Stress levels in EMS personnel: a national survey.

OBJECTIVE: The purpose of this study was to evaluate stress levels in emergency medical services personnel across the United States. DESIGN: Confidential, 20-question survey tool, Medical Personnel Stress Survey--Abbreviated (MPSS-R). A total score of 50 indicates average stress levels. A score of 12.5 on the subset measurements of somatic distress, job dissatisfaction, organizational stress, and negative attitudes towards patients indicates average levels of stress. Data were analyzed using ANOVA and t-test. INTERVENTIONS: None. RESULTS: A total of 658 of 3,000 emergency medical technicians (EMTs) (22%) completed the survey. The mean value of 69.3 +/- 6.3 for the total stress scores was very high. Mean values for the subset scores were: somatic distress = 19.6 +/- 3.3; organizational stress = 17.3 +/- 2.4; job dissatisfaction = 17.0 +/- 2.6; negative attitudes towards patients = 15.5 +/- 2.3. Characteristics predicting higher stress were EMT-basic (A) licensure, basic life support (BLS) only service provider, volunteer status, new employee working in a small EMS organization, and providing service to a small town. CONCLUSION: Stress levels in EMS personnel were very high, were manifested primarily as somatic distress, secondarily as organizational stress and job dissatisfaction, and lastly as negative patient attitudes. Stress levels and subset manifestations of occupational stress among EMS personnel varied depending on gender, marital status, age, level of training and function, on salaried or volunteer status, length of time as an EMT, and size of the organization, city, and population served. Care should be taken to address stresses peculiar to individual EMS system needs.

Performance of a system to determine EMS dispatch priorities.

Inappropriate use of emergency medical services (EMS) for nonemergencies strains EMS resources and limits efficiency. Protocol-driven dispatch systems attempt to correct the imbalance that exists between demand and available resources by prioritizing 911 calls. This study compared dispatch priority decisions with apparent patient need, based on emergency department (ED) presentation, by matching 320 ED charts with corresponding EMS dispatch and run information. The priorities assigned by the system based on dispatch information were compared with those assigned by a three-member panel of physicians based on ED presentation. The physicians and dispatchers agreed on the need for advanced life support (ALS) versus basic life support (BLS) transport 74% of the time. There was only 43% agreement on the more detailed 4-level classification system. The system assigned the highest level of dispatch utilizing combined ALS and first responders to a significantly greater degree than did the physicians. It was concluded that protocol systems for setting dispatch priorities utilize EMS resources to a higher degree than actually required based on ED presentation.

Evolution of rescue systems: a comparison between Cologne and Cleveland.

INTRODUCTION: Comparisons of different emergency medical services (EMS) systems often are reduced to simple comparisons between distinct facilities or strategies (e.g., prehospital physician versus paramedic, "scoop and run" versus "stay and play"). METHODS: The EMS systems of similar cities (Cologne and Cleveland) in two different countries (Germany and the United States) are compared. The comparison is seen from the perspective of an evolutionary standpoint that reflects the development of the EMS system in connection with the special environments. Data on rescue times, facilities, and (trauma) outcomes are compared. RESULTS: No statistically significant differences in outcome between the systems were detected. CONCLUSION: Both systems are developed in special environments and are optimized over decades, which explains the similarities in outcome.

Stress levels in EMS personnel: a longitudinal study with work-schedule modification.

OBJECTIVE: To determine if stress levels of emergency medical services (EMS) personnel can be reduced by adjusting work schedules to personnel preferences. METHODS: A prospective, longitudinal, cohort study with a work-schedule modification intervention was performed. All EMS personnel employed by the City of Cleveland EMS were eligible for participation. EMS employees voluntarily completed an abbreviated medical personnel stress survey (MPSS-R), a 20- question validated stress-assessment tool, in September 1989, February 1991, and September 1991. A new scheduling pattern was introduced March 1991. At that time, 27 EMS employees volunteered to work the new schedule (12 hours/ shift: 3 days on/2 days off/2 days on/3 days off). The remaining 109 EMS employees remained on the old schedule (8 hours/shift: 6 days on/2 days off). RESULTS: Mean MPSS-R stress scores increased significantly from September 1990 (61.9 +/- 7.87) to September 1991 (65.08 +/- 7.23) (p < 0.05). In September 1991, mean stress scores of EMS personnel working the new schedule (64.39 +/- 7.82) were not significantly lower than stress scores of EMS personnel working the old schedule (65.25 +/- 7.10). CONCLUSION: Stress in EMS personnel increased despite a new schedule pattern designed to accommodate the preferences of EMS personnel.

Comparative performance of the Baxt Trauma Triage Rule.

