Rural Emergency Medical Services Research Articles

Adequacy of musculoskeletal pain control by emergency medical services providers compared to an emergency department gold standard

Study objectives: Pain management by emergency medical services (EMS) personnel has received limited attention in the literature. We examine the adequacy of EMS pain control for musculoskeletal complaints compared with the criterion standard of subsequent emergency department (ED) pain management. Methods: This retrospective, consecutive case series examined EMS and ED records for all patients who had a chief complaint of musculoskeletal pain and were transported in a 3-month period to the sponsor hospital by a suburban or rural paramedic EMS system. Data collected included demographics, pain medications given, adverse drug reactions, EMS disposition, and ED medications given within 1 hour of physician examination. Patients with major trauma or injuries greater than 2 weeks old were excluded. Data were analyzed descriptively. Institutional review board approval was obtained. Results: Age and sex were similar among groups. Patients were determined to need pain medications if treated by the ED or if they were treated by EMS and there was no documentation in the ED record that treatment was inappropriate. Using these criteria, 64 of 173 patients required pain medication. Of patients requiring pain medications, EMS treated 23% (n=15). Patients with evidence of fracture were more likely to receive EMS pain medications (5/11, 45%). There were only 2 EMS adverse drug reactions; in both cases, the patients were sleepy but easily arousable. Conclusion: Of all patients requiring pain medications, EMS failed to treat 77% (49/64). Potential reasons for EMS undertreatment of musculoskeletal pain include failure to recognize pain, fear of adverse reactions, underappreciation of pain morbidity, and absence of pain control education.

Out-of-hospital analgesia in adults and children

Study objectives: Numerous studies have assessed the delivery of analgesia in the emergency department; however, few have assessed analgesia delivery in the out-of-hospital setting. We describe the use of out-of-hospital analgesia in adults and children with suspected extremity fractures or burns. Methods: This was a retrospective review of all patient encounters in a statewide emergency medical services (EMS) database from January 2001 through December 2002. The statewide database consists of a mix of rural and small urban EMS systems with more than 200,000 annual patient encounters. Records for all patients with fractures or burns, excluding multisystem trauma and head injuries, were included. Data collected included age, type of injury, pain medication administration, and adjunctive therapies for fracture management. Interventions including oral suctioning, oral or nasal airway, bag-valve-mask ventilation, endotracheal intubation, cardiopulmonary resuscitation, and naloxone use were collected for patients receiving analgesia. This study was approved by the hospital institutional review board. Results: A total of 426,767 EMS runs were reviewed. Fractures or burns were identified in 25,647 patients. Of these, 21,393 patients were included in the study, with 4,254 meeting exclusion criteria. There were 2,120 (9.9%) patients younger than 18 years compared with 19,273 (90.1%) patients who were 18 years and older. Overall, 9.9% of patients received any type of analgesia. The rate of analgesia use in patients younger than 18 years was 13.0% (95% confidence interval [CI] 11.6% to 14.5%). For patients 18 years and older, 9.5% received analgesia (95% CI 9.1% to 10%). Of the 20,584 patients with fractures, 49.7% (95% CI 47.5% to 51.9%) of children and 23.2% (95% CI 22.6% to 23.8%) of adults were splinted. Cold application for patients with fractures occurred in 38.0% (95% CI 37.5% to 42.0%) of children and 14.8% (95% CI 14.3% to 15.3%) of adults. An intravenous line was placed in 21.9% of children and 22.3% of adults. Adults receiving analgesia were more likely to undergo an intervention for airway or vascular compromise compared with those receiving no analgesia (1.1% versus 0.5%). Only 1 child (0.1%) who received analgesia required any of the airway or cardiac interventions. Conclusion: In this study, children were more likely to receive analgesia for their injuries compared with adults. In addition, children were more likely to receive adjunctive therapy for fracture management. The need for airway or cardiac interventions in patients receiving analgesia was limited. The overall rate of analgesia delivery remains low.

Unrecognized misplacement of endotracheal tubes in a mixed urban to rural emergency medical services setting.

