Jeremy T. Cushman

The Epidemiology of Emergency Medical Services Use by Children: An Analysis of the National Hospital Ambulatory Medical Care Survey

Objective. There is an absence of nationally representative data describing pediatric patients who use emergency medical services (EMS) andthe factors associated with EMS use by children. This study characterizes pediatric emergency department (ED) visits for which the patient arrived by EMS andidentifies factors associated with those visits using a nationally representative database. Methods. A secondary analysis of the ED component of the 1997–2000 National Hospital Ambulatory Medical Care Survey was performed. The dependent variable was the mode of arrival to the ED (EMS vs. not EMS), andindependent variables were grouped into four domains: demographic, clinical, system, andservice characteristics. Bivariate analyses andmultivariate logistic regression analyses were conducted. Results. There were 110.9 million ED visits by children aged <19 years between 1997 and2000. Pediatric patients constituted 27.3% of all ED visits during this time, and7.9 million (7.1%) of these patients arrived via EMS. Pediatric patients represented 13% of all EMS transports. The annual EMS utilization rate by children was 26 per 1,000, compared with 66 per 1,000 in the adult population (p < 0.001). Sixteen percent of children transported by EMS were admitted to the hospital. Sixty-two percent of pediatric patients arriving at the ED by EMS were transported as a result of injury or poisoning. Characteristics significantly associated with arrival by EMS in the final multivariate model included demographic (age, African American race, urban residence), clinical (need for greater immediacy of care, illnesses associated with certain diagnoses), andservice (greater number of diagnostic services) variables. Conclusions. Pediatric patients transported by EMS are more likely to have injuries andpoisoning, andhave higher-acuity illness than those arriving at the ED by other means. The epidemiology of pediatric EMS use may have important operational, training, andpublic health implications andrequires further study.

Topographic Position of Forelimb Motoneuron Pools Is Conserved in Vertebrate Evolution

The neuromotor conservatism hypothesis predicts that neuromotor patterns in homologous tetrapod muscles are conserved evolutionarily despite the musculoskeletal modifications of vertebrate limbs. A complete description of the anatomical organization of the neurons innervating homologous limb muscles is a prerequisite to any test of the neuromotor conservatism hypothesis. This study uses the retrograde neuronal tracer WGA-HRP to selectively label the motor neuron pools of seven homologous forelimb muscles in mice (Mus musculus) and iguanas (Iguana iguana): Mm. pectoralis, spinodeltoideus, biceps brachii, lateral and long heads of triceps brachii, and the supraspinatus and infraspinatus (in mice) or their reptilian homolog, the supracoracoideus (in iguanas). In vertebrates, motoneurons are arranged in longitudinal columns of cells in the ventral horn of the spinal cord. Mouse motor pools average 1,952 μm in length, except the pectoralis pool which averaged 2,949 μm in length. Iguana pools average 3,196 μm in length. The number of neurons per pool ranged from 70–199 in mice and from 58–114 neurons in iguanas. In both iguanas and mice the motor pools for the spinodeltoids, biceps, and the supracoracoideus (or its mammalian homologs) lie anterior to the pectoralis and triceps motor pools. In the transverse plane, the pectoralis pool lies medial to those of the triceps. The pools of the biceps and spinodeltoids are located dorsal and lateral to those of the pectoralis and supracoracoideus (or its homologs in mammals). The resulting motor pool maps support the hypothesis that the anatomical organization of motoneurons in ancestral reptiles has been retained in these two tetrapod descendents.

Ambulance Personnel Perceptions of Near Misses and Adverse Events in Pediatric Patients

Abstract Objective. To identify emergency medical services (EMS) provider perceptions of factors that may affect the occurrence, identification, reporting, and reduction of near misses and adverse events in the pediatric EMS patient. Methods. This was a subgroup analysis of a qualitative study examining the nature of near misses and adverse events in EMS as it relates to pediatric prehospital care. Complementary qualitative methods of focus groups, interviews, and anonymous event reporting were used to collect results and emerging themes were identified and assigned to specific analytic domains. Results. Eleven anonymous event reports, 17 semistructured interviews, and two focus groups identified 61 total events, of which 12 were child-related. Eight of those were characterized by participants as having resulted in no injury, two resulted in potential injury, and two involved an ultimate fatality. Three analytic domains were identified, which included the following five themes: reporting is uncommon, blaming errors on others, provider stress/discomfort, errors of omission, and limited training. Among perceived causes of events, participants noted factors relating to management problems specific to pediatrics, problems with procedural skill performance, medication problems/calculation errors, improper equipment size, parental interference, and omission of treatment related to providers’ discomfort with the patients age. Few participants spoke about errors they had committed themselves; most discussions centered on errors participants had observed being made by others. Conclusions. It appears that adverse events and near misses in the pediatric EMS environment may go unreported in a large proportion of cases. Participants attributed the occurrence of errors to the stress and anxiety produced by a lack of familiarity with pediatric patients and to a reluctance to cause pain or potential harm, as well as to inadequate practical training and experience in caring for the pediatric population. Errors of omission, rather than those of commission, were perceived to predominate. This study provides a foundation on which to base additional studies of both a qualitative and quantitative nature that will shed further light on the factors contributing to the occurrence, reporting, and mitigation of adverse events and near misses in the pediatric EMS setting.

