Emergency Medical Services Paramedics Research Articles

Blood lactate after pre-hospital blood transfusion for major trauma by helicopter emergency medical services.

The appropriate use of blood components is essential for ethical use of a precious, donated product. The aim of this study was to report in-hospital red blood cell (RBC) transfusion after pre-hospital transfusion by helicopter emergency medical service paramedics. A secondary aim was to assess the potential for venous blood lactate to predict ongoing transfusion. All patients who received RBC in air ambulance were transported to a single adult major trauma centre, had venous blood lactate measured on arrival and did not die before ability to transfuse RBC were included. The association of venous blood lactate with ongoing RBC transfusion was assessed using multi-variable logistic regression analysis and reported using adjusted odds ratios (aOR). The discriminative ability of venous blood lactate was assessed using area under receiver operating characteristics curve (AUROC). From 1 January 2016 to 15 May 2019, there were 165 eligible patients, and 128 patients were included. In-hospital transfusion occurred in 97 (75.8%) of patients. Blood lactate was associated with ongoing RBC transfusion (aOR: 2.00; 95% confidence interval [CI]: 1.36-2.94). Blood lactate provided acceptable discriminative ability for ongoing transfusion (AUROC: 0.78; 95% CI: 0.70-0.86). After excluding patients with early deaths, a quarter of those who had prehospital RBC transfusion had no further transfusion in hospital. Venous blood lactate appears to provide value in identifying such patients. Lactate levels after pre-hospital transfusion could be used as a biomarker for transfusion requirement after trauma.

Prehospital portable ultrasound for safe and accurate prehospital needle thoracostomy: a pilot educational study

BackgroundSimulated needle thoracostomy (NT) using ultrasound may reduce potential injury, increase accuracy, and be as rapid to perform as the traditional landmark technique following a brief educational session. Our objective was to determine if the use of an educational session demonstrating the use of handheld ultrasound to Emergency Medical Services (EMS) staff to facilitate NT was both feasible, and an effective way of increasing the safety and efficacy of this procedure for rural EMS providers.MethodsA pre/post-educational intervention on a convenience sample of rural North American EMS paramedics and nurses. Measurement of location and estimated depth of placement of needle thoracostomy with traditional landmark technique was completed and then repeated using handheld ultrasound following a training session on thoracic ultrasound and correct placement of NT.ResultsA total of 30 EMS practitioners participated. Seven were female (23.3%). There was a higher frequency of dangerous structures underlying the chosen location with the landmark technique 9/60 (15%) compared to the ultrasound technique 1/60 (1.7%) (p = 0.08). Mean time-to-site-selection for the landmark technique was shorter than the ultrasound technique at 10.7 s (range 3.35–45 s) vs. 19.9 s (range 7.8–50 s), respectively (p < 0.001). There was a lower proportion of correct location selection for the landmark technique 40/60 (66.7%) when compared to the ultrasound technique 51/60 (85%) (p = 0.019). With ultrasound, there was less variance between the estimated and measured depth of the pleural space with a mean difference of 0.033 cm (range 0–0.5 cm) when ultrasound was used as compared to a mean difference of 1.0375 cm (range 0–6 cm) for the landmark technique (95% CI for the difference 0.73–1.27 cm; p < 0.001).ConclusionsTeaching ultrasound NT was feasible in our cohort. While time-to-site-selection for ultrasound-guided NT took longer than the landmark technique, it increased safe and accurate simulated NT placement with fewer identified potential iatrogenic injuries.

Challenges of Emergency Medical Services Response to Arasbaran Twin Earthquakes; a Content Analysis

