Primary Impression Research Articles

Influence of patient race on administration of analgesia by student paramedics

BackgroundDisparities in the management of pain are associated with factors that include social status, age and race. As there is limited data regarding the influence of race on analgesia provided by paramedics this study investigated associations between patient race and student paramedic management of pain.MethodsRetrospective study of student paramedic records entered in the FISDAP Skill Tracker database between 1 January 2014 to 31 December 2015. Cases were extracted if aged 16 to 100 years, the patient was alert and the primary or secondary impression was trauma. The primary outcome of interest was the association between patient race and student paramedic administration of any analgesia. The adjusted odds of patients receiving any analgesic was tested with logistic regression using a stepped modelling approach.Results59,915 cases were available for analysis; median age was 50 years (IQR 39 years), 50.1% were female (n = 30,040). Fall was the most common case type 43% (n = 26,009) of cases. 14.1% of patients received any analgesia (n = 8424). Caucasian patients have significantly higher odds of receiving analgesia than non-Caucasian patients (p < 0.001). When analgesic administration is adjusted for gender, age category and injury cause, African Americans have the lowest logged odds of receiving any analgesia when compared to Caucasian patients (OR 0.60, p < 0.001).ConclusionThe results indicate inequality in the provision of analgesia by student paramedics based on patient race. This suggests a need for interventions to reduce disparities in care based on race.

Abstract P407: Stroke Dispatch, Provider Impression and Critical Pre-Hospital Time Intervals: NEMSIS, 2016

Introduction: Stroke management guidelines have established several recommendations to ensure a proper response by Emergency Medical Services (EMS), including EMS arrival at the scene in ≤8 minutes (response time, RT), and an on-scene time (OST) of ≤15 minutes. Understanding factors associated with achieving these time intervals may help to focus EMS interventions. Hypothesis: We assessed the hypothesis that RT and OST for suspected patients with a dispatch of stroke are more likely to fall within guideline recommendations than those with a dispatch for non-stroke related events. Methods: Using the 2016 National Emergency Medical Services Information System (NEMSIS), a database of patient care reports resulting from 911 calls, we extracted cases with a primary or secondary provider impression of stroke, their EMS arrival to the scene (RT) ≤8 minutes and OST of ≤15 minutes. The sample included persons aged ≥18 years with non-missing sociodemographic data on sex, race/ethnicity, rurality and dispatch calls of events. The percentages of 911 cases, stroke events, and time intervals of interest were calculated. Chi-square tests was used to assess associations. Results: There were 153,730 events (1.4% of all 911 transports) with a primary or secondary provider impression of stroke. Within these events, 69.5% had a RT ≤8 minutes, and 49.2% had an OST ≤15 minutes: differences varied within all sociodemographic groups. A significant difference was found between those dispatched as stroke and those dispatched as other, with a greater proportion of dispatched strokes having both a RT ≤8 minutes (70.2% vs 68.8%) and OST ≤15 minutes (53.0% vs 45.6%). Conclusion: In conclusion, we found a significantly higher proportion of patients dispatched as stroke falling within the critical time intervals of response time and on-scene time. Future EMS stroke education should place more focus on dispatcher knowledge of stroke signs and symptoms, as an integral pre-hospital partner in improving the stroke system of care.

Performance of the RACE Score for the Prehospital Identification of Large Vessel Occlusion Stroke in a Suburban/Rural EMS Service

