Maladaptive Cognitions in EMS Professionals as a Function of the COVID-19 Pandemic.

INTRODUCTION: The coronavirus disease pandemic has pro-foundly affected emergency medical services (EMS) profes-sionals, but the emotional impact is unknown. METHODS: This was a cross-sectional survey of North Carolina EMS profes-sionals from April to May 2021. EMS professionals on an ac-tive roster were included. With pandemic-related perceptions, the 15-item Posttraumatic Maladaptive Beliefs Scale (PMBS) was used to quantify the severity of maladaptive cognition. Significant univariate variables were used to create a hier-archical linear regression to assess the potential impact of pandemic-related factors on maladaptive cognition scores. RESULTS: Overall, 811 respondents were included; of those, 33.3% were female, 6.7% were minorities, and 3.2% were Latinx; the mean age was 41.11 ± 12.42 years. Mean scores on the PMBS were 37.12 ± 13.06 and ranged from 15 to 93. PMBS scores were 4.62, 3.57, and 3.99 points higher, respec-tively, in those with increased anxiety, those who trusted their sources of information, and those who reported to work de-spite being symptomatic. Pandemic-specific factors accounted for 10.6% of the variance in PMBS total scores (ΔR2 = 0.106, ΔF[9, 792]; p < .001). Psychopathological factors accounted for an additional 4.7% of the variance in PMBS total scores (ΔR2 = 0.047, ΔF[3, 789]; p < .001). CONCLUSION: Given that 10.6% of the difference in PMBS scores can be explained by pandemic- related factors, maladaptive cognitions in EMS are a considerable concern and could lead to the development of significant psychopathology post-trauma.

Secondary trauma response in emergency services systems (STRESS) project: quantifying and predicting vicarious trauma in emergency medical services personnel.

Introduction: There is a lack of literature exploring vicarious trauma (VT) in emergency medical services (EMS) personnel. VT is emotional countertransference that occurs between the clinician and patient. The presence of trauma- or stressor-related disorders could be a factor in the rising suicide rate in these clinicians. Methods: This was a cross-sectional statewide study of American EMS personnel, using one-stage area sampling. Nine EMS agencies were selected to participate based on geographic area, who then provided data about annual call volume and mix. The Impact of Event Scale-Revised was used to quantify VT. Univariate analyses used chi-square and ANOVA to evaluate the relationship between VT and various psychosocial and demographic characteristics. Factors significant in the univariate analyses were included in a logistic regression to determine predictors of VT while controlling for potential confounders. Results: A total of 691 respondents participated in the study, of which 44.4% were female and 12.3% were minorities. Overall, 40.9% had VT. Of those, 52.5% scored high enough to potentially illicit immune system modulation. Compared to those without VT, more than four times as many EMS professionals with VT self-reported as currently in counselling (9.2% v. 2.2%; p < 0.01). Approximately one in four EMS professionals (24.0%) had considered suicide, while nearly half (45.0%) knew an EMS provider who had died by suicide. There were multiple predictors of VT, including female sex (odds ratio [OR] 1.55; p = 0.02) and childhood exposure to emotional neglect (OR 2.28; p < 0.01) or domestic violence (OR 1.91; p = 0.05). Those with other stress syndromes, such as burnout or compassion fatigue, were 2.1 and 4.3 times more likely to have VT, respectively. Conclusions: Among study participants, 41% suffered from VT, and 24% had considered suicide. As a largely understudied phenomenon in EMS professionals, additional research on VT should focus on causality and the mitigation of sentinel events experienced in the workplace.

Estimated Cost-Effectiveness of Implementing a Statewide Tranexamic Acid Protocol for the Management of Suspected Hemorrhage in the Prehospital Setting.

