Understanding the Role of Empathy and Gender on EMS Clinician Occupational Stress and Mental Health Outcomes.

BACKGROUND: Emergency Medical Service (EMS) clinicians experience high levels of occupational stress due to long hours, short staffing, and patient deaths, among other factors. While gender has been partially examined, little is known regarding the role of empathy on occupational stress and mental health (MH) outcomes among EMS clinicians. Therefore, the current study examines the moderating role of empathy and, separately, gender on associations between occupational stress and mental health. METHODS: A cross-sectional examination of EMS clinician occupational and personal wellbeing was conducted via an anonymous, electronic survey. Information on clinician demographics, and validated measures of occupational stress, burnout, and MH outcomes were collected. Empathy was assessed using the Toronto Empathy Scale (TEQ). Descriptive/bivariate statistics were conducted for variables of interest. Separate multivariable regression models evaluated associations between occupational stress and mental health outcomes. Empathy and gender were examined as potential moderators using interactions. RESULTS: A total of 568 EMS clinicians completed the survey. High levels of mental health difficulties were reported (34.0% anxiety, 29.2% depression, 48.6% burnout). Increased occupational stress was associated with increased anxiety (OR =1.08, 95% CI 1.05-1.10), depression (OR = 1.09, 95% CI 1.06-1.10), and burnout (OR = 1.10, 95% CI 1.07-1.12). No moderation analyses were significant. Greater resilience was associated with lower depression, anxiety, and burnout. CONCLUSION: EMS clinicians, much like other first responders, experience considerable occupational stress, of which is associated with mental health difficulties and burnout. Findings underscore the need for intervention programs aimed at reducing the impact of occupational stress and the promotion of resilience. Continuing to understand the full scope of EMS mental health, including the role of resilience, is imperative, particularly in light of future public emergencies.

The Female Emergency Medical Services Experience: A Mixed Methods Study.

BACKGROUND: Emergency Medical Services (EMS) is a challenging profession. Little is known if there are gender differences in the experiences among EMS clinicians. Therefore, our aim was to understand and characterize the occupational experiences of female EMS clinicians. METHODS: A mixed methodological study was conducted among currently licensed female EMS clinicians via focus group and self-report survey data. Three focus groups (n = 5, 4, 13, respectively) were conducted with participants purposively recruited from primarily Northeastern EMS agencies. Through ongoing collaborations, a recruitment advertisement was provided to EMS leadership at respective agencies for distribution among their female staff. Sessions were recorded and transcribed for thematic analysis. A six-phase inductive analytical approach was utilized to evaluate focus group data. Qualitative findings were utilized to inform a cross-sectional, self-report survey consisting of occupational specific experiences, such as harassment and pregnancy, and validated measures of mental wellbeing. Descriptive statistics were used to describe the study sample and female EMS clinician occupational and personal experiences. RESULTS: A total of 22 female EMS clinicians participated across the three focus group sessions. Four major themes were identified: 1) the female EMS experience; 2) impact on personal wellbeing; 3) impact on occupational wellbeing; and 4) coping mechanisms. Each theme had multiple subthemes. There were 161 participants that attempted the 72-item survey, 13 partial and 148 competed surveys. Median age was 32 years (IQR: 25-42), and the majority were EMT-Bs (55.1%). Approximately 70.0% met the criteria for probable anxiety, 53.9% probable depression and 40.9% elevated symptoms of burnout. Almost 73.0% reported workplace harassment, with most experiences being perpetrated by patients and coworkers. Over 61.0% reported reconsideration of their career in EMS. Overall, survey data indicated interactions with peers and leadership, and social support were positive. CONCLUSIONS: Findings highlight the need to improve the occupational experiences of female EMS clinicians to preserve and encourage the continuation of their participation in this workforce. Specifically tailored interventions aimed at protecting and improving their overall wellbeing are critical, particularly considering the increased occupational burden resulting from the pandemic. Future research should aim to understand specific predictors of adverse mental health outcomes among this population.

