Christopher A. Kahn

Emergency Medical Services Out-of-Hospital Scene and Transport Times and Their Association With Mortality in Trauma Patients Presenting to an Urban Level I Trauma Center

STUDY OBJECTIVE We determine the association between emergency medical services (EMS) out-of-hospital times and mortality in trauma patients presenting to an urban Level I trauma center. METHODS We conducted a secondary analysis of a prospective cohort registry of trauma patients presenting to a Level I trauma center during a 14-year period (1996 to 2009). Inclusion criteria were patients sustaining traumatic injury who presented to an urban Level I trauma center. Exclusion criteria were extrication, missing or erroneous out-of-hospital times, and intervals exceeding 5 hours. The primary outcome was inhospital mortality. EMS out-of-hospital intervals (scene time and transport time) were evaluated with multivariate logistic regression. RESULTS There were 19,167 trauma patients available for analysis, with 865 (4.5%) deaths; 16,170 (84%) injuries were blunt, with 596 (3.7%) deaths, and 2,997 (16%) were penetrating, with 269 (9%) deaths. Mean age and sex for blunt and penetrating trauma were 34.5 years (68% men) and 28.1 years (90% men), respectively. Of those with Injury Severity Score less than or equal to 15, 0.4% died, and 26.1% of those with a score greater than 15 died. We analyzed the relationship of scene time and transport time with mortality among patients with Injury Severity Score greater than 15, controlling for age, sex, Injury Severity Score, and Revised Trauma Score. On multivariate regression of patients with penetrating trauma, we observed that a scene time greater than 20 minutes was associated with higher odds of mortality than scene time less than 10 minutes (odds ratio [OR] 2.90; 95% confidence interval [CI] 1.09 to 7.74). Scene time of 10 to 19 minutes was not significantly associated with mortality (OR 1.19; 95% CI 0.66 to 2.16). Longer transport times were likewise not associated with increased odds of mortality in penetrating trauma cases; OR for transport time greater than or equal to 20 minutes was 0.40 (95% CI 0.14 to 1.19), and OR for transport time 10 to 19 minutes was 0.64 (95% CI 0.35 to 1.15). For patients with blunt trauma, we did not observe any association between scene or transport times and increased odds of mortality. CONCLUSION In this analysis of patients presenting to an urban Level I trauma center during a 14-year period, we observed increased odds of mortality among patients with penetrating trauma if scene time was greater than 20 minutes. We did not observe associations between increased odds of mortality and out-of-hospital times in blunt trauma victims. These findings should be validated in an external data set.

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.

The worsening of ED on-call coverage in California: 6-year trend

To reassess problems with on-call physician coverage in California, we repeated our anonymous 2000 survey of the California chapter of the American College of Emergency Physicians. Physicians responded from 77.4% of California emergency departments (EDs), 51.0% of ED directors, and 34% of those surveyed. Of 21 specialties, on-call availability worsened since 2000 for 9, was unchanged for 11, and improved for 1. Of ED directors, 54% report medical staff rules require on-call duty, down from 72% in 2000. Hospitals have increased specialist on-call payments (from 21% to 35%, with 75% paying at least one specialty). Most emergency physicians (80.3%) report insurance status negatively affects on-call physician responsiveness, up from 42% in 2000. Emergency departments with predominantely minority or uninsured patients had fewer specialists and more trouble accessing them. Insurance status has a major negative effect on ED consultation and follow-up care. The on-call situation in California has worsened substantially in 6 years.

Secure scalable disaster electronic medical record and tracking system.

Introduction: Electronic medical records (EMR) are considered superior in documentation of care for medical practice. Current disaster medical response involves paper tracking systems and radio communication for mass casualty incidents (MCIs). These systems are prone to errors, may be compromised by local conditions, and are labor intensive. Communication infrastructure may be impacted, overwhelmed by call volume, or destroyed by the disaster, making self-contained and secure EMR response a critical capability. As the prehospital disaster EMR allows for more robust content including Protected Health Information (PHI), security measures must be instituted to safeguard these data. Objectives: To develop a secure prehospital disaster triage/EMR system that prevents unintentional disclosure of private information, may be used by prehospital personnel during the MCI triage process, and can be relayed via wireless system to local and distant medical assets. Methods: The Wireless Information System for medicAl Response in Disasters (WIISARD) Research Group developed a handheld linked wireless EMR system utilizing current technology platforms. Smart phones connected to radio frequency identification (RFID) readers may be utilized to efficiently track casualties resulting from the incident. Medical information may be transmitted on an encrypted network to fellow prehospital team members, medical dispatch, and receiving medical centers. Results: This system has been field tested in a number of exercises with excellent results and future iterations will incorporate robust security measures. Conclusions: A secure prehospital triage EMR improves documentation quality during disaster drills.

