Lynne Fullerton-Gleason

Classifying undetermined poisoning deaths

Objective: To classify poisoning deaths of undetermined intent as either suicide or unintentional and to estimate the extent of underreported poisoning suicides. Methods: Based on 2002 statewide death certificate and medical examiner data in Utah, the authors randomly selected one half of undetermined and unintentional poisoning deaths for data abstraction and included all suicides. Bivariate analyses assessed differences in demographics, death characteristics, forensic toxicology results, mental health history, and other potentially contributing factors. Classification and regression tree (CART) analysis used information from unintentional and suicide poisoning deaths to create a classification tree that was applied to undetermined poisoning deaths. Results: The authors analyzed 41 unintentional, 87 suicide, and 84 undetermined poisonings. Undetermined and unintentional decedents were similar in the presence of opiates, physical health problems, and drug abuse. Although none of the undetermined decedents left a suicide note, previous attempt or intent to commit suicide was reported for 11 (13%) of these cases. CART analysis identified suicidal behavior, drug abuse, physical health problems, depressed mood, and age as discriminating between suicide and unintentional poisoning. It is estimated that suicide rates related to poisoning are underreported by approximately 30% and overall suicide rates by 10%. Unintentional poisoning death rates were underreported by 61%. Conclusions: This study suggests that manner of death determination relies on circumstance dependent variables that may not be consistently captured by medical examiners. Underreporting of suicide rates has important implications in policy development, research funding, and evaluation of prevention programs.

PREHOSPITAL ADMINISTRATION OF MORPHINE FOR ISOLATED EXTREMITY INJURIES: A CHANGE IN PROTOCOL REDUCES TIME TO MEDICATION

Objective. To evaluate the effect of a new protocol allowing paramedics to administer morphine without a physician order to patients with extremity trauma with respect to time of morphine administration, scene time, morphine amount and number of doses per patient, and proportion of patients receiving morphine. Methods. Data were abstracted from transport forms for a ten-month period prior to the implementation of the new protocol and for nine months after implementation. Data elements included patient age and sex, date, time of EMS arrival on scene, amount and number of morphine doses, and total number of patients transported. Results. Implementation of the new protocol was associated with a decrease in time between emergency medical services (EMS) arrival on scene and administration of the first dose of morphine from 18.8 to 16.7 minutes, a difference of 2.1 minutes [95% confidence interval (95%CI) 1.3, 2.9]. The proportion of patients receiving analgesia at the scene, rather than during transport, increased from 62.7% before the protocol change to 69.5% after, an increase of 6.8% (95% CI 2.7, 11.0). Transports before and after implementation of the new protocol did not differ with respect to patient sex, age, or chief complaint; number of morphine doses or total morphine administered per patient; or proportion of prehospital patients receiving morphine. Conclusions. A change in protocol that permits trained paramedics to administer morphine without physician approval reduces time to analgesia administration without influencing the amount of morphine delivered per patient or the rate of prehospital morphine use. Further study should measure the effect on base hospital physician interruptions and patient outcome.

Child Maltreatment in American Indian and Alaska Native Communities: Integrating Culture, History, and Public Health for Intervention and Prevention

This article addresses child maltreatment intervention and prevention among American Indians and Alaska Natives. The authors argue that history and culture must be included as context and variables for developing and implementing prevention programs in Indian Country. They propose that the public health violence prevention model would benefit from incorporating tenets of the history and culture(s) of diverse groups, in this instance American Indians and Alaska Natives. The authors offer an approach that focuses on population- and individual-level risk and protective factors for child maltreatment intervention and prevention in American Indian/Alaska Native communities. They include suggestions and examples for doing the work in Indian Country.