To determine the rate of unrecognized endotracheal tube misplacement when performed by emergency medical services (EMS) personnel in a mixed urban and rural setting. The authors conducted a prospective, observational analysis of out-of-hospital endotracheal intubations (EIs) performed by EMS personnel serving a mixed urban, suburban, and rural population. From July 1, 1998, to August 30, 1999, emergency physicians assessed and recorded the position of out-of-hospital EIs using auscultation, direct laryngoscopy, infrared CO(2) detectors, esophageal detector devices, and chest x-ray. The state EMS database also was reviewed to determine the number of EIs involving patients transported to the authors' medical center and paramedic assessment of success for these encounters. A total of 167 out-of-hospital EIs were recorded, of which 136 (81%) were deemed successful by EMS personnel. Observational forms were completed for 109 of the 136 patients who arrived intubated to the emergency department. Of the studied patients, 12% (13 of 109) were found to have misplaced endotracheal tubes. For the patients with unrecognized improperly placed tubes, 9% (10 of 109) were in the esophagus, 2% (2 of 109) were in the right main stem, and 1% (1 of 109) were above the cords. Paramedics serving urban and suburban areas did not perform significantly better (p < 0.05) than intermediate-level providers serving areas that are more rural. The incidence of unrecognized misplacement of endotracheal tubes by EMS personnel may be higher than most previous studies, making regular EMS evaluation and the out-of-hospital use of devices to confirm placement imperative. The authors were unable to show a difference in misplacement rates based on provider experience or level of training.

Unrecognized Misplacement of Endotracheal Tubes in a Mixed Urban to Rural Emergency Medical Services Setting

Abstract Objective: To determine the rate of unrecognized endotracheal tube misplacement when performed by emergency medical services (EMS) personnel in a mixed urban and rural setting. Methods: The authors conducted a prospective, observational analysis of out‐of‐hospital endotracheal intubations (EIs) performed by EMS personnel serving a mixed urban, suburban, and rural population. From July 1, 1998, to August 30, 1999, emergency physicians assessed and recorded the position of out‐of‐hospital EIs using auscultation, direct laryngoscopy, infrared CO 2 detectors, esophageal detector devices, and chest x‐ray. The state EMS database also was reviewed to determine the number of EIs involving patients transported to the authors' medical center and paramedic assessment of success for these encounters. Results: A total of 167 out‐of‐hospital EIs were recorded, of which 136 (81%) were deemed successful by EMS personnel. Observational forms were completed for 109 of the 136 patients who arrived intubated to the emergency department. Of the studied patients, 12% (13 of 109) were found to have misplaced endotracheal tubes. For the patients with unrecognized improperly placed tubes, 9% (10 of 109) were in the esophagus, 2% (2 of 109) were in the right main stem, and 1% (1 of 109) were above the cords. Paramedics serving urban and suburban areas did not perform significantly better (p &lt; 0.05) than intermediate‐level providers serving areas that are more rural. Conclusions: The incidence of unrecognized misplacement of endotracheal tubes by EMS personnel may be higher than most previous studies, making regular EMS evaluation and the out‐of‐hospital use of devices to confirm placement imperative. The authors were unable to show a difference in misplacement rates based on provider experience or level of training.

ENDOTRACHEAL INTUBATION IN A RURAL EMS STATE: PROCEDURE UTILIZATION AND IMPACT OF SKILLS MAINTENANCE GUIDELINES

Objective. Recent American Heart Association (AHA) guidelines have suggested that advanced life support (ALS) providers should have “regular field experience,” defined as six to 12 intubations/year, as a prerequisite to patient endotracheal intubation (EI). The authors sought to assess the impact of this guideline on rural emergency medical services (EMS) practice. Methods. Statewide EMS records were reviewed for the calendar years 1997-2001. Data reviewed included the number of providers eligible to perform ALS skills (including EI), number of procedures performed per year by EMS provider, patient age, gender, and prehospital diagnosis. The institutional review board approved the study. Results. During the study period, a total of 957,836 patient encounters occurred with an average of 1,352 ALS providers annually eligible to perform EI. In the five-year period, there were 5,615 total EI attempts with a range of 37%-42% of eligible providers annually performing EI. A mean of 18 providers per year with a range of 1.8%-0.8% of EI-eligible providers annually attempted EI in more than five patients. One hundred thirty-seven pediatric EI encounters occurred during the five-year period with an annual range of 1.4%–2.7% of eligible providers attempting pediatric EI. During the five-year investigation, EI success rate was reported as 84% by providers with fewer than five annual intubation encounters and 86% by providers with more than five encounters. Conclusion. Rural EMS providers rarely use EI skills, particularly in pediatric patients. If recent AHA intubation guidelines are to be followed in rural EMS settings, a small number of EMS providers will meet minimum EI utilization requirements.

