Prehospital Medicine Research Articles

Linking Competency with Training Needs: Session Summary on Disaster Studies and Evaluation, Session BO-17.

This section of Prehospital and Disaster Medicine (PDM) presents reports and summaries of the 19th World Congress on Disaster and Emergency Medicine (WCDEM) held in Cape Town, South Africa in April of 2015. Abstracts of Congress oral and poster presentations were published in April 2015 as a supplement to PDM (Volume 30, Supplement 1). Reports and session summaries of the 19th World Congress on Disaster and Emergency Medicine.

Is Australasia producing too many emergency physicians? No.

Is Australasia producing too many emergency physicians? No.

Ultrasound in pre-hospital trauma care

Pre-hospital medicine is developing rapidly. Increasingly, specialist pre-hospital medical practitioners are working in this environment and paramedics are advancing their skill base. Tools traditionally associated with hospital care are now used pre-hospital to improve diagnosis and intervention. In this paper, we assess the developing role of ultrasound in improving trauma care in the pre-hospital arena. Focused ultrasound is used to facilitate early diagnosis of pneumothorax and intraperitoneal/pericardial haemorrhage in trauma victims. Ultrasound may have a role in assessing the circulating blood volume, fracture diagnosis and triage in mass casualty scenarios. Information obtained using ultrasound may change diagnoses and consequently alter therapy, as well as patient disposition by highlighting injuries not identified on physical examination. Receiving hospitals can be alerted to injuries requiring intervention upon arrival. Ultrasound is also used to reduce complications and improve performance in numerous procedures such as obtaining vascular and intra-osseous access, paracentesis and tracheal tube placement. There is emerging evidence that ultrasound may be used safely pre-hospital without increasing on-scene times and with results comparable to use in hospital.

Review of point-of-care testing and biomarkers of cardiovascular diseases in emergency and prehospital medicine

Medical reasoning must be constructed on clinical evidence-based biology and follow a process of a priori assumptions. The introduction of a solution of point-of-care testing must result from any work involving clinicians, biologists, and administration. Several solutions of point-of-care testing allow the dosage of cardiac enzymes (CPK, myoglobin, and troponin) or BNP in less than half an hour time. The point-of-care testing saves time in obtaining the results earlier. It seems to allow timesaving on the overall care of the patient and the duration of his stay in the emergency department. By its technique and the relevance of its results, point-of-care testing is suitable for prehospital use.

Use of capnographs to assess quality of pediatric ventilation with 3 different airway modalities

ObjectivesPrehospital pediatric airway management is difficult and controversial. Options include bag-mask ventilation (BMV), endotracheal tube (ETT), and laryngeal mask airway (LMA). Emergency Medical Services personnel report difficulty assessing adequacy of BMV during transport. Capnography, and capnograph tracings in particular, provide a measure of real-time ventilation currently used in prehospital medicine but have not been well studied in pediatric patients or with BMV. Our objective was to compare pediatric capnographs created with 3 airway modalities. MethodsThis was a prospective study of pediatric patients requiring ETT or LMA ventilation during elective surgical procedures. Data were collected during BMV using 2 bag types (flow-inflating and self-inflating). The ETT or LMA was placed and ventilation with each bag type repeated. Ten- to 14-second capnographs were reviewed by 2 blinded anesthesiologists who were asked to assess ventilation and identify the airway and bag type used. Descriptive statistics, κ, and risk ratios were calculated. ResultsTwenty-nine patients were enrolled. Median age was 4.4 years (2 months to 16.8 years). One hundred sixteen capnographs were reviewed. Reviewers were unable to differentiate between airway modalities and agreed on adequacy of ventilation 77% of the time (κ = 0.6, P < .001). Bag-mask ventilation was rated inadequate more frequently than ETT or LMA ventilation. There were no difference between ETT and LMA ventilation and no difference between the 2 bag types. ConclusionCapnographs are generated during BMV and are virtually identical to those produced with ETT or LMA ventilation. Attention to capnographs could improve outcomes during emergency treatment and transport of critically ill pediatric patients requiring ventilation with any of these airway modalities.

