Objective: The scope of practice (SOP) for flight paramedics (FPs) remains a controversial issue for air medical directors. This study's objective was to determine the current level and breadth of FPs'SOP.

Methods: A 6-item survey of lead FPs in all 158 air medical programs throughout the U.S. The survey addressed five issues: 1)Certifications required of FPs above state certification; 2) Procedures included in SOP; 3) Medications FPs are allowed to administer; and 4) Requirements needed to expand FPs’ SOP. Views on establishing a National FP certification (NFPC) to alter their current SOP.

Results: Survey response was 57% (90/158). Ten responding programs (11%) did not utilize FPs. Of the 80 programs (89%) that utilize FPs, 76 programs (95%) required certification in ACLS, 65 (81%) in PALS, and 50 (63%) in BCLS. Paramedics were allowed to perform cricothyroidotomy in 68 programs (85%), pericardiocentesis in 24 programs (30%), and tube thoracostomy in 23 programs (29%). A wide spectrum of medications were approved for administration by FPs, including streptokinase in 37 programs (46%), r-TPA in 51 (64%), and succinylcholine in 50 (63%). In 61 programs (76%), the SOP was determined solely by the air medical director. Eighteen respondents (23%) believed that the development of a NFPC program would alter their SOP.

Objective: In our community the majority of patients presenting to the ED with acute chest pain come by car and do not recall their MD suggesting EMS. How do private MD's (our customers) view EMS?

Methods: Single mailing survey to all 238 physicians with admitting privileges in Medicine at an urban, tertiary care hospital (722 beds). EMS services provided by 2 private ALS systems and 35 volunteer ALS services operating under one physician medical director and identical protocols. Survey consisted of a scenario with a cardiac patient in the home of the MD, followed by opinions regarding EMS.

Results: 50% return. Respondents were 79% male, mean age 44 ±14yr, 68% internal medicine, 11% cardiologists. Given a patient with acute chest pain at the MD's home, 90% would call EMS, 10% would drive patient. 16% chose to drive for safety concerns, 83% because it was faster. Of those who chose EMS, 10% made negative comments regarding paramedics “playing doctor”. The following perceptions were noted: 3% of respondents indicated paramedics take “too long” to respond to calls, 26% indicated paramedics delay patient arrival to the hospital, and 6% indicated patients get too nervous if told to take an ambulance. On the other hand, 59% indicated EMS prevents cardiac arrests, 83% indicated paramedics can appropriately treat cardiac arrest, and 13% agreed paramedics can provide similar treatment for chest pain patients as hospitals.

Purpose: Among pediatric patients, cardiopulmonary arrests account for a small, but important, percentage of responses by emergency medical services (EMS). EMS prehospital assessment of medical and traumatic arrests in the pediatric patient were compared with that of the Office of Medical Investigator (OMI) autopsy reports to assess differences and implications for EMS training and prevention in pediatric arrests.

Methods: Retrospective review of ambulance run forms from an urban EMS system with OMI autopsy correlation. Patients less than fifteen years of age and younger who were treated by prehospital personnel from November 1, 1990, to October 31, 1991, for a medical or traumatic arrest. Proportions were analyzed using chi-square analysis or Fisher's exact test and agreement was assessed using the Kappa statistic.

Results: Ambulance runs were reported for 2,586 pediatric patients. Of these, forty-two (1.6%) suffered arrests, with thirty-two (76%) medical arrests and ten (24%) traumatic arrests. Children one year of age or less accounted for 75% of the medical arrests while children greater that one year of age accounted for 80% of the traumatic arrests (p = 0.003). Overall mortality was 81%. When EMS prehospital assessment of medical and traumatic arrests were compared with OMI reports, there was good agreement (kappa = 0.70) for Sudden Infant Death Syndrome (SIDS), but poor agreement (kappa = 0.37) for child abuse.

Purpose: Difficulties with physical assessment inherent to the helicopter environment have led to suggestion that aeromedical crews may be unable to identify hemo- or pneumothorax (HTX/PTX) while in-flight. This study was conducted to determine the frequency of missed HTX/PTX in trauma patients undergoing air transport.

Methods: One year (1994) of an air medical service's trauma transports to a Level I trauma center were analyzed to identify patients undergoing tube thoracostomy (TT) within 2 hours of trauma center arrival. Patients who had received intra-transport needle thoracostomy were excluded. Records were reviewed to determine how HTX/PTX was diagnosed at the trauma center.

