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.

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.

Using G-FAST to recognize emergent large vessel occlusion: a training program for a prehospital bypass strategy.

INTRODUCTION: The shorter the time between the onset of symptoms and reperfusion using endovascular thrombectomy, the better the functional outcome of patients. A training program was designed for emergency medical technicians (EMTs) to learn the gaze-face-arm-speech-time test (G-FAST) score for initiating a prehospital bypass strategy in an urban city. This study aimed to evaluate the effect of the training program on EMTs. METHODS: All EMTs in the city were invited to join the training program. The program consisted of a 30 min lecture and a 20 min video which demonstrated the G-FAST evaluation. The participants underwent tests before and after the program. The tests included (1) a questionnaire of knowledge, attitudes, confidence, and behaviors towards stroke care; and (2) watching 10 different scenarios in a video and answering questions, including eight sub-questions of G-FAST parameters, and choosing a suitable receiving hospital. RESULTS: In total, 1058 EMTs completed the training program. After the program, significant improvement was noted in knowledge, attitudes, and confidence, as well as scenario judgement. The performance of the EMTs in evaluating G-FAST criteria in comatose patients was relatively poor in the pre-test and improved significantly after the training course. Although the participants answered the G-FAST items correctly, they tended to overtriage the patients and refer them to higher-level hospitals. CONCLUSIONS: A short training program can improve the ability to identify stroke patients and choose a suitable receiving hospital. A future training program could put further emphasis on how to evaluate comatose patients and choose a suitable receiving hospital.

Supraglottic airway device placement by respiratory therapists.

OBJECTIVE: Respiratory Therapists (RTs) are some of the first staff to arrive at in-hospital incidents where cardiopulmonary resuscitation (CPR) is needed, yet at some facilities, their ability to intubate is limited by hospital scope of practice. During the intubation process, CPR is often interrupted which could potentially increase the likelihood of adverse patient outcomes. Training RTs to secure the airway using non-intubation methods may reduce or eliminate time for CPR interruptions and allow for earlier continuous/uninterrupted chest compressions. DESIGN: A pilot study was developed to assess the effectiveness of a new policy for RT scope of practice. METHODS: RTs were trained for supraglottic airway device placement prior to procedure initiation. After each device insertion event, RTs completed a written survey. Time between cardiac arrest and device insertion, number of insertion attempts, ease of placement, technical specifications of the device, complications, and survival were compiled and compared between supraglottic airway device and endotracheal tube (ETT) placement. RESULTS: Procedural information from 23 patients who received a supraglottic airway device during the trial was compared to retrospective data of CPR events requiring intubation from the previous year. Time between initiation of cardiac arrest and advanced airway placement decreased significantly (p < 0.0001) when RTs placed the supraglottic airway device (4.7 min) versus ETT at CPR events the previous year (8.6 min). Device-associated complications were minimal and patient mortality was the same regardless of device. CONCLUSION: We propose that more RTs should be trained to insert supraglottic airway devices during inpatient CPR events.

Association of Prehospital Advanced Life Support by Physician With Survival After Out-of-Hospital Cardiac Arrest With Blunt Trauma Following Traffic Collisions: Japanese Registry-Based Study.

