Mark Hauswald

Can paramedics safely decide which patients do not need ambulance transport or emergency department care

Objectives. To determine whether paramedics can safely decide which patients do not require ambulance transport or emergency department (ED) care. Methods. This was a prospective survey and linked medical record review. Paramedics completed a brief questionnaire for each patient they transported to a university hospital ED during a one-month period. A faculty emergency physician masked to the survey results reviewed hospital records. Ambulance transport was defined as “needed” if the charted differential diagnosis included diagnoses that could necessitate treatment in an ambulance. ED care was defined as “needed” if treatment of these diagnoses would necessitate resources not available in local urgent care centers (UCCs). Results. Two hundred thirty-six patients were transported; 183 corresponding ED charts were found. Agreement between paramedics and need determined by ED chart review was low for both transport method [kappa (κ) = 0.47, 95% confidence interval (95% CI) = 0.34-0.60] and ED care (κ = 0.32, 95% CI = 0.17-0.46). Paramedics recommended alternative transport for 97 patients, 23 of whom needed ambulance transport. Paramedics recommended non-ED care for 71 patients, 32 of whom needed ED care. Conclusion. Paramedics cannot safely determine which patients do not need ambulance transport or ED care.

Cervical spine movement during airway management: Cinefluoroscopic appraisal in human cadavers

The objective of this study was to determine which airway maneuvers cause the least cervical spine movement. A controlled laboratory investigation was performed in a radiologic suite, using eight human traumatic arrest victims who were studied within 40 minutes of death. All subjects were ventilated by mask and intubated orally, over a lighted oral stylet and flexible laryngoscope, and nasally. Cinefluoroscopic measurement of maximum cervical displacement during each procedure was made with the subjects supine and secured by hard collar, backboard, and tape. The mean maximum cervical spine displacement was found to be 2.93 mm for mask ventilation, 1.51 mm for oral intubation, 1.65 mm for guided oral intubation, and 1.20 mm for nasal intubation. Ventilation by mask caused more cervical spine displacement than the other procedures studied (ANOVA: F = 9.298; P = .00004). It was concluded that mask ventilation moves the cervical spine more than any commonly used method of endotracheal intubation. Physicians should choose the intubation technique with which they have the greatest experience and skill.

Designing a prehospital system for a developing country: Estimated cost and benefits

Many of the costs associated with prehospital care in developed countries are covered in budgets for fire suppression, police services, and the like. Determining these costs is therefore difficult. The costs and benefits of developing a prehospital care system for Kuala Lumpur, Malaysia, which now has essentially no emergency medical services (EMS) system, were estimated. Prehospital therapies that have been suggested to decrease mortality were identified. A minimal prehospital system was designed to deliver these treatments in Kuala Lumpur. The potential benefit of these therapies was calculated by using statistics from the United States corrected for demographic differences between the United States and Malaysia. Costs were extrapolated from the current operating budget of the Malaysian Red Crescent Society. Primary dysrhythmias are responsible for almost all potentially survivable cardiac arrests. A system designed to deliver a defibrillator to 85% of arrests within 6 minutes would require an estimated 48 ambulances. Kuala Lumpur has approximately 120 prehospital arrhythmic deaths per year. A 6% resuscitation rate was chosen for the denominator, resulting in seven survivors. Half of these would be expected to have significant neurological damage. Ambulances cost

Comparison of a vacuum splint device to a rigid backboard for spinal immobilization.

53,000 (US dollars) to operate per year in Kuala Lumpur; 48 ambulances would cost a total of

Spinal immobilization in trauma patients: is it really necessary?

2.5 million. Demographic factors and traffic problems would significantly increase the cost per patient. Other therapies, including medications, airway management, and trauma care, were discounted because both their additional cost and their benefit are small. Transport of patients (including trauma) is now performed by police or private vehicle and would probably take longer by ambulance. A prehospital system for Kuala Lumpur would cost approximately

Prescribing analgesics : The effect of patient age and physician specialty

2.5 million per year. It might save seven lives, three of which would be marred by significant neurological injury. Developing countries would do well to consider alternatives to a North American EMS model.