INTRODUCTION: Hemorrhage is responsible for up to 40% of all traumatic deaths. The seminal CRASH-2 trial demonstrated a reduction in overall mortality following early tranexamic acid (TXA) administration to bleeding trauma patients. Following publication of the trial results, TXA has been incorporated into many prehospital trauma protocols. However, the cost-effectiveness of widespread TXA adoption by EMS is unknown. OBJECTIVE: To estimate the cost-effectiveness of statewide implementation of a TXA protocol. METHODS: The North Carolina Trauma Registry was queried to identify potential TXA patients using the a priori criteria of age ≥18 years, suspected hemorrhage, penetrating or blunt injury, and prehospital blood pressure <90 mmHg and heart rate >110 bpm. Using life tables adjusted for age, sex, and race, and the absolute risk reductions in mortality with early TXA administration reported in the literature, the life-years gained were calculated for each potential life saved. Implementation costs consisted of initial stocking, training, and replacement costs. Projected reduction in hospitalization costs were based on estimates reported in the literature. Economic analyses were conducted from societal and state EMS system perspectives. To assess the robustness of the model, univariate and bivariate sensitivity analyses were performed on selected input variables. RESULTS: Based on the TXA inclusionary criteria, 159 patients could potentially receive TXA per year. In the base-case scenario with a projected absolute mortality reduction of 3%, an additional 4.8 lives per year in NC would be saved, with an estimated 191 total life-years gained. The statewide implementation and operation cost was $305,122 in year 1, and continued operating costs were $6,042 in years 2 and 3, yielding a cost per life saved of $63,967 in year 1 and $1,267 in years 2 and 3. The cost per life-year gained was $1,595 in year 1 and $32 in years 2 and 3. Annual hospitalization costs would potentially be reduced by $1,828,072. CONCLUSION: Previous studies have demonstrated the clinical effectiveness of early TXA administration to patients with hemorrhage. Our modeling of the financial implications and clinical benefits of implementing a statewide TXA protocol suggests that prehospital TXA is a cost-effective treatment.

Secondary Traumatic Stress in Emergency Services Systems Project: Quantifying the Effect of Personal Trauma Profiles on Lifetime Prevalence of Suicidality in Emergency Medical Services Personnel.

OBJECTIVE: Within the last 20 years, there has been a 500% increase in public safety suicides, the exact cause of which is unknown. METHODS: This was a cross-sectional survey of emergency medical services (EMS) personnel. Nine EMS agencies were selected to participate based on geography and population. The survey assessed sociodemographic, occupational, and military factors. Childhood adversity and traumatic experiences were evaluated using the Adverse Childhood Experiences Questionnaire and the Life Events Checklist for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, respectively. Using factors significant in univariate analyses, a logistic regression was conducted to determine predictors of suicidality while controlling for potential confounders. RESULTS: A total of 681 EMS providers participated; 56.1% were male, 12.6% were minorities, and 72.8% were paramedics. Nearly a quarter (24.4%) had considered suicide. Approximately twice as many had received counseling for a stress-related event, and 1.5 times as many identified as currently in counseling. Indigenous populations were 4.76 times more likely to have suicidality (odds ratio [OR] = 4.76; 95% confidence interval [CI], 1.22-18.62). Suicidality was 97% more likely in EMS professionals with prior military service (OR = 1.97; 95% CI, 1.08-3.57) and 2.22 times more likely in sexual minorities (OR = 2.22; 95% CI, 1.16-4.25). Emotional abuse (OR = 1.86; 95% CI, 1.08-3.21) and burnout (OR = 2.88; 95% CI, 1.78-4.66) were also predictive. CONCLUSIONS: Suicidality is an indisputable concern for the EMS profession and represents a multifaceted issue that must be addressed.

Predictors of COVID-19 Vaccination Among EMS Personnel.

INTRODUCTION: Unvaccinated emergency medical services (EMS) personnel are at increased risk of contracting coronavirus disease 2019 (COVID-19) and potentially transmitting the virus to their families, coworkers, and patients. Effective vaccines for the severe acute respiratory syndrome coronavirus 2 virus exist; however, vaccination rates among EMS professionals remain largely unknown. Consequently, we sought to document vaccination rates of EMS professionals and identify predictors of vaccination uptake. METHODS: We conducted a cross-sectional survey of North Carolina EMS professionals after the COVID-19 vaccines were widely available. The survey assessed vaccination status as well as beliefs regarding COVID-19 illness and vaccine effectiveness. Prediction of vaccine uptake was modeled using logistic regression. RESULTS: A total of 860 EMS professionals completed the survey, of whom 74.7% reported receiving the COVID-19 vaccination. Most respondents believed that COVID-19 is a serious threat to the population, that they are personally at higher risk of infection, that vaccine side effects are outweighed by illness prevention, and the vaccine is safe and effective. Despite this, only 18.7% supported mandatory vaccination for EMS professionals. Statistically significant differences were observed between the vaccinated and unvaccinated groups regarding vaccine safety and effectiveness, recall of employer vaccine recommendation, perceived risk of infection, degree of threat to the population, and trust in government to take actions to limit the spread of disease. Unvaccinated respondents cited reasons such as belief in personal health and natural immunity as protectors against infection, concerns about vaccine safety and effectiveness, inadequate vaccine knowledge, and lack of an employer mandate for declining the vaccine. Predictors of vaccination included belief in vaccine safety (odds ratio [OR] 5.5, P=<0.001) and effectiveness (OR 4.6, P=<0.001); importance of vaccination to protect patients (OR 15.5, P=<0.001); perceived personal risk of infection (OR 1.8, P=0.04); previous receipt of influenza vaccine (OR 2.5, P=0.003); and sufficient knowledge to make an informed decision about vaccination (OR 2.4, P=0.024). CONCLUSION: In this survey of EMS professionals, over a quarter remained unvaccinated for COVID-19. Given the identified predictors of vaccine acceptance, EMS systems should focus on countering misinformation through employee educational campaigns as well as on developing policies regarding workforce immunization requirements.

