Mark J. Greenwood

An Algorithmic Approach to Prehospital Airway Management

Airway management, including endotracheal intubation, is considered one of the most important aspects of prehospital medical care. This concept paper proposes a systematic algorithm for performing prehospital airway management. The algorithm may be valuable as a tool for ensuring patient safety andreducing errors as well as for training rescuers in airway management.

Alternate Airways in the Prehospital Setting (Resource Document to NAEMSP Position Statement)

In the United States, advanced level rescuers often use endotracheal intubation (ETI) to provide oxygenation and ventilation to apneic or hypoventilating patients. Alternate airways are devices that facilitate oxygenation and ventilation without the use of an endotracheal tube (Table 1). Other terms used to describe an alternate airway include rescue airway device, alternative airway, secondary airway, failed airway device, difficult airway device, salvage airway and backup airway, among others. Although rescuers typically use alternate airways when ETI is not feasible, these devices are occasionally used as the primary airway device. This resource document reviews the rationale and data supporting the availability and use of alternate airways in prehospital airway care.

RECOMMENDEDGUIDELINES FORUNIFORMREPORTING OFDATA FROMOUT-OF-HOSPITALAIRWAYMANAGEMENT: POSITIONSTATEMENT OF THENATIONALASSOCIATION OFEMS PHYSICIANS

Henry E. Wang, M.D.(1) Robert M. Domeier, M.D. (2) Douglas F. Kupas, M.D. (3) Mark J. Greenwood, D.O., J.D. (4, 5) Robert E. O’Connor, M.D. (6) Presented at: National Association of EMS Physicians Annual Meeting, January 18, 2003, Panama City, Florida. Author Affiliations: (1) Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. (2) Department of Emergency Medicine, St. Joseph Mercy Hospital, Ann Arbor, Michigan. (3) Department of Emergency Medicine, Geisinger Health System, Danville, Pennsylvania. (4) Department of Emergency Medicine, University of Chicago, Chicago, Illinois. (5) AeroMed at Spectrum Health, Grand Rapids, Michigan. (6) Department of Emergency Medicine, Christiana Care Health System, Newark, Delaware. Contact: Henry E. Wang, M.D. Assistant Professor Department of Emergency Medicine University of Pittsburgh School of Medicine 230 McKee Place, Suite 400 Pittsburgh, PA 15213 (412)-303-7793 wanghe@msx.upmc.edu

Structured Communication for Patient Safety in Emergency Medical Services: A Legal Case Report

Abstract Providers of emergency medical services (EMS) must communicate vital information during critical phases of operations. Errors in communications, for example, the failure to hear a directive, will compromise safe and effective patient care. This article presents a case that resulted in litigation because of communication failures during the interfacility transfer of a trauma patient who subsequently died in the ambulance. The communication failure involved members of a ground ambulance crew, their dispatcher, and a supervisor. The failure of the emergency medical technician (EMT) who was driving to hear from the treating EMT and her dispatcher vital information pertaining to changes in their destination and of plans to intercept another ambulance, or alternatively, the drivers ignoring this information, led to a delay in care and may have contributed to the patients death. Factors contributing to the cause of this communication failure may have been related to the nature of the EMS setting: the physical separation between crew members (the driver, and the care provider in the back of the ambulance); the noise of the ground ambulance transport environment, most notably, the siren; and the stress of treating a patient in critical condition. The case highlights the importance of using structured forms of communication, specifically the read-back tool and the critical assertion strategy, to limit failures in communication during EMS operations and in operations in other high-risk medical settings.

Exposure to HIV: medical management and legal implications.

The management of exposures to HIV, whether occurring in the occupational or non-occupational setting, involves balancing the risk and inconvenience of antiviral therapy that lacks strong evidence of efficacy against the benefit of it possibly preventing a potentially fatal disease. Clinicians increasingly will be responsible for managing Health Care Workers (HCWs) and other persons exposed to HIV. This will require making a clinical assessment of the risk of HIV transmission and making recommendations for postexposure prophylaxis (PEP) according to the CDC, and other guidelines. Management also requires applying the elements of the doctrine of informed consent, considering involuntary testing of source patients, and reporting of exposure incidents. Proper management will protect all those involved: the exposed person will be protected from unacceptable risks either of contracting HIV, should PEP be indicated, or harm caused by PEP when it is not; the source patient will be protected from unconstitutional invasions of privacy. Finally, the clinician will be protected from claims of malpractice as a result of management of an HIV exposure.

Immunity Protection and Delayed Transfer of Patient Care by EMS Providers: A Medical-Legal Analysis

In emergency medical service (EMS) systems, the transfer of patient care to persons at the receiving facility is delayed when EMS providers stop en route to the facility, or postpone entering after arrival, to perform tasks. When these tasks are prolonged and inessential, the delay in transferring care is judged to be inappropriate. When transfer of care is inappropriately delayed, EMS providers, supervisors, and medical directors may lose the immunity provided by their states EMS Act. This article analyzes the legal issues surrounding inappropriate delays in transfer of care by EMS providers. Loss of statutory immunity may occur for reasons of public policy, as reflected in case law and under the reasonableness standard. Without immunity, persons involved in the transfer of patients to receiving facilities may be subject to liability under ordinary rather than gross negligence standards.