Edward T. Dickinson

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.

The effectiveness of midazolam as a single pharmacologic agent to facilitate endotracheal intubation by paramedics

OBJECTIVEnEndotracheal intubation (ETI) remains the gold standard for securing a patients airway. In recent years, the use of pharmacologic agents to assist paramedics achieve successful intubation of problematic airways has become more common. This study was done to determine the efficacy of intravenous midazolam, a short-acting benzodiazepine, as a drug to facilitate intubation in patients resistant to conventional ETI.nnnMETHODSnThis retrospective observational study reviewed the 22-month experience of a suburban municipal EMS system after midazolam was introduced as an agent to be used for systemic sedation to facilitate ETI. All calls where midazolam was used were reviewed on a monthly basis by investigators via retrospective review of the prehospital care reports.nnnRESULTSnDuring the study period 13,212 emergency responses occurred, resulting in 154 ETIs by paramedics. Midazolam was used to facilitate 20 (13%) of these ETIs. Clenched teeth and failed conventional intubation were the most commonly cited indications for facilitated intubation. Eleven patients had medical complaints and nine were trauma patients. Successful ETI with midazolam was achieved in 17 of 20 (85%) cases. In 85% (15 of 17) of these cases, a single dose of midazolam was sufficient for ETI [mean dose 3.6 mg (SD 1.1 mg)]. The three patients with failed ETI received multiple doses of midazolam [mean dose 5.0 mg (SD 2.0 mg)].nnnCONCLUSIONnThe prehospital use of single-dose IV midazolam is generally effective in accomplishing facilitated ETI in patients resistant to conventional (nonpharmacologic) ETI.

Effectiveness of mechanical versus manual chest compressions in out-of-hospital cardiac arrest resuscitation: A pilot study

A prospective, randomized effectiveness trial was undertaken to compare mechanical versus manual chest compressions as measured by end-tidal CO2 (ETCO2) in out-of-hospital cardiac arrest patients receiving advanced cardiac life support (ACLS) resuscitation from a municipal third-service, emergency medical services (EMS) agency. The EMS agency responds to approximately 6,700 emergencies annually, 79 of which were cardiac arrests in 1994, the study year. Following endotracheal intubation, all cardiac arrest patients were placed on 100% oxygen via the ventilator circuit of the mechanical cardiopulmonary resuscitation (CPR) device. Patients were randomized to receive mechanical CPR (TCPR) or human/manual CPR (HCPR) based on an odd/even day basis, with TCPR being performed on odd days. ETCO2 readings were obtained 5 minutes after the initiation of either TCPR or HCPR and again at the initiation of patient transport to the hospital. All patients received standard ACLS pharmacotherapy during the monitoring interval with the exception of sodium bicarbonate. CPR was continued until the patient was delivered to the hospital emergency department. Age, call response interval, initial electrocardiogram (ECG) rhythm, scene time, ETCO2 measurements, and arrest outcome were identified for all patients. Twenty patients were entered into the study, with 10 in each treatment group. Three patients in the TCPR group were excluded. Measurements in the HCPR group revealed a decreasing ETCO2 during the resuscitation in 8 of 10 patients (80%) and an increasing ETCO2 in the remaining 2 patients. No decrease in ETCO2 was noted in the TCPR group, with 4 of 7 patients (57%) actually showing an increased reading and 3 of 7 patients (43%) showing a constant ETCO2 reading. The differences in the ETCO2 measurements between TCPR and HCPR groups were statistically significant. Both groups were similar with regards to call response intervals, patient ages, scene times, and initial ECG rhythms. One patient in the TCPR group was admitted to the hospital but later died, leaving no survivors in the study. TCPR appears to be superior to standard HCPR as measured by ETCO2 in maintaining cardiac output during ACLS resuscitation of out-of-hospital cardiac arrest patients.

Geriatric Use of Emergency Medical Services

STUDY OBJECTIVEnTo quantify use by geriatric patients of emergency medical services (EMS) compared with that by young adult patients.nnnMETHODSnWe conducted a retrospective, consecutive case series over a 6-month period in a suburban, all-paramedic municipal EMS system serving 76,500 residents, of whom approximately 15% are 65 years of age or older and 33% are between 25 and 45 years old. Patient age, the sole entry criterion, was used to distinguish two groups: the young adult group, defined as patients 25 to 45 years old; and the geriatric group, defined as patients 65 years or older.nnnRESULTSnOf the 2,712 patients whose cases were reviewed during the study period, 1,734 (65%) met the entry criterion. The geriatric group (n=1,043) accounted for 39% of the total call volume, compared with the young adult group (n=690), which accounted for 25% of total call volume. Patients in the young adult group were 7.3 times more likely to have been in a motor vehicle accident, whereas the GP group was 2.6 times more likely to have cardiorespiratory complaints, 1.8 times more likely to have fallen, and 1.7 times more likely to have minor medical problems requiring transportation and more frequently required advanced life support (ALS) care (54% versus 33%) (P<.001 for all comparisons). Scene times for geriatric patients were found to be longer than those for young adults (ALS, P<.001; basic life support [BLS], P<.05). However, costs billed to the patient were greater for young adults for all care rendered (BLS, P<.001; ALS, P<.05).nnnCONCLUSIONnUse by geriatric patients of EMS differed significantly from that by young adults. Geriatric patients used EMS more frequently and required more ALS care than did young adults. Although geriatric patients required longer scene times for EMS care, young adults incurred greater charges for service. These findings, although perhaps system specific, speak to the need for ongoing analysis of EMS health care delivery to better serve a population increasing in age.