Secondary Traumatic Stress in Emergency Services Systems (STRESS) Project: Quantifying and Predicting Compassion Fatigue in Emergency Medical Services Personnel.

Introduction: Compassion fatigue (CF) is defined as the acute or gradual loss of benevolence that occurs after exposure to critical incident stress. Colloquially referred to as the "cost of caring," CF can affect an individual's future response to stressful situations and is unhealthy for caregivers.Objective: To identify the prevalence and predictors of CF in EMS professionals.Methods: This was a cross-sectional survey of EMS personnel using one-stage area sampling. Nine EMS agencies recruited based on location and geographic region provided data on service area and call mix. Respondents were surveyed in-person during monthly training. The survey evaluated the relationship between CF and psychosocial factors using the Professional Quality of Life Scale (ProQOL). Parametric and non-parametric tests were used where appropriate for the univariate analysis. Those factors significant in the univariate analysis were included in the multivariable analysis. A logistic regression was conducted to determine predictors of CF while controlling for potential confounders.Results: A total of 686 EMS personnel completed the survey. Altogether, 48% had CF, of which 50.8% were male and 14% were minorities. Compared to those without CF, more than 4 times as many respondents with CF (n = 28[8.6%] v. 7[2.0%]) self-reported as currently in counseling and over a third (n = 109[33.1%]) had considered suicide. Irrespective of the presence of CF, one in two knew another EMS professional who had completed suicide. African-American EMS professionals were 3 times more likely to have CF (OR:3.1;p = 0.009). Mean scores on the ProQOL CF subscale were 10 points higher in those with CF compared to those without (27.1[±4.34] v. 17.04[±2.9]). EMS personnel were 48% more likely to have CF if they knew an EMS provider who completed suicide (p = 0.047). Additionally, those with concomitant traumatic stress syndromes, such as vicarious trauma and burnout, were 4.61 and 3.35 times more likely to have CF, respectively.Conclusions: CF is a considerable concern for EMS professionals and there are several modifiable factors that may reduce the prevalence of this cumulative stress syndrome. Additional research should focus on causal factors and mitigation strategies, as well as the individual and agency impact of CF on the prehospital work environment.

Estimated Cost Effectiveness of Influenza Vaccination for Emergency Medical Services Professionals.

INTRODUCTION: Because of their frequent contact with compromised patients, vaccination against influenza is recommended for all healthcare workers. Recent studies suggest that vaccination decreases influenza transmission to patients and reduces worker illness and absenteeism. However, few emergency medical services (EMS) agencies provide annual vaccination, and the vaccination rate among EMS personnel remains low. Reticence among EMS agencies to provide influenza vaccination to their employees may be due in part to the unknown fiscal consequences of implementing a vaccination program. In this study, we sought to estimate the cost effectiveness of an employer-provided influenza vaccination program for EMS personnel. METHODS: Using data from published reports on influenza vaccination, we developed a cost-effectiveness model of vaccination for a hypothesized EMS system of 100 employees. Model inputs included vaccination costs, vaccination rate, infection rate, costs associated with absenteeism, lost productivity due to working while ill (presenteeism), and medical care for treating illness. To assess the robustness of the model we performed a series of sensitivity analyses on the input variables. RESULTS: The proportion of employees contracting influenza or influenza-like illness (ILI) was estimated at 19% among vaccinated employees compared to 26% among non-vaccinated employees. The costs of the vaccine, consumables, and employee time for vaccination totaled $44.19 per vaccinated employee, with a total system cost of $4,419. Compared to no vaccination, a mandatory vaccination program would save $20,745 in lost productivity and medical costs, or $16,325 in net savings after accounting for vaccination costs. The savings were 3.7 times the cost of the vaccination program and were derived from avoided absenteeism ($7,988), avoided presenteeism productivity losses ($10,303), and avoided medical costs of treating employees with influenza/ILI ($2,454). Through sensitivity analyses the model was verified to be robust across a wide range of input variable assumptions. The net monetary benefits were positive across all ranges of input assumptions, but cost savings were most sensitive to the vaccination uptake rate, ILI rate, and presenteeism productivity losses. CONCLUSION: This cost-effectiveness analysis suggests that an employer-provided influenza vaccination program is a financially favorable strategy for reducing costs associated with influenza/ILI employee absenteeism, presenteeism, and medical care.

