bluuebunny/crossref_metadata_2025 huggingface dataset:
Medical Coverage of a Marathon: Establishing Guidelines for Deployment of Health Care Resources
Authors: Ellis David G. , Verdile Vincent P. , Paris Paul M. , Heller Michael B. , Kennedy Robert , Cox Roy , Irrgang James , Fu Freddie
Published: July 2016

Introduction:

Few prearranged events provide better opportunities for emergency health system coordination and planned disaster management than does medical coverage of a major city marathon. No guidelines exist as to the appropriate level of care that should be provided for such an event.

Methods:

The medical coverage for 2,900 marathon runners and an estimated 500,000 spectators along a 26.2-mile course over city streets for the 1986 Pittsburgh Marathon was examined prospectively. Support groups included physicians, nurses, and medical students from area hospitals and emergency departments and podiatrists, physical therapists, athletic trainers, and massage therapists from the Pittsburgh area. Emergency medical services were provided by city and county advanced life support (ALS) and basic life support (BLS) units, the American Red Cross, and the Salvation Army. A total of 641 medical volunteers participated in the coverage. Data were collected by volunteers as to acute medical and sports medical complaints of all patients, their vital signs, and the treatment provided. Medical care was provided at 20 field aid-stations along the race route (including a station every mile afier the 12-mile mark, and at four stations at the finish line).

Results:

Race day weather conditions were unusually warm with a high temperature of 86°F (30°C), relative humidity of 64%, partly sunny with little ambient wind, and a high wet bulb-globe temperature of 78°F (25.6°C). Records were obtained on 658/2,900 (25%) runner-patients of which 52 (8%) required transportation to area hospitals after evaluation at aid-stations: three were admitted to intensive care units. Analysis showed that 379/658 (58%) of the patients were treated at the finish line medical areas, and of the remaining 279 patients treated on the course, 218/279 (78%) were seen at seven, mile-aid-stations between 16.2 and 22.8 miles. The conditions of heat and humidity constitute a near “worst-case” scenario and the numbers of medical personnel that should be available to deliver acute care of hyperthermia/hypothermia and fluid/electrolyte disorders are recommended. Also it is recommended that approximately 50% of medical personnel and equipment should be deployed in the finish line area and that 80% of the remaining resources on the race course be deployed in aid-stations located every mile between miles 16 and 23.
Thoraco-Lumbar Spinal Instability during Variations of the Log-Roll Maneuver
Authors: Suter Robert E. , Tighe Thomas V. , Sartori John , Reed Kendell
Published: July 2016

Introduction:

The “log-roll” maneuver is a common method of moving patients with suspected spinal injuries despite the fact that there is very little published information concerning its effectiveness.

Methods:

Lateral thoraco-lumbar motion and rotation during five variations of the log-roll maneuver were examined radiographically in fourteen healthy adults. Variations included the addition of axial traction and alterations in subject arm position.

Results:

While no rotational differences were noted between variations, substantial differences in lateral displacement were identified between individual subjects and techniques. This variability seemed to be due to differences in individual body habitus, particularly the shoulder/thorax to pelvis proportions and the amount of periabdominal fat. The addition of traction decreased motion in 59% of attempts but increased motion in 18%. While definitive recommendations cannot be made based upon these data, only one variation of the log-roll techniques examined consistently minimized lateral spinal motion in subjects tested. This variation involved positioning the subject with arms fully extended at their sides with palms resting on the lateral portion of their thighs and maintaining this position throughout the procedure.

Conclusions:

Pending further studies, it may be advisable to utilize this variation in patients with suspected thoraco-lumbar trauma.
Survey of Emergency Medical Technicians' Ability to Cope with the Deaths of Patients During Prehospital Care
Authors: Norton Robert L. , Bartkus Edward A. , Schmidt Terri A. , Paquette Jan D. , Moorhead John C. , Hedges Jerris R.
Published: July 2016

Hypothesis:

Emergency medical technicians (EMTs) find that the death of patients in their care is stressful.

Population:

Random sample of certified EMTs in one state (Levels I–IV).

Methods:

A blinded, self-administered survey was sent to a random sample of 2,500 EMTs. Demographic data obtained were: level of training; hours worked each month; population of area served; age; gender; number of deaths per year; training for coping prehospital deaths; and availability of protocols and on-line medical advice for out-of-hospital deaths. A five-point, Likert scale was used to rate the frequency of perceived stress experienced by EMTs in specific situations and the routine practice for notification of survivors. Univariable analysis was performed using Spearman's Rank correlation, Kruskal-Wallis test, and Mann-Whitney U-test. Multivariable correlations were performed using forward and backward step-wise logistic regression analysis. A significance level of 0.05 was used throughout.

