Impact of Prehospital Pain Management on Emergency Department Management of Injured Children.

OBJECTIVE: Provision of analgesia for injured children is challenging for Emergency Medical Services (EMS) clinicians. Little is known about the effect of prehospital analgesia on emergency department (ED) care. We aimed to determine the impact of prehospital pain interventions on initial ED pain scale scores, timing and dosing of ED analgesia for injured patients transported by EMS. METHODS: This is a planned, secondary analysis of a prospective multicenter cohort of children with actual or suspected injuries transported to one of 11 PECARN-affiliated EDs from July 2019-April 2020. Using Wilcoxon rank sum for continuous variables and chi-square testing for categorical variables, we compared the change in EMS-to-ED pain scores and timing and dosing of ED-administered opioid analgesia in those who did and those who did not receive prehospital pain interventions. RESULTS: We enrolled 474 children with complete prehospital and ED pain management data. Prehospital interventions were performed on 262/474 (55%) of injured children and a total of 88 patients (19%) received prehospital opioids. Children who received prehospital opioids with or without adjunctive non-pharmacologic pain management experienced a greater reduction in pain severity and were more likely to receive ED opioids in higher doses earlier and throughout their ED care. Non-pharmacologic pain interventions alone did not impact ED care. CONCLUSIONS: We demonstrate that prehospital opioid analgesia is associated with both a significant reduction in pain severity at ED arrival and the administration of higher doses of opioid analgesia earlier and throughout ED care.

Does an individualized feedback mechanism improve quality of out-of-hospital CPR?

BACKGROUND: Despite its prevalence, survival from out-of-hospital cardiac arrest remains low. High quality CPR has been associated with improved survival in cardiac arrest patients. In early 2014, a program was initiated to provide feedback on CPR quality to prehospital providers after every treated cardiac arrest. OBJECTIVE: To assess whether individualized CPR feedback was associated with improved CPR quality measures in the prehospital setting. METHODS: This before and after retrospective review included all treated adult out-of-hospital cardiac arrest in patients in an urban community. Data was compared prior to and after the initiation of the CPR feedback program. We compared the percent of encounters reaching the system defined benchmarks as well as the average values for compression fraction, compression rate, compression depth, and pre-shock pause in the before period compared to the after period. RESULTS: There were 159 encounters in the before period and 117 in the after. Compared to the before group, the after group had higher average compression rates (111.2/min vs 113.8/min; p=0.042), increased compression depths (4.9cm vs 5.6cm; p<0.001), and increased rates of benchmark achievement for compression depth greater than 5cm (48.1% vs 72.6%; p<0.001). No significant difference was noted in pre-shock pause (21.4s vs 14.7s; p=0.068). Additionally, no difference was noted between groups for compression fraction, though goal achievement was high in both groups. CONCLUSION: We found that individual CPR feedback is associated with marginally improved quality of CPR in the prehospital setting. Further investigation with larger samples is warranted to better quantify this effect.

Chest compression duration influences outcome between integrated load-distributing band and manual CPR during cardiac arrest.

BACKGROUND: The Circulation Improving Resuscitation Care (CIRC) Trial found equivalent survival in adult out-of-hospital cardiac arrest (OHCA) patients who received integrated load-distributing band CPR (iA-CPR) compared to manual CPR (M-CPR). We hypothesized that as chest compression duration increased, iA-CPR provided a survival benefit when compared to M-CPR. METHODS: A pre-planned secondary analysis of OHCA of presumed cardiac etiology from the randomized CIRC trial. Chest compressions duration was defined as the total number of minutes spent on compressions during resuscitation and identified from transthoracic impedance and accelerometer data recorded by the EMS defibrillator. Logistic regression was used to model the interaction between treatment and duration of chest compressions and was covariate-adjusted for trial site, patient age, witnessed arrest, and initial shockable rhythm. Primary outcome was survival to hospital discharge. RESULTS: We enrolled 4231 subjects and of those, 2012 iA-CPR and 2002 M-CPR had complete outcome and duration of chest compressions data. While covariate-adjusted odds ratio for survival to hospital discharge was 1.86 in favor of iA-CPR (95% CI 1.16-3.0), there was an interaction between duration and study arm. When this was factored into the multivariate equation, the odds ratio for survival to hospital discharge showed a significant benefit for iA-CPR vs. M-CPR for chest compression duration greater than 16.5 min. CONCLUSION: After adjusting for compression duration and duration-treatment interaction, iA-CPR showed a significant benefit for survival to hospital discharge vs. M-CPR in patients with OHCA if chest compression duration was longer than 16.5 min.

