Basic Emergency Medical Technicians Research Articles

Prehospital emergency life-saving technicians promote the survival of trauma patients: A retrospective cohort study

ObjectiveAppropriate decisions by medical technicians at a trauma scene may influence a patient's prognosis. Emergency life-saving technicians (ELSTs) are certified specialists trained with the knowledge to provide advanced techniques for prehospital emergency care in Japan. However, the benefit of treatment by ELSTs compared to basic emergency medical technicians (BEMTs) remains unclear. The aim of this study is to determine whether treatment by ELSTs improves outcomes for trauma patients. MethodsWe retrospectively reviewed the Japan Trauma Data Bank for the years 2004 to 2017. Patients transferred to the hospital directly from the trauma scene and at least 16 years old were included in this study. The following criteria were used to exclude patients; presence of burns, untreatable severe traumas, unknown ELST attendance, and missing prognosis. We compared two groups (ELST group: patients transported by emergency medical services (EMS) with the presence of at least one ELST; BEMT group: patients transported only by BEMTs). Primary outcome was survival to discharge. Secondary outcomes were the need of definitive treatments defined by surgical intervention, intravascular radiology and blood transfusion at the receiving hospital within 24 h. A multivariable logistic regression model was used to calculate odds ratio (OR) and confidence intervals (CI) adjusted by age, sex, revised trauma score, and Injury severity score (ISS). ResultsOverall survival to discharge did not improve significantly (adjusted OR 1.13, 95% CI 0.99–1.30) with ELST intervention. In-hospital blood transfusion was more frequently required in the ELST group (adjusted OR 1.10, 95% CI 1.01–1.20). Emergency interventions (adjusted OR 1.03, 95% CI 0.97–1.09) were not different between the groups. In stratified analysis, the benefit of ELST attendance for survival was observed among patients with ISS <16 (adjusted OR 1.53, 95% CI 1.10–2.15), aged 65 years or older (adjusted OR 1.27, 95% CI 1.07–1.52), during the earlier study period (2004–2008, adjusted OR 1.50, 95% CI 1.14–1.97), and shorter transportation time (adjusted OR 1.21, 95% CI 1.03–1.41). ConclusionsDispatch systems with ELST should be considered for trauma transports, which may benefit elderly or moderate severity trauma groups, with shorter transportation time conditions.

Comparison between Pediatric-Sized and Adult-Sized Bag-Valve-Mask Ventilation for Achieving Appropriate Tidal Volume in Simulated Adult Out-of-Hospital Cardiac Arrest in a Moving Ambulance

Background: Previous studies proposed that ventilation with pediatric-sized bag-valve-mask (BVM) ventilation resulted in more appropriate tidal volume (Vt) in adult patients than adult-sized BVM ventilation. However, those studies were conducted in stationary, non-moving environment. The authors hypothesized that the result of BVM ventilation in this treatment setting may be different when the investigation was conducted in a moving ambulance. Objective: To compare pediatric-sized and adult-sized BVM ventilation for achieving appropriate Vt in simulated adult out-of-hospital cardiac arrest (OHCA) in a moving ambulance. Materials and Methods: The present study was a randomized crossover trial. Registered nurses (RNs) and basic emergency medical technicians (EMT-Bs) were recruited to perform resuscitation ventilation on a medical training manikin. All participants performed both the pediatric-sized at 500 cc, and the adult-sized at 1,600 cc, BVM ventilation during 30 to 2 chest compressions to ventilation ratio during simulated OHCA in a moving ambulance. Adult-sized mask was used for both scenarios. The manikin was ventilated for 10 minutes during each scenario. The percentage of appropriate Vt was compared between scenarios. The percentages of low Vt at less than 400 cc and high Vt at more than 600 cc between groups were also evaluated. Results: Fifty-two volunteers with 57.7% RNs and 42.3% EMT-Bs were included. Of those 52 volunteers, 44 had less than five years of pre-hospital ventilation experience. The mean Vt was 239.0 cc and 444.5 cc in the pediatric-sized and the adult-sized BVM groups, respectively (p&lt;0.001). Low Vt was observed in 100% of pediatric-sized BVM ventilation. In the adult-sized ventilation group, 52.1±25.6% had appropriate Vt, 11.4±18.6% had high Vt, and 36.5±29.1% had low Vt (p&lt;0.001). Conclusion: A comparison between pediatric-sized and adult-sized BVM ventilation in simulated adult OHCA in a moving ambulance demonstrated the superiority of the adult-sized BVM over the pediatric-sized BVM for achieving appropriate Vt in adult OHCA. Keywords: Bag-valve-mask ventilation; Tidal volume; Out-of-hospital cardiac arrest; Ambulance

