Needle Thoracostomy in the Prehospital Setting: A Retrospective Observational Study.

BACKGROUND: The use of needle thoracostomy (NT) is a common prehospital intervention for patients in extremis or cardiac arrest due to trauma; however, controversy surrounds its use. The purpose of this study is to compare outcomes, effectiveness, and complications of NT in an Emergency Medical Services (EMS) system that includes urban, rural, and wilderness environments. METHODS: This is a retrospective observational study of all patients who had NT performed in a four county EMS system with a catchment area of greater than 1.6 million people. All prehospital records where NT was performed were queried for demographics, mechanism of injury, initial status, and clinical change following NT. Hospital records were queried for exam findings on arrival to the hospital, any complications from NT, and final outcome. The Trauma Registry was accessed to obtain Injury Severity Scores. Information was manually abstracted by study investigators and univariate analysis utilizing chi-squared and two-tailed t-tests were initially conducted before a multivariate analysis was conducted utilizing a binary logistic regression model. RESULTS: A total of 169 patients with a mean age of 38 years were included in this study; 87% were male and 61% sustained blunt trauma. The overall mortality rate was 79%; 77% in the blunt trauma group; and 83% in the penetrating group, with no significant difference between the two groups relative to mortality (p = 0.336). There was a significant difference in survival between patients who were initially presented as a stat trauma versus as a trauma arrest (52% versus 99%, p > 0.001). The multivariate model with regard to survival supported that reported clinical change after NT (p = 0.001) and status (p = 0.0001) are important indicators of survival. No complications from NT were reported. CONCLUSIONS: NT can safely be performed by paramedics in an EMS system that includes urban, rural, and wilderness settings. Its efficacy does not differ between patients suffering from blunt versus penetrating trauma; however, it appears most beneficial for patients who are unstable but still have vital signs.

Needle Thoracostomy for Patients with Prolonged Transport Times: A Case-control Study.

UNLABELLED: Introduction The use of prehospital needle thoracostomy (NT) is controversial. Some studies support its use; however, concerns exist regarding misplacement, inappropriate patient selection, and iatrogenic injury. Even less is known about its efficacy in situations where there is a delay to definitive care. Hypothesis/Aim To determine any differences in survival of patients who underwent NT in the setting of prolonged versus short transport times, and to describe differences in mechanisms and complications between the two groups. METHODS: This was a retrospective, matched, case-control study of trauma patients in a four county Emergency Medical Service (EMS) system from April 1, 2007 through April 1, 2013. This system serves an urban, rural, and wilderness catchment area. A prehospital database was queried for all patients in whom NT was performed, identifying 182 patients. When these calls were limited to those with prolonged transport times, the search was narrowed to 32 cases. A matched control group, based on age and gender, with short transport times was then created as a comparison. Data collected from prehospital and hospital records included: demographics; mechanism of injury; call status; response to NT; and final outcome. Univariate and multivariate analyses were conducted, as appropriate, to assess the primary outcome of survival and to further elucidate the descriptive data. RESULTS: There was no difference in survival between the case and control groups, either when evaluated with univariate (34% vs 25%; P=.41) or multivariate (odds ratio=0.99; 95% CI, 0.96-1.02; P=.57) analyses. Blunt trauma was the most common mechanism in both groups, but penetrating trauma was more common in the control group (30% vs 9%; P=.003). Patients in the control group were also more likely to have no vital signs on initial assessment (62% vs 31%; P=.003). More patients in the case group were described as having clinical improvement after NT (34% vs 19%; P=.03). No complications of NT were reported in either group. CONCLUSIONS: There was no significant difference in survival between patients with prolonged versus short transport times who underwent NT. Patients with prolonged transport times were more likely to have sustained blunt trauma, have vital signs on EMS arrival, and to have clinical improvement after NT.

Where wilderness, medicine, technology, and religion collide.

We report a case of a man injured in Yosemite National Park (YNP) whose use of technology and refusal of medical care, based on his Christian Science religious beliefs, created multiple challenges to the providers working to rescue and care for him. This case illustrates how our increasingly diverse and complex world requires flexibility and openness to provide the optimal care, both in the wilderness and in the front country.

Improvised traction splints: a wilderness medicine tool or hindrance?