Immediate Lower Extremity Tourniquet Application to Delay Onset of Reperfusion Injury after Prolonged Crush Injury

Reperfusion after severe crush injury is an infrequent, but life-threatening condition. It is a unique aspect of prehospital medicine that occurs in the presence of emergency responders attempting to extricate and treat patients who have suffered a crushing injury. These events are unlikely to occur in the hospital setting and, as a result, remain poorly studied. Some evidence exists regarding prophylaxis, but the efficacy of these treatments has not been clearly established. The use of commercial tourniquets to delay the onset of reperfusion injury has previously been described in theory. Extensive literature now exists supporting the safety of tourniquet use in limb trauma and this potential life-saving measure requires further study in patients with crush injury. We present a case of prehospital tourniquet application to delay reperfusion injury after crush injury that resulted in a reduction in morbidity and complete limb salvage. Key words: crush injury, prehospital, reperfusion injury, tourniquet

Can the critically ill consent to participation in commercial television programmes? An Australian prehospital and emergency medicine perspective.

The fly-on-the-wall medical documentary is a popular television phenomenon. When patients can give appropriate consent to filming, the final product can be both educational for the public and rewarding for its subjects. However, in the dynamic world of emergency and prehospital medicine, consenting critically ill patients before filming is a significant challenge. The main barriers to gaining valid consent in the field and in the ED are limited time to inform the patient and the diminished capacity of the sick patient. Although there is an argument that involvement in a commercial film might be beneficial to several parties, including the patient, these benefits do not amount to therapeutic necessity if prior consent is not obtainable. Despite this, we still see acutely incapacitated patients featured in some television programmes. In these cases, the conventional process of consent might be being sidestepped in order to obtain permission for broadcast retrospectively. This alternative process fails to recognise that incapacitated patients require protection from an invasion of privacy that occurs when a crew is filming their resuscitations. This harm has already occurred by the time consent is sought. Ultimate responsibility for defending the patients' interests during their medical treatment rests with the medical practitioner. We argue that filming a patient without prior consent in both the prehospital and emergency environment is ethically unsound: it threatens trust in the healthcare relationship and might compromise the patient's dignity and privacy. Robust guidelines should be developed for all healthcare professionals who engage with commercial film crews.

Femoral Traction Splints in Mountain Rescue Prehospital Care: To Use or Not to Use? That Is the Question

To determine the incidence of femur fractures in mountain rescue in England and Wales. To investigate the attitudes of rescuers toward the use of femoral traction splints. To review the literature for evidence on the use of traction splints in prehospital medicine and test the hypothesis that femoral traction splints reduce morbidity and mortality in patients with a fractured femur. The Mountain Rescue England and Wales database was searched for cases of suspected fractured femur occurring between 2002 and 2012, a questionnaire was sent to all mountain rescue teams in England and Wales, and a literature review was performed. Relevant articles were critically reviewed to identify the evidence base for the use of femoral traction splints. Femur fractures are uncommon in mountain rescue, with an incidence of suspected femur fractures on scene at 9.3 a year. Traction splints are used infrequently; 13% of the suspected femur fractures were treated with traction. However, rescuers have a positive attitude toward traction splints and perceive few disadvantages to their use. No trials demonstrate that traction splints reduce morbidity or mortality, but a number describe complications resulting from their use. Femur fractures are rare within mountain rescue. Traction splints may be no more effective than other methods of splinting in prehospital care. We failed to identify evidence that supports the hypothesis that traction splints reduce morbidity or mortality. We advocate the use of a femoral traction splints but recognize that other splints may also be appropriate in this environment.

Effectiveness of the Valsalva Manoeuvre for reversion of supraventricular tachycardia.