I NFLUENZA I MMUNIZATIONS P ROVIDED BY EMS A GENCIES : T HE MEDICVAX P ROJECT

Objective. Emergency medical services (EMS) agencies may be an underutilized resource for provision of preventive health services. This study sought to demonstrate the feasibility for EMS agencies to provide influenza immunizations. Methods. This prospective, observational cohort study was conducted with urban, suburban, and rural EMS agencies that volunteered to participate. EMS managers and paramedics attended an orientation program, and then developed and implemented recruitment strategies. Adult volunteer subjects who met Centers for Disease Control and Prevention criteria for influenza vaccination were enrolled. Paramedics obtained informed consent, determined subject eligibility, administered the vaccine, and observed each subject for 10 minutes. Paramedics, EMS managers, and subjects completed surveys; EMS managers reported costs and resource utilization. Data were analyzed descriptively. Results. Ninety paramedics from 15 EMS agencies in three counties participated. Subjects were recruited by print and broadcast media and enrolled at 73 events held at retail establishments, community events, EMS stations, churches, senior citizen complexes, and private residences. Of the 2,075 adults immunized, 1,014 (49%) did not receive influenza vaccination in the previous year. Seven hundred five (34%) reported that they probably would not have been vaccinated elsewhere. Fixed cost for each immunization was $3.42. The EMS managers estimated their variable costs to range from zero dollars (volunteer agencies with all donated expenses) to $15.31 per immunization. No adverse events were reported. Subjects, paramedics, and EMS managers indicated a high level of satisfaction with the project. Conclusion. The MEDICVAX Project demonstrated the feasibility of EMS agencies to safely provide influenza immunizations. The project reached some adults who likely would not have been immunized.

Evaluation of prehospital insertion of the laryngeal mask airway by primary care paramedics with only classroom mannequin training

The laryngeal mask airway (LMAtrade mark airway) provides adequate ventilation and offers a suitable alternative for airway management in patients with cardiac arrest if primary care paramedics do not have intubation skills or are unable to intubate. Training in the use of the LMA usually occurs in the operating room. To describe the use of the LMA by paramedics in prehospital adult non-traumatic cardiac arrest patients after classroom mannequin training. The study took place in a suburban rural emergency medical service. This is a 2-phase observational study of the effect of paramedic training for LMA insertion using a mannequin and the success rate in the prehospital setting. All paramedics successfully completed classroom mannequin training. All subsequent prehospital adult non-traumatic cardiac arrest patients from mid-February 1999 to Mar. 31, 2000, were eligible. Subjective assessment of chest expansion, ease of ventilation and auscultation defined adequacy of ventilation. Data collected included the number of insertion attempts, reasons for failure, ease of insertion, adverse events and reasons for not attempting intubation. Statistical analysis comprised descriptive frequencies, chi-squared tests for comparison of categorical variables and analysis of variance for continuous variables. 208 paramedics (100%) successfully completed training. The mean number of attempts was 1, and only 4 (2.1%) paramedics required a second attempt with a mannequin. The paramedics' perception of ease of use comparing the LMA with a bag valve mask (BVM) was evenly distributed across the 3 descriptors: 70 (39%) scored the LMA as easier to use, 57 (31%) as more difficult, and 54 (30%) stated there would be no difference. Of the 291 arrests during the study period, insertion of the LMA was attempted in 283 (97.3%) and was successful in 199 (70%) patients. The LMA became dislodged in 5 (2.5%) cases and was removed in 12 (6%) to clear vomit from the airway. The overall success rate was 182 (64%). The incidence of regurgitation prior to attempted insertion of the LMA was 28% (79 patients). Success rates did not vary significantly with the incidence of vomiting prior to insertion (p = 0.11). The majority of the paramedics evaluated LMA insertion as Very easy 49/220 (22.3%) or Easy 87/220 (39.6%). Paramedic evaluation of ease of use varied with success (p = 0.001). This study reports a 100% training success rate with a mannequin and a 64% success with LMA insertion and ventilation in the field by paramedics among adult out-of-hospital non-traumatic cardiac arrest patients.

