Paramedic System Research Articles

An International Community Paramedic Career Structure

Introduction - Internationally, prehospital workers practice in a wide range of community paramedicine roles. It can be unclear where community paramedics fit within existing paramedicine career structures and their professional capabilities are sometimes ill-defined or misunderstood. This study aimed to clarify some of these questions through the development of a community paramedic career structure and descriptions of their professional capabilities at different levels of practice. Methods - The career structure was developed on the premise that paramedicine is an evolving autonomous health discipline. It was designed through the synthesis of the paramedicine literature, key regulatory frameworks, and advice from two panels of international community paramedicine experts. These purposively recruited panellists comprised practicing community paramedics, students and educators, professional leaders, and subject matter experts. Thematic analysis was undertaken of their open-text on-line questionnaire responses. After feedback from the first panel a paramedic system modernization continuum was used to fashion community paramedic career structures to meet the needs of paramedic systems at different stages of development. These structures were tested with members of the second panel. Findings - A five-step career structure was designed and conceptually separated into two distinct but related pathways to facilitate international comparability across paramedic systems in terms of professional autonomy and levels of education. Structural and cultural characteristics are represented through professional capability statements and indicative education levels that are incorporated into a paramedic system continuum ranging from directive to professionally autonomous paramedic systems. Discussion - Although this study was conducted through the lens of community paramedicine, it might further international discussion of how attractive career structures could improve paramedic retention more broadly. Successful implementation of this career structure requires the support of key stakeholders in the face of strong structural and cultural barriers that continue to challenge innovations designed to respond to changing opportunities and needs in paramedicine.

The association between paramedic service system hospital offload time and response time.

To address an important care issue in Canada, we tested the association between paramedic system hospital offload and response time, while considering the impact of other system-level factors. Data from Calgary, Alberta (2014-2017), included median offload (exposure) and response (outcome) time aggregated by hour, with covariates paramedic system episodes of care-dispatch and arrival of a response unit-and hospital transport arrivals (collectively called volume), time of day, and season. Analyses used linear regression and modified Poisson models. 301,105 EMS episodes of care over 26,193 1-h periods were included. For any given 1-h period, the median (IQR) across all episodes of care for offload time, response time, episodes of care, and hospital transport arrivals were 55.3 (45.7, 66.3) min, 8.6 (7.6, 9.8) min, 12 (8, 16) episodes, and 8 (5, 10) hospital arrivals, respectively. Multivariable modelling revealed a complex association differing over levels of exposure and covariates, requiring description using "light stress" and "heavy stress" system scenarios. The light scenario was defined as median offload of 30min and volume < 10th percentile (six episodes and four hospital arrivals), in the summer, and the heavy scenario as median offload of 90min and volume > 90th percentile (17 episodes and 13 hospital arrivals), in the winter. An increase is reported in minutes:seconds for median hourly response time between scenarios by time of day: 1:04-4:16 (0000-0559h.), 0:42-2:05 (0600-1159h.), 0:57-3:01 (1200-1759h.), and 0:18-2:21 (1800-2359h.). Increasing offload is associated with increased response time; however the relationship is complex, with a greater impact on response time noted in select situations such as high volume in the winter. These observations illustrate the interdependence of paramedic, ED, and inpatient systems and provide high-yield targets for polices to mitigate the risk to community availability of paramedic resources at times of high offload delay/system stress.