Introduction:One of the most important concerns in responding to disasters is providing Basic Life Support (BLS) services. Considering the key role of Emergency Medical Services (EMS) in providing BLS, the purpose of this study is to investigate the experience of provincial EMS during their response to the Arasbaran twin earthquakes and its challenges in Iran.Methods:This study was conducted using a qualitative approach and the conventional content analysis method. Data were collected through Focused Group Discussions (FGD) and semi-structured in-depth interviews with purposively-selected EMS paramedics and officials in East Azerbaijan Province, Iran. To form the main categories, the interviews were encoded in three stages and the similar codes were placed under the same subcategories and merged. Results:A total of 26 EMS paramedics participated in the study. The codes extracted from the interviews, after three stages of reduction, were placed in the top ten categories, including the lack of preparedness and coordination, dead bodies' management challenges, responders’ psychosocial support, deficiencies in supplies and ambulances, difficulty of access to rural areas, volunteer management, non-documentation of the experiences, communication challenges, recalling, and deploying of EMS responders. Conclusion:Timely response of the EMS and paramedics’ sense of responsibility for providing services were positive and successful points about the emergency response operations. The weaknesses of EMS should, therefore, be addressed through transferring of experiences and by planning and arranging training courses.

Should a Physician Ever Violate SWAT or TEMS Protocol in a Mass Casualty Incident?

Mass casualty incidents involving active shooters are becoming more common, and many involve special weapons and tactics team responses. Standard of care is to have tactical emergency medical services paramedics or physicians direct triage and administer immediate interventions. In these situations, a clinical and ethical value is to do the greatest good for the greatest number of people. Cases in which beneficence and justice are at odds are particularly complex. This commentary on such a case argues that directing resources to patients most likely to survive accords triage principles and explores ethical complexity in resource allocation decisions.

Reasons for the termination of resuscitation in out-of-hospital cardiac arrests before and after the COVID-19 pandemic in Korea

The incidence of out-of-hospital cardiac arrest (OHCA) gradually increased during the coronavirus disease 2019 (COVID-19) pandemic, and the number of cases requiring termination of resuscitation (TOR) also rose. This study aimed to analyze the reasons for TOR of OHCA cases over 2 years (2019–2020). This retrospective observational study was conducted using data gathered from prehospital emergency medical service (EMS) care reports generated in Seoul between 01 January 2019, and 31 December 2020. We included OHCA cases reported to the EMS system in this study. Patients who experienced cardiac arrest for a non-medical cause and received cardiopulmonary resuscitation (CPR) from EMS paramedics at the scene were excluded. The variables of demographics and comorbidities, arrest location, identity of the bystander, cause of cardiac arrest, first monitored electrocardiographic (ECG) rhythm, and reason for TOR were investigated. We compared data for 1 year before and after the start of the COVID-19 pandemic. A total of 10,872 OHCAs with TOR were included in this study; of these, 6238 cardiac arrest cases were terminated without resuscitation attempts during the COVID-19 period compared to 4634 during the pre-COVID-19 period. During the COVID-19 period, the proportion of women in the total population decreased, while the median age increased (p &lt; 0.001). Patients with comorbidities, the frequency of asystole rhythm at first monitoring, and the number of witnessed cardiac arrests significantly increased (p &lt; 0.001). The proportion of TOR cases due to decisions made by a medical director and refusal of CPR by family members also significantly increased, while that due to clear evidence of death decreased (p &lt; 0.001). In conclusion, there was a significant change in the reason for TOR before and after the COVID-19 pandemic in Korea.

Clinical competencies of emergency medical services paramedics in responding to emergency conditions using Objective Structured Clinical Examination (OSCE) in Guilan

Objective: Evaluating the abilities of emergency medical services (EMS) staff who are in the frontline of the diseases could be an excellent reflection of the accuracy of curriculum both before and after graduation. This study was done to determine the clinical competencies of Guilan EMS staff in responding to emergency conditions using Objective Structured Clinical Examination (OSCE). Methods: In this descriptive study, 70 EMS staff from selected Emergency Centres in Guilan were recruited. Data were collected using a questionnaire and a checklist which included 9 different skills. Validity of the checklist was assessed by obtaining the opinions of 10 experts. The content validity index (CVI) and content validity ratio (CVR) of the checklist were 0.7 and 0.8, respectively. The reliability of the checklist was obtained using the test-retest method (r=0.89). In order to collect data, observations were done using the designated checklist. Data were analysed using SPSS software version 22 and descriptive statistical tests. Results: Findings showed that 56.3% of the paramedics got good scores for trauma competency but the mean scores for two competencies of spinal cord immobilization and vehicle extrication were low, indicating major skills problem. There was a statistically significant relationship between education (P=0.02) and work experience (P=0.03) as well as clinical skills in confronting trauma. Conclusion: Although the EMS staff had an acceptable range of performance in most of the skills, it seems that there is a need for training of performance-based competencies in which paramedics had a poor performance.

