Advanced Prehospital Care Research Articles

The Need for a UK Helicopter Emergency Medical Service by Night: A Prospective, Simulation Study

BackgroundMajor trauma commonly occurs at night. Helicopter emergency medical services (HEMS) can provide advanced prehospital care to victims of major trauma but do not routinely operate at night in the United Kingdom. We sought to prospectively examine the need for a night HEMS service in Kent, Surrey, and Sussex in the United Kingdom. MethodsA 4-month, prospective study was conducted (July 1, 2012-October 31, 2012). HEMS dispatch paramedics were present in the ambulance dispatch center and undertook simulated HEMS activations when a suitable case was identified. All trauma cases from the 4-month study period were collated. Five independent HEMS clinicians reviewed the simulated tasking and trauma cases and gave an opinion on whether the patient met HEMS activation criteria. ResultsA mission rate of 1 case per night was predefined as cost-effective. During the prospective study, 145 calls were identified by the HEMS dispatch paramedic as appropriate for an HEMS response. If HEMS had deployed to all 145 incidents, this would have resulted in an average mission rate of 1.2 activations per night. Two hundred eight incidents were identified as potentially appropriate for HEMS activation. Responding to all 208 incidents would have resulted in a mean activation rate of 1.7 per night. ConclusionThis study justifies the need for Kent, Surrey and Sussex Air Ambulance Trust to operate a service at night for a trial period, with an estimated average mission load of 1 per night spread over the entire night period. Further research is warranted to determine the potential impact of a night HEMS service on outcome from major trauma.

Prehospital stroke care: new prospects for treatment and clinical research.

Brain cells die rapidly after stroke and any effective treatment must start as early as possible. In clinical routine, the tight time-outcome relationship continues to be the major limitation of therapeutic approaches: thrombolysis rates remain low across many countries, with most patients being treated at the late end of the therapeutic window. In addition, there is no neuroprotective therapy available, but some maintain that this concept may be valid if administered very early after stroke. Recent innovations have opened new perspectives for stroke diagnosis and treatment before the patient arrives at the hospital. These include stroke recognition by dispatchers and paramedics, mobile telemedicine for remote clinical examination and imaging, and integration of CT scanners and point-of-care laboratories in ambulances. Several clinical trials are now being performed in the prehospital setting testing prehospital delivery of neuroprotective, antihypertensive, and thrombolytic therapy. We hypothesize that these new approaches in prehospital stroke care will not only shorten time to treatment and improve outcome but will also facilitate hyperacute stroke research by increasing the number of study participants within an ultra-early time window. The potentials, pitfalls, and promises of advanced prehospital stroke care and research are discussed in this review.

Has the Time for Advanced Pre-Hospital Care of Severe Sepsis Finally Arrived?

Has the Time for Advanced Pre-Hospital Care of Severe Sepsis Finally Arrived?

Prehospital care data for traffic injury prevention: what Pakistani research tells us

Pakistan is facing an increasing burden of road traffic injuries (RTI). Previous studies showed that prehospital care data could be useful in RTI burden assessment. Recently, an advanced prehospital care system based on international guidelines was established in Pakistan. Our situational analyses indicated several discrepancies in their data—for example, using single sheets for recording multiple patient data thus facilitating missing information; subjective reporting of outcome (stable or okay); no electronic data entry, and underused global position system tracking for identifying crash locations. Furthermore, no stakeholders were identified to use this data for prevention purposes. In conclusion, the great potential for prehospital care data has not been explored in Pakistan, and devoting appropriate structural and human resources could be the key for future RTI advocacy and decision-making for prevention purposes.

