Derek R Cooney

Ambulance diversion and emergency department offload delay: resource document for the National Association of EMS Physicians position statement.

Abstract The emergency medical services (EMS) system is a component of a larger health care safety net and a key component of an integrated emergency health care system. EMS systems, and their patients, are significantly impacted by emergency department (ED) crowding. While protocols designed to limit ambulance diversion may be effective at limiting time on divert status, without correcting overall hospital throughput these protocols may have a negative effect on ED crowding and the EMS system. Ambulance offload delay, the time it takes to transfer a patient to an ED stretcher and for the ED staff to assume the responsibility of the care of the patient, may have more impact on ambulance turnaround time than ambulance diversion. EMS administrators and medical directors should work with hospital administrators, ED staff, and ED administrators to improve the overall efficiency of the system, focusing on the time it takes to get ambulances back into service, and therefore must monitor and address both ambulance diversions and ambulance offload delay. This paper is the resource document for the National Association of EMS Physicians position statement on ambulance diversion and ED offload time. Key words: ambulance; EMS; diversion; bypass; offload; delay

Evaluation of ambulance offload delay at a university hospital emergency department.

BackgroundAmbulance offload delay (AOD) has been recognized by the National Association of EMS Physicians (NAEMSP) as an important quality marker. AOD is the time between arrival of a patient by EMS and the time that the EMS crew has given report and moved the patient off of the EMS stretcher, allowing the EMS crew to begin the process of returning to service. The AOD represents a potential delay in patient care and a delay in the availability of an EMS crew and their ambulance for response to emergencies. This pilot study was designed to assess the AOD at a university hospital utilizing direct observation by trained research assistants.FindingsA convenience sample of 483 patients was observed during a 12-month period. Data were analyzed to determine the AOD overall and for four groups of National Emergency Department Overcrowding Scale (NEDOCS) score ranges. The AOD ranged from 0 min to 157 min with a median of 11 min. When data were grouped by NEDOCS score, there was a statistically significant difference in median AOD between the groups (p < 0.001), indicating the relationship between ED crowding and AOD.ConclusionThe median AOD was considered significant and raised concerns related to patient care and EMS system resource availability. The NEDOCS score had a positive correlation with AOD and should be further investigated as a potential marker for determining diversion status or for destination decision-making by EMS personnel.

Backboard time for patients receiving spinal immobilization by emergency medical services

BackgroundUse of backboards as part of routine trauma care has recently come into question because of the lack of data to support their effectiveness. Multiple authors have noted the potential harm associated with backboard use, including iatrogenic pain, skin ulceration, increased use of radiographic studies, aspiration and respiratory compromise. An observational study was performed at a level 1 academic trauma center to determine the total and interval backboard times for patients arriving via emergency medical services (EMS).FindingsPatients were directly observed. Transport time was recorded as an estimate of initiation of backboard use; arrival time, nurse report time and time of removal from the backboard were all recorded. National Emergency Department Overcrowding Study (NEDOCS) score, Emergency Severity Index (ESI) and demographic information were recorded for each patient encounter. Forty-six patients were followed. The mean total backboard time was 54 min (SD ±65). The mean EMS interval was 33 min (SD ±64), and the mean ED interval was 21 min (SD ±15). The ED backboard interval trended inversely to ESI (1 = 5 min, 2 = 10 min, 3 = 25 min, 4 = 26 min, 5 = 32 min).ConclusionPatients had a mean total backboard time of around an hour. The mean EMS interval was greater than the mean ED interval. Further study with a larger sample directed to establishing associated factors and to target possible reduction strategies is warranted.