A MIODARONE AND R URAL E MERGENCY M EDICAL S ERVICES C ARDIAC A RREST P ATIENTS : A C OST A NALYSIS

Objective: Recent American Heart Association guidelines suggest amiodarone as an antiarrhythmic in refractory ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT). The authors sought to assess the impact of amiodarone use on outcomes and cost associated with this practice in a rural emergency medical services (EMS) state. Methods: Statewide EMS records were reviewed for the calendar year 1999. Data reviewed included prehospital diagnosis, medications given by prehospital providers to patients with cardiac arrest, and procedures performed, including cardiopulmonary resuscitation (CPR) and defibrillation. Cost-benefit analysis assumed the cost of amiodarone treatment to be $137.65 per patient encounter. Absolute risk reduction (ARR) and number needed to treat (NNT) analysis utilized resuscitation rates published in the ARREST and ALIVE trials. Results: During the study period, EMS providers diagnosed 2,189 patients as having cardiac arrest. Five hundred thirty-five (24.4%) cardiac arrest patients were defibrillated. One hundred sixty patients (7.3%), including 15 who did not receive defibrillation, were given lidocaine during resuscitation efforts. The annual cost increase from current practice for a statewide amiodarone VF/VT protocol was $21,822.40 (10,572.87%). The initial cost to stock EMS vehicles for this protocol would be $50,115.52. The cost-benefit analysis yielded a potential for one additional patient survival to hospital discharge in Maine per 3.125 years of system-wide practice at a cost of $68,840.00. Conclusion: Based on current data, instituting amiodarone treatment for refractory VF and pulseless VT in a rural EMS setting requires the investment of substantial resources, relative to current treatment strategies, for any potential survival benefit.

T IME S AVED WITH THE U SE OF E MERGENCY W ARNING L IGHTS AND S IREN W HILE R ESPONDING TO R EQUESTS FOR E MERGENCY M EDICAL A ID IN A R URAL E NVIRONMENT

Objective. To determine whether the use of warning lights and siren saves a significant amount of time for ambulances responding to requests for emergency medical aid in a rural emergency medical services (EMS) setting. Methods. A prospective design was used to determine run times for ambulances responding to calls with lights and siren (code 3) and for a similarly equipped “chase” ambulance traveling to the same destination via the same route without lights and siren, while obeying all traffic laws (code 2) within a rural setting. Data were collected for run time intervals, distance traveled, visibility, road surface conditions, time of day, and day of the week. Descriptive statistics, a paired Student's t-test, and analysis of variance were used to test for significant differences between code 2 and code 3 operations, as well as the other variables listed above. Results. Sixty-seven runs were timed during a 21-month period. The average code 3 response interval was 8.51 minutes. The average code 2 response interval was 12.14 minutes. The 3.63 minutes saved on average represents significant time savings of 30.9% (p < 0.01). Shorter runs had higher time savings per mile than the longer runs. Run distance was the only variable that was statistically significant in affecting time saved during a code 3 response. Conclusion. Code 3 operation by EMS personnel in a rural EMS setting saved significant time over code 2 operation when traveling to a call.