OBJECTIVES: To investigate whether a traction splint made from improvised materials is as efficacious as commercially available devices in terms of traction provided and perceived comfort and stability. METHODS: This was a prospective randomized crossover study utilizing 10 healthy, uninjured volunteers. The subjects were randomized to be placed in 4 different traction devices, in differing order, each for 30 minutes. Three of the traction splints are commercially available: The HARE, Sager, and Faretech CT-EMS. The fourth traction device was an improvised splint made as described in Medicine for the Backcountry: A Practical Guide to Wilderness First Aid. At the end of 30 minutes the pounds of force created by each device was measured. The volunteers were also asked at that time to subjectively report the comfort and stability of the splint separately on a scale from 1 to 10. RESULTS: All traction splints performed similarly with regard to the primary outcome measure of mean pounds of traction created at the end of 30 minutes of application with results ranging from 10.4 to 13.3 pounds. There was little difference reported by participants in regard to stability or comfort between the 4 traction devices. CONCLUSIONS: In this small pilot study, an improvised traction splint was not inferior to commercially available devices. Further research in needed in this area.

The effect of mandatory nurse ratios on patient care in an emergency department.

BACKGROUND: In 2004, California enacted mandatory nurse-to-patient ratios in an effort to improve patient care. OBJECTIVES: The aim of the study was to look at the association between nursing ratios and quality of care in an urban teaching Emergency Department (ED). METHODS: This was an observational study, looking at indicators of quality care before and after the introduction of nursing ratios in an urban California ED serving a mainly indigent population. Indicators examined included wait times; patients who left without being seen (LWBS); medication errors; acute coronary syndrome (ACS) patients receiving aspirin; and time to antibiotics in pneumonia patients. Means and proportions were analyzed using t-tests and chi-squared, as appropriate. RESULTS: All measured wait times increased significantly in 2004 compared to 2003, including room time (from 79 to 123 min, p = 0.0001), throughput time (from 365 to 397 min, p = 0.001), and admission time (from 447 to 552 min, p = 0.0001). Patients who LWBS decreased (from 11.9 % to 11.2%, p = 0.0002). Time to antibiotics in pneumonia patients decreased (from 103 to 62 min, p = 0.002). There were no statistically significant differences in medication errors or administration of aspirin in ACS patients. CONCLUSIONS: All wait times increased after implementation of mandatory nursing ratios. Some indicators of quality care improved, whereas others showed no measurable differences. Further research is needed to further define the effect of nursing ratios on quality of patient care.

Lightning safety awareness of visitors in three California national parks.

OBJECTIVE: To assess the level of lightning safety awareness among visitors at 3 national parks in the Sierra Nevada Mountains of California. METHODS: A 12-question, short answer convenience sample survey was administered to participants 18 years of age and over concerning popular trails and points of interest with known lightning activity. There were 6 identifying questions and 5 knowledge-based questions pertaining to lightning that were scored on a binary value of 0 or 1 for a total of 10 points for the survey instrument. Volunteers in Fresno, California, were used as a control group. Participants were categorized as Sequoia and Kings Canyon National Park (SEKI), frontcountry (FC), or backcountry (BC); Yosemite National Park (YNP) FC or BC; and Fresno. Analysis of variance (ANOVA) was used to test for differences between groups. RESULTS: 467 surveys were included for analysis: 77 in Fresno, 192 in SEKI, and 198 in YNP. National park participants demonstrated greater familiarity with lightning safety than individuals from the metropolitan community (YNP 5.84 and SEKI 5.65 vs Fresno 5.14, P = .0032). There were also differences noted between the BC and FC subgroups (YNP FC 6.07 vs YNP BC 5.62, P = .02; YNP FC 6.07 vs SEKI FC 5.58, P = .02). Overall results showed that participants had certain basic lightning knowledge but lacked familiarity with other key lightning safety recommendations. CONCLUSIONS: While there are statistically significant differences in lightning safety awareness between national parks and metropolitan participants, the clinical impact of these findings are debatable. This study provides a starting point for providing educational outreach to visitors in these national parks.

Prehospital Traction Splint Use in Midthigh Trauma Patients.