Improved outcomes for out-of-hospital cardiac arrest patients treated by emergency life-saving technicians compared with basic emergency medical technicians: A JCS-ReSS study report

BackgroundEmergency life-saving technicians (ELSTs) are specially trained prehospital medical providers believed to provide better care than basic emergency medical technicians (BEMTs). ELSTs are certified to perform techniques such as administration of advanced airways or adrenaline and are considered to have more knowledge; nevertheless, ELSTs’ effectiveness over BEMTs regarding out-of-hospital cardiac arrest (OHCA) remains unclear. We investigated whether the presence of an ELST improves OHCA patient outcomes. MethodsIn a retrospective study of adult OHCA patients treated in Japan from 2011 to 2015, we compared two OHCA patient groups: patients transported with at least one ELST and patients transported by only BEMTs. The primary outcome measure was one-month favorable neurological outcomes, defined as Cerebral Performance Category ≤ 2. A multivariable logistic regression model was used to calculate odds ratios (ORs) and their confidence intervals (CIs) to evaluate the effect of ELSTs. ResultsIncluded were 552,337 OHCA patients, with 538,222 patients in the ELST group and 14,115 in the BEMT group. The ELST group had a significantly higher odds of favorable neurological outcomes (2.5% vs. 2.1%, adjusted OR 1.39, 95% CI 1.17–1.66), one-month survival (4.9% vs. 4.1%, adjusted OR 1.37, 95% CI 1.22–1.54), and return of spontaneous circulation (8.1% vs. 5.1%, adjusted OR 1.90, 95% CI 1.72–2.11) compared with the BEMT group. However, ELSTs’ limited procedure range (adrenaline administration or advanced airway management) did not promote favorable neurological outcomes. ConclusionsCompared with the BEMT group, transport by the ELST group was associated with better neurological outcomes in OHCA.

Abstract 322: Prehospital Care From Emergency Life-Saving Technicians Promotes the Survival of Trauma Patients

Introduction: Optimal trauma care strategies remain a matter of debate. Prehospital trauma care protocols for paramedics range from no intervention to full field stabilizations. In Japan, emergency life-saving technicians (ELSTs) are certified specialists trained to provide advanced techniques and knowledge for prehospital emergency care. They can give fluid resuscitation and inform the receiving hospital for definitive surgery. However, the effectiveness of ELSTs over basic emergency medical technicians (BEMTs) regarding trauma transport remains unclear. Hypothesis: We tested whether the presence of an ELST improves the outcomes of trauma patients. Methods: We retrospectively studied 2004- 2017 data from the Japan Trauma Data Bank (JTDB). Inclusion criteria were patients age ≥ 16 with at least one Abbreviated Injury Scale (AIS) score ≥ 3 trauma. Exclusion criteria were patients with burns, AIS score = 6 in any region, and missing data. We compared two trauma patient groups. ELST group: patients transported by EMS including at least one ELST. BEMT group: patients transported only by basic EMS personnel. The primary outcome measure was survival at discharge. A multivariable logistic regression model was used to adjust for patient baseline characteristics. Results: Included were 124,563 patients, with 119,352 patients in the ELST group and 5,211 patients in the BEMT group. Patients’ ages (ELST vs. BEMT [Mean ± SD]: 57 ± 22 vs. 59 ± 22 years, p &lt; 0.01) were lower and transportation time (15 ± 12 vs. 17 ± 14 min, p &lt; 0.01) was shorter in the ELST group. Gender (male: 64 vs. 64 %, p = 0.66), proportion of blunt trauma (96 vs. 96 %, p = 0.10), proportion of blood transfusion (15 vs. 14 %, p = 0.11) and Injury Severity Score (16 ± 11 vs. 16 ± 11, p = 0.28) were similar between groups. Revised Trauma Score (7.0 ± 1.9 vs. 7.1± 1.7, p &lt; 0.01) was lower in the ELST group and proportion of emergency surgery (12 vs. 11 %, p &lt; 0.01) was higher in the ELST group, indicating that ELSTs treat more severe cases. In the multivariable logistic regression, the ELST group had higher odds for survival (adjusted OR: 1.18, 95% CI: 1.01-1.37). Conclusions: ELSTs encountered more severe cases than BEMTs. After adjustment, transport by the ELST group was associated with improved survival of trauma patients.

