Emergency Medical Services Department Research Articles

Epidemiology of Emergency Medical Services-Assessed Mass Casualty Incidents according to Causes.

To effectively mitigate and reduce the burden of mass casualty incidents (MCIs), preparedness measures should be based on MCIs’ epidemiological characteristics. This study aimed to describe the epidemiological characteristics and outcomes of emergency medical services (EMS)-assessed MCIs from multiple areas according to cause. Therefore, we extracted the records of all MCIs that involved ≥ 6 patients from an EMS database. All patients involved in EMS-assessed MCIs from six areas were eligible for this study, and their prehospital and hospital records were reviewed for a 1-year period. The EMS-assessed MCIs were categorized as being caused by fire accidents (FAs), road traffic accidents (RTAs), chemical and biological agents (CBs), and other mechanical causes (MECHs). A total of 362 EMS-assessed MCIs were identified, with a crude incidence rate of 0.6–5.0/100,000 population. Among these MCIs, 322 were caused by RTAs. The MCIs involved 2,578 patients, and 54.3% of these patients were women. We observed that the most common mechanism of injury varied according to MCI cause, and that a higher number of patients per incident was associated with a longer prehospital time. The highest hospital admission rate was observed for CBs (16 patients, 55.2%), and most patients in RTAs and MECHs experienced non-severe injuries. The total number of deaths was 32 (1.2%). An EMS-assessed MCI database was established using the EMS database and medical records review. Our findings indicate that RTA MCIs create a burden on EMS and emergency department resources, although CB MCIs create a burden on hospitals’ resources.

A survey of a population of anaesthesiologists from South India regarding practices for rapid sequence intubation in patients with head injury.

Background and Aims:Evidence and utility of the individual steps of the rapid sequence induction and tracheal intubation protocols have been debated, especially in the setting of traumatic brain injury. The purpose of this survey was to determine preferences in the current approach to rapid sequence intubation (RSI) in head injury patients among a population of anaesthesiologists from South India.Methods:A questionnaire was E-mailed to all the members of the Indian Society of Anaesthesiologists’ South Zone Chapter to ascertain their preferences, experience and comfort level with regard to their use of rapid sequence intubation techniques in adult patients with head injury. Participants were requested to indicate their practices for RSI technique for a head-injured patient upon arrival at the Emergency Medical Services department of their hospital.Results:The total response rate was 56.9% (530/932). Of the total respondents, 35% of the clinicians used cricoid pressure routinely, most respondents (68%) stated that they pre-oxygenate the patients for about 3 min prior to RSI, thiopentone (61%) and propofol (34%) were commonly used prior to intubation. Rocuronium was the muscle relaxant of choice for RSI among the majority (44%), compared to succinylcholine (39%). Statistical analyses were performed after the initial entry onto a spreadsheet. Data were summarised descriptively using frequency distribution.Conclusion:In a rapid sequence intubation situation, the practice differed significantly among anaesthesiologists. Owing to disagreements and paucity of evidence-based data regarding the standards of RSI, it is apparent that RSI practice still has considerable variability in clinical practice.

Eighteen grams of glucose are necessary to treat severe hypoglycaemia: experience from the Emergency Medical Services Department

Eighteen grams of glucose are necessary to treat severe hypoglycaemia: experience from the Emergency Medical Services Department

World Trade Center-related physical and mental health burden among New York City Fire Department emergency medical service workers

ObjectivesTo describe the health burden among Fire Department of the City of New York (FDNY) emergency medical service (EMS) workers and examine its association with work at the World Trade...

Considerations for Safe EMS Transport of Patients Infected with Ebola Virus

The Nebraska Biocontainment Unit through the Nebraska Medical Center in Omaha, Nebraska, recently received patients with confirmed Ebola virus from West Africa. The Nebraska Biocontainment Unit and Omaha Fire Department's emergency medical services (EMS) coordinated patient transportation from airport to the high-level isolation unit. Transportation of these highly infectious patients capitalized on over 8 years of meticulous planning and rigorous infection control training to ensure the safety of transport personnel as well as the community during transport. Although these transports occurred with advanced notice and after confirmed Ebola virus disease (EVD) diagnosis, approaches and key lessons acquired through this effort will advance the ability of any EMS provider to safely transport a confirmed or suspected patient with EVD. Three critical areas have been identified from our experience: ambulance preparation, appropriate selection and use of personal protective equipment, and environmental decontamination.

