Advanced Life Support Units Research Articles

Patient Selection for Advanced Prehospital Care in a Two-Level Emergency Medical System

In Jerusalem, the Emergency Medical Service is the sole prehospital provider for a population of 450,000 residents. Ambulances are dispatched from a centrally located first-aid center. Separate basic and advanced life support (MICU) ambulances are provided. Basic life support units are staffed by Emergency Medical Technicians (EMTs) trained to provide first aid and cardiopulmonary resuscitation (CPR). These units are dispatched to service persons in whom advanced life support (ALS) services are not likely to be required. The MICU is staffed by paramedical personnel plus a qualified physician. In order to maximize the efficiency of the service an attempt was made to use the MICU only for patients who may benefit from ALS interventions.Selection of patients for whom the ALS unit may be required is accomplished by switchboard operators. These personnel routinely dispatch the MICU for definite emergencies such as unconsciousness or absence of breathing. All other cases have been reported first to an on-call physician who ultimately decides whether or not to dispatch the MICU. This method of determining priority for dispatch is called the Consultation-Dispatch System (CDS). This method of determining priority seemed inefficient, so an alternative system was implemented that did not require prior physician consultation. This brief report details the impact of this change on system operation and MICU activity.

Outcomes in unsuccessful field resuscitation attempts

To determine the outcomes of patients who did not regain vital signs after prehospital advanced cardiac life support, we studied adult patients who sustained nontraumatic out-of-hospital cardiac arrest. Our study consisted of a 20-month retrospective review of 244 charts beginning January 1986. Twelve patients were excluded for drug overdose, family request, or unavailable data. Of the remaining 232 patients, 51 had a rhythm and pulse on arrival at the emergency department. The record of each of the remaining 181 patients was analyzed for age, sex, location, witness, CPR initiator, advanced life support unit response time, initial field rhythm, and initial ECG rhythm. Outcome alternatives were dead in emergency department or hospital admission. All hospitalized patients were further evaluated for survival to discharge and neurologic status at discharge. Ten of the 181 patients (6%) who failed prehospital resuscitation survived to hospitalization, and one (0.6%) was discharged neurologically intact. Survival to hospital admission did not correlate with any of the variables studied except gender. The one patient who survived a failed prehospital resuscitation was not endotracheally intubated in the field. Our data support the practice of pronouncing adult nontraumatic cardiac arrest victims who fail to respond to advanced cardiac life support efforts in the field as dead at the scene.

A priority dispatch system for emergency medical services

A decision tree priority dispatch system for emergency medical services (EMS) was developed and implemented in Atlanta and Fulton County, Georgia. The dispatch system shortened the average response time from 14.2 minutes to 10.4 minutes for the 30% of patients deemed most urgent (P less than or equal to .05); resulted in a significant increase in the use of advanced life support units for this group (P less than or equal to .02); decreased the number of calls that required a backup ambulance service; and significantly increased conformity to national EMS response time standards for critically ill and injured patients (P less than or equal to .0009). Due to dispatch error, 0.3% of calls were dispatched as least severe but subsequently were found to be most urgent.

Reduction of mortality from prehospital myocardial infarction by prudent patient activation of mobile coronary care system

Numerous recent studies have documented the fact that lives are saved by prehospital mobile coronary care units (MCCU).lm6 As a result, such units, of various designs and types, have proliferated in the United States and in Europe.7v8 In spite of this development in emergency medical services (EMS), there is still some uncertainty regarding its impact on death from acute myocardial infarction (AMI) and sudden death in patients with coronary artery disease (CAD). Furthermore, arguments have been raised that MCCU often serve patients at low risk of death, who could well be treated by other means? This presentation is concerned with our S-year experience with a mobile coronary care system in Columbus, Ohio. A single advanced life support (ALS) vehicle manned by a physician and paramedics (Heartmobile) was added to a long-standing and well-utilized EMS system in April, 1969. Over the next 8 years the ALS system as well as the entire EMS system grew dramatically.‘O With respect to cardiac emergencies, it had been our impression that persons served by the ALS units were predominantly those with high risk of death. This was clearly true of an original cohort of 214 consecutive cases analyzed in 1970 when the Heartmobile was in use. However, we had no data concerning those patients with AM1 not seen by the EMS system. As a result, factors influencing patient decisions to use the