Shaping the future design of paramedicine: A knowledge to action framework to support paramedic system modernization

BackgroundOver the past two decades, the demands placed on modern paramedic systems has changed. Paramedic services can no longer continue to operate on a traditional response model where more ambulances are deployed to meet the rising demand of patients calling for their health needs. Recent research has explored system design in paramedicine and its relationship with organizational performance. Two subsequent paramedic systems have been identified with one, the Professionally Autonomous paramedic system, being linked to higher performance. Yet, how to operationalize this model for system modernization continues to be a gap in practice. ObjectiveTo provide health leaders and policy makers with a framework from which to drive paramedic system modernization. MethodsThis study uses the Knowledge to Action framework to develop an implementation plan for systems that seek to modernize their service delivery model toward that of a Professionally Autonomous paramedic system. ResultsA detailed plan of the steps required to undertake system transformation are outlined. Whilst this framework outlines the components required for system modernization, it does not propose an in-depth outline of each of the steps required to achieve each component. Rather, end users are encouraged to develop individual implementation plans tailored to the local context using the comprehensive tools outlined within. ConclusionThis knowledge to action framework provides health leaders and policy makers with a uniform roadmap for paramedic system modernization intended to improve health (clinical) outcomes as well as health system outcomes through the Professional Autonomous paramedicine model.

No Two Systems Are the Same: Paramedic Perceptions of Contemporary System Performance Using Prehospital Quality Indicators.

Introduction In recent years, researchers have identified two new models of paramedicine within the Anglo-American paramedic system known as the Directive and Professionally Autonomous paramedic systems. The research team now seek to compare paramedic perception of system performance between the two systems using prehospital quality indicators. Methods Paramedics employed within Anglo-American paramedic systems undertook a survey evaluating their experience and perception of system performance against a set of modified prehospital quality indicators. Data were collected using a survey combining single-choice questions with matrix multiple-choice questions. Key results were cross-tabulated with demographic (informant) and system factors to compare performance between the two new paramedic systems. Results The survey indicated a substantial difference in perceived clinical and operational performance between the Professionally Autonomous and Directive paramedic systems, with the Professionally Autonomous paramedic system performing consistently better in all 11 prehospital quality indicator domains. Conclusion The results of this survey are a vital step in helping paramedics, health leaders, and academics understand the complex relationship between paramedic system design and system performance, and, for the first time, provides empirical evidence upon which to make a conscious decision to adopt one system or the other.

A conceptual framework for the exploration of the relationship between systems of paramedicine and system performance

BackgroundOver the past 60 years since its inception, the Anglo-American Paramedic System has continued to grow and evolve. While brief and fragmented accounts of the differences between systems have been noted in the literature, until recently there has been a paucity of research that explores and identifies sub-models of paramedicine within the Anglo-American Paramedic System. ObjectivesThis article describes a conceptual framework that sets a roadmap for defining and comparing two newly identified sub-models of the Anglo-American Paramedic System. MethodsA conceptual framework for the exploration of these novel sub-models was developed on the basis of the work completed by Donabedian as well as Turncock and Handler. These two sub-models worked to develop a model for quality assessment and performance measurement in the public health system. ResultsThe conceptual framework consists of six components that are strongly related to each other: system design, macro context, mission and purpose, structure, service delivery models and quality outcome measures. While this framework relates specifically to two novel paramedic systems known as the Professionally Autonomous an Directive paramedic systems, it can be used to measure any integrated health model. ConclusionThe conceptual framework described in this paper provides a stepwise roadmap for the definition and comparison of the newly identified paramedic systems to better inform future research that defines and compares paramedic system design and performance.

Exploring the structure and characteristics of the Anglo-American paramedic system in developed countries: a scoping review

PurposeThis study aims to map and examine the existing evidence to provide an overview of what is known about the structure and characteristics of the Anglo-American paramedic system in developed countries.Design/methodology/approachThe review includes results examining the structure and characteristics of the Anglo-American paramedic system in English-speaking developed countries. Databases, including Embase, MEDLINE, Web of Science, EBSCOhost, CINAHL, Google Scholar and Epistemonikos, were searched from the inception of the databases. A grey literature search strategy was conducted to identify non-indexed relevant literature along with forward and backward searching of citations and references of included studies. Two reviewers undertook title and abstract screening, followed by full-text screening. Finally, data extraction was performed using a customised instrument. Included studies were summarised using narrative synthesis structured around broad themes exploring the structure and characteristics of the Anglo-American paramedic system.FindingsThe synthesis of information shows that varying models (or subsystems) exist within the Anglo-American paramedic system. The use of metaphorical models based on philosophical underpinnings are used to describe two novel subsystems within the Anglo-American paramedic system. These are the professionally autonomous and directive paramedic systems, with the directive model being further categorised into the rescue and hospital-managed submodels.Originality/valueThis study is the first of its kind to explore the modern subcategorisation of the Anglo-American paramedic system using a realist lens as the basis for its approach.