Study on disaster response competencies of 119 EMTs

Purpose: This study was conducted to investigate the disaster response competencies of 119 emergency medical technicians (EMTs). Methods: The subjects of this study were 226 119 EMT’s at the fire station located in G province. The questionnaire consisted of 5 sub-factors and 29 items for measuring disaster response competencies and the collected data were analyzed using SPSS program. Results: Disaster response competency comprising immediate response, patient triage, patient treatment, patient transport, and collaboration support were 3.48, 3.64, 3.52, 3.64, and 3.16, respectively. Advanced EMTs scored significantly higher in patient triage (p<.001), treatment (p<.001), and transport (p=.022) competency than basic EMTs. Conclusion: In order to improve disaster response competency, it is necessary not only to enhance individual ability but also to continue disaster management training with related organizations.

The State of Emergency Medical Services (EMS) Systems in Africa.

A survey was conducted between 2013 and 2014 by distributing a detailed EMS system questionnaire to experts in paper and electronic versions. The questionnaire ascertained EMS systems' jurisdiction, operations, finance, clinical care, resources, and regulatory environment. The discovery of respondents with requisite expertise occurred in multiple phases, including snowball sampling, a review of published scientific literature, and a rigorous search of the Internet. The survey response rate was 46%, and data represented 49 of 54 (91%) African countries. Twenty-five EMS systems were identified and distributed among 16 countries (30% of African countries). There was no evidence of EMS systems in 33 (61%) countries. A total of 98,574,731 (8.7%) of the African population were serviced by at least one EMS system in 2012. The leading causes of EMS transport were (in order of decreasing frequency): injury, obstetric, respiratory, cardiovascular, and gastrointestinal complaints. Nineteen percent of African countries had government-financed EMS systems and 26% had a toll-free public access telephone number. Basic emergency medical technicians (EMTs) and Basic Life Support (BLS)-equipped ambulances were the most common cadre of provider and ambulance level, respectively (84% each). Emergency Medical Services systems exist in one-third of African countries. Injury and obstetric complaints are the leading African prehospital conditions. Only a minority (<9.0%) of Africans have coverage by an EMS system. Most systems were predominantly BLS, government operated, and fee-for-service. Mould-Millman NK , Dixon JM , Sefa N , Yancey A , Hollong BG , Hagahmed M , Ginde AA , Wallis LA . The state of Emergency Medical Services (EMS) systems in Africa. Prehosp Disaster Med. 2017;32(3):273-283.

119 구급대원의 영유아에 대한 응급처치 현황 및 응급처치 지식과 수행 자신감 비교

Purpose: The purpose of this study was to improve the quality of prehospital care provided to infants and toddlers (preschoolers) based on questionnaire findings. Methods: A total of 1,634 running sheets from 119 centers of D city from patients older than 1 month and less than 7 years of age from January 1, 2013 to December 31, 2013 were reviewed for 119 emergency medical technicians (EMTs) activity analysis. And a self-reported questionnaire about knowledge and competency in prehospital care of preschoolers was completed by 159 EMTs at fire stations in D city. Data were analyzed using IBM SPSS Statistics for Windows, Version 21.0. Results: Of 1,634 patients, 58.6% were call to 119 due to disease, 33.8% due to injuries and 7.5% due to traffic accident. Knowledge and confidence in treating preschoolers was significantly higher among paramedic EMTs than basic EMTs. The 119 EMTs surveyed indicated that training for preschooler prehospital care was most needed. Conclusion: In order to provide high quality prehospital care for preschoolers transported to emergency rooms, it is necessary to equip ambulances with the proper equipment. In addition, EMTs should be provided educational opportunities and clinical training.

