Paramedic Units Research Articles

Prehospital Treatment of Atrial Fibrillation: Infusion Pump for Bolus and Infusion?

Objective The prehospital treatment for stable patients with atrial fibrillation with rapid ventricular response is rate-controlling agents such as calcium channel blockers, often diltiazem given as a bolus. At our agency we encourage the use of a bolus given via the infusion pump over two to four minutes immediately followed by a maintenance infusion, given concerns of recurrent tachycardia or hypotension secondary to rapid bolus administration. We examined if administering a bolus and infusion via an infusion pump shows better heart rate (HR) control at arrival to the emergency department (ED) compared with administration of a bolus only, while maintaining hemodynamic stability during transport. We also analyzed if a patient received a second bolus within 60 min of arrival to the ED. Methods We used a retrospective propensity-matched cohort of prehospital patients with atrial fibrillation for whom diltiazem was administered, from 1/1/2018 to 12/31/2021, in our system of 10 New Jersey paramedic units. We analyzed the age, gender, and initial HR and used it to match groups. We analyzed the mode and time of administration, dosage of the bolus, and presence of hypotension prehospitally. Results The matched groups contained 145 patients who received a prehospital diltiazem bolus only (BO) and 146 patients who received a diltiazem bolus and infusion (BI). There was no significant difference between the mean change in HR from initial paramedic arrival to ED arrival between the two groups (BO 38 vs. BI 34, p = 0.16). There was no significant difference in the need for a second bolus within the first 60 min of arrival to the ED (BO 9.7% vs. BI 11.6%, p = 0.30). Patients in the BO group were more likely to experience prehospital hypotension then in the BI group (BO 17.2% vs BI 8.2%, p = 0.01), despite receiving smaller initial bolus doses (BO 14.2 mg vs. BI 17.4 mg, p < 0.001). Conclusion Our results show no significant differences in HR control or need for repeat bolus at the ED with the use of a diltiazem infusion following a diltiazem bolus. However, even when administering larger boluses, the use of an infusion pump resulted in less hypotension.

High ​performance prehospital ​airway ​management: Raising the ​bar with ​education, ​rapid ​sequence ​intubation, ​suction ​assisted ​laryngoscopy ​airway ​decontamination, ​video ​laryngoscopy, and ​skills ​proficiency

BackgroundOur prehospital EMS system has focused on prehospital airway management, with the advent of rapid sequence intubation and video laryngoscopy. Through education and continuous quality improvement intubation success rates using the “Glidescope Go” device have continued to improve and remain the primary tool for airway management in our system. ObjectiveOur objective was to demonstrate how education, rapid sequence intubation (RSI), suction-assisted laryngoscopy airway decontamination (SALAD), video laryngoscopy (VL), and skills proficiency can be used together to systemically improve paramedic airway management success to nearly 100%. MethodsStudy Design: Retrospective cohort of airway management procedures performed by paramedics on prehospital patients. Setting: 10 New Jersey paramedic units. Population: Patients that had airway management completed by paramedics from 1/1/2020 to 12/31/2021. Data Analysis: We analyzed the use of RSI, first pass intubation success rates, overall intubation success rates, supraglottic airway use (i-gel®), and overall airway management success rates. Historical annual first pass success rates are also included for context. ResultsThe database contained 990 patients. Of these patients the first pass intubation success rates were 92.7% over the study period. The overall intubation success rates were 98%, and intubation success rates using RSI were 99%. Backup supraglottic airways were placed in remaining cases, bringing overall airway management success rates to 99.5%. ConclusionWe found that paramedic intubation success rates using SALAD and VL were at 98%. A prehospital airway management strategy focused on education and skills proficiency can minimize the risk of this important skill and has potential to improve patient outcomes.

Patients Seeking Retreatment after Community Paramedic Assessment and Treatment: Piloting a Community Paramedic Unit Program in Southwest Finland

Community paramedic (CP) units are becoming more popular in enhancing a person’s access to the need for care assessment and treatment in acute but non-life-threatening health issues. Simultaneously CP units can reduce the strain on emergency departments (EDs) by treating patients effectively at home. The efficacy of CP units is proven in previous studies, but the details of conditions patients seek retreatment at the ED after a CP unit visit are largely unknown. This study aimed to categorize CP unit patients (n = 229) seeking retreatment after a CP unit visit and investigate links between CP unit actions and patients seeking retreatment. The study was based on a data set from a six-month CP unit pilot program in Finland. The main results show that 82% of the patients assessed and treated by the CP unit did not seek retreatment. Low back symptoms and nausea were the main problems patients presented to the ED within 96 h after the CP visit. On-call physician consultation (p = 0.335) or CP unit treatment time (p = 0.629) were not associated with the frequency of ED presentation. Further studies are needed in order to investigate which types of emergency medical missions are the most suitable for CP units. The findings of this study support the effectiveness of community paramedicine programs.