Prehospital continuous positive airway pressure (CPAP) for acute respiratory distress: a randomised controlled trial

ObjectiveTo compare the efficacy of continuous positive airway pressure (CPAP) versus usual care for prehospital patients with severe respiratory distress.MethodsWe conducted a parallel group, individual patient, non-blinded randomised controlled trial...

Comparison of Prehospital Scales for Predicting Large Anterior Vessel Occlusion in the Ambulance Setting

The efficacy of endovascular thrombectomy (EVT) for symptomatic large anterior vessel occlusion (sLAVO) sharply decreases with time. Because EVT is restricted to comprehensive stroke centers, prehospital triage of patients with acute stroke codes for sLAVO is crucial, and although several prediction scales are already in use, external validation, head-to-head comparison, and feasibility data are lacking. To conduct external validation and head-to-head comparisons of 7 sLAVO prediction scales in the emergency medical service (EMS) setting and to assess scale feasibility by EMS paramedics. This prospective cohort study was conducted between July 2018 and October 2019 in a large urban center in the Netherlands with a population of approximately 2 million people and included 2 EMSs, 3 comprehensive stroke centers, and 4 primary stroke centers. Participants were consecutive patients aged 18 years or older for whom an EMS-initiated acute stroke code was activated. Of 2812 acute stroke codes, 805 (28.6%) were excluded, because no application was used or no clinical data were available, leaving 2007 patients included in the analyses. Applications with clinical observations filled in by EMS paramedics for each acute stroke code enabling reconstruction of the following 7 prediction scales: Los Angeles Motor Scale (LAMS); Rapid Arterial Occlusion Evaluation (RACE); Cincinnati Stroke Triage Assessment Tool; Prehospital Acute Stroke Severity (PASS); gaze-face-arm-speech-time; Field Assessment Stroke Triage for Emergency Destination; and gaze, facial asymmetry, level of consciousness, extinction/inattention. Planned primary and secondary outcomes were sLAVO and feasibility rates (ie, the proportion of acute stroke codes for which the prehospital scale could be reconstructed). Predictive performance measures included accuracy, sensitivity, specificity, the Youden index, and predictive values. Of 2007 patients who received acute stroke codes (mean [SD] age, 71.1 [14.9] years; 1021 [50.9%] male), 158 (7.9%) had sLAVO. Accuracy of the scales ranged from 0.79 to 0.89, with LAMS and RACE scales yielding the highest scores. Sensitivity of the scales ranged from 38% to 62%, and specificity from 80% to 93%. Scale feasibility rates ranged from 78% to 88%, with the highest rate for the PASS scale. This study found that all 7 prediction scales had good accuracy, high specificity, and low sensitivity, with LAMS and RACE being the highest scoring scales. Feasibility rates ranged between 78% and 88% and should be taken into account before implementing a scale.

Association between prehospital prognostic factors and out-of-hospital cardiac arrest: Effect of rural-urban disparities.

