bluuebunny/crossref_metadata_2025 huggingface dataset:
A Meta-Analysis of Hepatitis B Serologic Marker Prevalence in EMS Personnel
Authors: Menegazzi James
Published: July 2016

Introduction:

The risk of exposure to the Hepatitis B Virus (HBV) is a known occupational health risk in medical personnel. The specific risk in emergency medical services (EMS) personnel in the United States (U.S.) is not known. Estimates have ranged from 0.6 to 30.0% The purpose of this investigation was to provide an estimate of the prevalence of this exposure, to determine if this risk is homogeneous throughout the U.S., and to provide an estimate of relative risk. The study hypothesis was that the risk of exposure to HBV is not homogeneous throughout the U.S.

Methods:

All articles containing HBV studies of non-immunized EMS personnel (physicians, nurses, and emergency medical service technicians [EMTs]) were considered, provided they reported at least two of the following seromarkers: hepatitis B (HB) surface antigen; HB surface antibody; and/or HB core antibody. A computerized literature search of a database (MEDLARS) from 1980–1989 was performed. Reference sections of relevant articles and texts also were searched. The chi-square test of homogeneity of proportion was used, assuming binomial distribution. The alpha error rate was set at 0.05.

Results:

Seven articles from 1982 to 1989 qualified for inclusion. The average rate of prevalence for all studies was 14.04% (160/1,140), with a 95% confidence interval of 11.40 to 16.68%. The chi-square test was statistically significant (chi-square=12.59, 6 df, p<.01), suggesting that the risk of exposure is not homogeneous throughout the U.S., and may not be homogeneous within a city, nor between prehospital and hospital personnel. When compared to CDC estimates for the general population in the U.S., this analysis suggests that the EMS personnel tested run three times (2.8) greater risk of HBV exposure than does the general population.

Conclusion:

EMS personnel run a great risk of exposure to HBV with a nationwide prevalence of 14.04%, but this risk is not spread homogeneously throughout the country.
Medical Aspects of Urban Heavy Rescue
Authors: Moede John D.
Published: July 2016

The concept of Urban Heavy Rescue is gaining increasing recognition within the emergency response community. Urban Heavy Rescue has come to denote the unique demands for special equipment and personnel as the result of structural collapse. Recent earthquakes in California, the Philippines, and Soviet Armenia as well as the building collapses in Brownsville, Texas, and New York City provided excellent demonstrations of the concept of specialized structural collapse teams. These events even have prompted the Federal Emergency Management Agency (FEMA) to establish a National Urban Search and Rescue System of special task forces trained in victim location and extrication from collapsed structures. This system will comprise an immediate federal response mechanism for assisting first responders in such activities. The National Search and Rescue System was based on post-event evaluations that pointed out a need not only for more applicable equipment and trained personnel, but also for the timely placement of the these resources.
Opportunity for Seatbelt Usage by ALS Providers
Authors: Cook Richard T. , Meador Steven A. , Buckingham Barry D. , Groff Lee V.
Published: July 2016

Purpose:

Prehospital care providers commonly indicate that they cannot wear seat belts owing to their need to be unrestrained while delivering care to the patient in the back of the ambulance. Each year, providers are injured in situations in which seat belts have been shown to be protective. Are ALS providers able to wear a seat belt and provide care in an ambulance?

Methods:

The ALS providers were asked to complete a form following calls during which they rode with a patient in the back of an ambulance. They indicated the amount of time which they felt they would have needed to have been unrestrained by seat belts and the reasons. There were no attempts to regulate or quantify seat belt usage. Additional information was gathered from the trip report.

Results:

The percentage of the time of each trip during which they felt they needed to be unrestrained was calculated for each trip. The mean was 41%. The mean transport time was 14.7 minutes. Sub-groupings by protocol type, showed that for cardiac arrest patients, providers felt they needed to be unrestrained for 82% of the duration of transport, for patients with “chest pain or cardiac dysrhythmia” 63%, for “shortness of breath” 38%, and for trauma patients 41%. Excluding cardiac arrest patients, the nine patients were assigned by the providers to have the most critical level of case severity required unrestrained time of 72%. Those nine patients with the lowest severity level requires that the provider by unrestrained only 18% of the time. Management of intravenous line and patient assessments most frequently were cited as reasons for needing to be unrestrained.

Conclusion:

Perceived need of ALS providers to be unrestrained varied with respect to the type of call, with cardiac arrest patient transports having the greatest need to be unrestrained. However, on the average, providers felt they needed to be unrestrained only 41% of the time; markedly less on some types of call, with cardiac arrest patient transports having the greatest need to be unrestrained. However, on the average, providers felt they needed to be unrestrained only 41% of the time; markedly less on some types of calls. The ALS providers should be able to wear seat belts for at least part of the time, on most ALS calls.
Multi-Agency, Prehospital Evaluation of the Pharyngeo-Tracheal Lumen (PTL) Airway
Authors: McMahan Sabina , Ornato Joseph P. , Racht Edward M. , Cameron Julia
Published: July 2016

Introduction:

The purpose of this study was to assess subjectively the performance of the pharyngeo-tracheal lumen (PTL) airway in a multi-agency, prehospital emergency medical service (EMS) environment.