People with the cardiac arrhythmia supraventricular tachycardia (SVT) frequently present to clinicians in the prehospital and emergency medicine settings. Restoring sinus rhythm by terminating the SVT involves increasing the refractoriness of atrioventricular nodal tissue within the myocardium by means of vagal manoeuvres, pharmacological agents, or electrical cardioversion. A commonly used first-line technique to restore the normal sinus rhythm (reversion) is the Valsalva Manoeuvre (VM). This is a non-invasive means of increasing myocardial refractoriness by increasing intrathoracic pressure for a brief period, thus stimulating baroreceptor activity in the aortic arch and carotid bodies, resulting in increased parasympathetic (vagus nerve) tone. To assess the evidence of effectiveness of the VM in terminating SVT. We updated the electronic searches of the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 7); MEDLINE Ovid (1946 to August week 3, 2014); EMBASE Classic and EMBASE Ovid (1947 to 27 August 2014); Web of Science (1970 to 27 August 2014); and BIOSIS Previews (1969 to 22 August 2014). We also checked trials registries, the Index to Theses, and the bibliographies of all relevant publications identified by these strategies. We included all randomised controlled trials (RCTs) that examined the effectiveness of VM in terminating SVT. Two review authors independently extracted the data using a standardised form. We assessed each trial for internal validity, resolving any differences by discussion. We then extracted and entered data into Review Manager 5. In this update, we did not identify any new RCT studies for inclusion. We identified two RCT studies as ongoing that we are likely to include in future updates. Accordingly, our results are unchanged and include three RCTs with a total of 316 participants. All three studies compared the effectiveness of VM in reverting SVT with that of other vagal manoeuvres in a cross-over design. Two studies induced SVT within a controlled laboratory environment. Participants had ceased all medications prior to engaging in these studies. The third study reported on people presenting to a hospital emergency department with an episode of SVT. These participants were not controlled for medications or other factors prior to intervention.The two laboratory studies demonstrated reversion rates of 45.9% and 54.3%, whilst the clinical study demonstrated reversion success of 19.4%. This discrepancy may be due to methodological differences between studies, the effect of induced SVT versus spontaneous episodic SVT, and participant factors such as medications and comorbidities. We were unable to assess any of these factors, or adverse effects, further, since they were either not described in enough detail or not reported at all.Statistical pooling was not possible due to heterogeneity between the included studies. We did not find sufficient evidence to support or refute the effectiveness of VM for termination of SVT. Further research is needed, and this research should include a standardised approach to performance technique and methodology.

Pre-Hospital Medicine: A Glimpse of the Future

The availability and utilisation of technology in pre-hospital medicine has increased exponentially in the past half-century. New technologies, including telepresence, robotics and 3D printing, will revolutionise the way we practise in the 21st century. In order to maintain relevance and continue to provide exceptional patient care, we must stay abreast of technological advances, critically appraise new technologies, and be early adapters to change.

The Administration of Prehospital Ketamine for Chemical Restraint Does Not Prolong On-Scene Times Compared to Haloperidol Based Sedation

Introduction Agitated patients who present a danger to themselves or emergency medical services (EMS) providers may require chemical restraints. Haloperidol is employed for chemical restraint in many EMS services. Recently, ketamine has been introduced as an alternate option for prehospital sedation. On-scene time is a unique metric in prehospital medicine which has been linked to outcomes in multiple patient populations. When used for chemical restraint, the impact of ketamine relative to haloperidol on on-scene time is unknown. Objective To evaluate whether the use of ketamine for chemical restraint was associated with a clinically significant (≥5 minute) increased on-scene time compared to a haloperidol based regimen. Methods Patients who received haloperidol or ketamine for chemical restraint were identified by retrospective chart review. On-scene time was compared between groups using an unadjusted Student t-test powered to 80% to detect a ≥5 minute difference in on-scene time. Results 110 cases were abstracted (Haloperidol = 55; Ketamine = 55). Of the patients receiving haloperidol, 11/55 (20%) were co-administered a benzodiazepine, 4/55 (7%) received diphenhydramine and 34/55 (62%) received the three drugs in combination. There were no demographic differences between the haloperidol and ketamine groups. On-scene time was not statistically different for patients receiving a haloperidol based regimen compared to ketamine (18.2 minutes, [95% CI 15.7-20.8] vs. 17.6 minutes, [95% CI 15.1-20.0]; p = 0.71). Conclusions The use of prehospital ketamine for chemical restraint was not associated with a clinically significant (≥5 minute) increased on-scene time compared to a haloperidol based regimen.

