Torben K. Becker

Ethical Challenges in Emergency Medical Services: Controversies and Recommendations

Emergency Medical Services (EMS) providers face many ethical issues while providing prehospital care to children and adults. Although provider judgment plays a large role in the resolution of conflicts at the scene, it is important to establish protocols and policies, when possible, to address these high-risk and complex situations. This article describes some of the common situations with ethical underpinnings encountered by EMS personnel and managers including denying or delaying transport of patients with non-emergency conditions, use of lights and sirens for patient transport, determination of medical futility in the field, termination of resuscitation, restriction of EMS provider duty hours to prevent fatigue, substance abuse by EMS providers, disaster triage and difficulty in switching from individual care to mass-casualty care, and the challenges of child maltreatment recognition and reporting. A series of ethical questions are proposed, followed by a review of the literature and, when possible, recommendations for management.

The use of portable ultrasound devices in low- and middle-income countries: a systematic review of the literature.

To review the scientific literature pertaining to the use of hand‐carried and hand‐held ultrasound devices in low‐ and middle‐income countries (LMIC), with a focus on clinical applications, geographical areas of use, the impact on patient management and technical features of the devices used.

Society for Academic Emergency Medicine's Global Emergency Medicine Academy: Global Health Elective Code of Conduct

Resumen El numero de residentes y estudiantes de medicina que participan en asignaturas optativas de salud global en medicina de urgencias y emergencias (MUE) se ha incrementado exponencialmente en los ultimos anos. Las asignaturas optativas de salud global siguen siendo un instrumento fuerte de reclutamiento y pueden contribuir a la formacion de los alumnos. Sin embargo, segun crece el numero de estudiantes que llevan a cabo experiencias internacionales en el campo de la MUE global, se tiene la necesidad de desarrollar estandares aceptables de comportamiento en el escenario internacional. Los miembros de la Global Emergency Medicine Academy (GEMA) se dieron cuenta de la ausencia de recomendaciones internacionales o guias para estas experiencias.[1-3] Un grupo de miembros voluntarios de la GEMA se comprometieron con la tarea de crear un documento que pudiese usarse por los estudiantes cuando llevaran a cabo asignaturas optativas de salud global. Los autores procedian de diversas instituciones y tenian distintos niveles de formacion y experiencia internacional. En el desarrollo de este documento, se llevo a cabo una revision sistematica en la literatura de cualquier informacion en codigos de conducta/profesionalidad[4, 5] cuando se trabaja en el escenario internacional; tambien se revisaron documentos similares de numerosas instituciones[6, 7] de diferentes especialidades[8] y se busco ent la literatura gris.[9] Las referencias clave seleccionadas se muestran mas abajo. Esta informacion se combino para producir un unico documento, que se reviso usando una metodologia de consenso hasta que alcanzo un acuerdo por parte de todos los miembros del grupo. El documento resultante se muestra en la figura de mas abajo. Se anima a las instituciones comprometidas con la formacion de estudiantes a adoptar este como estandar de su formacion en salud global.

Global emergency medicine

OBJECTIVES The Global Emergency Medicine Literature Review (GEMLR) conducts an annual search of peer-reviewed and grey literature relevant to global emergency medicine (EM) to identify, review, and disseminate the most important new research in this field to a worldwide audience of academics and clinical practitioners. METHODS This year, our search identified 4,818 articles written in six languages. These articles were distributed among 20 reviewers for initial screening based on their relevance to the field of global EM. Two additional reviewers searched and screened the grey literature. A total of 224 articles were deemed appropriate by at least one reviewer and were approved by their editor for formal scoring of overall quality and importance. RESULTS Of the 224 articles that met our predetermined inclusion criteria, 56% were categorized as Emergency Care in Resource-limited Settings, 18% as EM development, and 26% as Disaster and Humanitarian Response. A total of 28 articles received scores of 16 or higher and were selected for formal summary and critique. Inter-rater reliability for two reviewers using our scoring system was good, with an intraclass correlation coefficient of 0.625 (95% confidence interval = 0.512 to 0.711). CONCLUSIONS In 2012 there were more disaster and humanitarian response articles than in previous years. As in prior years, the majority of articles addressed the acute management of infectious diseases or the care of vulnerable populations such as children and pregnant women.