Results:

There were 654 respondents with a mean age of 35.5±8.3 yr; 83% were men. Their highest level of training was: 4% EMT-I, 43% EMT-II, 18% EMT-III, 33% EMT-IV. They saw an average of 9.6 deaths/year and spent an average of 20±17 minutes with survivors. 62 % found treatment of a patient that was dying or died in their care was commonly a stressful experience. Factors that made notification of the family about the prehospital death emotionally difficult included: fewer hours worked/month; working in a smaller community; lower level of EMT training; female gender; and fewer deaths seen during the previous year. The same factors were associated with general emotional difficulty in treatment of a patient who died during prehospital care. Online [direct] medical direction by physicians was common (73%), but did not lessen the difficulty of notification. It did reduce the emotional difficulty for specific clinical situations. Written protocols for not attempting resuscitation were common (66%), but only 44% had protocols for termination of resuscitation. Resuscitation of the clearly dead for the benefit of the family (10%) or for the EMT (5%) was practiced infrequently. Most (67%) respondents had some formal training in dealing with death and the dying patient. Such training did not correlate with less difficulty in notification of survivors or in coping with the deaths of patients in their care.

Conclusion:

EMTs perceive they have emotional difficulty when prehospital deaths occur and survivors must be notified. Less experience and a lower level of EMT training correlate with more difficulty in coping with patient death. Protocols and on-line [direct] medical control can provide support for the EMT in coping with out-of-hospital deaths. Most notification of survivors is handled by EMTs with formal training to cope with patients that are dying or who die during prehospital care.
9-1-1 EMS Process in the Loma Prieta Earthquake
Authors: Thiel Charles C. , Schneider James E. , Hiatt Donald , Durkin Michael E.
Published: July 2016

The Santa Cruz County 9-1-1 emergency response system was taxed severely with over 1,000 calls during the first seven hours following the Loma Prieta earthquake. It remained functional and responsive, making 229 ambulance runs in the 72-hour period following the earthquake. Initially, the demand was very high compared to normal, but decreased to slightly greater than normal levels during the second day. A fewer than normal number of advanced life support transports were required, and the number of vehicular accident cases were fewer than normal following the earthquake. The 9-1-1 center adopted an abbreviated procedure and only attempted to determine if the call was a medical emergency and the location for dispatch. During the initial emergency period, there were an unusually low proportion of transports and an unusually high number of cases in which the patient was not located. The medical system in Santa Cruz County was able to accommodate the injury load: the health care system was extensive; its three community hospitals were not damaged severely; and there was light demand.

Based on this experience, a revised 9-1-1 emergency medical services (EMS) procedure is recommended for disaster periods: 1) the dispatcher inquires whether the patient can be transported by other means; 2) the caller is asked to explain the need for an ambulance in order to assign a priority to the request; and 3) the caller is asked to cancel the call if there no longer is a need. This procedure is expected to improve disaster management of limited ambulance resources during and following a disaster, while maintaining rapid call processing.
Follow-up and Outcome of Patients Who Decline or Are Denied Transport by EMS
Authors: Zachariah Brian S. , Bryan David , Pepe Paul E. , Griffin Monica
Published: July 2016

Introduction:

In recent years, several authors have begun to address the medical and legal risks associated with patients refusing or being refused transport by emergency medical services (EMS) systems. However, data regarding patient outcomes still are lacking.

Purpose:

The purpose of this study was to determine: 1) why patients are not transported; and 2) the subsequent outcome of these patients.

Setting:

A busy, suburban, volunteer EMS service with indirect medical control, but no guidelines for non-transport of patients.

Methods:

A retrospective review of the records of 158 consecutive EMS incidents in which an ambulance was called, but the patient was not transported. Follow-up was attempted by telephone contact with the patient and/or family.

Results:

Telephone follow-up was established successfully for 93 cases (59%). Of the 93 patients, 60 (64.5%) subsequently sought care from a physician, 15 of whom (25%) later were admitted. The mean hospital stay was 6.6±7.9 days (median=3 days) with a range of 1–30 days. Two were admitted to an intensive care unit (ICU) and two others died. Of the 93 study cases, 43 (46%) involved situations in which the patient refused transport. Paramedics declined transport or mutually agreed not to transport in 50 cases (54%). This latter category accounted for 11 (73%) of the 15 hospitalizations. Ten percent of patients (or their families) stated that they were dissatisfied with the non-transport decisions.

Conclusions:

Serious, even fatal outcomes were identified in the follow-up of patients not transported by EMS. Although a direct causal relationship was not established within the context of this study, situations in which EMS personnel either denied transport (or mutually agreed with the patient not to transport by ambulance) were twice as likely to result in hospitalization than were those cases in which the patients declined transportation against the advice of the EMS personnel.
Who Calls the Shots? EMS Operations Control and the Role of the Communications Center
Authors: Suter Robert E.
Published: July 2016

Once ignored by health care and management theorists, emergency medical service (EMS) has begun to attract attention to its traditional policies and practices. Long-standing notions about job qualifications, job responsibilities, organizational structure, and operations control are being challenged by alternative approaches such as System Status Management (SSM), Computer-Aided Dispatch (CAD), and Emergency Medical Dispatch (EMD). One important characteristic of these new models is their emphasis on the role of the communications center in controlling operations. Convincing arguments for these systems have been advanced, and they have been implemented successfully in many areas.

