Michael R. Baumann

ENDOTRACHEAL INTUBATION IN A RURAL EMS STATE: PROCEDURE UTILIZATION AND IMPACT OF SKILLS MAINTENANCE GUIDELINES

Objective. Recent American Heart Association (AHA) guidelines have suggested that advanced life support (ALS) providers should have “regular field experience,” defined as six to 12 intubations/year, as a prerequisite to patient endotracheal intubation (EI). The authors sought to assess the impact of this guideline on rural emergency medical services (EMS) practice. Methods. Statewide EMS records were reviewed for the calendar years 1997-2001. Data reviewed included the number of providers eligible to perform ALS skills (including EI), number of procedures performed per year by EMS provider, patient age, gender, and prehospital diagnosis. The institutional review board approved the study. Results. During the study period, a total of 957,836 patient encounters occurred with an average of 1,352 ALS providers annually eligible to perform EI. In the five-year period, there were 5,615 total EI attempts with a range of 37%-42% of eligible providers annually performing EI. A mean of 18 providers per year with a range of 1.8%-0.8% of EI-eligible providers annually attempted EI in more than five patients. One hundred thirty-seven pediatric EI encounters occurred during the five-year period with an annual range of 1.4%–2.7% of eligible providers attempting pediatric EI. During the five-year investigation, EI success rate was reported as 84% by providers with fewer than five annual intubation encounters and 86% by providers with more than five encounters. Conclusion. Rural EMS providers rarely use EI skills, particularly in pediatric patients. If recent AHA intubation guidelines are to be followed in rural EMS settings, a small number of EMS providers will meet minimum EI utilization requirements.

A STANDING-ORDER PROTOCOL FOR CRICOTHYROTOMY IN PREHOSPITAL EMERGENCY PATIENTS

Objective. To study utilization, indications, and outcomes associated with the use of a statewide, emergency medical services (EMS) standing-order protocol for cricothyrotomy. Methods. A statewide EMS database was queried for patients who received cricothyrotomy under a standardized, standing-order protocol. Patient EMS and hospital records were reviewed in a defined sequence with information recorded on a standardized collection form. Results. EMS records included eight years of practice with 1.5 million patient encounters. For each year studied, approximately 540 emergency medical technicians (EMTs) were certified to perform cricothyrotomy. State EMS providers performed a collective mean of eight cricothyrotomy procedures per year (range, 1–17), for a total of 68 cricothyrotomies performed within the eight-year period. Hospital records were available for review in 61 patients. Fifty-six patients received cricothyrotomy by open surgical incision, six by needle with jet ventilation, and one by both methods. Categorization of cricothyrotomy patients as trauma or medical was 61% trauma and 39% medical. Thirty-six patients (59%) were in cardiac arrest on EMS arrival and 12 patients (20%) died during transport. Thirteen trauma patients (21%) were admitted with eight patients surviving to discharge (13%). The neurologic impairment at time of hospital discharge was severe in four, moderate in two, and minimal or none in two patients (3%). Conclusion. A considerable percentage of cricothyrotomy procedures were performed on patients with non-trauma-related diagnoses in this investigation describing a standing-order EMS protocol for cricothyrotomy. The majority of patients undergoing cricothyrotomy with this protocol were in cardiac arrest at the time of cricothyrotomy, with a small minority of patients surviving to hospital discharge and fewer surviving neurologically intact.