P ROFILE OF THE P REHOSPITAL S YSTEM IN M ADAGASCAR

Objective. To delineate the present characteristics of emergency medical services (EMS) on the island of Madagascar. Methods. This was a retrospective study of ambulance runs over a five-year period. The island covers 587,041 square kilometers with a population of 15 million, of whom 78% live in rural areas. Results. Madagascar has 0.13 EMS workers per 1,000 people in urban areas, compared with 0.001 EMS workers per 1,000 people in rural areas. The urban physician/population ratio is 1 per 8,160, while in rural areas the ratio is 1/30,000. There is no “911” dispatching system. The EMS system offers transport services in 90% of ambulance runs. Ambulance calls are dispatched by police and fire departments in 80% of cases and by private calls in the remaining 20%. Madagascar has a telephone/population ratio of 1 per 239. Each vehicle is staffed by two emergency medical technicians (EMTs) who are paid by local hospitals and clinics that operate under a medical director. Urban EMS covers an average radius of 100 km, in contrast to the community-based rural EMS that serves a radius of only 25 km. The EMS system receives critically ill patients in 35% of its runs, obstetrical emergencies in 30%, surgical emergencies in 25%, and pediatric emergencies in the remaining 10%. Conclusion. This study shows that urban EMS is more organized, has a better-developed infrastructure, and has more personnel than its counterparts in rural areas. Future work will determine the impact of a rising population shift from rural to urban areas on this evolving EMS system.

Unique curriculum for emergency medicine residents as medical directors for rural out-of-hospital agencies.

Many rural communities have difficulty maintaining a medical director for their emergency medical services (EMS). Local physicians may be overwhelmed, be hesitant to take on additional responsibilities, and feel unskilled in providing the necessary leadership. Without a medical director, rural EMS agencies are frequently forced to shut down, thus depriving the community of local out-of-hospital care. To meet the needs of rural EMS agencies for medical direction, to provide a unique opportunity for emergency medicine (EM) residents to acquire EMS medical direction skills, and to fulfill the obligation of EM residencies to provide both didactic and experiential training in EMS. This article describes a curriculum, now being used in Colorado, for placing EM residents as EMS medical directors for rural out-of-hospital agencies that have lost their medical directors. Residents visit these rural communities 6-12 times a year, provide continuing education through interactive lectures, develop or revise EMS protocols and policies, perform quality assurance reviews, troubleshoot problems, and assist in EMS planning for the community. Residents are supervised by the Colorado state EMS medical director. This unique program enables local EMS agencies to continue their service while providing clear educational benefit for the EM residents. This paper demonstrates how this program has been working successfully in the state of Colorado by placing residents in four distinct rural and mountainous communities.

Paramedic judgment of the need for trauma team activation for pediatric patients.

To determine the value of paramedic judgment in determining the need for trauma team activation (TA) for pediatric blunt trauma patients. A prospective, observational study was conducted at the ED of Children's Hospital Medical Center of Akron between July 12, 1996, and February 28, 1997, in cooperation with Akron Fire Department emergency medical technician-paramedics (EMT-Ps). The ED provides on-line and off-line medical control for pediatric transports. Patients with minor or no identifiable injuries are released at the scene with the instructions to see a physician. The remainder are transported to the ED. The decision for TTA is based on ED trauma protocols as well as emergency physician judgment of injury severity in combination with the judgment of the treating paramedic. During the study, EMT-Ps were asked (before physician input) whether, based solely on their judgment, a patient needed TTA. Patients 0-14 years old who were involved in motor vehicle crashes, bike crashes, or falls from a height of >10 feet were included in the study. TTA was defined as necessary if the patient was admitted to the intensive care unit (ICU) or operating room (OR) for nonorthopedic surgical procedures. Out-of-hospital, ED, and hospital records were reviewed. Coroners' records as well as medical records of all trauma admissions during the study period were reviewed to ensure that the patients released at the scene were not mistriaged. One hundred ninety-two patients met study criteria. Eighty-five patients (44%) were transported to the ED, of whom 12 had TTA. EMT-Ps requested TTA for 10 of these patients, and 2 patients had TTA per ED trauma protocol. Two of the patients who were judged by EMT-Ps to need TTA were admitted to the ICU/OR, and neither of the patients identified by ED trauma protocol to require TTA were admitted to the ICU/OR. Two initially stable patients who did not have TTA deteriorated after arrival to the ED. Both were admitted to the ICU. The sensitivity and specificity of paramedic judgment of the need for TTA for pediatric blunt trauma patients were 50% (95% CI 9.2-90.8) and 87.7% (95% CI 78.0-93.6), respectively. The positive and negative predictive values were 16.7% (95% CI 2.9-49.1) and 97.3% (95% CI 89.6-99.5). None of the patients released at the scene was mistriaged based on the review of the coroners' and trauma admission records. Results of this investigation indicate that a small percentage of pediatric blunt trauma patients require TTA. EMT-P judgment alone of the need for TTA for pediatric blunt trauma patients is not sufficiently sensitive to be of clinical use. The low sensitivity is explained by the deterioration in the clinical condition of 2 initially stable patients. The paramedic disposition decisions from the scene were always accurate. Nontransport by emergency medical services (EMS) may be acceptable in some uninjured pediatric trauma patients. Injured pediatric trauma patients who appear to be stable may deteriorate shortly after injury. However, if a pediatric patient appears injured, transport from the scene and examination by a trauma specialist are needed. Finally, the role of paramedic judgment must be further defined by larger studies with urban, rural, and suburban EMS systems before it can be used as a sole predictor of TTA.