Introduction: Emergency Medical Services (EMS) providers may identify and preferentially transport patients experiencing large vessel occlusion (LVO) stroke to appropriate treatment centers. The Rapid Arterial oCclusion Evaluation (RACE) scale was created for prehospital LVO detection, yet few studies have evaluated its function in real-world EMS settings. Our objective was to assess the prehospital performance of the RACE scale for detecting LVO stroke following implementation at a large suburban/rural agency in the United States. Methods: In this retrospective analysis, all 9-1-1 patients with an EMS provider primary or secondary impression of stroke treated by the agency between June 1, 2016 and November 1, 2017 were eligible for inclusion. Patient data were abstracted using a standardized form completed by receiving hospitals. Performance for LVO detection at each RACE cutoff value was evaluated using sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). A receiver operating characteristic (ROC) curve was used to evaluate the discrimination of the RACE scale overall. A secondary analysis of RACE for patients experiencing strokes best treated at comprehensive stroke centers (LVO and intracerebral hemorrhage [ICH]) was conducted. Results: There were 440 patients with a documented RACE score and hospital outcome data included in the analysis. About half (51%, n = 220) were female and the median age was 70 years (IQR: 59–81). Last known well time was under 4.5 hours for 76% of patients (n = 261). Over half (61%, n = 269) had a hospital discharge diagnosis of stroke and 64/440 (15%) were classified as LVO. The ROC curve demonstrated adequate discrimination with a c-statistic of 0.72. Performance for identifying LVO in the prehospital setting was greatest for RACE scores ≥5 with a sensitivity of 66% and specificity of 72%, PPV of 29%, and NPV of 93%. A RACE score ≥5 for both LVO and ICH demonstrated sensitivity: 63%, specificity: 77%, PPV: 47% and NPV: 86%. Conclusion: The RACE scale demonstrated acceptable discrimination, yet the sensitivity and positive predictive value were lower in this cohort of EMS professionals in the United States than in the original validation study conducted in Spain. Further work is needed to determine the optimal prehospital screening tool for identification of LVO.

Palliative care in paramedic practice: A retrospective cohort study

Background: Paramedics may be involved in the care of patients experiencing a health crisis associated with palliative care. However, little is known about the paramedic’s role in the care of these patients. Aim: To describe the incidence and nature of cases attended by paramedics and the care provided where the reason for attendance was associated with a history of palliative care. Design: This is a retrospective cohort study. Setting/participants: Adult patients (aged >17 years) attended by paramedics in the Australian state of Victoria between 1 July 2015 and 30 June 2016 where terms associated with palliative care or end of life were recorded in the patient care record. Secondary transfers including inter-hospital transport cases were excluded. Results: A total of 4348 cases met inclusion criteria. Median age was 74 years (interquartile range 64–83). The most common paramedic assessments were ‘respiratory’ (20.1%), ‘pain’ (15.8%) and ‘deceased’ (7.9%); 74.4% (n = 3237) were transported, with the most common destination being a hospital (99.5%, n = 3221). Of those with pain as the primary impression, 359 (53.9%) received an analgesic, morphine, fentanyl or methoxyflurane, and 356 (99.2%) were transported following analgesic administration. Resuscitation was attempted in 98 (29.1%) of the 337 cases coded as cardiac arrest. Among non-transported cases, there were 105 (9.6%) cases where paramedics re-attended the patient within 24 h of the previous attendance. Conclusion: Paramedics have a significant role in caring for patients receiving palliative care. These results should inform the design of integrated systems of care that involve ambulance services in the planning and delivery of community-based palliative care.

A comparison of call volumes before, during, and after Hurricane Harvey

BackgroundThere is currently minimal data regarding the demand placed on Emergency Medical Services in the wake of hurricanes and other natural disasters. This retrospective review provides an opportunity to analyze call volumes to EMS and their distribution before, during, and after Hurricane Harvey in one area on the Texas Gulf Coast. ObjectivesCall volumes from Galveston Area Ambulance Authority were reviewed to provide insights for allocation of resources during natural disasters, identifying weaknesses in the current EMS system, and recommending proactive changes for future disasters. MethodsThis study was conducted based on data gathered from the Galveston Area Ambulance Authority which records the call volumes to EMS as well as the paramedics' primary impression of the patients. An analysis of variance (ANOVA) was used to calculate the differences in mean number of calls among the selected days for the periods before, during, and after the hurricane. Also, a paired t-test was used to calculate the difference in means for calls per day and the number calls during the peak days. Statistical significance was set at P ≤ 0.05 with a 95% confidence interval. ResultsThe 6 days prior to the storm had an average of 48 ± 6 calls, the 6 days during the storm had an average of 50 ± 15 calls, and the 6 days after the storm had an average of 49 ± 14 calls (p = 0.95). The peak number of calls between August 19–September 5 occurred the last 2 days of the storm, into the first 2 days after the storm. The average call volume for these four days was 65 ± 3 calls compared to the average number of calls for the total 18 days which was 49 ± 12 calls (p = 0.008). During the peak days, there were large percentages of calls due to: injury, general pain, respiratory distress, chest pain, and generalized weakness. ConclusionsEMS and emergency departments can expect peak volumes in the last days of a natural disaster as well as the first few days after the event with increases in injuries, general pain, respiratory distress, chest pain, and generalized weakness. EMS education, proper hospital staffing, and increased telemedicine/community paramedicine usage presents opportunities to increase efficiency in community healthcare during natural disasters.