Case Report: Delayed Subclavian Vein Injury Secondary to Clavicular Malunion

BACKGROUND Fractures of the clavicle are extremely common, representing 2.6-12% of all fractures and 35-44% of all shoulder girdle injuries; 69-82% of these fractures occur in the middle third of the clavicle. Vascular injuries relating to clavicle fracture are usually due to extreme force applied to the clavicle in an acute setting. No other reports of delayed subclavian vein laceration were found on literature search. OBJECTIVES We present this case to increase awareness among emergency physicians of the potential delayed presentation of this rare condition. CASE REPORT A 21-year-old man presented to the Emergency Department with acute swelling of the base of the neck after carrying a heavy load on his left shoulder the night before. He had been recovering from a clavicle fracture for 2 months. Malunion of his left midshaft clavicle fracture led to subclavian vein injury and formation of a large hematoma secondary to reinjury that occurred at work the night before presentation. Computed tomography revealed a 9-cm hematoma at the fracture site. The patient was found to have a subclavian vein injury without evidence of arterial injury or nervous system involvement. The patient was admitted for observation and subsequently discharged without need for surgical intervention. CONCLUSION Subclavian vein laceration is a rare complication of clavicle fracture. Patient education at discharge after conservative management is important due to the risk of vascular complications from malunion and reinjury.

Massive acute colonic pseudo-obstruction successfully managed with conservative therapy in a patient with cerebral palsy

Acute colonic pseudo-obstruction (ACPO), also known as Ogilvie syndrome, is a massive dilation of the colon in the absence of mechanical obstruction. Treatment measures may include anticholinergic agents such as neostigmine, colonoscopy, or fluoroscopic decompression, surgical decompression, and partial or complete colectomy. We reviewed the case of a 26-year-old male with cerebral palsy who had a history of chronic intermittent constipation who presented to the emergency department (ED) with signs of impaction despite recurrent fleet enemas and oral polyethylene glycol 3350. The patient was found to have a massive colonic distention of 26 cm likely because of bowel dysmotility, consistent with ACPO. This article includes a discussion of the literature and images that represent clinical examination, x-ray, and computed tomography (CT) findings of this patient, who successfully underwent conservative management only. Emergency department detection of this condition is important, and early intervention may prevent surgical intervention and associated complications.

Performance of emergency physicians utilizing a video-assisted semi-rigid fiberoptic stylet for intubation of a difficult airway in a high-fidelity simulated patient: a pilot study

BackgroundThis study was designed to evaluate emergency physician success and satisfaction using a video-assisted semi-rigid fiberoptic stylet, the Clarus Video System (CVS), during a simulated difficult airway scenario.FindingsEmergency physicians (EPs) of all levels were first shown a brief slide show and three example videos, and then given 20 min to practice intubating a mannequin using both the CVS and standard direct laryngoscopy (DL). The mannequin was then placed in a c-collar and set to simulate an apneic patient with an edematous tongue and trismus. Each EP was given up to three timed attempts with each technique. They rated their satisfaction with the CVS, usefulness for their practice, and the effectiveness of the tutorial. Direct laryngoscopy had a 65% success rate on the first attempt, 20% on the second, and 15% required three or more. The CVS had a 100% success rate with a single attempt. Average time for independent DL attempts was 43.41 s (SD = ±26.82) and 38.71 s (SD = ±34.14) with CVS. Cumulative attempt times were analyzed and compared (DL = 74.55 ± 68.40 s and CVS = 38.71 ± 34.14 s; p = 0.028). EPs rated their satisfaction with, and usefulness of, the CVS as ≥6 out of 10.ConclusionEmergency physicians were able to successfully intubate a simulated difficult airway model on the first attempt 100% of the time. Emergency physicians were satisfied with the CVS and felt that it would be useful in their practice.

Gas gangrene and osteomyelitis of the foot in a diabetic patient treated with tea tree oil

Diabetic foot wounds represent a class of chronic non-healing wounds that can lead to the development of soft tissue infections and osteomyelitis. We reviewed the case of a 44-year-old female with a diabetic foot wound who developed gas gangrene while treating her wound with tea tree oil, a naturally derived antibiotic agent. This case report includes images that represent clinical examination and x-ray findings of a patient who required broad-spectrum antibiotics and emergent surgical consultation. Emergency Department (ED) detection of these complications may prevent loss of life or limb in these patients.