Methods:

Data were recorded by the EMS provider on 1,647 adult patients (age range 16–92 years) in whom a PTL or endotracheal (ET) airway insertion was attempted. Analysis of variance and Fisher's Exact tests were used for statistical analysis.

Results:

There were no significant differences between the PTL and ET groups, either in patient demographics or in rates of successful ventilation with either airway overall or in trauma-related versus non-trauma-related cases, male versus female patients, or volunteer versus paid EMS providers. Basic life support (BLS) providers were able to ventilate successfully with the PTL as frequently as were ALS providers using the ET tube.

Conclusions:

The PTL appears to be a useful primary airway for BLS providers and for ALS providers who are called upon infrequently to manage an airway acutely. The PTL also may be used as an alternate airway for ALS providers when tracheal intubation cannot be accomplished. Further study is needed to define the effectiveness of the PTL in the management of patients with trauma-related injuries.
Endogenous Digoxin-Like Factor: Possible Emergency Implications
Authors: Bagrov Alexey Ya
Published: July 2016

The existence of endogenously produced, digoxin-like factor(s) is clear. The implications of die presence of this circulating substance are substantial for the practice of emergency medical care. Clearly, EDLF plays an important role in the generation of dysrhythmias associated with an AMI. Treatment with AA could become routine early in the course of management of some patients with AMI and in die treatment of some forms of hypertension
A Cost-Effectiveness Analysis of Pediatric Intraosseous Infusion as a Prehospital Skill
Authors: Garrison Herbert G. , Downs Stephen M. , McNutt Robert A. , Griggs Thomas R.
Published: July 2016

Purpose:

To determine the clinical efficacy, patient volume, and program costs that justify pediatric intraosseous (IO) infusion as a routine skill for the treatment of patients with cardiac arrest in a prehospital system.

Methods:

A decision analytic model was constructed to include patient outcomes and costs to society. Critical variables for the analysis were: 1) time to vascular access; 2) success of vascular access; 3) clinical efficacy (i.e., the percentage of lives saved by early vascular access); 4) number of patients requiring IO annually; and 5) the cost of an IO program. Program costs included training and equipment expenses. Sensitivity analysis, which repeatedly evaluates the model using different values for the critical variables, identified those values at which IO would be cost-effective.

Results:

With an estimated 80% success rate for IO access within five minutes, the cost-per-life-saved would be [US] $161,000. This cost-effectiveness ratio assumed annual program expenses of $2,000 and one patient per year needing IO. The cost-effectiveness ratio also required a clinical efficacy of 2% for vascular access. To prove that the clinical efficacy of vascular access is in fact 2%, epidemiologic studies would require a sample of nearly 9,000 patients.

Conclusions:

This analysis suggests IO probably is cost-effective given a clinical efficacy above 2%. While the true efficacy may be below this value, clinical studies are unlikely to have sufficient size to prove it. Therefore, emergency medical services (EMS) medical directors must make the decision to utilize IO based on their own beliefs about its clinical efficacy. Further, it must be considered in the context of other prehospital programs which may be more cost-effective. Such analyses permit establishment of rational priorities to rank programs in prehospital systems.
Emergency Physician Interpretation of Prehospital, Paramedic-Acquired Electrocardiograms
Authors: Schaffer Jeffrey A. , Valenzuela Terence D. , Wright Arthur L. , Clark Lani , Brakema Riemke M. , Goldman Steven , Spaite Daniel W.
Published: July 2016

Hypothesis:

Emergency physician interpretation of prehospital, paramedic-acquired, electrocardiograms (ECG) is accurate judged by comparison with that of a reference cardiologist.

Methods:

Twelve-lead ECGs were obtained by paramedics in the field from 150 patients with acute chest pain. The ECGs were transmitted by cellular telephone to a central location. Each ECG was assessed for evidence of acute myocardial infarction (AMI) by: 1) a third-year, emergency medicine resident (EMP-R); 2) a residency-trained, board-certified, emergency physician (EMP-RT); 3) an emergency physician board certified under the practice option (EMP-PT); and 4) a board-certified cardiologist. Agreement between each emergency physician and the cardiologist was assessed by the kappa statistic. Hospital records were reviewed for final diagnosis of each patient.

Results:

Sixteen of 150 (10.7%) patients received a hospital discharge diagnosis of AMI. Sensitivity of physician interpretation ranged from 0.31 to 0.56. All physicians achieved specificity of 0.99. False-positive rates for the physicians ranged from 0.18–0.29. The mean positive predictive value for the four physicians was 0.77±0.05; the mean negative predictive value was 0.94±0.01. The total agreements between the EMP-R, EMP-RT, and EMP-PT and the cardiologists were 0.97, 0.96, and 0.97, respectively. Kappa values for agreement between the emergency physicians and the cardiologist ranged from 0.65–0.79.