Post-war development of emergency medicine in Kosovo.

OBJECTIVES: To (1) investigate emergency medical care priorities in Kosovo, (2) assess Kosovo's post-war development of emergency medical services and (3) identify expectations. METHODS: An instrument with seven open-ended questions, approved by the institutional review board, was designed for in-person interviews (preferred) or written survey. The survey was administered in October 2003 at the Kosovo University Clinical Center, Pristina, Kosovo, and one regional hospital. Targeted participants were emergency care providers, clinical consultants and health policy consultants. Surveys were conducted by interview with simultaneous interpretation by a native Albanian speaker, an orthopaedic surgeon or in written Albanian form. The responses were evaluated quantitatively and qualitatively. RESULTS: 13 respondents participated in the study: 10 gave interviews and 3 provided written response; 7 were emergency care providers, 4 were emergency care consultants and 2 were health policy consultants. Emergency care priorities were defined as trauma, cardiac disease and suicide. Most respondents believed that emergency medicine as a specialised field was a post-war development. The international community was credited with the provision of infrastructure, supplies and training. Most respondents denied any harm from international assistance. However, some respondents described instances of inappropriate international investment. Ongoing needs are training of providers and equipping of facilities and vehicles. Improved hospital management, political administration and international involvement are thought to be necessary for continued development. CONCLUSIONS: Survey respondents agreed on priorities in emergency care, credited the international community with development to date, and identified administrative structures and international training support as the keys to ongoing development.

The influence of demographic factors on seatbelt use by adults injured in motor vehicle crashes.

This study determined demographic factors associated with reported seatbelt use among injured adults admitted to a trauma center. A retrospective chart review was conducted including all patients admitted to a trauma center for injuries from motor vehicle crashes (MVC). E-codes (i.e. ICD-9 external cause of injury codes) were used to identify all patients injured in a MVC between January 1995 and December 1997. Age, sex, race, residence zip code (i.e. a proxy for income based on geographic location of residence), position in the vehicle, and seatbelt use were obtained from the trauma registry. Forward logistic regression was used to identify significant predictors of seatbelt use. Complete data was available for 1366 (82%) patients. Seatbelt use was reported for 45% of patients under age of 25 years, 52% of those 25-60 years, and 68% of those over 60 years. Overall, seatbelt use was reported for 45% of men and 63% of women, as well as for 56% of Caucasians (i.e. Whites) and 34% of African Americans. In addition, seatbelt use was reported for 33% of those earning less than $20,000 per year and 55% of those earning over $20,000. Finally, seatbelt use was reported for 57% of drivers and 43% of passengers. Logistic regression revealed that age, female gender, Caucasian race, natural log of income, and driver were all significant predictors of reported seatbelt use. These results show that seatbelt use was more likely to be reported for older persons, women, Caucasians, individuals with greater incomes, and drivers. Seatbelt use should be encouraged for everyone; however, young people, men, African Americans, individuals with lower incomes, and passengers should be targeted specifically.

The golden hour: scientific fact or medical "urban legend"?

The term "golden hour" is commonly used to characterize the urgent need for the care of trauma patients. This term implies that morbidity and mortality are affected if care is not instituted within the first hour after injury. This concept justifies much of our current trauma system. However, definitive references are generally not provided when this concept is discussed. It remains unclear whether objective data exist. This article discusses a detailed literature and historical record search for support of the "golden hour" concept. None is identified.

Medical communication: do our patients understand?