Disparity in Naloxone Administration by Emergency Medical Service Providers and the Burden of Drug Overdose in US Rural Communities

We determined the factors that affect naloxone (Narcan) administration in drug overdoses, including the certification level of emergency medical technicians (EMTs). In 2012, 42 states contributed all or a portion of their ambulatory data to the National Emergency Medical Services Information System. We used a logistic regression model to measure the association between naloxone administration and emergency medical services certification level, age, gender, geographic location, and patient primary symptom. The odds of naloxone administration were much higher among EMT-intermediates than among EMT-basics (adjusted odds ratio [AOR] = 5.4; 95% confidence interval [CI] = 4.5, 6.5). Naloxone use was higher in suburban areas than in urban areas (AOR = 1.41; 95% CI = 1.3, 1.5), followed by rural areas (AOR = 1.23; 95% CI = 1.1, 1.3). Although the odds of naloxone administration were 23% higher in rural areas than in urban areas, the opioid drug overdose rate is 45% higher in rural communities. Naloxone is less often administered by EMT-basics, who are more common in rural areas. In most states, the scope-of-practice model prohibits naloxone administration by basic EMTs. Reducing this barrier could help prevent drug overdose death.

Evidence in support of a back-to-basics approach in out-of-hospital cardiopulmonary resuscitation vs "advanced" treatment.

Aman clutches his chest and collapses on the sidewalk. Call 911. Surelywewant themostadvanced life support (ALS) available—paramedics capable of intubating, administering intravenousmedications, andmanaging complex arrhythmias, as well as transport to the hospital. Or do we? Is it possible that he might do better with less-intensive interventions, especially if theyweredonemore skillfully and safely (facemaskbagging insteadof intubation) aswell asmore quickly, so hewould arrive faster to the hospital for definitive care? The value of advanced interventionsmight be especially small in urban areas where they prolong the normally short travel times to hospital. In sum, is it possible that basic life support (BLS)—using automatic defibrillators, cardiopulmonary resuscitation, and airway management without intubation—could be as good or better? (The term BLS in this commentary is used to describe units with basic emergency medical technicians who are also trained to use semiautomatic defibrillators but donot use advanced airway techniques or administer intravenous drugs.) Sanghavi et al1 provide us with provocative data in answer to this question in this issue of the JAMA Internal Medicine. They report on 39 000Medicare patients treated for outof-hospital cardiac arrest using billing data to determine whether patients receivedALSorBLS. The authors found that patients receivingALShad43% lower survival to hospital discharge, 51%hadmore poor neurologic function, and 30%had higher costs. The study by Sanghavi et al1 uses a different methodology thanmost previous studies of prehospital care; the population and analysis were based on billings for level of emergencymedical system(EMS) response, rather thanfromclinical records of presentation and treatment at the scene. Thismethodologyhasbothstrengthsandweaknesses.The strength is the sample size and generalizability. The weakness is that the analysis requires complex assumptions (including comparable variables known to affect cardiac arrest outcomes in both patient cohorts) and imputation of many missing values. The authors conducted multiple sensitivity analyses; the supporting arguments seem conservative and supportive of their assumptions. Their approach is similar to comparing theoutcomesofacutemyocardial infarction treated bycardiologistsvsprimarycarephysicians; it tests thecaresystem as a whole rather than each individual treatment. Certainvalid overall conclusions couldbe reachedwithout knowinganythingabout theexact clinicalmanagementused ineach case, as long as patient characteristics are the same.Whether the quality and validity of administrative data used this way is better or worse than the typical EMS database is unknown, but the likelihood that their findings are true is strengthened by its consistency with a growing body of research demonstrating the ineffectiveness of many ALS therapies. To understand why the value of ALS is still being debated some45yearsafter its inception,onemust trace itshistory.The studies that launchedresuscitation in theearly 1960swerecase reportsor smalluncontrolledcaseseriesofasphyxiatedhealthy youngdogs. Thedrugs used then (andnow) preceded the 1962 USFoodandDrugAdministration requirement that efficacybe demonstratedfortheir intendeduse.Researchmethodologywas far less sophisticated, and few or none of these studies would be published in anymajor journal today. These first reports appeared to fulfil adreamof centuries— thereversalofdeath itself.Defibrillationand intravenousdrugs spread quickly from their origins in the operating room to the first coronary care units and then experimentally to out-ofhospital use. Initially, treatment was by physicians in ambulances, targeted only at populations of patients having acute infarction. Soon ALS was in use by nascent EMS systems (focused primarily on improving trauma care) and the newly inventedparamedics, for anyandall comers.Thescientific foundationwasweakandanecdotal; therewereno largeprospective studiesor controlled trials, qualityoversightwasminimal, and bias for positive outcomes was common. By the 1990s,muchbetterquality studiesbegan toemerge. The largeOntario Prehospital AdvancedLife Support (OPALS) multicenter prospective study in 2004 was rigorously constructed and conducted to quality control standards seldom seen inEMSsystems.2 (This studywas intended tobe randomize clinical trial [RCT] but could not be owing to the belief of paramedics that itwas unethical towithholdALS, despite absence of proof of its efficacy). Adding ALS to a rapiddefibrillation systemdidnotproduceany improvement in survival or neurologic or health utility outcome in any subgroup. The results were replicated in a large, similar study in Taiwan. In2009,anRCTof 1183patientswithcardiacarrest inNorway randomized half of them to receive no intravenous ALS drugs; there was no difference in survival to hospital discharge or neurological outcome.3 A 2009 Cochrane summary found no difference between endotracheal intubation and other airway management strategies in emergency situations, including out-of-hospital cardiac arrest.4 And now we add the findings of Sanghavi et al.1 This negative trend is all too familiar inmedical research. Initial studies of a treatment are small, poorly controlled, and mostly positive, but then larger more rigorous studies follow that are all negative. This Related article page 196 Outcomes After Out-of-Hospital Cardiac Arrest Original Investigation Research

