The initial Glasgow Coma Score (GCS) obtained by prehospital personnel on seizure victims is associated with the likelihood of treatment and transport.

Prehospital data were collected prospectively for all patients presenting with seizures to a mid-sized emergency medical services system during a five-month period. A total of 419 cases occurred (62.8% male, 37.2% female). Seizure frequency was highest in infants under the age of three years and in adults in their late 20s. A GCS was recorded in 378 cases (90.2%, study group). The GCS was >10 in 304 patients (80.4%) and ≤10 in 74 (19.6%). Patients with GCS≤10 were more likely to receive: oxygen (50.0% vs. 20.1%, p<.0001); IV (35.1% vs. 8.9%, p<.0001); intravenous (IV) medications (16.2% vs. 1.0%, p<.0001); and transport (97.3% vs. 76.3%, p<.0001).

Seizure patients with a GCS of ≤10 were more likely to receive a variety of prehospital treatments and to be transported than were patients with GCS >10. However, the clinical indicators that were used to make the decision that it was “safe” not to transport nearly one-third of the patients are unclear. Essentially no data exist regarding the parameters impacting treatment and transport of seizure patients. Future investigations with outcome data, are needed to determine whether low risk criteria can be developed to identify those patients (if any) that do not require treatment or transport. A GCS may provide an objective, reproducible parameter upon which to begin formulating such criteria.

Little information is available in the performance of infant ventilation by basic life support (BLS) personnel.

There are no significant differences between mouth-to-mouth (M-M), mouth-to-mask (M-Ma), pediatric bag-mask (PBM), and adult bag-mask (ABM) devices in the percent of acceptable breaths delivered by BLS providers.

Fifty certified BLS providers performed five ventilation methods in random sequences for 60 seconds each on a 5kg infant mannequin following standardized instructions. Supplemental oxygen, 10 l/min, was supplied with one M-Ma trial and PBM methods. Airway patency, peak airway pressure (PAP), ventilatory rate (VR), tidal volume, and delivered oxygen concentration (FiO2) were recorded. The percent of breaths with excessive PAP (i.e., >30 mmHg), percent of acceptable breaths using loose (i.e., 25−125ml) and strict (i.e., 50−100ml) criteria, and FiO2 at at 15, 30, 45, and 60 seconds were compared between ventilation methods using ANOVA.

For all subjects and those with a patent airway (n=36), there were no significant differences in the percentage of acceptable breaths between the respective ventilation methods using loose or strict criteria. The proportion of excessive breaths produced by PBM (56±6) (mean±SEM; all subjects) and ABM (41±6.2) was significantly greater than M-Ma, with and without a patent airway. Although RR and the percentage of excessive breaths were not significantly different, the percentage of acceptable breaths and FiO2 delivered with each ventilation method was significantly better in the patent airway group.

For BLS providers, M-Ma ventilation with supplemental O2 provided the best method of initial infant ventilation based upon the percent of acceptable breaths, oxygen delivery, and fewest excessive pressure breaths.

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

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

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.

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.

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.

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.

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.

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.

Pending further studies, it may be advisable to utilize this variation in patients with suspected thoraco-lumbar trauma.

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.

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

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

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.

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.

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.

A principal cause of death following presumed recovery from an episode of shock is the development of shockogenic trauma [post-resuscitation syndrome]. The causes of this complication remain unclear and its various treatments continue to be controversial.

The use of perfusion of the blood of patients suffering shockogenic trauma through a donor pig spleen mill decrease the mortality from the complications of this process.

Freshly harvested pig spleens were adjoined to the venous circulation of patients suffering severe shockogenic trauma and the patient's blood perfused through them for periods of 30-60 minutes. The mortality rates of similar patients treated in this manner were compared with those not treated. Blood analyses included measures of the functions of the renal, immune, and coagulation systems.

The experience with 212 Extracorporeal Joinings of Donor (pig) Spleens (EJDS) by means of a veno-venous shunt for the treatment of 86 patients with severe shock trauma and its complications is reported. The clinical effects consisted of decreasing signs of intoxication, namely reduction in fever and in the severity of associated encephalopathy. Extracoporeal joinings on donor (pig) spleens (EJDS) was followed by a decline in the concentration of “middle molecules,” fibrinogen levels, leucocyte intoxication index, and the number of circulating immune complexes at different times following complexion of the procedure. The number of blood cells remained constant. On the following day, there occurred an increase in the number of thrombocytes. In addition, there was a decline in the quantity of circulating particles in the plasma. The level of plasma creatinine remained constant.

Extracoporeal circulation through donor (pig) spleens (EJDS) has an important influence on that part of the immune system that performs the functions of phagocytosis, and also increases the levels of chemokinetic and chemotaxc reactions.