Conclusions:

Residency-trained or board-certified emergency physician interpretations of prehospital, paramedic-acquired 12-lead ECGs show a high degree of agreement with reference cardiologist interpretations.
Unexpected ALS Procedures on Non-Emergency Ambulance Calls: The Value of a Single-Tier System
Authors: Wilson Bryan , Gratton Matthew C. , Overton Jerry , Watson William A
Published: July 2016

Background:

In a single-tier, advanced-life-support (ALS) emergency medical service (EMS) system, ALS-trained staff in ALS-equipped vehicles respond to all ambulance calls. In some two-tier systems, basic life support (BLS) vehicles respond to calls which are determined initially to be non-emergency based on dispatcher triage. I emergency requiring ALS is discovered (or recognized) by BLS personnel, then a subsequent ALS response can be requested.

Purpose:

The purpose of this study was to determine the frequency of ALS care provided on ambulance calls initially dispatched as non-emergency.

Setting:

A single-tier, all-ALS provider, EMS system, serving an urban population of 475,000 with an annual response volume of 45,000 calls.

Methods:

A retrospective review of all prehospital transports initially dispatched as non-emergency from 1 January 1989 to 1 January 1990 that resulted in an ALS intervention being performed was conducted. An ALS intervention was defined as, “administration of a medication, endotracheal intubation, attempted IV insertion, and/or ECG monitoring.”

Results:

A total of 6,362 non-emergency calls were identified; of these 309 (5%) were upgraded to emergency while the responding unit was in route. Of 6,053 non-emergency calls remaining, 710 (11.7%) involved the provision of one or more ALS interventions. Of these, 296 (42%) received an IV, 24 (3%) a medication, and three (0.4%) were intubated. Calls that were upgraded by dispatchers required one or more interventions in 144/309 calls (46.6%). This was statistically significantly different than for the non-upgraded calls.

Conclusion:

Despite the use of strict dispatching protocols, 11.7% of patients prioritized as non-emergent unexpectedly received ALS care after evaluation by ALS personnel. These results add support for the use of a single-tier, ALS ambulance system.
Use of Selective Decontamination in the Prevention of Infection After Accidental Irradiation
Authors: Brook Itzhak , Ledney G. David
Published: July 2016

Exposure to radiation induces a reduction in the number of gastrointestinal, anaerobic bacterial flora, and an increase in the number of Enterobacteriaceae that are associated with sepsis and mortality. Antimicrobials that suppress anaerobic flora have a deleterious effect on survival by promoting earlier enterobacterial sepsis. In contrast, in studies of animals and immunosuppressed patients, antimicrobials that inhibit gram-negative enteric bacteria and preserve the anaerobic flora have shown a beneficial effect by preventing bacterial translocation and fatal sepsis. The quinolone antimicrobials hold potential for therapy of endogenous and exogenous infection after irrodiation.
Guidelines for Rescue Training of the Lay Public
Authors: Abrams Joel I. , Pretto Ernesto A. , Angus Derek , Safar Peter
Published: July 2016

The fundamental goal of emergency medical response in disaster is to save lives and reduce injury and permanent disability. It has been observed that urgent emergency medical care of seriously injured earthquake casualties trapped under building rubble, cannot be provided unless the victims have been extricated and transported to medical facilities by friends or relatives, or are accessible to field rescue and medical teams. Equally important is the fact that extrication of seriously injured, trapped victims by laypersons is hazardous, unless the following conditions are met: 1) the rescuer has basic knowledge of extrication, and; 2) there is early application of effective life-supporting first-aid (LSFA) and/or advanced trauma life support (ATLS) at the scene. Time is the critical factor in such an effort. In previous studies of death and dying in earthquakes, it was noted that extrication of trapped victims will be attempted by survivors. Therefore, it is suggested that citizens living in regions of high seismic risk and trained in basic search and rescue and in LSFA are the most immediate resource for early response after an earthquake. An accompanying paper addresses the issue of citizen LSFA training. This paper focuses on the basic concepts of search and rescue training for the lay public.
The Role of Health Sectors in Disaster Preparedness: Floods in Southeastern China, 1991
Authors: Xiaohong Shao
Published: July 2016

Disasters, whether natural or man-made, usually are unpredictable. Efforts to reduce morbidity and mortality from a disaster should be put forth before it occurs.

A brief survey is presented of the worst flood to occur in a hundred years that affected eight provinces in Southeast China. The disaster preparedness and reposnse for Anhui Province, the hardest hit area, is summarized. The disaster preparedness was comprehensive, and cooperation was achieved among various specialties: military forces; firefighters; civil engineers; mechanics; police; provincial governors; the medical sectors; and so forth. Among these groups, the role of medical sectors was of great importance in reducing disease that would have resulted from such a disaster

The measures undertaken by the medical sectors included development of an organization to reduce the impact of disaster; training of medical personnel in techniques of rescue and in treatment of victims in disaster areas; development of a plan to assist the leadership in decision-making and establishing support for disaster preparedness; and maintaining sufficient capacity in general hospitals for the admission of victims from disaster areas.
Intermediate ALS Providers' Level of Interest in Paramedic Education
Authors: Walz Bruce J.
Published: July 2016

Objective:

To examine the level of interest in paramedic upgrade education among a sample of intermediate-level emergency medical technicians, referred to as cardiac rescue technicians (CRT), to obtain education to upgrade to the paramedic level.