Emergency medicine in Egypt: Current situation and future prospects

Introduction Emergency medicine is in the early development phase in Egypt. It was first registered in 2001 and although there are about 250 physicians finished their training in the specialty, less than 20 still work in Egypt and others moved to work through the world, mainly to Arab Gulf region. There is not a specialty society in emergency medicine, although there is an Egyptian Society of Intensive Care Medicine and Trauma (ESICT) with an interest in emergency medicine. Emergency care The Emergency Medical Services Department of the Ministry of Health (MOH) is involved in the pre-hospital aspects of emergency medicine. Over the past three years, the MOH has acquired approximately 1200 new full equipped ambulances greatly expanding its pre-hospital capabilities and response. This service provider through basic life support practitioners. In the meantime, personnel within the MOH continue to provide Hospital Emergency departments through the country with new equipment and episodic short training programs for staff in the care of trauma patients and cardiac life support. Emergency medicine training programs The Egyptian specialty board is a 4year formal training program is considered the leader institute in emergency medicine training in Egypt which started early of 2001 with more than 200 graduates until now. The most disadvantage of the program is lacking of specialist trainers and it mainly depends on skilled personnel from other specialities in each hospital, most of them are unaware of the specialty curriculum and updated guidelines in Emergency medicine. There are three university hospitals give academic master degree in Emergency medicine but they are away behind the basic training requirements although they have good approved curriculum did not come to real practice yet. The future Although Egypt was one of the first countries outside USA which considered Emergency medicine as specialty, immigration of trained Emergency physicians, leaving the positions for unqualified personnel from other specialities and lacking of resources had affected the specialty badly. For Emergency to move forward, we should depend on specialists to build the emergency society with annual international conference and local policies and guidelines and outreach programs to rural and borders regions.

Provision of Out-of-hospital Analgesia to Older Fallers With Suspected Fractures: Above Par, but Opportunities for Improvement Exist

Paramedics frequently attend older patients who have fallen and sustained suspected fractures, a population of patients who may be at risk of inadequate analgesic care. This prospective study aimed to describe the rate and effectiveness of analgesia administered by paramedics to older patients with suspected fractures secondary to falls and to identify predictive factors associated with provision of analgesia. A cohort of older patients aged greater than 65 years with suspected fall-related fractures was extracted from a database of 1,610 cases collected during a prospective, nonconsecutive observational study of older people who had fallen and received an ambulance response from October 1, 2010, through June 30, 2011. Fall-specific data, collected on scene by paramedics using a specially designed data form, were linked to patient clinical records and dispatch information. Descriptive analyses were performed to describe rates and effectiveness of analgesic administration, and multivariate logistic regression was conducted to identify factors associated with provision of analgesia. Of 1,610 patients in the observational study database, there were 333 patients identified as having suspected fractures, thus forming the study population. The mean (±SD) age was 82 (±8) years, and 75% were female. Suspected fractures of the hip were most common (42%). An initial pain score was recorded in 67% of cases, and the median initial pain severity was 8 of 10 (interquartile range [IQR] = 5 to 9). Overall, 60% received analgesia, and 80% of those received parenteral opiates. Intravenous (IV) morphine was most common (63%), followed by methoxyflurane (39%) and intranasal fentanyl (17%). Administration of oral analgesics was uncommon. Analgesia was considered to be clinically effective (≥30% relative reduction in pain severity) in 62% of cases. Patients with suspected hip fractures had greater odds of receiving analgesia compared to those with suspected fractures at other anatomical sites (odds ratio [OR] = 2.7, 95% confidence interval [CI] = 1.17 to 6.32; p = 0.02). Compared to those with mild pain, the odds of receiving analgesia increased significantly for patients with moderate pain (OR = 6.5, 95% CI = 2.3 to 18.8; p < 0.0001) and severe pain (OR = 31.1, 95% CI = 9.9 to 97.6; p < 0.0001). In this population of older people who fell and sustained suspected fractures, two-thirds received paramedic-administered analgesia. The majority of patients received clinically effective analgesia, and the presence of a suspected hip fracture increased the likelihood of receiving pain relief.

The frequency of hypertension crises in the emergency medical service department in tuzla.