Impact of prehospital mechanical ventilation: A retrospective matched cohort study of 911 calls in the United States.

Prehospital use of ventilators by emergency medical services (EMS) during 911 calls is increasing. This study described the impact of prehospital mechanical ventilation on prehospital time intervals and on mortality.This retrospective matched-cohort study used 4 consecutive public releases of the US National Emergency Medical Services Information System dataset (2011–2014). EMS activations with recorded ventilator use were randomly matched with activations without ventilator use (1 to 1) on age (range ± 2 years), gender, provider's primary impression, urbanicity, and level of service.A total of 5740 EMS activations were included (2870 patients per group). Patients in the ventilator group had a mean age of 69.1 (±17.3) years with 49.4% males, similar to the non-ventilator group. Activations were mostly in urban settings (83.8%) with an advanced life support level of care (94.5%). Respiratory distress (77.8%) and cardiac arrest (6.8%) were the most common provider's primary impressions. Continuous positive airway pressure was the most common mode of ventilation used (79.2%).Mortality was higher at hospital discharge (29.0% vs 21.1%, P = .01) but not at emergency department (ED) discharge (8.4% vs 7.4%, P = .19) with prehospital ventilator use. Both total on-scene time and total prehospital time intervals increased with reported ventilator use (4.10 minutes (95% confidence interval [CI]: 2.71–5.49) and 3.59 minutes (95% CI: 3.04–4.14), respectively).Ventilator use by EMS agencies in 911 calls in the US is associated with higher prehospital time intervals without observed impact on survival to ED discharge. More EMS outcome research is needed to provide evidence-based prehospital care guidelines and targeted resource utilization.

Emergency Medical Services Experience With Barb Removal After Taser Use By Law Enforcement: A Descriptive National Study.

Conducted electrical weapons (CEWs), including Thomas A. Swift Electric Rifles (TASERs), are increasingly used by law enforcement officers (LEOs) in the US and world-wide. Little is known about the experience of Emergency Medical Service (EMS) providers with these incidents. This study describes EMS encounters with documented TASER use and barb removal, characteristics of resulting injuries, and treatment provided. This retrospective study used five combined, consecutive National Emergency Medical Services Information System (NEMSIS; Salt Lake City, Utah USA) public-release datasets (2011-2015). All EMS activations with documented TASER barb removal were included. Descriptive analyses were carried out. The study included 648 EMS activations with documented TASER barb removal, yielding a prevalence rate of 4.55 per 1,000,000 EMS activations. Patients had a mean age of 35.9 years (SD=18.2). The majority were males (80.2%) and mainly white (71.3%). Included EMS activations were mostly in urban or suburban areas (78.3%). Over one-half received Advanced Life Support (ALS)-level of service (58.2%). The most common chief complaint reported by dispatch were burns (29.9%), followed by traumatic injury (16.1%). Patients had pain (45.6%) or wound (17.2%) as a primary symptom, with most having possible injury (77.8%). Reported causes of injury were mainly fire and flames (29.8%) or excessive heat (16.7%). The provider's primary impressions were traumatic injury (66.3%) and behavioral/psychiatric disorder (16.8%). Only one cardiac arrest (0.2%) was reported. Over one-half of activations resulted in patient transports (56.3%), mainly to a hospital (91.2%). These encounters required routine EMS care (procedures and medications). An increase in the prevalence of EMS activations with documented TASER barb removal over the study period was not significant (P=.27). At present, EMS activations with documented TASER barb removal are rare. Routine care by EMS is expected, and life-threatening emergencies are not common. All EMS providers should be familiar with local policies and procedures related to TASER use and barb removal.El SayedM, El TawilC, TamimH, MailhacA, MannNC. Emergency Medical Services experience with barb removal after TASER use by law enforcement: a descriptive national study. Prehosp Disaster Med. 2019;34(1):38-45.