Paramedics accurately estimate the closest trauma hospital for ground transport.

Ground ambulance scene transports of trauma system patients to six participating trauma hospitals in Multnomah County, Oregon from 1 January 1986 to 1 January 1987 were studied. Transports involving multiple patients or pediatric patients were excluded.

A retrospective analysis was performed on consecutive patient transports to be taken to the closest trauma hospital as required by protocol. The availability of each hospital to receive trauma patients was monitored continuously by a central communications facility. Paramedics were provided hospital availability data at the time of patient system entry. When several hospitals were available, the paramedics were required by protocol to select the “closest” hospital. Subsequently, the vector distance from the trauma site to each of the available hospitals was measured using a grid map. This method was validated by odometer measurement (r2 = 0.924). Chisquare analysis was used to analyze hospital bypasses to specific hospitals.

Of the 1193 eligible patients entered into the trauma system, 160 (13%; 95% CI = 11–15%) transports bypassed the closest available hospital for a receiving hospital ≥1 mile more distant. There were 11 (1%; 0–2%) patients transported to a hospital more than five miles more distant. Of the 132 patients with a trauma score (TS) <12, 15 (11%; 6–18%) were taken to a hospital one mile or further beyond the closest hospital. None (0%; 0–2%) were transported more than five miles past the closest hospital. Of the six hospitals, three were bypassed more than one mile significantly more often then they received bypass patients. One hospital received such patients four times more than it was bypassed (p <.001).

While paramedics generally can identify the closest hospital for trauma patient transport, some systematic hospital bypass errors occur. If a community wants assurance of an equitable patient distribution among participating trauma hospitals and assignment of the closest geographic hospital for injured patients, then map vector distance determination to identify the closest available hospital should supplement paramedic dispatching.

To study the natural outcome of patients refusing prehospital transportation (PT).

A total of 188 consecutive patients who refused PT in an urban, advanced life support (ALS), emergency medical services (EMS) system were studied. Of these, 77 (41 %) were male, and the average age was 51 years. Patients were entered into the study group only once.

Only 94 (50%) patients could be reached by telephone follow-up. Seven (7%) of these 94 patients had abnormal vital signs, 33 (35%) had cardiopulmonary complaints, 16 (17%) had an altered level of consciousness, nine (10%) were involved in accidents, and eight (8%) had abdominal pain. Six (6%) patients were admitted to the hospital, two (2 %) received ALS-level treatment by the paramedics and then refused conveyance, and 31 (33 %) either saw or contacted a physician. Consultation with an EMS physician was initiated for nine (5%) refusals. Of all the patients contacted, six (6%) needed PT for hospitalization.

As only 50% of the patients refusing prehospital transportation could be reached using follow-up telephone calls, the 6% figure probably underestimates the true number of patients requiring PT. Telephone follow-up is an inadequate means of determining the natural outcome for this patient population. The ALS nature of many of the complaints combined with the lack of consistent physician consultation, exposes the EMS system to an undefined medico-legal liability risk.

Suicidal patients who refuse prehospital transport pose a difficult problem for emergency medical services. A survey was conducted in an attempt to assess the current strategies for involuntary transport of such patients.

The medical directors of 135 of the largest EMS systems in the United States were mailed a questionnaire requesting descriptions of the operating procedures for dealing with suicidal patients who refuse transport.

Fifty-nine of 130 questionnaires (45%) were returned. Seventeen emergency medical services (EMS) systems (29%) serve populations of less the 250,000, while 41 (69%) serve populations greater than 250,000. Cumulatively, respondents represent an excess of 2.1-million EMS responses per year, of which 0.5%-10.0% involve behavioral emergencies. Eleven of the 59 responding systems (19%) have urritten, explicit policies guiding the management of suicidal patients who refuse to be transported. Involuntary commitment proceedings are initiated in the prehospital setting in 25 of the 59 services (42%). Of these 25, the initiation of commitment proceedings is performed by the following (more than one may apply to a given system): 11 (44%) by base-station physicians, six (24%) by the emergency medical technician (EMT), 23 (92%) by a police officer, and five (20%) by family or friends. Ten of the 59 systems (17%) require a mental health delegate to authorize commitment. Two physicians can mandate involuntary commitment in one of the responding systems. Of the 25 systems that actually perform involuntary commitment in the prehospital setting, seven (28%) have established policies. Of the 34 systems which do not perform involuntary prehospital commitment, four (12%) have policies to guide the care of suicidal patients who refuse care.

Suicidal patients commonly confront emergency medical services, yet many systems lack explicit policies for dealing with such patients. Widely varied strategies are used to authorize transport of patients who are suicidal and refuse to be transported.