Impact of the San Diego county firestorm on emergency medical services.

BACKGROUND: In October 2003, San Diego County, California, USA, experienced the worst firestorm in recent history. During the firestorm, public health leaders implemented multiple initiatives to reduce its impact on community health using health updates and news briefings. This study assessed the impact of patients with fire-related complaints on the emergency medical services (EMS) system during and after the firestorm. METHODS: A retrospective review of a prehospital database was performed for all patients who were evaluated by advanced life support (ALS) ambulance personnel after calling the 9-1-1 emergency phone system for direct, fire-related complaints from 19 October 2003 through 30 November 2003 in San Diego County. The study location has an urban, suburban, rural, and remote resident population of approximately three million and covers 4,300 square miles (2,050 km2). The prehospital patient database was searched for all patients with a complaint that was related directly to the fires. Charts were abstracted for data, including demographics, medical issues, treatments, and disposition status. RESULTS: During the firestorm, fire consumed > 380,000 acres (> 938,980 hectares), including 2,454 residences and 785 outbuildings, and resulted in a total of 16 fatalities. Advanced life support providers evaluated 138 patients for fire-related complaints. The majority of calls were for acute respiratory complaints. Other complaints included burns, trauma associated with evacuation or firefighting, eye injuries, and dehydration. A total of 78% of the injuries were mild. Twenty percent of the victims were firefighters, most with respiratory complaints, eye injuries, or injuries related to trauma. A total of 76% of the patients were transported to the hospital, while 10% signed out against medical advice. CONCLUSION: Although the firestorm had the potential to significantly impact EMS, pre-emptive actions resulted in minimal impact to emergency departments and the prehospital system. However, during the event, there were a number of lessons learned that can be used in future events.

Evaluation of pediatric glucose monitoring and hypoglycemic therapy in the field.

As specific indications for glucose monitoring in pediatric patients are not standardized, we sought to evaluate our EMS system regarding the use of this test, so that objective data can be used for prehospital provider education. We performed a 5-year electronic search of prehospital records to assess pediatric patients who had glucose monitoring performed, with subgroup analysis on those requiring therapy. We found that 6018 pediatric patients received glucose monitoring with the most common chief complaints for testing including: seizure, "other medical," trauma head/neck, and OD/poisoning. Of these, 270 (4.5%) required therapy for hypoglycemia with an additional 100 (1.7%) patients receiving treatment without use of the paramedic's monitor. Age breakdowns for therapy were as follows: 0-4 years, 44 (11.9%); 5-9, 36 (9.7%); 10-14, 58 (15.7%); 15-19, 232 (62.7%). In the prehospital setting, the need to treat hypoglycemia in pediatric patients is infrequent. The chief complaints associated with the highest frequencies of hypoglycemia are seizures and altered neurologic status.

Community trial to decrease ambulance diversion hours: the San Diego county patient destination trial.

STUDY OBJECTIVE: Emergency department (ED) ambulance diversion is a major issue in many communities. When patients do not reach requested facilities, challenges in care are compounded by lack of available medical records and delays in transferring admitted patients back to the originally requested facility. We seek to evaluate a community intervention to reduce ambulance diversion. METHODS: This was a community intervention in a county of 2.8 million individuals. Ambulance diversion guidelines were revised for all ambulance agencies and EDs. Participation by EDs was voluntary, and main outcome measures, which included ambulance transports, ambulance diversions, and bypass hours, were compared for the pretrial, trial, and posttrial periods. RESULTS: A total of 235,766 patients were transported to an ED by advanced life support ambulance during the 2-year study period. There was a significant decrease in the number of patients who did not reach the requested facility because of ambulance diversion for the trial period (n=322) and posttrial period (n=449) compared with the pretrial period (n=1,320; -998 diverted patients per month [95% confidence interval (CI) -1,162 to -833 patients] and -871 diverted patients per month [95% CI -963 to -780 patients], respectively). There was also a significant decrease in average monthly hours on diversion for the trial period (n=1,079) and posttrial period (n=1,774) compared with the pretrial period (n=4,007; -2,928 hours on bypass [95% CI -3,936 to -1,919 hours on bypass] and -2,232 hours on bypass [95% CI -3,620 to -2,235 hours on bypass], respectively). CONCLUSION: A voluntary community-wide approach to reducing hospital ED diversion and getting more ambulance patients to requested facilities was effective.

9-1-1 responses for shopping cart and stroller injuries.

BACKGROUND: On average, 24,000 children a year are treated in the emergency departments (EDs) for shopping cart injuries, with over 650 children a year requiring hospital admission. The authors sought to evaluate the incidence and outcomes of children in the community evaluated by paramedics because they were injured in shopping cart or stroller-related incidences. METHODS: Retrospective design in which prehospital patients records were searched for all patients under 14 years old who were injured in an incident involving a shopping cart or stroller and were responded to by paramedics. Records were reviewed for demographics, injury type, and disposition. RESULTS: During the 3 1/2 year study period, a total of 241 cases were identified with 120 being shopping cart-related and 121 stroller-related. The most frequent ages for stroller injuries were 0 to 6 months and for shopping cart injuries was one year of age. Falls were the most common mechanism of injury, 70.3% for shopping carts and 47.5% for strollers, with head injuries accounting for 53% and 59% of the primary injuries in each group. An additional 12% and 18% suffered primary facial injuries. 77% of patients were transported by paramedics to an ED for evaluation, with 19% of parents signing out against medical advice. 8.2% were admitted to the hospital and there were no deaths. CONCLUSIONS: Shopping cart and stroller-related injuries are a common mechanism of injury for pediatric patients responded to by paramedics. This is an area which continued parental education is needed.

