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Volume 11 - June 1996

Contents

Page 5 of 9

Forum

  • To the Editor

  • C. Keith Stone, Stephen H. Thomas
  • Published online by Cambridge University Press:
    17 February 2017, p. 120
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Oral Presentations

  • 23. Ambulance Sphygmomanometer Accuracy: Can It Affect Triage to the Trauma Center?

  • Charles E. Cady, Ronald G. Pirrallo, Clarence E. Grim
  • Published online by Cambridge University Press:
    28 June 2012, p. S33
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  • Objectives: To determine the accuracy of sphygmomanometers (SPHYGs) from a metropolitan EMS system and quantitate the mis-triage of adult blunt trauma patients based on erroneous systolic blood pressure (SBP) readings.

    Methods-A: A cross-sectional, convenient sample of 150 SPHYGs was checked for accuracy using industry standards. Mean high and low deviations were calculated at 90 mmHg.

    Methods-B: Retrospectively, a frequency distribution of the initial SBPs of all blunt trauma patients, age ≥21, seen in 1994 was plotted to characterize our study population. The numbers of patients potentially over- or under-triaged were identified when their reported SBP was corrected for using the mean high and low deviation plus 2 SDs.

    Results-A: Overall, 25.3% of the SPHYGs were inaccurate. At 90 mmHg, 28.0% (42/150) were inaccurate with 16.7% (7/42) high by 4.6±1.5 mmHg and 81.0% (34/42) low by 6.2±4.2 mmHg; one was inoperable.

    Results-B: 1,005 adult blunt trauma patients were evaluated; 61 were eliminated: 35 had initial SBPs of 0 mmHg and 26 had no SBP recorded (n = 944). The mean initial SBP was 138 ±30mmHg, and 3.8% (36/944) of the patients had SBPs <90 mmHg. Potentially, 2.0% (19/944) of the patients were undertriaged (initial erroneously high SBP reading 90–98 mmHg) and 2.5% (24/944) over-triaged (initial erroneously low SBP reading 74–90 mmHg).

Brief Report

  • The Esophageal Detector Device: Accuracy and Reliability in Difficult Airway Settings

  • Christopher E. Kapsner, David C. Seaberg, Charles Stengel, Kaveh Ilkhanipour, James Menegazzi
  • Published online by Cambridge University Press:
    28 June 2012, pp. 60-62
  • Introduction:

    The esophageal detector device (EDD) recently has been found to assess endotracheal (ET) tube placement accurately. This study describes the reliability of the EDD in determining the position of the ET tube in clinical airway situations that are difficult.

    Methods:

    This was a prospective, randomized, single-blinded, controlled laboratory investigation. Two airway managers (an emergency-medicine attending physician and a resident) determined ET-tube placement using the EDD in five swine in respiratory arrest. The ET tube was placed in the following clinical airway situations: 1) esophagus; 2) esophagus with 1 liter of air instilled; 3) trachea; 4) trachea with 5 ml/kg water instilled; and 5) right mainstem bronchus. Anatomic location of the tube was verified by thoracotomy of the left side of the chest.

    Results:

    There was 100% correlation between the resident and attending physician's use of the EDD. The EDD was 100% accurate in determining tube placement in the esophagus, in the esophagus with 1 liter of air instilled, in the trachea, and in the right mainstem bronchus. The airway managers were only 80% accurate in detecting tracheal intubations when fluid was present.

    Conclusions:

    The EDD is an accurate and reliable device for detecting ET-tube placement in most clinical situations. Tube placement in fluid-filled trachea, lungs, or both, which occurs in pulmonary edema and drowning, may not be detected using this device.

Organizing and Training for Service Delivery-Preparedness, Prevention, and Protection

  • Introduction

  • Barbara K. Fonkert
  • Published online by Cambridge University Press:
    28 June 2012, pp. S15-S16
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Collective Review

  • Sources of Stress Among Emergency Medical Technicians (Part I): What Does the Research Say?

  • Edwin Boudreaux, Cris Mandry
  • Published online by Cambridge University Press:
    28 June 2012, pp. 296-301

  • Research repeatedly has demonstrated that organisms exhibit adaptive physiological, emotional, and behavioral responses when exposed to noxious or threatening environmental stimuli. However, when the noxious stimuli are excessive or prolonged, efforts to cope may become overwhelmed, and the adaptive responses can turn into maladaptive reactions (e.g., illness, depression, and impaired performance). According to this model of stress, people who work in occupations that continually place them in danger or repeatedly force them to encounter psychologically demanding or distressing situations would appear to be at greater risk for developing adverse stress reactions.