Importance: Controversy remains as to whether advanced life support (ALS) or basic life support (BLS) is superior for critically ill and injured patients, including out-of-hospital cardiac arrest (OHCA) and major trauma, in the prehospital setting. Objective: To assess whether prehospital ALS should be provided for traumatic OHCA and who should perform it. Design, Setting, and Participants: Japanese government-managed nationwide population-based registry data of patients with OHCA transported to an emergency hospital were analyzed. Patients who experienced traumatic OHCA following a traffic collision from 2013 to 2014 were included. Patients provided prehospital ALS by a physician were compared with both patients provided ALS by emergency medical service (EMS) personnel and patients with only BLS. The data were analyzed on May 1, 2017. Exposures: Advanced life support by physician, ALS by EMS personnel, or BLS only. Main Outcomes and Measures: The primary outcome was 1-month survival. The secondary outcomes were prehospital return of spontaneous circulation and favorable neurologic outcomes with the Glasgow-Pittsburgh cerebral performance category score of 1 or 2. Results: A total of 4382 patients were included (mean [SD] age, 57.5 [22.2] years; 67.9% male); 828 (18.9%) received prehospital ALS by physician, 1591 (36.3%) received prehospital ALS by EMS personnel, and 1963 (44.8%) received BLS only. Among these patients, 96 (2.2%) survived 1 month after OHCA, including 26 of 828 (3.1%) for ALS by physician, 25 of 1591 (1.6%) for ALS by EMS personnel, and 45 of 1963 (2.3%) for BLS. After adjusting for potential confounders using multivariable logistic regression, ALS by physician was significantly associated with higher odds for 1-month survival compared with both ALS by EMS personnel and BLS (adjusted OR, 2.13; 95% CI, 1.20-3.78; and adjusted OR, 1.94; 95% CI, 1.14-3.25; respectively), whereas there was no significant difference between ALS by EMS personnel and BLS (adjusted OR, 0.91; 95% CI, 0.54-1.51). A propensity score-matched analysis in the ALS cohort showed that ALS by physician was associated with increased chance of 1-month survival compared with ALS by EMS personnel (risk ratio, 2.00; 95% CI, 1.01-3.97; P = .04). This association was consistent across a variety of sensitivity analyses. Conclusions and Relevance: In traumatic OHCA, ALS by physician was associated with increased chance of 1-month survival compared with both ALS by EMS personnel and BLS.

Comparison of success rates between two video laryngoscope systems used in a prehospital clinical trial.

OBJECTIVES: The primary aims of this study were to compare paramedic success rates and complications of two different video laryngoscopes in a prehospital clinical study. METHODS: This study was a multi-agency, prospective, non-randomized, cross over clinical trial involving paramedics from four different EMS agencies. Following completion of training sessions, six Storz CMAC™ video laryngoscopes and six King Vision™ (KV) video laryngoscopes were divided between agencies and placed into service for 6 months. Paramedics were instructed to use the video laryngoscope for all patients estimated to be ≥ 18 years old who required advanced airway management per standard operating procedure. After 6 months, the devices were crossed over for the final 6 months of the study period. Data collection was completed using a telephone data collection system with a member of the research team (available 24/7). First attempt success, overall success, and success by attempt, were compared between treatment groups using exact logistic regression adjusted for call type and user experience. RESULTS: Over a 12-month period, 107 patients (66 CMAC, 41 KV) were treated with a study device. The CMAC had a significantly higher likelihood of first attempt success (OR = 1.85; 95% CI 0.74, 4.62; p = 0.188), overall success (OR = 7.37; 95% CI 1.73, 11.1; p = 0.002), and success by attempt (OR = 3.38; 95% CI 1.67, 6.8; p = 0.007) compared to KV. Providers reverted to direct laryngoscopy in 80% (27/34) of the video laryngoscope failure cases, with the remaining patients having their airways successfully managed with a supraglottic airway in 3 cases and bag-valve mask in 4 cases. The provider-reported complications were similar and none were statistically different between treatment groups. Complication rates were not statistically different between devices. CONCLUSION: The CMAC had a higher likelihood of successful intubation compared to the King Vision. Complication rates were not statistically different between groups. Video laryngoscope placement success rates were not higher than our historical direct laryngoscopy success rates.

Unfit for duty? Evaluation of 4 years of paramedic preemployment fitness screening test results.