Method:

The design of this study was a descriptive, cross-sectional study utilizing a mailed survey instrument.

Results:

Most of the CRTs reported interest in advancement to the paramedic level with the most active CRTs significantly more interested in upgrading than were those with lower grade of activity. Preference was for the upgrade training to be offered as a single course, two nights per week. Respondents also indicated an interest in receiving college credits for the course.

Conclusion:

Active volunteer, intermediate-level emergency medical technicians (EMTs) in Maryland are interested in participating in the education necessary to advance them to the paramedic level.
Clinical Guidelines for Delayed or Prolonged Transport: III. Spine Injury
Authors:   Rural Affairs Committee,   National Association of Emergency Medical Services Physicians
Published: July 2016

Conventional emergency medical services (EMS) guidelines recommend that essentially every victim of any significant trauma be treated in the field as having an unstable spine injury. For example, any victim of any motor vehicle crash generally is assumed to have an unstable spine injury and is transported to the hospital in full-spine immobilization. This approach generally is reasonable and appropriate for the conventional EMS context of rapid transport, because patient symptoms and physical examination often are unreliable for the time period immediately following the event.

The specialized context of delayed or prolonged transport, however, requires a closer look at assessment criteria and treatment procedures for spine injury. Full-spine immobilization, if it is not required, can be unnecessarily difficult, impractical, impossible, and even dangerous during prolonged evacuation, especially in severe environments or when using improvized equipment. Prolonged transport also provides an opportunity to repeat patient surveys and to observe changes in the patient's condition over time.
Natural Hazards: Causes and Effects: A Course in Disaster Management
Authors: Perez Eddie , Thompson Paul
Published: July 2016

This self-study course will meet the needs of people involved in disaster management for both sudden-onset natural disasters (i.e., earthquakes, floods, hurricanes) and slow-onset disasters (i.e., famine, drought). The course is designed for government personnel, representatives of private, voluntary agencies, and other individuals interested in disaster management.

The nine lessons for the course will be published successively in Prehospital and Disaster Medicine. Self-assessment tests will accompany each lesson. There also is a final examination offered for those who wish to earn continuing education units (CEUs) through the University of Wisconsin—Disaster Management Center (UW-DMC).
Blood Transfusion Requirements Among War Casualties in Sarajevo
Authors: Begovic Mirza , Mazlagic Damir , Straus Slavenka , Mazlagic Brankica
Published: July 2016

Introduction:

The safe and timely provision of blood is of crucial importance in the prevention and mitigation of morbidity and mortality due to trauma. The use of blood in the treatment of war casualties, soldiers as well as civilians, was analyzed retrospectively and the impact of massive blood transfusion on blood banking services and reserves of blood during the war in Sarajevo was assessed.

Methods:

A retrospective analysis of 3,215 war casualties (1,815 civilians plus 1,400 military) who arrived to the casualty reception center of the State Hospital of Sarajevo during the period 11 May through 31 October 1992 was performed. Blood usage was reviewed in three stages: within 24 hours (h) of admission, after seven days of hospitalization, and after 30 days of hospitalization. The types of injury, survival rate, and blood-usage rate in a sample of 37 war casualties who required massive blood transfusions (MBT) during the period 11 May through 31 December 1992 was examined.

Results:

The civilian casualty rate in this series of patients was 56.5%. A total of 1,217/3,215 (37.9%) casualties were hospitalized. In this study, 16% (504/3,215) of total number of persons wounded received blood transfusion. Of these patients, 504/1,217 (41.4%) were transfused. A total of 971.1 liters of blood were transfused through 31 October 1992; 68% within 24 h of admission, 91% within the first seven days, and 100% within the first 30 days. From a total of 37 MBT recipients, 36 (97%) were injured by firearms. Survival rate among MBT patients was 30%. The MBT recipients comprised 2% of total hospitalized patients and 6% of total number of patients transfused. The amount of blood needed during episodes of MBT was 15% of total blood used through 31 December 1992.

Conclusions:

Based on these data, prospective requirements for blood usage should take into account casualty triage, as follows: for each casualty transported to the hospital, hospitalized, or transfused, 0.302, 0.796, and 1.912 liters of blood respectively, will be needed for the first 30 days of treatment. Recipients of massive blood transfusions are a significant drain on blood reserves in war. This experience can be utilized in the development of revised guidelines for blood usage for an entire population affected by war.
Emergency Medical Services Liability Litigation in the United States: 1987 to 1992
Authors: Morgan David L. , Wainscott Michael P. , Knowles Heidi C.
Published: July 2016

Introduction:

Although emergency medical services (EMS) liability litigation is a concern of many prehospital health care providers, there have been no studies of these legal cases nationwide and no local case studies since 1987.

Methods:

A retrospective case series was obtained from a computerized database of trial court cases filed against EMS agencies nation-wide. All legal cases that met the inclusion criteria were included in the study sample. These cases must have involved either ambulance collisions (AC) or patient care (PC) incidents, and they must have been closed between 1987 and 1992.