A consensus-based template for documenting and reporting in physician-staffed pre-hospital services

BackgroundPhysician-staffed pre-hospital units are employed in many Western emergency medical services (EMS) systems. Although these services usually integrate well within their EMS, little is known about the quality of care delivered, the precision of dispatch, and whether the services deliver a higher quality of care to pre-hospital patients. There is no common data set collected to document the activity of physician pre-hospital activity which makes shared research efforts difficult. The aim of this study was to develop a core data set for routine documentation and reporting in physician-staffed pre-hospital services in Europe.MethodsUsing predefined criteria, we recruited sixteen European experts in the field of pre-hospital care. These experts were guided through a four-step modified nominal group technique. The process was carried out using both e-mail-based communication and a plenary meeting in Stavanger, Norway.ResultsThe core data set was divided into 5 sections: "fixed system variables", "event operational descriptors", " patient descriptors", "process mapping", and "outcome measures and quality indicators". After the initial round, a total of 361 variables were proposed by the experts. Subsequent rounds reduced the number of core variables to 45. These constituted the final core data set. Emphasis was placed on the standardisation of reporting time variables, chief complaints and diagnostic and therapeutic procedures.ConclusionsUsing a modified nominal group technique, we have established a core data set for documenting and reporting in physician-staffed pre-hospital services. We believe that this template could facilitate future studies within the field and facilitate standardised reporting and future shared research efforts in advanced pre-hospital care.

Transitioning Paramedics Into Emergency Nurses: A Unique Population of New Nurses

The United States Department of Health and Human Services predicts a nursing shortage of 1 million registered nurses by the year 2020.1 Specialty areas like the emergency department pose a unique challenge in recruiting and retaining nurses. This article will explore an alternate avenue to developing expert emergency nurses by transitioning advanced prehospital care providers into emergency nurses.

International comparison of prehospital trauma care systems

Given the recent emphasis on developing prehospital trauma care globally, we embarked upon a multicentre study to compare trauma patients' outcome within and between countries with technician-operated advanced life support (ALS) and physician-operated (Doc-ALS) emergency medical service (EMS) systems. These environments represent the continuum of prehospital care in high income countries with more advanced prehospital trauma care systems. Five countries with ALS-EMS system and four countries with Doc-ALS EMS system provided us with de-identified patient-level data from their national or local trauma registries. Generalised linear latent and mixed models was used in order to compare emergency department (ED) shock rate (systolic blood pressure (SBP) <90mmHg) and early trauma fatality rate (i.e. death during the first 24h after hospital arrival) between ALS and Doc-ALS EMS systems. Logistic regression was used to compare outcomes of interest among different countries, accounting for within-system correlation in patient outcomes. After adjustment for patient age, sex, type and mechanism of injury, injury severity score and SBP at scene, the ED shock rate did not vary significantly between Doc-ALS and ALS systems (OR: 1.16, 95% CI: 0.73-1.91). However, the early trauma fatality rate was significantly lower in Doc-ALS EMS systems compared with ALS EMS systems (OR: 0.70, 95% CI: 0.54-0.91). Furthermore, we found a considerable heterogeneity in patient outcomes among countries even with similar type of EMS systems. These findings suggest that prehospital trauma care systems that dispatch a physician to the scene may be associated with lower early trauma fatality rates, but not necessarily with significantly better outcomes on other clinical measures. The reasons for these findings deserve further studies.

Traumatic Atlanto-occipital Dislocation

Atlanto-occipital dislocation, once considered rare and fatal, has become more common. Reasons for improved survival are training, efforts of prehospital care givers, improved diagnostics, and a collaborative healthcare approach to the patient. Advanced prehospital care strategies and diligence in educating prehospital providers are the core elements in preventing further injury and facilitating injury identification. Coupled with improved diagnostics, time to injury identification and treatment initiation is accelerated. This pediatric case study presents a coordinated plan of care demonstrating appropriate prehospital strategies and a team approach to care resulting in a positive patient outcome.

Atendimento pré-hospitalar: caracterização das ocorrências de acidente de trânsito

OBJETIVO: identificar as ocorrências atendidas por um serviço de atendimento pré-hospitalar e caracterizar as decorrentes de corte acidente de trânsito em relação ao horário, dia da semana e configuração da equipe envolvida no atendimento. MÉTODOS: estudo descritivo transversal, com análise de 6.430 ocorrências de solicitação de socorro atendidas de julho a setembro de 2003. RESULTADOS: a incidência de trauma foi 35,2% sendo 57,9% decorrentes de acidentes de trânsito. A maioria das ocorrências aconteceu à tarde, em todos os dias da semana. A equipe de suporte básico, constituída por auxiliar ou técnico de enfermagem e motorista, foi a que mais realizou atendimentos (84,5%). A enfermeira participou em 11,2% das ocorrências, sendo 4,3% na equipe de suporte avançado e o médico em 8,3%. CONCLUSÃO: os resultados destacam o envolvimento da equipe de suporte básico no atendimento pré-hospitalar e indicam a necessidade de prevenção desses agravos e de qualificação dos trabalhadores para estruturação do trabalho baseado na interdisciplinaridade.