Out-of-hospital cardiac arrest (OHCA) is associated with a poor prognosis and a highly variable survival rate. Few studies have focused on outcomes in rural and urban groups while also evaluating underlying diseases and prehospital factors for OHCAs. To investigate the relationship between the patient's underlying disease and outcomes of OHCAs in urban areas versus those in rural areas. We reviewed the emergency medical service (EMS) database for information on OHCA patients treated between January 2015 and December 2019, and collected data on pre-hospital factors, underlying diseases, and outcomes of OHCAs. Univariate and multivariate logistic regression analyses were used to evaluate the prognostic factors for OHCA. Data from 4225 OHCAs were analysed. EMS response time was shorter and the rate of attendance by EMS paramedics was higher in urban areas (p<0.001 for both). Urban area was a prognostic factor for >24-h survival (odds ratio [OR]=1.437, 95% confidence interval [CI]: 1.179-1.761). Age (OR=0.986, 95% CI: 0.979-0.993). EMS response time (OR=0.854, 95% CI: 0.811-0.898), cardiac arrest location (OR=2.187, 95% CI: 1.707-2.795), attendance by paramedics (OR=1.867, 95% CI: 1.483-2.347), and prehospital defibrillation (OR=2.771, 95% CI: 2.154-3.556) were independent risk factors for survival to hospital discharge, although the influence of an urban area was not significant (OR=1.211, 95% CI: 0.918-1.584). Compared with rural areas, OHCA in urban areas are associated with a higher 24-h survival rate. Shorter EMS response time and a higher probability of being attended by paramedics were noted in urban areas. Although shorter EMS response time, younger age, public location, defibrillation by an automated external defibrillator, and attendance by Emergency Medical Technician-paramedics were associated with a higher rate of survival to hospital discharge, urban area was not an independent prognostic factor for survival to hospital discharge in OHCA patients.

Endotracheal intubation during out-of-hospital cardiac arrest: New insights from recent clinical trials.

Airway management is an important intervention during resuscitation of out‐of‐hospital cardiac arrest (OHCA). Endotracheal intubation is commonly used by emergency medical services paramedics in the advanced airway management of OHCA, but numerous studies question its safety and effectiveness. Furthermore, there is now increasing use of supraglottic airway devices. In this review, we provide an overview of 3 recent randomized clinical trials of advanced airway management (Pragmatic Airway Resuscitation Trial [PART], AIRWAYS‐2, and Cardiac Arrest Airway Management [CAAM]) and highlight new information that is available to guide OHCA airway management practices.

Feasibility of prehospital delivery of remote ischemic conditioning by emergency medical services in chest pain patients: protocol for a pilot study

BackgroundRemote ischemic conditioning (RIC) is a non-invasive procedure with hypothesized therapeutic benefits for patients experiencing an acute ST-elevation myocardial infarction (STEMI). Further study of emergency medical services (EMS) delivery of RIC in the prehospital setting is needed to inform the design and methods for future clinical trials of RIC in STEMI patients. The main objective of this pilot study is to assess the feasibility of prehospital delivery of RIC by EMS providers in the United States.MethodsWe will conduct a single-arm study of the standard RIC procedure (i.e., up to 4 cycles of alternating 5-min inflation and 5-min deflation of an upper arm cuff) administered by EMS paramedics in 50 patients experiencing acute onset chest pain. The investigational autoRIC® device (CellAegis Devices, Inc., Toronto, Ontario) will be initiated by paramedics during ground ambulance transport. Automated RIC cycles will continue through emergency department arrival and stay. The primary endpoint will be the completion of all 4 cycles of RIC without interruption. We will also examine study procedures and collect qualitative data from study participants and paramedics.DiscussionTo our knowledge, this will be the first study in the United States to assess the feasibility of completing the 40-min RIC procedure when initiated during ground ambulance transport. Findings from this pilot study will be used to optimize the design and methods for a future efficacy trial of RIC in acute STEMI patients.Trial registrationNCT03400579 (ClinicalTrials.gov). Registered on 17 January 2018.

Ketamine for Rapid Sedation of Agitated Patients in the Prehospital and Emergency Department Settings: A Systematic Review and Proportional Meta-Analysis

