Evaluation of Posttraumatic Stress Disorder Screening Measures of Emergency Medical Services Clinicians in Urban and Suburban New York During the Coronavirus Disease 2019 Pandemic.

OBJECTIVE: The objective of this study was to assess the psychological impact of the coronavirus disease 2019 (COVID-19) pandemic on the self-reported rates of posttraumatic stress disorder (PTSD) among emergency medical services (EMS) clinicians in urban and suburban settings that were one of the primary epicenters during the first wave of the COVID-19 pandemic. METHODS: Anonymous surveys containing the PTSD Checklist-Specific (PCL-S) were sent electronically between November 2020 and April 2021 to EMS clinicians working in 2 EMS agencies. A threshold score ≥ 36 was considered a positive screen for PTSD symptomology; a score ≥ 44 was considered a presumptive PTSD diagnosis. RESULTS: Of the 214 surveys sent, 107 responses were returned. The total PCL-S scores suggested PTSD symptoms were present in 33% of responding EMS clinicians (95% confidence interval [CI], 24.1%-42.5%), and 25% (95% CI, 17.6%-34.7%) met the criteria for a presumptive diagnosis of PTSD. Regression revealed increasing PCL-S scores were associated with thoughts of job resignation (+3.8; 95% CI, 1.1-6.4; P = .006), whereas lower PCL-S scores were related to the degree that respondents believed emotional support was available at their institution (-3.6; 95% CI, -6.8 to -0.4; P = .03). CONCLUSION: Sixth months after the first wave of the COVID-19 pandemic, one third of participating EMS clinicians screened positive for PTSD symptoms. Pandemic planning must address the mental health of EMS clinicians to reduce subsequent burnout and maintain a healthy workforce.

Work-, lifestyle-, and health-related factors among women and men working in the emergency medical services.

Objectives. This study aimed to describe work-, lifestyle-, and health-related factors among ambulance personnel, and to analyse differences between women and men. Methods. The cross-sectional study (N = 106) included self-reported and objective measures of work, lifestyle, and health in 10 Swedish ambulance stations. The data collection comprised clinical health examination, blood samples, tests of physical capacity, and questionnaires. Results. A high proportion of the ambulance personnel reported heavy lifting, risk of accidents, threats and violence at work. A low level of smoking and alcohol use, and a high level of leisure-time physical activity were reported. The ambulance personnel had, on average, good self-rated health, high work ability and high physical capacity. However, the results also showed high proportions with risk factors for cardiovascular disease (CVD), e.g., high blood pressure, and high levels of blood lipids. More women than men reported high work demands. Furthermore, women performed better in tests of physical capacity and had a lower level of CVD risk factors. Conclusions. Exposure to work-related factors that might affect health was common among ambulance personnel. Lifestyle- and health-related factors were somewhat contradictory, with a low proportion reporting lifestyle-related risk factors, but a high proportion having risk factors for CVD.

Ultra-forward surgical support for special operations forces. Conception, development and certification of the French Special Operations Surgical Team (SOST) airborne capability.

When special operations forces (SOF) are in action, a surgical team (SOST) is usually ground deployed as close as possible to the combat area, to try and provide surgical support within the golden hour. The French SOST is composed of 6 people: 2 surgeons, 1 scrub nurse, 1 anaesthetist, 1 anesthetic nurse and 1 SOF paramedic. It can be deployed in 45 min under a tent or in a building. However, some tactical situations prevent the ground deployment. A solution is to deploy the SOST in a tactical unprepared aircraft hold, to make it possible to offer DCS, to treat non-compressible exsanguinating trauma, without any ground logistical footprint. This article describes the stages of the design, development and certification process of the airborne SOST capability. The authors report the modifications and adaptations of the equipment and the surgical paradigms which make it possible to solve the constraints linked to the aeronautical and combat environment. Study type/level of evidence Care management Level of Evidence IV.

A comparison of tracheal intubation using intubrite laryngoscope and conventional MAC laryngoscope: An open, prospective, crossover manikin study.