Adenosine for the Treatment of PSVT in the Prehospital Arena: Efficacy of an Initial 6 mg Dosing Regimen

To confirm the efficacy of prehospital administration of adenosine, using a 6 milligram (mg) initial dosing regimen, for the treatment of paroxysmal supraventricular tachycardia (PSVT). Urban, suburban, rural emergency medical services (EMS) system in Clark County, Washington with advanced life support (ALS) patient transports. Concurrent, paramedic Medical Incident Report (MIR) review was conducted for 102 patients receiving prehospital adenosine during a 42-month period. Patients were administered 6 mg of adenosine using an intravenous (i.v.) bolus followed by 10 ml of balanced salt solution flush. If the patient's rhythm remained unchanged, the dosing regimen was increased to 12 mg followed by a 10 ml flush. This was repeated once more if the rhythm remained unchanged, to a total maximum dose of 30 mg. Medical direction for administration of adenosine was in the form of standing orders rather than direct (on-line) medical control. Seventy-four of 102 patients had PSVT as determined by physician analysis of the initial six-second electrocardiographic rhythm strip (ECG) recording. Sixty-six of these patients converted their cardiac rhythm from PSVT using adenosine; 46 (70%) converted with the initial 6 mg bolus. Fifteen patients converted after receiving the second dose (12 mg); and five patients required 30 mg. These results show that for paramedics, adenosine is an effective treatment for PSVT. An initial bolus of 6 mg converts the majority of cases. Eighty-nine percent of cases of confirmed PSVT converted with adenosine administration.

Seroprevalence of hepatitis B and hepatitis C among rural emergency medical care personnel

To identify the prevalence of serologic markers of hepatitis B and hepatitis C among rural prehospital providers, a prospective descriptive study was conducted of a rural county emergency medical services (EMS) system. Participants included 107 prehospital care providers: 102 EMT-Bs, 1 paramedic, and 4 law enforcement first responders. Blood samples taken from prehospital care providers were tested for hepatitis B surface antigen (HBsAg), antibody to HBsAg (HBsAb), antibody to hepatitis B core antigen (HBcAb), and antibody to hepatitis C (anti-HC). The 107 providers had a total of 635 years of EMS experience (5.93 years per subject). Three providers (3%) had received previous blood transfusions, 7 (7%) had worked in a metropolitan area, and 6 (6%) had multiple sexual partners prior to the study. No provider reported intravenous drug use or known homosexual or bisexual contact. Only one sample tested positive for hepatitis C antibody (anti-HC) and hepatitis surface antibody (HBsAb). Rural prehospital care personnel have a low prevalence (0.9%) of exposure to hepatitis B and hepatitis C. Despite this fact, continued vigilance should be maintained in preventing transmission of bloodborne illnesses.