CONTEXT: Traction splint (TS) use during emergency medical system transport has been theorized to relieve pain, limit continued injury from loose bone fragments, and decrease potential bleeding space in the injured thigh. AIMS: This study aimed to evaluate the benefit of prehospital TS (PTS) application, using data from the trauma registry at a large Level 1 trauma center. METHODS: A retrospective review of patients from the NTRACS© and Trauma One© registry at an American College of Surgeons-verified Level 1 trauma center was conducted. All patients treated between the years 2001 and 2011 who were assigned a diagnosis International Classification of Diseases-9 code of 821.01 (closed fracture of shaft and femur) and 821.11 (open fracture of shaft and femur) (femur fracture [FF]) were included. STATISTICAL ANALYSIS: All categorical variables between the first groups were compared using Pearson's Chi-square and Fisher's exact test analysis. Comparisons were made using unpaired t-tests and Mann-Whitney test or Kruskal-Wallis one-way ANOVA, followed by Dunn's post hoc pairwise comparisons. RESULTS: Patients with a TS and those without indicated that the patients with no traction split (NTS) had sustained injuries beyond a FF (14.43 ± 9.740 vs. 18.59 ± 12.993, P < 0.001). The three groups of TS placement (PTS, hospital, and NTS) only used patients with Injury Severity Score < 9 (n = 218). Hospital length of stay (LOS) was found to be significant (P = 0.05) between the patients who received a hospital TS (3.10 ± 1.709) and NTS (5.42 ± 5.144). CONCLUSION: PTS can lower LOS and mortality. Further research is needed to confirm these findings.

Assessment of Physician Well-being, Part One: Burnout and Other Negative States.

Physician well-being is a complex and multifactorial issue. A large number of tools have been developed in an attempt to measure the nature, severity, and impact of both burnout and well-being in a range of clinical populations. This two-article series provides a review of relevant tools and offers guidance to clinical mentors and researchers in choosing the appropriate instrument to suit their needs, whether assessing mentees or testing interventions in the research setting. Part One begins with a discussion of burnout and focuses on assessment tools to measure burnout and other negative states. Part Two of the series examines the assessment of well-being, coping skills, and other positive states.

Needle Thoracostomy: Does Changing Needle Length and Location Change Patient Outcome?

BACKGROUND: Needle thoracostomy (NT) is a common prehospital intervention for patients in extremis or cardiac arrest due to trauma. The purpose of this study is to compare outcomes, efficacy, and complications after a change in policy related to NT in a four-county Emergency Medical Services (EMS) system with a catchment area of greater than 1.6 million people. METHODS: This is a before and after observational study of all patients who had NT performed in the Central California (USA) EMS system. The before, anterior midclavicular line (MCL) group consisted of all patients who underwent NT from May 7, 2007 through February 28, 2013. The after, midaxillary line (MAL) axillary group consisted of all patients who underwent NT from March 1, 2013 through January 30, 2016, after policy revisions changed the timing, needle size, and placement location for NT. All prehospital and hospital records where NT was performed were queried for demographics, mechanism of injury, initial status and post-NT clinical change, reported complications, and final outcome. The trauma registry was accessed to obtain Injury Severity Scores (ISS). Information was manually abstracted by study investigators and examined utilizing univariate and multivariate analyses. RESULTS: Three-hundred and five trauma patients treated with NT were included in this study, of which, 169 patients (the MCL group) were treated with a 14-guage intravenous (IV) catheter at least 5.0-cm long at the second intercostal space (ICS), MCL after being placed in the ambulance; and 136 patients (the MAL group) were treated with a 10-guage IV catheter at least 9.5-cm long at the fifth ICS, MAL on scene. The mean ISS was lower in the MAL cohort (64.5 versus 69.2; P=.007). The mortality rate was 79% in both groups. The multivariate model with regard to survival supported that a lower ISS (P<.001) and reported clinical change after NT (P=.003) were significant indicators of survival. No complications from NT were reported. CONCLUSIONS: Changing the timing, length of needle, and location of placement did not change mortality in patients requiring NT. Needle thoracostomy was used more frequently after the change in policy, and the MAL cohort was less injured. No increase in reported complications was noted. WeichenthalLA, OwenS, StrohG, RamosJ. Needle thoracostomy: does changing needle length and location change patient outcome? Prehosp Disaster Med. 2018;33(3):237-244.