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.

Effect of Night Vision Goggles on Performance of Advanced Life Support Skills by Emergency Personnel

Night vision goggles (NVGs) are used by military personnel operating in low-light environments. It is not known whether NVGs can be used by medical personnel to provide emergency care under such conditions. This was a randomized controlled study to determine the effect of NVGs on the performance of intravenous line insertion (IVI) and endotracheal intubation (El) on training manikins. Emergency physicians and paramedics were randomized to perform EI and IVI in ambient light or in total darkness using NVGs. Each skill was repeated three times, and averages were determined. The average times for EI in ambient light and with NVGs were 48.4 and 188.2 seconds, respectively (SE of 13.4 seconds for both; p < 0.0001). The average times for IVI in ambient light and with NVGs were 34.7 and 73.7 seconds, respectively (SE of 4.1 seconds for both; p < 0.0001). Emergency personnel were able to successfully perform these skills using NVGs, but their times were significantly longer than in ambient light.

Delayed cardiovascular sequelae from Kawasaki syndrome.

The cardiovascular complications of Kawasaki syndrome (KS) are potentially life-threatening. Such complications are usually associated with early stages of the disease and involve symptoms related to myocarditis myocardial ischemia. This report describes an unusual case of a 12-year-old girl with a remote history of KS who presented with supraventricular tachycardia (SVT). The potential relationship between KS and SVT based on results of previous clinicopathologic studies of the conduction system of patients with KS is discussed; this discussion also addresses the importance of early identification, appropriate treatment, and prompt referral once the diagnosis of KS has been made.

Refusal of base station physicians to authorize narcotic analgesia

293 The relief of pain and suffering is a basic principle of medicine. The prehospital use of analgesics to relieve pain associated with traumatic injuries is poorly standardized and has been reported to be inadequate.1–4 In addition, the use of narcotic analgesics for the relief of pain has long been considered problematic due to the medical dogma that the use of such agents will render the patient incapable of giving informed consent for those surgical procedures necessary to treat the underlying cause of his or her pain.5,6 We report two cases where paramedics’ requests for intravenous (IV) morphine to treat isolated extremity injuries were refused by base station physicians providing online medical oversight because those physicians felt that the use of morphine would alter the patient’s ability to be consented for potential surgery after arrival at the hospital.

Managed Care Organizations: A Link in the Chain of Survival?☆☆☆

Managed care organizations (MCOs) have proliferated throughout the United States. Interaction by patients, physicians, and emergency medical services systems with MCOs is evolving. Although MCOs have had some notable successes in reducing health care expenditures, the way in which MCO enrollees gain access to emergency medical care remains a contested issue. We present the cases of two patients who died after they delayed calling 911 in keeping with the rules of their MCO.

Managed care enrollee utilization of 911 medical services

OBJECTIVEnTo determine the mechanism by which managed care organization (MCO) enrollees enter the emergency medical services (EMS) system.nnnMETHODSnAll enrollees belonging to the regions largest MCO and transported to emergency departments by a paramedic-level municipal EMS system were identified from billing records. Dispatch logs were examined to determine the time and origin of the call to the 911 communication center. Patient care records were used to obtain age, the level of care delivered (advanced or basic life support), and whether the patient received any medications while out of hospital. Hospital admission was also determined.nnnRESULTSnOver a six-month period, 195 enrollees were transported. Three modes of 911 EMS system entry were identified: group I-enrollees who called 911 directly; group II-enrollees who called the MCO triage center, who then called 911 on behalf of the patient; and group III--enrollees who were sent to the MCO health center for evaluation, and subsequently the MCO called 911 to transfer the patient to the hospital. Of the 195 patients transported to the emergency department, the dispositions of 108 (55%) patients were obtained. Group I (n = 109) patients were more likely to be transported in the evening (3 PM to 11 PM), less likely to require advanced life support therapies, and less likely to be admitted to the hospital when compared with groups II (n = 32) and III (n = 54) patients. Group III patients were the most likely to receive advanced life support care and require admission to the hospital.nnnCONCLUSIONnThe majority of MCO enrollees called 911 directly, and were most likely to do so during evening hours. Enrollees who called 911 directly (group I) had a trend toward lower acuity, based on the lowest ALS utilization of any group. Those enrollees who most frequently required advanced life support were those who received initial treatment at the MCO center prior to EMS transport. Though EMS system-specific, this type of descriptive analysis is helpful in assisting both EMS systems and MCOs to better assess utilization of 911 EMS resources by MCO enrollees. This study also challenges the prudent layperson paradigm.