Despite these developments, variations of the traditional model which minimizes the importance of the communications center and emphasizes control by field supervisors still characterize many, if not most, EMS systems in the United States. While this probably is due to a natural resistance to change and local political concerns, data supporting the new systems unfortunately are only anecdotal. Except for superficial comparisons, the traditional and alternative approaches have not been examined in light of accepted management theory and principles. Therefore, this paper will analyze the communications center and operations control from a theoretical standpoint to determine where in an EMS organization, control is exercised most naturally, and how these findings could impact on management effectiveness.
Recommendations for Life-Supporting First-Aid Training of the Lay Public for Disaster Preparedness
Authors: Angus Derek C. , Pretto Ernesto A. , Abrams Joel I. , Safar Peter
Published: July 2016

In catastrophic disasters such as major earthquakes in densely populated regions, effective Life-Supporting First-Aid (LSFA) and basic rescue can be administered to the injured by previously trained, uninjured survivors (co victims). Administration of LSFA immediately after disaster strikes can add to the overall medical response and help to diminish the morbidity and mortality that result from these events. Widespread training of the lay public also may improve bystander responses in everyday emergencies. However, for this scheme to be effective, a significant percentage of the lay population must learn the eight basic steps of LSFA. These have been developed by the International Resuscitation Research Center in collaboration with the World Association for Emergency and Disaster Medicine, the City of Pittsburgh Department of Public Safety, and the American Red Cross (Pennsylvania chapter). They include: 1) scene survey; 2) airway control; 3) rescue breathing (mouth-to-mouth); 4) circulation (chest compressions; may be omitted for disasters, but should be retained for everyday bystander response); 5) abdominal thrusts for choking (may be omitted for disasters, but retained for everyday bystander response); 6) control of external bleeding; 7) positioning for shock; and 8) call for help.
Factors Influencing Treatment of Asthma in Children in the Prehospital Setting
Authors: Tortella Bartholomew J. , Marrocco Annicol D. , Lavery Robert F. , Killeen Noel
Published: July 2016

Study Objective:

The purpose of this study is to describe treatment of asthma in children by paramedics.

Design:

Retrospective review of an advanced life support (ALS) run reports over a one-year period.

Setting:

Review of paramedic response to pediatric respiratory emergencies in an urban, primarily inner-city, prioritized, dual-response emergency medical services (EMS) system.

Participants:

Patients < 19 years of age complaining of shortness of breath, paramedics, pediatric residents, and attending physicians.

Measurements and Main Results:

The medical records of 383 patients were reviewed for demographic and medical information. The population was separated into an ALS treatment group (received ALS) and a NO-ALS group (evaluation and/or oxygen only). Sixty percent of the patients (n = 231) were classified into the ALS group; 89% received epinephrine. Sixty-six percent (n = 101) of the NO-ALS patients received evaluation only, and the remaining 34% (n = 51) were evaluated and received oxygen. The ALS patients were older and had significantly higher respiratory rates and accessory muscle use than did the NO-ALS patients. Relief was reported in 66 % of ALS patients. No adverse reactions were reported in the ALS group. Determining factors influencing ALS treatment included age, the use of medications at home, wheezing, accessory muscle use, respiratory rate, and presence or absence of upper respiratory infection (URI) symptoms.

Conclusions:

This study demonstrates that asthma constitutes the majority of pediatric emergencies in the prehospital setting in this inner-city EMS system. The ALS treatment of pediatric asthma improves patient status. Factors which may influence paramedic judgment in treating asthma in children may be inappropriate. There is a critical need for further research in the prehospital treatment of pediatric asthma and in developing education interventions directed at the entire spectrum of prehospital care of pediatric emergencies.
The Effect of a Quality Improvement Feedback Loop on Paramedic Skills, Charting, and Behavior
Authors: O'Connor Robert E. , Megargel Ross E.
Published: July 2016

Objective:

A mechanism was initiated for conveying quality improvement (QI) results to paramedics as a means of improving chart documentation in difficult-to-correct areas. This study examines the impact of this QI feedback loop on charting, resuscitation rates from cardiac arrest, endotracheal intubation (ETI) success rates, and trauma scene times.

Design:

Paramedic trip sheets were reviewed before and after the institution of the QI feedback hop in this interrupted time series design.

Setting:

The New Castle County, Delaware, Paramedic Program.

Participants:

All New Castle County paramedics participated in the study.

Interventions:

In January 1990, the medical director began to circulate a QI summary among the paramedics in an effort to improve performance and chart documentation. The summary focused on the management of respiratory distress or arrest, cardiac arrest, and major trauma. The success rate for ETI was compared with the rate of field resuscitation from cardiac arrest, the percentage of unjustified prolonged trauma scene times (longer than 10 minutes), and the percent compliance with minimum endotracheal intubation documetation (ETID) requirements from a six-month period before institution of the QI feedback mechanism with data obtained from a six-month period after the program had been operational for one year.

Results:

Comparing results from before with after the initiation of the QI program, the ETI success rate was 273 of 295 (92.5%) before and 300 of 340 (88.2%) after (X2= 3.04, p <.1, ns); field resuscitations totaled 26 of 187 (13.9%) before and 44 of 237 (18.6) after (X2= 1.40, p <.25, ns); ETID rate was 249 of 295 (84.4%) before and 336 of 340 (98.8%) after (X2= 44.24, p <.001), and unjustified prolonged trauma scene times were 69 of 278 (24.8%) before and seven of 501 (1.4%) after (X2= 320.5, p <.001).