Evaluation of a Model for Improving Emergency Medical and Trauma Services for Children in Rural Areas

Study objective: To evaluate the effectiveness of a rural emergency medical and trauma services project in increasing the knowledge and confidence of emergency care personnel in the management of acutely ill and injured children. Methods: This prospective, quasi-experimental study used an untreated control group design with pretest and posttest of prehospital and hospital-based emergency care personnel in two rural counties in central Ohio. Project evaluation compared 50 emergency care providers from the intervention county with 43 emergency care providers from the control county. Changes in knowledge and confidence of these personnel in the assessment and management of pediatric emergencies were compared. Results: Providers in the intervention county demonstrated a significantly greater increase in test scores regarding knowledge of pediatric emergencies than did providers in the control county ( P=.001). Significantly greater improvement was also seen when comparisons of test scores were made for field ( P=.02) and hospital ( P=.03) emergency care personnel separately. Self-reports on a visual analog scale indicated that providers in the project intervention county had a significantly greater decrease in anxiety than did control subjects when presented a scenario of a child experiencing a respiratory arrest ( P=.01). On the basis of scores from a five-point Likert scale, emergency personnel in the intervention county had a greater increase in confidence regarding management of the pediatric airway ( P=.0003) and a greater increase in the belief that they had adequate pediatric training ( P=.000001) after participating in the project than emergency personnel in the control county. Conclusion: The rural pediatric emergency medical and trauma services project was effective in increasing the knowledge and confidence of emergency care personnel in the management of acutely ill and injured children. This project offers a model that can be replicated in other rural areas nationally. [Smith GA, Thompson JD, Shields BJ, Manley LK, Haley KJ: Evaluation of a model for improving emergency medical and trauma services for children in rural areas. Ann Emerg Med April 1997; 29:504-510.]

Accuracy of rural ems provider interpretation of three-lead ecg rhythm strips

Objective. To measure the accuracy of lead II rhythm strip interpretations performed by advanced life support (ALS) emergency medical technicians (EMTs) in a rural emergency medical services (EMS) system.Methods. An electronic rhythm simulator was used to produce 24 three-lead electrocardiogram (ECG) rhythm strips. The rhythms were shown to 57 ALS EMTs participating in regularly scheduled continuing education classes. The participants were asked to identify the rhythms.Results. The three-lead ECG interpretations were generally accurate, although there was some difficulty in distinguishing between specific types of tachydysrhythmias and atrioventricular (AV) block. The overall accuracy of the rhythm interpretations was 79.2%, ranging from 45.6% (second-degree type II heart block) to 98.2% (sinus bradycardia). The sensitivity for specific tachydysrhythmias ranged from 68.4% (supraventricular tachycardia) to 86.0% (atrial fibrillation); the sensitivity for specific types of AV block ranged from 45.6% (second-degree, type II) to 71.9% (third-degree).Conclusion. In this EMS system, ECG interpretations are generally accurate, with tachydysrhythmias and AV blocks being the source of most discrepancies.

Does basic life support in a rural EMS system influence the outcome of patients with respiratory distress?

The purpose of this study was to determine whether basic life support, prehospital emergency medical care in a rural area affects the hospital course of patients with respiratory distress. Medical records for patients admitted from the emergency department with a discharge diagnosis related to respiratory disease were reviewed. Data collected included: 1) mode of arrival; 2) initial symptom; 3) vital signs; 4) prehospital interventions applied; 5) hospital days; 6) discharge status; and 7) principal diagnosis. Multiple logistic regression analysis was used to predict length of hospital stay. Charts for 603 patients were reviewed. Complete data for all variables included in the logistic regression analysis were available for 471 patients (78.1%). Because 55 patients died, only 416 (69.0%) were included in the multiple regression analysis conducted to predict length of hospital stay. Logistic regression analysis demonstrated that patients who arrived by ambulance and older patients were more likely to die; patients with higher systolic blood pressures were more likely to survive. Only patient age predicted length of hospital stay, with older patients having longer stays. Basic life support prehospital care in this rural emergency medical services system does not result in a lower mortality rate or a shorter hospital stay for a broad group of patients with respiratory distress who require hospital admission. Although this study is limited to a single population and a single emergency medical services system, it is one of only a few studies of outcome in basic life support systems.

Simplifying the assessment of rural emergency medical services trauma transport.