ABSTRACTObjectives:The aim of this study was to evaluate a frequency and clinical presentation of hypertension crises due to age, gender, duration and seriousness at Emergency Medical Service Department of the “Dr Mustafa Šehovic” Health Care Center Tuzla.Methods:The research was conducted in the period between November 2009 and April 2010 and involved 180 examinees of both genders, aging between 30 and 80 years of age with the diagnosis of arterial hypertension. The examinees were divided into two groups: control group consisting of examinees without hypertension crisis (95 examinees) and experimental group consisting of examinees with hypertensive crisis (85 examinees). Descriptive statistical methods were used in the statistical data processing.Results:The research results showed that there had been significantly more female examinees than the male ones (60% vs. 40%; p=0.007). The average age of male examinees was 55.83±11.06 years of age, and the average age of female examinees was 59.41±11.97 years of age. The hypertension crisis frequency was 47.22%, where the hypertensive urgencies were statistically significantly more present than the hypertensive emergencies (16.47%vs.83.53%; p<0.0001). The largest number of experimental group examinees (28.23%) belonged to the age group of 60 to 69 years of age; urgency 26.76% and emergency 35.71%. The largest number of examinees with hypertensive crisis (49.41%) appeared in the period between 6.00 p.m. and 11.59 p.m. The largest number of emergency group examinees (69.01%) had been treated for arterial hypertension for ten years, and the examinees from the emergency group (42.86%) had been treated for 10, 11 and 20 years. The average blood pressure value at the hypertensive crisis examinees was 204.82/126.58 mmHg.Conclusions:The frequency of hypertensive crises in the Emergency Medical Service Department is high and it reaches 47.22%. Hypertensive urgencies were significantly more present in terms of statistics than the hypertensive emergencies (83.53% vs. 16.47%; p<0.0001).

An integrated disaster response information surveillance system

This paper describes the design and development of an integrated disaster response information surveillance (IDRIS) wireless system for use by the emergency medical service (EMS). IDRIS is built on two complimentary models: the architectural model and the computational model. Using front end tablet PCs equipped with wireless technology IDRIS is a real-time data recording, information display, storage, communication and tracking system to be used by the EMS department personnel at disaster sites. With its built-in two complementary models coupled with features to adapt to user behaviour (to suit different conditions), we believe that IDRIS has the potential to be a key component for disaster management strategies, a system for surveillance of diseases and detecting unusual syndromes.

Accuracy of Pre-Hospital Identification of Stroke (P04.059)

Objective: Determine accuracy of emergency medical service (EMS) identification of stroke. Background Activation of stroke systems by EMS may expedite time to intervention for stroke patients. Gropen et al. reported on sensitivity and impact of EMS identification of stroke. We additionally explored specificity and predictive values (PV) of EMS and emergency department (ED) evaluations. Design/Methods: We reviewed records of all patients transported by EMS to the Loyola University ED between 10/1/2010 and 6/30/2011. EMS impressions, ED physician diagnosis (DX), and neurology discharge diagnosis (DDX) were compared to determine sensitivity, specificity, and PV of EMS and ED identification of stroke. For patients with EMS impression of stroke, or DDX of stroke, additional parameters explored included: age, iv tPA administration, Cincinnati Stroke Scale (CSS), NIHSS, and time from ED arrival to neurology consult. Results: 5300 EMS patient records were included: 84 had EMS impression of stroke, with 49 true positives (TP), 35 false positives (FP), 47 false negatives (FN), and 5169 true negatives (TN); sensitivity was 51.04%, specificity 99.33%, positive PV 58.33%, and negative PV 99.10% (p Conclusions: EMS identifies stroke with high specificity, though lesser sensitivity. Pre-hospital stroke team activation may therefore help in decreasing the time to treatment. Improving the sensitivity of EMS and ED identification of stroke is needed for early identification of additional possible stroke patients. Disclosure: Dr. Wild has nothing to disclose. Dr. Kim has nothing to disclose. Dr. Hyman has nothing to disclose. Dr. Venizelos has nothing to disclose. Dr. Cichon has nothing to disclose. Dr. Schneck has nothing to disclose.