Conclusion:

The use of QI feedback had little effect on psychomotor skills such as the ETI success rate or resuscitation rate, but had a dramatic effect on chart documentation, as evidenced by ETID rate, and behavior, as evidenced by the reduction in prolonged trauma scene times. The use of QI feedback is recommended as a means of correcting charting deficiencies or modifying behavior.
Paramedic Documentation of Indicators for Cervical Spine Injury
Authors: Pennardt Andre M. , Zehner Wm. John
Published: July 2016

Introduction:

Current paramedic training mandates complete immobilization of all patients, symptomatic or not, whose mechanism of injury typically is viewed as conducive to spinal trauma. It is common to observe confrontations between paramedics and walking, asymptomatic accident victims who fail to understand why they should “wear that collar and be strapped to that board.” Immobilized, frustrated patients then may wait for hours in a busy emergency department until a physician declares them to be without spinal injury. Patients frequently refuse treatment and transport.

Hypothesis:

Algorithms exist for physicians to “clear” the cervical spine (C-spine) without radiography. It was hypothesized that paramedics routinely assess and document these indicators in their patient evaluations.

Methods:

A retrospective chart review was conducted on 161 patients (Group 1) admitted to a regional medical center with a diagnosis of C-spine injury over a 52-month period. The charts of 225 motor vehicle accident (MVA) victims (Group 2) transported by ambulance to the emergency department over a five-month period then were studied. Indicators for C-spine injury documented by emergency medical service (EMS) personnel were abstracted.

Results:

All patients underwent mental status assessment and full spinal immobilization (neck and back) by EMS crews prior to transport to the hospital. Two or more indicators of possible C-spine injury were documented on each prehospital care report (PCR).

Conclusion:

Paramedics already assess most, if not all, of the criteria standard to C-spine clearance algorithms, but are inconsistent in their documentation of the presence or absence of all of the relevant findings.
Experiences from the World Health Organization Missions in Sarajevo, 1992–1993
Authors: Rubin Margareta
Published: July 2016

As a physician and aid worker for the World Health Organization (WHO), I spent some months during the winter (1992-1993) in the besieged city of Sarajevo and another month during the spring (1993) in northeastern Bosnia.

Impressions from such an experience, in the middle of a war in Europe, naturally mark one's mind. As one who has seen Sarajevo's people desperately fight to survive the winter, during constant bombardment, and with lack of everything associated with basic needs such as fuel, food, water, and drugs, I will never forget. I could speak a long time about the hardship, as well as the helpfulness, friendship, and even happiness amid grief and misery. There were joyful parties with Bosnian songs and music, dinners with food made of almost nothing at all and held in homes seriously damaged by shelling. Sarajevo, that magic city, became a mysterious attraction to us foreigners. Once we had been there, we had to go back to see how the city was surviving. We all had the “Sarajevo Syndrome.”
Epidemiology and Surgical Management of Abdominal War Injuries in Sarajevo: State Hospital of Sarajevo Experience
Authors: Vujovic Branko , Mazlagic Damir
Published: July 2016

Background:

In war, abdominal injuries constitute a significant proportion of the total injuries. These injuries are associated with high mortality and their treatment poses dianostic, surgical, and therapeutic dilemmas. This article presents the epidemiology of abdominal war injuries during the siege of Sarajevo, and briefly describes the surgical techniques and therapeutic practices used in their treatment.

Methods:

A retrospective medical record review was performed of 273 war casualties with trauma to visceral and vascular structures in the abdomen inflicted during a 7.5 month period in 1992.

Results:

Most patients underwent exploratory laparotomy. Six percent had negative laparotomies, and there were no deaths in this group. In 18.3%, injuries were limited to one organ system, while 81.7% sustained combined injuries to multiple-organ systems. The crude mortality rate was 26.0%. Mortality rate excluding deaths within 24 hours of injury was 10.3%. Injuries were caused by metal fragments from artillery shrapnel, mortar and contact mines, or hand grenades. Because of a shortage of colostomy bags, resections of the colon with primary end-to-end anastomoses rather than colostomy were performed in 72% of the cases.

Conclusions:

Mortality was highest in those victims with four or more injured organ systems (81.3%) or with major vascular injuries (64.7%). The primary cause of death within the first 24 hours was prolonged hemorrhagic shock.
Hospital Disaster Operations During the 1989 Loma Prieta Earthquake
Authors: Martchenke Julie , Pointer James E.
Published: July 2016

Objective:

To study hospital disaster operations following a major United States disaster.

Design:

Researchers interviewed all 51 hospital administrators and 49 of 51 emergency department (ED) charge nurses and emergency physicians who were on duty at the study hospitals during the 13-hour period immediately following the 1989 Loma Prieta earthquake.

Setting:

The 51 acute-care hospitals in the six northern California counties most affected by the Loma Prieta earthquake.

Measurements:

Questionnaires and inperson interviews.