Secondary Traumatic Stress in Emergency Services Systems (STRESS) Project: Quantifying Personal Trauma Profiles for Secondary Stress Syndromes in Emergency Medical Services Personnel With Prior Military Service.

BACKGROUND: EMS personnel are often exposed to traumatic material during their duties. It is unknown how prior military experience affects the presence of stress in EMS personnel. METHODS: This was a prospective cross-sectional study. Nine EMS agencies provided data on call mix, while individuals were recruited during training evolutions. The survey evaluated sociodemographic factors and the relationship between childhood trauma and previous military service using the Adverse Childhood Experiences questionnaire, Life Events Checklist DSM-5, and Military History Questionnaire. Descriptive statistics calculated personal trauma profiles, comparing civilian EMS personnel to those with prior service. Hierarchical linear regression assessed the predictive utility of military history to scores on the Impact of Events Scale-Revised. RESULTS: A total of 765 EMS personnel participated in the study; 52.8% were male, 11.4% were minorities, and 11.6% had prior military service. A total of 64.4% of civilian EMS providers had any stress syndrome, while that number was 71.8% in those with prior military service. Hierarchical linear regression identified that years of service and the performance of combat patrols or other dangerous duty accounted for a unique criterion variance in the regression model. CONCLUSIONS: Prior military service or combat deployments alone do not contribute to the presence of stress syndromes. However, performance of combat patrols or other dangerous duties while deployed was a contributing factor. These results must be interpreted holistically, as other factors contribute to the presence of vicarious trauma (VT) in EMS personnel who are also veterans.

Predictive Utility of End-Tidal Carbon Dioxide on Defibrillation Success in Out-of-Hospital Cardiac Arrest.

INTRODUCTION: The likelihood of survival from ventricular fibrillation (VF) declines 7%-10% per minute until successful defibrillation. When VF duration is prolonged, immediate defibrillation of the ischemic myocardium is less likely to result in ROSC, and repeated unsuccessful defibrillations are associated with post-resuscitation myocardial dysfunction. Thus, the timing of defibrillation should be based upon the probability of shock success-a function of VF duration. Unfortunately, VF duration is often unknown in out-of-hospital cardiac arrest (OHCA) and a better predictor of shock success is needed. OBJECTIVE: To assess the ability of end-tidal carbon dioxide (EtCO2) to predict successful defibrillation in OHCA. METHODS: This retrospective study included adult patients among four EMS systems who experienced non-traumatic OHCA from August, 2015-July, 2017 and received one or more defibrillations. First and succedent shocks were analyzed separately. First shocks represented EMS-attempted defibrillation of patients who had not received a prior AED shock, whereas succedent shocks included all shocks subsequent to the first. Logistic regression provided odds ratios (OR) for first shocks resulting in ROSC, while a generalized estimating equation was used to analyze succedent shocks. RESULTS: Among 324 patients, 869 shocks were delivered by EMS (153 first and 716 succedent shocks). Layperson CPR was performed in 48.1% of cases and 21.6% received an AED shock before EMS arrival. First defibrillation ROSC was more likely with layperson CPR (OR = 4.41;p = 0.01) and increasing EtCO2 (OR = 1.03/mmHg;p = 0.01). No other variables were statistically significant. Notably, only one patient with EtCO2 < 20 mmHg was successfully defibrillated on the first shock. The probability of ROSC was higher with increasing values of EtCO2 when layperson CPR was provided, yet remained relatively unchanged across all values of EtCO2 ≥ 20 mmHg without layperson CPR. The optimal threshold first shock EtCO2 was 27 and 32 mmHg for those with/without layperson CPR, respectively. EtCO2 was not a predictor of ROSC for succedent shocks. CONCLUSIONS: An optimal defibrillation threshold EtCO2 of 27 and 32 mmHg was observed for patients with and without layperson CPR, respectively. Further studies are warranted to verify these results and to evaluate the clinical effect of delaying defibrillation in favor of chest compressions until these values are attained.