Defining two novel sub models of the Anglo-American paramedic system: A Delphi study

IntroductionWhile brief and fragmented accounts of the differences between systems have been noted in the literature, until recently there has been a lack of research that explores and identifies new sub-models of paramedicine within the Anglo-American paramedic system. MethodsA Delphi method was used to gain consensus among international paramedic experts regarding two new models of paramedicine known as the Directive and Professionally Autonomous paramedic systems. Following the development of a preliminary definition, a set of questions were established for experts aimed at defining the new sub-models; the responses were reviewed and amended based on feedback before being re-distributed to an expanded group of participants for further rounds of questions. Rounds continued until consensus was achieved. ResultsConsensus was achieved for both statements regarding the Professionally Autonomous paramedic system definition in round 2, 85.7% (n = 18). Following analysis and revision of the definition, the additional two statements regarding the Directive paramedic system achieved consensus in round 3, 100% (n = 19). ConclusionThis Delphi study was the first study to explore a standardised definition for two newly identified sub-models of the Anglo-American paramedic system with the overall results used to help inform high performing system design for modern Anglo-American paramedic systems into the future.

An Inter-Agency Expert Panel's Prioritisation of Clinical Quality Improvement Topics in a Paramedic System

Introduction Quality improvement (QI) programs have become common in paramedic systems, but they are often limited to individual agencies. Modern paramedicine involves many different agencies and inter-agency QI programs would better reflect their co-operative efforts. Similarly, inter-agency use of clinical outcome measurements can offer system level performance data. This study's intent was to explore the feasibility of planning an inter-agency QI program that uses outcome measures. Methods This study used a modified Delphi methodology. A 49-member panel of inter-agency representatives was convened to identify and prioritise clinical outcome-based topics. Over a 3-month period, two online surveys were conducted followed by a 1-day face-to-face meeting. Results The study demonstrated very high participation rates. Results progressed from an initial wide range of 38 topics to a final consensus of two: infection/sepsis and patient safety/care pathways, complete with outcome measures. Conclusion Inter-agency quality improvement planning is an under investigated area, but this study demonstrates that it is feasible. Additionally, this planning can incorporate clinical outcome measures that inform system level discussions about quality. Other paramedic agencies may draw on the study's processes when planning their own quality improvement programs.

Task-shift Model in Pre-hospital Care and Standardized Nationwide Data Collection in Japan: Improved Outcomes for Out-of-hospital Cardiac Arrest Patients.

Out-of-hospital cardiac arrest (OHCA) is a growing worldwide public health concern. Previously, Japan experienced poorer outcomes among OHCA patients than in other high-income countries. In the early 1990s, through policy changes, the Japanese government introduced a task-shift model in pre-hospital care. Some medical practices previously provided by physicians exclusively were delegated to non-physicians, including laypeople. Additionally, we initiated a nationwide data collection system for evaluation. We started a nationwide registry of OHCA patients, a paramedic system to provide advanced life-support care, and basic life-support training for laypeople. In the 2000s, the procedures paramedics could provide were expanded, laypeople were allowed to use automated external defibrillators, and the Utstein style was introduced to the national registry.Consequently, pre-hospital advanced care and bystander first-aid increased, registry-based research contributed to evidence-based practices, and―most importantly―outcomes of OHCA patients considerably improved. These Japanese experiences demonstrate that streamlining pre-hospital care, including bystander interventions and standardized data collection, can improve OHCA patient outcomes. Despite this progress, however, there still exist many issues to be addressed in response to the changing and increasing care demands within Japan’s aging population.