On-scene time in advanced trauma life support by anaesthesiologists

Severe injury is the leading cause of death among the young. Trauma systems have improved management of the severely injured and increased survival rates, but there is no level-1 evidence of advanced prehospital trauma care. Advanced prehospital trauma care prolongs on-scene time, which may imply a risk of significant delay in definitive trauma care. The aim of this study was to evaluate on-scene time and influence of (1) the presence of an anaesthesiologist on-scene, (2) prehospital intubation, (3) entrapment, and (4) injury severity. A cohort of registry-based patients brought to Aarhus Trauma Centre. Data were consecutively reported. On-scene time was defined as the time from vehicle arrival to departure. Severe injury is defined by an injury severity score >15. The study was conducted over the period 1998-2000; only patients brought primarily to the trauma centre were included. Statistical tests used include chi, Kruskal-Wallis, Wilcoxon's rank sum and Spearman's rho. Seven hundred and forty-one patients triaged to Aarhus Trauma Centre from which we obtained all information in 596 cases constituted the study group. In 472 cases, an anaesthesiologist was present. On-scene times, median and 95% confidence interval, were as follows: entire study group (n=596) 15.5 min (15-17); ambulance only: 14.0 min (12-15); anaesthesiologist present, no intubation, no entrapment: 15.0 min (14-16); intubation, no entrapment: 21.5 min (16-27); entrapment, no intubation: 21.5 min (17-25); both intubation and entrapment: 22.0 min (16-36). The presence of an anaesthesiologist prolonged the median on-scene time by 1 min and in cases of prehospital intubation by 7.5 min. This result was no different from the prolongation caused by entrapment.

Protocol for advanced prehospital emergency care of severe head injury

To analyze the frequency of systemic factors leading to secondary brain insults in victims of serious head trauma in a prehospital setting and to evaluate a protocol for the advanced prehospital emergency care by mobile intensive care unit (i.e., the French Samu-Smur system). Prospective study, over a period of 24 months. This prospective study involved 60 victims of severe head injuries (with the exception of polytrauma patients). Tracheal intubation was performed on each patient under direct laryngoscopy and after induction of anaesthesia (fentanyl-etomidate-rocuronium). Controlled ventilation and vascular loading (objectives: SpO(2) >or= 97%, PETCO(2) between 30 and 35 mmHg, SAP >or= 90 mmHg) were administered. Hypoxaemia was found to be the most frequent cause of secondary insults (57% of patients with SpO(2) < 97%). In the case involving an accident that occurred 17 km from the hospital (with extremes of 6-65 km), the speed of medical intervention was note-worthy: tracheal intubation was performed 50 min after the accident, and the patient was admitted into a trauma centre 101 min after impact (median). However, faster intervention could be obtained if the transmission of the alert was improved. The conditions under which the tracheal intubation was performed were found to be satisfactory (difficult intubation 1.6%) without deteriorating the haemodynamic status. This is probably related to the use of muscle relaxants and the choice of etomidate as the first line hypnotic in the prehospital emergency care.

Inadequate ventilation of patients with severe brain injury: a possible drawback to prehospital advanced trauma care?

To assess the appropriateness of arterial carbon dioxide tension control in a group of 92 patients with traumatic brain injury who, despite receiving advanced prehospital care, showed no improved outcome in comparison with a group homogeneous but for a lower level of prehospital care. A retrospective registration of the early in-hospital arterial carbon dioxide tension of the patients intubated and ventilated on scene. Patients were excluded if the arterial carbon dioxide tension did not reflect prehospital ventilation or its alteration might have been intentional or unavoidable. Arterial carbon dioxide tension was normal (35-45 mmHg) in only six of the 16 suitable cases (37.5%), was elevated (>45 mmHg) in three cases (18.75%), low (25-35 mmHg) in five cases (31.25%), and extremely low (<25 mmHg) in two cases (12.5%). Potentially dangerous alterations in capnia occurred in the majority of patients analysed. The possible consequences and causes are discussed. Further studies are needed to assess the consequences of any deviation from ideal standards, and to set realistic standards of arterial carbon dioxide tension control during prehospital ventilation.