Red Blood Cell Transfusion: Experience in a Rural Aeromedical Transport Service

INTRODUCTION The administration of blood products to critically ill patients can be life-saving, but is not without risk. During helicopter transport, confined work space, communication challenges, distractions of multi-tasking, and patient clinical challenges increase the potential for error. This paper describes the in-flight red blood cell transfusion practice of a rural aeromedical transport service (AMTS) with respect to whether (1) transfusion following an established protocol can be safely and effectively performed, and (2) patients who receive transfusions demonstrate evidence of improvement in condition. METHODS A two-year retrospective review of the in-flight transfusion experience of a single-system AMTS servicing a rural state was conducted. Data elements recorded contemporaneously for each transfusion were analyzed, and included hematocrit and hemodynamic status before and after transfusion. Compliance with an established transfusion protocol was determined through structured review by a multidisciplinary quality review committee. RESULTS During the study, 2,566 missions were flown with 45 subjects (1.7%) receiving in-flight transfusion. Seventeen (38%) of these transports were scene-to-facility and 28 (62%) were inter-facility. Mean bedside and in-flight times were 22 minutes (range 3-109 minutes) and 24 minutes (range 8-76 minutes), respectively. The most common conditions requiring transfusion were trauma (71%), cardiovascular (13%) and gastrointestinal (11%). An average of 2.4 liters (L) of crystalloid was administered pre-transfusion. The mean transfusion was 1.4 units of packed red blood cells. The percentages of subjects with pre- and post-transfusion systolic blood pressures of <90 mmHg were 71% and 29%, respectively. The pre- and post-transfusion mean arterial pressures were 62 mmHg and 82 mmHg, respectively. The pre- and post- transfusion mean hematocrit levels were 17.8% and 30.4%, respectively. At the receiving institution, 9% of subjects died in the Emergency Department, 18% received additional transfusion within 30 minutes of arrival, 36% went directly to the operating room, and 36% were directly admitted to intensive care. Thirty-one percent of subjects died prior to hospital discharge. There were no protocol violations or reported high-risk provider blood exposure incidents or transfusion complications. All transfusions were categorized as appropriate. CONCLUSIONS In this rural AMTS, transfusion was an infrequent, likely life-saving, and potentially high-risk emergent therapy. Strict compliance with an established transfusion protocol resulted in appropriate and effective decisions, and transfusion proved to be a safe in-flight procedure for both patients and providers.

Performance of Endotracheal Intubation and Rescue Techniques by Emergency Services Personnel in an Air Medical Service

Background. Literature spanning the last two decades has identified potential harm associated with out-of-hospital endotracheal intubation performed by ground paramedics. Previous researchers have reported intubation success rates of 66% to 97% in the air medical setting. Objective. To examine the success of endotracheal intubation and rescue techniques performed by air medical personnel during the first eight years of operation of the air ambulance service. Methods. This study was a retrospective survey of health records utilizing data from LifeFlight of Maines airway procedure quality review database, covering the first eight years of system encounters. Results. During the study period, 369 intubation encounters occurred. Rapid-sequence intubation medications were administered in 345 (93.5%) cases. Flight personnel successfully performed endotracheal intubation in 340 (92.1%) encounters. Unsuccessful intubations were managed with an alternative definitive airway, rescue airway, or bag–valve–mask. Laryngeal mask airway (n = 11) was the most commonly used rescue airway device. Conclusions. During the first eight years of operation of this air medical transport system, flight personnel were able to successfully perform endotracheal intubation in 92.1% of cases.

Emergency Medical Services Triage Using the Emergency Severity Index: Is it Reliable and Valid?

INTRODUCTION Efficient communication between emergency medical services (EMS) and ED providers using a common triage system may enable more effective transfers when EMS arrives in the emergency department. We sought (1) to evaluate inter-rater reliability between Emergency Severity Index (ESI) assignments designated by EMS personnel and emergency triage nurses (registered nurses [RNs]) and (2) to evaluate the validity of EMS triage assignments using the ESI instrument. METHODS This prospective, observational study evaluated inter-rater reliability in ESI scores assigned by prehospital personnel and RNs. EMS providers were trained to use the ESI by the same methods used for nurse training. EMS personnel assigned triage scores to patients independent of assignments by the RN. Inter-rater reliability, differences based on provider experience, and validity of EMS triage assignments (sensitivity and specificity) were evaluated. RESULTS Seventy-five paired, blinded triages were completed. Overall concordance between EMS providers and RNs was 0.409 (95% confidence interval [CI], 0.256-0.562). Agreement for EMS providers with less experience was 0.519 (95% CI, 0.258-0.780), whereas concordance for those with more experience was 0.348 (95% CI, 0.160-0.536; χ(2) = 1.413, df = 1, P = .235). Sensitivity ranged from 0% to 67.86%. Specificity ranged from 68.09% to 97.26%. CONCLUSIONS We observed moderate concordance between EMS and RN ESI triage assignments. EMS sensitivity for correct acuity assignment was generally poor, whereas specificity for correctly not assigning a particular level was better. Additional research investigating the potential causes of the poor agreement that we observed is warranted.

A systematic review of smoking cessation interventions in the emergency setting.