    Both anecdotal evidence and empirical research suggest that prehospital emergency medical services (EMS) may be a particularly high-stress field, placing emergency medical technicians (EMTs) at risk for developing such maladaptive stress reactions. This article reviews and synthesizes the empirical literature investigating the sources of stress among EMTs, and concludes with critical comments and guidelines for future research. The authors intend this review to be a resource for investigators conducting research in this area, as well as a convenient summary for anyone interested in learning more about the stressors EMTs experience, particularly mental health professionals and EMS administrators coordinating stress-management programs for EMTs.

Oral Presentations

  • 56. Managed Care Organization Enrollee Utilization of 911 Emergency Medical Services

  • Edward T. Dickinson, Vincent P. Verdile, Timothy B. Duncan, Kerry A. Bryant
  • Published online by Cambridge University Press:
    28 June 2012, p. S34
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  • Purpose: The accessibility of emergency medical services (EMS) for enrollees of managed care organizations (MCOs) is currently a topic of national debate. The mechanisms by which enrollees currently enter the EMS system have not been well described. The purpose of this study was to determine how these patients enter our EMS system.

    Methods: All enrollees who belong to the region's largest MCO and who were transported to hospital EDs by the paramedic level municipal EMS department were identified from billing records. Members of the MCO are mandated to call the MCO prior to seeking any emergency care. Dispatch logs were then examined to determine the time and origin of the call to the 911 communications center. Patient care records were used to obtain patient age, the level of care (ALS vs. BLS), and whether the ALS patient received medications (ALS Meds).

    Results: Over a six month period 195 enrollees were transported to EDs, Three modes of system entry were identified: Group I—enrollees who called 911 directly; Group II—enrollees who called the MCO triage center who then called 911 for the patient; and Group III—enrollees who were sent to the MCO center for evaluation and subsequently the MCO called 911 to transport the patient to the hospital.

Original Research

  • Does Ambulance Crew Size Affect On-Scene Time or Number of Prehospital Interventions?

  • Lawrence H. Brown, Charles F. Owens, Jr., Juan A. March, Elizabeth A. Archino
  • Published online by Cambridge University Press:
    28 June 2012, pp. 214-217
  • Introduction:

    While large cities typically staff ambulances with two emergency medical services (EMS) professionals, some EMS agencies use three people for ambulance crews. The Greenville, North Carolina, EMS agency converted from three-person to two-person EMS crews in July 1993. There are no published reports investigating the best crew size for out-of-hospital emergency care.

    Hypothesis:

    Two-person EMS crews perform the same number and types of interventions as three-person EMS crews. Two-person EMS crews do not have longer on-scene times than do three-person EMS crews.

    Methods:

    Data for the two most common advanced life support calls in this system—seizures and chest pains—were collected for the months of June and August 1993. Three-person EMS crews responded to both types of calls in June. In August, two-person EMS crews responded to seizure calls; two-person EMS crews accompanied by a fire department engine (pumper) with additional manpower responded to chest pain calk. The frequency of specific interventions, number of total interventions, and scene times for the August calls were compared to their historical control groups, the June calls.

    Results:

    One hundred twenty-six patient contacts were included in the study. There were no significant differences in total number or types of procedures performed for the two patient groups. Mean on-scene time for patients with seizures was 11.0±4.2 minutes for three-person crews and 19.4±8.3 minutes for two-person crews (p <0.001). Mean on-scene time for patients with chest pain was 13.6±4.9 minutes for three-person crews, and 15.4±3.2 minutes for two-person crews assisted by fire department personnel (p >0.05).

    Conclusion:

    Two-person EMS crews perform the same number of procedures as do three-person EMS crews. However, without the assistance of additional responders, two-person EMS crews may have statistically significantly longer onscene times than three-person EMS crews.

Medical-Psychological Management of Large-Scale Disasters

  • Mid- and Long-Term Effects of Disasters on Victims

  • Ann-Marie Rosavage
  • Published online by Cambridge University Press:
    28 June 2012, p. S16
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Forum

  • To the Editor

  • David J. Pronchik, Scott W. Melanson, Joseph Sexton
  • Published online by Cambridge University Press:
    17 February 2017, pp. 121-122
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Article Commentary

Medical-Psychological Management of Large-Scale Disasters

  • Post-Traumatic Stress Reactions in Children and Adults After the 1988 Spitak Earthquake in Armenia

  • Armen Goenjian
  • Published online by Cambridge University Press:
    28 June 2012, p. S17
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Erratum

  • Correction

  • Published online by Cambridge University Press:
    17 February 2017, p. 122
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  • A misprint occurred in “Early Predictors of Sepsis in the Motor-Vehicle Crash Trauma Victim” by Jeanette K. Previdi, RN, BSN, MPH, CEN, C. Gene Cayten, MD, MPH, Daniel W. Bryne, MS, published in Vol. 11, No. 1.