Relationship of Restraint Use, Patient Injury, andAssaults on Ems Personnel

Objective. We hypothesized that the assaults on EMS personnel by patients requiring restraints can be correlated with demographic information, patient condition, andother scene information such as presence the of law enforcement. Methods. The study was a one-year cross-sectional study of paramedic restraint use andassault on EMS personnel in an urban area. A data collection form was completed by EMS for each patient placed in restraints. Study outcome variable was “Assault on EMS personnel.” Predictor variables included demographic andEMS call information, patient condition, law-enforcement related variables, andthe paramedics perception of the need for chemical restraints. To compare predictor andoutcome variables, a multivariable model with odds ratios and95% confidence intervals was used. Results. The study included 271 restrained patients over a 12-month period from April 2002 to April 2003. Seventy-seven (28%) cases were positive for assaults on EMS personnel. Multivariable analysis including 8 variables, indicated the following 6 variables were associated with assault on EMS personnel: time of day between midnight and6 am (OR = 4.4, 95% CI = 1.6–12.7); female patient (OR for males 0.6, 95% CI = 0.3–1.0); violent patient (OR = 10.1, 95%CI = 2.3–48.2); patient injured under supervision (OR = 3.9, 95% CI = 1.1–13.8); arrested patient (OR = 4.4, 95% CI = 1.1–18.5); andperceived need for chemical restraint (OR = 2.1, 95% CI = 1.2–3.9). Conclusion. Multiple factors are correlated with assaults on EMS personnel by patients requiring restraints. By specifically targeting patients exhibiting these factors, EMS providers can help prevent injury to themselves. Patients not exhibiting these factors may be less dangerous.

The relationship between paramedics' level of education and degree of commitment ☆

INTRODUCTION Emergency medical services (EMS) personnel attrition is a serious concern. Two fundamental psychological constructs linked to attrition are organizational and occupational commitment. OBJECTIVE To determine if there is a relationship between a paramedics degree of occupational/organizational commitment and the following: (1) levels of education and (2) type of employment. METHODS This was a cross-sectional study of paramedics in 6 states that require continued paramedic national registration. The data collection instrument consisted of demographic and occupational and organizational commitment sections. For level of education, the primary independent variable, each subject was placed into 1 of 3 groups: (1) certificate, (2) associates or bachelors degree in EMS (degree), and (3) paramedic certificate or degree with a non-EMS postbaccalaureate degree. Type of employment (fire based vs non-fire based) was also used as an independent variable. Organizational and occupational commitment was measured using validated scales for each. Analysis of variance was used for the comparisons between levels of each of the independent variables. A P < .05 was considered significant. RESULTS For occupational commitment, the participants with certificate level of education had a significantly higher score (88.9) than did those with either the degree (83.6) or postbaccalaureate (80.9) level of education. There were no significant differences for total organizational commitment. There were also no overall differences in occupational and organizational commitment between fire- and non-fire-based employees. CONCLUSION Paramedic occupational commitment shows a statistically significant decrease with increased level of education. Factors associated with commitment of more highly educated paramedics need to be explored.

The new mexico school nurse and emergency medical services emergency preparedness course : Program description and evaluation

Illness and injuries are common among students and school staff. Therefore, school nurses must be prepared. In this study, a 16-hour scenario-based emergency preparedness course for school nurses was evaluated for its effectiveness. Effectiveness was measured by (a) traditional methods (written exams and confidence surveys) and (b) skills and performance evaluations in simulated emergencies called On-site Mock Emergency Scenarios. School nurses who completed the emergency preparedness course showed significant improvement in knowledge, confidence, and On-site Mock Emergency Scenarios scores that measured each nurse’s ability to apply knowledge in simulated emergencies.

A Comparison of Law Enforcement and Medical Examiner Reports in a Violent-Death Surveillance System

This study compared information gathered from medical examiner reports to information gathered from law enforcement reports in characterizing incidents of homicide and homicide followed by suicide that were abstracted for a public health violent-death surveillance system. The authors found that law enforcement reports contribute substantively to the surveillance system and often augment or provide additional information to the medical examiner reports. The utility of law enforcement data, particularly the narrative information, must be balanced with the time needed to gather the law enforcement reports and funding limitations. As violent-death surveillance needs grow, linking police and other law enforcement data with medical examiner and other public health data sources will provide a clearer picture of the circumstances relating to homicide and other violent deaths at the state and national level.