BACKGROUND: Preemployment testing is utilized by many ambulance services. Surprisingly, there is limited published research on the efficacy of this testing in determining an employee's ability to complete the requirements of this physically demanding occupation. OBJECTIVES: The purpose of this study was to analyze the preemployment fitness test results from a 4-year cohort of paramedic students from an Australian university. To date, no published studies have reported on the fitness test scores for paramedic students or on whether overall test score is biased toward any particular test components. Similarly, no data have been presented on whether there are gender differences in scores for individual test components or overall test score. METHODS: Retrospective cohort study of de-identified data from 4 years of data from Paramedic Science students (n = 251) (mean age = 24.9 years). Data were recorded from the Queensland Ambulance Service (QAS) Health Related Fitness Test (HRFT), a preemployment fitness test used by an Australian state ambulance service. HRFT score is calculated out of a possible 100 points and is based on performance scores in nine component fitness tests. Raw test scores for each of these component tests are ranked on a 0-4 scale prior to these data being scaled and summed to generate the overall HRFT score. An overall score >24.99 is awarded a "Pass." Results. Five individuals failed to "Pass" the HRFT. Overall HRFT scores were influenced significantly by performance in the strength tests, with males also recording significantly (p < 0.005) higher scores in all of the strength tests than females. Similarly, approximately 40% of the female participants, compared to 6% of males, achieved an overall test "Pass" and yet gained a ranked score of 0 in at least three of the component tests. CONCLUSIONS: It was concluded that the scoring system did not exclude participants with poor fitness levels, as many participants recorded low scores in several test components yet still passed the test. We recommend that before redesigning the HRFT, studies should be first conducted on the occupational demands and physical standards required for this important profession.

Rural EMS en route IV insertion improves IV insertion success rates and EMS scene time.

BACKGROUND: Emergency medical service (EMS) personnel are trained to insert intravenous (IV) lines at trauma scenes if the time for insertion does not prolong scene time. However, EMS providers continue to insert IV lines on scene. METHODS: A rural EMS provider provided trauma patient EMS IV insertion data for a 1-year period. No IV lines were inserted en route during this period. During the following 1-year period, a prospective trauma patient study protocol was instituted in which all IV insertions were attempted while en route to the emergency room. RESULTS: Three hundred six trauma patients had IV attempts on scene, and 341 trauma patients had IV insertion attempts en route. The average EMS on-scene time with IV insertions on scene was 19.8 minutes (IV insertion success, 79%) compared with 13.9 minutes (IV insertion success, 93%) on-scene time with IV insertions en route. CONCLUSIONS: EMS IV insertion en route significantly decreases on-scene time and improves IV insertion success rates.

Patient identification errors are common in a simulated setting.

STUDY OBJECTIVE: We evaluate the frequency and accuracy of health care workers verifying patient identity before performing common tasks. METHODS: The study included prospective, simulated patient scenarios with an eye-tracking device that showed where the health care workers looked. Simulations involved nurses administering an intravenous medication, technicians labeling a blood specimen, and clerks applying an identity band. Participants were asked to perform their assigned task on 3 simulated patients, and the third patient had a different date of birth and medical record number than the identity information on the artifact label specific to the health care workers' task. Health care workers were unaware that the focus of the study was patient identity. RESULTS: Sixty-one emergency health care workers participated--28 nurses, 16 technicians, and 17 emergency service associates--in 183 patient scenarios. Sixty-one percent of health care workers (37/61) caught the identity error (61% nurses, 94% technicians, 29% emergency service associates). Thirty-nine percent of health care workers (24/61) performed their assigned task on the wrong patient (39% nurses, 6% technicians, 71% emergency service associates). Eye-tracking data were available for 73% of the patient scenarios (133/183). Seventy-four percent of health care workers (74/100) failed to match the patient to the identity band (87% nurses, 49% technicians). Twenty-seven percent of health care workers (36/133) failed to match the artifact to the patient or the identity band before performing their task (33% nurses, 9% technicians, 33% emergency service associates). Fifteen percent (5/33) of health care workers who completed the steps to verify patient identity on the patient with the identification error still failed to recognize the error. CONCLUSION: Wide variation exists among health care workers verifying patient identity before performing everyday tasks. Education, process changes, and technology are needed to improve the frequency and accuracy of patient identification.

The out-of-hospital validation of the Canadian C-Spine Rule by paramedics.