BACKGROUND: New devices are more available in the pre-hospital environment operational theaters and emergency departments. One is an intubrite laryngoscope (INT) with Dual LED lighting that combines ultraviolet and white LED. The study aimed to compare the efficacy of endotracheal intubation using INT and conventional laryngoscope performed by inexperienced paramedics (paramedics students) and paramedics with experience in advanced airways management in full and limited accessibility settings. METHODS: It was an open, prospective, crossover manikin study. Sixty paramedics and paramedic students were recruited. Participants were divided into 2 equal groups depending on their experience (n = 30). Experienced participants were further randomly divided into 2 groups (n = 15). Inexperienced participants were also randomly divided into 2 groups (n = 15). The criterion of inexperience was 5 or fewer intubation by any laryngoscope. Inexperience participants were asked to perform tracheal intubation in standard pre-hospital settings (without limited access to manikin) (scenario A) and difficult pre-hospital settings (limited access to manikin - narrow space between benches) (scenario B). Experience participants were asked to intubate manikin in difficult pre-hospital settings. RESULTS: In the normal pre-hospital environment, the success rate after the first attempt was 56,7% for conventional laryngoscope and 66,7% for intubrite. However, the overall effectiveness of tracheal intubation using both laryngoscopes in 3 attempts was 90% for both devices. The successful rate of first attempt intubation in a difficult environment by inexperienced was 73,3% for INT and 50% for conventional laryngoscope. Overall effectiveness was 83,3% and 86,7% respectively. The successful rate of first attempt intubation in the experienced group was 86,7% with INT compared to 60% with a conventional laryngoscope in difficult settings. Overall effectiveness was 96,7% for both devices. CONCLUSION: Intubrite provided better working conditions and make up for deficiencies in successful tracheal intubation by inexperienced participants in a normal and difficult environment. Tracheal intubation with intubrite was more effective in the experienced group. Tracheal intubation effectiveness with intubrite was also higher in the experienced group.

Improving paramedic responses for patients dying at home: a theory of change-based approach.

BACKGROUND: Paramedics are increasingly being called to attend patients dying from advanced incurable conditions. However, confidence to deal with such calls varies, with many feeling relatively unskilled in this aspect of their role. A number of interventions have been piloted to improve their skills in end-of-life care (EoLC) but without a fully specified theoretical model. Theory of Change models can provide theoretical and testable links from intervention activities to proposed long-term outcomes and indicate the areas for assessment of effectiveness. This study aimed to develop an intervention for improving paramedic EoLC for patients in the community. METHODS: A Theory of Change approach was used as the overarching theoretical framework for developing an intervention to improve paramedic end-of-life skills. Nine stakeholders - including specialist community paramedics, ambulance call handlers and palliative care specialists - were recruited to five consecutive online workshops, ranging between 60 and 90 min. Each workshop had 2-3 facilitators. Over multiple workshops, stakeholders decided on the desired impact, short- and long-term outcomes, and possible interventions. During and between these workshops a Theory of Change model was created, with the components shared with stakeholders. RESULTS: The stakeholders agreed the desired impact was to provide consistent, holistic, patient-centred, and effective EoLC. Four potential long-term outcomes were suggested: (1) increased use of anticipatory and regular end-of-life medications; (2) reduced end-of-life clinical and medication errors; (3) reduced unnecessary hospitalisations; (4) increased concordance between patient preferred and actual place of death. Key interventions focused on providing immediate information on what to do in such situations including: appraising the situation, developing an algorithm for a treatment plan (including whether or not to convey to hospital) and how to identify ongoing support in the community. CONCLUSIONS: A Theory of Change approach was effective at identifying impact, outcomes, and the important features of an end-of-life intervention for paramedics. This study identified the need for paramedics to have immediate access to information and resources to support EoLC, which the workshop stakeholders are now seeking to develop as an intervention.

Exploring the characteristics of successful prehospital trauma care teams: Insights from military trauma care simulations.

BACKGROUND: Trauma care teams play a crucial role in determining the outcomes of trauma victims. The composition and training of these teams can vary. Our study seeks to examine the characteristics of successful military Advanced Life Support (ALS) teams and the factors that affect them. METHODS: A retrospective study was conducted at the Israel Defense Force (IDF) Military Medical Academy throughout 2021, where prehospital medical teams were observed in trauma care simulations. Teams were led by ALS providers (military physicians or paramedics) trained in IDF Military Trauma Life Support. Demographic and training data were collected. Teams were categorized into high or subpar performance groups based on simulation scores. Specific skills were assessed by trauma instructors using a points system. Scores were compared between the groups and analyzed for correlations with demographic and training data. RESULTS: Overall, 63 team simulations were analyzed, with teams led by a military paramedic in 78% of simulations. The mean overall simulation performance was 81% ±6.2, and there were no differences in scores of single or multicasualty simulations. A total 3% of the teams achieved successful results and were more likely to have a paramedic as the ALS provider ( p = 0.028). A sensitivity analysis excluding physicians was conducted and showed that high-performance teams had significantly higher skill assessments for primary survey ( p = 0.004), injury recognition ( p = 0.002), exposure ( p = 0.006), adherence to clinical practice guidelines ( p = 0.032), and medical device use ( p = 0.002). CONCLUSION: Our study found that ALS provider is associated with overall simulation performance in prehospital ALS teams, with military paramedics more likely to be successful. These findings have implications for the training and staffing of prehospital ALS teams, suggesting that teams should be composed accordingly and that training should focus on skills affected by the ALS provider type. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Tiros na escola: algumas referências para a psicologia na assistência à comunidade escolar / School shotting: some references for psychology in school comunity support / Tíros em la escuela: algunas referencias para la psicología em la asistencia à comunidad escolar