New methods of deciding which patients require trauma center transport continue to be devised. Baxt recently published a Trauma Triage Rule (TTR) using anatomic injury, blood pressure, and elements of the Glascow Coma scale which can be used to identify adult major trauma patients. The purpose of this study was to compare the TTR against three previously published trauma triage instruments; the Triage-Revised Trauma Score, the Prehospital Index, and the CRAMS scale. We applied these rules to a data base of trauma patients transported by the Cleveland, Ohio Emergency Medical Services System. All four instruments identified adult trauma patients who either died or required emergent operations with sensitivities of at least .85. The specificity of the TTR exceeded that of the CRAMS. We conclude that the TTR is an effective means of identifying patients who either die or require emergent operation.

Prehospital pulse oximetry: useful or misused?

STUDY OBJECTIVE: This study evaluated the ability of emergency medical technicians (EMT-As) and emergency medical technicians-paramedics (EMT-Ps) to use pulse oximetry measurements in determining patient oxygen requirements. DESIGN: Prospective case series. SETTING: Cleveland emergency medical services (EMS) system. TYPE OF PARTICIPANTS: Five hundred thirty-two consecutive patients transported to Cleveland area hospitals by the Cleveland EMS system; no exclusions. INTERVENTIONS: EMT-Ps and EMT-As predicted patients' supplemental oxygen requirements based on clinical assessment. Pulse oximetry was performed while patients were breathing room air (RA SpO2). Treatment intervention, including oxygen supplementation and medication given, oxygen saturation after intervention, and oxygen saturation on arrival at the hospital, was also recorded. Therapy guided by the patient's initial RA SpO2 was reviewed to determine the appropriateness of oxygen therapy. RESULTS: Data were analyzed using the chi 2 test and correlation analysis. Eleven percent (59) of patients transported by Cleveland EMS had an initial RA SpO2 of less than 91%. Advanced life support units increased oxygen supplementation on all desaturated patients, whereas basic life support units failed to make appropriate increases in FIO2 in 20% (two) of desaturated patients (P less than .0001). Sixty percent (164) of patients transported by EMT-Ps and 62% (162) of patients transported by EMT-As had an initial RA SpO2 of 97% or greater. EMT-Ps gave supplemental oxygen therapy to all but 7% (11) of these already well-saturated patients, and EMT-As gave supplemental oxygen to all but 6% (nine) of these patients. EMT-Ps administered a higher FIO2 than they had predicted clinically necessary to 2% (four) of patients with an initial RA SpO2 of 97% of greater, whereas EMT-As gave a higher FIO2 than initially predicted to 16% (25) of such patients (P less than .0001). CONCLUSION: EMT-Ps were more likely to appropriately base oxygen therapy on oximetry measurements than were EMT-As. Both groups failed to decrease supplemental oxygen in patients with high explicit protocols for EMS systems contemplating the use of oximetry to guide oxygen therapy. Our results further suggest that pulse oximetry could be used to avoid unnecessary oxygen therapy on a significant number of patients transported by EMS systems because they are already well saturated on room air.

A comparison of EMT judgment and prehospital trauma triage instruments.

A number of instruments have been devised to aid in the triage of trauma patients. Little work, however, has been done to demonstrate that these triage instruments offer an advantage over the judgment of an emergency medical technician (EMT) in determining which patients require transportation to a trauma center. The purpose of this study was to compare EMT judgment against three scoring systems; the triage-revised Trauma Score, the Prehospital Index, and the CRAMS scale. Data were gathered on trauma victims transported by the City of Cleveland EMS system. The EMTs rated the patient's overall severity on a 4-point scale and estimated the probability of patient mortality. We found that the EMT prediction of mortality was as accurate as the various scores. In a subset of patients, we also found that the EMT assessment performed as well as the scoring systems in identifying patients who either died or required emergent operative intervention. We conclude that EMT judgment is as accurate as these three scoring systems in identifying patients at high risk for death or the need for immediate operative intervention.

A controlled trial of nebulized isoetharine in the prehospital treatment of acute asthma.

Acute asthma is a potentially life-threatening disorder, recognizable to the prehospital care provider. While therapies are available to the prehospital care provider for treating acute asthma, no previous controlled studies have been performed demonstrating the treatment in the field is efficacious and safe. The authors conducted a controlled trial of the prehospital use of nebulized isoetharine in an urban emergency medical services system. Fifty-two patients with acute asthma were studied. Patients were initially evaluated with a peak flow meter. Half of the patients received isoetharine, while the control group received basic life support only. There was no difference in baseline values. Peak expiratory flow increased from 138 L/min to 148 L/min in the control group, while it increased from 149 L/min to 218 L/min in the treatment group (P less than .001). The authors conclude that paramedic treatment of acute asthma with nebulized isoetharine is effective in improving pulmonary function and clinical status during transport.