Lawrence H. Brown

The perceived importance of paramedic skills and the emphasis they receive during ems education programs

OBJECTIVE The National Standard Curriculum for paramedics is currently being revised. There is little scientific evidence of what does and what does not work in prehospital care, and of whether the National Standard Curriculum prepares paramedics for the field. To provide some basis for the current revisions to the National Standard Curriculum, the authors determined which prehospital skills are perceived by paramedics to be the most important, and whether the emphasis placed on those skills during initial and continuing education programs corresponds with the perceived importance. METHODS Surveys listing 21 paramedic skills were mailed to the directors of 41 EMS agencies who agreed to participate in the study. The directors distributed the surveys to 1,364 paramedics affiliated with their organizations. The participants were asked to rate the importance of each skill, and the emphasis placed on each skill during their initial and continuing education. Skills were ranked on a scale of 0 to 4, with 0 representing no importance or emphasis, and 4 representing the most possible importance or emphasis. RESULTS Six-hundred of the 1,364 (44%) surveys were returned. Respondents had a mean of 9.9 +/- 5.6 years of EMS experience, and 5.4 +/- 4.0 years of experience as paramedics. The three skills ranked highest in importance were: 1) endotracheal intubation; 2) defibrillation; and 3) assessment. Importance in prehospital care was ranked equal to or higher than emphasis in both initial and continuing education for all skills except splinting and urinary catheterization, which received higher rankings for emphasis in initial education. Emphasis in initial education equaled or exceeded the emphasis in continuing education for all skills except intraosseous infusion. CONCLUSION The perceived importance of most prehospital skills is very high, and exceeds the emphasis placed on those skills during both initial and continuing education programs. These findings have implications for medical directors, EMS instructors, and persons involved with the revision of the National Standard Curriculum.

Potential time savings by prehospital administration of activated charcoal

OBJECTIVE Activated charcoal (AC) has been proven useful in many toxic ingestions. Theoretically, administration of AC in the prehospital environment could save valuable time in the treatment of patients who have sustained potentially toxic oral ingestions. The purpose of this study was to determine the frequency of prehospital AC administration and to identify time savings that could potentially result from field AC administration. METHODS Adult patients with a chief complaint of toxic ingestion who had complete emergency medical services (EMS) and emergency department (ED) records and no medical treatment (gastric emptying, AC administration) prior to EMS arrival were eligible for inclusion. Data obtained from EMS and ED records included time of EMS departure from the scene, time of EMS arrival at the ED, and time of administration of AC in the ED. Since most EMS agencies in this system do not insert gastric tubes, patients requiring gastric tube placement for administration of AC were excluded. RESULTS Twenty-nine of 117 (24.8%) adult patients received oral AC with no other intervention. None of the 117 patients received AC in the prehospital setting. The EMS transport time for these patients ranged from 5 to 43 minutes (mean 16.2 +/- 9.7 minutes). The delay from ED arrival to AC administration ranged from 5 to 94 minutes (mean 48.8 +/- 24.1 minutes), and was more than 60 minutes for 14 (48.2%) of the patients. The total time interval from scene departure to ED AC administration ranged from 17 to 111 minutes (mean 65.0 +/- 25.9 minutes). CONCLUSIONS In a selected subset of patients who tolerate oral AC, prehospital administration of AC could result in earlier and potentially more efficacious AC therapy. Prospective study of the benefits and feasibility of prehospital AC administration is indicated.

Does the ambulance environment adversely affect the ability to perform oral endotracheal intubation

OBJECTIVE Oral endotracheal intubation (ETI) is the preferred method of controlling the airway in critically ill or injured patients. It was postulated that time could be saved if intubation was performed in the ambulance en route to the hospital. This study was designed to determine whether the ambulance environment adversely affected the ability of emergency medical technicians at the advanced-intermediate level (EMT-AI) to perform oral ETI. HYPOTHESIS The restrictive environment of a moving ambulance would affect adversely the ability of EMT-AIs to perform ETI compared with a controlled setting. This would result in a significant increase in the time necessary to perform ETI in the ambulance compared with a controlled setting not complicated by restrictive space and motion. METHODS Twenty on-duty EMT-AIs were recruited to volunteer for this prospective, nonrandomized, nonblinded trial. All participants performed three consecutive oral ETIs on an airway mannequin in two settings: 1) in the back of a moving ambulance; and 2) on a table in the rescue squad station. Of the participants, 10 performed the intubations in the ambulance first; the remainder performed the intubations at the station first. Time for intubation with the mannequin was recorded by stopwatch. The mean times for intubation in both settings were compared by Students t-test (p < 0.05). RESULTS All intubation attempts were successful. The mean time for intubation in the station was 13.0 +/- 3.4 seconds. The mean time in the ambulance setting was 13.2 +/- 5.3 seconds. There was no significant difference between the intubation times in the two settings (p = 0.88). CONCLUSION The environment of a moving ambulance does not appear to hinder the ability of EMT-AIs to perform oral ETI in a laboratory setting with a mannequin model.