Buprenorphine Field Initiation of ReScue Treatment by Emergency Medical Services (Bupe FIRST EMS): A Case Series

The opioid epidemic is currently a leading health crisis in the United States, and evidence supports Medication for Opioid Use Disorder (MOUD) as the most effective treatment (2). In our EMS system we are observing an ever increasing number of patients who, due to refusing transport after naloxone rescue, represent an access void at the point of overdose. We present a case series to illustrate a new treatment paradigm utilizing front line EMS paramedic units and high dose buprenorphine to treat withdrawal symptoms with next day bridge to long term care. The three patients described are exemplary cases, meant to represent overall characteristics of the intervention prior to complete data collection. Each patient was revived from opioid overdose with naloxone. Paramedics then treated each patient with 16 mg of buprenorphine to relieve and prevent withdrawal symptoms. Patients were provided with outpatient follow up irrespective of ED transport. To the best of our knowledge, this is the first EMS agency in the United States providing MOUD in the prehospital setting at the point of overdose. This innovative program provides EMS with education and tools to promote patient engagement. While still in its infancy, this approach utilizes existing EMS resources to bring MOUD to the prehospital setting, offering a new avenue to long term care. Keywords: Opioid, buprenorphine, emergency medical services, medication assisted therapy, naloxone, overdose

Articles That May Change Your Practice: Dexmedetomidine

Sedation is commonly used in the intensive care unit (ICU) to reduce patient discomfort, improve tolerance with mechanical ventilation, reduce metabolic demands during respiratory and hemodynamic instability, and prevent accidental device removal. Delirium is a serious complication and has been associated with increased morbidity, prolonged hospital stay, worse functional recovery, and long-term decline in cognitive function. Moreover, recent studies showed that delirium was associated with increased short- and long-term mortality in patients admitted to ICUs. For decades, gamma-aminobutyric acid (GABA) receptor agonists (including propofol and benzodiazepines) have been the standard of care for sedation in the ICU. However, evidence suggests these agents may increase the risk of delirium. Russell D. MacDonald, MD, MPH, FCFP, FRCPC, is the medical director at Ornge Transport Medicine; medical director at Toronto Paramedic Services; an associate professor in the Faculty of Medicine at the University of Toronto; and an attending staff member at Sunnybrook Health Sciences Centre in Toronto, Ontario, Canada. He can be reached at [email protected] Adam Greene, BHSc, CCP, is the critical care paramedic unit chief at British Columbia's Emergency Health Services in Vancouver, British Columbia, Canada.

Looking back 70 years at the evolution of the paramedic

As the National Health Service (NHS) celebrates its 70-year-anniversary this month, Douglas Chamberlain, founder of the first paramedic unit in Europe, looks back at the evolution of the paramedic since the NHS was founded in 1948.

Weekly Checks Improve Real-Time Prehospital ECG Transmission in Suspected STEMI.

This was a natural experiment of consecutive patients with field-identified STEMI transported to a single percutaneous coronary intervention (PCI)-capable hospital in a regional STEMI system before and after implementation of scheduled test ECG transmissions. In November 2014, paramedic units began weekly test transmissions. The mobile intensive care nurse (MICN) confirmed the transmission, or if not received, contacted the paramedic unit and the department's nurse educator to identify and resolve the problem. Per system-wide protocol, paramedics transmit all ECGs with interpretation of STEMI. Receiving hospitals submit patient data to a single registry as part of ongoing system quality improvement. The frequency of successful ECG transmission and time to intervention (FMC2B and D2B times) in the 18 months following implementation was compared to the 10 months prior. Post-implementation, the time the ECG transmission was received was also collected to determine the transmission gap time (time from ECG acquisition to ECG transmission received) and the advanced notification time (time from ECG transmission received to patient arrival). There were 388 patients with field ECG interpretations of STEMI, 131 pre-intervention and 257 post-intervention. The frequency of successful transmission post-intervention was 73% compared to 64% prior; risk difference (RD)=9%; 95% CI, 1-18%. In the post-intervention period, the median FMC2B time was 79 minutes (inter-quartile range [IQR]=68-102) versus 86 minutes (IQR=71-108) pre-intervention (P=.3) and the median D2B time was 59 minutes (IQR=44-74) versus 60 minutes (IQR=53-88) pre-intervention (P=.2). The median transmission gap was three minutes (IQR=1-8) and median advanced notification time was 16 minutes (IQR=10-25). Implementation of weekly test ECG transmissions was associated with improvement in successful real-time transmissions from field to hospital, which provided a median advanced notification time of 16 minutes, but no decrease in FMC2B or D2B times. D'ArcyNT, BossonN, KajiAH, BuiQT, FrenchWJ, ThomasJL, ElizarrarazY, GonzalezN, GarciaJ, NiemannJT. Weekly checks improve real-time prehospital ECG transmission in suspected STEMI. Prehosp Disaster Med. 2018;33(3):245-249.