Results:

There were 76 cases that met the inclusion criteria. Half of these cases involved an AC, and the other cases alleged negligence of a PC encounter. Thirty (78.9%) of the plaintiffs in the AC cases were other motorists, and 35 (92.1%) of the plaintiffs in the PC cases were EMS patients. Almost half of the cases named an individual (usually an emergency medical technician or paramedic) as a codefendant. Thirty-one (40.8%) of the cases were closed without any payment to the plaintiff. There were five cases with plaintiffs' awards or settlements greater than [US] $1 million. Most (71.0%) ofthe ACs occurred in an intersection or when one vehicle rear-ended another vehicle. The most common negligence allegations in the PC cases were arrival delay, inadequate assessment, inadequate treatment, patient transport delay, and no patient transport.

Conclusion:

Risk management for EMS requires specific knowledge of the common sources of EMS liability litigation. This sample of recent legal cases provides the common allegations of negligence. Recommendations to decrease the legal risk of EMS agencies and prehospital providers are suggested.
Patient-Data Collection System Used During Medical Operations After the 1994 San Fernando Valley-Northridge Earthquake
Authors: Leonard Ralph B. (Monty) , Stringer Lew W. , Alson Roy
Published: July 2016

Introduction:

In large disasters, such as earthquakes and hurricanes, rapid, adequate and documented medical care and distribution of patients are essential.

Methods:

After a major (magnitude 6.7 Richter scale) earthquake occurred in Southern California, nine disaster medical assistance teams and two Veterans Administration (VA) buses with VA personnel responded to staff four medical stations, 19 disaster-assistance centers, and two mobile vans. All were under the supervision of the medical support unit (MSU) and its supervising officer. This article describes the patient-data collection system used. All facilities used the same patient encounter forms, log sheets, and medical treatment forms. Copies of these records accompanied the patients during every transfer. Centers for Disease Control and Prevention data classifications were used routinely. The MSU collected these forms twice each day so that all facilities had access to updated patient flow information.

Results:

Through the use of these methods, more than 11,000 victims were treated, transferred, and their cases tracked during a 12-day period.

Conclusions:

Use of this system by all federal responders to a major disaster area led to organized care for a large number of victims. Factors enhancing this care were the simplicity of the forms, the use of the forms by all federal responders, a central data collection point, and accessibility of the data at a known site available to all agencies every 12 hours.
Medical Director for Air Medical Transport Programs
Authors: Eljaiek Luis F. , Norton Robert , Carmona Richard
Published: July 2016

The National Association of Emergency Medical Services Physicians (NAEMSP) recognizes that the position of medical director of air medical transport program is an integral part of the program. Therefore, guidelines for education, experience, and performance of the medical director are essential to ensure quality patient care and provide a safe, proficient, and cost-effective operation.
Out-of-Hospital Use of a Pulse Oximeter to Determine Systolic Blood Pressures
Authors: McCluskey Brendan , Addis Michael , Tortella Bartholomew J. , Lavery Robert F.
Published: July 2016

Study objective:

Blood pressure (BP) in the out-of-hospital setting is one of the most important diagnostic tools used by emergency medical services (EMS) providers. Conventional methods of palpation and auscultation can be time consuming, and the measurements often are inaccurate because of the adverse working conditions encountered. Pulse oximetry waveform systolic blood pressure (POWSBP) measurement has been used successfully in emergency departments to monitor BP. The objective of this study was to compare the accuracy of field POWSBP measurements obtained by noninvasive electronic BP measurement (NIBPM), auscultation, and palpation in the out-of-hospital environment.

Design:

Blood pressure measurements used for this study were obtained by POWSBP, NIBPM (PROPAQ model 102; Protocol Systems, Beaverton, Oregon USA), auscultation, and palpation on patients in moving ambulances. Measurement of POWSBP was accomplished by observing the return of the waveform on the pulse oximeter at the time of cuff deflation. The order in which the readings were obtained as well as the arm chosen for measurement were randomized.

Setting and participants:

Paramedics and emergency medical technicians in an urban, inner-city emergency medical services (EMS) system.

Measurements and main results:

Bloopressure measurements were sampled from 69 patients. Regression analysis identified significant correlation between POWSBP and the four methods utilized, with r = 0.92 for NIPBM, r = 0.95 for auscultation, and r = 0.97 for palpation, all significant at p<0.0001.

Conclusions:

The use of POWSBP measurement is a fast, easy, and accurate technique with which to measure systolic BP in the field. It may have special importance for noisy environments and moving vehicles in which conventional methods of auscultation or palpation may be difficult.
Does the Ambulance Environment Adversely Affect the Ability to Perform Oral Endotracheal Intubation?
Authors: Gough John E. , Thomas Stephen H. , Brown Lawrence H. , Reese James E. , Stone C. Keith
Published: July 2016

Objective:

Oral endotracheal intubation (ETI) is the preferred method of controlling the airway in critically ill or injured patients. It was postulated that time could be saved if intubation was performed in the ambulance en route to the hospital. This study was designed to determine whether the ambulance environment adversely affected the ability of emergency medical technicians at the advanced-intermediate level (EMT-AI) to perform oral ETI.