Public perceptions of a rural emergency medical services system.

INTRODUCTION To determine the awareness of citizens and physicians concerning the capabilities of a rural emergency medical services (EMS) system. HYPOTHESIS Citizens and physicians are unaware of the capabilities of the EMS system. METHODS Residents were selected randomly from the local telephone directory and asked a series of structured questions about their EMS agency. A written survey was distributed to area physicians. Chi-square analysis was used to compare the proportion of respondents who knew the available interventions in their community with the proportion of those who did not. Statistical significance was inferred at p < 0.01. RESULTS A total of 49% of the citizens were able to identify available skills, and 41.4% of the physicians were able to identify available skills. Physicians were less likely than were the citizens to be able to identify the skills performed by each provider (p < 0.001). CONCLUSION This study indicates that both physicians and the lay public have little understanding of the capabilities of their EMS system.

Does Ambulance Crew Size Affect On-Scene Time or Number of Prehospital Interventions?

INTRODUCTION While large cities typically staff ambulances with two emergency medical services (EMS) professionals, some EMS agencies use three people for ambulance crews. The Greenville, North Carolina, EMS agency converted from three-person to two-person EMS crews in July 1993. There are no published reports investigating the best crew size for out-of-hospital emergency care. HYPOTHESIS Two-person EMS crews perform the same number and types of interventions as three-person EMS crews. Two-person EMS crews do not have longer on-scene times than do three-person EMS crews. METHODS Data for the two most common advanced life support calls in this system--seizures and chest pains--were collected for the months of June and August 1993. Three-person EMS crews responded to both types of calls in June. In August, two-person EMS crews responded to seizure calls; two-person EMS crews accompanied by a fire department engine (pumper) with additional manpower responded to chest pain calls. The frequency of specific interventions, number of total interventions, and scene times for the August calls were compared to their historical control groups, the June calls. RESULTS One hundred twenty-six patient contacts were included in the study. There were no significant differences in total number or types of procedures performed for the two patient groups. Mean on-scene time for patients with seizures was 11.0 +/- 4.2 minutes for three-person crews and 19.4 +/- 8.3 minutes for two-person crews (p < 0.001). Mean on-scene time for patients with chest pain was 13.6 +/- 4.9 minutes for three-person crews, and 15.4 +/- 3.2 minutes for two-person crews assisted by fire department personnel (p > 0.05). CONCLUSION Two-person EMS crews perform the same number of procedures as do three-person EMS crews. However, without the assistance of additional responders, two-person EMS crews may have statistically significantly longer on-scene times than three-person EMS crews.

Accuracy of rural EMS provider interpretation of three-lead ECG rhythm strips

OBJECTIVE To measure the accuracy of lead II rhythm strip interpretations performed by advanced life support (ALS) emergency medical technicians (EMTs) in a rural emergency medical services (EMS) system. METHODS An electronic rhythm simulator was used to produce 24 three-lead electrocardiogram (ECG) rhythm strips. The rhythms were shown to 57 ALS EMTs participating in regularly scheduled continuing education classes. The participants were asked to identify the rhythms. RESULTS The three-lead ECG interpretations were generally accurate, although there was some difficulty in distinguishing between specific types of tachydysrhythmia and atrioventricular (AV) block. The overall accuracy of the rhythm interpretations was 79.2%, ranging from 45.6% (second-degree type II heart block) to 98.2% (sinus bradycardia). The sensitivity for specific tachydysrhythmias ranged from 68.4% (supraventricular tachycardia) to 86.0% (atrial fibrillation); the sensitivity for specific types of AV block ranged from 45.6% (second-degree, type II) to 71.9% (third-degree). CONCLUSION In this EMS system, ECG interpretations are generally accurate, with tachydysrhythmias and AV blocks being the source of most discrepancies.

A breathing manikin model for teaching nasotracheal intubation to EMS professionals.