Prospective correlation of arterial vs venous blood gas measurements in trauma patients.

OBJECTIVE The objective of this study is to assess if venous blood gas (VBG) results (pH and base excess [BE]) are numerically similar to arterial blood gas (ABG) in acutely ill trauma patients. METHODS We prospectively correlated paired ABG and VBG results (pH and BE) in adult trauma patients when ABG was clinically indicated. A priori consensus threshold of clinical equivalence was set at ± less than 0.05 pH units and ± less than 2 BE units. We hypothesized that ABG results could be predicted by VBG results using a regression equation, derived from 173 patients, and validated on 173 separate patients. RESULTS We analyzed 346 patients and found mean arterial pH of 7.39 and mean venous pH of 7.35 in the derivation set. Seventy-two percent of the paired sample pH values fell within the predefined consensus equivalence threshold of ± less than 0.05 pH units, whereas the 95% limits of agreement (LOAs) were twice as wide, at -0.10 to 0.11 pH units. Mean arterial BE was -2.2 and venous BE was -1.9. Eighty percent of the paired BE values fell within the predefined ± less than 2 BE units, whereas the 95% LOA were again more than twice as wide, at -4.4 to 3.9 BE units. Correlations between ABG and VBG were strong, at r(2) = 0.70 for pH and 0.75 for BE. CONCLUSION Although VBG results do correlate well with ABG results, only 72% to 80% of paired samples are clinically equivalent, and the 95% LOAs are unacceptably wide. Therefore, ABG samples should be obtained in acutely ill trauma patients if accurate acid-base status is required.

Distracted Driving, A Major Preventable Cause of Motor Vehicle Collisions: “Just Hang Up and Drive”

For years, public health experts have been concerned about the effect of cell phone use on motor vehicle collisions, part of a phenomenon known as “distracted driving.” The Morbidity and Mortality Weekly Report (MMWR) article “Mobile Device Use While Driving - United States and Seven European Countries 2011” highlights the international nature of these concerns. Recent (2011) estimates from the National Highway Traffic Safety Administration are that 10% of fatal crashes and 17% of injury crashes were reported as distraction-affected. Of 3,331 people killed in 2011 on roadways in the U.S. as a result of driver distraction, 385 died in a crash where at least one driver was using a cell phone. For drivers 15–19 years old involved in a fatal crash, 21% of the distracted drivers were distracted by the use of cell phones. Efforts to reduce cell phone use while driving could reduce the prevalence of automobile crashes related to distracted driving. The MMWR report shows that there is much ground to cover with distracted driving. Emergency physicians frequently see the devastating effects of distracted driving on a daily basis and should take a more active role on sharing the information with patients, administrators, legislators, friends and family.

Characteristics of Hospitals Diverting Ambulances in a California EMS System

INTRODUCTION While several reports discuss controversies regarding ambulance diversion from acute care hospitals and the mortality, financial, and resource effects, there is scant literature related to the effect of hospital characteristics. HYPOTHESIS/PROBLEM The objective of this study was to describe specific paramedic receiving center characteristics that are associated with ambulance diversion rates in an Emergency Medical Services system. METHODS A retrospective observational study design was used. The study was performed in a suburban EMS system with 27 paramedic receiving centers studied; one additional hospital present at the beginning of the study period (2000-2008) was excluded due to lack of recent data. Hospital-level and population-level characteristics were gathered, including diversion rate (hours on diversion/total hours open), for-profit status, number of specialty services (including trauma, burn, cardiovascular surgery, renal transplant services, cardiac catheterization capability [both interventional and diagnostic], and burn surgery), average inpatient bed occupancy rate (total patient days/licensed bed days), annual emergency department (ED) volume (patients per year), ED admission rate (percent of ED patients admitted), and percent of patients leaving without being seen. Demographic characteristics included percent of persons in each hospitals immediate census tract below the 100% and 200% poverty lines (each considered separately), and population density within the census tract. Bivariate and regression analyses were performed. RESULTS Diversion rates for the 27 centers ranged from 0.3%-14.5% (median 4.5%). Average inpatient bed occupancy rate and presence of specialty services were correlated with an increase in diversion rate; occupancy rate showed a 0.08% increase in diversion hours per 1% increase in occupancy rate (95% CI, 0.01%-0.16%), and hospitals with specialty services had, on average, a 4.1% higher diversion rate than other hospitals (95% CI, 1.6%-6.7%). Other characteristics did not show a statistically significant effect. When a regression was performed, only the presence of specialty services was related to the ambulance diversion rate. CONCLUSIONS Hospitals in this study providing specialty services were more likely to have higher diversion rates. This may result in increased difficulty getting patients requiring specialty care to centers able to provide the needed level of service. Major limitations include the retrospective nature of the study, as well as reliance on multiple data systems.