응급구조사의 DNR에 대한 인식과 윤리적 태도

Purpose: This descriptive study examined awareness of and ethical attitudes associated with Do Not Resuscitate (DNR) orders in 119 emergency medical technicians (EMTs). Method: In total, 255 paramedics and basic EMTs completed questionnaires between March and May, 2013. Data were analyzed using the SPSS WIN 18.0 program. Results: A chi-square analysis revealed significantly different responses given by paramedics and basic EMTs: Paramedics gave "the reason in which DNR is not necessary", as being "due to unclear DNR decision time" whereas basic EMTs answered that this was "due to a legal problem" (<TEX>$x^2$</TEX> = 12.680, p < .05). Paramedics disagreed with the statement, "It is natural for medical teams to have less interest in patients with DNT orders", whereas basic EMTs agreed with the statement (<TEX>$x^2$</TEX> = 6.666, p < .05). Conclusion: A unified manual on attitude toward DNR orders, taking account of social and culture factors, needs to be developed. This research provides a base line for future research.

구급대원의 의복관리를 위한 감염관리 인지도와 수행도

Purpose : A descriptive study design was used to investigate infection management awareness and infection management performance for clothing management in 119 emergency medical technicians (EMTs).Method : 188 paramedics and basic EMTs completed questionnaires betwee n March 1 and April 30, 2013 in Jeollabuk-do.Results : Participants' average score for infection control awareness w as 2.69 and that for performance was 1.58, with the differences being statistically significant (t=931.455, p=.003). Participants' general characteristics resulted in differences in infection management performance. Women (1.63) have scored higher than men (1.28), and the difference was statistically si gnificant (t=11.174, p=.001). Participants who had clinical experience (1.63) had higher scor es than participants who did have clinical experience before (1.53) and, again, the difference wa s significant (t=7.167, p=.009).투고일: 2014년 3월 13일 심사완료일: 2014년 4월 15일 게재확정일: 2014년 8월 18일 *Corresponding Author: Hyeong-Wan YunDepartment of Emergency Medical Technology, VISION University, College of Jeonju, 235, Cheonjam-ro, Wansan-gu, Jeonju-si, Jeollabuk-do, 560-760, Republic of KoreaTel: +82-63-220-4132 Fax: +82-63-220-4139 E-mail: antikil ler12@naver.com

119 구급대원의 곤충교상환자에 대한 응급처치 현황 및 개선방안

Purpose : This study aimed to improve quality of prehospital emergency care for the insect bite patients by figuring out its current situations and problems. Methods : This study was conducted to 219 insect bite patients who were transferred to the hospital by 119 ambulance in D-City from July 1, 2009 to June 30, 2011. This study was a descriptive study by 119 run sheets. A total of 171 emergency medical technicians(EMTs) working in D-city and C-province completed the questionnaire. All of data were analyzed by SPSS 18.0. Results : Among the 219 patients, bee sting accounted for 62.6% and wasp sting accounted for 20.1%. Some patients complained of dizziness, headache, dyspnea, and disturbance of consciousness. The 119 EMTs initially treated the patients with oxygen supply to 57 patients (31.1%). Knowledge toward insect bite was statistically significant (p=.000) between advanced EMTs and basic EMTs. The obstacle to the prehospital care, many EMTs answered that the obstacle was due to the lack of 119 EMTs. Conclusion : It is necessary to differentiate the patients' symptoms and provide the better prehospital emergency care to verify the exact symptoms and signs.