Advanced Care or Advanced Life Support – What are we Providing?

The field of paramedicine has undergone significant change and modernisation over the past 50 years. Presently there are no consistent terms or lexicon used across the profession to describe different levels of advanced practice. This inconsistency risks creating confusion as the professionalisation of paramedic practice continues. As well, many empirical studies support the claim that communication and the importance of managing language actively plays a crucial role in supporting change and in shaping the new paradigm. Therefore, the way one uses communication, and the deliberate choice of words to describe advance practice, will support change in the desired direction. This article explores these terms and their attendant influences on perceptions of practice to argue for change towards the standardised use of the term ‘advanced care paramedic’ across the Anglo-American paramedic system.

北海道道南圏における「指導的救急救命士」の導入とその効果 ―地方での救急救命士生涯教育への取り組み―

北海道道南圏における「指導的救急救命士」の導入とその効果 ―地方での救急救命士生涯教育への取り組み―

Canadian Paramedic Experience with Intramuscular Ketamine for Extreme Agitation: A Quality Improvement Initiative

Background There are no published reports in Canada examining paramedic use of ketamine for highly agitated patients or excited delirium syndrome. We employed a Plan, Do, Study, Act (PDSA) quality improvement approach to evaluate the safety and effectiveness of advanced care paramedic administered intramuscular (IM) ketamine for patients with extreme agitation in the out-of-hospital setting. Methods Data were prospectively collected from July 2018 to January 2019 when advanced care paramedics with specific training administered IM ketamine as an alternative to midazolam. Paramedics used a clinical audit form to document the ketamine dose, patient response on the Richmond Agitation Sedation Scale (RASS) at time intervals, adverse effects, and any airway management interventions they performed. Results Thirty-three patients received either 4 mg/kg or 5 mg/kg of ketamine. Combining data for both doses, the median change in RASS score at 5 minutes post-ketamine was 3 (range 0 to 8) and statistically significant for each dose. There were seven cases (21%) with reported adverse effects including SpO2 &lt;90% (3/7), hypersalivation (3/7), trismus or teeth grinding (2/7), muscular rigidity (1/7) and laryngospasm (1/7). Statistical analysis confirmed that the incidence of adverse events was not dose dependent. Basic airway management was performed in one-third of all cases. Conclusion We piloted the implementation of ketamine for sedation in our paramedic system by employing a PDSA cycle. Ketamine 5 mg/kg IM provided effective control of acutely agitated patients with adequate sedation at 5 minutes post-delivery. Any adverse events that occurred as a result of IM ketamine were readily managed with basic airway management interventions.

The Structure and Characteristics of Anglo-American Paramedic Systems in Developed Countries: A Scoping Review Protocol

Introduction Paramedicine has undergone significant change in the past two decades. While the Anglo-American paramedic system continues to grow there appears to be a dearth of published literature regarding modern categorisation of this evolving paramedic system. The objective of this scoping review is to examine and map the existing evidence to provide an overview of the characteristics and structural similarities and differences of Anglo-American paramedic systems in English-speaking developed countries. Methods Databases, including Embase, MEDLINE, Web of Science, EBSCOhost, CINAHL, Google Scholar and Epistemonikos, will be searched from inception. A grey literature search strategy has also been developed to identify non-indexed relevant literature. Citations and references of included studies will also be searched. Two reviewers will undertake title and abstract screening, followed by full text screening. Data extraction will be conducted using a customised instrument. Inclusion criteria: results examining management, leadership or governance in paramedicine related to the Anglo-American paramedic model in English-speaking developed countries will be included in the review. Included studies will be summarised using narrative synthesis structured around themes of management, leadership and governance in paramedicine.