A atuação em situações de emergências e desastres apresentam-se como um dos grandes desafios na atuação dos profissionais da Psicologia, demandando intervenções singulares, desde o primeiro contato com as vítimas e o com entorno afetado pelo ocorrido, passando pelo trabalho interdisciplinar e interinstitucional junto aos órgãos públicos de segurança, justiça, assistência e saúde. O presente artigo tem como objetivo apresentar, por meio da experiência na assistência às vítimas na Escola Estadual Raul Brasil, as particularidades e adversidades enfrentadas durante o primeiro semestre de intervenções emergenciais que antecederam a contratação de psicólogos por parte do poder público municipal para continuidade das ações. Por meio de relatos de experiência em intervenções psicológicas, obtidos em diferentes instituições para a assistência às vítimas, este trabalho também visa apresentar alternativas que possam servir de referências para a intervenção do psicólogo e da psicóloga em situações de emergências e desastres, especialmente ocorridas na comunidade escolar. Observou-se que a realização do trabalho interdisciplinar e interinstitucional somado à participação da direção da escola no planejamento das ações e a realização de plantões psicológicos e rodas de conversa junto à comunidade escolar foram fundamentais para a assistência às vítimas do ocorrido.(AU)

Timely response to emergency and disaster situations is a major challenge for Psychology professionals and require particular interventions, from initial contact with the victims and the affected environment to interdisciplinary and interinstitutional collaboration with public security, justice, assistance and health agencies. Based on the experience of providing assistance to the victims of the State School Raul Brasil, this paper presents the adversities and specificities faced during the first semester of emergency interventions implemented before psychologists were hired by municipal officials for the continuity of care. By analyzing experience reports on psychological interventions obtained from different institutions for victim assistance, this paper proposes alternatives to be used as reference for psychological intervention in emergency and disaster situations, especially those experienced by the school community. Interdisciplinary and interinstitutional collaboration with the school board for planning actions and offering psychological services and conversation circles for the school community was fundamental to assist the victims.(AU)

La actuación en situaciones de emergencias es uno de los grandes desafíos a los profesionales de la psicología, pues demanda intervenciones singulares desde el primer contacto con las víctimas y con el contexto afectado por lo ocurrido, pasando por la interdisciplinaridad e interinstitucionalidad junto a los organismos públicos de seguridad, justicia, asistencia y salud. Este artículo tiene como objetivo presentar, por medio de la experiencia de la asistencia a las víctimas del colegio estadual Raul Brasil (en São Paulo, Brasil), las particularidades y adversidades enfrentadas durante el primer semestre de las intervenciones de emergencia que antecedieron la contratación de psicólogos por parte del municipio para continuidad de las acciones. Por medio de reportes de experiencia en intervenciones psicológicas, obtenidos en diferentes instituciones para la asistencia a las víctimas, este estudio también pretende presentar alternativas que puedan servir de referencia en la intervención de psicólogos y psicólogas en situaciones de emergencia y desastres, especialmente ocurridas en la comunidad escolar. Se verificó que la realización del trabajo interdisciplinar e interinstitucional, la participación de la dirección del colegio en la implementación de acciones y la realización de guardias psicológicas y círculos de conversación con la comunidad escolar fueron fundamentales para una asistencia a las víctimas.(AU)

Providing palliative care at home aligns with the professional identity of paramedics: a qualitative study of paramedics and palliative health care providers.