Living with prostate cancer: a mixed-method evaluation of group therapy intervention to alleviate psychological distress in a Canadian setting.

PURPOSE: To assess the effects of group therapy focused on the experience of living with prostate cancer (PC) on depression and mental well-being among men with the disease and to explore participant experiences of a guided opportunity to 'speak the unspeakable' as it pertains to living with PC. METHODS: We used a mixed-method convergent design. Participants completed four validated self-report questionnaires at baseline, immediately after the final session, and at three, six, and 12 months follow-up. A repeated measures mixed-effect model examined the effects of the program on depression, mental well-being, and masculinity. Seven focus groups (n = 37) and 39 semi-structured individual interviews explored participant reactions at follow-up. RESULTS: Thirty-nine (93%) participants completed the questionnaires at all follow-ups. Responses indicated improved mental well-being up to three months (p < 0.01) and a decrease in depressive symptoms to 12 months (p < 0.05). Qualitative analysis revealed how the cohesive group environment alleviated psychological stress, enabled participants to identify significant issues and concerns in their lives, and improved communication and relationship skills that were of value in the group as well as with family and friends. The facilitation was essential to guiding participants to 'speak the unspeakable.' CONCLUSION: Men with PC who speak of their experience in a group setting with a guided process incorporating features of a life review appear to gain insight into the impact of PC in their lives, experience diminished features of depression and isolation, and enhance their communication skills within the groups as well as with family members and friends.

Eyebrow Shape Preference Across Age, Gender, and Self-reported Ethnic Group.

BACKGROUND: Preference in eyebrow shape has been studied in young women, but less so in older adults, men, and a wide variety of ethnic groups. OBJECTIVE: To identify preference in eyebrow shape across age groups, genders, and ethnic groups for both the survey responder and the observed subject. METHODS: Digital images of subjects from 3 age groups (18-39, 40-59, and 60+ years), 2 genders (female and male), and 4 self-identified ethnic backgrounds were edited to correspond to 5 brow shapes (Anastasia, head-up, horizontal, rounded, and tail-up). Panels of images representing the same subject with different brow shapes were displayed and responders ranked them in order of attractiveness via an online survey. RESULTS: Six hundred fifty-two responders answered the survey. Survey responders generally preferred the Anastasia shape, but not in all subgroups. Strength of preference in eyebrow shape was more marked when observing images of women and less marked when observing men. CONCLUSION: An arched brow, such as the Anastasia shape, was the preferred eyebrow shape. This study is limited by its survey nature, underrepresentation of self-identified Black study responders, and categorization of data. Despite these findings, the authors advocate determining eyebrow shape preference individually with patients during cosmetic consultations.

Reduction in Interfacility Transfer Response Time after Implementation of an AutoLaunch Protocol.

Background: Interfacility transfers (IFTs) are an essential component of healthcare systems to allow movement of patients between facilities. It is essential to limit any delays in patients receiving the care they require at the receiving facility. The primary objective of this study was to assess whether IFT response time was reduced after implementation of an AutoLaunch protocol, in which an ambulance is dispatched to the sending facility prior to acceptance of the patient by the receiving facility. The secondary objective was to describe the frequency and amount of time ambulances had to stage outside the sending facility in situations where the ambulance arrived prior to the patient being accepted by the receiving facility. Methods: This was a retrospective pre-post analysis of patients undergoing IFT for services not available at the sending facility between October 1, 2018 and September 30, 2019, with the AutoLaunch protocol being implemented on March 25, 2019. IFT response time was defined as the time the transfer request was initially made to the time the ambulance arrived at the sending facility. Dispatch call logs and transport records were analyzed before and after implementation of the AutoLaunch protocol to assess for a difference in IFT response time as well as frequency and amount of time ambulances had to stage. Results: Of 1,881 IFTs analyzed, 885 (47.0%) were completed under the traditional protocol and 996 (53.0%) were completed under the AutoLaunch protocol. The median IFT response time under the traditional protocol was 27.5 minutes (interquartile range (IQR): 17.9, 43.3), compared with 19.9 minutes (IQR: 12.8, 28.2) under the AutoLaunch protocol (p < 0.01), representing a 27.6% reduction in response time, or 7.6 minutes saved. Of the 996 AutoLaunch transfers, there were 215 incidents (21.6%) in which the IFT ambulance had to stage, and the median staging time was 10.1 minutes (IQR: 4.9, 24.2). Conclusions: Implementation of our AutoLaunch protocol resulted in a significant reduction in ambulance response time for interfacility transfers. Further studies are needed to assess whether the reduction in response time is associated with improved patient outcomes for certain conditions.