Impact of Hurricane Ike on the call volumes of Houston Fire Department emergency medical services

Little is known about the capacity and activity of emergency medical services (EMS) during large-scale disasters. This article provides a case study of the role of EMS in one large urban city during a major hurricane. The authors analyzed changes in call volume data from the City of Houston Fire Department's EMS during Hurricane Ike. Descriptive and statistical analyses are used to explain surges and statistical differences in volumes. Demand for EMS care can increase approximately 40 percent during surges in the disaster cycle, placing extreme burdens on system capacity and workload. The largest increase in demand came from respiratory problems, falls, and chest pains, with the largest decrease in calls from motor vehicle accidents. A strategy for managing surges in prehospital care from major disasters is a requirement for modern EMS.

Utilization of Prehospital Dispatch Protocols to Identify Low-Acuity Patients

Objectives. To describe the experience of a U.S. emergency medical services (EMS) agency utilizing a dispatch algorithm to identify low-acuity patients and determine whether secondary telephone triage by a nurse was associated with subsequent hospital admission among those patients. Methods. This was a retrospective study of all patients meeting the low-acuity Omega classification by the Medical Priority Dispatch System (MPDS) in a large urban EMS system, conducted in two phases. Patients were excluded from the study if a refusal for transport was obtained, the call was received from a third-party caller, the MPDS system was not used, the patient was being referred from a skilled nursing facility, school, or university nursing office or physician's office, or if the call was referred to the Carolina Poison Center. Patients were enrolled over two phases using two different versions of the MPDS protocol, and in phase 2 patients were offered the option of speaking with an advice-line nurse. The outcome of interest was emergency department disposition, classified as hospital admission or discharge home. Admission to an intensive care unit (ICU) bed was also collected as a subcategory of hospital admission. Results. Of the 1,862 patients in phase 1, 69.3% were discharged home from the emergency department, whereas in phase 2, 73.0% of the 1,078 patients were discharged home. Individuals were most frequently admitted to the hospital across both phases if they had a dispatch determinant of pregnancy, psychiatric/behavioral, fall, sick person. Hospital admission was also associated with receiving an EMS or emergency department procedure. There were 530 patients in phase 2 who underwent secondary triage by an advice-line nurse. Among this cohort of patients, 134 (25.3%) required subsequent hospital admission, with a further three (2.2%) requiring an ICU admission. Conclusions. This study identified a method for classifying patients during the dispatch period as low-acuity while attempting to ensure that those individuals received the medical care that they needed. Key words: emergency medical services; emergency medical dispatch; triage.

Sustained Ventricular Fibrillation in an Alert Patient: Preserved Hemodynamics with a Left Ventricular Assist Device

Emergency medical services (EMS) encountered an alert patient with sustained ventricular fibrillation with preserved hemodynamics via a left ventricular assist device (LVAD). Multiple firings of the patient's implantable defibrillator were the only sign that this patient was experiencing the usually fatal ventricular arrhythmia. Initial attempts at rhythm conversion with amiodarone and 200-J biphasic shocks were unsuccessful. The patient was finally defibrillated to normal sinus rhythm after a 360-J biphasic shock. This case conference highlights the increasing prevalence of LVADs. These devices are used not only as a bridge to cardiac transplantation, but also as definitive therapy for patients in end-stage cardiac failure. Ventricular fibrillation has been shown to be well tolerated in patients with LVADs, and we discuss a standard of care for these patients. The occurrence of sustained ventricular fibrillation in patients with ventricular assist devices represents a challenging situation for EMS and emergency department providers and one that will be increasingly encountered in the future.