BACKGROUND: An innovative program, 'Paramedics Providing Palliative Care at Home,' was implemented in Nova Scotia, Canada in 2015. Roles like this are part of an evolving professional identity; role discordance or lack of clarity not only hinders professionalization but may impair the wellbeing, and career longevity of paramedics. This study explored the alignment of providing palliative support at home with paramedic professional identity. METHODS: Qualitative description was employed, with thematic analysis of focus groups with paramedics and palliative health care providers. Recruitment posters were sent through the professional college (paramedics) and program managers (health care providers). Focus groups followed a semi-structured guide, discussing understanding of and experiences with the role and its alignment with professional identity. Challenges to paramedic palliative support and fit with professional identify were explored. Thematic content analysis was ongoing while focus groups were being conducted, until no new codes were found. Codes were combined, sorted into categories, and ultimately, agreed-upon themes. Saturation of themes was reached. RESULTS: Eleven paramedics and twenty palliative health care providers participated. Four themes reflected paramedic's expanded role: (1) patient centeredness and job satisfaction with provision of palliative support, (2) a bridging role, (3) paramedic as advocate and educator, (4) provision of psychosocial support. Four themes reflected paramedic's professional identity: (1) evolution of paramedicine as a skilled clinical profession, (2) helping people and communities, (3) paramedic skill set aligns with work in palliative care, and (4) changing paramedic mindset. CONCLUSION: Paramedics and palliative health care providers highlighted the provision of palliative care as part of a positive growth of paramedicine as a health profession, and a good fit with professional identity. Novel roles like this are important in the evolution of our health care system faced with increasing pressures to get the right care with the right provider at the right time.

RéSUMé: CONTEXTE: Un programme innovant, " Programme de soins palliatifs paramédicaux à domicile ", a été mis en œuvre en Nouvelle-Écosse, au Canada, en 2015. Les rôles de ce type font partie d'une identité professionnelle en évolution ; la discordance ou le manque de clarté des rôles non seulement entrave la professionnalisation, mais peut aussi nuire au bien-être et à la longévité de la carrière des ambulanciers paramédicaux. Cette étude a exploré l'alignement de la prestation de soutien palliatifs à domicile avec l'identité professionnelle des ambulanciers paramédicaux. MéTHODES: Une description qualitative a été employée, avec une analyse thématique de groupes de discussion avec des ambulanciers paramédicaux et des prestataires de soins palliatifs. Des affiches de recrutement ont été envoyées par le biais du collège professionnel (paramédicaux) et des gestionnaires de programmes (prestataires de soins de santé). Les groupes de discussion ont suivi un guide semi-structuré, discutant de la compréhension et des expériences du rôle et de son alignement avec l'identité professionnelle. Les défis du soutien palliatif paramédical et son adéquation avec l'identité professionnelle ont été explorés. L'analyse du contenu thématique s'est poursuivie pendant la tenue des groupes de discussion, jusqu'à ce qu'aucun nouveau code ne soit trouvé. Les codes ont été combinés, triés en catégories et, finalement, en thèmes convenus. La saturation des thèmes a été atteinte. RéSULTATS: Onze ambulanciers paramédicaux et vingt prestataires de soins palliatifs ont participé. Quatre thèmes reflétaient le rôle élargi des ambulanciers paramédicaux : 1) l'orientation vers le patient et la satisfaction professionnelle à l'égard de la prestation de soutien palliatifs, 2) un rôle de transition, 3) les ambulanciers paramédicaux à titre de défenseurs et d'éducateurs, 4) un soutien psychosocial. Quatre thèmes reflétaient l'identité professionnelle des ambulanciers paramédicaux : 1) l'évolution de la profession paramédicale en tant que profession clinique qualifiée, 2) l'aide aux personnes et aux collectivités, 3) l'ensemble des compétences des ambulanciers paramédicaux s'harmonise avec le travail en soins palliatifs, et 4) l'évolution de l'état d'esprit des ambulanciers paramédicaux. CONCLUSION: Les ambulanciers paramédicaux et les prestataires de soins palliatifs ont souligné que la prestation de soins palliatifs faisait partie d'une croissance positive de la profession paramédicale en tant que profession de la santé et correspondait bien à l'identité professionnelle. Des rôles novateurs comme celui-ci sont importants dans l'évolution de notre système de soins de santé, confronté à des pressions croissantes pour obtenir les bons soins auprès du bon prestataire au bon moment.

Paramedic use of the Physician Order for Life-Sustaining Treatment (POLST) for medical intervention and transportation decisions.