Training and experience are more important than the type of practitioner for intubation success

A meta-analysis by Lossius and colleagues demonstrated a higher endotracheal intubation (ETI) success rate for physicians compared with nonphysicians [1]. We reanalysed the data from Lossius and colleagues to investigate the relationship between the clinicians’ levels of training and ETI success rates, utilising the ‘Overview of included studies’ spreadsheet published online as an additional fi le. We created a variable for a high level of ETI training taken from the ‘extensively trained’ description in the ‘EMS manning’ column. We assumed the physicians to also be highly trained in ETI, as they entirely comprised emergency physicians and anaesthesio logists. Our multivariate meta-regression analysis, adjusting for the training and the type of practitioners, found a 2% diff erence in intubation success (P = 0.12) between physicians and nonphysicians (Table 1), which was not statistically signifi cant. Rapid sequence induction was left out of the fi nal model, because all physicians utilised this induction and its inclusion would needlessly infl ate variance. Lossius and colleagues compared ETI success rates of highly trained anaesthesiologists and emergency physicians from northwestern Europe with paramedics and nurses from the rest of the world [1]. One study incorporated in their meta-analysis included rural basic emergency medical technicians with no previous ETI experience [2]. Perhaps unsurprisingly, the authors showed increased ETI success rates for highly trained physicians compared with such a varied group of nonphysicians. However, our re-analysis suggests that the diff ering level of ETI training between clinicians, not the type of clinician, might be more important for successful ETI.

A Comparison of the Speed, Success Rate, and Retention of Rescue Airway Devices Placed by First-responder Emergency Medical Technicians: A High-fidelity Human Patient Simulation Study

BackgroundCurrent airway management for most first-responder basic emergency medical technicians (EMT-Bs) does not include the use of blind-advanced-airway devices. ObjectiveTo compare the speed, success rates, and skill retention with which EMT-Bs providers can place three blind-advanced-airway devices. MethodsProspective study of 43 EMT-Bs trained in the use of the Esophageal-Tracheal-Combitube® (ETC), King LT® (KLT), and Laryngeal Mask Airway™ (LMA). The time it took each participant to place each device correctly and ventilate a human patient simulator was assessed. Primary outcome measures were the success rate of proper insertion for each device and time interval from initiation of mouth insertion to initiation of chest rise. To assess skill retention, at 3 months the providers were reassessed under exact conditions. ResultsAt Day 1, time required to place an ETC, LMA, and KLT were 32.7 ± 12.3, 19.2 ± 6.2, and 20.1 ± 6.6 s, respectively. Using paired t-tests, LMA and KLT were faster than ETC, p < 0.0001. At 3 months, pair-wise comparisons showed the ETC took longer to place than the KLT and LMA, p < 0.0001; and the LMA took longer to place than the KLT, p = 0.0034 (36.4 ± 13.1 ETC, 24.8 ± 12.4 LMA, 19.0 ± 6.9 KLT). There was no statistical difference of failures in placing any device. ConclusionsComparison of three rescue airway devices placed by EMT-Bs providers showed that it takes significantly longer to place an ETC compared to an LMA and KLT both on Day 1 and 3 months later. Three-month retention studies revealed that it took significantly longer to place an LMA compared to the KLT.

Out-of-Hospital Cardiac Arrest: First Documented Experience in a Mexican Urban Setting