Results: Only 11 patients who had not received aeromedical needle decompression underwent TT at the receiving center. Two of the 11 were trauma arrests and received TT as part of thoracotomy, without air or blood return on TT. None of the remaining 9 patients had TT on clinical suspicion alone. Four had normal physical examination and underwent TT after chest X-ray (CXR). Remaining patients had no HTX/PTX clues on exam or CXR; one had a small HTX identified on chest computed tomography and the other four received intra-operative TT because of rib fractures in the setting of multisystem trauma.

Purpose: The purpose of this study was to measure the quality of life of cardiac arrest long-term survivors.

Design: Prospective outcome evaluation.

Setting: The emergency medical system of a mid-sized city.

Type of participants: Prehospital cardiac arrest victims who had a resuscitation attempt from 5/93 through 12/95 and were discharged alive. Patients <18 were excluded.

Measurements: Patients were surveyed by mail. Non-responders were telephoned. The questions assessed Glasgow-Pittsburgh overall performance (GPOP) scores before and after the cardiac arrest. Additional items assessed physical, role, affective, and cognitive functioning, and global health status.

Main Results: 760 cases were collected. 40 had unknown vital status at hospital discharge. The survival rate to hospital discharge for the 270 patients with cardiac etiology and initial rhythm of ventricular fibrillation was 15%, and it was 6% for the other 450 patients. Of 68 survivors, 23 died before a survey was sent; two had unknown addresses. 21 patients (49%) responded, and four refused to participate. The mean interval from cardiac arrest to survey response was 531 days. Ten reported good post-arrest GPOP scores, 5 had moderate disability, 4 severe disability, and 2 were comatose. Cognitive function was improved in 1, unchanged 6, slightly worse 7, markedly worse 4, and none in 3. Eleven patients reported feeling happy. Global healdi was excellent for 2, very good 8, good 5, fair 2, and poor 3.

Purpose: The wide spread use of orotracheal intubation with rapid sequence induction has made it difficult for EMS professionals to gain experience in nasotracheal intubation (NTI) in a controlled supervised setting. The purpose of this study was to determine if a training session on NTI with a breathing manikin can be used to improve skill and comfort of EMS professionals.

Methods: A prospective trial was conducted with a convenience sample of 16 emergency medical service professionals, previously trained in nasotracheal intubation techniques. For the training session a Laerdal airway manikin was modified by replacing the lungs with a bag-valve mask device, to simulate breathing with an inspiratory and expiratory phase. Following verbal instruction, and with direct supervision, each participant practiced NTI using the breathing manikin. Each participant completed a questionnaire, both before and after the training session, to determine self assessed comfort and skill level for both oral and nasal intubations (0 = lowest, 10 = highest). The pre and post intervention scores were compared using the Wilcoxon signed-rank test, £ = 0.01.

Objective: To determine the prevalence and outcome of out-of-hospital ventricular tachycardia (VT) cardiac arrest with a prolonged QT interval and to identify the subset with torsades de pointes (TdP).

Methods: Design: Retrospective review. Setting: Fire department-based paramedic system. Participants: Non-traumatic VT cardiac arrest (1/91-12/94) with a supraventricular perfusing rhythm (SVPR) and a measurable QT interval. Interventions: QT interval was measured from a SVPR and corrected QT interval (QTc) was calculated (prolonged if ≥0.45 sec). VT was classified as polymorphic or monomorphic.

Results: 190 patients met inclusion criteria. 51% of patients had a prolonged QTc (PQTc). The overall hospital discharge rate was 28.4%. No difference with respect to paramedic-witnessed arrests in each QTc group was found (25.8% normal QTc [NQTc] vs. 27.8% PQTc; p = 0.752). Patients with PQTc were less likely to be discharged from the hospital (19.6% vs. 37.6%; p = 0.01). Patients with PQTc were not more likely to have PVT (37% vs. 40%; p = 0.705). 16 (8.4%) patients had TdP. 27.8% of TdP and 26.8% of non-TdP patients were discharged (p = 0.912).

Purpose: Because overall EMS system response depends on ambulance availability, we conducted a prospective study of the EMS turnaround interval. This interval consists of the delivery and recovery intervals as defined in Spaite's EMS time-interval model.

