Christopher B. Colwell

Paramedic knowledge, attitudes, and training in end-of-life care.

INTRODUCTIONnParamedics often are asked to care for patients at the end of life. To do this, they must communicate effectively with family and caregivers, understand their legal obligations, and know when to withhold unwanted interventions. The objectives of this study were to ascertain paramedics attitudes toward end-of-life (EOL) situations and the frequency with which they encounter them; and to compare paramedics preparation during training for a variety of EOL care skills.nnnMETHODSnA written survey was administered to a convenience sample of paramedics in two cities: Denver, Colorado and Los Angeles, California. Questions addressed: (1) attitudes toward EOL decision-making in prehospital settings; (2) experience (number of EOL situations experienced in the past two years); (3) importance of various EOL tasks in clinical practice (pronouncing and communicating death, ending resuscitation, honoring advance directives (ADs)); and (4) self-assessed preparation for these EOL tasks. For each task, importance and preparation were measured using a four-point Likert scale. Proportions were compared using McNemar chi-square statistics to identify areas of under- or over-preparation.nnnRESULTSnTwo hundred thirty-six paramedics completed the survey. The mean age was 39 years (range 22-59 years), and 222 (94%) were male. Twenty percent had >20 years of experience. Almost all participants (95%; 95% CI = 91-97%) agreed that prehospital providers should honor field ADs, and more than half (59%; 95% CI = 52-65%) felt that providers should honor verbal wishes to limit resuscitation at the scene. Ninety-eight percent of the participants (95% CI = 96-100%) had questioned whether specific life support interventions were appropriate for patients who appeared to have a terminal disease. Twenty-six percent (95% CI = 20-32%) reported to have used their own judgment during the past two years to withhold or end resuscitation in a patient who appeared to have a terminal disease. Significant discrepancies between the importance in practice and the level of preparation during training for the four EOL situations included: (1) understanding ADs (75% very important vs. 40% well prepared; difference 35%: 95% CI = 26-43%); (2) knowing when to honor written ADs (90% very important vs. 59% well-prepared; difference 31%: 95% CI = 23-38%); and (3) verbal ADs (75% very important vs. 54%well-prepared, difference 21%: 95% CI = 12-29%); and (4) communicating death to family or friends (79% very important vs. 48% well prepared, difference 31%: 95% CI = 23-39%). Paramedics preparation in EOL skills was significantly lower than that for clinical skills such as endotracheal intubation or defibrillation.nnnCONCLUSIONSnThere is a need to include more training in EOL care into prehospital training curricula, including how to verify and apply ADs, when to withhold treatments, and how to discuss death with victims family or friends.

Safety of prehospital intravenous fentanyl for adult trauma patients.

BACKGROUND: Little is known about the safety of intravenous fentanyl for adult trauma patients in the prehospital setting. Our objective was to study the hemodynamic effect of prehospital intravenous fentanyl in initially normotensive adult trauma patients. METHODS: A quasi-experimental design was used to compare adult trauma patients who received intravenous fentanyl and those who did not receive fentanyl in a large regional prehospital system and its affiliated Level I trauma center. Emergent adult trauma patients were included with an initial prehospital Glasgow Coma Scale score of ≥13 and systolic blood pressure >90 mm Hg. Patients were stratified into two groups, those who received a single dose of intravenous fentanyl (100 &mgr;g) and those who did not. The outcome was initial emergency department (ED) shock index (heart rate divided by systolic blood pressure). Multivariable linear regression was used to estimate the effect of fentanyl on ED shock index while adjusting for prehospital shock index, age, gender, Trauma Injury Severity Score, and the propensity for receiving fentanyl. RESULTS: Seven hundred sixty-three patients were included, of whom 217 (28%) received fentanyl. The groups had comparable demographics (age, gender, and race/ethnicity) but different clinical characteristics (ED vital signs, Injury Severity Score, mechanism, and ED disposition). The adjusted ED shock index of fentanyl patients improved (-0.03; 95% confidence interval: −0.05 to 0.00; p = 0.02) compared with no fentanyl. CONCLUSION: Prehospital intravenous fentanyl did not adversely affect the initial ED shock index in adult trauma patients. Additional research should be performed to confirm and extend our findings. LEVEL OF EVIDENCE: III.

Motor vehicle crash severity estimations by physicians and prehospital personnel

Abstract Objective. To determine whether emergency physicians (EPs) and prehospital emergency medical services (EMS) personnel differ in their assessment of motor vehicle crash (MVC) severity and the potential for serious injury when viewing crash scene photographs. Methods. Attending and resident EPs, paramedics, and emergency medical technicians (EMTs) from a single emergency medicine system used a web-based survey platform to rate the severity of 100 crash photographs on a 10-point Likert scale (Crash Score) and the potential for serious injury on a 0–100% scale (Injury Score). Serious injury was defined as skull fracture or intracranial bleeding, spine fracture or spinal cord injury, intrathoracic or intraabdominal injury, or long bone fracture. Crash and Injury Scores were stratified into EP and paramedic/EMT (EMS) groups and the mean score was calculated for each photo. Spearman rank correlation coefficients with 95% confidence intervals (95% CI) and Bland-Altman plots were constructed to assess agreement. Secondary analyses were performed after categorizing data into quartiles based on participants’ estimations of MVC severity. Results. A total of 54 attending and 53 resident EPs, 156 paramedics, and 34 EMTs were invited to participate in the survey. Of these, 39 (72%) attending and 46 (87%) resident EPs, 107 (69%) paramedics, and 17 (50%) EMTs completed the survey. A total of 183 (88%) surveys were completed in full. The overall Crash Score correlation coefficient between EPs and EMS was 0.98 (95% CI, 0.97–0.99). The Crash Score correlation coefficients for each quartile were 0.86 (0.57–0.97), 0.93 (0.85–0.96), 0.58 (0.16–0.85), and 0.88 (0.66–0.97), respectively. The overall Injury Score correlation coefficient between EPs and EMS was 0.98 (0.88–0.97). The Injury Score correlation coefficients for each quartile were 0.94 (0.48–0.91), 0.76 (0.50–0.92), 0.80 (0.69–1.00), and 0.94 (0.57–0.97), respectively. Conclusion. Although overall agreement between EPs and EMS personnel was excellent, differences in estimation of crash severity and potential for injury were identified among crashes estimated to be moderate in severity.