A Model for an Efficient Paramedic System in Towns and Cities

A Model for an Efficient Paramedic System in Towns and Cities

Assessing the Prevalence and Predictors of Bullying Among Emergency Medical Service Providers

Background: Bullying as a stressor in the workplace has been evaluated in numerous settings. It has never been evaluated in the emergency medical service (EMS) environment where bullying can occur from many different sources. The Negative Acts Questionnaire-Revised (NAQ-R) is a 22-question validated tool for evaluating bullying. Our hypothesis was that we could identify a shortened version of the NAQ-R that identifies bullying as accurately as the full screening tool. Methods: This was a cross sectional study of EMS providers in our local EMS transport agency. The local EMS agency transports approximately 50,000 patients per year and is a paramedic level response system. Results on the NAQ-R were on a 5-point Likert scale for each of 22 different categories of bullying that were summed by adding each questions 1–5 response for the 22 questions. Respondents were also categorized as victims or non-victims of bullying based on being positive for any of the 22 types of bullying at least once a week. We performed a binomial decision tree analysis and a cross-validation. Results: Data were collected from 153 providers. Mean age was 33 ± 10 years and 50% were male. Total years in EMS were 8 ± 8 years. NAQ-R summed results in our group ranged between 22 and 88, with an average of 40 ± 15. A NAQ-R score of 33 or less was 91% accurate in identifying non-victims and a score of 45 or more was 94% accurate in identifying victims. The majority at 51% (77/152) of respondents were victims of one or more types of bullying. A combination of five questions was 94% accurate in identifying a victim of bullying among EMS providers. Cross validation resulted in a misclassification risk estimate of 0.12 ± .03. Conclusion: NAQ-R bullying scores in EMS are similar or higher than numbers in other fields. Five questions on the NAQ-R were 94% accurate in identifying victims of bullying in EMS providers.

Paramedics and professionalism: Looking back and looking forwards

Journal of Paramedic PracticeVol. 5, No. 1 CommentParamedics and professionalism: Looking back and looking forwardsAnna van der Gaag, John DonaghyAnna van der GaagSearch for more papers by this author, John DonaghySearch for more papers by this authorAnna van der Gaag; John DonaghyPublished Online:16 Aug 2013https://doi.org/10.12968/jpar.2013.5.1.8AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Donaghy J (2011) The student experience of university paramedic education/training-from classroom learning to situational understanding. In preparation for the award of Professional Doctorate in Education (EdD). University of Hertfordshire (unpublished). This document is available on request from the author. Google ScholarFreidson E (2004) Professionalism, the third logic. Polity, Cambridge Google ScholarFurber R (2008) Curriculum Guidance and Competency Frameword (2nd Edn). College of Paramedics, Bridgewater Google ScholarHPC (2011) Professionalism in healthcare professionals. www.hpc-uk.org/assets/documents/10003771Professionalisminhealthcareprofessionals.pdf (accessed 14 December 2012) Google ScholarLave J and Wenger E (1991) Situated Learning: legitimate Peripheral Participation. Cambridge University Press, Cambridge Crossref, Google ScholarMcLachlan, John C et al. (2009) The Conscientiousness Index: A Novel Tool to Explore Students’ Professionalism. Academic Medicine. Issue: Volume 84(5): 559–65 Crossref, Google ScholarMorrow G et al. (2011) Professionalism in healthcare professionals. Health and Care Professions Council ./?mode=pdetail&id=8494&sid=8494&pdetail=69983 (accessed 4 January 2013) Google ScholarPapadakis MA, Hodgson CS, Teherani C et al. (2004) Unprofessional behavior in medical school is associated with subsequent disciplinary action by a state medical board’, Academic Medicine. 79: 244–9 Crossref, Google ScholarQuality Assurance Agency (2004) Benchmark Statement. The Quality Assurance Agency, Gloucestershire Google ScholarWenger E (1998) Communities of practice: Learning, Meaning and Identity, Cambridge University Press Crossref, Google Scholar FiguresReferencesRelatedDetailsCited byDefining two novel sub models of the Anglo-American paramedic system: A Delphi studyAustralasian Emergency Care, Vol. 25, No. 3Community paramedicine: cost–benefit analysis and safety evaluation in paramedical emergency services in rural areas – a scoping review9 June 2022 | BMJ Open, Vol. 12, No. 6Overcoming Stigma of Mental Illness in Paramedicine: A Model for Future Practice30 January 2023 | Australasian Journal of Paramedicine, Vol. 19A bibliometric analysis of paramedicine publications using the Scopus database: 2010–2019International Emergency Nursing, Vol. 59The psychometric properties of the professionalism at work questionnaire for paramedicine students6 January 2021 | International Journal of Emergency Services, Vol. 10, No. 2Community paramedicine—cost–benefit analysis and safety with paramedical emergency services in rural areas: scoping review protocol25 September 2020 | BMJ Open, Vol. 10, No. 9Professionalism and Professionalisation in the Discipline of Paramedicine1 January 2019 | Australasian Journal of Paramedicine, Vol. 16The role of the mentor in professional knowledge development across four professionsInternational Journal of Mentoring and Coaching in Education, Vol. 7, No. 1Community paramedicine model of care: an observational, ethnographic case study2 February 2016 | BMC Health Services Research, Vol. 16, No. 1Striving for the professionalisation of Australian paramedics29 September 2013 | International Paramedic Practice, Vol. 3, No. 3The role of the Health and Care Professions Council29 September 2013 | Journal of Paramedic Practice, Vol. 5, No. 7 14 January 2013Volume 5Issue 1ISSN (print): 1759-1376ISSN (online): 2041-9457 Metrics History Published online 16 August 2013 Published in print 14 January 2013 Information© MA Healthcare LimitedPDF download

