David Jaslow

Ems-initiated refusal and alternative methods of transport

OBJECTIVES 1) To describe characteristics of patient transport protocols in those U.S. cities that sanction EMS-initiated refusal of transport; and 2) to describe the frequency and type of alternatives to emergency ambulance transport. METHODS EMS systems in every one of the 200 largest cities in the United States were surveyed by telephone regarding EMS-initiated refusal policies, involvement of physicians in the decision-making process, and the presence or absence of alternatives to EMS transport. RESULTS 100% of the target population responded to the telephone survey. Only 34 (17%) EMS systems have written protocols that allow EMS providers to refuse emergency ambulance transport for patients judged to have minor illness or injury after examination. Twenty-one (62%) of these EMS systems do not require on-line physician approval for EMS-initiated refusals. Seven (21%) EMS systems that allow refusal of transport also have a formalized alternative transport program in place. Nationwide, only 19 (10%) cities surveyed offer some type of alternative to ambulance transport, most commonly taxi and minivan. CONCLUSION The authors report the first national survey of EMS-initiated refusal practices. Few urban EMS systems have implemented this policy to decrease utilization by persons with low-acuity illness or injury. This may be related to the fact that few EMS systems currently have alternatives to emergency ambulance transport.

Characteristics of state legislation governing medical care at mass gatherings

UNLABELLED Organized mass gathering medical care (MGMC) has existed in the United States for 30 years, but there is little evidence to support any standard of care or uniformity in its delivery. OBJECTIVE To determine whether MGMC regulations exist within state EMS legislation and to describe the characteristics of any such regulations. METHODS The authors conducted a cross-sectional survey of U.S. state EMS directors in fall 1998 to determine the prevalence of formal legislation governing MGMC. The lead author received copies of legislation from every state EMS office that indicated such legislation existed. RESULTS Responses were obtained from all 50 state EMS offices and that of the District of Columbia (n = 51). Only six (12%) states provide regulatory guidance for MGMC. These regulations reside within departments of health in all six states and within the divisions of EMS in three of these six. Only one state requires physician oversight of a medical action plan and minimum staffing by EMS personnel, respectively. No state addresses early defibrillation capability or EMS scope of practice. There is no agreement on the definition of either a mass gathering or minimum resource deployment. Public health and hygiene practices at mass gatherings also lack uniformity. CONCLUSION Few states regulate MGMC. Existing regulations are poorly developed and lack both standardized terminology and content.

An emergency department-based field response team: Case report and recommendations for a “go team”

Few crises are more distressing to prehospital care providers than the inability to care for a patient who is desperately ill due to entrapment. Occasionally, these patients require medical care above and beyond the scope of practice at the paramedic level. Although a federal response system is in place to provide physician-level out-of-hospital medical care during presidential declarations of disaster,1 there is a paucity of scientific literature concerning an organized emergency department response to assist local fire/rescue or EMS agencies with patient care activities. The George Washington University Medical Center (GWUMC) Department of Emergency Medicine has developed such a prehospital emergency medicine capability in conjunction with the District of Columbia Fire and EMS Department (DCFEMSD). A case report and issues related to physician response into the prehospital environment are presented.

A Cost-effective Prescription for Radiological Emergency Preparedness in Community Hospital Emergency Departments

personnel, decontamination station’s staff and training of ED, and ED reinforcement medical and ancillary staff. The main sites that were prepared and later drilled included: The decontamination site in which patients with possible radiologic contamination were decontaminated and received emergency care, The staff radiation clearance stations, The designated ED areas for care of potentially contaminated patients, The uncontaminated ED areas including areas for acute stress reaction victims, The ED imaging facilities and a designated OR for care of contaminated patients requiring surgical decontamination, or other urgent surgeries, in patients of whom routine external decontamination was insufficient. A total of 220 hospital employees participated in formal training sessions, preparatory internal drills and the final full scale drill. Conclusion: The “dirty-bomb” scenario for a receiving hospital is challenging. It requires identification of radiological contamination in terror related bomb explosion victims, safely decontaminating the victims while minimizing staff exposure, and allowing prompt care of both conventional and radiation related injuries. A successful response also requires designated radiation detection and monitoring equipment, and vigorous training of a large proportion of the hospital’s staff.