STUDY OBJECTIVE: We designed the Canadian C-Spine Rule for the clinical clearance of the cervical spine, without need for diagnostic imaging, in alert and stable trauma patients. Emergency physicians previously validated the Canadian C-Spine Rule in 8,283 patients. This study prospectively evaluates the performance characteristics, reliability, and clinical sensibility of the Canadian C-Spine Rule when used by paramedics in the out-of-hospital setting. METHODS: We conducted this prospective cohort study in 7 Canadian regions and involved alert (Glasgow Coma Scale score 15) and stable adult trauma patients at risk for neck injury. Advanced and basic care paramedics interpreted the Canadian C-Spine Rule status for all patients, who then underwent immobilization and assessment in the emergency department to determine the outcome, clinically important cervical spine injury. RESULTS: The 1,949 patients enrolled had these characteristics: median age 39.0 years (interquartile range 26 to 52 years), female patients 50.8%, motor vehicle crash 62.5%, fall 19.9%, admitted to the hospital 10.8%, clinically important cervical spine injury 0.6%, unimportant injury 0.3%, and internal fixation 0.3%. The paramedics classified patients for 12 important injuries with sensitivity 100% (95% confidence interval [CI] 74% to 100%) and specificity 37.7% (95% CI 36% to 40%). The kappa value for paramedic interpretation of the Canadian C-Spine Rule (n=155) was 0.93 (95% CI 0.87 to 0.99). Paramedics conservatively misinterpreted the rule in 320 (16.4%) patients and were comfortable applying the rule in 1,594 (81.7%). Seven hundred thirty-one (37.7%) out-of-hospital immobilizations could have been avoided with the Canadian C-Spine Rule. CONCLUSION: This study found that paramedics can apply the Canadian C-Spine Rule reliably, without missing any important cervical spine injuries. The adoption of the Canadian C-Spine Rule by paramedics could significantly reduce the number of out-of-hospital cervical spine immobilizations.

The disappearing endotracheal tube: historic skill threatened by lack of practice & new devices.

When paramedics were first introduced in the 1970s, one of the most controversial aspects of their training program was endotracheal intubation (ETI). Prior to that, the skill of intubating the trachea was purely the domain of physicians and nurse anesthetists. Thus, it was difficult to secure time when paramedic students could practice their intubations skills on live patients. In actuality, many paramedics of that era were graduated without ever having the opportunity to perform an ETI on a living patient.

Airtraq vs standard laryngoscopy by student paramedics and experienced prehospital laryngoscopists managing a model of difficult intubation.

Two consecutive, randomised, cross-over trials compared intubation success rates in third-year paramedic students and experienced prehospital practitioners using the Airtraq or a Macintosh laryngoscope with flexible stylet in a manikin model of a Cormack and Lehane grade III/IV laryngoscopic view. First-time intubation rates for the Macintosh and Airtraq for students were 0/23 (0%) vs 10/23 (44%) (44% difference, 95% CI 26-63%, p < 0.001) and for experienced laryngoscopists were 14/56 (25%) vs 47/56 (84%) (59% difference, 95% CI 42-72%, p < 0.0001), respectively. First-time oesophageal intubation rates for students were 15/23 (65%) vs 3/23 (13%) (-52% difference, 95% CI -25 to -72%, p < 0.001) and for experienced practitioners 9/56 (16%) vs 0/56 (0%) (-16% difference, 95% CI -9 to -28%, p = 0.0014). Student paramedics and experienced prehospital laryngoscopists managing a manikin model of a grade III/IV view had increased first-time intubation rates and had lower rates of oesophageal intubation with the Airtraq compared with a standard laryngoscope.

Paramedic intubation errors: isolated events or symptoms of larger problems?

Paramedics provide life-saving emergency medical care to patients in the out-of-hospital setting, but only selected emergency interventions have proved to be safe or effective. Endotracheal intubation (the insertion of an emergency breathing tube into the trachea) is an important and high-profile procedure performed by paramedics. In our study population, we found that errors occurred in 22 percent of intubation attempts, with a frequency of up to 40 percent in selected ambulance systems. These findings indicate frequent errors associated with this life-saving technique. These events might be emblematic of larger issues in the structure and delivery of out-of-hospital emergency care.

Errors of omission in the treatment of prehospital chest pain patients.