BACKGROUND: Physician Order for Life-Sustaining Treatment forms (POLST) exist in some format in all 50 states. The objective of this study is to determine paramedic interpretation and application of the California POLST for medical intervention and transportation decisions. METHODS: This study used a prospective, convenience sample of California Bay Area paramedics who reviewed six fictional scenarios of patients and accompanying mock POLST forms. Based on the clinical case and POLST, paramedics identified medical interventions that were appropriate (i.e. non-invasive positive pressure airway) as well as transportation decisions (i.e. non-transport to the hospital against medical advice). EMS provider confidence in their POLST interpretation was also assessed. RESULTS: There were 118 paramedic participants with a mean of 13.3 years of EMS experience that completed the survey. Paramedics routinely identified the selected medical intervention on a patients POLST correctly as either comfort focused, selective or full treatment (113-118;96%-100%). For many clinical scenarios, particularly when a patient's POLST indicated comfort focused treatment, paramedics chose to use online medical oversight through base physician contact (68-73;58%-62%). In one case, a POLST indicated "transport to hospital only if comfort needs cannot be met in current location", 13 (14%) paramedics elected to transport the patient anyway and 51 (43%) chose "Non-transport, Against Medical Advice". The majority of paramedics agreed or strongly agreed that they knew how to use a POLST to decide which medical interventions to provide (106;90%) and how to transport a patient (74;67%). However, after completing the cases, similar proportions of paramedics agreed (42;36%), disagreed (43;36%) or were neutral (30;25%) when asked if they find the POLST confusing. CONCLUSION: The POLST is a powerful tool for paramedics when caring patients with serious illness. Although paramedics are confident in their ability to use a POLST to decide appropriate medical interventions, many still find the POLST confusing particularly when making transportation decisions. Some paramedics rely on online medical oversight to provide guidance in challenging situations. Authors recommend further research of EMS POLST utilization and goal concordant care, dedicated paramedic POLST education, specific EMS hospice and palliative care protocols and better nomenclature for non-transport in order to improve care for patients with serious illness.

Approaches of 112 ambulance service staffers to children with burns: A survey assessment.

BACKGROUND: We aimed to evaluate the knowledge of 112 ambulance service staffers (doctors, nurses, emergency medical technicians [EMTs], and paramedics [PMs]) who were the first intervention to pediatric patients with burn injuries regarding first intervention and patient transfer. METHODS: The study included 373 personnel working in 112 ambulance services in Ankara province. Participants were asked 17 questions to measure their knowledge of burns in children. Statistical analysis was performed with the Statistical Package for Social Sciences 21.0. RESULTS: Of the participants, 26 (7%) were doctors, 25 (6.7%) nurses, 180 (48.3%) EMTs, and 142 (35.3%) PMs. Of the participants, 118 stated that they always calculate the burn surface area, while only five (1.3%) marked the correct choice of the Lund Browder scheme to the question by which method they calculated. One hundred twenty one personnel (32.4%) use the Parkland formula to calculate the amount of fluid to be given during transfer while only 7 (1.9%) use the Galveston formula, which is more suitable for chil-dren. Of the participants, 56 (15%) answered as lactated Ringer's solution which is the correct fluid to the question of which fluid do you give at the scene and during the transfer. One hundred fifty-three participants (41%) responded correctly to the scenario question expected to recognize inhalation damage while only 138 (37%) responded correctly as 'I do immediately intubate' to the inhalation injury described scenario question. One out of 373 (0.3%) participants marked the appropriate procedure for a patient who had a 50% scald burn during the first intervention and transfer. The rate of topical lidocaine use of participants was high (70.8%). Of the 373 participants, only 33 (8.8%) thought themselves competent for first aid and transfer of children with burns. If training on the subject was held, 333 personnel (89.3%) wanted to participate. CONCLUSION: It is expected that the knowledge of 112 ambulance services who see pediatric burn patients first, perform the first intervention, and provide transfer would be suitable. However, our questionnaire shows that these personnel have insufficient knowledge and need to be trained.

A mixed methods end-user assessment to determine the ideal supraglottic airway device for inclusion into the medic's aid bag.

BACKGROUND: Many advancements in supraglottic airway technology have occurred since the start of the Global War on Terrorism. While the Tactical Combat Casualty Care guidelines previously recommend the i-gel device, this is based on little data and minimal end-user input. OBJECTIVE: We sought to use a mixed methods approach to investigate the properties of an ideal device for inclusion into the medic's aid bag. METHODS: We performed prospective, serial qualitative studies to uncover and articulate themes relative to airway device usability with 68W-combat medics. 68W are trained roughly to the level of a civilian advanced emergency medical technician with a heavier focus on trauma care. Physicians with airway expertise demonstrated the use of each device and provided formal training on all the presented devices. We then administered performed focus groups to solicit end-user feedback along with survey data. RESULTS: We enrolled 250 medics during the study. The preponderance of medics were of the rank E4 (28%) and E5 (44%). Only 35% reported ever placing a supraglottic airway in a real human. When reporting on usability, the i-gel had the highest median score, ease of manipulation, grip comfort and ease of insertion while also scoring the best in regard to requiring minimal training. The other compared devices had no clear highest score. Qualitative data saturated around a strong preference for the BaskaMask and/or the i-gel airway device, with the least favorite being the AirQ and the LMA Fastrach airway devises. There was a strong qualitative alignment in how both the BaskaMask and i-gel provided ease of use and simplicity of training. CONCLUSION: There were strong qualitative preferences for two specific airway devices: Baska Mask and i-gel. However, many medics commented on their previous experience with the i-gel compared with the other devices, which may have biased them toward the i-gel. The overall data suggest that medics would prefer a device engineered with features from several devices. LEVEL OF EVIDENCE: Therapeutic/care management; Level V.