Pre hospital medical services and paramedic engagement in Australian health care - Improving the pathways of care through collaborative action

Pre hospital medical services and paramedic engagement in Australian health care - Improving the pathways of care through collaborative action

Identification of a Neurologic Scale That Optimizes EMS Detection of Older Adult Traumatic Brain Injury Patients Who Require Transport to a Trauma Center

Objective. We sought to identify a scale or components of a scale that optimize detection of older adult traumatic brain injury (TBI) patients who require transport to a trauma center, regardless of mechanism. Methods. We assembled a consensus panel consisting of nine experts in geriatric emergency medicine, prehospital medicine, trauma surgery, geriatric medicine, and TBI, as well as prehospital providers, to evaluate the existing scales used to identify TBI. We reviewed the relevant literature and solicited group feedback to create a list of candidate scales and criteria for evaluation. Using the nominal group technique, scales were evaluated by the expert panel through an iterative process until consensus was achieved. Results. We identified 15 scales for evaluation. The panel's criteria for rating the scales included ease of administration, prehospital familiarity with scale components, feasibility of use with older adults, time to administer, and strength of evidence for their performance in the prehospital setting. After review and discussion of aggregated ratings, the panel identified the Simplified Motor Scale, GCS-Motor Component, and AVPU (alert, voice, pain, unresponsive) as the strongest scales, but determined that none meet all EMS provider and patient needs due to poor usability and lack of supportive evidence. The panel proposed that a dichotomized decision scheme that includes domains of the top-rated scales –level of alertness (alert vs. not alert) and motor function (obeys commands vs. does not obey) –may be more effective in identifying older adult TBI patients who require transport to a trauma center in the prehospital setting. Conclusions. Existing scales to identify TBI are inadequate to detect older adult TBI patients who require transport to a trauma center. A new algorithm, derived from elements of previously established scales, has the potential to guide prehospital providers in improving the triage of older adult TBI patients, but needs further evaluation prior to use.

Factors important to professional progress among students of prehospital medicine in Bolivia

Factors important to professional progress among students of prehospital medicine in Bolivia

Right people, right time: prehospital and retrieval medicine.

Right people, right time: prehospital and retrieval medicine.

Students’ perception of a paramedic shadowing experience during a critical care Advanced Pharmacy Practice rotation

ObjectiveTo describe students’ perception of a paramedic shadowing experience (PSE) incorporated into a critical care advanced pharmacy practice experience (APPE) rotation based in a community hospital. MethodsAn electronic survey instrument was developed and distributed to students who completed a critical care APPE rotation and participated in a PSE to assess students’ perception. ResultsOf 18 students, 13 completed the survey. Students rated the PSE highly in opportunity to be exposed to pre-hospital medicine (mean = 4.46 ± 0.66) and as beneficial in enhancing student understanding of interdisciplinary patient care (4.69 ± 0.48). Most students agreed that the PSE encouraged the application of knowledge in a real-world setting (4.38 ± 0.76). The majority of students strongly agreed that the PSE should be offered to future APPE students as part of a critical care rotation (4.69 ± 0.48). ConclusionsThe PSE was perceived by pharmacy students to be a beneficial experience and a unique opportunity to apply knowledge to patient care in a pre-hospital setting. A paramedic shadowing experience for APPE students represents a novel method of introducing pharmacy students to interdisciplinary patient care.

