Prehospital Medical Care Research Articles

032. Prehospital Medical Care in Disasters in Lithuania: When to Use Special Medical Rescue Groups?

032. Prehospital Medical Care in Disasters in Lithuania: When to Use Special Medical Rescue Groups?

368 MULTIPLE TRAUMA IN CHILDHOOD: REVIEW OF 130 CASES

Trauma remains the leading cause of death in the pediatric age group, despite recent advances in prevention and treatment. In this study we retrospectively analyzed 130 multiple trauma pediatric patients out of 726 pediatric patients with simple injuries treated at Rambam Medical Center during the years 1988-1989. Road accidents and falls from height were the most common causes of injury. Mean age was 7 years (range 0.5 to 15 years) with male to female ratio of 2.7:1. Overall mortality in this series was 9.2%. Fifty seven patients (44%) did not get any prehospital medical care and 5 of them with Injury Severity Score (ISS) >25 - all died. In contrast 11/18 (61%) patients with ISS>25 who were treated by medical teams survived. On arrival to the Emergency Room 15% of patients were hypothermic (<34°c). Six were in hypovolemic shock - all of them died. Most common injuries included: Head trauma (n=91), limb injuries (n=69), abdominal trauma (n=34) and thoracic trauma (n=34). Severe injury with Pediatric Trauma Score (PTS) <=6 was found in 39 patients and 12 of them died. All deaths were associated with ISS>25 and severe head injury. There was no mortality in patients with PTS>=7 or ISS<25. In conclusion: 1.the prehospital care of pediatric patients has a great impact on survival. 2. Multiple trauma in pediatric patients with head injury is associated with a high mortality rate. 3. No mortality of patients with PTS > 7 emphasizes the importance of designated trauma centers for these patients.

After Hurricane Andrew. An EMS perspective.

This manuscript serves as a brief overview of the prehospital and emergency medical care delivery system in the area devastated by Hurricane Andrew. There is unlimited information available from the hundreds of workers, both paid and volunteer, as well as, the residents and victims of the hurricane.

Ethical challenges in emergency medical services. A special contribution of the Ethics Committee, National Association of Emergency Medical Services Physicians.

Patient autonomy, beneficence, and justice are the fundamental ethical principles of an emergency medical service. Ethical conflicts are present in the daily practice of prehospital care. These conflicts surround issues of resuscitation, futile therapy, consent, and refusal of care, duty, and confidentiality. Emergency medical services must remain fair and equitable, equally available to those it is designed to serve, regardless of the patient's social or economic status. Establishing priorities for patient care is dictated by medical and operational concerns. Education and information regarding ethical issues are important for the providers of prehospital medical care as well as the medical director. Policies and protocols must continue to be developed to address requests to limit resuscitation, such as refusal of care and patient confidentiality. Policies should be developed in conjunction with experienced legal advice. Current training does not equip even the most advanced prehospital care provider to deal easily with every potential situation. Many learn by experience, some are guided by clear policy. Ideally, medical control personnel will be educated, interested, and available to address dilemmas which arise. Where possible, policies and procedures should be developed to address ethical issues which are likely to be faced by EMS personnel.

Diagnosis of Premature Ventricular Complexes: Common and Often Forgotten Rules

Prehospital and hospital emergency medical care providers frequently rely on the electrocardiogram (ECG) to assist them in the differential diagnosis of complex patient problems and as such, the ECG often constitutes a major determinant of the definitive treatment selected. The purpose of this exercise is to review a small portion of the vast area of ECG interpretation: specifically, those rules that guide the practitioner in the diagnosis of Premature Ventricular Complexes (PVCs).Premature ventricular complexes (PVCs) occur in multiple individuals in multiple settings. Due to these differences, the causes, implications, and treatment of PVCs must be individualized. Thus, the scope possible for this discussion is huge. Consequently, this exercise will focus only on helping the practitioner correctly identify PVCs.