Tracking and Accident Detection in Automobiles Using GPS and GSM Technology

This paper describes the design and development of an automatic tracking and accident detection (ATAD) system in automobiles. Oman rated as the highest causality in road accidents among GCC, according to figures released by the World Health Organization (WHO). Lack of proper reporting about the exact location add delay in paramedic unit to reach, results the loss of precious human life. The proposed single-board in-vehicle embedded system equipped with the SIM28M GPS to get geographic coordinates, SIM800 GSM modem to send the Google map link as text message, SW-420 vibration sensor to sense the collision, and the ATmega328P microcontroller as core processing unit. The vibration beyond the threshold level, say during collision is detected by the vibration sensor and this information is transferred to the microcontroller. The microcontroller gets the latitude and longitude from the GPS receiver. This coordinates send as Google map link through the GSM modem to the concern persons whose mobile numbers are stored in the memory. This text message directly loads the exact location in Google map instead of searching the location using the coordinates. This saves a precious time and victim may receive the immediate medical attention. This ATAD system serves as a complete portal to exchange information such as, real-time navigation of vehicle location, monitoring of collision, update of geographic coordinates on-demand or at regular interval and fuel shutdown using servomotor on command in case of theft.

The Menopausal Symptoms of Paramedics at a Tertiary Care Center

Objective: To assess paramedic menopausal symptoms on theinpatient unit and outpatient unit.Methods: This was a cross sectional study. Data collect by fill thequestioner, the questioner fill by menopausal paramedic on Prof. Dr.R. D. Kandou Manado Hospital from October 2016 to January 2017.Data were analyzed using SPSS 22.0 for Windows.Results: Of 60 paramedics, 30 were divided to inpatient unit andthe other 30 were divided to outpatient unit. By the menopauserating scale, somatic and urogenital complaint in statistical testhave no significant differences. Psychology complaint with a moderatecomplaints on inpatient unit have 19 paramedic (63%) and12 paramedic (40%) on outpatient paramedic, in statistical havea significant differences (x2=9.62, p=0.022). On the total scoremenopausal complaints, the moderate complaints 18 paramedic(60%) on the inpatient unit and the minor complaints 21 paramedic(70%) on the outpatient unit, in statistical have a significantdifferences (x2=6.97, p=0.031).Conclusion: There is no significant difference in somatic andurogenital complaints on paramedic inpatient unit and outpatientunit. There is a significant difference in psychological complaintsand total score menopausal complaints on paramedic inpatientunit and outpatient unit.[Indones J Obstet Gynecol 2017; 5-4: 208-212]Keywords: menopause, menopause rating scale, paramedic

Validation of the pre-hospital Qatar Early Warning Score (QEWS) to determine transport priority

Background: Ambulance Paramedics are dispatched to all calls while Critical Care Paramedic (CCP) units only attend potentially “life threatening” cases (Priority 1). Ambulance Paramedics (AP) triaged patients based on clinical judgment and experience creating a risk of Priority 1 under or over-triage. QEWS was designed to supplement priority decision-making process based on physiological values used as a trigger to identify patients with a potential risk of deterioration. The objective of this study was to undertake a comparison of the QEWS score calculated from retrospective vital signs data to that of the priority decision-making by ambulance crews. Methods: In our retrospective study, data entered into the Ambulance Service clinical database over a nine-month period before QEWS implementation was analysed for comparison of the priority decision made by the crew for each patient versus the calculated QEWS value based on the first set of six relevant vital signs (Heart rate, Respiratory rate, Systolic blood pressure, Temperature, Oxygen saturation, AVPU). Only cases with patients over 18 years old were included. Results: Of 34,908 retrieved cases, 27,915 (79.97%) had sufficient data to retrospectively determine QEWS. The mean age was 38.62 (+15.84) years and 21,453 (76.85%) were male patients. Priority decision-making correlated in 25,850 cases (92.6%), with 286 (1.11%) Priority 1 and 25,564 (98.89%) Priority 2 patients. In 1,662 cases (5.95%), QEWS retrospectively triaged patients higher and in 1.44%, QEWS triaged patients lower. Conclusions: Physiological variables are an established predictor of risk regarding a patient's condition. Hospital-based early warning scores have been validated and implemented successfully. Only one published pre-hospital scoring system has been validated for triage. Under-triage appears to be a common problem in medical patients. QEWS potentially could address this under-triage issue and appears to be a valid scoring system to implement for prioritising patients to routine or urgent transport, or CCP intervention.