Video or Telephone? A Natural Experiment on the Added Value of Video Communication in Community Paramedic Responses.

STUDY OBJECTIVE: The objective of this study was to determine the effect of video versus telephonic communication between community paramedics and online medical control physicians on odds of patient transport to a hospital emergency department (ED). METHODS: This was a retrospective analysis of data from a telemedicine-capable community paramedicine program operating within an advanced illness management program that provides home-based primary care to approximately 2,000 housebound patients per year who have advanced medical illness, multiple chronic conditions, activities of daily living dependencies, and past-year hospitalizations. Primary outcome was difference in odds of ED transport between community paramedicine responses with video communication versus those with telephonic communication. Secondary outcomes were physicians' perception of whether video enhanced clinical evaluation and whether perceived enhancement affected ED transport. RESULTS: Of 1,707 community paramedicine responses between 2015 and 2017, 899 (53%) successfully used video; 808 (47%) used telephonic communication. Overall, 290 patients (17%) were transported to a hospital ED. In the adjusted regression model, video availability was not associated with a significant difference in the odds of ED transport (odds ratio 0.80; 95% confidence interval 0.62 to 1.03). Online medical control physicians reported that video enhanced clinical evaluation 85% of the time, but this perception was not associated with odds of ED transport. CONCLUSION: We found support that video is considered an enhancement by physicians overseeing a community paramedicine response, but is not associated with a statistically significant difference in transport to the ED compared with telephonic communication in this nonrandom sample. These results have implications for new models of out-of-hospital care that allow patients to be evaluated and treated in the home.

Utility of Emergency Medical Dispatch (EMD) Telephone Screening in Identifying COVID-19 Positive Patients.

Background: In response to the COVID-19 pandemic, Emergency Medical Services (EMS) systems have received guidelines as part of coordinated response efforts aimed at mitigating exposures and ensuring occupational wellbeing, including recommendations of Personal Protective Equipment (PPE) utilization, and modifications of Emergency Medical Dispatch (EMD) caller queries. The aim of the study was to estimate the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of an EMD telephone screening process for the identification of hospital diagnosed COVID-19 positive patients. Methods: A retrospective cohort study was conducted of adult EMS encounters presenting to hospitals within a large health system from March 16-June 30, 2020. EMD telephone screening status was defined as either "positive" or "negative" and was collected from prehospital medical records. COVID-19 positive patients were confirmed via hospital laboratory diagnosis and were matched to their prehospital medical record data. Patient demographics and EMS encounter level data, such as Dispatch Code and Priority level, were also collected. Estimations of sensitivity, specificity, PPV and NPV were made. Emergency telephone screening status was stratified by COVID-19 diagnosis to describe discordant pairs. Results: Of the 3,443 total encounters screened, there were 652 patients who were subsequently COVID-19 positive per hospital diagnosis (18.9%). Approximately 5.0% of all encounters did not screen positive on EMD screening but were later COVID-19 positive. Conversely, 44.2% of encounters screened positive for COVID-19, but were subsequently negative. Sensitivity of the EMD telephonic screening was estimated as 75.0% (95% CI 71.7%, 78.3%) and specificity was 45.5% (95% CI 43.7%, 47.4%). The PPV was 24.3% (95% CI 22.5%, 26.0%), and NPV 88.6% (95% CI 87.0%, 90.3%). Conclusions: The sensitivity of the EMD telephonic screening process was moderately able to identify COVID-19 positive patients. There is a need to reevaluate and revise guidelines and recommendations, specifically modified caller queries, as part of ongoing pandemic emergency response efforts in order to reduce transmissions and maximize patient and provider safety.