Global Emergency Medicine: A Review of the Literature From 2011: GLOBAL EM LITERATURE REVIEW FROM 2011

OBJECTIVES The Global Emergency Medicine Literature Review (GEMLR) conducts an annual search of published and unpublished articles relevant to global emergency medicine (EM) to identify, review, and disseminate the most important research in this field to a wide audience of academics and practitioners. METHODS This year, 7,924 articles written in seven languages were identified by our search. These articles were divided up among 20 reviewers for initial screening based on their relevance to the field of global EM. An additional two reviewers searched the grey literature. A total of 206 articles were deemed appropriate by at least one reviewer and approved by their editor for formal scoring of their overall quality and importance. RESULTS Of the 206 articles that met our predetermined inclusion criteria, 24 articles received scores of 17 or higher and were selected for formal summary and critique. Interrater reliability for our scoring system was good with an interclass correlation coefficient of 0.628 (95% confidence interval = 0.51 to 0.72). CONCLUSIONS Compared to previous reviews, there was a significant increase in the number of articles that were devoted to emergency care in resource-limited settings, with fewer articles related to disaster and humanitarian response. The majority of articles that met our selection criteria were reviews that examined the efficacy of particular treatment regimens for diseases that are primarily seen in low- and middle-income countries.

An assessment of ventilation and perfusion markers in out-of-hospital cardiac arrest patients receiving mechanical CPR with endotracheal or supraglottic airways

AIM OF THE STUDY Mechanical chest compression (MCPR) devices are considered equivalent to manual compressions in patient outcomes in out-of-hospital cardiac arrest (OHCA). However, recent data suggest possible harm in patients with a supraglottic airway device (SGA) during MCPR. The aim of this study was to evaluate differences in direct and indirect markers of ventilation and perfusion in patients with cardiac arrest receiving MCPR and who had their airway managed with an endotracheal tube (ETT) or SGA. METHODS We retrospectively reviewed Emergency Medical Services (EMS) agencies and emergency department (ED) records over a two-year period. We included patients with OHCA who underwent MCPR and who had an advanced airway placed. The primary outcome was differences in intra-arrest end-tidal carbon dioxide (etCO2) measurements. Secondary outcomes included intra-arrest ventilation rates, rates of prehospital return of spontaneous circulation (ROSC), blood pressure upon prehospital ROSC, and 24-h survival. RESULTS Valid data sets were available for 126 patients. Eighty-four (66.7%) had an ETT placed, and 42 (33.3%) had a SGA placed. Twenty-eight (22.6%) achieved prehospital ROSC. Twenty-four-hour survival data were available for 13 (10.3%) of these patients. There were no significant differences in primary or secondary outcomes. CONCLUSION In this retrospective study, we found no evidence of differences in markers of ventilation, perfusion or prehospital ROSC and survival in patients with OHCA who had their airway managed with either an ETT or SGA while receiving MCPR.

Feasibility of Paramedic Performed Prehospital Lung Ultrasound in Medical Patients with Respiratory Distress

Abstract Objective: Prehospital ultrasound is not yet widely implemented. Most studies report on convenience samples and trauma patients, often by prehospital physicians or critical care clinicians. We assessed the feasibility of paramedic performed prehospital lung ultrasound in medical patients with respiratory distress. Methods: Paramedics at 2 ambulance stations in the city of Pittsburgh, Pennsylvania, USA underwent a 2-hour training session in prehospital lung ultrasound using the SonoSite iViz, a handheld ultrasound device. Emergency medical services (EMS) command center (EMS-CC) physicians were instructed in the interpretation of lung ultrasound images. Paramedics enrolled patients presenting with signs and symptoms of respiratory distress over a 3-month period. The ultrasound exam included anterior and lateral views from both sides of the chest. Images were transmitted wirelessly using a mobile hotspot device and uploaded into an online image archiving system. Images were interpreted remotely by the EMS-CC physicians, and 2 expert sonographers provided an overread. We assessed agreement between EMS-CC physicians and experts, as well as between chart-review derived ED diagnosis and both EMS-CC physician and expert interpretation. We defined four a priori hypotheses that would need to be met for the intervention to be considered “feasible.” Results: A total of 34 of 78 (43.6%) eligible patients had an ultrasound exam completed. Image transmission was successful in 25 (73.5%) of cases where ultrasound was performed. The primary reason for not enrolling an otherwise eligible patient was equipment failure (25.0%), followed by patient acuity and patient refusal (18.2% each). A total of 20 (58.8%) completed scans were deemed uninterpretable upon expert review. Agreement between EMS physicians and experts was poor. Agreement between EMS-CC physicians and ED diagnosis, as well as between experts and ED diagnosis, was fair. The predetermined thresholds for feasibility were not met. Conclusions: Paramedic performed prehospital lung ultrasound for patients with respiratory distress and remote interpretation by EMS physicians did not meet the predetermined thresholds to be considered “feasible” in a real-world environment with currently available technologies. This study identified important barriers to the implementation of prehospital lung ultrasound, which should be addressed in future studies.