BackgroundRapid tranquilization of agitated patients can prevent injuries and expedite care. Whereas antipsychotics and benzodiazepines are commonly used for this purpose, ketamine has been suggested as an alternative. ObjectiveThe aim of this systematic review is to determine the safety and effectiveness of ketamine to sedate prehospital and emergency department (ED) patients with undifferentiated agitation. MethodsStudies and case series of patients receiving ketamine for agitation were included. Studies were excluded if ketamine was used for analgesia, procedural sedation, asthma, or induction. Information sources included traditional and gray literature. ResultsThe initial search yielded 1176 results from 14 databases. After review of titles and abstracts, 32 studies were reviewed and 18 were included in the analysis, representing 650 patient encounters. The mean dose of ketamine was 315 mg (SD 52) given intramuscularly, with adequate sedation achieved in 7.2 min (SD 6.2, range 2–500). Intubation occurred in 30.5% of patients (95% confidence interval [CI] 27.0–34.1%). In the majority of those patients, ketamine was administered by paramedics during ground transport and the patient was intubated on ED arrival. When ketamine was administered in the ED, the intubation rate was 1.8% (95% CI 0.0–4.4%); in air medical transport, the rate was 4.9% (95% CI 0.0–10.3%). Other reported side effects included: vomiting, 5.2% (2.3–8.1%); hypertension, 12.1% (5.7–18.6%); emergence reactions, 3.5% (1.4–5.6%); transient hypoxia, 1.8% (0.1–3.6%) and laryngospasm, 1.3% (0.3–2.3%). ConclusionsKetamine provides rapid sedation for undifferentiated agitated patients and is associated with higher intubation rates when used by ground Emergency Medical Services paramedics, compared with ED or air medical transport patients. Other side effects are common but usually self-limiting.

Developing a Complex Simulation Training Program for Emergency Medical Services Paramedics Using a High-Fidelity Simulation Model

Developing a Complex Simulation Training Program for Emergency Medical Services Paramedics Using a High-Fidelity Simulation Model

Emergency Medical Services as a Strategy for Improving ST-Elevation Myocardial Infarction System Treatment Times

BackgroundReducing delays in time to treatment is a key goal of ST-elevation myocardial infarction (STEMI) emergency care. Emergency medical services (EMS) are a critical component of the STEMI chain of survival. Study ObjectiveWe sought to assess the impact of the careful integration of EMS as a strategy for improving systemic treatment times for STEMI. MethodsWe conducted a study of all 747 nontransfer STEMI patients who underwent primary percutaneous coronary intervention (PCI) in Dallas County, Texas from October 1, 2010 through December 31, 2011. EMS leaders from 24 agencies and 15 major PCI receiving hospitals collected and shared common, de-identified patient data. We used 15 months of data to develop a generalized linear regression to assess the impact of EMS on two treatment metrics—hospital door to balloon (D2B) time, and symptom onset to arterial reperfusion (SOAR) time, a new metric we developed to assess total treatment times. ResultsWe found statistically significant reductions in median D2B (11.1-min reduction) and SOAR (63.5-min reduction) treatment times when EMS transported patients to the receiving facility, compared to self-transport. In addition, when trained EMS paramedics field-activated the cardiac catheterization laboratory using predefined specified protocols, D2B times were reduced by 38% (43 min) after controlling for confounding variables, and field activation was associated with a 21.9% reduction (73 min) in the mean SOAR time (both with p < 0.001). ConclusionActive EMS engagement in STEMI treatment was associated with significantly lower D2B and total coronary reperfusion times.

Comparison in Effectiveness and Safety Between a Supraglottic Airway Device and Endotracheal Intubation in Out-of-Hospital Cardiac Arrest in The Netherlands

Comparison in Effectiveness and Safety Between a Supraglottic Airway Device and Endotracheal Intubation in Out-of-Hospital Cardiac Arrest in The Netherlands

Validation of the Los Angeles Pre-Hospital Stroke Screen (LAPSS) in a Chinese Urban Emergency Medical Service Population

