Stanford Lee

On-Line Medical Control Versus Protocol-Based Prehospital Care☆☆☆★

STUDY OBJECTIVE To compare on-scene time, appropriateness of therapy, and accuracy of paramedic clinical assessments when prehospital care was provided with the use of on-line medical control (OLMC) by EMS-certified nurses from a single base station or by paramedics using chief complaint-based protocols. METHODS We assembled a prospective before-and-after series to compare OLMC (phase 1) and protocol (phase 2) care rendered by all paramedics in a single urban municipality using a single base station. The subjects were consecutively enrolled patients who met protocol inclusion criteria and presented with altered level of consciousness, nontraumatic chest pain, or shortness of breath. For both phases, EMS and corresponding ED records were compiled; all references identifying phase were removed. After establishing interrater reliability, we randomly assigned charts to one of two reviewers for scoring. Complaint-specific scoring elements included on-scene time, assessments performed, presence or absence of indications for common treatments, treatments given, paramedic diagnosis, and emergency physician diagnosis. The percentages of inappropriate treatment decisions and paramedic diagnostic accuracy (versus that of the receiving emergency physician) were calculated. RESULTS Phase 1 comprised 287 patients, phase 2 294. Interrater reliability between the two scorers was high. Of 2,190 elements scored jointly, the raters agreed in 97%, with kappa-values ranging from .6 to 1.0. On-scene time was 1 minute shorter during phase 2 (95% confidence interval [CI] for difference in median time, 0 to 2 minutes; P < .03). From phase 1 to phase 2 (relative risk [RR], 1.5; 95% CI, 1.0 to 2.1), inappropriate treatment decisions decreased from 7.4% to 5.1%. The percentage of cases in which paramedics and physicians were in complete diagnostic agreement was high (77% to 78%) and did not change across phases. CONCLUSION The use of protocols resulted in small improvements in both on-scene time and the appropriateness of therapeutic decisions, without a change in agreement between paramedic and physician. Protocol care for these three chief complaints is clinically safe and, by reducing training and staffing considerations, may offer a cost-effective alternative to OLMC.

Epiglottitis presenting as acute pulmonary edema

Presented is the case of a 2 1/2-year-old with acute pulmonary edema associated with epiglottitis prior to intubation. The patient complained only of odynophagia and had one brief episode of apnea and flaccid posturing. Chest radiograph demonstrated pulmonary edema. A soft tissue radiograph of the neck confirmed the diagnosis of epiglottitis. The patient was managed successfully with prompt intubation, PEEP, and antibiotics. Pulmonary edema associated with epiglottitis may be more common than previously recognized. It may occur prior to or after intubation. When pulmonary edema is clinically evident, PEEP should be administered early.