Photographic assessment of postsurgical facial scars epidermally sutured with rapidly absorbable polyglactin 910 or nylon: A randomized clinical trial.

BACKGROUND: Surgeons use absorbable and nonabsorbable sutures for epidermal wound closure. No large, randomized studies have compared the effect of these suture types on facial scar appearance. OBJECTIVE: To assess postsurgical facial scar appearance using either rapidly absorbable polyglactin 910 or nylon for epidermal closure. METHODS: Randomized, blinded, split-scar clinical trial. A total of 105 patients with facial wounds resulting from Mohs micrographic surgery excisions were randomly assigned for epidermal closure with rapidly absorbable 5-0 polyglactin 910 (Vicryl Rapide) on one half of the repair and 5-0 nylon (Ethilon) on the other half. Two physicians (1 dermatologist and 1 plastic surgeon), unaware of the original suture location, examined photographs of each healed wound at 6 months after surgery and graded the appearance of each half of the scar using the visual analog scale, wound evaluation scale, and Stony Brook Scar Evaluation Scale. RESULTS: At 6 months, there was no significant difference in the combined mean (standard deviation) visual analog scale scores (83.1 [14.2] and 83.0 [13.7]), Stony Brook Scar Evaluation Scale scores (4.3 [0.9] and 4.4 [0.9]), or wound evaluation scale scores (5.3 [1.1] and 5.2 [1.1]) for rapidly absorbable polyglactin 910 versus nylon (P = .72, .57, and .21, respectively). LIMITATIONS: Single institution. CONCLUSIONS: Both rapidly absorbable polyglactin 910 and nylon sutures placed through the epidermis resulted in an equivalent photographic appearance of facial scars at 6 months after surgery.

Access to Primary Care for Persons Recently Released From Prison.

We aimed to determine if a history of recent imprisonment affects access to primary care. Using patient roles, we telephoned to request an initial appointment with all family physicians (n = 339) who were accepting new patients in British Columbia, Canada. We sequentially assigned patient scenarios: male or female recently released from prison; male or female control. Controls were 1.98 (95% CI, 1.59-2.46) times as likely to be offered an appointment compared with persons recently released from prison, with an absolute risk difference of 41.8% (95% CI, 31.0-52.5). Our study suggests discrimination is a barrier to primary care for people released from prison, even with universal health insurance. We need to improve access to primary care during the high-risk period following prison release.

Editorial Commentary: SLAP Repair-The Anterosuperior Portal for Anchor Placement Is Best.

The anterosuperior rotator interval portal for SLAP repair anchor placement is the perfect balance between obtaining the proper anchor trajectory and respecting the rotator cuff integrity.

Low-acuity presentations to the emergency department: Reasons for and access to other health care providers before presentation.