Comparison of the 1999 and 2006 Trauma Triage Guidelines: Where Do Patients Go??

Abstract Background. In 2006, the Centers for Disease Control and Prevention (CDC) released a revised Field Triage Decision Scheme. It is unknown how this modified scheme will affect the number of patients identified by emergency medical services (EMS) for transport to a trauma center. Objectives. To determine the change in the number of patients transported by EMS who meet the 2006 scheme, compared with the 1999 scheme, and to determine how the scheme change would affect under- and overtriage rates. Methods. The EMS providers in charge of care for injured adult patients transported to a regional trauma center in three mid-sized cities were interviewed immediately after completing transport. All injured patients were included, regardless of severity. The interview included patient demographics, vital signs, apparent anatomic injury, and the mechanism of injury. Included patients were then followed through hospital discharge. The 1999 and 2006 scheme criteria were each retrospectively applied to the collected data. The numbers of patients identified by the two schemes were determined. Patients were considered to have needed a trauma center if they had nonorthopedic surgery within 24 hours, were admitted to an intensive care unit (ICU), or died. Data were analyzed using descriptive statistics including 95%% confidence intervals. Results. EMS interviews were conducted for 11,892 patients and outcome data were unavailable for one patient. The average patient age was 48 years; 51%% of the patients were men. Providers reported bringing 54%% of the enrolled patients to the trauma center based on their local trauma protocol. Medical record review identified 12%% of the enrolled patients as needing a trauma center. Use of the 2006 scheme would have resulted in 1,423 fewer patients (12%%; 95%% confidence interval [[CI]]:11%%–13%%) being identified as needing a trauma center by EMS providers (40%%; 95%% CI: 39%%–41%% versus 28%%; 95%% CI: 27%%–29%%). Of those patients, 1,344 (94%%) did not actually need the resources of a trauma center, whereas 78 (6%%) actually needed the resources of a trauma center and would have been undertriaged. Conclusion. Use of the 2006 Field Triage Decision Scheme would have resulted in a significant decrease in the number of patients identified as needing the resources of a trauma center. These changes reduced overtriage while causing a small increase in the number of patients who would have been undertriaged. Key words: wounds and injury; triage; emergency medical services; emergency medical technicians; decision scheme

A consensus-based criterion standard for trauma center need.

BACKGROUND In civilian trauma care, field triage is the process applied by prehospital care providers to identify patients who are likely to have severe injuries and immediately need the resources of a trauma center. Studies of the efficacy of field triage have used various measures to define trauma center need because no “criterion standard” exists, making cross-study comparisons difficult. This study aimed to develop a consensus-based functional criterion standard definition of trauma center need. METHODS Local and national experts were recruited for participation. Blinded key informant interviews were conducted in order of availability until no new themes emerged. Themes identified during the interviews were used to develop a Modified Delphi survey, which was electronically delivered via Survey Monkey. The trauma center need criteria were refined iteratively based on participant responses. Participants completed additional surveys until there was at least 80% agreement for each criterion. RESULTS Fourteen experts were recruited. Five participated in key informant interviews. A Modified Delphi survey was administered five times (four modifications based on the expert’s responses). After the fifth round, there was at least 82% agreement on each criterion. The final definition included 10 time-specific indicators: major surgery, advanced airway, blood products, admission for spinal cord injury, thoracotomy, pericardiocentesis, cesarean delivery, intracranial pressure monitoring, interventional radiology, and in-hospital death. CONCLUSION We developed a consensus-based functional criterion standard definition of needing the resources of a trauma center, which may help to standardize field triage research and quality assurance in trauma systems as well as allow for cross study comparisons.