Physician staffed helicopter emergency medical service dispatch via centralised control or directly by crew – case identification rates and effect on the Sydney paediatric trauma system

BackgroundSevere paediatric trauma patients benefit from direct transport to dedicated Paediatric Trauma Centres (PTC). Parallel case identification systems utilising paramedics from a centralised dispatch centre versus the crew of a physician staffed Helicopter Emergency Medical Service (HEMS) allowed comparison of the two systems for case identification rates and subsequent timeliness of direct transfer to a PTC.MethodsPaediatric trauma patients over a two year period from the Sydney region with an Injury Severity Score (ISS) > 15 were retrospectively identified from a state wide trauma registry. Overall paediatric trauma system performance was assessed by comparisons of the availability of the physician staffed HEMS for patient characteristics, transport mode (direct versus indirect) and the times required for the patient to arrive at the paediatric trauma centre. The proportion of patients transported directly to a PTC was compared between the times that the HEMS service was available versus the time that it was unavailable to determine if the HEMS system altered the rate of direct transport to a PTC. Analysis of variance was used to compare the identifying systems for various patient characteristics when the HEMS was available.ResultsNinety nine cases met the inclusion criteria, 44 when the HEMS system was operational. Patients identified for physician response by the HEMS system were significantly different to those that were not identified with higher median ISS (25 vs 18, p = 0.011), and shorter times to PTC (67 vs 261mins, p = 0.015) and length of intensive care unit stays (2 vs 0 days, p = 0.045). Of the 44 cases, 21 were not identified, 3 were identified by the paramedic system and 20 were identified by the HEMS system, (P < 0.001). Direct transport to a PTC was more likely to occur when the HEMS dispatch system was available (RR 1.81, 95% CI 1.20-2.73). The median time (minutes) to arrival at the PTC was shorter when HEMS available (HEMS available 92, IQR 50-261 versus HEMS unavailable 296, IQR 84-583, P < 0.01).ConclusionsPhysician staffed HEMS crew dispatch is significantly more likely to identify cases of severe paediatric trauma and is associated with a greater proportion of transports directly to a PTC and with faster times to arrival.