The objective of this study was to determine emergency department (ED) patient's understanding of common medical terms used by health care providers (HCP). Consecutive patients over 18 years of age having nonurgent conditions were recruited from the EDs of an urban and a suburban hospital between the hours of 7 a.m. and 11 p.m. Patients were asked whether six pairs of terms had the same or different meaning and scored on the number of correct answers (maximum score 6). Multiple linear regression analysis was used to assess possible relationships between test scores and age, sex, hospital site, highest education level, and predicted household income (determined from zip code). Two hundred forty-nine patients (130 men/119 women) ranging in age from 18 to 87 years old (mean = 39.4, SD = 14.9) were enrolled on the study. The mean number of correct responses was 2.8 (SD = 1.2). The percentage of patients that did not recognize analogous terms was 79% for bleeding versus hemorrhage, 78% for broken versus fractured bone, 74% for heart attack versus myocardial infarction, and 38% for stitches versus sutures. The percentage that did not recognize nonanalogous terms was 37% for diarrhea versus loose stools, and 10% for cast versus splint. Regression analysis (R2 = .13) revealed a significant positive independent relationship between test score and age (P < .024), education (P < .001), and suburban hospital site (P < .004). Predicted income had a significant relationship with test score (P < .001); however, this was no longer significant when controlled for the confounding influence of age, education and hospital site. Medical terminology is often poorly understood, especially by young, urban, poorly educated patients. Emergency health care providers should remember that even commonly used medical terminology should be carefully explained to their patients.

The lay public's expectations of prearrival instructions when dialing 9-1-1.

OBJECTIVE: To determine whether the lay public expects public safety answering points (PSAPs) to provide prearrival instructions. METHODS: Two thousand telephone numbers were randomly generated from all listed residential numbers in a county containing urban, suburban, and rural communities served by 26 enhanced 9-1-1 PSAPs. Only a minority of the PSAPs provided prearrival instructions. Research assistants made two attempts to contact an individual at each telephone number. A survey was administered to any person who answered the telephone provided the person was at least 18 years of age and gave verbal consent. The respondents were asked their age, level of education, and gender. They were also asked what number they would call for first aid or an ambulance and whether they would expect telephone instructions from the dispatcher if a close relative was choking, not breathing, bleeding, or giving birth. RESULTS: One thousand twenty-four individuals were successfully contacted; and 524 (51%) were at least 18 years of age and agreed to participate. The respondents' mean age was 50 (standard deviation 19 years). Sixty-five percent of the respondents were female; and 90% had at least a high school diploma. Only 37% had previously called 9-1-1 (nine-one-one) for an emergency. Ninety-seven percent said they would dial either 9-1-1 (85%) or 9-11 (nine-eleven) (12%) in an emergency. Seventy-six percent (95% CI: 73%-80%) expected prearrival instructions for all four medical conditions. Specifically, prearrival instructions were expected by: 88% for choking (95% CI: 85%-90%), 87% for not breathing (95% CI: 84%-90%), 89% for bleeding (95% CI: 86%-91%), and 88% for childbirth (95% CI: 86%-91%). Ninety-nine of 117 respondents (81%) served by a PSAP that did not provide prearrival instructions expected to receive phone instructions for all four emergencies. Logistic regression revealed that knowing to dial 9-1-1 or 9-11 in an emergency was the only significant predictor of prearrival instruction expectation [p < 0.03, odds ratio 3.4 (95% CI: 1.16-9.78)]. Age, gender, service by a PSAP providing prearrival instructions, and level of education were not predictive. CONCLUSION: The lay public expects prearrival instructions when calling 9-1-1, although they may not currently receive this service.

Duration of patient immobilization in the ED.

In this article we seek to determine the duration of immobilization in patients presenting to the emergency department (ED). We conducted a 10-week prospective study of a convenience sample of patients transported to a level one trauma center immobilized with a backboard and cervical collar. Total backboard time (TBT) was measured from the time the ambulance left the scene to the time the patient was removed from the backboard, while total ED backboard time (TEDBT) was measured from the time of arrival at the ED to the time of backboard removal. There were 138 patients entered in the study. Insufficient data excluded 36 patients from further analysis. TBT was available for 92 patients and averaged 63.63 (+/-45.87) minutes. Dividing patients into those who were removed from the backboard prior to radiographs (n = 85), the TBT average was 53.9 minutes (+/-30.1), whereas the average for those who had radiographs prior to removal from the backboard (n = 7) was 181.3 minutes (+/-41.6). There were 102 patients for whom TEDBT was available and averaged 46.36 (+/-44.88) minutes. Dividing patients into those who were removed from the backboard prior to radiographs (n = 95), the TEDBT average was 37.6 minutes (+/-29.6), whereas the average for those who had radiographs prior to removal from the backboard (n = 7) was 165.3 minutes (+/-49.7). Patients are left on backboards for significant periods of time even when no radiographs are taken prior to backboard removal.