Barriers to and Enablers for Prehospital Analgesia for Pediatric Patients

Abstract Objective. To identify and investigate the barriers and enablers perceived by paramedics regarding the administration of analgesia to pediatric emergency medical services (EMS) patients. Methods. This was a qualitative study in which in-depth semistructured interviews of a purposively-sampled group of 16 paramedics were performed before achieving redundancy. The interviews were structured and the data were thematically analyzed. Emerging themes were categorized into four domains, and novel themes were identified and further explored. Results. Thirteen of 16 paramedics reported success with analgesia in children at least once in their careers. Provider anxiety, unfamiliarity and discomfort with pediatrics, unfamiliarity with the protocol, insufficient didactic and clinical education, and concern for adverse effects from analgesic agents were perceived as barriers to pediatric pain management. The paramedics had differing beliefs about the importance of pain control, the role of parents in medical care for children, and the paramedics ability to assess pediatric patients. Having a positive relationship with online medical control and using commercially available assistive guides were viewed as enablers for pediatric pain management. The response from paramedic supervisors and emergency department staff, unwanted attention from authority figures, perceived superiority of hospital care, difficulty obtaining intravenous access, and overall culture of stinginess in medication administration played important roles in an overall preference to defer pediatric analgesia. Some paramedics mentioned a specific experience or mentoring relationship with a more seasoned provider who taught them the importance of pain management. Paramedics reported various effects of transport distance on their decision to administer analgesia. Conclusions. We have identified a number of previously unrecognized barriers to and enablers for prehospital pediatric analgesia. The majority of these factors lead to an overall preference of paramedics to defer administration of analgesic agents. A number of educational and EMS system changes could be made to address these barriers and increase the frequency of appropriate pediatric prehospital analgesia.

Does Mechanism of Injury Predict Trauma Center Need

Abstract Objective. To determine the predictive value of the mechanism-of-injury step of the American College of Surgeons Field Triage Decision Scheme for determining trauma center need. Methods. Emergency medical services (EMS) providers caring for injured adult patients transported to the regional trauma center in three midsized communities over two years were interviewed upon emergency department (ED) arrival. Included was any injured patient, regardless of injury severity. The interview collected patient physiologic condition, apparent anatomic injury, and mechanism of injury. Using the 1999 Scheme, patients who met the physiologic or anatomic steps were excluded. Patients were considered to need a trauma center if they had nonorthopedic surgery within 24 hours, had intensive care unit admission, or died prior to hospital discharge. Data were analyzed by calculating positive likelihood ratios (+LRs) and 95% confidence intervals (CIs) for each mechanism-of-injury criterion. Results. A total of 11,892 provider interviews were conducted. Of those, one was excluded because outcome data were not available, and 2,408 were excluded because they met the other steps of the Field Triage Decision Scheme. Of the remaining 9,483 cases, 2,363 met one of the mechanism-of-injury criteria, 204 (9%) of whom needed the resources of a trauma center. Criteria with a +LR ≥5 were death of another occupant in the same vehicle (6.8; CI: 2.7–16.7), fall >20 feet (5.3; CI: 2.4–11.4), and motor vehicle crash (MVC) extrication time >20 minutes (5.1; CI: 3.2–8.1). Criteria with a +LR between >2 and <5 were intrusion >12 inches (4.2; CI: 2.9–5.9), ejection (3.2; CI: 1.3–8.2), and deformity >20 inches (2.5; CI: 1.9–3.2). The criteria with a +LR ≤2 were MVC speed >40 mph (2.0; CI: 1.7–2.4), pedestrian/bicyclist struck at a speed >5 mph (1.2; CI:1.1–1.4), bicyclist/pedestrian thrown or run over (1.2; CI: 0.9–1.6), motorcycle crash at a speed >20 mph (1.2; CI: 1.1–1.4), rider separated from motorcycle (1.0; CI: 0.9–1.2), and MVC rollover (1.0; CI: 0.7–1.5). Conclusion. Death of another occupant, fall distance, and extrication time were good predictors of trauma center need when a patient did not meet the anatomic or physiologic conditions. Intrusion, ejection, and vehicle deformity were moderate predictors. Key words: wounds and injury; triage; emergency medical services; emergency medical technicians; predictors; mechanism of injury; trauma center

Effect of Intensive Physician Oversight on A Prehospital Rapid-Sequence Intubation Program