OBJECTIVE: To describe the demographic characteristics of patients who present to the emergency department (ED) for low-acuity issues and to explore their self-reported contact with other sources of primary health care before presenting to the ED. DESIGN: Survey distributed in the ED waiting room. SETTING: A high-volume ED in Vancouver, BC. PARTICIPANTS: A total of 232 respondents aged 18 years or older in the ED waiting room. MAIN OUTCOME MEASURES: Actions taken to seek health care for the current issue before presenting to the ED and predictors of first seeking nonurgent care. RESULTS: Of the 398 people approached, 232 (58.3%) people completed the survey. Exactly half (95% CI 43.6% to 56.4%) sought alternative care before presenting to the ED. Predictors for having sought alternative care included illness presentation and longer symptom duration, while injury presentation and work-related presentation were associated with not seeking alternative care. Most participants (162 patients, 87.6%) believed that the ED was the most appropriate place for them to receive care for their problem, while only 87 (45.3%) believed that an adjacent primary care clinic would be an acceptable alternative. CONCLUSION: Many patients do attempt to seek alternative care before presenting to the ED with low acuity issues. Most patients believe that the ED is the best place for them to receive care and are uncertain about using a primary care alternative. Further research is needed to explore barriers and motivators patients face in their decisions to seek care, as well as potential patient education methods to improve appropriate ED use.

Real-World Efficacy of 1064-nm Nd:YAG Laser for the Treatment of Onychomycosis.

BACKGROUND: Onychomycosis is a cosmetic and, at times, medical concern; therefore, effective and safe alternatives to treatment are needed. OBJECTIVE: To determine the efficacy of a 1064-nm Nd:YAG laser for the treatment of onychomycosis in a real-world setting. METHODS: A single-centre retrospective chart review was conducted between 2012 and 2013. One hundred consecutive patients with a culture- and/or potassium hydroxide-confirmed diagnosis of onychomycosis were treated at least twice. Baseline and follow-up photographs were taken, and the change in degree of clinical nail involvement of the subject's great toenail was determined by a blinded reviewer using validated planimetry measurement. RESULTS: A total of 199 hallux nails from 100 subjects were assessed. The mean infected area decreased from 53.2% at baseline to 50.8% at the end of the study (paired t test, P = .054; Wilcoxon signed rank test, P = .006). Degree of nail involvement was statistically significantly associated with amount of improvement; subjects who had the greatest degree of nail involvement improved the most, while those with less severe disease showed a worsening of nail appearance (Kruskal-Wallis test, P < .001). Three-quarters (72.6%) of nails that had more than 67% nail involvement showed statistically significant improvement (χ2 test, P = .001). Adverse events were limited to mild to moderate pain at the time of therapy. A total of 76 subjects were assessed for treatment satisfaction: 60% were very satisfied with treatment despite limited clinical improvement in some cases. CONCLUSIONS: Laser therapy has a very limited positive clinical effect on the appearance of onychomycosis after 2 treatment sessions.

Continuous versus interrupted sutures for facial surgery repair: a randomized prospective study.

BACKGROUND: The cosmetic appearance of a facial scar is a concern for patients undergoing Mohs micrographic surgery (MMS). Although suturing technique may influence scar cosmesis, few studies have been published comparing suturing methods for MMS repair. OBJECTIVE: To compare the cosmetic appearance of facial MMS scars sutured with either continuous or interrupted percutaneous nylon sutures. MATERIALS AND METHODS: Patients with facial MMS defects were randomized to have half their scar sutured with interrupted 5-0 nylon stitches, whereas the other half of the scar was closed with running 5-0 nylon stitches. The appearance of each half of the scar was assessed at 1 week, 8 weeks, and 6 months by the principal investigator. Blinded photographic evaluation at 1 week and 6 months was completed by a plastic surgeon and general dermatologist. RESULTS: A total of 105 patients were entered into the trial, and 101 completed all time point assessments. There was no statistically significant difference in scar outcome using each of the 3 scar assessment scales, at any time point, for any assessor (blinded and nonblinded). CONCLUSION: Interrupted and continuous 5-0 nylon sutures result in an equivalent final cosmetic appearance of facial MMS scars. Given its advantages, running sutures may be the preferred closure technique for facial repair.

Safety, efficacy, and pharmacokinetics/pharmacodynamics of daclizumab (anti-CD25) in patients with adult T-cell leukemia/lymphoma.