Ambulance, fire, and police dispatch times compared with the atomic clock.

OBJECTIVES: To quantify any differences between the times used by public safety answering points (PSAPs) in a multijurisdictional county compared with the atomic clock and to determine whether there was consistency in any time differences. METHODS: All 25 ambulance, fire, and police PSAPs were contacted by telephone. The current time in hours, minutes, and seconds on the dispatch center's timepiece was requested. The atomic clock time was simultaneously recorded. Time differences between the reported and atomic clock times were calculated and the absolute values were used to calculate the mean difference. The procedure was repeated one week later. Consistency in time deviation was evaluated by subtracting the time differences between weeks 1 and 2 for each center. RESULTS: All 25 centers were contacted and three declined to participate. Time differences ranged from -551 to 117 seconds (mean difference: 61.2 +/- 120.3) for week 1 and -103 to 79 seconds (mean difference: 36.9 +/- 33.4) for week 2. Time deviations between weeks 1 and 2 were: 0 seconds for one center, 1 to 30 seconds for 12 centers, 31 to 60 seconds for four centers, and more than 60 seconds for five centers. CONCLUSIONS: The maximum time difference between dispatch center and atomic clock times was 551 seconds. This difference may be clinically significant for time-dependent research, quality improvement tasks, or medical legal reviews when multiple PSAPs are involved. Lack of consistency in time deviation over one week suggests systematic adjustment for these differences may not be possible.

Delay in ED arrival resulting from a remote helipad at a trauma center.

INTRODUCTION: Ground transport from a remote helipad at a trauma center may delay patient arrival in the ED and affect patient morbidity and mortality. Prehospital care providers must be aware of the magnitude of any delay when selecting the most expedient means of transport for trauma patients. This study quantifies the time required for a 0.6-mile ground transport from a remote trauma center helipad to an ED through two traffic signals along one city street. METHODS: The trauma registry was queried for all patients transported directly from the scene to the regional trauma center by helicopter between January 1993 and October 1996. Prehospital records were used to supplement missing time data; patients with incomplete data were excluded. Ground transport time was calculated by subtracting the time that the helicopter arrived at the remote helipad from the time the ambulance arrived at the ED. Mean ground transport time and standard deviation were calculated. RESULTS: Three-hundred-eighty-nine trauma patients were transported directly from the scene to the regional trauma center by helicopter. Complete data were available for 345 patients (89%). Mean ground transport time was 5.2 +/- 2.3 minutes. CONCLUSION: The need for ground ambulance transport from this remotely located trauma center helipad adds more than 5 minutes to total prehospital time. This delay in ED arrival may be significant for some patients and should be taken into account when selecting the most appropriate mechanism of patient transport and planning helipad construction.

Use of a geographic information system to determine appropriate means of trauma patient transport.