Results:

The most frequently noted problem was lack of communications within and among organizations. Hospitals received inadequate information about the disaster from local governmental agencies. Forty-three percent of hospitals had inadequate back-up power configurations, and five hospitals sustained total back-up generator failures. Twenty hospitals performed partial evacuations.

Conclusions:

The Loma Prieta earthquake did not cause total disruption of hospital services. Hospitals need to work with local governmental agencies and internal hospital departments to improve disaster communications.
Comparison of Interventions in Prehospital Care by Standing Orders Versus Interventions Ordered by Direct [On-line] Medical Command
Authors: Holliman C. James , Wuerz Richard C. , Miguel Gaspar Vazquez-de , Meador Steven A.
Published: July 2016

Objective:

The aim of this study was to compare the patient care measures provided by paramedics according to standing orders versus measures ordered by direct [on-line] medical command in order to determine the types and frequency of medical command orders.

Design:

Prospective identification of patient care measures done as part of a prehospital quality assurance program.

Setting:

An urban paramedic service in the northeast United States with direct medical command from three local hospitals.

Participants:

One thousand eight paramedic reports from October 1992 through March 1993.

Interventions:

All patient care interventions recorded as done by standing orders or by direct medical command orders. Errors in patient care were determined by the same criteria as in the prior two studies of the same system.

Results:

Direct medical command gave orders in 143/1,008 (14.2%) cases. Paramedics performed 2,453/2,624 (93.5%) of the total patient care interventions using standing orders. In 61 cases (6.1 %), medical command ordered a potentially beneficial intervention not specified by standing orders or not done by the paramedic. 21/171 (12.3%) command orders were for additional doses of epinephrine or atropine in cardiac arrest cases (where the initial doses had been given under standing orders), and 59/171 (34.5%) were for interventions already mandated or permitted by standing orders. The paramedic error rate was 0.6%, and the medical command error rate was 1.8% (unchanged form the prior study of the same standing-orders system).

Conclusion:

Direct medical command gave orders in 14% of cases in this standing-orders system, but 35% of command orders only reiterated the standing orders. More selective and reduced uses of on-line command could be done in this system with no change in the types or numbers of patient care interventions performed.
Disabling Job Injuries Among Urban EMS Providers
Authors: Tortella Bartholomew J. , Lavery Robert F.
Published: July 2016

Objective:

Nationwide data were collected concerning serious, disabling injuries requiring hospitalization (SDIH) or deaths among urban emergency medical services (EMS) providers.

Design and Setting:

A mail survey of EMS systems was conducted among the 200 most populated U.S. cities.

Participants:

Participants were training and operations officers of urban EMS systems.

Measurements and Main Results:

Ninety forms (45%) were returned with 88 evaluable (44%). There were 81 SDIHs for a rate of one in 31,616 dispatches. No deaths were reported. Body parts most frequently injured were the hand (22%), head (19%), foot (16%), and eye (14%). Although 90% of fire-based EMS systems (fire-EMS) provided helmets, eye protection, safety shoes, and gloves, less than half (45%) of nonfire-EMS did so. Three (4%) SDIHs resulted from acts of violence.

Conclusion:

Occupational injuries of EMS personnel are at a serious level. Fire-based EMS systems experienced a higher rate of hand SDIHs despite the provision of protective equipment. Few nonfire-EMS staff are provided with safety equipment, which may have resulted in a relatively high number of head and hand SDIHs. Fire-EMS medical directors need to take an active role in verifying that protective equipment is adequate and appropriate to allow the performance of field EMS duties without being too cumbersome. Medical directors of nonfire-EMS must be advocates for the provision of basic protective equipment aimed at mitigating SDIHs of EMS staff.
Outcome in an Urban Pediatric Trauma System with Unified Prehospital Emergency Medical Services Care
Authors: VanRooyen Michael J. , Sloan Edward P. , Barrett John A. , Smith Robert F. , Reyes Hernan M.
Published: July 2016

Hypothesis:

Pediatric mortality is predicted by age, presence of head trauma, head trauma with a low Glasgow Coma Scale (GCS) score, a low Pediatric Trauma Score (PTS), and transport directly to a pediatric trauma center.

Population:

Studied were 1,429 patients younger than 16 years old admitted to or declared dead on arrival (DOA) in a pediatric trauma center from January through October, 1988. The trauma system, which served 3-million persons, included six pediatric trauma centers.

Methods:

Data were obtained by a retrospective review of summary statistics provided to the Chicago Department of Health by the pediatric trauma centers.

Results:

Overall mortality was 4.8% (68 of 1429); 32 of the patients who died (47.1%) were DOA. The in-hospital mortality rate was 2.6%. Head injury was the principal diagnosis in 46.2% of admissions and was a factor in 72.2% of hospital deaths. The mortality rate was 20.3% in children with a GCS≤10 and 0.4% when the GCS was >10 (odds ratio [OR] = 67.0, 95% CI = 15.0–417.4). When the PTS was ≤ 5, mortality was 25.6%; with a PTS > 5, the mortality was 0.2% (OR = 420.7, 95% CI = 99.3–2,520). Although transfers to a pediatric trauma center accounted for 73.6% of admissions, direct field triage to a pediatric trauma center was associated with a 3.2 times greater mortality risk (95% CI = 1.58–6.59). Mortality rates were equal for all age groups. Pediatric trauma center volume did not influence mortality rates.

