A reported in-field, prospective evaluation of 227 prehospital patient assessments by advanced life support (ALS) emergency medical technicians (EMTs) found a frequent failure to measure vital signs. The objective of this retrospective review was to report the omission frequency of vital signs found in a centralized emergency medical services (EMS) data collection system.

The EMS database contained information from 90,480 optically scanned, prehospital patient encounter forms. Each record identified EMT skill levels, response times, dispatch type, vital signs, medical and trauma information, treatment, and patient disposition. Records for 1989 and 1990 were collected from 92 rural EMS providers who responded to emergency medical and trauma events.

Of 90,480 emergency responses, 14,129 (15.6%) were false alarms, deceased, or canceled without vital patient contact. Valid encounters were documented for 76,351 (84.4%) patient contacts. Systolic blood pressure measurements were not recorded for 13,262 (17.4%) patients. Diastolic blood pressure was not recorded for 14,272 (18.7%) patients. A pulse record was not recorded for 12,125 (15.9%) patients. A ventilatory rate was absent in 12,958 (17.0%) patient records.

This study found a frequent failure by non-metropolitan basic life support (BLS) and advanced life support (ALS) EMTs to record vital signs on prehospital emergency patient encounter forms. It supports a previous report of direct in-field observations of ALS EMTs failing to measure vital signs during patient assessment. The impact of vital sign omissions upon individual patient care can be assessed only by receiving medical control physicians. In the absence of effective emergency physician networking, the statewide magnitude of the problem among BLS and ALS EMTs has not been recognized as a system issue.

The purposes of this study are to quantify the use of nitroglycerin (NTG) in prehospital care, to detect deviations from the Standing Medical Orders (SMO), to determin the effectiveness of its administration, and the incidence of clinically significant adverse reactions (hypotension, bradycardia).

Retrospective review of 7683 Advanced Life Support (ALS) telemetry, base-station contacts over a three month period (June, July, Auguest 1990) to identify all prehospital patient contacts in which NTG was utilized.

The Resource Hospital/Telemetry Base-Station a two community hospitals/Telemetry Base-Stations for the Chicago North EMS System.

There were 445 runs in which NTG was indicated as per SMO. Two hundred eighty-eight patients (64.7%) received NTG for appropriate indications as per SMO, 203 for ischemic chest pain (45.6%), 79 for pulmonary edema (17.7%), and six for both (1.3%). There were 157 (35.5%) runs in which NTG was indicated, but not administered. There were 22 patients who received NTG for indications that deviated from the SMO. Reassessment data concerning the subjective symptom was completed on 118 patients (40.9%), 92 (45.3%) patients with chest pain and 26 with dyspnea (32.9%). Following the administration of NTG, 21 patients (10.1%) with chest pain were unchanged, while 13 with dyspnea (15.3%) improved, 13 patients (15.3%) were unchanged, and none worsened. In 121 patients, the systolic blood pressure (SBP) decreased, while 24 were unchanged (5.4%), and 28 had an increase (6.3%). The mean initial value SBP was 176±44 mmHg and the repeat mean SBP was 164±41 mmHg with a mean decrease of 12±22 mmHg. The diastolic blood pressure (DBP) decreased in 87 patients, was unchanged in 53 (11.9%), and increased in 33 (7.4%). The initial mean DBP was 97±24 mmHg, the repeat mean DBP was 92±23 mmHg, a mean decrease of 5±15 mmHg. Only one patient became hypotensive with the administration of NTG and was successfully resusticated with a fluid bolus of 300 ml normal saline.

In this EMS system, NTG is under-utilized based on the indications delineated by this system's SMOs. Reassessment is documented infrequently, but when completed, clinically significant adverse reactions are rare. Since the incidence of hypotension and bradycardia are rare, the inability to establish an IV line should not preclude the administration of NTG.

Privately transported, major trauma patients made up approximately 4% of the total trauma patients population at a major, regional trauma center which treats over 90% of all major trauma victims in the geographic area. This study was undertaken to evaluate the patient profile of those individuals who did not access 9-1-1 for transport to a trauma center, including their reasons for such non-use.

Data on all major trauma occurring within Dade County, Florida, were collected by the county trauma registry.

In the last six months of 1989, 1,672 patients were entered into the trauma registry. One-thousand-six-hundred-thirteen (1,613) were transported by professional ground or air services, 59 by private vehicle. For those patients transported directly from the Emergency Department to the Operating Room, only 35% of private vehicle patients entered surgery within 90 minutes of presentation compared to 57% of those who gained access to the 9-1-1 system and used emergency medical services (EMS). One-half of those patients who did not use 9-1-1 did not have telephone access. Patient acuity was similar for those transported by private vehicle compared to those transported by basic or advanced life support units. Private vehicle transport often delayed patient triage and assessment. Thus, for a number of lower income patients, 9-1-1 access was difficult.

Underestimation of the severity of the injury or fear of delay in rescue response were prominent reasons for non-use of 9-1-1. While educational efforts should concentrate on decreasing inappropriate 9-1-1 use for nonemergencies, the causes of underutilization should not be ignored.