Roles of a helicopter emergency medical service in mass casualty incidents

The Connecticut helicopter emergency medical service (HEMS) has responded to 12 mass casualty incidents (MCI) in two years. Eight were drills and four were actual events. An MCI response plan was instituted prior to the onset of the HEMS program. All MCIs were reviewed to determined actual victims, knowledge of MCI prior to lift-off, and roles of the HEMS. The actual roles were compared with the pre-established roles. The four actual MCIs (building expolosion, hotel fire, bus rollover and plane crash) were reviewed. Sixty-seven victims were involved. Prenotification occurred in one MCI. The roles of the HEMS in each MCI were: triage {n=4}, medical treatment {n=}, transport {n=3}, augmented response {n=1}, and air surveillance {n=0}. The roles of HEMS response to MCI should be well-defined prior to an event. Air medical benefits include response within a large geographic area, highest level of prehospital medical care, identification of trauma receiving hospitals, and facilitation of transport.

Mid-year report

The Connecticut helicopter emergency medical service (HEMS) has responded to 12 mass casualty incidents (MCI) in two years. Eight were drills and four were actual events.An MCI response plan was instituted prior to the onset of the HEMS program. All MCIs were reviewed to determined actual victims, knowledge of MCI prior to lift-off, and roles of the HEMS. The actual roles were compared with the pre-established roles. The four actual MCIs (building expolosion, hotel fire, bus rollover and plane crash) were reviewed. Sixty-seven victims were involved. Prenotification occurred in one MCI. The roles of the HEMS in each MCI were: triage {n=4}, medical treatment {n=}, transport {n=3}, augmented response {n=1}, and air surveillance {n=0}.The roles of HEMS response to MCI should be well-defined prior to an event. Air medical benefits include response within a large geographic area, highest level of prehospital medical care, identification of trauma receiving hospitals, and facilitation of transport.

The Need for a Prehospital DNR System

Initiation of cardiopulmonary resuscitation when the death is the result of an end-stage, irreversible, and imminently terminal illness against the patient's prior request is immoral and indefensible. Medical providers should withhold treatments that are futile, and individuals have the right to refuse this invasive therapy.The use of Do-Not-Resuscitate (DNR) orders has become a standard of medical care in health care institutions and should be incorporated into the prehospital medical care system. The American College of Emergency Physicians (ACEP) supports their use, and the National Association of Emergency Medical Services Physicians (NAEMSP) has developed a consensus paper endorsing the use of prehospital DNR orders. The Joint Commision on the Accreditation of Hospitals (JCAH) recommends the use of DNR orders and the American Heart Association (AHA), in Standards and Guidelines for Advanced Cardiac Life Support, recognizes their validity. It is time for EMS systems to develop and implement policies and procedures, with adequate safeguards, to allow the withholding of CPR in specific circumstances. The claim that DNR orders cannot be honored in the prehospital setting is a self-fulfilling prophecy. If an emergency medical services (EMS) system lacks strong medical leadership or believes that a prehospital DNR system cannot work–a communitywide DNR program never will come into existence. Dying patients will continue to suffer the indignity and burden of unnecessary and futile treatments that serve no benefit to the patient and only serve to alienate and anger the family members.

Prehospital Fluid Administration in Trauma

Emergency Medicine has become an accepted specialty in the medical community, and with the recognition has come the responsibility for those of us who teach and practice it to study our clinical practices. We must be satisfied that our clinical judgments are well- founded, not only in emergency departments, but also in our special role as providers of prehospital medical care. With the advent of trauma centers and Advanced Trauma Life Support (ATLS) training, the pivotal issues of the prehospital care of the trauma victim, and the timeliness of transporting these patients to appropriate receiving hospitals have resulted in a pair of recurring criticisms in the medical literature.

Implementation of a computerized management information system in an urban fire department

An important aspect in the effective management of an emergency medical services system is the ability to monitor system performance. To provide this information on a timely basis, a comprehensive data collection system is required. We describe the design, implementation, use, and effect of a comprehensive, computerized data retrieval system within an urban fire department. Building on a data collection system already in place, it was possible to minimize the cost and accelerate the training process. A comparison is included between the different type of systems available for use with prehospital providers. Use of prehospital data collection systems results in more in-depth understanding of system operations and the status of prehospital medical care provided to the community.

California EMSC project establishes guidelines for rural pediatric emergency care.