Conclusions:

Head injury and death occur in all age groups, suggesting the need for broad prevention strategies. Specific GCS and PTS values that predict mortality can be used in emergency medical services (EMS) triage protocols. Although the high proportion of transfers mandates systemwide transfer protocols, the lower mortality in these patients suggests appropriate EMS field triage. These factors should be considered as states develop pediatric trauma systems.
Pedestrian Intoxication and Fatal Traffic Accident Injury Patterns
Authors: Williams James S. , Graff Jonathan A. , Uku Justin M.
Published: July 2016

Introduction:

Sixteen percent of all motor-vehicle fatalities are pedestrian, and accidents involving pedestrians are associated with the highest morbidity and mortality rates. Classic pedestrian injury patterns have been described. However, it has been suggested that the pattern may differ if the pedestrian is intoxicated. The role of pedestrian intoxication on motor-vehicle accident injury patterns has not been well-delineated.

Hypothesis:

Intoxicated pedestrian traffic victims have an injury pattern that is more serious and more rapidly fatal than is the pattern for nondrinking victims.

Methods:

Autopsies of 223 consecutive pedestrian victims were reviewed and grouped according to the presence of alcohol in the blood: Group I, Negative (n = 165); Group II, Positive (n = 58). Gender, age, anatomic injuries, survival time, time of day, and year also were examined.

Results:

Results indicated that there were more males in Group II (79%) than in Group I (64%); younger victims, younger than 40 years old, in Group II (70%) than in Group I (34%); fewer victims older than 60 years old in Group II (8%) than in Group I (38%). Group II sustained more frequent and more severe injuries—two times the frequency of the cervical spine, liver, upper and lower extremity, pelvic and rib fractures and thoracolumbar spine injuries; three times more aortic injuries; five times more heart injuries. Death occurred within 24 hours in 95% of those in Group II and in 67% of those in Group I. Accidents occurred from 1500h to 2300h in 67% of Group II and in 53% of Group I victims.

Conclusion:

Intoxicated pedestrian accident victims are predominantly young men, struck between 1500h and 0700h; they have an injury pattern that is two to five times more serious than is the pattern for the sober victims.
Liability Immunity as a Legal Defense for Recent Emergency Medical Services System Litigation
Authors: Morgan David L. , Trail William R. , Trompler Vicky A.
Published: July 2016

Background:

Although many emergency medical services (EMS) providers are concerned about liability litigation, no comprehensive, national studies of EMS appelate cases have been published. Information about these cases and the use of liability immunity (sovereign immunity, emergency medical care immunity, or Good Samaritan immunity) as a defense could be used for EMS risk management and better patient care.

Objective:

To review recent EMS system civil litigation cases to determine their common characteristics and the number that used liability immunity as a legal defense.

Methods:

An observational study of the WESTLAW computerized database of legal cases from all state and federal appellate courts. All legal cases that named a member of the EMS system as a defendant, involved either a patient-care incident or ambulance collision, and received an appellate court opinion from 1987 through 1992, were studied.

Results:

Eighty-six cases were identified and analyzed. Most cases (85%) were related to a patient-care incident, and 71 % of the cases involved a death or significant physical injury. More than 49% of the patient cases alleged inadequate assessment or treatment, and 27% alleged delay in ambulance arrival or no ambulance arrival. There were 11 cases (15%) that alleged no transport of the patient to the hospital. Liability immunity was used as a defense in 53% of the cases. The appellate courts ruled in favor of 68% of the defendants that did not use an immunity defense and in favor of 72% of those that did use liability immunity.

Conclusion:

There have been a large number of recent appellate cases involving EMS systems. The common characteristics of many of these cases demonstrate the need for providing rapid ambulance arrival, proper assessment and treatment, and rapid patient transportation to a hospital. Although liability immunity was used as a legal defense by most EMS system defendants, the appellate court outcome was similar regardless of its use.
Paramedic Field Instructors: An Approach to Training the Newest Paramedics While Maintaining the Interest of the Most Successful Senior Paramedics
Authors: Krochmal Paul , Moore Jessie , Shea Kathleen , Kiessling Mark , Blaustein David , Schriver John
Published: July 2016

A unique approach to providing orientation and supervised field experience for newly graduated paramedics and for the continuing education and recognition of experienced, skilled, operational paramedics is described. A group of 30 paramedic field instructors (PFI) was selected following application, development of criteria for selection, and interviews. This program had a positive effect in both realms during its first year of operation in the emergency medical services system in which it was implemented.
Mobile Medical Relief and Military Assistance in Somalia
Authors: VanRooyen Michael J. , VanRooyen Julia B. , Sloan Edward P. , Ward Edward
Published: July 2016

Introduction:

Mobile medical clinics were established by an international medical relief organization to provide health care to victims of the war in Somalia. The study's purpose was to examine the prevalence of diseases seen and the effectiveness of mobile medical clinics, and to evaluate military support in security and care provisions.