STUDY OBJECTIVE Cigarette smoking remains the leading cause of preventable death in the United States, and tobacco use rates are known to be higher among emergency department (ED) patients than in the general population. Despite recommendations from the Society for Academic Emergency Medicine and the American College of Emergency Physicians, many emergency clinicians remain uncertain about the benefits of providing ED-based smoking cessation interventions. To address this gap in knowledge, we performed a systematic review of cessation interventions initiated in the adult or pediatric ED setting. METHODS We conducted an electronic search of the MEDLINE and CINAHL databases through February 2014 and hand searched references from potentially relevant articles. We identified eligible studies, evaluated bias and validity, and extracted data and synthesized findings. RESULTS Seventeen studies underwent critical appraisal, with 13 included in qualitative synthesis. The majority (11/13, 85%) of investigations did not report significant differences in tobacco abstinence between cessation intervention groups. The 2 studies reporting significant differences in cessation both used motivational interviewing-based interventions. Two studies evaluated patient satisfaction with ED-based tobacco cessation interventions, and both reported greater than 90% satisfaction. CONCLUSIONS Findings indicate that ED visits in combination with ED-initiated tobacco cessation interventions are correlated with higher cessation rates than those reported in the National Health Interview Survey. Clear data supporting the superiority of one intervention type were not identified. Lack of a standardized control group prevented quantitative evaluation of pooled data, and future research is indicated to definitively evaluate intervention efficacy.

Implementing an electronic point-of-care medical record at an organized athletic event: challenges, pitfalls, and lessons learned.

Objective: We examined the feasibility of implementing an electronic health record (EHR) at an international running event. Design: Institutional review board-approved observational study. Setting: An annual international running event supported by an on-site medical facility. Participants: All registered athletes. Intervention: Web-based EHR provided at no cost. Participants were asked to populate it with essential health data. The EHR was accessed for runners requiring medical services. Main Outcome Measures: Obstacles to EHR utilization, reliability of EHR functionality in the field, and ability to correctly match runners to their EHR. Results: Only 320 (5%) of the participants utilized the EHR. Repeated notification, no cost, and ready access proved to be insufficient drivers for use. Lack of reliable Internet connectivity hampered full functionality. “Bib swapping” may pose a risk for participant misidentification with resultant electronic medical error. Conclusions: Barriers to the successful utilization of an EHR were identified. Despite education and promotion, voluntary participant enrollment was a challenge. Mandatory enrollment will be required if universal EHR adoption is the goal. Internet connectivity needs to be logistically planned. Future efforts should focus on measures to ensure that EHRs are correctly matched to participants. Bib swapping must be eliminated if athletes are to be identified by their assigned numbers.

Ophthalmic diagnoses in the ED: herpes zoster ophthalmicus

The epidemiology, pathophysiology, and clinical presentation of herpes zoster ophthalmicus in the emergency department is discussed with an emphasis on the identification of the numerous potential ocular complications. Emergency physicians need to be able to recognize the clinical features of herpes zoster ophthalmicus and initiate appropriate therapy and referral.

Unintentional ingestion of ziprasidone in a 22-month-old.

Unintentional ingestions are a common presentation to the emergency department in the pediatric population. However, very few ingestions of an atypical antipsychotic, such as ziprasidone, have been described in the emergency medicine literature. While the prevalence of these newer antipsychotics increases in the general population, emergency physicians can expect to see more patients with accidental or intentional overdoses. Many emergency physicians may be unfamiliar with the presentation, initial workup, and expected clinical course of such an overdose. We describe a case of an unintentional ingestion of ziprasidone tablets in a 22-month-old girl who presented to the emergency department with somnolence, drooling, and poor tone.

Reliability and validity of the Modified Preverbal, Early Verbal Pediatric Pain Scale in emergency department pediatric patients

INTRODUCTION Research has demonstrated that children are at particular risk for oligoanalgesia due to assessment difficulties when they are unable to self-report. We sought to evaluate the psychometric properties of the Modified Preverbal, Early Verbal Pediatric Pain Scale (M-PEPPS) when used in an emergency department pediatric population. METHODS We conducted a secondary analysis of data from a prospective, observational study of pain in emergency patients to evaluate the M-PEPPS tool. Data from 118 pediatric patients was subjected to item analysis, reliability analysis, and common factor analysis. RESULTS Item difficulties suggest that the items capture the range of pain states from mild to severe. Corrected item-total correlations indicate that the instrument discriminates between various levels of pain. Common factor analysis yielded a single, unrotated common factor solution providing evidence that the M-PEPPS measures the single construct of pain. Cronbachs alpha for the scale (0.954) suggests excellent reliability. CONCLUSIONS Findings indicate that the M-PEPPS instrument is reliable when used by emergency nurses to measure pediatric pain. The single-factor common factor solution provides support for the scale as measuring the single construct of pain. Additional research is necessary to establish the degree of change in score required for a clinically meaningful reduction in pain to be present.