Prehospital personnel discretion pediatric trauma team activations: Too much of a good thing?

PURPOSE: Trauma team activation is essential to provide rapid assessment of injured patients, however excessive utilization can overburden systems. We aimed to identify predictors of over triage and evaluate impact of prehospital personal discretion trauma activations on the over triage rate. METHODS: Retrospective comparative study of pediatric trauma patients (<18 years) evaluated after activation of the trauma team to those evaluated as a trauma consult treated between 2010 and 2013. Cohort matching of trauma activated and consult patients was done on the basis of patients' age and ISS. RESULTS: 1363 patients including 359 trauma team activations were evaluated. Median age was 6 years, Injury Severity Score (ISS) 4, 116 (8.5%) required operative intervention and 20 (1.4%) died. Matched analysis using age and ISS showed trauma activated patients were more likely to have penetrating MOI (4.7% vs.1.7%; p = 0.03) and need ICU admission(32.9% vs.16.7%; p = 0.0001). State of Florida discrete criteria based trauma activated patients when compared to paramedic discretion activations had a higher ISS (9 vs.5; p = 0.014), need for ICU admission (36.5% vs.20.4%; p = 0.004), ICU LOS(2 vs.0 days; p = 0.02), hospital LOS(2 vs.2 days; p = 0.014) and higher likelihood of death(4.9% vs.0%;p = 0.0001). Moreover, paramedic discretion trauma activated patients were similar to trauma consult patients in terms of ISS score(p = 0.86), need for ICU admission(p = 0.86), operative intervention(p = 0.86), death(p = 0.86) and hospital LOS(p = 0.86), with a considerably higher cost of care(p = 0.0002). CONCLUSION: Discrete criteria-based trauma team activations appear to more reliably identify patients likely to benefit from initial multidisciplinary management.

Cadaver as an educational tool increasing the effectiveness of Combat Application Tourniquet use in extremity injuries.

BACKGROUND: One of the most frequent life-threatening emergencies is extremity haemorrhage. In such cases, patient survival depends on a fast on-scene intervention. Thus, both the potential witnesses and medical emergency staff should have the ability to control haemorrhages. However, simulator-based courses do not fully reflect the structures and physiology of the human body. Therefore, invasive procedure training in trauma patients is limited. The present study aims to evaluate the effectiveness of cadavers as educational tools during a training course in extremity haemorrhage control with the use of the Combat Application Tourniquet (CAT). METHODS: This study was conducted among 31 paramedic students, who applied a tourniquet to the upper extremity of an unembalmed (fresh) human cadaver with simulated bleeding. Two time measurements were performed, the latter being preceded by a short CAT application training on a human cadaver. RESULTS: The mean time needed to stop the simulated bleeding in the first attempt was 38.33 seconds (SD±35.14). After the training, the mean time decreased to 20.58 seconds (SD±5.77). A statistically significant difference was observed between these two values (p=0.004). CONCLUSION: This study demonstrated that training conducted on human cadavers led to a significant improvement in the effectiveness of CAT use. Cadavers constitute a high-quality educational tool that, after adequate preparation, allows for practicing invasive medical procedures, such as extremity haemorrhage control.

The effects of a community-based disaster drill of simulating Disaster Medical Assistance Team (DMAT) on the knowledge and attitudes.

BACKGROUND: We evaluated the effects of community-based disaster drill of simulating disaster medical assistance team on the knowledge and the attitudes. METHODS: Eight hours disaster drills, including didactic lectures, table simulation, and outdoor field simulation, were developed for participants who were recruited from community health centers, emergency departments, fire stations, emergency medical technicians' academy, and emergency information center in the Seoul Metropolitan City area from 2006 to 2008. We surveyed on the knowledge and the attitude using designed questionnaire before and after drill. We compared changes using t-test and repeated measure ANOVA. RESULTS: In this study, 14 community-based drills were performed and 525 (79.4%) people responded to both pre- and post-drill survey. Of these, the doctor was the second common occupation (26.9%) after volunteer students (47.1%). Overall, knowledge and attitude score significantly increased from 3.9±1.0 to 4.3±0.9 (p<0.001) and from 21.4±3.4 to 22.4±3.2 (p<0.001), respectively. The difference among professional license groups between pre- and post-drill knowledge level was significant (p=0.03), while the difference among jobs for attitude between pre- and post-drill was not different (p=0.78). CONCLUSION: Disaster drills on the establishment and operation of DMAT may affect both knowledge and attitude of participants positively.