Intravenous vs. intraosseous access and return of spontaneous circulation during out of hospital cardiac arrest

Introduction: Guidelines endorse intravenous (IV) and intraosseous (IO) medication administration for cardiac arrest treatment. Limited clinical evidence supports this recommendation. A multiagency, retrospective study was performed to determine the association between parenteral access type and return of spontaneous circulation (ROSC) in out of hospital cardiac arrest. Methods: This was a structured, retrospective chart review of emergency medical services (EMS) records from three agencies. Data was analyzed from adults who suffered OHCA and received epinephrine through EMS established IV or IO access during the 18‐month study period. Per regional EMS protocols, choice of parenteral access type was at the providers discretion. Non‐inferiority analysis was performed comparing the association between first access type attempted and ROSC at time of emergency department arrival. Results: 1310 subjects met inclusion criteria and were included in the analysis. Providers first attempted parenteral access via IV route in 788 (60.15%) subjects. Providers first attempted parenteral access via IO route in 552 (39.85%) subjects. Rates of ROSC at time of ED arrival were 19.67% when IV access was attempted first and 19.92% when IO access was attempted first. An IO first approach was non‐inferior to an IV first approach based on the primary end point ROSC at time of emergency department arrival (p = 0.01). Conclusion: An IO first approach was non‐inferior to an IV first approach based on the end point ROSC at time of emergency department arrival.

A prospective evaluation of the contribution of ambient temperatures and transport times on infrared thermometry readings of intravenous fluids utilized in EMS patients

BackgroundDuring cold weather months in much of the country, the temperatures in which prehospital care is delivered creates the potential for inadvertently cool intravenous fluids to be administered to patients during their transport and care by emergency medical services (EMS). There is some potential for patient harm from unintentional infusion of cool intravenous fluids. Prehospital providers in these cold weather environments are likely using fluids that are well below room temperature when prehospital intravenous fluid (IVF) warming techniques are not being employed. It was hypothesized that cold ambient temperatures during winter months in the study location would lead to the inadvertent infusion of cold intravenous fluids during prehospital patient care.MethodsTrained student research assistants obtained three sequential temperature measurements using an infrared thermometer in a convenience sample of intravenous fluid bags connected to patients arriving via EMS during two consecutive winter seasons (2011 to 2013) at our receiving hospital in Syracuse, New York. Intravenous fluids contained in anything other than a standard polyvinyl chloride bag were not measured and were not included in the study. Outdoor temperature was collected by referencing National Weather Service online data at the time of arrival. Official transport times from the scene to the emergency department (ED) and other demographic data was collected from the EMS provider or their patient care record at the time of EMS interaction.ResultsTwenty-three intravenous fluid bag temperatures were collected and analyzed. Outdoor temperature was significantly related to the temperature of the intravenous fluid being administered, b = 0.69, t(21) = 4.3, p < 0.001. Transport time did not predict the measured intravenous fluid temperatures, b = 0.12, t(20) = 0.55, p < 0.6.ConclusionsUse of unwarmed intravenous fluid in the prehospital environment during times of cold ambient temperatures can lead to the infusion of cool intravenous fluid and may result in harm to patients. Short transport times do not limit this risk. Emergency departments should not rely on EMS agencies’ use of intravenous fluid warming techniques and should consider replacing EMS intravenous fluids upon ED arrival to ensure patient safety.

Meningeal carcinomatosis diagnosed during stroke evaluation in the emergency department

A 70-year-old female presented to the emergency department with a 3-day history of intermittent dysphasia and right facial droop. Computed tomography (CT) and magnetic resonance imaging (MRI) were obtained, and the patient was found to have meningeal carcinomatosis, also known as leptomeningeal metastases. Meningeal carcinomatosis is a rare metastatic complication of some solid tumors and hematopoietic neoplasms, and has a median survival rate of 2.4 months. The role of the emergency physician is to appropriately diagnose this condition, treat emergent side effects, provide symptomatic relief, and ensure multi-disciplinary management.