Hypothesis:

The restrictive environment of a moving ambulance would affect adversely the ability of EMT-AIs to perform ETI compared with a controlled setting. This would result in a significant increase in the time necessary to perform ETI in the ambulance compared with a controlled setting not complicated by restrictive space and motion.

Methods:

Twenty on-duty EMT-AIs were recruited to volunteer for this prospective, nonrandomized, nonblinded trial. All participants performed three consecutive oral ETIs on an airway mannequin in two settings: 1) in the back of a moving ambulance; and 2) on a table in the rescue squad station. Of the participants, 10 performed the intubations in the ambulance first; the remainder performed the intubations at the station first. Time for intubation with the mannequin was recorded by stopwatch. The mean times for intubation in both settings were compared by Student's t-test (p<0.05).

Results:

All intubation attempts were successful. The mean time for intubation in the station was 13.0±3.4 seconds. The mean time in the ambulance setting was 13.2±5.3 seconds. There was no significant difference between the intubation times in the two settings (p = 0.88).

Conclusion:

The environment of a moving ambulance does not appear to hinder the ability of EMT-AIs to perform oral ETI in a laboratory setting with a mannequin model.
Enhancing Critical Thinking in Paramedic Continuing Education
Authors: Dalton Alice L.
Published: July 2016

Critical thinking has become a buzzword, especially in medical education. The challenge is first to determine what skills compose critical thinking and what teaching techniques promote critical-thinking skills, and then to determine how to apply these techniques effectively and efficiently to a given population in the classroom.

This article begins with a working definition of critical thinking and explores the parameters and skills implied or stated in the definition. Then a teaching environment constructed around a model of critical thinking and characteristics of the audience is described. A specific teaching method, suggested by research and designed to exercise critical-thinking skills, is then applied to a specific patient problem in a continuing education class. Preliminary outcomes are presented.

The purpose of this article is to propose a productive and efficient educational method for promoting and enhancing critical-thinking skills appropriate for paramedic-level continuing education.
Comparison of Inhaled Metaproterenol via Metered-dose and Hand-held Nebulization in Prehospital Treatment of Bronchospasm
Authors: Rottman Steven J. , Robinson Nancy E. , Birnbaum Marvin L.
Published: July 2016

Introduction:

Although the efficacy of the administration of beta-adrenergic bronchodilators has been demonstrated, the best method available for the delivery of these drugs in the prehospital setting has not been defined. This paper compares the effects of administration of metaproterenol when administered by paramedics using either a metered-dose inhaler (MDI) or a hand-held nebulizer (HHN).

Hypothesis:

There is no difference in the effects produced in patients suffering from smooth bronchiolar muscle spasm by metaproterenol when delivered either by a standard metered-dose inhaler or with a hand-held nebulizer.

Participants:

Consecutive prehospital patients complaining of difficulty breathing with clinical evidence of bronchospasm and with a history of asthma, chronic obstructive pulmonary disease, or emphysema who were not in extremis.

Methods:

Prior to the administration of metaproterenol, a peak expiratory flow rate (PEFR) was obtained. This measurement was repeated five minutes following the conclusion of the administration of metaproterenol. Patients in Burbank, California, received the treatment using a standard metered-dose inhaler, and those in Madison, Wisconsin, received the drug using a hand-held nebulizer. Peak expiratory flow rates were compared using Student's t-tests with Bonferroni's correction. Statistical significance was set at p <0.05.

Results:

Data were collected from 36 consecutive patients by the paramedics of the Burbank Fire Department and from 32 consecutive patients by the paramedics of the Madison Fire Department. For the metered-dose inhaler group, the mean value for peak expiratory flow rate for the pre-treatment test was 95.4 ±88.1 1/min, and after treatment was 109.4 ±89.3 1/min (p <0.001). For the hand-held nebulizer group, the mean value for peak expiratory flow rate before the administration of the metaproterenol was 96.1 ±76.3 1/min and following the treatment was 149.1 ±92.9 1/min (p <0.001). The mean values for the differences between the control peak expiratory flow rate and the post-treatment peak expiratory flow rate for the metered-dose inhaler group was +14.0 ±27.4 1/min, and for the hand-held nebulizer group was +53.0 ±69.1 1/min (p <0.003).