The attrition condition: use of a preparatory course to reduce EMT course attrition and improve performance on North Carolina certification exams.

INTRODUCTION: A growing concern in emergency medical services (EMS) education is student attrition. Perchance, there is a population of nonmatriculate students lacking prerequisite academic skills or who are otherwise ill prepared for the unique requirements of the EMS profession. Consequently, addressing these issues could promote academic and occupational preparedness, thereby reducing emergency medical technician (EMT) course attrition. OBJECTIVE: To measure the impact of a preparatory course designed to address academic and psychosocial skills affecting EMT course completion. METHODS: We conducted a retrospective analysis of a 24-hour preparatory course using a before-and-after nonexperimental design. The course included the EMT preparatory curriculum, program orientation, work-force-preparedness skills, and an academic skills assessment. All students who were enrolled in an EMT course at a single study site between July 2008 and December 2011 were included. Chi-square analysis was performed on attrition categories defined by CoAEMSP (Academic, Disciplinary, Attendance, Health, Financial, Personal, Never Attended) and state exam categories (Airway, Medical, Trauma, Operations, Pediatrics, Preparatory, Assessment). A logistic regression model calculated the odds ratio (OR) of course completion as a function of preparatory course completion while controlling for demography. RESULTS: The historical control group consisted of 117 (58.5%) students enrolled prior to implementation of the preparatory course, while the remaining 83 (41.5%) students in the intervention group completed the course. Overall attrition was 115 (57.5%) students, with lower rates observed in the intervention group (32.5 vs. 75.2%, p < 0.01). Among noncompleters, the majority originated from the control groups in attrition categories of Academic (4.8 vs. 39.3%, p < 0.01) and Never Attended (1.2 vs. 14.5%, p < 0.01). Students who took the preparatory course were more likely to achieve course completion (OR = 5.17, p < 0.01). The use of the preparatory course produced a higher first-time test-taker pass rate despite showing little difference in individual categories. CONCLUSIONS: Students who participated in an EMS preparatory course were 5 times more likely to achieve course completion and perform higher on most portions of the state exam; and the proportion of students that enrolled but never attended an EMT course was reduced. Unlike prior studies, we did not observe a paradoxical increase in other attrition categories after addressing academic preparedness. These findings may prove useful for EMS educators tasked with program planning.

Probability of a shockable presenting rhythm as a function of EMS response time.

INTRODUCTION: Survival from cardiac arrest is associated with having a shockable presenting rhythm (VF/pulseless VT) upon EMS arrival. A concern is that several studies have reported a decline in the incidence of VF/PVT over the past few decades. One plausible explanation is that contemporary cardiovascular therapies, such as increased use of statin and beta blocker drugs, may shorten the duration of VF/PVT after arrest. As a result, EMS response time would become an increasingly important factor in the likelihood of a shockable presenting rhythm, and consequently, cardiac arrest survival. OBJECTIVE: To develop a model describing the likelihood of shockable presenting rhythm as a function of EMS response time. METHODS: We conducted a retrospective observational study of cardiac arrest using the North Carolina Prehospital Care Reporting System (PreMIS). Inclusionary criteria consisted of adult patients suffering nontraumatic cardiac arrests witnessed by a layperson between January 1 and June 30, 2012. Patients defibrillated prior to EMS arrival were excluded. Chi-square and t-tests were used to analyze the relationship between shockable presenting rhythm and patient age, gender, and race; response time measured as elapsed minutes between 9-1-1 call receipt and scene arrival; and bystander CPR. Logistic regression was used to calculate the adjusted odds ratio (OR) of shockable presenting rhythm as a function of response time while controlling for statistically significant covariates. RESULTS: A total of 599 patients met inclusion criteria. Overall, VF/PVT was observed in 159 patients (26.5%). VF/PVT was less likely with increasing EMS response time (OR 0.92, 95% CI = 0.87-0.97, p < 0.01) and age (OR 0.98, 95% CI = 0.97-0.99, p < 0.01), while males (OR 1.98, 95% CI = 1.29-3.03, p < 0.01) and Caucasians (OR 1.86, 95% CI = 1.17-2.95, p < 0.01) were more likely to have shockable presenting rhythm. Bystander CPR was not associated with shockable presenting rhythm, although EMS response time was longer among patients with bystander CPR compared to those without (9.83 vs. 8.83 minutes, p < 0.01). CONCLUSIONS: We found that for every one minute of added ambulance response time, the odds of shockable presenting rhythm declined by 8%. This information could prove useful for EMS managers tasked with developing EMS system response strategies for cardiac arrest management.