Katrina Changed Us (and Me) in So Many Ways

Geographic circumstances: I volunteered to serve incoming evacuated children 350 miles from New Orleans and remain committed to the institution and area. About the author: I am currently a full-time faculty member at Texas Children's Hospital and associate professor of pediatrics and clinical chief in the section of emergency medicine at the Baylor College of Medicine. I serve as assistant medical director for the City of Houston Fire Department Emergency Medical Services. I am a member of the Section on Emergency Medicine Executive Committee for the American Academy of Pediatrics. I am involved in local, statewide, regional, and national committees related to pediatric emergency medicine and prehospital pediatrics. I continue to credit much of my current motivation in disaster preparation and response to my incredible experience during the Katrina event. It is safe to say that the mere mention of Hurricane Katrina continues to stir up good and bad memories for those of us who helped with Houston's response to the New Orleans evacuees. I tend to be a “glass-is-half-full” person, so most of what I remember and see today as a result of Katrina is the good in people. Our city opened its arms without hesitation to more than 200 000 evacuees, both before and after Katrina's arrival in New Orleans. As a result, we as a people and a city are better for it. Before 2005 and Hurricane Katrina, pediatrics was an afterthought, at best, in the minds of most of our region's disaster planners. After learning of the first group of 25 000 evacuees en route to the Houston Astro Arena Complex several days after the storm struck, we (the emergency pediatricians of Baylor College of Medicine and Texas Children's Hospital) inserted ourselves without invitation into the mass casualty medical response. We arrived at the facility unannounced … Address correspondence to Paul E. Sirbaugh, DO, Department of Pediatrics, Baylor College of Medicine, 6621 Fannin St, Suite A2210.23, Houston, TX 77030. E-mail: sirbaugh{at}bcm.tmc.edu

A case study on the application of an approximated hypercube model to emergency medical systems management

This paper describes an application of the approximated hypercube model to Lisbon emergency medical services (EMS) management, namely for assessing alternative dispatching rules for assigning ambulances to emergency calls. The approximated hypercube (A-hypercube) is a queuing theory model that computes several performance measures such as average response time, server workloads or the probability of all servers being busy (loss probability). The assumptions of the extended model are Poisson customer arrivals, general service time (customer and server dependent) and a fixed preference assignment rule of servers to customers. The fact that dispatching rules are precisely a model parameter, turn this model into a valuable tool in the definition of efficient operating rules. In this paper, we propose new expressions for the computation of system performance measures during periods in which the emergency call arrival process is not stationary. Different dispatching rules are evaluated by comparing the system performance measures obtained from the extended A-hypercube model and a simulation model, using data collected from the Lisbon EMS Department.

Comparison between atosiban and nicardipine in inducing hypotension during in-utero transfers for threatening premature delivery

The aim of this study was to compare the frequency of hypotension induced by oxytocin antagonist atosiban and nicardipine. This case-control study enrolled 14 pregnant women presenting with threatening premature delivery treated with atosiban and managed by a physician-staffed Emergency Medical Service Department (French Emergency Medical Service system) during inter-hospital transfers. A control group of 42 consecutive pregnant women presenting with threatening premature delivery managed during inter-hospital transfers during the same period and treated with nicardipine was set up. The control group was recruited after matching on confounding variables: age 38 years or less and no previous cardiovascular disease to avoid factors related to the occurrence of cardiovascular events, duration of out-of-hospital management of at least 60 min to have similar likelihood of side-effect occurrence, and parity 2 or less and gestational age from 25 to 32 weeks to make comparable groups from the obstetrical viewpoint. Frequency of hypotension was compared between the two groups. Hypotension was observed in two patients (8%) in the atosiban-group and in five patients (14%) in the nicardipine-group, which is not significantly different (P>0.99). Despite the notion that oxytocin antagonist atosiban has limited or no systemic adverse effects, these results suggest that this cost-consuming drug does not avoid hypotension and cannot help to reduce the level of monitoring.

Influenza Vaccination among Emergency Medical Services and Emergency Department Personnel

Objectives. Influenza vaccination has long been recommended for health care workers, but vaccination rates among this group have been low. Data on emergency medical services (EMS) personnel's vaccination status have not been published. This study compared self-reported vaccination rates and barriers among EMS and emergency department (ED) personnel. Methods. We conducted a cross-sectional survey of full-time EMS providers servicing metropolitan Rochester, New York, and a convenience sample of ED personnel in an academic medical center in Rochester, New York. Surveys, completed during July and August 2006, focused on influenza vaccination status for the 2005–2006 season and opinions regarding the vaccination. Immunization rates of EMS providers and ED personnel were compared using the chi-square calculation. Results. Surveys were completed by 128 EMS providers (100% of eligible) and 128 ED personnel (100% of approached). Among EMS providers, 27 of 128 (21%; 95% confidence interval [CI] 14%–29%), and among ED personnel, 83 of 128 (65%; 95% CI 56%–73%) reported receiving an influenza vaccination in the preceding year (p < 0.001). Among interventions that could lead to an increase in influenza vaccination, the most commonly chosen by EMS providers and ED personnel alike were “no waiting” vaccination at work (71% and 62%, respectively) and free vaccination (59% and 50%, respectively). When asked about important factors in the decision whether to get an influenza vaccination the following season, the most common responses were frequency of exposure (71%, 69%) and concern about secondarily exposing family members (62%, 60%). Conclusion. EMS providers reported low influenza vaccination levels in 2005–2006, even as compared with ED personnel. This failure to receive vaccination poses potential risk to the workers themselves and their patients. Resolution of reported barriers could lead to higher vaccination rates.