The authors determine whether assessments of effects of rural emergency medical service (EMS) system characteristics on trauma outcomes (using patient-level data) are significantly biased if the Injury Severity Score (ISS) is not available. The data are from ambulance trip reports merged with the trauma registry data for the Georgia EMS region VI trauma center hospital, located in Augusta. All 294 trauma patients for the rural counties surrounding Richmond County for the calendar year 1991 who were not dead at the scene and were treated at the trauma center are included. A 20% random sample of trauma patients from Richmond county from May to September 1991 not dead at the scene and treated at the trauma center yielded an additional 96 cases. Excluding 43 patients with missing data yields 347 trauma cases with 18 trauma deaths. A logistic regression model for trauma mortality is estimated using the Revised Trauma Score (RTS), ISS, type of trauma, and patient age (analogous to the standard Trauma Related Injury Severity Score model). The predicted probability of patient mortality from this model is compared with the predicted probability of mortality when the logistic regression model omits ISS. Correlations between the difference in predicted probability (i.e., the error in predicted probability associated with the omitted ISS variable) and EMS system characteristics are determined. Although ISS adds to the predictive power of the trauma outcome model, the errors in predicted probabilities associated with the omission of ISS generally are small and uncorrelated with patient or EMS system characteristics, with the exception of patient gender. In rural settings, where a patient's ISS generally is not available, studies of rural EMS system characteristics and trauma outcomes may use RTS, patient age, and type of trauma to control for expected survival. The patient's ISS does not appear to be essential, at least for the rural area analyzed in this study.

Simplifying the assessment of rural emergency medical service trauma transport.

The authors determine whether assessments of effects of rural emergency medical services (EMS) system characteristics on trauma outcomes using patient-level data are biased significantly if the Injury Severity Score (ISS) is not available. Data are taken from ambulance trip reports merged with the trauma registry data for the Georgia EMS region VI trauma center hospital, located in Augusta. All 294 trauma patients for the rural counties surrounding Richmond County for the calendar year 1991 who were not dead at the scene and who were treated at the trauma center are included. A 20% random sample of trauma patients from Richmond county from May 1991 to September 1991 not dead at the scene and treated at the trauma center yielded an additional 96 cases. Excluding 43 patients with missing data yields 347 trauma cases with 18 trauma deaths. A logistic regression model for trauma mortality is estimated using the Revised Trauma Score, ISS, type of trauma, and patient age (analogous to the standard Trauma Related Injury Severity Score model). The predicted probability of patient mortality from this model is compared with the predicted probability of mortality when the logistic regression model omits ISS. Correlations between the difference in predicted probability (ie, the error in predicted probability associated with the omitted ISS variable) and EMS system characteristics are determined. Although ISS adds to the predictive power of the trauma outcome model, the errors in predicted probabilities associated with the omission of ISS generally are small and uncorrelated with patient or EMS system characteristics, with the exception of patient gender. In rural settings, where a patient's ISS generally is not available, studies of rural EMS system characteristics and trauma outcomes may use Revised Trauma Score, patient age, and type of trauma to control for expected survival. The patient's ISS does not appear to be essential, at least for the rural area analyzed in this study.

Evaluation of agricultural rescue course by providers.

To assess the characteristics of rural emergency medical services providers involved in the prehospital care of victims of agricultural injuries and determine which aspects of an agricultural rescue course were perceived as most useful. A questionnaire was sent to participants of a course designed for agricultural prehospital providers who had attended a farm accident rescue course between 1986 and 1993. A rural referral center in central Wisconsin. The questionnaire was sent to all persons who had participated in the course. Respondents to the questionnaire characterized their service experience and rated the topic areas in usefulness and whether the subject should be included in future courses. A total of 459 surveys (44% of potential respondents) was returned. Of the respondents, 316 (74.4%) were men, and the mean age was 39.4 years. There were 247 (60.8%) who were volunteers, and an additional 126 (31%) were paid, on-call workers. There were 232 (56.4%) basic providers, and 365 (87.5%) were from a rural area. Many (n = 149; 36.9%) had not responded to farm accidents during the past year. Training course topics rated most useful were machinery extrication, tractor overturn, and enclosed-space rescue. Respondents to an evaluation of an agricultural rescue course primarily were rural, basic providers. Future development of courses for emergency medical technicians involved in agriculture rescue must account for this level of training. Such courses should be short and modular with an emphasis on continuing education, practice, and focus on the identified needs of the participants.