Abstract Objective. To examine the effects of adding close concurrent and retrospective physician oversight, consistent with National Association of EMS Physicians (NAEMSP) recommendations, to an existing regional prehospital rapid-sequence intubation (RSI) program. Methods. This study involved a retrospective cohort of patients receiving RSI between January 1, 2004, and July 31, 2008. On January 1, 2007, an updated program including additional concurrent and retrospective physician oversight, increased RSI-specific continuing medical education, and cadaver laboratory training was implemented. Study patients were divided into a preintervention group (group 1) and a postintervention group (group 2) based on date of medical care. Data regarding baseline characteristics, airway management, medication usage, and performance factors were compared between the groups. A retrospective review by two emergency medical services (EMS) physicians assessed whether the RSI was “clearly indicated” based on a predetermined set of criteria. Results. There were 109 RSIs performed in group 1 and 54 in group 2. Absolute increases in the use of both basic life support (BLS) (5%, p = 0.2) and advanced life support (ALS) (41%, p = 0.001) airway techniques were observed. Increases in postintubation administration of midazolam (30%, p = 0.001) and morphine (24%, p = 0.001) and a decrease for vecuronium (–28%, p = 0.001) were observed. There was no statistically significant difference in the intubation success rates (92% vs. 94%) and the frequencies of recognized esophageal endotracheal tube (ETT) placement (5% vs. 6%). The number of unrecognized esophageal ETT placements remained zero. Physician chart review demonstrated an absolute increase in “clearly indicated” RSIs (17%, p = 0.01). Conclusions. Close concurrent and retrospective physician oversight consistent with recommendations from the NAEMSP is associated with improved cognitive skills in paramedics, including appropriate patient selection for RSI. Further research is warranted to validate this model and optimize where resources are best used to enhance patient safety and improve clinical management for this controversial paramedic skill.

Injury Patterns and Levels of Care at a Marathon

INTRODUCTION Marathons pose many challenges to event planners. The medical services needed at such events have not received extensive coverage in the literature. OBJECTIVE The objective of this study was to document injury patterns and medical usage at a category III mass gathering (a marathon), with the goal of helping event planners organize medical resources for large public gatherings. METHODS Prospectively obtained medical care reports from the five first-aid stations set up along the marathon route were reviewed. Primary and secondary reasons for seeking medical care were categorized. Weather data were obtained, and ambient temperature was recorded. RESULTS The numbers of finishers were as follows: 4,837 in the marathon (3,099 males, 1,738 females), 814 in the 5K race (362 males, 452 females), and 393 teams in the four-person relay (1,572). Two hundred fifty-one runners sought medical care. The days temperatures ranged from 39 to 73 degrees F (mean, 56 degrees F). The primary reasons for seeking medical were medication request (26%), musculoskeletal injuries (18%), dehydration (14%), and dermal injuries (11%). Secondary reasons were musculoskeletal injuries (34%), dizziness (19%), dermal injuries (11%), and headaches (9%). Treatment times ranged from 3 to 25.5 minutes and lengthened as the day progressed. Two-thirds of those who sought medical care did so at the end of the race. The majority of runners who sought medical attention had not run a marathon before. CONCLUSIONS Marathon planners should allocate medical resources in favor of the halfway point and the final first-aid station. Resources and medical staff should be moved from the earlier tents to further augment the later first-aid stations before the majority of racers reach the middle- and later-distance stations.

Identification of a neurologic scale that optimizes EMS detection of older adult traumatic brain injury patients who require transport to a trauma center.

Abstract Objective. We sought to identify a scale or components of a scale that optimize detection of older adult traumatic brain injury (TBI) patients who require transport to a trauma center, regardless of mechanism. Methods. We assembled a consensus panel consisting of nine experts in geriatric emergency medicine, prehospital medicine, trauma surgery, geriatric medicine, and TBI, as well as prehospital providers, to evaluate the existing scales used to identify TBI. We reviewed the relevant literature and solicited group feedback to create a list of candidate scales and criteria for evaluation. Using the nominal group technique, scales were evaluated by the expert panel through an iterative process until consensus was achieved. Results. We identified 15 scales for evaluation. The panels criteria for rating the scales included ease of administration, prehospital familiarity with scale components, feasibility of use with older adults, time to administer, and strength of evidence for their performance in the prehospital setting. After review and discussion of aggregated ratings, the panel identified the Simplified Motor Scale, GCS-Motor Component, and AVPU (alert, voice, pain, unresponsive) as the strongest scales, but determined that none meet all EMS provider and patient needs due to poor usability and lack of supportive evidence. The panel proposed that a dichotomized decision scheme that includes domains of the top-rated scales –level of alertness (alert vs. not alert) and motor function (obeys commands vs. does not obey) –may be more effective in identifying older adult TBI patients who require transport to a trauma center in the prehospital setting. Conclusions. Existing scales to identify TBI are inadequate to detect older adult TBI patients who require transport to a trauma center. A new algorithm, derived from elements of previously established scales, has the potential to guide prehospital providers in improving the triage of older adult TBI patients, but needs further evaluation prior to use.