Conclusions:

In the prehospital setting the administration of metaproterenol using a hand-held nebulizer is more effective than delivering the drug using a metered-dose inhaler. The hand-held nebulizer is easier to use and delivers a higher dose of the drug than is convenient using the metered-dose inhaler.
The Effects of Stressors on Emergency Medical Technicians (Part II): A Critical Review of the Literature, and a Call for Further Research
Authors: Boudreaux Edwin , Mandry Cris
Published: July 2016

Part I of this series of articles about stress among emergency medical technicians (EMTs) reviewed the potential sources of EMT stress. This article investigates the other side of the stress equation and provides a critical review of the empirical literature on the effects of stressors on EMTs. It is subdivided into sections corresponding to trends in the research, including: 1) predictors of higher stress levels; 2) differences in stress responses among EMTs, other health professionals, and firefighters; and 3) various physiologic, psychologic, and job performance responses. It identifies some of the methodologic flaws found in the EMT-stress literature that are noted in Part I, and provides further direction for future research. To maintain homogeneity, this review is limited to those articles published in scholarly journals. Studies investigating constructs such as job dissatisfaction and burnout were not included unless the study also included a measure of stress or stressors.
Acceptance of an Injury-Prevention Program in Rural Communities: A Preliminary Study
Authors: Moore Edwin , McComas John
Published: July 2016

Introduction:

Considerable attention is being addressed to injury prevention. This study addresses the acceptance of a home injury-prevention survey as an injury-prevention tool in rural communities.

Purpose:

The purpose of this study was to evaluate public acceptance of a home injury-prevention survey as a tool to educate and enlighten the public about home injuries.

Methods:

All patients with home injuries who came to Wetzel County Hospital Emergency Department were asked if they would participate in a home injury-prevention survey. The study was conducted from 01 May to 01 July 1995. Paramedics were used as interviewers because of the closeness they enjoy with the community.

Results:

During the study period, 2,104 patients came to the emergency department of Wetzel County Hospital. Of these, 386 sought care because of an injury sustained in their homes. From this group, 23 (5.9%) patients agreed to participate in a home injury-prevention study; 363 (94.1%) refused.

Conclusion:

A home injury-prevention survey alone does not seem to be an effective tool to aid in the reduction of home injuries, because it is not embraced by the general public.
Infant Feeding Practices in Complex Emergencies: A Case Study Approach
Authors: O'Connor Mary E. , Burkle Frederick M. , Olness Karen
Published: July 2016

The majority of deaths associated with complex emergencies are attributed to infants and children under the age of five years. Most of these deaths are related to preventable diseases such as malnutrition, diarrhea, and malaria. Infant feeding emergencies have emerged as a major factor in complex emergencies. This paper reviews the current information relative to infant feeding, and uses four case studies as educational tools for the management of infant feeding emergencies.

Child mortality rates in refugee population have been linked directly to protein-energy malnutrition (PEM). Breast feeding has many advantages over all other forms of feeding for children up to the age of two years of age. These advantages are discussed in detail in this paper. In addition, the appropriate and inappropriate uses of breast-milk substitutes (BMS) are discussed. Breast feeding also may play a role in the spread of HIV infections from the mother to the infant. However, in the setting of complex emergencies in the developing world, the risk of an infant dying of malnutrition and infection when not breastfed is likely to be greater than is the risk of death due to HIV acquisition through breastfeeding.

The physiology of lactation is reviewed with particular reference to the roles of prolactin, oxytocin, and the feedback inhibitor of lactation (FIL) hormone. No medications have been demonstrated to augment milk production that can be used in a practical sense in complex emergencies. Lastly, the principles promulgated by the WHO and UNHCR for the feeding of infants and children in emergencies and for milk powder distribution are summarized.
Demographic Methods to Assess Food Insecurity: A North Korean Case Study
Authors: Robinson W. Courtland , Lee Myung Ken , Hill Kenneth , Hsu Edbert , Burnham Gilbert
Published: July 2016

In complex emergencies, especially those involving famine and/or wide-spread food insecurity, assessments of malnutrition are critical to understanding the population's health status and to assessing the effectiveness of relief interventions. Although the Democratic People's Republic of Korea (DPRK) has benefited from some of the largest, most sustained appeals in the history of the World Food Program (WFP), the government in Pyongyang has placed restrictions on international efforts to gather data on the health and nutritional status of the affected population.

Question: Lacking direct means to assess the nutritional status of the North Korean populace, what other methodologies could be employed to measure the public health impacts of chronic food shortage?

The paper begins with a review of methods for assessing nutritional status, particularly in emergencies; a brief history of the North Korean food crisis (1995–2001), and a review of the available nutritional and health data on the DPRK. The main focus of the paper is on the results of a survey of 2,692 North Korean adult migrants in China. Recognizing certain biases and limitations, the study suggests that sample households have experienced an overall decline in food security, as evidenced by both the decline in government rations from an average of 120 grams per person per day to less than 60 grams per day, and by the increase in the percentage of households relying on foraging or bartering of assets as their principal source of food. It also is apparent that the period 1995–1998 has been marked by elevated household mortality, declining fertility, and steadily rising out-migration. Taken together, the signs point toward famine, whether that is defined as a discrete event—that is, as a regional failure in food production or distribution leading to elevated mortality from starvation and associated disease—or as a more complex social process whose sub-states include not only elevated mortality, but declining fertility, eating of alternative ‘famine foods’, transfer of assets, and the uprooting and separation of families.
Comparison of Emergency Resuscitation with Colloids and Crystalloids
Authors: Shoemaker William C.
Published: July 2016

Clinical management is exceedingly difficult to evaluate in emergency patients because resuscitation is often chaotic, disorderly, and frantic. Resuscitation depends upon many factors: the primary illness or injury, the amount of blood and fluid losses, the patient's age, the prior state of health, the associated medical conditions, the time delay in instituting therapy, the volume and rate of fluids administered, and, finally, the choice of fluids given. Although it is difficult to control the effects of these complex interrelated factors, their influence may be evaluated by stratifying patients and then comparing the direct effects and outcome measures within each stratum.