OBJECTIVE The widespread use of orotracheal intubation with rapid-sequence induction has made it difficult for emergency medical services (EMS) professionals to gain experience in nasotracheal intubation (NTI) in a controlled and supervised setting. The purpose of this study was to determine whether a training session on NTI with a breathing manikin can be used to improve the self-assessed skill level and comfort of EMS professionals. METHODS A prospective trial was conducted with a convenience sample of 33 EMS professionals, previously trained in NTI techniques. For the training session, a Laerdal airway manikin was modified by replacing the lungs with self-inflating resuscitation bag. The bag could then be squeezed to simulate breathing, with an inspiratory and expiratory phase. Following didactic instruction, and with direct supervision, each participant practiced NTI using this breathing manikin. Each participant completed a questionnaire, both before and after the training session, to determine self-assessed comfort and skill level for both oral and nasal intubations (0 = lowest, 10 = highest). The pre- and postintervention scores were compared using the Wilcoxon signed-rank test, alpha = 0.01. RESULTS Following the training session, the comfort level for NTI by the participants increased significantly from a median value of 2 to 7 (p = 0.001). Furthermore, the self-assessed skill level for NTI following the training session increased significantly from a median value of 4 to 8 (p = 0.0001). As expected, there were no significant differences noted in self-assessed skill level for orotracheal intubation following the training session. However, there was statistically significant improvement in self-assessed comfort levels for orotracheal intubation after the skills laboratory, p = 0.0001. CONCLUSION For EMS professionals, a training session for NTI using a relatively inexpensive and easily assembled breathing manikin model increases both comfort and self-assessed skill level.

Do pulse checks cause a significant delay in the initial defibrillation sequence

This study was undertaken to determine if checking for a pulse between initial defibrillations causes a clinically significant delay in the administration of the defibrillations. Ten emergency department nurses and 10 emergency medicine resident physicians were timed delivering three successive defibrillations (200, 300 and 360 J) to a manikin under three randomly assigned scenarios: (1) without pulse checks; (2) with pulse checks performed by an assistant; and (3) with pulse checks performed by the participant. All participants performed the three defibrillation scenarios using three different models of defibrillators. Repeated measures analysis of variance was used to compare mean defibrillation times for the three scenarios. The mean time was 20.4 +/- 1.0 s for defibrillation without pulse checks; 20.2 +/- 1.2 s with pulse checks by an assistant and 22.0 +/- 2.0 s with pulse checks by the participant. There was a statistically significant difference between no pulse checks and pulse checks by the participant. No statistically significant difference was noted between no pulse checks and pulse checks by an assistant. We conclude that checking for a pulse does cause a statistically significant delay in the administration of defibrillations. This difference, however, is not likely to be clinically relevant.

The readability of prehospital care research forum abstracts

OBJECTIVE The Prehospital Care Research Forum sponsors both oral and poster presentations of emergency medical services (EMS) research in conjunction with JEMS Corporations annual EMS Today Conference. Attendance at the research presentations, historically, has been poor. This descriptive study was designed to measure the readability of the Prehospital Care Research Forum abstracts in order to determine whether the abstracts are difficult to read, and thus are a deterrent to attendance at the oral and poster research presentations. METHODS The 31 abstracts published in the 1995 Prehospital Care Research Forum supplement to the Journal of Emergency Medical Services were analyzed using a computerized reading-level testing program. Six different reading-level tests were used to determine the readability of the abstracts. RESULTS The overall reading level for the 31 abstracts ranged from grade 7 to grade 20, with a mean grade level of 12.3. The mean Flesch reading ease score for the 31 abstracts ranged from 3.4 to 66.1, with a mean score of 36.0 +/- 14.4. CONCLUSION The abstracts for the Prehospital Care Research Forum presentations are not overly difficult to read. It is unlikely that readability of the abstracts is a factor in the interest, or lack of interest, in the proceedings of the Prehospital Care Research Forum.

19. A Breathing Manikin Model for Teaching Nasotracheal Intubation to EMS Professionals

Purpose : The wide spread use of orotracheal intubation with rapid sequence induction has made it difficult for EMS professionals to gain experience in nasotracheal intubation (NTI) in a controlled supervised setting. The purpose of this study was to determine if a training session on NTI with a breathing manikin can be used to improve skill and comfort of EMS professionals. Methods : A prospective trial was conducted with a convenience sample of 16 emergency medical service professionals, previously trained in nasotracheal intubation techniques. For the training session a Laerdal airway manikin was modified by replacing the lungs with a bag-valve mask device, to simulate breathing with an inspiratory and expiratory phase. Following verbal instruction, and with direct supervision, each participant practiced NTI using the breathing manikin. Each participant completed a questionnaire, both before and after the training session, to determine self assessed comfort and skill level for both oral and nasal intubations (0 = lowest, 10 = highest). The pre and post intervention scores were compared using the Wilcoxon signed-rank test, £ = 0.01.