Maximizing comfort and minimizing ischemia: A comparison of four methods of spinal immobilization ☆

In this study, comparison of a vacuum splint device to a rigid backboard was made with respect to comfort, speed of application, and degree of immobilization. The study was a prospective, nonblinded comparative study conducted at a statewide emergency medical services (EMS) training facility and included a convenience sample of emergency medical technician (EMT) and paramedic students. The vacuum splint was judged to be significantly more comfortable on a 10-point scale than the rigid backboard after subjects had been lying on each device for 30 minutes (P < .001). It was also faster to apply: 131.6 +/- 24.3 seconds versus 154.6 +/- 22.2 seconds (P < .001). Various measures of immobilization were similar for the two devices. The vacuum splint provided better Immobilization of the torso and less slippage on a gradual lateral tilt. The rigid backboard with head blocks was slightly better at immobilizing the head. Vacuum splints offer a significant improvement in comfort over a traditional backboard for the patient with possible spinal injury. They can be applied in reasonable time frames and provide a similar degree of immobilization when compared to a standard rigid backboard.

Fire fatalities among New Mexico children

The acute management of potential spinal injuries in trauma patients is undergoing radical reassessment. Until recently, it was mandatory that nearly all trauma patients be immobilized with a back board, hard cervical collar, head restraints, and body strapping until the spine could be cleared radiologically. This practice is still recommended by many references. It is now clear that this policy subjects most patients to expensive, painful, and potentially harmful treatment for little, if any, benefit. Low-risk patients can be safely cleared clinically, even by individuals who are not physicians. Patients at high risk for spinal instability should be removed from the hard surface to avoid tissue ischemia. Understanding the rationale for these changes requires knowledge of mechanisms of injury, physiology, and biomechanics as they apply to spinal injuries.

A re-conceptualisation of acute spinal care

To determine if patient age or physician specialty influences the willingness to prescribe pain medication, a mail survey was made of all emergency physicians, family practice physicians, and pediatricians listed as practicing in a single, middle sized, urban county in the southwest. The survey instrument presented a typical case of otitis media complicated only by pain so severe that the patient had been unable to sleep. Physicians were asked specifically if they would prescribe an analgesic and if so what kind. Emergency and family practice physicians were presented on a random basis with cases that were identical except the age was given as two or 22 years old. Pediatricians were given only the two year old. Eighty percent (137/165) of the surveys were completed and returned. Only 28% of the physicians would prescribe medications stronger than acetaminophen or nonsteroidal antiinflammatory drugs. There was a trend toward more narcotic analgesics for the 22 year old (41 vs 22% Fishers exact test P = 0.03). Emergency physicians were the most generous, prescribing narcotics (codeine or oxycodone compounds) half the time (50%) versus one quarter of the time (22%) for family practice physicians and pediatricians (Fishers exact test, P<0.01). Pediatricians and family practice physicians did not differ (20 vs. 25%, P = 0.8). Potent analgesics are rarely prescribed by our sample physicians. Children are somewhat less likely to receive narcotics than adults with the same complaint. Emergency physicians are more likely to prescribe potent analgesics than are family practice physicians or pediatricians.

SEAT BELT USE IN A DEVELOPING COUNTRY: COVERT NONCOMPLIANCE WITH A PRIMARY ENFORCEMENT LAW IN MALAYSIA

Objective. To determine which of four methods of spinal immobilization causes the least ischemic pain. Methods. A prospective, nonblinded comparative trial was conducted at a statewide emergency medical services training facility using a convenience sample of emergency medical technician students. After lying motionless for 10 minutes, students evaluated each device using a 10-centimeter visual analog scale. Subjective comfort was used as a measure of ischemia. Results. Comfort scores were significantly different for all methods (F = 101, p 1 < 0.001). A backboard padded with a gurney mattress and eggcrate foam (the equivalent of a spinal rehabilitation bed) caused the least ischemic pain (9.6 cm, 95% CI, 8.9 to 9.8 cm). A backboard padded with a gurney mattress was the second most comfortable device (7.0 cm, 95% CI, 6.4 to 7.4 cm). A backboard padded with a folded blanket was the third most comfortable (3.3 cm, 95% CI, 2.6 to 4.9 cm). The backboard alone caused the most pain (0.8 cm, 95% CI, 0.7 to 2.1 cm). Conclusion. Increasing the amount of padding on a backboard decreased the amount of ischemic pain caused by immobilization.