Methods:

This is a descriptive case series conducted over a 6-month period. Physicians determined clinical diagnoses, and clinic personnel assigned security scores (one to five) based on: 1) crowd control; 2) the incidence of looting; and 3) threats of violence by individuals demanding treatment.

Setting:

Mobile medical teams that provided health care to regions in urban and rural Somalia assisted by United States and Italian military forces.

Participants:

At 149 mobile clinics, 25,265 patients were treated.

Interventions:

Medical treatment included dispensing medications, intravenous rehydration, and minor surgical procedures. The effectiveness of security measures was scored based on: 1) effective crowd control; 2) the lack of theft or threats of violence; and 3) the unimpaired operation of the clinic.

Results:

Medical teams treated 25,265 patients. The most common medical problems encountered were skin infections (19.5%), upper and lower respiratory tract infections (16.1%), and gastroenteritis with dehydration (7.1%). Malnutrition was seen in 4.7% of cases, and trauma accounted for only 0.7% of complaints. When military escorts were provided, the mean security score was 43% higher (4.85 ±0.46) as compared to the absence of a military escort (3.40 ±0.60) (p <0.001).

Conclusions:

Mobile medical clinics were found to be effective in this setting despite difficult conditions, limited therapeutic modalities, and few in-patient facilities. Infectious diseases were most common, while malnutrition and trauma were less commonly seen. The cooperation of United States and Italian military forces facilitated relief efforts by maintaining security, particularly in unstable areas.
Disaster Preparedness and Response as Primary Health Care
Authors: Kirsch Thomas D.
Published: July 2016

The need for search and rescue and medical care following a sudden impact disaster is immediate and often overwhelming. In the past, governments and international organizations have relied on external assistance for these efforts. Because the life expectancy of severely injured and trapped victims is limited, the response must come first from the impact area itself. The preponderance of disaster research demonstrates that the local populace overwhelmingly is responsible for search-and-rescue efforts. Emergency medical care, e.g., that delivered in the first 24 hours to 48 hours after a disaster, also is overwhelmingly from local or regional resources. Outside and, perhaps, even international assistance is required for medium- and long-term response, but is of limited benefit for the “emergency phase.”
Prehospital Communications During the Loma Prieta Earthquake
Authors: Martchenke Julie , Rusteen Jeff , Pointer James E.
Published: July 2016

Introduction:

On 17 October 1989, the Loma Prieta Earthquake shook the San Francisco Bay area, home to more than 6 million people. This study examined the effectiveness and function of emergency medical services (EMS) communications after this event.

Methods:

The six Bay area counties most affected by the Loma Prieta Earthquake were surveyed using a 156-part questionnaire. This study examined the functioning of the primary 9-1-1 county dispatch centers. Paramedics involved in a set of defined activities during the period after the earthquake also were surveyed. Emergency medical services directors also were questioned by telephone using an interview tool developed for this purpose. All areas concerning disaster response were not queried. Ten specific areas were considered, including: 1) preparation for disaster; 2) the impact of the earthquake; 3) reconnaissance; 4) call volume; and 5) others.

Results:

Coordination among the various agencies responsible for disaster response and mitigation needs more study. Uniform response plans for medical mutual aid need development. Government support similar to police and fire department arrangements for mutual aid are not in place. Additional planning and training for disasters at all levels need reassessment. The communication-center personnel indicated that they did not call for more resources, but instead accepted volunteers at dispatch centers and extra assistance. Once engaged, however, most communications centers (CCs) had great difficulty tracking and controlling all the units under their jurisdiction. In some large urban counties, some ambulances were idled awaiting calls but lost their communications centers, while other ambulance personnel were trying to handle multiple patients and requests for services.

Conclusions:

Significant help from a state or federal agency likely will be unavailable for a substantial period after a catastrophic regional event. Important coordination among EMS agencies for disaster response is poor or absent. Although fatalities and casualties were limited compared to what could have occurred, great confusion reigned for varying periods of time after the earthquake. Communications among local agencies, counties, and the state were problematic. Information flow to hospitals was cited frequently as a problem, making it difficult for hospitals to prepare adequately. Medical mutual-aid help was disorganized and inadequately controlled. The training of personnel and the method of recall for disaster response need to be examined.
Survey of Medical Services at Major League Baseball Stadiums
Authors: Ma O. John , Pirrallo Ronald G. , Rubin Jonathan M.
Published: July 2016

Objective:

To analyze the availability and level of medical services for fans at major league baseball games in the United States.

Methods:

A 10-item questionnaire was sent to the operations managers of each of 28 major league baseball stadiums. The survey was distributed in cooperation with a major league baseball club. Telephone follow-up was used to complete missing responses. The survey addressed five areas of fan medical services: 1) health-care provider availability and compensation; 2) advanced cardiac life support (ACLS) capabilities, including equipment; 3) presence of on-site ambulance(s); 4) fan fatalities; and 5) alcohol consumption limitations.