Influence of Ca and Sr Addition on Impression Creep Behavior of Mg-4Al-RE Alloy

The impression creep behavior of Mg-4Al-RE-0.8Ca-0.2Sr (AEXJ4110) alloy was investigated under the applied stresses of 55, 75, 95 MPa and the temperatures of 398, 423, 448 K on a special apparatus. The results showed that the microstructure of AEXJ4110 alloy consisted of acicular Al11La3, granular Al2La, bone shape Al2Ca and fish-bone shape Al4Sr. The impression creep resistance of AE41 alloy was improved by adding Ca and Sr. The primary impression creep depth of AEXJ4110 alloy was increased with increasing applied stress and temperature. The creep strain rates of AEXJ4110 alloy under different stresses and temperatures were a power function of time. The constitutive equation of steady-state impression creep for AEXJ4110 alloy can be written as $$\dot{\varepsilon }_{\text{s}} = 9.71 \times 10^{ - 3} (E/T)(\sigma /E)^{4.3} \exp (( - 100.449 + 3368.98(\sigma /E))/RT)$$ with stress exponent n 4.3 and creep activation energy Qc about 100.449 kJ/mol. The impression creep mechanism of AEXJ4110 alloy in the temperature range of 398-448 K and stress range of 55-95 MPa is controlled by dislocation climb dominated by self-diffusion of magnesium atoms impeded by the precipitated phases with high melting temperatures.

Immediate dentures part 2: denture construction

Abstract: These two review articles aim to provide a comprehensive summary on immediate dentures. In this second part, the various stages of immediate denture construction are discussed. These include primary and master impressions, jaw registration, wax try-in and fitting the prosthesis. However, it has been explained that each stage may not be carried out in every immediate denture construction case. This paper concludes with a discussion on methods of addition to immediate dentures, if and when further teeth are lost. CPD/Clinical Relevance: Immediate dentures are commonly used to provide patients with tooth replacement immediately following extractions to maintain aesthetics and function. Therefore, they are an integral part of a dentist's armamentarium.

Hypoglycemic Patient Transported by EMS inMakkah Region, 2017

Objective:To estimate the incident rate of the hypoglycemic patients transported by EMS and to evaluate EMS primary impression for these patients. Methods and Design: Retrospective, observational study was based on data for 150,563 SAUDI RED CRESENT AUTHORITY Transported Patients during 2017. Subjects were defined as having Hypoglycemia if EMS personnel recorded a primary impression of hypoglycemia or low blood glucose (<60 mg/dL Or unspecified low). The outcome of interest was patient transport or non-transport to an emergency department or other care settings. Results:Among 150,563 eligible encounters, 1984(1.29%) were diagnosed with hypoglycemia, of which 536 (27%) were not transported. Non-transported was more likely among male adult patients age (40-59), initial blood glucose <60 mg/dl or EMS arrival time midnight – 6 A.M. Conclusion: A low rate of the non-transported patient to ED, Imperfect agreement between a primary impression of hypoglycemia and documented low blood glucose.

Prospective Countywide Surveillance and Autopsy Characterization of Sudden Cardiac Death: POST SCD Study.

