitation facilities. Accordingly, this discussion reviews the current applicable trends in resuscitation science and presents a rationale for resuscitation center designation within EMS systems. Potential barriers to the establishment of such centers are discussed and strategies to overcome them are proposed.

Influence of sex on the out-of-hospital management of chest pain.

BACKGROUND Sex disparities in the diagnosis and treatment of chest pain or suspected angina have been demonstrated in multiple clinical settings. Out-of-hospital (OOH) care for chest pain is protocol-driven and may be less likely to demonstrate differences between men and women. OBJECTIVES The objectives were to investigate the relationship between sex and the OOH treatment of patients with chest pain. The authors sought to test the hypothesis that OOH care for chest pain patients would differ by sex. METHODS A 1-year retrospective cohort study of 683 emergency medical services (EMS) patients with a complaint of chest pain was conducted. Included were patients taken to any one of three hospitals (all cardiac referral centers) by a single municipal EMS system. Excluded were patients transported by basic life support (BLS) units, those younger than 30 years, and patients with known contraindications to any of the outcome measures. Multivariable regression was used to adjust for potential confounders. The main outcome was adherence to state EMS protocols for treatment of patients over age 30 years with undifferentiated chest pain. Rates of administration of aspirin, nitroglycerin, and oxygen; establishment of intravenous (IV) access; and cardiac monitoring were measured. RESULTS A total of 342 women and 341 men were included. Women were less likely than men to receive aspirin (relative risk [RR] = 0.76; 95% confidence interval [CI] = 0.59 to 0.96), nitroglycerin (RR = 0.76; 95% CI = 0.60 to 0.96), or an IV (RR 0.86; 95% CI = 0.77 to 0.96). These differences persisted after adjustment for demographics and emergency department (ED) evaluation for acute coronary syndrome (ACS) as a blunt marker for cardiac risk. Women were also less likely to receive these treatments among the small subgroup of patients who were later diagnosed with acute myocardial infarction (AMI). CONCLUSIONS For OOH patients with chest pain, sex disparities in treatment are significant and do not appear to be explained by differences in patient age, race, or underlying cardiac risk.

Delayed cardiac tamponade in a patient with penetrating chest trauma

We describe a case of cardiac tamponade due to pulmonary artery laceration as a late sequela in a patient who had sustained penetrating chest trauma. A 35-yr-old man presented to our emergency department complaining of pleuritic left chest pain, shortness of breath, and fever 19 days after being hospitalized for a stab wound to the left chest. During his first hospitalization, chest X-ray study, echocardiogram, and central venous pressure determination were all normal. On second presentation, he had a cardiac tamponade and underwent a median sternotomy. A pulmonary artery laceration was discovered and repaired. The postoperative course was complicated by readmission for postcardiotomy syndrome. This case demonstrates that late and unexpected complications can occur in patients with penetrating chest trauma and a normal initial evaluation.

Utilization of the 911 system as an identifier of domestic violence.

This cross-sectional study was performed to determine (1) whether female victims of domestic violence (DV) are more likely to use the 911 system than nonvictims (NVs) and (2) whether DV and NVs call 911 for different reasons so that 911 may be used as a screening tool for abuse. The study was performed in an academic adult urban emergency department (ED). Ambulatory female patients presenting to the ED were studied. Eligible patients were administered a brief survey by trained research assistants. Questions included (1) history of DV, (2) relationship of assailant to victim, (3) chief complaint, and (4) use of the 911 system. Records of 911 calls were obtained by patients address. Four hundred sixty-one women were enrolled in the study. One hundred seven (23%) reported a history of DV. Intimate partners accounted for 67.2% of assailants. DV victims were more likely to be single and younger (P < .05). Of DV victims, 77% reported calling 911 for any reason in the past 2 years compared with 47% of nonvictims (difference = 30%; 95% CI, 19%, 40%). DV victims were more likely to call 911 than nonvictims for definite and possible cases of domestic dispute (1.4 v0.5 calls, P = .007; 11.7 v6.1 calls, P = .0003). Victims and nonvictims did not differ in the number of nondomestic dispute calls (8.4 v6.2 calls; P = .15). DV victims were more likely to access the 911 system and call for domestic disturbances compared with nonvictims. 911 calls may serve as an indicator of ongoing abuse and may identify women at risk, providing a potential opportunity for intervention.