Brief Report

  • In-Field Extremity Amputation: Prevalence and Protocols in Emergency Medical Services

  • Kathryn E. Kampen, Jon R. Krohmer, Jeffrey S. Jones, J.M. Dougherty, Robert K. Bonness
  • Published online by Cambridge University Press:
    28 June 2012, pp. 63-66
  • Objective:

    To determine current experience, attitudes, and training concerning the performance of in-field extremity amputations in North America.

    Design:

    Cross-sectional, epidemiological survey.

    Participants:

    Emergency medical services (EMS) directors from the 200 largest metropolitan areas in North America and attendees at the 1992 Mid-Year National Association of EMS Physicians Meeting.

    Interventions:

    The survey consisted of five questions focusing on demographic and operational data, the frequency of occurrence of the performance of in-field amputations, personnel responsible for performing the procedure, existing written protocols for the procedure, and the scope of training provided.

    Results:

    A total of 143 surveys was completed. Eighteen respondents (13%) reported a total of 26 in-field extremity amputations in the past five years. The most common cause for the injuries requiring amputations was motor-vehicle accidents. In the majority of cases (53.2%), trauma surgeons were responsible for performing the amputation, followed by emergency physicians (36.4%). Of respondents, 96% stated that there was no training available through their EMS agencies related to the performance of in-field extremity amputations. Only two EMS systems had an existing protocol regarding in-field amputations.

    Conclusions:

    The results suggest a need for established protocols to make the procedure easily accessible when needed, especially in large metropolitan EMS systems. This information should be emphasized during EMS training and reinforced through continuing education.

Oral Presentations

  • 61. Can Melatonin Improve Adaptation To Night Shift? A Pilot Study Using an Urban EMS System

  • Michael Tremea, Mark James, Jeffrey Jones, Jon Krohmer
  • Published online by Cambridge University Press:
    28 June 2012, p. S34
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  • Purpose: To determine whether melatonin (N-acetyl-5-methoxytryptamine) is effective in helping prehospital personnel working consecutive night shifts reset their biological clock and minimize circadian rhythm disruption.

    Methods: A double-blinded, randomized, cross-over study was performed using 12 paramedic volunteers. Paramedics were working a span of consecutive night (2300-0700) shifts and received either a melatonin capsule (6 mg) or placebo to be taken prior to each of the consecutive day sleeps. Each participants completed a total of four spans of consecutive night shifts (2-melatonin, 2-placebo). Collected data included daily sleep diaries, quantification of alcohol/caffeine consumed, and possible drug side-effects. Assessment of job performance, mood and alertness were measured every day using 10-cm visual analog scales (VAS).

    Results: Analysis of sleep diaries demonstrated no significant difference (p >0.05) between the two treatments in respect to mean sleep latency (melatonin = 15.4 min. vs. placebo = 14.6 min), mean sleep duration (melatonin = 6.7 hrs. vs. placebo = 6.9 hrs), or subjectively rated sleep quality (melatonin = 5.8 VAS vs placebo = 5.6 VAS). Similarly, no significant benefits were noted between the mean VAS scores for daily job performance, mood and alertness. Adverse effects were rare, one patient taking melatonin reported a prolonged sedative effect.

    Conclusion: Despite widespread belief in the benefits of melatonin as a hypnotic agent, no clinical benefits were noted in terms of daytime sleep or job performance in paramedics working consecutive night shifts.

Original Research

  • Comparison of High-Dose Epinephrine Versus Standard-Dose Epinephrine in Adult Cardiac Arrest in the Prehospital Setting

  • Richard D. Carvolth, Ardith J. Hamilton
  • Published online by Cambridge University Press:
    28 June 2012, pp. 219-222
  • Objective:

    To compare the efficacy of high-dose epinephrine (HDE) with standard-dose epinephrine (SDE) in the management of cardiac arrest in adults in the prehospital setting.

    Hypothesis:

    The use of HDE will improve the outcome of adult patients in cardiac arrest.

    Methods:

    In a general population of 700,000 persons, in a mixed geographical area of 2,200 square miles, a 12-month retrospective study of SDE and a 12-month prospective trial of HDE were conducted involving adult patients in cardiac arrest in the prehospital setting. Treatment was provided by paramedic-level clinicians. In the control group, patients were treated according to existing American Heart Association cardiac resuscitation guidelines using SDE (defined as 1.0 mg boluses to a maximum dose of 4 mg). In the test group, the same guidelines were revised to use HDE (defined as a rapid sequence of 5, 10, and 15 mg boluses to a total dose of 30 mg).