Out-of-hospital cardiac arrest is one of the leading causes of death in Mexico, but many survival and prognostic factors are unknown. The aim of this study was to assess out-of-hospital cardiac arrest in a Mexican city. This was a prospective, cohort study that evaluated the records of the major ambulance services in the city of Queretaro, Mexico. Means, standard deviation, and percentages for the categorical variables were obtained. Logistic regression was performed to determine the effects between interventions, times, and return of spontaneous circulation (ROSC). For an 11-month period, 148 out-of-hospital cardiac arrest cases were recorded. The mean age of the victims was 54 +/- 22.6 years and 90 (65.3%) were males. Forty-nine cases were related to cardiac disease, 46 to other disease, 27 to trauma, 18 to terminal illnesses, and three to drowning. Twelve (8.6%) patients had a pulse upon hospital arrival, but none survived to discharge. No victims were defibrillated prior to ambulance arrival. The collapse-assessment interval was 22.5 +/- 19:1 minutes, the mean value for the ambulance response times was 13:6 +/-10:4 minutes. Basic emergency medical technicians applied chest compressions to 40 victims (27.2%), controlled the airway in 32 (21.8%), and defibrillated seven (4.8%). Chest compressions and airway control showed an OR of 8 and 12 respectively for ROSC. The poor survival rate in this study emphasizes the need to improve efforts in provider training and public education. Authorities must promote actions to enhance prehospital emergency services capabilities, shorten response times, and provide community education to increase the chances of survival for out-of-hospital cardiac arrest victims in Mexico.

Feasibility of Basic Emergency Medical Technicians to Perform Selected Advanced Life Support Interventions

Objective. Emergency medical technician-basic (EMT-B) providers often provide the initial care to victims of out-of-hospital cardiac arrest. While automated external defibrillators enable EMT-B providers to deliver rescue shocks, patients in cardiac arrest may require additional interventions that EMT-B providers may not presently deliver. We sought to evaluate the feasibility of training EMT-B providers to provide additional cardiac resuscitation procedures using the laryngeal mask airway (LMA) andintraosseous (IO) access. Methods. In this prospective observational study, we trained 18 EMT-B providers to use the LMA andIO drill (EZ-IO) in a three-hour educational session. Working in two-person teams, the rescuers performed a simulated ventricular fibrillation resuscitation. We evaluated placement success as well as elapsed time to placement of the LMA andEZ-IO. Results. EMT-B providers successfully placed the LMA in 14 of 18 scenarios (78%; 95% confidence interval, 52% to 94%), with a mean of two attempts for placement. Subjects successfully placed the EZ-IO in 17 of 18 scenarios (94%; 95% confidence interval, 73% to 100%), all on the first attempt. The median time to LMA placement following the third shock was 109 seconds (interquartile range, 58–158) andthe median time to EZ-IO placement was 72 seconds (interquartile range, 50–93) after LMA placement. Conclusions. EMT-B providers demonstrated moderate success in performing advanced-level cardiac resuscitation interventions. These observations suggest potential for expanding the role of basic-level rescuers in cardiopulmonary resuscitation. Key words: cardiopulmonary resuscitation; emergency medical services; simulation; out-of-hospital cardiac arrest; intraosseous; laryngeal mask airway.

All-advanced life support vs tiered-response ambulance systems *

In this discussion, two principal types of ambulance deployment systems were compared and contrasted: 1) the multipurpose, sole-provider all-advanced life support (all-ALS) ambulance system in which all ambulance-related services (emergent and nonemergent) for a city or region are provided by one fleet of ambulances, each of which is staffed by ALS providers (paramedics); and 2) the tiered ambulance system (tiered) in which some 911 ambulances are staffed by paramedics and others are staffed by basic emergency medical technicians (EMT-Bs) who provide basic life support (BLS) care. When managed with advanced system status management (SSM) techniques, the multipurpose, sole-provider all-ALS ambulance system can significantly reduce response intervals while simultaneously providing both fiscal and operational efficiencies. It can also be used to readily integrate and expand the scope of services for the ambulance provider service, such as interfacility transfers, thus increasing revenues. On the other hand, in large urban centers, the tiered ambulance system can be used to reduce response intervals to critical calls, primarily through the use of sophisticated dispatch triage protocols. This approach requires fewer paramedics in the system and appears, in some systems, to also provide medical care advantages in terms of skills utilization for individual ALS providers as well as a more concentrated focus for medical supervision. Therefore, both of these deployment systems can offer certain advantages depending on local emergency medical services (EMS) system needs as well as the local philosophy of health care delivery. Applicability must therefore be considered in terms of local service demands and other factors that affect the EMS system, including catchment population, statutory and jurisdictional issues, available funding, accessibility of receiving facilities, and medical quality concerns. PREHOSPITAL EMERGENCY CARE 2000;4:1-6

Out-of-Hospital Administration of Albuterol for Asthma by Basic Life Support Providers