Methods: An on-site observer, while monitoring EMS radio traffic, recorded the delivery and recovery activities of personnel from a large urban EMS system at a university hospital ED. System policy permits a maximum 30 minute turnaround interval. Prospectively defined subintervals were analyzed.

Results: A convenience sample of 122 patient deliveries was collected. Observed and radio-reported arrival at the hospital differed by -1′24″; to +11′8″. Time from arrival to removal of the patient from the ambulance averaged 59″ (range 13″-2′53″), and time from patient removal to ED entry averaged 42″ (10″ - 5′22″). While the mean time for the verbal report to ED staff was 33″ (2″-5′20″), it was 0 = 15″ in 36% of cases. Time from ED entry to placement of the patient on an ED bed averaged 2′11″ (33″-9′35″). Writing the report averaged 17′12″ (5′20″-52′11″). The mean time off radio was 29′51″ (ll′43″-53′37″) and the mean time the ambulance was at the ED was 30′01″ (11′25″-1°17′53″). Observed and radio-reported ambulance departures differed by -4′31″ to +23′32″. In 22% of cases, departure was reported on radio more than 5′after actual departure.

Objective: Traditional EMS teaching identifies mechanism of injury as an important predictor of spine injury. Clinical criteria to select patients for immobilization are being studied in Michigan and have been implemented in Maine. Maine requires automatic immobilization of patients with “a positive mechanism” clearly capable of producing spine injury. The purpose of this study is to determine if mechanism of injury effects the ability of clinical criteria to select patients with spine injury.

Design: Multicenter Prospective Cohort.

Methods: EMS personnel completed a check-off data sheet on out-of-hospital spine immobilized patients. Data included mechanism of injury and yes/no determinations of the clinical criteria: altered mental status, neurologic deficit, evidence of intoxication, spinal pain or tenderness, and suspected extremity fracture. Hospital outcome data included confirmation of spine injury and treatment required. Mechanisms of injury were tabulated and rates of spine injury for each mechanism was calculated. The patients were divided into high-risk and low-risk groups.

Results: Data was collected on 6,500 patients. There were 213 (3.3%) patients with spine injuries identified. There were 1,065 patients with 100 (9.4%) injuries in the high-risk mechanism group, and 5435 patients with 113 (2%) injuries in the low-risk group. Clinical criteria identified 96 of 100 (96%) injuries in the high risk mechanism group and 106 of 113 (94%) in the low-risk group.

Purpose: To determine the most frequent sources of injuries from the interior of motor vehicles involved in crashes.

Methods: We searched the National Highway Traffic Safety Administration's National Accident Sampling System to determine the most frequent sources of injuries. This database includes sources of injuries resulting from crashes from January 1, 1991 to December 31, 1992.

Purpose: Standard prehospital practice includes frequent immobilization of blunt trauma patients, some based solely on mechanism. Unnecessary cervical spine (c-spine) immobilization does have disadvantages, including morbidity such as low back pain and splinting, increased scene time and costs, and patient-paramedic conflict. Emergency physicians (EPs) use clinical criteria to clear trauma patients of c-spine injury. If paramedics were able to apply clinical criteria in the out-of-hospital setting, then unnecessary c-spine immobilization could be safely avoided. We designed a prospective, randomized, simulated trial to determine the level of agreement between paramedic and EP assessment of clinical indicators of cervical spine injury. We hypothesized that there would be substantial agreement between paramedic and EP evaluation of standardized patients.

Methods: A convenience sample of ten paramedics and ten attending EPs participated. Ten standardized patients, with various combinations of positive and negative findings, were examined simultaneously by EP-paramedic pairs. Each pair evaluated five randomly assigned patients for six clinical criteria, which were: 1) alteration in consciousness, 2) evidence of intoxication, 3) complaint of neck pain, 4) cervical tenderness, 5) neurologic deficit or complaint, and 6) distracting injury. If any criterion was positive, that was considered an immobilization decision. The kappa statistic was utilized to determine level of agreement between the two groups for each individual criterion and for the immobilization decision. A kappa of 0.40 to 0.75 denotes good reproducibility and >0.75 denotes excellent reproducibility.

Objective: Determine whether radio alerts to paramedics after 7 minutes of on-scene time reduces total on-scene time for trauma patients.

Methods: Paramedics radio base once they determine ACS criteria were met. Paramedics were informed by radio when 7 minutes lapsed on-scene. Dispatch times were recorded.