There has been persistent controversy over the relative merits of crystalloids and colloids in fluid resuscitation. We studied reviews of fluid management of all hypotensive patients seen in the adult surgical section of the Emergency Department (ED) during a 2½ year period, to compare the conventional crystalloid resuscitation which had been standard for this busy university-run county hospital with a fluid management protocol consisting of about 1/4 A colloids depending on age, cardiac history, and CVP.
Pathologic Studies: An Essential Guide
Authors: Moossy John
Published: July 2016

To emphasize the importance of pathologic studies to physicians and biomedical scientists should be “preaching to the converted.” Unfortunately there are disturbing signs that this is not so, particularly in clinical medicine. The autopsy rate is declining globally and some authors have even unwisely implied in print that modern diagnostic techniques render the autopsy and other pathologic studies superfluous. Fortunately, pathologists continue to expose and resist such attitudes by means of analytical discussion of the problem. The role of pathologic study remains an essential one in both clinical and experimental studies of therapy of all types.

The term pathologic studies includes: pathologic anatomy (the autopsy and surgical biopsy); clinical pathology (hematology, chemistry, microbiology, immunologyl and experimental pathology.
Role of Trauma Score in Triage of Mass Casualties
Authors: Champion Howard R. , Sacco William J.
Published: July 2016

The development of emergency medical services (EMS) systems in the United States, incorporating various levels of sophistication in prehospital care and echelons of capability in hospital resource availability, has brought new connotations to the word “triage” (sorting).

Heretofore, triage consisted entirely of estimating treatment needs so that prioritized transfer of patients could be made to hospitals. The decision is no longer binary, since the introduction of Trauma Centers requires the triage decision maker to not only decide which patient first, but also which patient to which hospital. Clear cut decision rules for this process applied to routine civilian emergency medical practice have yet to emerge.
Space-Borne Systems in Support of Emergency and Disaster Medicine
Authors: Heath Gloria W. , Freibaum Jerry , Richards Paul B.
Published: July 2016

The quick re-establishment of communications is vital to all disaster relief operations, but simple effective means of doing so are usually lacking. The unpredictability of the type, time, and location of catastrophic or disaster events requires a communications capability which is mobile, versatile, and dependable under all conditions of weather and terrain. Similar needs are essential for emergency medical services and search and rescue operations. These are problems without national boundaries.
Computer Modeling of Rural Emergency Medical Services Delivery Systems
Authors: Shuman Larry J. , Sepulveda Jose , Wolfe Harvey , Esposito Gerald
Published: July 2016

RURALSIM is a sophisticated computer simulation model designed as an aid in planning and evaluating rural emergency medical services (EMS) systems. Written in SIMULA, it has been successfully used in Indiana County, Pennsylvania, to study the potential effects of changes in existing vehicle placement and relocation strategies, vehicle dispatching policies and alternative forms of prehospital care, including the ability of the system to respond to a disaster.

RURALSIM is a stochastic, dynamic, event-oriented computer model. Stochastic means that all random events, such as the occurrence of an incident, are generated according to appropriate probability distributions obtained from empirical data. Dynamic means that events occur over time and that the model selects the appropriate incident rates and response strategies for the particular time and day simulated.
The Evaluation of Resuscitation and Critical Care Equipment: A Quality Assurance Service for the User
Authors: Knickerbocker G. Guy
Published: July 2016

Several thousand distinct medical devices exist and for each one the user usually has a choice from among a number of manufacturers. The process whereby a clinician or hospital purchasing agent makes a selection from a number of competing brands may be based on anything from, on the one extreme, little more than an emotional attraction to a particular brand name to, at the other end of the spectrum, a fully enlightened choice after an inhouse evaluation together with extensive additional information. This paper will describe, with concrete examples drawn from the ensemble of equipment used in the fields of resuscitation and critical care, how Emergency Care Research Institute evaluates such devices, investigates hazards associated with these instruments, and communicates this information to users.
Cardiopulmonary Resuscitation (CPR) Training in Developing Regions
Authors: Lane John C.
Published: July 2016

In Third World countries there are many priorities that take precedence over cardiopulmonary resuscitation (CPR). Some more common concerns are malnutrition, infectious diseases (malaria, tuberculosis, measles and polio) and children's diseases such as diarrhea and dehydration. Other priorities such as sanitation, housing, primary and professional education, jobs and birth control, inflation (118% for Brazil in 1980), energy crises and balance of payments are important government priorities. Accident prevention in civil construction and traffic education should be of paramount importance in a country that holds world records of accidents in both sectors. After we consider the above priorities, first aid education and CPR are to be taken into account. This does not mean that CPR training is not to be undertaken until all of the other priorities are satisfied, but it does mean that the availability of funds and motivation will be relegated to a lower priority in countries that are developing and have similar problems.