OBJECTIVE: To determine whether a geographic information system (GIS) and historical transport data can be used to create a map that identifies locations (zones) from which either ambulance or helicopter transport will result in shorter out-of-hospital times. METHODS: A retrospective, cross-sectional review of a trauma registry was conducted in a two-county region served by a single trauma center. Data were gathered for all patients transported directly to the trauma center between 1993 and 1996. Incident locations and times from first 911 contact until arrival at the trauma center (out-of-hospital time) were extracted. A GIS was used to create a reference map with all incident locations plotted and given z-coordinates corresponding to out-of-hospital time. Two contour surfaces were interpolated: one for all helicopter transports and one for all ground transports. Areas where the helicopter surface was lower than the ambulance surface were designated air zones since helicopter transport resulted in shorter out-of-hospital times. The remaining area was designated a ground zone since ambulance transport resulted in shorter out-of-hospital times. The mean out-of-hospital times were calculated for each mode of transport in both zones and were compared using a two-tailed t-test. RESULTS: An air zone was identified beginning between 5 and 16 miles from the trauma center. Mean (+/-SD) out-of-hospital time from the air zone was 50 +/- 9 minutes for helicopter transport (n = 54) and 63 +/- 14 minutes for ambulance transport (n = 140). The difference between the means was 13 minutes (p < 0.000001; 95% CI = 8.95 to 17.05). Mean out-of-hospital time from the ground zone was 68 +/-16 minutes for helicopter transport (n = 122) and 32 +/- 14 minutes for ambulance transport (n = 2,047). The difference between the means was 36 minutes (p < 0.000001; 95% CI = 33.59 to 38.41). CONCLUSIONS: A GIS and historical transport data can be used to create a map identifying locations from which either helicopter or ambulance transport will minimize out-of-hospital time. Inappropriate choice of transport mode is associated with increased out-of-hospital time.

A multi-state survey of videotaping practices for major trauma resuscitations.

The objective of this study was to determine the prevalence and problems, both perceived and actual, associated with videotaping major trauma resuscitations. A cross-sectional two-part survey of trauma centers was conducted. Part 1 determined demographic information and videotaping status. Part 2 asked trauma centers that were not doing videotaping (NVTCs) about their plans, past experience, and perceived problems. Videotaping trauma centers (VTCs) were asked about mechanics, responsibility, utilization, and problems. A total of 221 centers were surveyed; 20% VTCs, 70% NVTCs, and 10% NVTCs that had videotaped in the past (PVTC). Among VTCs, 53% reported problems with videotaping including lack of personnel (40%) and time (40%) to administer the program. Videotaping, however, was found to be an effective quality improvement tool in 95% of the VTCs. Of the NVTCs, 70% perceived problems with implementing a videotaping program; these included medicolegal (34%) and patient confidentiality (22%) concerns. Of the PVTCs, 90% stated that they had problems with videotaping including lack of staff support (33%) and lack of personnel to assist with the program (24%). In conclusion, staff participation and adequate personnel outweigh medicolegal concerns as actual videotaping problems. Videotaping is perceived to be an effective performance improvement tool.

Comparison of staples versus sutures in the repair of penetrating cardiac wounds.

BACKGROUND: Several literature reports advocate the use of skin staplers for repair of penetrating cardiac wounds during emergency thoracotomy. Our study goal was to objectively determine if stapling is a more efficient method of closure compared with suturing without compromising the strength of the repair. METHODS: This randomized, nonblinded study was conducted in a swine model. A total of four incisions, two per ventricle, were made in each animal. The 2-cm full-thickness incisions were repaired with either sutures or staples, and the time required to close each wound was recorded. After wound repair, the animals were killed. The four wounds were isolated by removing 4.0-cm strips of myocardium oriented perpendicular to the incision. Each strip was then placed on a tensile force testing machine, and the breaking strength of the sutures and staples was measured. RESULTS: The tensile force test showed that stapled and sutured wounds have equivalent mechanical strength. The mean time of closure for stapled wounds was substantially less than that for sutured wounds. CONCLUSION: In this swine model, stapling took significantly less time and had equal mechanical strength compared with suturing for repair of penetrating cardiac wounds. Stapling during emergent resuscitation may be preferable to suturing.

Wound irrigation with tap water.

OBJECTIVE: The study hypothesis was that irrigation with tap water is as efficacious as irrigation with sterile saline in removing bacteria from simple lacerations in preparation for wound closure. METHODS: The study was conducted in a laboratory rat model previously described in the literature for evaluating wound irrigation techniques. The study used a randomized, blinded crossover design using 10 animals. Two full-thickness skin lacerations were made on each animal and each wound was inoculated with standardized concentrations of a Staphylococcus aureus broth. Wounds were irrigated for 4 minutes with normal saline from a syringe or 4 minutes with tap water from a faucet. Tissue specimens were sampled from each laceration prior to and following irrigation. Bacterial counts per gram of tissue were determined for each specimen and compared pre- and postirrigation. RESULTS: Preirrigation bacterial counts were not significantly different for saline vs tap water specimens. The wounds irrigated with saline had a mean reduction in bacterial count of 54.7% (SD=+/-28%), while the wounds irrigated with tap water had a mean reduction in bacterial count of 80.6% (SD=+/-20%) (p < 0.05, 2-tailed, paired t-test). CONCLUSIONS: In this animal model, bacterial decontamination of simple lacerations was not compromised, and was actually improved using tap water irrigation. This is most likely due to the mechanical differences in the types of irrigation. In certain instances, such as with upper-extremity lacerations, tap water irrigation would likely be cheaper and less labor-intensive than irrigation with normal saline from a syringe.