Results: The control group (Nov. 1-30, 1995) of 135 consecutive patients were reviewed without a radio alert. The test group (Dec. 1-31, 1995) of 103 consecutive patients, with a radio alert message 7 minutes after scene arrival were also reviewed. Groups were matched for extrication times, blunt versus penetrating trauma, age, etc. We analyzed both groups for the interval of time from announcement of “trauma alert,” (when paramedics determined the patient met ACS criteria or from the time extrication was complete (if applicable) to the time en route to the hospital. Average on-scene time for the control group was 13.7 minutes [range 4-35] versus test group 9.3 minutes [range 2-26] (p <0.001).

Purpose: The purpose of this study was to determine if there were differences in tidal volume (Vt), minute volume (MV), average mask leak per breath (ML), gastric insufflation (GI), and peak airway pressure (PAP) when ventilating a non-intubated mannikin with a bag-valve (BV), manually triggered ventilator (MTV) and automated ventilator (AV). Our hypothesis was that there would be no differences among devices for any of these variables.

Methods: This was a prospective in vitro experimental model. A convenience sample of 19 emergency medical technicians (EMTs) ventilated a non-intubated mannikin-mechanical test lung model with BV, MTV (flow rate 40 L/min; pressure relief 55 cm H2O), and AV (800 ml/breath; rate 12). Each subject, blinded to volume and pressure gauges, used each device for two minutes at both normal (0.1 cm H2O) and poor (0.04 cm H2O) compliances. Vt, MV, GI, and PAP were measured directly and ML was calculated. Data were analyzed with repeated measures ANOVA and Bonferoni-Dunn multiple comparison test with alpha set at 0.05.

Introduction: Monophasic defibrillation waveforms are presently the standard of care in clinical use for trans-thoracic defibrillation. Recently, there has been renewed interest in biphasic waveforms. This interest reflects the superior performance demonstrated with biphasic waveforms in implantable defibrillators (ICD). External defibrillation research on two biphasic truncated exponential waveforms has been reported in which the waveforms were compared clinically to a damped sine waveform. A limitation of these transthoracic waveforms is the insufficiency of fundamental design principles used to determine the waveform characteristics.

Methods: We developed design principles to determine the optimal waveform characteristics of an external biphasic truncated exponential waveform based on myocardial cell response model. The cell response model incorporates critical transthoracic elements into a recently published and experimentally validated intracardiac model used to design ICD waveforms. We determined the optimal leading-edge voltage (LEV), phase durations (in milliseconds, Ph1 D, Ph2 D), and delivered energies (ED) for the reported external biphasic waveforms (WF) using the model with 78 W for trans-chest resistance. We compared our results against those reported for the biphasic waveforms.

Purpose: The practice of helicopter emergency medical services is variable in its mission profile, crew configuration, and transport capabilities. We sought to describe the characteristics of physician air medical directors in the United States.

Methods: We surveyed medical directors concerning their education, training, transport experience, and roles/responsibilities in critical care air transport programs.

Results: Two page surveys were mailed to 281 air medical services. Three programs merged or were dissolved. Data from 122/278 (43.9%) air medical directors were analyzed. One-hundred eleven respondents reported residency training in: Emergency Medicine (EM) 44 (39.6%), Internal Medicine (IM) 18 (16.2%), General Surgery (GS) 18 (16.2%), Family Practice (FP) 12 (10.8%), dual-trained (EM/IM, EM/FP, IM/FP) 11 (9.9%) and others 8 (7.2%). Medical directors’ roles/responsibilities consist, most frequently of: drafting protocols 108 (88.5%), QA/CQI activities 104 (85.3%), crew training 98 (80.3%), and administrative negotiations 95 (77.7%).

Aeromedical navigation to the scene of an accident using navigational assistance computer mapping software (NACM) can be difficult in rural areas due to the lack of topographic landmarks. In these instances, navigation is made easier using the Global Positioning Satellite (GPS) system to determine latitude and longitude.

Purpose: To determine the reliability and feasibility of portable GPS receivers compared with our current system of NACM (MAP EXPERT®) in the navigation of aeromedical transport flights.

Design: A non-randomized prospective trial comparing flights using either GPS or NACM. Setting: Flight program at a Level I trauma center.

Methods: GPS receivers (for transmitting location) were carried by half the helicopters and ground EMS units. The NACM system was used to transmit the location of the accident to the other flights. Data on flight time, distance, and accident location were collected. Pilots and EMS personnel using the portable GPS system completed a questionnaire regarding accuracy, reliability, and ease of use.