Use of Advanced Bleeding Control Mechanisms in Athletic Training: A Shift in the Thought Process of Prehospital Care—Part 1: Tourniquets

Two other competencies(Table 1), although not necessarily new to the list ofimmediate emergency management care skills, do requirefurther examination based on the current available scienceand standard of care in prehospital medicine. The purposeof this column is to provide athletic training educators(ATE) with evidence regarding the use of tourniquets in theprehospital setting as well as to be a resource on how toteach the management of external hemorrhage usingtourniquets.Trauma resulting in disruption of soft tissue is classified asan open or closed wound, and any significant loss ofintravascular volume may lead sequentially to hemodynam-ic instability, decreased tissue perfusion, cellular hypoxia,organ damage, and death.

EDITORIAL NOTE A case of plagiarism: "3D APPLICATIONS IN DISASTER MITIGATION AND MANAGEMENT: CORE RESULTS OF DITAC PROJECT" published in ISPRS 8th 3D GeoInfo Conference &amp; WG II/2 Workshop, XL-2/W2, 2013 WG II/2, 173–177

1, 2, 3, AFAM-Disaster Education, Application and Research Center, Istanbul Aydin University, Turkey Pre-hospital and Disaster Medicine Centre, Sweden UKBH University Clinic Bonn, Germany URGENTA – Clinical Emergency Hospital, Bucharest, Romania CRIMEDIM – Universita del Piemonte Orientale, Novara, Italy Global Risk Forum GRF Davos, Switzerland Bonn International Center for Conversion, Germany Hanover Associates, United Kingdom General and Teaching Hospital Celje, Slovenia Disaster German Aerospace Center, Germany Disaster Nations Health Career School of Management gGmbH, Germany Croatian Urgent Medicine and Surgery Association, Croatia

Prehospital paediatric emergencies treated by an Australian helicopter emergency medical service

The aim of this study was to describe the mechanism and severity of injuries in the paediatric population treated by an Australian helicopter emergency medical service and to examine the frequency and nature of interventions performed. This information is important for planning education and continuing professional development in prehospital medicine. The study is a retrospective cohort analysis of 349 patients under the age of 16 treated by CareFlight in Sydney, Australia, between April 2007 and April 2012. Data collected included age, type of incident, medication and fluid administered, procedures performed, receiving hospital, 24 h and 30-day mortality and injuries sustained. Falls (33%), motor vehicle incidents (30%), sport injury (14%) and immersion injury (12%) were the most common mechanisms. A total of 27 children died within 30 days; nontrauma cases were proportionally overrepresented in the deaths. With respect to tasking, 59% cases involved a severely or significantly injured child. Among the children, 97% with a traumatic mechanism were transferred directly to a paediatric trauma centre.In addition, 81% of children had at least one intervention by the helicopter emergency medical services team at the incident scene, most commonly intravenous cannulation (61%), crystalloid bolus (29%), intubation (21%) and intravenous analgesia administration (15%). Paediatric prehospital patients can be of high dependency, requiring urgent critical care procedures. Training in prehospital medicine should include paediatrics. It is essential that practitioners maintain skills in venous access, airway management and provision of adequate analgesia in children.

Prehospital Providers’ Perceptions of Emergency Calls Near Life’s End

The nature of emergency end-of-life calls is changing as people live longer and die from chronic illnesses. This study explored prehospital providers' perceptions of (1) end-of-life 911 calls, (2) the signs and symptoms of dying, and (3) medical orders for life sustaining treatment (MOLST). The exploratory-descriptive pilot study was survey based and cross-sectional. Calls to nursing homes occur most often, (47.8% every shift). The MOLST was seen infrequently (57.9% rarely never). The most frequent signs and symptoms of dying were diagnosis (76%), hospice involvement (82%), apnea (75%), mottling (55%), and shortness of breath (48%). The MOLST identifies wishes about intubation (74%), resuscitation (74%), life-sustaining treatment (72%), and cardiopulmonary resuscitation (70%). Synergy exists between the fields of prehospital, hospice, and palliative medicine which offers potential for improved education and care.