The effects of neutral positioning with and without padding on spinal immobilization of healthy subjects.

OBJECTIVES: To compare the incidences and severities of pain experienced by healthy volunteers undergoing spinal immobilization in the neutral position with and without occipital padding. To compare the incidence of pain when immobilized in the neutral position with the incidence in a nonneutral position. METHODS: Thirty-nine healthy volunteers over the age of 18 years who had no acute pain or illness, were not pregnant, and had no history of back problems or surgery voluntarily participated in a prospective, randomized, crossover study conducted in a clinical laboratory setting. Appropriately sized rigid cervical collars were applied to the subjects, who were then immobilized on wooden backboards with their cervical spines maintained in the neutral position using towels (padded) or plywood (unpadded) under their occiputs. The subjects were secured to the board with straps, soft head blocks, and tape for 15 minutes to simulate a typical ambulance transport time. The straps, head blocks, and tape were removed, and the subjects remained on the board for an additional 45 minutes to simulate a typical emergency department experience. The subjects were then asked to identify the location(s) of any pain on anterior and posterior body outlines and to indicate the corresponding severity of pain on a 10-cm visual analog scale. The subjects were also asked questions about movement, respiratory symptoms, and strap discomfort in an attempt to distract them from the true focus of the study (i.e., pain). A similar survey was given to each participant to complete 24 hours later. The same subjects were immobilized with the alternate occipital material a minimum of two weeks later utilizing the same procedure. They again completed both surveys. RESULTS: Pain was reported by 76.9% of the subjects following removal from the backboard for the unpadded trial and 69.2% of the subjects following the padded trial (p < 0.45). Twenty-three percent (23.1%) of the subjects reported neck pain after the unpadded trial, while 38.5% reported neck pain after the padded trial (p < 0.07). Occipital pain was reported by 35.9% in the unpadded trial and 25.6% in the padded trial (p < 0.29). Twenty-four hours later, pain was reported by 17.9% of the subjects following the unpadded trial and 23.1% of the subjects following the padded trial (p < 0.63). Eight percent (7.7%) reported neck pain 24 hours after the and unpadded trial and 12.8% after the padded trial (p < 0.5). Occipital pain was reported by 7.7% of the subjects 24 hours after the unpadded trial and 2.6% after the padded trial (p < 0.63). This study had a power of 0.90 to detect a difference of 30% between the trials. The authors found a significantly lower incidence of pain (p < 0.01) and occipital pain (p < 0.01) in their unpadded trial compared with that reported by Chan et al., who used neither padding nor neutral positioning to immobilize subjects. CONCLUSIONS: Pain is frequently reported by healthy volunteers following spinal immobilization. Occipital padding does not appear to significantly decrease the incidence or severity of pain. Alignment of the cervical spine in the neutral position may reduce the incidence of pain, but further studies should be conducted to substantiate this observation.

Triage, transportation, and destination decisions by out-of-hospital emergency care providers.