Results: This study included 51 flights; GPS (n = 26) and NACM (n = 25). There was no difference in the miles flown per minute in the NACM group (1.69 miles/minute) compared with the GPS group (1.70 miles/minute). Pilots and EMS personnel rated the GPS reliable, accurate, and easy to use for navigation.

Purpose: Treatment and prevention strategies regarding people who jump from medium height bridges over water could be optimized by an improved understanding of patient demographics and injury spectra. Currently, little is known about this EMS patient population. We sought to describe the demographics and injuries sustained by those who jumped or fell from medium height bridges.

Methods: We searched the River Rescue and EMS reports of a medium size city for the ten year period 1986–1995 to identify cases involving a person who jumped/fell from a bridge into water. Additional cases were identified by searching coroner and trauma center registries. For each case, we reviewed applicable EMS, hospital, and coroner records to determine patient demographics, treatment provided, and injuries sustained.

Results: We identified 76 cases of individuals who jumped/fell from bridges into water. Eighteen of the region's 24 bridges (40 to 100 feet high) were involved. Average patient age was 34.8 years, 87% were male, and 29% jumped during July. These jumps/falls resulted in 25 (33%) deaths and 22 (29%) uninjured persons. Of those who died, 18 (72%) drowned, sustaining no other detectable injuries. Hospitalized survivors and injured coroner cases suffered predominantly extremity and rib fractures, pneumo/hemothoraces, and closed head injuries. No neck injuries were identified. No patient whose advanced level EMS treatment exceeded basic monitoring and IV access survived.

Introduction: Prior studies have documented less than 3% survival for out-of-hospital cardiac arrest (CA) in D.C. EMS intubation has failed to improve extremely poor survival rates for out of hospital CA. This study will investigate whether the addition of automatic external defibrillator (AED) use will improve the negligible survival rate experienced in a system that transports 80,000 pts/yr; Thus replicating success with AED for CA in other centers.

Methods: Retrospective review of all CA data from D.C. EMS system from 1-12/91 (no AED) vs. 1-12/93 (AED in use). Supporting data from run sheets and hospital records was compared for years with and without the AED using student's t test, chi-square with p <0.05.

Results: In 1991 there were 414 out of hospital CAs arrests with an overall survival rate of 2.3% with a mean EMS arrival time of 10 minutes. There were no significant differences with respect to CA patients’ age, bystander CPR or BLS/ALS response times between two years (1991 and 1993) p = NS. In VF patients who comprised 26% and 24% of presenting rhythms for ’91 and ’93 respectively, the use of AEDs improved survival 3.8% vs. 29% with AEDs in ’93 (p <0.05). There was no difference in percentage of non-VF presenting rhythms or patient outcomes between the two groups.

Objective: The objective of this study is to identify potential problems associated with prehospital advanced airways by assessing the utilization, complications, and education associated with the use of portable suction equipment.

Methods: Fifty-one paramedics serving a university medical center were anonymously surveyed. The survey consisted of questions regarding: utilization, difficulties, bad outcomes, and training associated with portable suction equipment.

Results: Six of the paramedics set up and check suction equip ment for every airway procedure. The rest perform daily checks or rarely test equipment. Twenty-three medics reported equipment malfunctions: dead battery (12), improper set-up (5), clogged tubing (6). Twenty-six of the paramedics reported having at least one bad outcome due to malfunction of suction equipment. These were cases of failed intubation following at least one attempt. Seven bad outcomes were attributed to lack of suction equipment at scene. Paramedics carry suction equipment to the scene for less than twenty-five percent of calls. Three suction units were in use: S-SCORT (32), S-SCORT Jr. (11), and Impact (8). There was no difference in utilization or bad outcomes by unit type. Ninety-eight percent of the paramedics reported some type of formal training on use of suction equipment during airway procedures.

Purpose: To determine the reasons why patients with potentially serious complaints present to the Emergency Department by a non-EMS mode of transportation.

Methods: Prospective patient survey distributed during a one-month period to patients presenting to a military emergency department. Surveys were entered into a data base program and descriptive, parametric and non-parametric statistical tests utilized to examine characteristics of the two groups.

Results: The only significant difference between the ambulance and non-ambulance groups of the 158 participants was patient sex.