Task force St. Bernard: operational issues and medical management of a National Guard disaster response operation.

After Hurricane Katrina struck the Gulf Coast of the United States on 29 August 2005, it became obvious that the country was facing an enormous national emergency. With local resources overwhelmed, governors across the US responded by deploying thousands of National Guard soldiers and airmen. The National Guard has responded to domestic disasters due to natural hazards since its inception, but an event with the magnitude of Hurricane Katrina was unprecedented. The deployment of >900 Army National Guard soldiers to St. Bernard Parish, Louisiana in the aftermath of the Hurricane was studied to present some of the operational issues involved with providing medical support for this type of operation. In doing so, the authors attempt to address some of the larger issues of how the National Guard can be incorporated into domestic disaster response efforts. A number of unforeseen issues with regards to medical operations, medical supply, communication, preventive medicine, legal issues, and interactions with civilians were encountered and are reviewed. A better understanding of the National Guard and how it can be utilized more effectively in future disaster response operations can be developed.

Alcohol as a Factor in 911 Calls in Denver

Abstract Background: Excessive alcohol consumption is associated with a substantial number of emergency department visits annually and is responsible for a significant number of lives lost each year in the United States. However, a minimal amount is known about the impact of alcohol on the EMS system. Objectives: The primary objective was to determine the proportion of 9-1-1 calls in Denver, Colorado in which (1) alcohol was a contributing factor or (2) the individual receiving EMS services had recently ingested alcohol. The secondary objectives were to compare the characteristics of EMS calls and to estimate the associated costs. Methods: This was a prospective observational cohort study of EMS calls for adults from July 1, 2012, to June 30, 2014. Primary outcomes for the study were alcohol as a contributing factor to the EMS call and recent alcohol consumption by the patient receiving EMS services. Logistic regression was utilized to determine the associations between EMS call characteristics and the outcomes. Cost was estimated using historic data. Results: During the study period, 169,642 EMS calls were completed by the Denver Health Paramedic Division. Of these 71% were medical and 29% were trauma-related. The median age was 45 (interquartile range [IQR] 29–59) years, and 55% were male. 50,383 calls (30%) had alcohol consumption, and 49,165 (29%) had alcohol as a contributing factor. Alcohol related calls were associated with male sex, traumatic injuries including head trauma, emergent response, use of airway adjuncts, cardiac monitoring, glucose measurement, use of restraints, use of spinal precautions, and administration of medications for sedation. Estimated costs to the EMS system due to alcohol intoxication exceeded

Medical preparation for the 2008 Democratic National Convention, Denver, Colorado.

14 million dollars over the study period and required in excess of 37 thousand hours of paramedic time. Conclusions: Compared to 9-1-1 calls that do not involve alcohol, alcohol-related calls are more likely to involve male patients, emergent response, traumatic injuries, advanced monitoring, airway adjuncts, and medications for sedation. This represents a significant burden on the emergency system and society. Further studies are needed to evaluate whether additional interventions such as social services could be used to lessen this burden.

An Introduction to Clinical Emergency Medicine, 2nd ed.

T 2008 Democratic National Convention (DNC) was held in Denver, Colorado, from August 25 through August 28. This event drewmore than 50,000 attendees, celebrities, media, and protestors to the Denver area. The influx of people created unique challenges for the Denver Health Paramedic Division (DHPD) and Denver Health Medical Center’s Emergency Department that resulted in planning, training, and drilling for more than a year and half before the event. The DHPD worked cooperatively with dozens of allied agencies at the local, state, and federal government, as well as with nonprofit agencies and even protestor groups to ensure the health and safety of residents and visitors. The 2008 DNC was designated as a National Special Security Event in April 2006. The National Special Security Event designation provides additional federal financial support and security resources for large-scale events. The additional federal support and resources were focused on the prevention, response, and recovery to a major terrorist event. Consistent with planning for all major events within the city, the DHPD assumed the role of Medical Branch Lead within the City Office of Emergency Management framework for all DNCrelated planning and preparedness activities. Planning activities within the DHPD were split into eight functional groups: dispatch, hard zone, soft zone, citywide operations, hotels/venues, law enforcement support, hospitals, and logistics. The responsibilities of each zone and group are explained in Table 1. Venue planning was further complicated when DNC planners, relatively late in the planning stages, opted to move the last night of the convention from the indoor venue of the Pepsi Center, to the outdoor venue of Invesco Field at Mile High. This move required a massive overnight logistical effort to break down, move, and rebuild allmedical resourceswithin less than12hours. During the planning process for the event, a Medical Advisory Group (MAG) was created to coordinate planning between the DHPD, Denver Health Medical Center, other area hospitals, public health agencies, and environmental health agencies.