Studies of out-of-hospital cardiac arrest and sudden cardiac death (SCD) use emergency medical services records, death certificates, or definitions that infer cause of death; thus, the true incidence of SCD is unknown. Over 90% of SCDs occur out-of-hospital; nonforensic autopsies are rarely performed, and therefore causes of death are presumed. We conducted a medical examiner-based investigation to determine the precise incidence and autopsy-defined causes of all SCDs in an entire metropolitan area. We hypothesized that postmortem investigation would identify actual sudden arrhythmic deaths among presumed SCDs. Between February 1, 2011, and March 1, 2014, we prospectively identified all incident deaths attributed to out-of-hospital cardiac arrest (emergency medical services primary impression, cardiac arrest) between 18 to 90 years of age in San Francisco County for autopsy, toxicology, and histology via medical examiner surveillance of consecutive out-of-hospital deaths, all reported by law. We obtained comprehensive records to determine whether out-of-hospital cardiac arrest deaths met World Health Organization (WHO) criteria for SCD. We reviewed death certificates filed quarterly for missed SCDs. Autopsy-defined sudden arrhythmic deaths had no extracardiac cause of death or acute heart failure. A multidisciplinary committee adjudicated final cause. All 20 440 deaths were reviewed; 12 671 were unattended and reported to the medical examiner. From these, we identified 912 out-of-hospital cardiac arrest deaths; 541 (59%) met WHO SCD criteria (mean 62.8 years, 69% male) and 525 (97%) were autopsied. Eighty-nine additional WHO-defined SCDs occurred within 3 weeks of active medical care with the death certificate signed by the attending physician, ineligible for autopsy but included in the countywide WHO-defined SCD incidence of 29.6/100 000 person-years, highest in black men (P<0.0001). Of 525 WHO-defined SCDs, 301 (57%) had no cardiac history. Leading causes of death were coronary disease (32%), occult overdose (13.5%), cardiomyopathy (10%), cardiac hypertrophy (8%), and neurological (5.5%). Autopsy-defined sudden arrhythmic deaths were 55.8% (293/525) of overall, 65% (78/120) of witnessed, and 53% (215/405) of unwitnessed WHO-defined SCDs (P=0.024); 286 of 293 (98%) had structural cardiac disease. Forty percent of deaths attributed to stated cardiac arrest were not sudden or unexpected, and nearly half of presumed SCDs were not arrhythmic. These findings have implications for the accuracy of SCDs as defined by WHO criteria or emergency medical services records in aggregate mortality data, clinical trials, and cohort studies.

Assessment of a Surveillance Case Definition for Heroin Overdose in Emergency Medical Services Data

Assessment of a Surveillance Case Definition for Heroin Overdose in Emergency Medical Services Data

Proposal of the head-heart-base technique as an innovative method to describe and evaluate the aroma profile of wine and cider

ABSTRACTA novel method for the sensory evaluation of wine and cider is proposed that combines advantages of other commonly used techniques while simplifying a tasting protocol that is more accessible for unexperienced panelists. The method is based on panelist’s evaluation of samples in three discrete and directed steps; evaluation of head, heart, and base characters. The technique provides the sensory analyst with a simplified approach to difference testing and, in many instances, helps statistically differentiate samples by reducing panelist confusion. The head aroma is defined as the first impression after removing the lid from a covered glass prior to agitating the sample. The heart aroma is defined as the primary impression after agitating the sample. The base character is defined as the final aroma impression and retronasal evaluation of the product. Each component is evaluated independently using a generalized grouping of descriptors; sensory impression or grouping descriptors can be refined if the analyst aims to draw a higher level of detail or descriptive analysis from their panel. Application of the proposed analytical protocol suggests that the technique is simple for less-experienced panelists to learn and follow, and allowed them to easily focus on the testing attributes with minimal confusion of confounding factors.