As part of a grant demonstration project of the California Emergency Medical Services for Children (EMSC), Northern California Emergency Medical Services, Inc.(NCEMS) became involved in the assessment ,of pediatric emergency care in the rural communities of northeastern California. NCEMS is a private, nonprofit public benefit corporation that regulates prehospital emergency medical care by contractual agreement with 10 counties. This area encompasses more than 32,ooO square miles and has a population of approximately 500,CGO people. farmlands and rugged mountain terrain; primary industries are logging, farming, and tourism. The medical community parallels the population density of the region. There are 21 hospitals, with at least one hospital in each county. The bed capacity of the individual hospitals ranges from 8 to 200. Ten of the hospitals have a bed capacity of 30 or less. There are 21 emergency departments, 7 licensed as basic emergency departments and 14 licensed as standby. A trauma center that serves the southern portion of the region was designated in September of 1988. m=‘F OF IYIEEDS The EMSC project was initiated in May 1986; under the direction of James Seid,el, MD, ‘PhD, of Harbor-UCLA Medical Center, and funded in part by a grant from the U.S. Department of Health and Human Services, Health Resources and.Services Administration. * The project had a goal that concentrated primarily on the collection of data on pediatric emergencies and the development of a model for pediatric emergency medical services in rural and urban areas. Our efforts were focused on the management of children by both prehospital care providers and emergency departments in rural areas. We wanted to know specifically how many children we were caring for, what they were treated for, and the outcome of the care given in the NCEMS area. When we began our assessment of “what is,” we found that there were 21 pediatricians in the region and no pediatric surgeons or pediatric critical care specialists. Two counties were without any pediatricians, and four counties had only one each. The other 17 pediatricians practiced in the remaining two counties, which have the higher population densities. There were no pediatric intensive care units. Only two facilities had any formalized pediatric critical care within their adult intensive care unit.

A new model for providing prehospital medical care in large stadiums.

To determine proper priorities for the provision of health care in large stadiums, we studied the medical incident patterns occurring in a major college facility and combined this with previously reported information from four other large stadiums. Medical incidents were an uncommon occurrence (1.20 to 5.23 per 10,000 people) with true medical emergencies being even more unusual (0.09 to 0.31 per 10,000 people). Cardiac arrest was rare (0.01 to 0.04 events per 10,000 people). However, the rates of successful resuscitation in three studies were 85% or higher. The previous studies were descriptive in nature and failed to provide specific recommendations for medical aid system configuration or response times. A model is proposed to provide rapid response of advanced life support care to victims of cardiac arrest. We believe that the use of this model in large stadiums throughout the United States could save as many as 100 lives during each football season.

Severe anaphylactic reactions outside hospital: etiology, symptoms and treatment.

Twenty-seven patients with severe anaphylactic reactions were treated by two anesthesiologist-staffed ambulance helicopters during a 5-year period. All patients had signs of respiratory and/or circulatory failure. Cutaneous symptoms were described in 70% of the patients, gastrointestinal symptoms in 30% and central nervous symptoms in 85%. Wasp sting and drugs were the most common causes. Other etiologies were bee sting, snakebite, nuts and exercise. All patients were provided with advanced pre-hospital medical care. Epinephrine was employed in 78% of the patients. I.v. fluid therapy was started in 77%. Three patients (11%) needed endotracheal intubation. The time-span from onset of symptoms to medical attendance exceeded 45 min in two patients; both died. Of the surviving patients, 23 were hospitalized. The majority had no signs of respiratory or circulatory failure on arrival in the emergency room and needed only observation in the hospital.

Protocols for prehospital emergency medical care, 2nd edition

Protocols for prehospital emergency medical care, 2nd edition

Physician at the scene of an emergency.

Growth and maturation in the delivery of prehospital emergency medical care has been dramatic in the past 15 years. The increased availability and use of emergency medical services (EMS) has led to more frequent interactions between providers of prehospital care and the medical practitioner. This paper reviews the training and capabilities of emergency medical personnel and introduces the issue of medical control at the scene of an emergency. Also presented are the basics of emergency scene and victim stabilization. Physicians can help improve prehospital care by becoming familiar with local EMS capabilities and personnel.