The effect of seatbelt legislation on hospital admissions with road traffic injuries in an oil-rich, fast-developing country

The objective of the study was to examine the effect of seat-belt legislation on hospital admissions with road traffic injuries and was designed as a retrospective descriptive study. All motor vehicle crashes recorded during the period 2001 – 2004 were extracted from the Emergency Medical Service Department. Details of the crashes, injuries and safety devices used were studied. The present study revealed that safety belt usage rates have increased from 8% in 2001 to 67% in 2004 among patients admitted to hospital with injury after road traffic crashes. The admission rate of patients with road traffic injuries per 100 000 population reduced by 17.7%. The enforcement of the seat-belt legislation played a vital role in reduction of hospital admissions due to road traffic crashes.

Development of Systems of Care for ST-Elevation Myocardial Infarction Patients

The physician’s overarching role in the development of systems of care for ST-segment–elevation myocardial infarction (STEMI) is to advocate for achieving the goal of early infarct-artery patency for all patients with STEMI. An effective STEMI care system relies on a team of multiple physicians, nurses, emergency medical services (EMS) personnel, and other providers to work in an efficient, collaborative manner to deliver optimal patient care. Urgent, direct activation of the EMS system by the STEMI patient is ideal. Successful first response care by EMS or emergency department (ED) personnel followed by rapid access to revascularization requires standardized, evidence-based STEMI treatment protocols in accordance with the most current American College of Cardiology (ACC)/American Heart Association (AHA) guidelines. Physicians participating in the development of these protocols should include both interventional and noninterventional cardiologists, emergency medicine specialists, EMS physicians, and primary care physicians. Furthermore, to more effectively achieve success in developing and implementing these systems and networks, physicians must demonstrate a new paradigm of leadership, including the following: 1. A passionate and credible commitment to the goal of achieving timely infarct artery patency for all patients with STEMI; 2. An ability to obtain the full cooperation, collaboration, and support of hospital senior management and medical staff at local, referral, and regional levels; 3. The development and implementation of innovative team-based methods for overcoming professional, organizational, and regulatory barriers to ideal STEMI treatment; 4. Effectiveness in implementing protocols that are flexible with regard to geographic and other local issues; 5. Mastery of the use of efficient and credible clinical information systems that support timely data collection, quality and outcomes measurement, feedback, and transparency for both internal and public quality improvement initiatives; and 6. Prompt data collection and feedback. Currently, primary care and specialist physicians tend to work separately rather than in integrated networks in caring for patients with STEMI, particularly …

Medically Unnecessary Emergency Medical Services (EMS) Transports Among Children Ages 0 to 17 Years

Estimate the prevalence of medically unnecessary Emergency Medical Services (EMS) transports among children. We linked EMS and emergency department (ED) billing records for all EMS-to-hospital transports of children originating in three counties in South Carolina between January 1, 2001 and March 31, 2003. EMS responses resulting in no transport, transports to destinations other than the ED, or multiple trips for the same child in a single day could not be linked to ED data and were excluded. Medically unnecessary transports were identified with an algorithm using pre-hospital impressions, ED diagnoses and ED procedures. After exclusions, 5,693 transports of children between 0 and 17 years were available for study. Sixteen percent (16.4%) of all transports were medically unnecessary. Among children through age 12, upper respiratory and viral problems were the most common diagnoses associated with medically unnecessary transports; among older children, behavioral problems such as conduct disturbance or drug abuse were common. In multivariable analysis, the odds of an unnecessary transport were higher among younger children, non-white children, rural children, and children insured by Medicaid. The proportion of EMS transports which may be medically unnecessary is relatively modest compared to previous studies. However, many questions remain for future research. Further investigation should include examination of primary care availability and occurrence of unnecessary EMS use, existence of race-based disparities, and transports involving conduct disturbance and other behavioral conditions among children.