Interleukin-2 receptor α chain (CD25) is overexpressed in human T-cell leukemia virus 1 associated adult T-cell leukemia/lymphoma (ATL). Daclizumab a humanized monoclonal antibody blocks IL-2 binding by recognizing the interleukin-2 receptor α chain (CD25). We conducted a phase I/II trial of daclizumab in 34 patients with ATL. Saturation of surface CD25 on circulating ATL cells was achieved at all doses; however saturation on ATL cells in lymph nodes required 8 mg/kg. Up to 8 mg/kg of daclizumab administered every 3 weeks was well tolerated. No responses were observed in 18 patients with acute or lymphoma ATL; however, 6 partial responses were observed in 16 chronic and smoldering ATL patients. The pharmacokinetics/pharmacodynamics of daclizumab suggest that high-dose daclizumab would be more effective than low-dose daclizumab in treatment of lymphoid malignancies and autoimmune diseases (e.g., multiple sclerosis) since high-dose daclizumab is required to saturate IL-2R alpha in extravascular sites.

Global Health Initiatives: International Physician-to-Physician Consultation Programs.

PURPOSE: The goal of this article is to provide technical and operational blueprints for two successful global telehealth programs. METHODS: The authors designed a physician-to-physician consultation program to provide subspecialty expertise to physicians in war-torn Ukraine. Leveraging secure web applications, telehealth platforms, and image-sharing platforms, the authors repeatedly iterated upon infrastructure and workflows, which in turn facilitated the development of a parallel international program for US Department of State (DOS) employees and families. The authors provide descriptive statistics and metrics of both programs' successes and failures and detail iterative improvements with workflow visuals. To measure the added value of subspecialty imaging consultation, two radiologists performed a retrospective comparative review of the DOS program imaging reports, comparing the initial report to the consult report in consensus, measuring diagnostic report agreement, and rating the clinical impact of identified discrepancies on a three-point scale (mild, moderate, or major). Bivariate analyses using χ2 tests were conducted to assess associations between diagnostic discrepancies and patient or imaging factors. P values <.05 were considered to indicate statistical significance. RESULTS: The Ukraine program (May 2022 to August 2023) provided 114 patient consultations with 77 subspecialty radiology consults, >50 WhatsApp chats, and >1,000 messages exchanged, with a 92% overall consult request response rate. The DOS program (November 2022 to July 2023) provided 275 consultations with 70 subspecialty radiology consults and a 36% to 38% rate of alternative diagnoses, with 20% rated as incurring moderate or major clinical impact. Bivariate analyses demonstrated no significant patient or imaging association with diagnostic disagreements (P > .05 for all). CONCLUSIONS: Global telehealth infrastructure and multiple applications and platforms can be optimized in a workflow to provide efficient, high-level clinical and imaging consultation services across the globe.

A randomized controlled comparison of epidural analgesia and combined spinal-epidural analgesia in a private practice setting: pain scores during first and second stages of labor and at delivery.

BACKGROUND: There has been no prospective evaluation of combined spinal-epidural (CSE) analgesia in a private practice setting and few studies have focused on pain relief during the second stage of labor and at delivery. In this randomized controlled trial, we compared verbal pain scores during the first and second stages of labor and at delivery in women receiving CSE or traditional epidural analgesia at a busy private maternity hospital. METHODS: Healthy, term parturients received epidural or CSE analgesia for labor pain upon request. Epidural analgesia was initiated with 0.125% bupivacaine plus 2 µg/mL fentanyl, 15 mL; CSE analgesia was initiated with intrathecal plain bupivacaine 3.125 mg plus 5 µg fentanyl. Thereafter, patient-controlled epidural analgesia with 0.125% bupivacaine plus 2 µg/mL fentanyl was used for maintenance analgesia in both groups. The primary outcome was an assessment of "typical" pain, using a verbal rating pain score from 0 to 10, made at the end of the first stage of labor and shortly after delivery. RESULTS: Data from 398 epidural and 402 CSE subjects were analyzed. The typical verbal rating pain score during the first stage was lower in the CSE group (mean: 1.4 vs 1.9; P < 0.001; 99.5% confidence interval [CI] for difference: -0.92, -0.14). Pain scores during the second stage of labor (1.7 vs 1.9; P = 0.17; 99.5% CI for difference: -0.82, 0.28) and at delivery (2.0 vs 2.0; P = 0.77; 99.5% CI for difference: -0.73, 0.59) were the same between groups. Fewer patients received an epidural top-up dose in the CSE group (16.4% vs 25.6%; P = 0.002; 99.5% CI for difference: -17.0%, -1.0%). Epidural catheters were replaced in 1.2% CSE vs 2% in the epidural group (P = 0.39; 99.5% CI for difference: -3.3%, 1.8%). CONCLUSIONS: Compared with traditional epidural labor analgesia, CSE analgesia provided better first-stage analgesia despite fewer epidural top-up injections by an anesthesiologist.