Background and purposeEarly and accurate diagnosis of stroke by emergency medical service (EMS) paramedics is critical for reducing pre-hospital delays. The Los Angeles pre-hospital stroke screen (LAPSS) has been widely used as a validated screening tool for early identifying stroke patients by EMS paramedics. However, validation of LAPSS has never been performed in Chinese stroke population. This study is aimed to verify the LAPSS for early identifying stroke patients in a Chinese urban EMS.Methods76 paramedics of five urban first aid stations attached to Beijing 120 EMS were involved. The paramedics were trained by professionals to quickly screen patients based on LAPSS. Potential “target stroke” individuals who met the base LAPSS screen criteria were identified. Sensitivity and specificity analyses of the LAPSS were calculated.ResultsFrom June 10, 2009 to June 10, 2010, paramedics transported a total of 50,220 patients. 1550 patients who met the baseline screen criteria were identified as the potential “target stroke” population. 1130 patients had the completed LAPSS information datasheet and 997 patients were clinically diagnosed with stroke. The average time of completing the LAPSS was 4.3±3.0 minutes (median, 5 minutes). The sensitivity and specificity of the LAPSS in this study was 78.44% and 90.22%, respectively. After adjusting for age factor by excluding patients of >45 years old, the sensitivity was significantly increased to 82.95% with specificity unchanged.ConclusionThe paramedics of Beijing 120 EMS could efficiently use LAPSS as a screening tool for early identifying stroke patients. While the sensitivity of LAPSS in Chinese urban patient population was lower than those reported in previous LAPSS validation studies, the specificity was consistent with these studies. After excluded the item of “Age>45 years”, the sensitivity was improved.

Use of an Impedance Threshold Device to Treat Severe Hypotension in a Pregnant Woman: Case Report and Review of the Literature

BackgroundImpedance threshold device technology harnesses the patient's normal physiological mechanisms to increase circulation during hypotensive crises. We report the first clinical use of one version of this device on a spontaneously breathing hypotensive pregnant woman. ObjectiveThe objective of our study was to report this case to help Emergency Medical Service rescue personnel to noninvasively treat hypotensive but conscious spontaneously breathing patients. Case ReportA 28-year-old woman who was 21 weeks pregnant developed frank syncope at home but recovered spontaneously. When Emergency Medical Service paramedics arrived, her initial blood pressure and heart rate were 115/80 mm Hg and 125 beats/min, respectively. She suddenly complained of feeling anxious and developed profound bradycardia and hypotension, followed by 20 s of asystole. An impedance threshold device (ResQGARDTM) with −7 cmH2O resistance to inspiration was rapidly applied using a facemask. After four spontaneous breaths, blood pressure increased from 62/40 mm Hg to 106/66 mm Hg. She was hemodynamically stable thereafter. ConclusionsIn this case report, the multiple physiological effects of inspiration through −7 cmH2O resistance helped this pregnant hypotensive patient to rapidly and noninvasively restore adequate perfusion and reduced the duration of her hypotensive episode. To our knowledge, this is the first report of this technology in a pregnant hypotensive but spontaneously breathing patient.

Practical use, effects and complications of prehospital treatment of acute cardiogenic pulmonary edema using the Boussignac CPAP system

BackgroundEarly use of continuous positive airway pressure (CPAP) has been shown to be beneficial within the setting of acute cardiogenic pulmonary edema (ACPE). The Boussignac CPAP system (BCPAP) was therefore introduced into the protocols of emergency medical services (EMS) in a large urban region. This study evaluates the implementation, practical use and complications of this prehospital treatment.MethodsThis was a retrospective case series study. The study was carried out in a period shortly after the implementation of the BCPAP system on all EMS ambulances in the The Hague region. According to protocol, diagnosis of ACPE in the prehospital setting was left to the discretion of the EMS paramedics and the facial mask was applied immediately after the diagnosis had been made. Patients were selected through hospital registration and diagnostic criteria for ACPE. Only those patients showing evident clinical signs of ACPE were included. Patient characteristics, physiologic variables, clinical outcomes and complications were collected from EMS transport reports and hospital records.ResultsBetween 1 June 2008 and 30 April 2009 a total of 180 patients were admitted for ACPE. Of these, 76 (42%) had evident clinical signs of ACPE upon presentation and were included. Three patients were transferred and in 14 cases data were missing. Out of the remaining 59 patients, 16 (27%) received BCPAP. In 43 (73%) cases the mask was not applied. For 7 out of 43 cases that were eligible for BCPAP treatment but did not receive the facial mask, an explanation was found in the EMS transport record. No complications were recorded pertaining to using the BCPAP system.ConclusionsA significant portion of patients with clinical signs of acute cardiogenic pulmonary edema in the prehospital setting is not treated according to protocol using BCPAP. Based on the small group of patients that actually received BCPAP treatment, the facial mask seems feasible and effective for the treatment of acute cardiogenic pulmonary edema in the prehospital setting.