INTRODUCTION: The effectiveness of a tiered emergency medical services system often hinges upon the ability of initial care providers with little or no formal training to identify emergent patient needs and determine the best means to meet those needs. OBJECTIVES: To determine if out-of-hospital emergency care providers consistently make appropriate triage, transportation, and destination decisions; and to determine if experience and training have an effect on these decisions. METHODS: A survey consisting of 14 patient-care scenarios was administered to certified and non-certified out-of-hospital emergency-care providers (n = 311) from 20 randomly selected EMS agencies. These agencies were part of EMS systems that utilize one, two, and three tiered responses by ambulance and fire-based commercial, municipal, and volunteer agencies. Participants were asked to select the most appropriate mode of transport and destination facility using the assumption that they had responded to each scenario in a basic life support ambulance. Answers included transporting the patient to various receiving facilities or requesting a more advanced-level unit to respond to the scene. Transport times to receiving facilities and estimated times of arrival for advanced-level units were provided with each choice. Eight emergency physicians unanimously had agreed upon the most appropriate answer for each scenario. A two-tailed t-test was used to compare the scores of the certified and non-certified groups; and Spearman's Correlation Coefficients were used to test the effects of experience and training. RESULTS: Non-certified providers (n = 108) had a mean score of 32.6% or 4.6 (SD = 1.84) correct answers; certified providers (n = 203) had a mean score of 41.1% or 5.76 (SD = 2.12) correct answers (p < 0.000001). Spearman's Correlation Coefficients were: 1) individual provider level--(0.3978); 2) agency provider level--(0.2741); 3) hours worked per week--(0.2505); 4) years in EMS--(-0.0821); 5) commercial or volunteer provider--(0.2398); 6) agency call volume--(0.2012); 7) agency location--(0.0685), and 8) transporting versus non-transporting agency--(0.2523). CONCLUSIONS: A need exists for further education of out-of-hospital emergency care providers with respect to triage, transportation, and destination decisions. Provider experience and level of certification do not appear to affect these critical patient-care decisions.

The effect of injection speed on the pain of lidocaine infiltration.

OBJECTIVE: To determine whether reducing the speed of injection is effective in reducing injection pain for buffered and unbuffered lidocaine solutions. METHODS: A prospective, single-blind, randomized, crossover, laboratory study was performed. Adult volunteers were recruited from ED staff at an urban teaching hospital to serve as subjects. Twenty-nine subjects each received 4 1-mL injections into the dorsum of the hands. Each subject received fast and slow injections of buffered and unbuffered lidocaine. Subjects rated the pain of each injection on a 100-mm visual analog scale (VAS). Mean pain scores for each intervention were compared using analysis of variance. RESULTS: The mean pain VAS score for fast injection of buffered lidocaine was 14.1 mm. For slow buffered injection, the mean pain score was 11.4 mm (p = 0.98). For unbuffered lidocaine, the means were 28.7 mm for fast injection and 22.2 mm for slow injection (p = 0.40). CONCLUSIONS: Reducing injection speed did not produce a statistically significant change in injection pain for either buffered or unbuffered solutions.

A multisite survey of factors contributing to medically unnecessary ambulance transports.

OBJECTIVES: To determine the social and demographic factors associated with medically unnecessary ambulance utilization, and to determine the willingness of patients to use alternate modes of transportation to the ED. METHODS: A multisite prospective survey was conducted of all patients arriving by ambulance to 1 suburban and 4 urban EDs in New York State during a 1-week period. RESULTS: For 626 patients surveyed, 71 (11.3%) transports were judged medically unnecessary by the receiving emergency physicians using preestablished guidelines. The patient's type of medical insurance and age were significant predictors of unnecessary ambulance transport (stepwise forward logistic regression analysis). Of the 71 patients whose ambulance transports were deemed medically unnecessary, 42 (59%) were Medicaid recipients and 53 (74%) were < 40 years of age. The most common reason for using ambulance transport was lack of an alternate mode of transportation (38.5%), although 82% would have been willing to use an alternate mode of transportation if it had been available. Of those who had medically unnecessary ambulance use, 30% indicated that they would not pay for the ambulance service if billed and 50% believed the cost of their ambulance transports was < $100. More than 85% of the patients whose ambulance transports were deemed medically unnecessary were unemployed; and nearly 85% reported a net annual income of < $20,000. While 33% had a primary care provider, only 22% had attempted to contact their doctors before requesting an ambulance. CONCLUSIONS: Patient age < 40 years and Medicaid coverage were associated with medically unnecessary ambulance use. Those patients for whom ambulance use was considered medically unnecessary commonly had no alternate means of transportation. Providing alternate means of unscheduled transportation may reduce the incidence of unnecessary ambulance use.