Reducing Door-In to Door-Out Time for Patients Receiving a Mechanical Thrombectomy Using AutoLaunch Protocol.

Background: Door-in to door-out (DIDO) time for large vessel occlusion (LVO) stroke is an emerging stroke performance measure. Initial presentation at a non-Comprehensive Stroke Center (CSC) requires a transfer process that minimizes delays. Our objective was to assess whether DIDO time for stroke patients was reduced after implementation of an AutoLaunch protocol for interfacility transfers. Methods: This was a pre-post analysis of an AutoLaunch protocol for all acute stroke patients transferred to a CSC for mechanical thrombectomy. The distribution of DIDO times between patients transferred via the AutoLaunch and traditional dispatch protocols were compared. Results: We evaluated 92 interfacility transfers, with 22 utilizing the AutoLaunch protocol and 70 utilizing traditional dispatch. Among AutoLaunch transfers, the median DIDO time was 85 minutes (IQR: 71, 133), while the median DIDO time among the traditional transfers was 109 minutes (IQR, 84, 144) (p=0.044). Conclusion: Implementation of an AutoLaunch protocol for patients with suspected LVO was associated with a reduction in DIDO time to CSCs. Further studies should evaluate patient outcomes based on transfer strategies.

Prehospital transport and termination of resuscitation of cardiac arrest patients: A review of prehospital care protocols in the United States.

Background: The objective was to describe emergency medical services (EMS) protocol variability in transport expectations for out-of-hospital cardiac arrest (OHCA) patients and the involvement of online medical control for on-scene termination of resuscitation in the United States. Whether other aspects of OHCA care were mentioned, including the definition of a "pediatric" patient, and use of end-tidal carbon dioxide monitoring, mechanical chest compression devices (MCCDs), and extracorporeal membrane oxygenation (ECMO), were also described. Methods and Results: Review of EMS protocols publicly accessible from https://www.emsprotocols.org and through searches on the internet when protocols were unavailable on the website from June 2021 to January 2022. Frequencies and proportions were used to describe outcomes. Of 104 protocols reviewed, 51.9% state to initiate transport after return of spontaneous circulation (ROSC), 26.0% do not specify when to initiate transport, and 6.7% state to transport after ≥20 minutes of on-scene cardiopulmonary resuscitation for adults. For pediatric patients, 38.5% of protocols do not specify when to initiate transport, 32.7% state to transport after ROSC, and 10.6% state to transport as soon as possible. Most protocols (42.3%) did not specify the age that defines "pediatric" in cardiac arrest. More than half (51.9%) of the protocols require online medical control for termination of resuscitation. Most protocols mention the use of end-tidal carbon dioxide monitoring (81.7%), 50.0% mention the use of MCCDs, and 4.8% mention ECMO for cardiac arrest. Conclusions: In the United States, EMS protocols for initiation of transport and termination of resuscitation for OHCA patients are highly variable.