Teaching Methods Utilized During Medical Resuscitations in an Academic Emergency Department.

INTRODUCTION: One important skill that an emergency medicine trainee must learn is the resuscitation of the critically ill patient. There is research describing clinical teaching strategies used in the emergency department (ED), but less is known about specific methods employed during actual medical resuscitations. Our objective was to identify and describe the teaching methods used during medical resuscitations. METHODS: This was a prospective study involving review of 22 videotaped, medical resuscitations. Two teams of investigators first each reviewed and scored the amount and types of teaching observed for the same two videos. Each team then watched and scored 10 different videos. We calculated a Cohen's kappa statistic for the first two videos. For the remaining 20 videos, we determined means and standard deviations, and we calculated independent two-tailed t-tests to compare means between different demographic and clinical situations. RESULTS: The Cohen's kappa statistic was K=0.89 with regard to number of teaching events and K=0.82 for types of teaching observed. Of the resuscitations reviewed, 12 were in coding patients. We identified 148 episodes of teaching, for an average of 7.4 per resuscitation. The amount of teaching did not vary with regard to whether the patient was coding or not (p=0.97), nor based on whether the primary learner was a junior or senior resident (p=0.59). Questioning, affirmatives and advice-giving were the most frequently observed teaching methods. CONCLUSION: Teachers use concise teaching methods to instruct residents who lead medical resuscitations. Further research should focus on the effectiveness of these identified strategies.

Core content for wilderness medicine fellowship training of emergency medicine graduates.

Wilderness medicine is the practice of resource-limited medicine under austere conditions. In 2003, the first wilderness medicine fellowship was established, and as of March 2013, a total of 12 wilderness medicine fellowships exist. In 2009 the American College of Emergency Physicians Wilderness Medicine Section created a Fellowship Subcommittee and Taskforce to bring together fellowship directors, associate directors, and other interested stakeholders to research and develop a standardized curriculum and core content for emergency medicine (EM)-based wilderness medicine fellowships. This paper describes the process and results of what became a 4-year project to articulate a standardized curriculum for wilderness medicine fellowships. The final product specifies the minimum core content that should be covered during a 1-year wilderness medicine fellowship. It also describes the structure, length, site, and program requirements for a wilderness medicine fellowship.

Motion sickness: comparison of metoclopramide and diphenhydramine to placebo.

OBJECTIVES: This is an evaluation of the efficacy of metoclopramide (MTCP) or diphenhydramine (DPH) to relieve symptoms of motion sickness in patients being transported via ambulance in a mountainous setting. METHODS: This is a prospective, randomized, double-blinded, placebo-controlled study of patients transported by ambulance in the Sierra Nevada mountains of Fresno County. Consenting patients who met the inclusion criteria were asked to rate their motion sickness every five minutes using a visual analog scale (VAS) during transport. If motion sickness occurred, they were randomized to receive MTCP (20 mg IV), DPH (50 mg IV), or placebo (normal saline), and remaining symptoms were recorded every five minutes. If signs and symptoms of motion sickness persisted after 15 minutes, a rescue dose of MTCP was offered. RESULTS: Twenty-six patients were enrolled in the study. Twenty-two (84.6%) developed motion sickness and were randomized to MTCP, DPH, or placebo. Eight patients received MTCP, seven received DPH, and seven received placebo. The MTCP group showed a statistically significant decrease in the mean VAS score at 15 minutes compared to the DPH and placebo groups. There was no significant difference in the decrease in VAS score between the placebo and the DPH group. Twelve out of 22 patients requested a rescue dose of MTCP after 15 minutes. At 25 minutes, there was no significant difference in the VAS score between the three groups. CONCLUSION: During ambulance transport in a mountainous setting, the administration of MTCP is superior to both DPH and placebo in the treatment of motion sickness. Diphenhydramine is not superior to placebo.

Antiemetics in the ED: a randomized controlled trial comparing 3 common agents.