Comparing required dislodging forces between different types of posterior palatal seal

Background: In this study forces required to dislodge a maxillary complete denture were compared for different types of posterior palatal seals " Group 1 single beading design , Group 2 double beading design and group 3 with butter fly posterior palatal seal.Materials and Methods :Using a specially designed strain gauge force transducer and strain measuring device ,the force required to dislodge a maxillary complete denture measured and compared. Ten male subjects are selected with age range 55-65 yrs, the primary impression made in the usual manner and the final impression made with zinc oxide euogenol paste after the border seal made with tracing stick impression compound ,then the master cast duplicated using a heavy body silicone impression materials in order to produce a three additional casts, then the casts scraped to incorporate the posterior palatal seals and produce the three groups .a denture base constructed after postdum scraping.Results: Comparing the three groups the results shows that a significant difference found between the group 1 and 2 and group 1 and 3 with no significant difference found between group 2 and 3. Using ANOVA Table with LSD.Conclusion: No Design Provide superior priority than the other type of posterior palatal seals but a double beading and butter fly posterior palatal seal can improve the retention of a maxillary complete denture.

Technique Tips: The Use of a Novel Primary Impression Technique in a Patient with Microstomia

Technique Tips: The Use of a Novel Primary Impression Technique in a Patient with Microstomia

Елементи книжкового контенту: особливості проектування та впливу на читача (споживача)

The objective of the study was to find out the influence of book content elements on the target audience’s primary impression about the publication and their reading reactions. Methodology: The applicative base of the problem research are the results of a survey, which was made within reading audience (N = 600), publishers (N = 100), writers (N = 100) and librarians (N = 100) during May 30 – June 17 in 2018. The results of the survey were processed by sorting, classification, analysis and data comparison. The goals were to find out the main features of understanding the book content by the subjects of its creation and readers, to retrace the patterns of publishing preparation of book content elements, and the interdependence between the book’s perception and its design-conception. That is why different survey forms were used for the highlighted groups of respondents. The results. Publishers tend to overrate the influence of design-conception on reader’s choice. The primary impression and reactions about the publication correlate with the age and sex of the potential reader. Genre, title and author’s name have a key importance for readers, that is what writers also agree with. The title has the strongest influence on the teenager audience (under 16), and the weakest – on the audience at the age of 17–24. Author’s name has an essential value for the readers older than 45 years old, and the least – for teenagers under 16. Apart from author’s name and the book’s price, the most important is the title (for women) and the genre (for men). The book’s success depends on the efficiency of media field, built around the publication. Author’s status in the information field correlates with the interest regarding his next publications, thus forms its primary image, “semantic image”, even the image of publications, which are not completed.

PLUMBER Study (Prevalence of Large Vessel Occlusion Strokes in Mecklenburg County Emergency Response).

The recently proposed American Heart Association/American Stroke Association EMS triage algorithm endorses routing patients with suspected large vessel occlusion (LVO) acute ischemic strokes directly to endovascular centers based on a stroke severity score. The predictive value of this algorithm for identifying LVO is dependent on the overall prevalence of LVO acute ischemic stroke in the EMS population screened for stroke, which has not been reported. We performed a cross-sectional study of patients transported by our county's EMS agency who were dispatched as a possible stroke or had a primary impression of stroke by paramedics. We determined the prevalence of LVO by reviewing medical record imaging reports based on a priori specified criteria. We enrolled 2402 patients, of whom 777 (32.3%) had an acute stroke-related diagnosis. Among 485 patients with acute ischemic stroke, 24.1% (n=117) had an LVO, which represented only 4.87% (95% confidence interval, 4.05%-5.81%) of the total EMS population screened for stroke. Overall, the prevalence of LVO acute ischemic stroke in our EMS population screened for stroke was low. This is an important consideration for any EMS stroke severity-based triage protocol and should be considered in predicting the rates of overtriage to endovascular stroke centers.