Each year, approximately 40,000 patients with acute asthma are transported by the Fire Department of New York City (NYC) Emergency Medical Services (EMS). Out-of-hospital administration of bronchodilator therapy has, however, been restricted by scope of practice to advanced life support (ALS) providers. Since the rapid availability of ALS units cannot always be assured, some individuals with acute asthma may receive only basic life support (BLS) measures in the field. To demonstrate that basic emergency medical technicians (EMT-Bs) are able to effectively administer nebulized albuterol to asthma patients in the out-of-hospital environment. This was a prospective, observational cohort study of 9-1-1 asthma calls received by the NYC EMS system for patients between the ages of 1 and 65 years. Baseline peak expiratory flow rate (PEFR) and other clinical measures were obtained prior to and following BLS administration of one or two treatments with nebulized albuterol. Data were available for 3,351 patients over a one-year study period. One out-of-hospital albuterol treatment was given in 60%, while 40% of the patients received two. The PEFRs increased from 40.4% predicted (SD +/-21.0) to 54.8% predicted (SD +/-26.1), for a posttreatment improvement of 14.4% points (95% CI = 13.8 to 15.1). Other clinical outcome measures, including dyspnea index, respiratory rate, and use of accessory muscles, also showed improvement. This study demonstrates that EMT-Bs can effectively administer albuterol to acute asthma patients in the out-of-hospital environment.

Role of the physician in prehospital management of trauma: North American perspective.

To some extent or another, physicians have been involved in emergency medical services (EMS) systems in North America for decades. Over the years, physicians from different specialties have been involved with EMS, occasionally as full-time or part-time employees of the EMS system but more often on a voluntary or small contractual basis. Regardless of the employment relationship, most states and provinces now require by statute that each EMS system, particularly those providing advanced life support (ALS) services, have a designated EMS medical director. However, in the United States and most of Canada, such physicians typically oversee EMS systems by acting as administrative medical supervisors, educators, mentors, and, in some cases, even as system managers. Throughout many European countries, the physician is the primary care provider for a large percentage of the serious prehospital medical emergencies. In contrast, throughout North America, basic emergency medical technicians (EMTs) and paramedics (specially trained ALS providers) serve as the EMS system medical director's surrogates. In this system of care, such physician surrogates provide almost all of the prehospital medical care interventions without any on-scene physician presence. Nevertheless, because of their medical supervisory requirements, by statute, North American medical directors generally are still accountable for patient care. Therefore, in many areas of the United States and Canada, the responsible physicians also respond to EMS scenes on a routine basis. They do so, both announced and unannounced, independently or with EMS personnel. In this capacity, they can serve as a direct patient care resource for the EMTs, paramedics, and the patients themselves. However, by becoming an intermittent participating member of the EMS team in the unique out-of-hospital setting, these on-scene physicians can help to better scrutinize the care rendered and thus more effectively modify applicable protocols and training as needed. Historically, such practices have helped many EMS systems-not only in terms of reforming traditional protocols but also by helping to establish improved medical care priorities and even system management changes that affect patient care. In addition, active participation helps the accountable EMS physician not only to identify weaknesses in personnel skills and system approaches, but it also provides an opportunity for role modeling, both medically and managerially.

Use of the esophageal tracheal combitube™ by basic emergency medical technicians

The most appropriate airway device for use in EMS systems staffed by basic skilled EMTs with (EMT-Ds) or without (EMT-Bs) defibrillation capabilities is still a matter of debate. The purpose of this study was to assess the feasibility, safety and effectiveness of the Esophageal Tracheal Combitube (ETC™) when used by EMT-Ds in cardiorespiratory arrest patients of all etiologies. The EMTs had automatic external defibrillator (AED) training but no prior advanced airway technique skills. The prehospital intervention was reviewed using the EMTs cardiac arrest report, the AED tape recording of the event and the assessment of the receiving emergency physician. The patients’ hospital records and autopsy report were reviewed in search of complications. Eight hundred and thirty-one adult cardiac arrest patients were studied. Placement was successful in 725 (95.4%) of the 760 patients where it was attempted and ventilation was successful in 695 (91.4%). Immediate complications encountered, but not necessarily related to the use of the ETC™, were; subcutaneous emphysema (18), tension pneumothorax (5), blood in the oropharynx (15), and swelling of the pharynx (three). An autopsy was done in 133 patients; no esophageal lesions or significant injury to the airway structures were observed. Our results suggest that EMT-Ds can use the ETC™ for control of the airway and ventilation in cardiorespiratory arrest patients safely and effectively.