Helicopter trauma transport: an overview of recent outcomes and triage literature

The purpose of this review is to assess literature pertinent to outcomes benefits accrued by the use of helicopter emergency medical services for trauma transport. A previous annotated bibliography assessed literature published between 1980 and 2000. The goal of this paper is to address developments since fall 2001, and to cast recent studies in the light of earlier work in an attempt to provide a long-range overview of the relevant literature. In the year covered by this review, we identified four papers that directly assessed the association between the helicopter emergency medical services utilization and trauma outcome, and three that addressed the closely related issue of the helicopter emergency medical services triage appropriateness. An Italian study found no benefit associated with advanced prehospital care for patients with severe head injury. A US multicenter trial assessing blunt trauma transports found a substantial mortality reduction associated with helicopter use. Two other US studies, characterized by a similar 'natural experiment' design of assessing mortality changes on either side of a timepoint at which the helicopter emergency medical services availability ceased, reached opposite conclusions about the benefits of the service. Recent studies addressing the helicopter emergency medical services utilization in terms of triage were characterized by varying levels of agreement with the widely held belief that this service is characterized by overtriage. The preponderance of recent and previously extant evidence supports an argument that the helicopter emergency medical services transport is associated with significant benefit for some injured patients. The primary challenges at this time include the determination of which patients benefit and the elucidation of which aspects of the helicopter emergency medical services are responsible for any salutary effects of its utilization.

Prise en charge préhospitalière du traumatisé crânien grave

Advanced prehospital emergency care of patients with severe head injuries. Advanced prehospital emergency medical care of patients with a severe head injury must essentially focus on the impact of secondary cerebral insults of systemic origin on the outcome. The first objective of prehospital care is to prevent hypoxaemia and hypercapnia. Therefore, all patients with a Glasgow Coma Scale score equal to or lower than 8 must be treated with endotracheal intubation and controlled ventilation under continuous monitoring of SpO 2 and PETCO 2. Treatment is similar in head-injured patients with significant deterioration of consciousness level, seizures, respiratory distress, or severe facial and thoracoabdominal injuries. The endotracheal tube is inserted by the orotracheal route under direct laryngoscopy, after a rapid induction sequence of anaesthesia and immobilization of the cervical spine in neutral position. For the induction of anaesthesia in these high-risk patients (full stomach, unknown medical history, deteriorated haemodynamic status), etomidate and suxamethonium are the preferred agents. Sedation is maintained with an hypnotic-opioid association (fentanyl). Simultaneously, the main goal is the maintenance of an optimal cerebral perfusion pressure, as arterial hypotension severely worsens cerebral ischaemia. Volume loading is accomplished with 0.9% saline and hydroxyethyl starch.

Can preclinical medical students be integrated into the continuing medical education process by instructing prehospital care providers?