Investigate Emergency Physicians' knowledge about the Superfund Amendments and Reauthorization Act (SARA) Title III legislation, passed by the United States Congress in 1986, and to determine the factors contributing to their level of preparedness in dealing with patients exposed to toxic chemicals.

A 115-item questionnaire was mailed to the medical directors of all emergency departments (EDs) in the State of New York. The results of the cross-sectional survey were analyzed using standard statistical methods.

One hundred and eighty-seven (72%) of the directors of EDs in New York State responded to the survey. Three years after SARA was enacted, only 33% of the directors had heard about this legislation. Only 18% had been invited to attend the meetings of the Local Emergency Planning Committees (LEPC). Sixty percent of the directors knew whether or not the LEPC had devised plans that defined a role for their EDs in responding to environmental emergencies. This knowledge about community planning mainly had an effect on preparedness of the EDs. Preparedness also was predicted by how recently the EDs had treated patients exposed to toxic chemicals, the perception that emergency physicians had a legitimate role in planning for and responding to chemical emergencies, and how often emergency physicians had attended continuing education courses about hazardous materials.

Despite the finding that some emergency physicians are involved in community preparations, two main problems persist in planning a medical response to environmental emergencies. First, the ED directors generally are unaware of the legislation that mandates these preparations and are not interacting with community planners. Second, there is not full involvement by the local EDs in the LEPC planning efforts.

A procedure is needed to disseminate information about legislation which affects emergency physicians, such as SARA, and about regional planning for environmental emergencies. Dissemination should include education about the professions' role in planning for and providing care for patients exposed to toxic chemicals.

To characterize the prevalence and morbidity of injuries to emergency medical technicians EMTs) in New England [United States].

A survey was mailed to a 2% random sample of all registered EMTs in the six New England States. The identity of the EMTs remained anonymous, and a second mailing was used to improve return rate. The EMTs were requested to recall events that occurred during the previous six months.

A total of 439 of the 786 (56%) surveys were returned representing 13,875 hours of duty time in the six-month period. Seventy one percent of the EMTs were male with a mean age of 35 years. Sixty-six percent were basic-EMTs. Injury attack rates (number of injuries/100 EMTs/6 months) were: stress, 11.2; back, 10.5; extremity, 9.8; assault, 8.4; ambulance collision, 4.1; hearing loss, 2.5; and eye injury, 1.4. Twelve percent of the EMTs were injured more than once in the six-month period. The paramedics more frequently were involved in ambulance collisions, suffered from stress, and were less likely to injure their back. There were minor interstate differences. Disability due to back injury affected 2.5% of those surveyed, four EMTs lost duty time secondary to an assault, and 0.5% of the EMTs were out of work due to stress.

This survey begins to characterize the occupational risks of EMTs. The prevalence of back injuries, assault, stress, and extremity injuries seems to be too high. Educational programs and preventive interventions should be designed to minimize back injuries, stress, and assault. There is a need for more research nationwide in order to better characterize these injuries.

The Telemedicine Spacebridge, a satellite-mediated, audio-video-fax link between four United States and two Armenian and Russian medical centers, permitted remote American consultants to assist Armenian and Russian physicians in the management of medical problems following the December 1988 earthquake in Armenia and the June 1989 gas explosion near Ufa.

During 12 weeks of operations, 247 Armenian and Russian and 175 American medical professionals participated in 34 half-day clinical conferences. A total of 209 patients were discussed, requiring expertise in 20 specialty areas.

Telemedicine consultations resulted in altered diagnoses for 54, new diagnostic studies for 70, altered diagnostic processes for 47 and modified treatment plans for 47 of 185 Armenian patients presented. Simultaneous participation of several US medical centers was judged beneficial; quality of data transmission was judged excellent.

These results suggest that interactive consultation by remote specialists can provide valuable assistance to on-site physicians and favorably influence clinical decisions in the aftermath of major disasters.

Prehospital (EMS) personnel routinely enter patient's homes and often are the first trained persons to evaluate an ill or injured child. Therefore, it is vital for these individuals to recognize child abuse (CA), and to understand the proper procedures for reporting suspected cases.

A questionnaire was administered to prehospital care-givers participating in a seminar on pediatric emergencies. Questions were designed to test factual knowledge of CA and the correct reporting procedures, as well as to evaluate attitudes toward CA.

There were 48 responses to the questionnaire; 34 (71%) were paramedics, the remainder were emergency medical technicians (EMTs) and/or registered nurses (RNs). Thirty-three (69%) practiced either in a rural or suburban setting. Subjects had an average of 10.8 years of prehospital emergency-care experience. Twenty-eight (58%) reported no previous training in CA. All participants understood the nature of CA, were able to identify the various forms of CA, and believed CA to be a significant problem. However, 33 (69%) did not understand the legislation that mandates reporter status, and while 27 (56%) claimed to have reported CA, only 16 (33%) had made a report either to police or to children's services workers. Of the 21 who never had reported a case of CA, 14 (67%) believed that they never had encountered an abused child. The remainder were not certain, and therefore, did not report, or thought that the hospital staff would report.

While this subject deserves further study, it seems that many EMTs and paramedics lack a complete understanding of their role in the identification and reporting of CA. This information should be emphasized further in EMT and paramedic education, and should be reinforced through continuing education.