Successful Resuscitation: Novel Partnership between Paramedics and U.S. Coast Guard

In this article, we present a notable case that illustrates a novel partnership between a United States Coast Guard small boat station and a civilian paramedic response unit. Patients who experience medical emergencies in remote environments are at particularly high risk for morbidity and mortality. For the most serious conditions, delayed contact with Advanced Life Support (ALS) has grave results. Typically, these circumstances involve small groups of individuals and cannot be easily predicted. The waters off the coasts of Maui, Hawaii, however, host millions of residents and visitors annually, with activities including swimming, snorkeling, diving, parasailing, and other types of ocean recreation. As a result, medical and rescue emergencies are not uncommon, many with poor outcomes. Prior to October of 2013, a Coast Guard response boat crew with limited medical training and equipment responded to most off shore cases. Since October 2013, a paramedic from Maui County EMS co-responds aboard the Coast Guard boat with a full complement of ALS equipment. This partnership has resulted in some significant improvements in patient outcome, and strengthened a collaborative emergency services system. The experience has also indicated the need for continued improvement in early activation and communication, as well as reinforcing the importance of primary prevention.

Consumer perspectives of a community paramedicine program in rural Ontario.

To evaluate a community paramedicine program in rural Ontario, Canada, through the perceptions and experiences of consumers. An observational ethnographic approach was used to acquire qualitative data through informal discussions, semi-structured interviews and direct observation of interactions between consumers and community paramedics. The study was conducted in rural Ontario where a community paramedicine program has been established consisting of four components: ad hoc home visiting, ageing at home, paramedic wellness clinics and community paramedic response unit. Fourteen adult consumers participated, representing all program components. Consumer satisfaction and perceived benefits. Three main interlinked themes were identified: (i) improved health monitoring and primary health care access close to home; (ii) improved sense of security and support for vulnerable residents in the community; and (iii) improved consumer education and empowerment for enhanced health management. Consumers' reflections on their experiences and perceptions of a rural community paramedicine program indicate acceptance of paramedics in non-traditional preventative health care roles. This supports the desirability of investigating the potential development of community paramedicine programs in rural Australia to meet identified health service needs.

Optimal dispatching strategies for emergency vehicles to increase patient survivability

A major focus of emergency medical service (EMS) systems is to save lives and to minimise the effect of an emergency health incident. The objective of this research is to determine how to optimally dispatch paramedic units to emergency calls to maximise patients’ survivability. We formulate the problem as Markov decision process to obtain the optimal dispatching policies. These dispatching policies are developed incorporating the degree of the urgency of the call. The optimal policy provides an ordered preference (priority) list of ambulances to dispatch. The performance of the proposed dispatching rules is evaluated in terms of patients’ survivability rather than measuring the response time thresholds, as survival probability more directly mirrors patient outcomes. Computational examples show that dispatching the closest vehicle is not always optimal and that dispatching vehicles considering the priority of the call leads to an increase in the average survival probability of patients.

Challenges in the design and analysis of non-inferiority trials: a case study

The literature on the design, conduct, and analysis of non-inferiority trials is continuously evolving. Several design issues continue to be researched including the choice of active control, choice of non-inferiority margin, and optimal analytic approaches. To date, there has been relatively little in the literature documenting actual experiences with implementing available methodology for non-inferiority trials. This article serves as a case study and highlights some of the challenges encountered in the design of a Phase III non-inferiority trial in status epilepticus that is being conducted under a Food and Drug Administration Investigational New Drug Application (IND). The IND application was put on clinical hold by the Food Drug and Administration due to concerns with the design. Specifically, support for the active control, non-inferiority margin, and overall interpretability of trial results were questioned, and a recommendation was made to consider a superiority design. The authors describe their interactions with the Food Drug and Administration and their application of available methods and approaches to address these concerns. The investigators' response to the clinical hold provided detailed information to support the conduct of a non-inferiority trial. The study team received Food Drug and Administration approval to initiate the trial in October 2008. The trial enrollment began in June 2009 and is being conducted by roughly 800 paramedic units in over 40 Emergency Medicine Service systems across the United States. There is still a great deal of methodological research needed to fully understand the application and impact of the non-inferiority trial design. It is evident that non-inferiority trials have an important place in clinical trial design and analysis. These trials may be the only way and only opportunity to answer certain questions; so, they must be designed and conducted with rigor. This case study is an attempt to share our experiences in implementation.