Ventilator use by emergency medical services during 911 calls in the United States

BackgroundEmergency and transport ventilators use in the prehospital field is not well described. This study examines trends of ventilator use by EMS agencies during 911 calls in the United States and identifies factors associated with this use. MethodsThis retrospective study used four consecutive releases of the US National Emergency Medical Services Information System (NEMSIS) public research dataset (2011–2014) to describe scene EMS activations (911 calls) with and without reported ventilator use. ResultsVentilator use was reported in 260,663 out of 28,221,321 EMS 911 scene activations (0.9%). Patients with ventilator use were older (mean age 67±18years), nearly half were males (49.2%), mostly in urban areas (80.2%) and cared for by advanced life support (ALS) EMS services (89.5%). CPAP mode of ventilation was most common (71.6%).“Breathing problem” was the most common dispatch complaint for EMS activations with ventilator use (63.9%). Common provider impression categories included “respiratory distress” (72.5%), “cardiac rhythm disturbance” (4.6%), “altered level of consciousness” (4.3%) and “cardiac arrest”(4.0%).Ventilator use was consistently higher at the Specialty Care Transport (SCT) and Air Medical Transport (AMT) service levels and increased over the study period for both suburban and rural EMS activations. Significant factors for ventilator use included demographic characteristics, EMS agency type, specific complaints, provider's primary impressions and condition codes. ConclusionsProviders at different EMS levels use ventilators during 911 scene calls in the US. Training of prehospital providers on ventilation technology is needed. The benefit and effectiveness of this intervention remain to be assessed.

Implementation of the universal BLS termination of resuscitation rule in a rural EMS system

BackgroundEmergency Medical Services (EMS) are often the first medical providers to begin resuscitation of out-of-hospital cardiac arrest (OHCA) victims. The universal Basic Life Support Termination of Resuscitation (BLS-TOR) rule is a validated clinical prediction tool used to identify patients in which continued resuscitation efforts are futile. ObjectiveThe primary aim is to compare the rate of transport of OHCA cases before and after the implementation of a BLS-TOR protocol and to determine the compliance rate of EMS personnel with the new protocol in a largely volunteer, rural system. MethodsA retrospective cohort study was conducted using the statewide EMS electronic patient care report system. Cases were identified by searching for any incident that had a primary impression of “cardiac arrest” or a primary symptom of “cardiorespiratory arrest” or “death.” Data were collected from the two years prior to and following implementation of the BLS-TOR rule from January 1, 2012 through March 31, 2016. ResultsThere were 702 OHCA cases were identified, with 329 cases meeting inclusion criteria. The transport rate was 91.1% in the pre-intervention group compared with 69.4% in the post-intervention group (χ2=24.8; p<0.001). EMS compliance rate with the BLS-TOR rule was 66.7%. Of the 265 patients transported during the study, 87 patients met (post-intervention group; n=22) or retrospectively met (pre-intervention group; n=65) the BLS-TOR requirements for field termination of resuscitation. None of these patients survived to hospital discharge. ConclusionRural EMS systems may benefit from implementation and utilization of the universal BLS-TOR rule.

Hypoglycemia Patients and Transport by EMS in Alameda County, 2013–15

Objective: To estimate the rate, characteristics, and dispositions of hypoglycemia events among persons who received care from Alameda County, California, Emergency Medical Services (EMS). Methods: This study was based on data for 601,077 Alameda County EMS encounters during 2013–15. Subjects were defined as having hypoglycemia if EMS personnel recorded a primary impression of hypoglycemia or low blood glucose (<60 mg/dl or “unspecified low”). The outcome of interest was patient transport or non-transport to an emergency department or other care setting; we excluded 33,177 (6%) encounters which lacked clear disposition outcomes. Results: Among 567,900 eligible encounters, 8,332 (1.47%) were attributed to hypoglycemia, of which 1,125 (13.5%) were not transported. Non-transport was more likely among males, adult patients age <60, initial blood glucose >60 mg/dl or EMS arrival time 18:00–6:00. Conclusions: Without an understanding of EMS encounters and non-transport rates, surveillance based solely on emergency department and hospital data will significantly underestimate rates of severe hypoglycemia. Additionally, given that hypoglycemia is often safely and effectively treated by non-physicians, EMS protocols should provide guidance for non-transport of hypoglycemic patients whose blood glucose levels have normalized.