Recognition of Stroke by EMS is Associated with Improvement in Emergency Department Quality Measures

Abstract Objective: Hospital arrival via Emergency Medical Services (EMS) and EMS prenotification are associated with faster evaluation and treatment of stroke. We sought to determine the impact of diagnostic accuracy by prehospital providers on emergency department quality measures. Methods: A retrospective study was performed of patients presenting via EMS between September 2009 and December 2012 with a discharge diagnosis of transient ischemic attack (TIA), ischemic stroke (IS), or intracerebral hemorrhage (ICH). Hospital and EMS databases were used to determine EMS impression, prehospital and in-hospital time intervals, EMS prenotification, NIH stroke scale (NIHSS), symptom duration, and thrombolysis rate. Results: 399 cases were identified: 14.5% TIA, 67.2% IS, and 18.3% ICH. EMS providers correctly recognized 57.6% of cases. Compared to cases missed by EMS, correctly recognized cases had longer median on-scene time (17 vs. 15 min, p = 0.01) but shorter transport times (12 vs. 15 min, p = 0.001). Cases correctly recognized by EMS were associated with shorter door-to-physician time (4 vs. 11 min, p < 0.001) and shorter door-to-CT time (23 vs. 48 min, p < 0.001). These findings were independent of age, NIHSS, symptom duration, and EMS prenotification. Patients with ischemic stroke correctly recognized by EMS were more likely to receive thrombolytic therapy, independent of age, NIHSS, symptom duration both with and without prenotification. Conclusion: Recognition of stroke by EMS providers was independently associated with faster door-to-physician time, faster door-to-CT time, and greater odds of receiving thrombolysis. Quality initiatives to improve EMS recognition of stroke have the potential to improve hospital-based quality of stroke care.

Multicenter Validation of the Philadelphia EMS Admission Rule (PEAR) to Predict Hospital Admission in Adult Patients Using Out‐of‐hospital Data

OBJECTIVES The objective was to validate a previously derived prediction rule for hospital admission using routinely collected out-of-hospital information. METHODS The authors performed a multicenter retrospective cohort study of 1,500 randomly selected, adult patients transported to six separate emergency departments (EDs; three community and three academic hospitals in three separate health systems) by a city-run emergency medical services (EMS) system over a 1-year period. Patients younger than 18 years or who bypassed the ED to be evaluated by trauma, obstetric, or psychiatric teams were excluded. The score consisted of six weighted elements that generated a total score (0-14): age >or= 60 years (3 points); chest pain (3); shortness of breath (3); dizzy, weakness, or syncope (2); history of cancer (2); and history of diabetes (1). Receiver operator characteristic (ROC) curves for the decision rule and admission rates were calculated among individual hospitals and for the entire cohort. RESULTS A total of 1,102 patients met inclusion criteria. The admission rate for the entire cohort was 40%, and individual hospital admission rates ranged from 28% to 57%. Overall, 34% had a score of >or=4, and 29% had a score of >or=5. Area under the ROC curve (AUC) for the combined cohort was 0.83 for all admissions and 0.72 for intensive care unit (ICU) admissions; AUCs at individual hospitals ranged from 0.72 to 0.85. The admission rate for a score of >or=4 was 77%; for a score of >or=5 the admission rate was 80%. CONCLUSIONS The ability of this EMS rule to predict the likelihood of hospital admission appears valid in this multicenter cohort. Further studies are needed to measure the impact and feasibility of using this rule to guide decision-making.

T HE U TILITY OF T YMPANIC VERSUS O RAL T EMPERATURE M EASUREMENTS OF F IREFIGHTERS IN E MERGENCY I NCIDENT R EHABILITATION O PERATIONS

Objectives. Emergency incident rehabilitation (EIR) is the process by which firefighters receive medical screening and monitoring as well as oral rehydration while on the scene of intense or extended fire or rescue operations. A crucial parameter in EIR medical monitoring is temperature determination because heat-related illnesses are common. The objective of this study was to compare the use of oral temperature versus infrared tympanic temperature determinations of firefighters in the outdoor environment of EIR operations. Methods. This was a prospective observational study of firefighters participating in training scenarios involving heavy smoke and fire conditions at municipal fire training facilities. Outdoor temperature and relative humidity were obtained for each training session. Subjects were outfitted fully for fire fighting duties including full protective clothing and self-contained breathing apparatus (SCBA). Immediately on exiting the fire building, firefighters removed their SCBA masks, protective hoods, and helmets, and had simultaneous oral and tympanic temperatures taken (time 0). The subjects then sat outdoors for 10 minutes and their temperatures were again obtained (time 10). Oral and tympanic temperatures for both time points were calculated as means ± SD. An intraclass correlation coefficient was calculated to determine how closely the simultaneously obtained oral and tympanic temperatures determinations at T-0 and T-10 correlated with each other. Results. Forty-two firefighters (mean age, 44.6 years; SD 9.6) were enrolled during four separate training days. There was poor correlation between oral and tympanic temperatures in firefighters both at time 0 (r = 0.10) and at time 10 (r = 0.18). Conclusions. There is poor correlation between tympanic and oral temperature determinations in the EIR setting. Oral temperature determinations may be preferable to tympanic temperature determination in the EIR setting.