Can wikis be used to support case-based learning in paramedic education?

Higher education has seen a rapid increase in the use of Web 2.0 applications, such as wikis, blogs, podcasts and vodcasts. While their use and integration has been investigated by other cognate and non-cognate disciplines, this has yet to be formally undertaken by the paramedic discipline. Therefore, this article describes a pilot study that examines the student use of wikis to support case-based learning (CBL) within a Bachelor of Emergency Health (BEH) degree at Monash University. The aim of this study is to report student attitudes on group work using wikis during weekly CBL activities. Methods: a cross-sectional study using a convenience sample of second year undergraduate students enrolled in the BEH degree were surveyed using a short paper-based self-reporting questionnaire focused on attitudes towards wikis. Included with the questionnaire was a brief set of demographic questions. Results: overall, participants reported positive attitudes and perceptions towards the use of wikis and peer-based learning during the weekly clinical cases. For example, item 1: ‘I found the group wiki useful in completing the team task’ reported a median score of 3 (IQR 2-3), while item 3: ‘using wiki encouraged better participation of each group member in the case’ reported a median score of 2 (IQR 2-3). Despite the positive results, there were areas that require further attention such as social loafing, and development of a more flexible learning management system. Conclusion: although findings from this study are preliminary, it appears that wikis are a useful addition to CBL in paramedic clinical units. Further research is warranted using a larger sample size, and integrated and compared across both clinical and non-clinical units. Closer examination of discrete pedagogical issues such as peer- and self-based learning is also necessary, particularly with the increasing use of educational technology being used throughout higher education.

Cutting-edge Discussions of Management, Policy, and Program Issues in Emergency Care

Cutting-edge Discussions of Management, Policy, and Program Issues in Emergency Care

Prehospital intervention probability score: a novel method for determining necessity of emergency medical service units

Objective This article models use of emergency medical services (EMS) within a defined geographical area. Our goal was to develop an original quantitative method to delineate the need for EMS units within a geographical population. Methods Use of the EMS system within 11 municipalities was analyzed in 2007. The geospatial distributions of interventions during this year were examined, as well as the population dynamics of the region. A statistical model to determine the probability of an individual within the call area requiring an intervention was proposed using weighted population statistics and the application of an intervention probability. Results The observed interventional probability increased exponentially with age, notably after the age of 75. Areas with higher proportions of elderly residents had substantially higher rates of intervention and EMS use. Municipality H had the largest age-group of 20 to 24 years with an intervention probability of 0.34% (95% confidence interval [CI], 0.24-0.44), their more than 85-year age-group also had the largest intervention probability of 19.54% (95% CI, 15.60-23.48). Conclusions Contrary to current practice patterns of placing paramedic units in regions of greatest population density, we established a formula based on population vs intervention probability. We found the actual numbers of interventions performed are not dependent solely on population size but also are affected by the age of the population being served. This is particularly relevant to growing elderly communities. This determination will aid in the disbursement of limited prehospital resources in regions by improving availability of EMS personnel.

Do All Pediatric Patients Who Have a Febrile Seizure Require Transport by Advanced Life Support?

In the state of New Jersey, all pediatric patients who are transported to the hospital by emergency medical services for seizures are evaluated by both advanced life support (ALS) and basic life support (BLS) units. The state triage protocol mandates that a paramedic unit be dispatched. The purpose of this study is establish that the subset of those patients who experience simple febrile seizures could be safely transported by BLS, subsequently freeing much needed ALS resources. This study was performed using a retrospective chart review. Seventy-one consecutive patients who experienced febrile seizures and were transported to the Bristol-Meyers-Squib Children's Hospital/Robert Wood Johnson University Hospital via ALS were included. These patients were risk stratified into groups which were analyzed for interventions, including inpatient admission, medication delivery, intubation, or respiratory support. From this analysis, we are identified factors in the history and physical examination of patients in the field that would help to classify the patient as having a "simple febrile seizure" and thus significantly lowering the risk of any potential negative outcome. Simple febrile seizure patients are suitable for transport via BLS. Further studies should be done to confirm this conclusion.

Convergence

Convergence

Prehospital temperature control

We have increasingly noted that patients with traumatic injuries attended by the paramedic response unit of the Durban University of Technology, South Africa are hypothermic. Daytime winter temperatures in Kwa-Zulu...