A retrospective review of the prehospital use of activated charcoal

OBJECTIVE We studied the complications and timing implications of prehospital activated charcoal (PAC). Appropriateness of PAC administration was also evaluated. METHODS We retrospectively reviewed prehospital records over 32 months for overdose cases, where PAC was administered. Cases were assessed for amount and type of ingestant, clinical findings, timing of PAC, timing of transport and arrival into the emergency department (ED), and complications. Encounter duration in cases of PAC was compared with that, for all cases during the study period, where an overdose patient who did not receive activated charcoal was transported. RESULTS Two thousand eight hundred forty-five total cases were identified. In 441 cases, PAC was given; and complications could be assessed. Two hundred eighty-one of these had complete information regarding timing of ingestion, activated charcoal administration, and transport. The average time between overdose and PAC was 49.8 minutes (range, 7-199 minutes; median, 41.0 minutes; SD, 30.4 minutes). Complications included emesis (7%), declining mental status (4%), declining blood pressure (0.4%), and declining oxygen saturation (0.4%). Four hundred seventeen cases of PAC had documentation of timing of emergency medical service (EMS) arrival on scene and arrival at the ED. Average EMS encounter time was 29 minutes (range, 10-53 minutes; median, 27.9 minutes). Two thousand forty-four poisoning patients were transported who did not receive PAC. The average EMS encounter time for this group was 28.1 minutes (range, 4-82 minutes; median, 27.3 minutes), not significantly different (P =.114). CONCLUSIONS Prehospital activated charcoal did not appear to markedly delay transport or arrival of overdose patients into the ED and was generally safe.

Secure scalable disaster electronic medical record and tracking system

Introduction: Electronic medical records (EMR) are considered superior in documentation of care for medical practice. Current disaster medical response involves paper tracking systems and radio communication for mass casualty incidents (MCIs). These systems are prone to errors, may be compromised by local conditions, and are labor intensive. Communication infrastructure may be impacted, overwhelmed by call volume, or destroyed by the disaster, making self-contained and secure EMR response a critical capability. As the prehospital disaster EMR allows for more robust content including Protected Health Information (PHI), security measures must be instituted to safeguard these data. Objectives: To develop a secure prehospital disaster triage/EMR system that prevents unintentional disclosure of private information, may be used by prehospital personnel during the MCI triage process, and can be relayed via wireless system to local and distant medical assets. Methods: The Wireless Information System for medicAl Response in Disasters (WIISARD) Research Group developed a handheld linked wireless EMR system utilizing current technology platforms. Smart phones connected to radio frequency identification (RFID) readers may be utilized to efficiently track casualties resulting from the incident. Medical information may be transmitted on an encrypted network to fellow prehospital team members, medical dispatch, and receiving medical centers. Results: This system has been field tested in a number of exercises with excellent results and future iterations will incorporate robust security measures. Conclusions: A secure prehospital triage EMR improves documentation quality during disaster drills.

Commentary: Moving Forward by Looking Behind You

I cannot see a fatally injured child in my trauma center without feeling my small share of the terrible grief that childs parents are just starting to discover. No matter what the mechanism, no matter how unintentional the injury, I always find myself in a group of emergency department and trauma staff trying to cope with a deceptively simple question: how could this happen? After several years of dealing with the consequences of injuries, many emergency physicians start to wonder how they, just one person afloat in a sea of injured victims, can truly start to make a difference. Rather than merely rearranging the deck chairs on the Titanic, as a colleague of mine is fond of saying, perhaps the answer is in preventing that crash in the first place. Language: en