OBJECTIVE: Despite the widespread use of standard treatment protocols, there are few published data regarding paramedic protocol adherence. In this descriptive study, the authors sought to assess the frequency and nature of deviations from a standardized treatment protocol for the chief complaint of chest pain. They also sought to quantify any time delays in treatment of potential ischemic cardiac chest pain. METHODS: A retrospective review of written documentation obtained from four ambulance services in a mid-Atlantic state was completed. A convenience sample of consecutive emergency medical services (EMS) records was obtained from January 2001 to May 2002, and 75 calls were selected from each service (N = 300). RESULTS: Neither the median scene times nor the response times varied among the four services in the study. However, the suburban ambulance service (service 1) did have a significantly longer transport time (19 minutes) than the rural (14 minutes) and the urban (11 and 10 minutes) services (p < 0.05). Documentation of history and physical characteristics varied widely for each service. The patient took aspirin 10% of the time prior to EMS arrival, yet paramedics gave it additionally 50% of the time, while nitroglycerin was given in 73% of cases of suspected cardiac ischemia. Posttreatment vital signs for nitroglycerin were documented 30% of the time for three of the four services, while the other service documented these 75% of the time. Medical command contact varied by agency (80-100%), as did the receipt and completion of medical orders. CONCLUSIONS: Paramedics may delay transport of patients with potential cardiac ischemia. Deviations from protocol occur frequently and the care documented for prehospital patients with chest pain is variable. The expected care described by written protocols does not correlate with the treatment documented.

Intubation confirmation techniques associated with unrecognized non-tracheal intubations by pre-hospital providers.

This study examined pre-hospital intubations performed by paramedics, which were later determined to be non-tracheal upon arrival at an urban, academic emergency department (ED). The aim was to characterize the various confirmation techniques used among these unrecognized non-tracheal intubations. A retrospective review of the emergency medical services (EMS) quality assurance database was conducted over a period of 65 months. Paramedic patient care reports and hospital medical records were reviewed with regard to techniques used for airway evaluation. Simple descriptive statistics are used to summarize the data. During this study period, paramedics intubated 1643 patients. There were 35 (2%) intubations that were ultimately determined to be non-tracheal by receiving physicians. Among these, 20 (57%) were intubations for trauma indications. Seven patients (20%) were children (< 10 years). Fifteen patients (43%) did not have a pulse before intubation attempts. Overall, 21 (60%) had multiple confirmatory techniques employed by paramedics. The most commonly documented was 'equal lung sounds' (91%), followed by 'visualized cords' (52%). Per protocol, colorimetric end tidal CO2 was used selectively among patients with pulses, 9/20 (45%). Aspiration techniques were not used among this study population. Based on paramedic documentation, 17 (49%) of the non-tracheal intubations were potentially recognizable. An unrecognized, non-tracheal intubation is a potentially devastating consequence of failed airway management. We report a small, but important experience with failed pre-hospital airway management. In this EMS system, more frequent use of multiple confirmatory techniques (including end tidal CO2 detection) may help to reduce the incidence of this potentially life-threatening scenario.

An evaluation of paramedics' ability to screen older adults during emergency responses.

OBJECTIVES: This study evaluated the feasibility of using the emergency medical services (EMS) system as a public health provider by having paramedics screen older adults (age >or= 65 years) for influenza immunization status during emergency responses. It also determined the proportion of older-adult EMS patients who lacked an influenza vaccination. METHODS: A retrospective descriptive study was performed, with medical-record review for patients treated between January 2003 and April 2003. Patients were included if they were age 65 years and older, requested assistance via a 9-1-1 call, and were treated by one of 13 paramedics using a directed medical record. The authors calculated the proportion of patients successfully screened and the proportion who reported being nonimmunized. They also compared the patients screened and not screened by the EMS providers and patients who reported being immunized and reported being nonimmunized. RESULTS: Two hundred eighty-eight patients were eligible; the median age was 80 years, 53% were women, 73% were white, and 59% required advanced life support care. Paramedics successfully screened 177 patients (61%; 95% CI, 56-67%). Sixty-five patients (37%; 95% CI, 30-44%) reported being nonimmunized. Failure to screen was associated with a Glasgow Coma Scale score of 13 or less. Lack of immunization was associated with younger age and female gender. CONCLUSION: Paramedics can screen a majority of older adults for influenza immunization status during emergency responses. Older adult users of EMS reported lacking influenza vaccination at levels similar to national estimates. An EMS-based, paramedic-implemented screening program has the potential to identify older adults at risk for preventable illnesses and to augment traditional screening programs, but additional measures are needed to enhance screening rates.