Preplanned participation of paramedics in end-of-life care at home: A retrospective cohort study.

BACKGROUND: Paramedics commonly face acute crises of patients in palliative care, but their involvement in end-of-life care is not planned systematically. AIM: To evaluate a protocol for end-of-life care at home including pre-planned integration of paramedics and end-of-life care wards. DESIGN: Paramedic visits to patients in end-of-life care protocol were retrospectively studied. SETTING/PARTICIPANTS: All of the patients who had registered for the protocol between 1 March 2015 and 28 February 2017 in North Karelia, Finland, were included in this study. RESULTS: A total of 256 patients were registered for the protocol and 306 visits by paramedic were needed. A need for symptom control (38%) and transportation (29%) were the most common reasons for a visit. Paramedics visited 43% and 70% of the patients in areas with and without 24/7 palliative home care services, respectively (p < 0.001); while 58% of all the visits were done outside of office hours. Problems were resolved at home in 31% of the visits. The patient was transferred to a pre-planned end-of-life care ward and to an emergency department in 48% and 16% of the cases, respectively. More patients died in end-of-life care wards in areas without (54%) than with (33%) 24/7 home care services (p = 0.001). CONCLUSIONS: Integration of paramedics into end-of-life care at home is reasonable especially in rural areas without 24/7 palliative care services and outside of office hours. The majority of patients can be managed at home or with the help of an end-of-life care ward without an emergency visit.

Utility of Severity-Based Prehospital Triage for Endovascular Thrombectomy: ACT-FAST Validation Study.

BACKGROUND AND PURPOSE: Severity-based assessment tools may assist in prehospital triage of patients to comprehensive stroke centers (CSCs) for endovascular thrombectomy (EVT), but criticisms regarding diagnostic inaccuracy have not been adequately addressed. This study aimed to quantify the benefits and disadvantages of severity-based triage in a large real-world paramedic validation of the Ambulance Clinical Triage for Acute Stroke Treatment (ACT-FAST) algorithm. METHODS: Ambulance Victoria paramedics assessed the prehospital ACT-FAST algorithm in patients with suspected stroke from November 2017 to July 2019 following an 8-minute training video. All patients were transported to the nearest stroke center as per current guidelines. ACT-FAST diagnostic accuracy was compared with hospital imaging for the presence of large vessel occlusion (LVO) and need for CSC-level care (LVO, intracranial hemorrhage, and tumor). Patient-level time saving to EVT was modeled using a validated Google Maps algorithm. Disadvantages of CSC bypass examined potential thrombolysis delays in non-LVO infarcts, proportion of patients with false-negative EVT, and CSC overburdening. RESULTS: Of 517 prehospital assessments, 168/517 (32.5%) were ACT-FAST positive and 132/517 (25.5%) had LVO. ACT-FAST sensitivity and specificity for LVO was 75.8% and 81.8%, respectively. Positive predictive value was 58.8% for LVO and 80.0% when intracranial hemorrhage and tumor (CSC-level care) were included. Within the metropolitan region, 29/55 (52.7%) of ACT-FAST-positive patients requiring EVT underwent a secondary interhospital transfer. Prehospital bypass with avoidance of secondary transfers was modeled to save 52 minutes (95% CI, 40.0-61.5) to EVT commencement. ACT-FAST was false-positive in 8 patients receiving thrombolysis (8.1% of 99 non-LVO infarcts) and false-negative in 4 patients with EVT requiring secondary transfer (5.4% of 74 EVT cases). CSC bypass was estimated to over-triage 1.1 patients-per-CSC-per-week in our region. CONCLUSIONS: The overall benefits of an ACT-FAST algorithm bypass strategy in expediting EVT and avoiding secondary transfers are estimated to substantially outweigh the disadvantages of potentially delayed thrombolysis and over-triage, with only a small proportion of EVT patients missed.

Paramedic utilization of Vision, Aphasia, Neglect (VAN) stroke severity scale in the prehospital setting predicts emergent large vessel occlusion stroke.