Adult foreign body airway obstruction in the prehospital setting.

BACKGROUND: Although the treatment of foreign body airway obstruction in adults has been well studied, few data exist on the characterization of prehospital experiences. OBJECTIVES: To describe the frequency, etiologies, and treatments of foreign body airway obstruction in adults in the prehospital setting and to discuss the relative efficacies of treatments and presenting factors that predict overall patient outcome. METHODS: A San Diego County prehospital database was retrospectively reviewed for all adult patients over a 17-month period with data extracted on demographic characteristics, incident outcome, patient disposition, item involved in obstruction, location of episode, initial vital signs, initial level of consciousness, pertinent medical history, treatments initiated by bystanders and paramedics, and response to those treatments. RESULTS: During the study period, there were 513 cases of foreign body airway obstruction in adults. Of these, 17 (3.3%) died. The mean age was 65.0 years, with increasing age correlating with worse outcome. The item causing obstruction varied widely, with medications and meat being the most common items. The Heimlich maneuver was the most commonly used intervention, with an 86.5% rate of patient improvement. Magill forceps proved useful for three cases refractory to the Heimlich maneuver. Presenting vital sign aberrations, particularly with respiratory rate, correlated with poorer patient outcome. CONCLUSIONS: Foreign body airway obstruction represents a true emergency in adults, with a 3.3% mortality rate in the current study. The Heimlich maneuver was used frequently and with good success.

Paramedic self-reported medication errors.

BACKGROUND: Continuing quality improvement (CQI) reviews reflect that medication administration errors occur in the prehospital setting. These include errors involving dose, medication, route, concentration, and treatment. METHODS: A survey was given to paramedics in San Diego County. The survey tool was established on the basis of previous literature reviews and questions developed with previous CQI data. RESULTS: A total of 352 surveys were returned, with the paramedics reporting a mean of 8.5 years of field experience. They work an average of 11.0 shifts/month with an average of 25.4 hours and 6.7 calls/shift. Thirty-two (9.1%) responding paramedics reported committing a medication error in the last 12 months. Types of errors included dose-related errors (63%), protocol errors (33%), wrong route errors (21%), and wrong medication errors (4%). Issues identified in contributing to the errors include failure to triple check, infrequent use of the medication, dosage calculation error, and incorrect dosage given. Fatigue, training, and equipment setup of the drug box were not listed as any of the contributing factors. The majority of these errors were self-reported to their CQI representative (79.1%), with 8.3% being reported by the base hospital radio nurse, 8.3% found upon chart review, and 4.2% noted by paramedic during call but never reported. CONCLUSIONS: Nine percent of paramedics responding to an anonymous survey report medication errors in the last 12 months, with 4% of these errors never having been reported in the CQI process. Additional safeguards must continue to be implemented to decrease the incidence of medication errors.

Paramedic self-reported medication errors.

BACKGROUND: Continuing quality improvement (CQI) reviews reflect that medication administration errors occur in the prehospital setting. These include errors involving dose, medication, route, concentration, and treatment. METHODS: A survey was given to paramedics in San Diego County. The survey tool was established based on previous literature reviews and questions developed based on previous CQI data. RESULTS: A total of 352 surveys were returned, with the paramedics reporting a mean of 8.5 years of field experience. They work an average of 11.0 shifts/month with an average shift length of 25.4 hours and 6.7 calls/shift. Thirty-two responding paramedics (9.1%) reported committing a medication error in the past 12 months. Types of errors included dose-related errors (63%), protocol errors (33%), wrong route errors (21%), and wrong medication errors (4%). Issues identified in contributing to the errors include failure to triple check, infrequent use of the medication, dosage calculation error, and incorrect dosage given. Fatigue, training, and equipment setup of the drug box were not listed as any of the contributing factors. The majority of these errors were self-reported to their CQI representative (79.1%), with 8.3% reported by the base hospital radio nurse, 8.3% found on chart review, and 4.2% noted by the paramedic during the call but never reported. CONCLUSIONS: Nine percent of paramedics responding to an anonymous survey reported medication errors in the past 12 months, with 4% of these errors never having been reported in the CQI process. Additional safeguards must continue to be implemented to decrease the incidence of medication errors.

Airway obstruction in children aged less than 5 years: the prehospital experience.

BACKGROUND: Treatment of choking in children has been well studied, but few data are available on the various causes of the choking episodes in the pediatric population. OBJECTIVES: To assess frequency and to stratify etiologies of children less than 5 years of age who had a 911 advanced life support (ALS) ambulance response for airway obstruction. METHODS: A prehospital database was searched and information was collected defining type of obstruction, age of the child, parents' action, paramedic treatment, and incident outcome. RESULTS: There were 182 patients with airway obstruction under 5 years of age, of whom 99 (55%) were less than 1 year old. Liquid obstructions (i.e., formula, juices) were most common in the youngest children, whereas solid food and nonfood solid obstructions were most prevalent in children over 1 year old. One hundred seven (59%) of these obstructions resolved before paramedic arrival (69% of liquid obstructions, 72% of food, and 36% of nonfood solid objects). Interventions used by parents included bulb suction (3%), finger sweeps (6%), Heimlich maneuver (3%), and back blows (12%). Paramedics used ALS skills in only three cases. After paramedic evaluation, 47% of parents refused transport against medical advice (AMA). CONCLUSIONS: Although most episodes of pediatric airway obstruction will have been resolved by the time of paramedic arrival, age-specific and item-specific treatment skills need to be reinforced with parents and prehospital providers.