Advanced medical life support procedures in vitally compromised children by a helicopter emergency medical service

BackgroundTo determine the advanced life support procedures provided by an Emergency Medical Service (EMS) and a Helicopter Emergency Medical Service (HEMS) for vitally compromised children. Incidence and success rate of several procedures were studied, with a distinction made between procedures restricted to the HEMS-physician and procedures for which the HEMS is more experienced than the EMS.MethodsProspective study of a consecutive group of children examined and treated by the HEMS of the eastern region of the Netherlands. Data regarding type of emergency, physiological parameters, NACA scores, treatment, and 24-hour survival were collected and subsequently analysed.ResultsOf the 558 children examined and treated by the HEMS on scene, 79% had a NACA score of IV-VII. 65% of the children had one or more advanced life support procedures restricted to the HEMS and 78% of the children had one or more procedures for which the HEMS is more experienced than the EMS. The HEMS intubated 38% of all children, and 23% of the children intubated and ventilated by the EMS needed emergency correction because of potentially lethal complications. The HEMS provided the greater part of intraosseous access, as the EMS paramedics almost exclusively reserved this procedure for children in cardiopulmonary resuscitation. The EMS provided pain management only to children older than four years of age, but a larger group was in need of analgesia upon arrival of the HEMS, and was subsequently treated by the HEMS.ConclusionsThe Helicopter Emergency Medical Service of the eastern region of the Netherlands brings essential medical expertise in the field not provided by the emergency medical service. The Emergency Medical Service does not provide a significant quantity of procedures obviously needed by the paediatric patient.

Prehospital Intubation: The Right Tools in the Right Hands at the Right Time

David Lockey, FRCA, FIMC, RCS (Ed)† In this issue of the journal, Cobas et al. report that paramedics in the metropolitan area of Miami, Florida, had problems in 31% of all intubation attempts on trauma patients. It is highly likely that there are similar results in other emergency medical service (EMS) systems, but many may be reluctant to publish negative results. These clinicians in Miami, Florida, are therefore to be congratulated for placing these serious problems into the public spotlight. The observations from Miami, Florida, are in strong contrast to a previous prehospital study in Bordeaux, France, where senior emergency physicians had intubation problems in only 3% of the cases. This suggests that a significant factor in successful out-of-hospital advanced airway management may be the experience and training of the individual providers. The helicopter EMS paramedics in the study by Cobas et al. had greater success in airway management than their paramedic colleagues working in ground EMS units. This is not surprising because helicopter EMS personnel usually respond to more major trauma cases than their ground EMS colleagues and perform advanced airway management more often. Accordingly, they may also have more experience with alternative airway devices. For example, in Bordeaux, France, experienced emergency physicians used the intubating laryngeal mask airway device in 3% of patients with intubation difficulties (45 of 2082); of these, 96% could be ventilated with the rescue device (43 of 45). Thus, combining tracheal intubation with one single alternative airway device resulted in nearly 100% success rate in advanced airway management (2080 of 2082). In contrast, the patients in Miami, Florida, were managed in a rescue strategy with a laryngeal tube as an alternative airway device; interestingly, this group had the worst outcome. It may well be that, rather than demonstrating the different success rates of alternative airway devices, these results may simply be the surrogate marker for an extremely difficult airway situation, with a corresponding poor outcome. In general, the less experienced a rescuer is in advanced airway management, the more likely he or she is to need to use alternative airway devices. However, he or she is less likely to be successful using these devices. The question of which specific airway device should be used at which time has not been answered. Hypoxia in the field may develop rapidly, and the use of airway rescue techniques may again merely be a surrogate marker for bad outcome in patients with difficult airways, decreased physiological reserve, and more severe injury. There is reason to believe that hypoxia may develop more quickly in the field than during the administration of routine anesthesia in the operating room. This is due to hypoventilation, shock, and increased oxygen consumption. For example, although 4 min of oxygen administration increased Pao2 from 80 to 400 mm Hg during scheduled anesthesia, the corresponding increase in unstable emergency patients was only from 67 to 104 mm Hg Pao2. 4