BACKGROUND: Numerous stroke severity scales have been published, but few have been studied with emergency medical services (EMS) in the prehospital setting. We studied the Vision, Aphasia, Neglect (VAN) stroke assessment scale in the prehospital setting for its simplicity to both teach and perform. This prospective prehospital cohort study was designed to validate the use and efficacy of VAN within our stroke systems of care, which includes multiple comprehensive stroke centers (CSCs) and EMS agencies. METHODS: The performances of VAN and the National Institutes of Health Stroke Scale (NIHSS) ≥6 for the presence of both emergent large vessel occlusion (ELVO) alone and ELVO or any intracranial hemorrhage (ICH) combined were reported with positive predictive value, sensitivity, negative predictive value, specificity, and overall accuracy. For subjects with intraparenchymal hemorrhage, volume was calculated based on the ABC/2 formula and the presence of intraventricular hemorrhage was recorded. RESULTS: Both VAN and NIHSS ≥6 were significantly associated with ELVO alone and with ELVO or any ICH combined using χ2 analysis. Overall, hospital NIHSS ≥6 performed better than prehospital VAN based on statistical measures. Of the 34 cases of intraparenchymal hemorrhage, mean±SD hemorrhage volumes were 2.5±4.0 mL for the five VAN-negative cases and 17.5±14.2 mL for the 29 VAN-positive cases. CONCLUSIONS: Our VAN study adds to the published evidence that prehospital EMS scales can be effectively taught and implemented in stroke systems with multiple EMS agencies and CSCs. In addition to ELVO, prehospital scales such as VAN may also serve as an effective ICH bypass tool.

Beyond Tools: Continuous High-Fidelity Training at the Center of Successful First-Pass Intubation in Ground Emergency Medical Services.

OBJECTIVE: Increased emphasis on the use of video laryngoscopy in emergency medical services has potentially caused providers to forfeit the skills required to perform direct laryngoscopy. The purpose of this study was to determine if the introduction of a continuous high-fidelity training program improves first-pass intubation success in a non-rapid sequence induction ground-based emergency medical services agency with an established video laryngoscopy program. METHODS: This is a retrospective analysis of quality improvement data of advanced airway management performed by an ambulance service between 2012 and 2019. A mandatory biannual high-fidelity simulation training curriculum was introduced at the beginning of 2017. RESULTS: A total of 459 patients underwent intubation attempts during the 7-year study period. First-pass intubation success improved from 57.6% to 81.4%, an improvement of 23.8% (95% confidence interval [CI], 15.4-31.5; P < .001), and overall intubation success improved from 77% to 91%, an improvement of 14.1% (95% CI, 7.3-20.3; P < .001). The average number of intubation attempts per patient decreased by 0.19 (95% CI, 0.09-0.29; P < .0003). The mean time of arrival to intubation time increased by 2.21 minutes (95% CI, 0.84-3.58; P = .0016). CONCLUSION: Implementation of a high-fidelity airway training program is associated with improvements in overall endotracheal intubation and first-pass endotracheal intubation success rates in all adult patient categories.

Clinical value of bedside abdominal sonography performed by certified sonographer in emergency evaluation of blunt abdominal trauma.

PURPOSE: To investigate the accuracy and efficiency of bedside ultrasonography application performed by certified sonographer in emergency patients with blunt abdominal trauma. METHODS: The study was carried out from 2017 to 2019. Findings in operations or on computed tomography (CT) were used as references to evaluate the accuracy of bedside abdominal ultrasonography. The time needed for bedside abdominal ultrasonography or CT examination was collected separately to evaluate the efficiency of bedside abdominal ultrasonography application. RESULTS: Bedside abdominal ultrasonography was performed in 106 patients with blunt abdominal trauma, of which 71 critical patients received surgery. The overall diagnostic accordance rate was 88.68%. The diagnostic accordance rate for liver injury, spleen injury, kidney injury, gut perforation, retroperitoneal hematoma and multiple abdominal organ injury were 100%, 94.73%, 94.12%, 20.00%, 100% and 81.48%, respectively. Among the 71 critical patients, the diagnostic accordance rate was 94.37%, in which the diagnostic accordance rate for liver injury, spleen injury, kidney injury, gut perforation and multiple abdominal organ injury were 100%, 100%, 100%, 20.00% and 100%. The mean time for imaging examination of bedside abdominal ultrasonography was longer than that for CT scan (4.45 ± 1.63 vs. 2.38 ± 1.19) min; however, the mean waiting time before examination (7.37 ± 2.01 vs. 16.42 ± 6.37) min, the time to make a diagnostic report (6.42 ± 3.35 vs. 36.26 ± 13.33) min, and the overall time (17.24 ± 2.33 vs. 55.06 ± 6.96) min were shorter for bedside abdominal ultrasonography than for CT scan. CONCLUSION: Bedside ultrasonography application provides both efficiency and reliability for the assessment of blunt abdominal trauma. Especially for patients with free peritoneal effusion and critical patients, bedside ultrasonography has been proved obvious advantageous. However, for negative bedside ultrasonography patients with blunt abdominal trauma, we recommend further abdominal CT scan or serial ultrasonography scans subsequently.