Sustainable Resuscitation Ultrasound Education in a Low-Resource Environment: The Kumasi Experience

BACKGROUND Point-of-care-ultrasound (POCUS) is an increasingly important tool for emergency physicians and has become a standard component of emergency medicine residency training in high-income countries. Cardiopulmonary ultrasound (CPUS) is emerging as an effective way to quickly and accurately assess patients who present to the emergency department with shock and dyspnea. Use of POCUS, including CPUS, is also becoming more prevalent in low- and middle-income countries (LMICs); however, formal ultrasound training for emergency medicine resident physicians in these settings is not widely available. OBJECTIVES To evaluate the feasibility of integrating a high-intensity ultrasound training program into the formal curriculum for emergency medicine resident physicians in an LMIC. METHODS We conducted a pilot ultrasound training program focusing on CPUS for 20 emergency medicine resident physicians in Kumasi, Ghana, which consisted of didactic sessions and hands-on practice. Competency was assessed by comparing pretest and posttest scores and with an Objective Structured Clinical Examination (OSCE) performed after the final training session. RESULTS The mean score on the pretest was 61%, and after training, the posttest score was 96%. All residents obtained passing scores above 70% on the OSCE. CONCLUSION A high-intensity ultrasound training program can be successfully integrated into an emergency medicine training curriculum in an LMIC.

Bystander Cardiopulmonary Resuscitation: A Civic Duty

Improving the outcomes of patients suffering from cardiac arrest has been a seemingly ever-elusive goal of researchers around the world for decades. Even as survival rates have improved, high rates of out-of-hospital and in-hospital death, as well as anoxic brain injury, continue to be of concern to clinicians, patients, and society alike. In this issue of the American Journal of Bioethics, Rosoff and Schneiderman (2017) present their ethical assessment of the benefits and harms of cardiopulmonary resuscitation (CPR). In light of the potential for survival with poor neurological recovery, they question the value of current efforts aiming at improving bystander CPR. As doctors who care for the victims of cardiac arrest in all settings, from the ambulance to the emergency department, the intensive care unit, and the wards, their description of CPR as “fetish” is very alarming to us. Early chest compressions and, in patients with a shockable rhythm, early defibrillation are the two most important interventions for patients to improve survival and recovery from cardiac arrest (Kleinman et al. 2015; Perkins et al. 2015), a condition that affects more than 350,000 Americans alone every year (Mozaffarian et al. 2016). Decades of cardiac arrest research have failed to identify any other intervention, device, or medication as being similarly effective. Bystander CPR doubles to quadruples the likelihood of survival from cardiac arrest (Holmberg, Holmberg and Herlitz 2001; Wissenberg et al. 2013; Hasselqvist-Ax et al. 2015). Understanding the benefits of bystander CPR is easy: It is the shortened time interval between the cessation of circulation and subsequent restoration of a minimally effective blood flow that increases the odds of successful resuscitation with normal neurological function (Ono et al. 2016). We agree with Rosoff and Schneiderman that the treatment of any patient with cardiac arrest should always focus on achieving good neurological recovery, and not simply on crude survival rates, as brain injuries can be devastating to patients, families, and society alike. However, bystander CPR is our most effective tool to limit brain anoxia time. In fact, one could argue that “delayed” cardiopulmonary resuscitation by emergency medical services professionals without bystander involvement may only achieve cardiac resuscitation, as significant brain damage will often have occurred before their arrival. Bystander CPR, in contrast, optimizes the likelihood of both cardiac and neurological resuscitation. The bystander’s critical role in improving cardiac arrest outcomes, however, does not make him or her an expert in comprehensive cardiac arrest care or prognostication. More importantly, the odds of an individual person ever having to perform bystander CPR are low, making this a high-stress, once-in-a-lifetime situation that impairs rationale decision making, especially when faced with a family member. In fact, this scenario is the norm, as more than 60% of cardiac arrests occur at home. In this situation, the bystander needs to act immediately. It is thus unethical, unreasonable, and impossible to expect a layperson bystander to decide who will benefit from CPR and who will not. More importantly, it is also not necessary, as illustrated by the personal tale of a cardiac arrest survivor (Box 1): In Dr. Epitropoulos’ words, “Patients suffering life-threatening incidents seek to cede decision-making to . . . ‘someone who knows.’ . . . Just ‘save my life, please!” This concept of “ceding decision-making” (McQueen 2002) translates into a duty to resuscitate for the noninstitutionalized out-of-hospital cardiac arrest patient, whose medical history, life circumstances, and events leading up to the cardiac arrest are typically unknown. Given the timecritical nature of bystander CPR, any hesitation in initiating bystander CPR will simply decrease the odds of survival and good neurological outcome. This could paradoxically lead to a situation where this lifesaving intervention’s efficacy is dramatically reduced, returning us to the very situation that we need to move away

Cardiopulmonary ultrasound for critically ill adults improves diagnostic accuracy in a resource-limited setting: the AFRICA trial

To assess the effects of a cardiopulmonary ultrasound (CPUS) examination on diagnostic accuracy for critically ill patients in a resource‐limited setting.