Objective: To develop a model introducing medical students (MS) to the continuing medical education (CME) process while simultaneously developing a curriculum to enhance the relevant surgical anatomy knowledge base of the advanced prehospital care provider. Methods: A CME curriculum for teaching human anatomy was developed and approved by the governing state agencies for prehospital education. The curriculum focused on structures relevant to the prehospital care of the trauma patient in a case based format using common scenarios presented by surgery and emergency medicine faculty. Five year-one medical students who completed gross anatomy served as teaching staff and were given a structures list one week prior to the CME course. Human cadavers were prosected by the medical students prior to the CME program under the guidance of the surgical faculty. Course attendees and medical student staff were anonymously surveyed at the end of the program (rating scale 1 = low to 5 = high). Prehospital providers were given a multiple-choice posttest and surveyed at 3 months after the course with regard to applicability to their current practice. Data are means ± SD. Results: Nineteen licensed practicing paramedics attended the course. All of the paramedics scored above the 85% passing cutoff on the posttest (95.6% ± 6.2%). Instructor qualities were rated highly (4.62 ± 0.49) with no instructor rating less than a 3. MS believed themselves well prepared to teach (5 ± 0), and spent 2 ± 0.81 hours in preparation. They were only infrequently faced with questions they were not well prepared to answer (1.25 ± 0.5) and would uniformly participate in CME offerings in the future (5 ± 0). The CME program improved the MS view of CME (3 ± 0), prehospital education (3 ± 1.4), and the surgeon as educator (3.25 ± 1.5). At 3 months, the paramedics felt that the CME program significantly impacted the care they rendered (4.37 ± 0.76), and improved their understanding of injury complexes (4.53 ± 0.61), and resuscitation (4.26 ± 0.73). The cadaver course was uniformly recommended to coworkers (5 ± 0). Conclusions: This model provided prehospital care providers direct contact with clinically relevant human anatomy, enhanced their understanding of pertinent anatomy, and positively impacted their patient care. MS were introduced to the CME process and found it to be one with which they would become reinvolved. Furthermore, the MS felt prepared to present human anatomy, met the expectations of the course attendees, improved their understanding of prehospital education, and positively altered their perception of the surgeon as an educator. This process holds promise as both a model for prehospital education and as a tool for integrating MS into the role of allied health educator early in their career.

EMERGENCY DEPARTMENT MANAGEMENT OF TRAUMA

Initial assessment and management of severely injured patients may occur in a specialized area of an emergency department or in a specialized area of a trauma center. The time from injury until definitive management is of essence for survival of life-threatening trauma. The initial care delivered strongly influences patient morbidity and mortality. Prolonged transport times or inadequate prehospital care increases the requirement for early rapid restoration of tissue perfusion and reversal of physiologic disturbances on patient arrival. On the other hand, in urban areas, rapid emergency medical services (EMS) response times and advanced prehospital care increase the number of critically injured patients surviving sufficiently long to reach a hospital “in extremis.” Both scenarios provide challenges in the management of traumatized patients. This article addresses the management of severely injured patients after these patients reach a hospital emergency department or a trauma center.

Can the full range of paramedic skills improve survival from out of hospital cardiac arrests?

OBJECTIVE: To examine the effect of full implementation of advanced skills by ambulance personnel on the outcome from out of hospital cardiac arrest. SETTING: Patients with cardiac arrest treated at...

Ethical challenges in emergency medical services. A special contribution of the Ethics Committee, National Association of Emergency Medical Services Physicians.

Patient autonomy, beneficence, and justice are the fundamental ethical principles of an emergency medical service. Ethical conflicts are present in the daily practice of prehospital care. These conflicts surround issues of resuscitation, futile therapy, consent, and refusal of care, duty, and confidentiality. Emergency medical services must remain fair and equitable, equally available to those it is designed to serve, regardless of the patient's social or economic status. Establishing priorities for patient care is dictated by medical and operational concerns. Education and information regarding ethical issues are important for the providers of prehospital medical care as well as the medical director. Policies and protocols must continue to be developed to address requests to limit resuscitation, such as refusal of care and patient confidentiality. Policies should be developed in conjunction with experienced legal advice. Current training does not equip even the most advanced prehospital care provider to deal easily with every potential situation. Many learn by experience, some are guided by clear policy. Ideally, medical control personnel will be educated, interested, and available to address dilemmas which arise. Where possible, policies and procedures should be developed to address ethical issues which are likely to be faced by EMS personnel.

Reliability of prehospital rating scales for case severity and status change

The purpose of this report is to determine the reliability and sensibility of the currently available prehospital rating scales by a prospective evaluation of ambulance call reports using generalizability methodology. Sequential samples of emergency call data from the Hamilton Base Hospital Paramedic program database were used to sample calls randomly for a two-phase study. Phases I and II used blinded ambulance call report forms presented to six raters during three sessions in each phase. Generalizability (reliability) coefficients were then generated to determine the degree of reliability for the scales in both phases of the study. The generalizability coefficients for all scales are substantial or excellent using the standards commonly applied to agreement statistics. The conclusion of the study is that all ambulance officers can use the prehospital scales reliably. The reliability of these general measures is one of the parameters that will allow us to evaluate where basic and advanced prehospital care have an impact on overall patient outcome.

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.