Results:

Survey response was 100%. Healthcare providers are on-site at all stadiums: nurses (86%), physicians (75%), emergency medical technicians (EMTs, [68%]), and paramedics (50%). Ninety-six percent use a combination of health-care providers. The most common medical teams are nurse + EMT + physician (25 %) and nurse + EMT + paramedic + physician (18%). All health-care providers receive some form of compensation. All stadiums have at least one ACLS-certified provider; 96% have ACLS equipment. Ambulances are on-site 75% of the time. Sixty-eight percent of the clubs reported at least one fan fatality through the 1992 and 1993 seasons (mean 1.1, range 0–4). All clubs limit alcohol consumption; 96% use multiple approaches. The various approaches include: 1) specific inning discontinuation (86%); 2) maximum purchase (68%); 3) restricted sale locations (64%); and 4) crowd conduct (57%). Advertisement for responsible alcohol consumption is displayed at 75% of the stadiums; designateddriver programs exist at 46%.

Conclusions:

All major league baseball clubs provide medical services for fans. Furthermore, almost all stadiums have ACLS capabilities. Responsible alcohol consumption also is a recognized priority for fan safety.
Epidemiology of Pediatric EMS Practice: A Multistate Analysis
Authors: Joyce Steven M. , Brown Douglas E. , Nelson Elizabeth A.
Published: July 2016

Objective:

To describe the epidemiology of pediatric emergency medical services (EMS) practice in a large patient population from several geographic areas.

Design:

Retrospective computer analysis of EMS databases from four states using a common data set and analysis system.

Setting:

Pennsylvania, Tennessee, Mississippi, and Nevada (except Clark County), 1990 through 1992.

Methods:

All patient-care reports of patients 14 years old and younger were extracted from the EMS databases and analyzed for the following factors: age, gender, date, elapsed pre-hospital times, incident type, mechanism of injury, call disposition, illness or injuries encountered, severity of illness/injury (by abnormal vital signs), and basic life support (BLS) and advanced life support (ALS) treatment delivered.

Results:

A total of 1,512,907 patient care reports were reviewed. Those of 61,132 children were extracted for analysis. These children comprised about 4% of prehospital responses. Male subjects predominated (56%), and children aged 7 through 14 years represented 46% of cases. Most calls occurred in the evening and daylight hours. Children were transported by ambulance in 89% of cases, and care was refused in 7.7%. Mean response time was 9±16 minutes, mean scene time 12±14 minutes, and mean transport time 14±20 minutes. Traumatic incidents predominated at 42%, with motor vehicle accidents and falls the most common mechanisms. Blunt injuries accounted for 94% of trauma, whereas respiratory problems, seizures, and poisoning/overdose were the most common medical problems. Vital signs were obtained in 56% of cases. Abnormal vital signs were noted in 21% of these, and the presumptive causes were similar in distribution to those of the general population, with the addition of cardiac arrest. The most commonly used treatments were spinal immobilization, oxygen administration, intravenous access and several ALS medications. An ALS capability was available in more than half the runs, but ALS treatment was delivered in only 14% of those cases. Outcome data were not available.

Conclusion:

This multistate analysis of pediatric EMS epidemiology confirms findings reported in smaller regional studies, with several exceptions. Excessive scene times were not noted. Few children had serious disorders as evidenced by abnormal vital signs. An ALS treatment, when available, was used infrequently. These findings have implications for EMS planners and educators.
Comparison of High-Dose Epinephrine Versus Standard-Dose Epinephrine in Adult Cardiac Arrest in the Prehospital Setting
Authors: Carvolth Richard D. , Hamilton Ardith J.
Published: July 2016

Objective:

To compare the efficacy of high-dose epinephrine (HDE) with standard-dose epinephrine (SDE) in the management of cardiac arrest in adults in the prehospital setting.

Hypothesis:

The use of HDE will improve the outcome of adult patients in cardiac arrest.

Methods:

In a general population of 700,000 persons, in a mixed geographical area of 2,200 square miles, a 12-month retrospective study of SDE and a 12-month prospective trial of HDE were conducted involving adult patients in cardiac arrest in the prehospital setting. Treatment was provided by paramedic-level clinicians. In the control group, patients were treated according to existing American Heart Association cardiac resuscitation guidelines using SDE (defined as 1.0 mg boluses to a maximum dose of 4 mg). In the test group, the same guidelines were revised to use HDE (defined as a rapid sequence of 5, 10, and 15 mg boluses to a total dose of 30 mg).

Results:

The control group included 594 patients; the test group consisted of 580 patients. The overall survival rate to hospital admission in the control group was 14.5% (84 patients) and in the test group 15.3% (89 patients). The survival rate to hospital discharge in the control group was 4.9% (29 patients) versus 4.8% (28 patients) in the test group. For patients whose initial rhythms were ventricular fibrillation, survival to admission in the control group was 20.4% (39 patients) versus 24.4% (43 patients) in the test group. Survival to discharge for patients with ventricular fibrillation in the control group was 8.9% (17 patients) versus 10.8% (19 patients) in the test group.

Conclusion:

There was no statistically significant difference in overall rate of survival to hospital admission or discharge between patients treated with SDE and those treated with HDE, regardless of the initial rhythm.