Emergency Medicine in the United States. Role in Disaster Planning and Management

International organizations such as the World Association for Emergency and Disaster Medicine (Club of Mainz) have brought attention to the need for improved worldwide emergency medical services (EMS) systems and disaster preparedness (1). Similar concerns in the United States (US) for improved emergency medical care have resulted in the organization of emergency medicine as a new medical specialty (2). The practice of this specialty of medicine in some ways differs from the practice of emergency medicine, reanimation medicine, or resuscitology, in Europe. In the United States, emergency medicine specialists provide emergency care for the full range of emergency health conditions, including accidents and trauma, medical emergencies, toxicologic emergencies, psychiatric and social emergencies, and disasters. This care is provided primarily in hospital emergency departments and includes the immediate initial recognition, evaluation, treatment and disposition of these patients with acute illness and injury. For continuing care, patients are referred to their own physicians.Emergency medicine physicians provide medical direction for community EMS and supervise the prehospital emergency medical care provided by non-physicians (emergency medical technicians and paramedics). Emergency physicians engage in the administration, research and teaching of all aspects of emergency medical care. They also provide consultation to governmental and nongovernmental organizations on emergency health care issues. Recently, with the basic framework of emergency medicine established, attention is being given to disaster planning and management.

Altitude Illness

Septic shock is associated with hypovolemia resulting in organs failure and poor prognosis. The first step in hemodynamic resuscitation relies on early fluid expansion. In this study, we describe qualitative and quantitative fluid resuscitation of septic shock initially managed in a pre-hospital setting by a mobile intensive care unit.Patients with septic shock who received pre-hospital medical care were retrospectively analysed. Qualitative and quantitative fluid resuscitation performed in the pre-hospital setting were analysed. Applying the "grey zone" concept, we define 3 categories of fluid expansion indexed on ideal body weight (IBW): >20ml/kg, 10-20ml/kg and < 10ml/kg. The relationship between the pre-specified categories and mortality at day 28 were analyzed.Ninety-five patients were included. The origin of sepsis was mainly pulmonary (68%). Mortality reached 34%. Pre-hospital fluid expansion was performed using serum saline (98%) with a mean of 1158±559ml. An inversed linear relationship between pre-specified categories and mortality was observed. Using logistic regression model, significant association with mortality remained for fluid expansion indexed on IBW: p=0.02, ORa [CI95] = 0.93 [0.89-0.98]. For fluid expansion indexed on IBW < 10ml/kg, the OR [CI95] was 4.03 [1.78-9.41] (p=0.005) whereas for fluid expansion indexed on IBW > 20ml/kg, the OR [CI95] was 0.30 [0.13-0.66] (p=0.01).Pre-hospital fluid resuscitation in septic shock is mainly performed using crystalloids with quantitative fluid expansion lower than recommended. Low pre-hospital fluid expansion was associated with increased mortality. Further prospective studies are needed to evaluate the impact of optimized early fluid expansion on mortality in the prehospital management of septic shock.

The parkmedic program: Prehospital care in the national parks

The Parkmedic Program provides training and on-going supervision of national park rangers involved in advanced prehospital medical care in Yosemite, Kings Canyon, and Sequoia National Parks in California. This includes intravenous catheterization and drug administration in emergency situations. Course structure, experience to date, and recommendations for future programs are presented.

Medical control--what is it?

Medical control is essentially divided into three phases: prospective, immediate and retrospective. Adequate medical supervision of any paramedic system is necessary to guarantee quality of medical care. Anything short of physician control of prehospital medical care would be to abdicate our responsibilities to our patients.

A Rapid Response System for Out-Of-Hospital Cardiac Emergencies

We have reviewed several aspects of our initial 5 years' experience with an out-of-hospital emergency medical care system. This system is stratified and provides for rapid primary response and, when indicated, secondary response by specially trained paramedical personnel. Patient care is physician-supervised and closely monitored. Although considerable attention has been directed to acute complications of ischemic heart disease, particularly the problem of sudden cardiac death, the system is broadly based and responds to all medical emergencies. We are impressed with the ability of nonphysicians to acquire certain medical skills and judgment. Indeed, the effectiveness of this system is largely dependent on paramedical personnel. Such systems of prehospital emergency medical care will probably have an impact greater than that of hospital coronary care units in reducing the mortality from ischemic heart disease.