We sought to compare the efficacy of 3 intravenous antiemetic medications in ED patients complaining of moderate to severe nausea. This randomized, placebo-controlled, double-blind trial compares 1.25 mg droperidol, 10 mg metoclopramide, 10 mg prochlorperazine, and saline placebo. Adult ED patients complaining of nausea were eligible. Nausea was measured on a 100-mm visual analog scale at 0 and 30 minutes after treatment. A convenience sample of 100 patients was enrolled; 97 had complete data available for analysis. Of these, 22 patients received droperidol, 25 received metoclopramide, 24 received prochlorperazine, and 26 received placebo. Droperidol (-54.5 mm) was significantly better than metoclopramide (-40.2 mm) or prochlorperazine (-40.5 mm) at reducing nausea at 30 minutes (P = .04). There were no significant differences in rescue medication or patient satisfaction; however, droperidol had significantly higher akathisia (71.4% vs 23.5%) at 24-hour follow-up. When administered intravenously to adult patients with moderate to severe nausea, droperidol was more effective than metoclopramide or prochlorperazine but caused more extrapyramidal symptoms. Metoclopramide and prochlorperazine were not more effective than saline placebo. All patients improved over time and possibly with intravenous hydration.

The incidence and treatment of prehospital motion sickness.

OBJECTIVES: The authors' objectives were: 1) to determine the incidence of motion sickness during ambulance transport on a mountainous route in healthy volunteers, and 2) to determine if droperidol alleviated the signs and symptoms of motion sickness in those volunteers who developed it. METHODS: This was a prospective, randomized, double-blind, placebo-controlled trial. Subjects were healthy volunteers over age 18 and not currently taking an antiemetic. Participants were transported in the back of an ambulance over a mountainous road. Those who developed motion sickness rated their nausea on a 100-mm visual analog scale (VAS) and were randomized to receive placebo (saline) or 2.5 mg droperidol intravenously. Symptoms were recorded on a VAS every 5 minutes until the end of the transport. Incidence of motion sickness was calculated as a percentage with 95% confidence intervals (CIs). Pretreatment characteristics were compared with chi-square tests, and mean VAS scores were compared using t-tests. RESULTS: Thirty-seven subjects completed the study. Sixteen (43%, 95% CI=27%-59%) developed motion sickness. Fifteen were randomized and completed data collection. Eight received droperidol (mean baseline VAS, 45) and seven received placebo (mean baseline VAS, 40). Droperidol trended toward a greater mean reduction of nausea than placebo at 5 minutes (20 versus 4, p=0.077). CONCLUSIONS: The incidence of motion sickness during ambulance transport in a mountainous setting is substantial. There was a strong trend toward a positive treatment effect with droperidol. Further prospective study in an actual patient setting is warranted.

Impact of police and legislative initiatives on urban gunshot wound admissions.

BACKGROUND: This study aimed to assess the effects of local and state anti-crime initiatives on the number of gunshot wound admissions to a level 1 trauma center. METHODS: A retrospective time series analysis of gunshot wound admissions from July 1, 1990 to July 30, 1999 was performed at a level 1 trauma center. The gunshot wound admissions were divided into four subgroups: assault, suicide, accident, and police-involved gunshot wounds. The effects of the following three initiatives were studied: (1) the Three Strikes law; (2) a local police initiative, the Violent Crime Suppression Unit; and (3) the Use a Gun and You're Done law. The periods that corresponded with each intervention were defined, and the rates of gunshot wound-related admissions for all causes after each intervention were compared. RESULTS: During the study, 1,499 patients were admitted with gunshot wounds. These admissions involved 1,220 assaults, 196 suicide attempts, 52 accidents, and 31 police-involved cases. Over the defined periods, an average of 13.7 gunshot wound admissions (range, 7.9-15.5) occurred, most of which were assaults (mean, 10.8; range, 5.5-13). There were no differences across the periods for gunshot wound admissions among three of the subgroups: suicide, accidental, and police-related gunshot wounds. However, the assault subgroup showed a significant decrease across all the periods and a statistically significant decrease after enactment of the Use a Gun and You're Done law (p < 0.005). When control was used for an increasing number of police officers, however, the association was no longer statistically significant. CONCLUSIONS: Gunshot wound admissions attributable to assault at a level 1 trauma center decreased during a period when several local and state initiatives focused on decreasing violent crime were enacted. The causes likely were multifunctional, and included increasing the number of police officers as well as the enactment of new laws.