50: Emergency Medical Service in the Czech Republic

The aim of this presentation to bring out the organization of a out-of-hospital emergency care in the Czech republic with concentration on out-of-hospital emergency care in the region of South Moravia. Out-of-hospital emergency care is different in Europe in comparison with the U.S.A. Czech Republic as a Central Europe state does not practice a paramedic system as in the U. S. A., but medical doctor arrives to the patient. Czech legislative determinate arrive of medical teams at patients to 15 minutes. In accordance with this Czech legislation there were established stations of EMS (Emergency Medical Service) teams. Authors are employees of the EMS of South Moravia. This region is 7 196,5 km2 area [1/2 Havay island‘s] with population of 1.130.000 [Havay island’s]. There are 600 employees in 23 EMS stations with 41 EMS teams per days. EMS crews are organized as an Emergency Medical Team [EMT], Emergency Rescuer Team [ERT] and Helicopter Emergency Medical Team [HEMT].

Life or death. The social impact of paramedics and first responders in landmine-infested villages in northern Iraq

Landmines are indiscriminate weapons that mainly injure poor populations in the developing world. Pre-hospital treatment by village-based paramedics and first responders has reduced mortality, but little is known about the social impact of paramedic and first responder training in villages. The aim of this study was to understand how villagers in socially deprived, mine-infested villages experience the establishment of paramedic and first responder chains of survival. The study used focus-group interviews conducted in four villages in northern Iraq, to explore villagers' perceptions of the impact of paramedic and first responder training. The material was analyzed using grounded theory, with the main category identified entitled 'life or death', with three subcategories: 'living on the edge', 'demanding equal rights', and 'adapting to new needs'. The paramedics were perceived by the villagers as having a large impact on the social life of the village, first as an emergency medical resource, and also as a prerequisite for the villages' continued existence. The system represented one of the few services offered by outside society to villages that lacked health care, schools, electricity, roads, and clean water. Despite an improved economic situation in the larger society, conditions in the villages had deteriorated. Although originally intended as an emergency care system for land mine victims, the system was adapted to include the role of a general medical resource in the villages. This adaptation was perceived as useful by the villagers, and necessary for their continued trust in the system. A prerequisite for this adaptation was that the program coordinator was a villager himself, and that the program deviated from its originally fixed time period. This flexibility depended on very close cooperation between expatriate and local program managers. Our findings indicate that the paramedic system made a wider impact than just the provision of emergency health care. The program earned trust through a strong local anchor, and by adapting to the needs of the population served.

Rescue shock outcomes during out-of-hospital cardiac arrest

Questions remain about the optimal timing and method for treating ventricular fibrillation (VF) during out-of-hospital cardiac arrest, and a variety of treatment protocols are used. Detailed description of rescue shock outcomes during actual patient care under different protocols would allow rational comparison of treatment strategies. The purpose of this study is to describe rescue shock outcomes in a single system using a specific defibrillation protocol. Patient care records were examined for all adult (age> or =18 years) out-of-hospital cardiac arrest cases treated by an urban paramedic system during a 52-month interval. The immediate outcomes of monophasic rescue shocks were determined from the record and were classified as asystole, VF, restoration of organized electrical activity (ROEA), or restoration of spontaneous circulation (ROSC). Among 1496 cases of cardiac arrest, 654 received a median of 3 (IQR 1,5) rescue shocks. Of these cases, 408 (28%) had an initial rhythm of VF whereas VF developed later during resuscitation in the remainder. For an initial series of three escalating rescue shocks, most cases of ROSC (9%) and ROEA (12%) occurred after the first shock. The likelihood that a rescue shock would result in ROSC or ROEA increased with witnessed collapse, and rescue shock number. An initial rhythm of asystole was associated with a decreased likelihood that a rescue shock would result in ROEA. Witnessed collapse and an initial rhythm other than asystole were associated with an increased likelihood of rescue shock success. There is a small but real incremental gain in ROSC and ROEA from delivering three rescue shocks in rapid succession. The greater incidence of rescue shock success with later rescue shocks suggests that VF responds favorably to ongoing resuscitation.