Kivlehan Sm

Paramedic Perspectives on Barriers to Prehospital Acute Stroke Recognition.

ABSTRACT Background: Emergency Medical Service (EMS) providers are tasked with rapid evaluation, stabilization, recognition, and transport of acute stroke patients. Although prehospital stroke scales were developed to assist with stroke recognition, unrecognized challenges exist in the prehospital setting that hinder accurate assessment of stroke. The goal of this qualitative study was to systematically understand the challenges and barriers faced by paramedics in recognizing stroke presentations in the field. Methods: Paramedics from 12 EMS agencies serving a mix of rural, suburban, and urban communities in the State of California participated in five focus group discussions. Group size ranged from 3–8, with a total of 28 participants. Demographics of the participants were collected and focus group recordings were transcribed verbatim. Transcripts were subjected to deductive and inductive coding, which identified recurrent and divergent themes. Results: Strong consensus existed around constraints to prehospital stroke recognition; participants cited the diversity of stroke presentations, linguistic diversity, and exam confounded by alcohol and or drug use as barriers to initial evaluation. Also, lack of educational feedback from hospital staff and physicians and continuing medical education on stroke were reported as major deterrents to enhancing their diagnostic acumen. Across groups, participants reported attempting to foster relationships with hospital personnel to augment their educational needs, but this was easier for rural than urban providers. Conclusions: While challenges to stroke recognition in the field were slightly different for rural and urban EMS, participants concurred that timely, systematic feedback on individual patients and case-based training would strengthen early stroke recognition skills.

National trends in the utilization of emergency medical services for acute myocardial infarction and stroke.

Introduction The emergency medical services (EMS) system plays a crucial role in the chain of survival for acute myocardial infarction (AMI) and stroke. While regional studies have shown underutilization of the 911 system for these time-sensitive conditions, national trends have not been studied. Our objective was to describe the national prevalence of EMS use for AMI and stroke, examine trends over a six-year period, and identify patient factors that may contribute to utilization. Methods Using the National Hospital Ambulatory Medical Care Survey-ED (NHAMCS) dataset from 2003–2009, we looked at patients with a discharge diagnosis of AMI or stroke who arrived to the emergency department (ED) by ambulance. We used a survey-weighted χ2 test for trend and logistic regression analysis. Results In the study, there were 442 actual AMI patients and 220 (49.8%) presented via EMS. There were 1,324 actual stroke patients and 666 (50.3%) presented via EMS. There was no significant change in EMS usage for AMI or stroke over the six-year period. Factors independently associated with EMS use for AMI and stroke included age (OR 1.21; 95% CI 1.12–1.31), Non-Hispanic black race (OR 1.72; 95% CI 1.16–2.29), and nursing home residence (OR 11.50; 95% CI 6.19–21.36). Conclusion In a nationally representative sample of ED visits from 20003–2009, there were no trends of increasing EMS use for AMI and stroke. Efforts to improve access to care could focus on patient groups that underutilize the EMS system for such conditions.

Impact of nutrition interventions on pediatric mortality and nutrition outcomes in humanitarian emergencies: A systematic review

Malnutrition contributes to paediatric morbidity and mortality in disasters and complex emergencies, but summary data describing specific nutritional interventions in these settings are lacking. This systematic review aimed to characterise such interventions and their effects on paediatric mortality, anthropometric measures and serum markers of nutrition.

Syncope: Who Needs Imaging? Who Needs Admission?

A 60-year-old man presents to the emergency department (ED) by EMS with a report of sudden collapse while running a road race. It is a hot summer day, and he was at mile 5 of a 10 K race when he suddenly collapsed. He was helped up by bystanders after a report of roughly 1 min of unconsciousness. He has scrapes on his knees and elbows from the fall to pavement but is only complaining of fatigue. He is awake and alert, with mild tachycardia, a normal blood pressure, and a normal neurological exam. His respiratory rate is normal and he is afebrile. His skin is pale and warm, with some mild sweat. He reports that he has a history of hypertension and non-insulin-dependent diabetes. He takes metformin for the latter, but cannot recall his antihypertensive medication name. EMS has started a peripheral IV en route and given him 500 cm3 of normal saline. They report that a 12 lead ECG showed sinus tachycardia without any features concerning for arrhythmia or ischemia.