    Results:

    The control group included 594 patients; the test group consisted of 580 patients. The overall survival rate to hospital admission in the control group was 14.5% (84 patients) and in the test group 15.3% (89 patients). The survival rate to hospital discharge in the control group was 4.9% (29 patients) versus 4.8% (28 patients) in the test group. For patients whose initial rhythms were ventricular fibrillation, survival to admission in the control group was 20.4% (39 patients) versus 24.4% (43 patients) in the test group. Survival to discharge for patients with ventricular fibrillation in the control group was 8.9% (17 patients) versus 10.8% (19 patients) in the test group.

    Conclusion:

    There was no statistically significant difference in overall rate of survival to hospital admission or discharge between patients treated with SDE and those treated with HDE, regardless of the initial rhythm.

Article Commentary

Calendar

  • Calendar

  • Published online by Cambridge University Press:
    28 June 2012, p. 123
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Original Research

  • Prehospital Use of a Prototype Esophageal Detection Device: A Word of Caution!

  • Charles D. Marley, Jr., David R. Eitel, Mark F. Koch, Dean R. Hess, Michael A. Taigman
  • Published online by Cambridge University Press:
    28 June 2012, pp. 223-227
  • Objective:

    To determine the effectiveness of a prototype esophageal detection device (EDD) during use in the prehospital setting.

    Design/Setting:

    Prospective convenience sample in a prehospital setting.

    Population:

    Intubated adult patients.

    Interventions:

    The study device was used to determine esophageal or endotracheal placement of endotracheal tubes in intubated patients. Clinical means were used to confirm tube location. A data sheet was completed for each patient.

    Results:

    Of 105 uses of the device, 17 of 17 esophageal tubes were identified correctly (100% sensitivity). Sixty-five of 88 tracheal tubes were correctly identified (78% specificity). There was intermediate reinflation of the device on 13 of the 65 tracheal tubes. Five tests were indeterminate. There were no false negatives (negative predictive value 100%), but 18 false positives (positive predictive value 48%).

    Conclusion:

    This prototype EDD adequately identifies esophageally placed endotracheal tubes. Correct identification of endotracheally placed tubes was less sensitive. Much work needs to be done regarding the use of negative aspiration devices to identify placement of endotracheal tubes.

Oral Presentations

  • 65. The Evolution of the Prehospital Care of Pediatric Asthma

  • Anthony Ciccone, Carol Irving, Robert F. Lavery, Bartholomew J. Tortella
  • Published online by Cambridge University Press:
    28 June 2012, p. S35
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  • Purpose: The prevalence of asthma in the pediatric population is approximately 9% and the incidence of acute exacerbation in this population has been increasing. The purpose of this study was to determine if there has been a change in the pre-hospital presentation and treatment of pediatric asthma.

    Methods: This observational study was a retrospective consecutive case series comparing pediatric (#18 yrs) asthmatics treated and transported by an inner city EMS system over two years. (1987, 1992). Data collected included patient demographics, prehospital treatment, and evaluated diagnostic criteria used by paramedics to initiate treatment. Students t test was performed for continuous data and contingency analysis (chisquare) for non-continuous data. A Wilks stepwise discriminant analysis was performed on 1987 and 1992 data to evaluate diagnostic factors.

    Results: There were 407 transports in 1987 and 652 in 1992, representing a 60% increase. 237(56%) of patients received advanced life support (ALS) in 1987 and 344(53%) in 1992. Mean age of ALS patients in 1987 was 10.25 (±5.3) and was 8.03 (±2.8) in 1992 (p <0.001). Albuterol inhalation supplanted epinephrine (1987-205, 1992-1) and aminophylline (1987-15, 1992-1) as the treatment for asthma in our service system. The discriminant analysis revealed that in 1987, paramedics treatment decision making was influenced by age, cough, cold, and/or fever, home medications, accessory muscles, absence of wheezing, and normal respiratory rate. This changed in 1992 where only the presence or absence of wheezing and accessory muscle-use to be highly correlated with treatment decisions.

Medical-Psychological Management of Large-Scale Disasters

  • The Crash of United Flight 232: Rescue, Recovery, and Identification of Victims

  • Robert Monserrate
  • Published online by Cambridge University Press:
    28 June 2012, pp. S17-S18
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Page 5 of 9