Influence of Patient Weight on Prehospital Advanced Airway Procedure Success Rates.

OBJECTIVE: Previous investigations of the relationship between obesity and difficult airway management have provided mixed results. Almost universally, these studies were conducted in the hospital setting, and the influence of patient body weight on successful prehospital airway management remains unclear. Because patient weight could be one readily identifiable risk factor for problematic airway interventions, we sought to evaluate this relationship. METHODS: We conducted a retrospective analysis using the 2020 ESO Data Collaborative dataset. The inclusion criteria consisted of adult patients weighing >30kg with an attempted orotracheal intubation (OTI) and/or blind insertion airway device (BIAD) placement. Separate logistic regression models were developed to determine the influence of weight (dichotomized at 100 kg) on cumulative procedure success for OTI and BIAD, and linear regression models were used to identify trends for each across weight strata. RESULTS: A total of 45,344 patients met inclusionary criteria, among which 40,668(89.7%) suffered from a medical emergency, followed by 3,130(6.9%) with traumatic injuries, and 1,546(3.4%) attributable to a combined medical-trauma etiology. Cardiac arrest occurred either prior to EMS arrival or at some point during EMS care in 38,210(84.3%) patients. OTI was attempted in 18,153(40.0%) patients, while 21,597(47.6%) had a BIAD attempt and 5,594(12.3%) had both airway types attempted. The overall cumulative insertion success rates for OTI and BIAD were 79.5% and 92.7%, respectively. Altogether, 2,711(6.0%) had no advanced airway of any type successfully placed, which represents the overall failed advanced airway rate. After controlling for patient age, sex, minority status, and call type (medical vs. trauma), weight >100kg was associated with decreased likelihood of cumulative OTI success (OR = 0.64, p < 0.001), but higher likelihood of cumulative BIAD success (OR = 1.31, p < 0.001). Cumulative OTI success was associated with a negative 0.6% linear trend per 5 kg of body weight (p < 0.001) while cumulative BIAD success had a 0.2% positive trend (p < 0.001). CONCLUSION: This retrospective analysis of a national EMS database revealed that increasing patient weight was negatively associated with intubation success. A positive, but smaller, linear trend was observed for BIAD placement. Patient weight may be an easily identifiable predictor of difficult oral intubation and may be a consideration when selecting an airway management strategy.

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

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

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

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

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

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

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

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

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

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

Probability of Return of Spontaneous Circulation as a Function of Timing of Vasopressor Administration in Out-of-Hospital Cardiac Arrest.

INTRODUCTION: Vasopressors (epinephrine and vasopressin) are associated with return of spontaneous circulation (ROSC). Recent retrospective studies reported a greater likelihood of ROSC when vasopressors were administered within the first 10 minutes of arrest. However, it is unlikely that the relationship between ROSC and the timing of vasopressor administration is a binary function (i.e., ≤10 vs. >10 minutes). More likely, this relationship is a function of time measured on a continuum, with diminishing effectiveness even within the first 10 minutes of arrest, and potentially, some lingering benefit beyond 10 minutes. However, this relationship remains undefined. OBJECTIVE: To develop a model describing the likelihood of ROSC as a function of the call receipt to vasopressor interval (CRTVI) measured on a continuum. METHODS: We conducted a retrospective study of cardiac arrest using the North Carolina Prehospital Care Reporting System (PREMIS). Inclusionary criteria were all adult patients suffering a witnessed, nontraumatic arrest during January-June 2012. Chi-square and t-tests were used to analyze the relationships between ROSC and CRTVI; patient age, race, and gender; endotracheal intubation (ETI); automated external defibrillator (AED) use; presenting cardiac rhythm; and bystander cardiopulmonary resuscitation (CPR). A multivariate logistic regression model calculated the odds ratio (OR) of ROSC as a function of CRTVI while controlling for potential confounding variables. RESULTS: Of the 1,122 patients meeting inclusion criteria, 542 (48.3%) experienced ROSC. ROSC was less likely with increasing CRTVI (OR = 0.96, p < 0.01). Compared to patients with shockable rhythms, patients with asystole (OR = 0.42, p < 0.01) and pulseless electrical activity (OR = 0.52, p < 0.01) were less likely to achieve ROSC. Males (OR = 0.64, p = 0.02) and patients receiving bystander CPR (OR = 0.42, p < 0.01) were less likely to attain ROSC, although emergency medical services response times were significantly longer among patients receiving bystander CPR. Race, age, ETI, and AED were not predictors of ROSC. CONCLUSIONS: We found that time to vasopressor administration is significantly associated with ROSC, and the odds of ROSC declines by 4% for every 1-minute delay between call receipt and vasopressor administration. These results support the notion of a time-dependent function of vasopressor effectiveness across the entire range of administration delays rather than just the first 10 minutes. Large, prospective studies are needed to determine the relationship between the timing of vasopressor administration and long-term outcomes.

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

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

Creating a state medical response system for medical disaster management: the North Carolina experience.

The purpose of this work was to examine the creation and evolution of the North Carolina state medical response system (SMRS). During the past 30 years, states and local communities have developed a somewhat incongruent patchwork of medical disaster response systems. Several local or regional programs participated in the National Disaster Medical System; however, aside from the Disaster Medical Assistance Teams, most of these local resources lacked national standards and national direction. The September 11, 2001 terrorist attacks in Washington, DC and New York, and the anthrax-laced letters mailed to prominent individuals in the US media and others (bioterrorism) in the months that followed were tragic, but they served as both a tipping point and a unifying factor to drive preparedness activities on a national level. Each state responded to the September 11, 2001 attacks by escalating planning and preparedness efforts for a medical disaster response. The North Carolina SMRS was created based on the overall national direction and was tailored to meet local needs such as hurricane response. This article reviews the accomplishments to date and examines future aims. From regional medical response teams to specialty programs such as ambulance strike teams, burn surge planning, electronic inventory and tracking systems, and mobile pharmacy resources, the North Carolina SMRS has emerged as a national leader. Each regional coalition, working with state leadership, has developed resources and has used those resources while responding to disasters in North Carolina. The program is an example of how national leadership can work with state and local agencies to develop a comprehensive and effective medical disaster response system.

Continuity of an essential service during the COVID-19 pandemic: A systematic review and meta-analysis of vaccine perceptions and hesitancy in the emergency medical services profession.

During and subsequent to a natural disaster, there is an expectation that certain elements of society will continue to operate with a degree of normalcy. For example, it is expected that emergency medical services will continue to function and remain reliable for the community served. Expectations such as these are based on the presumed reliability of government and the assumption that those responsible for the relevant infrastructure will have made plans to ensure it remains functional and taken steps to mitigate known weaknesses. The COVID-19 pandemic provides a case in point. Specifically, data captured during the pandemic are now the subject of ongoing review and analysis, and the findings from such studies are being used to inform planning and preparedness for the next public health disaster. This particular study was conducted in response to circumstantial evidence indicating that frontline workers in the healthcare profession may share some of the same ambivalence towards transmission mitigation as seen in the general population when confronted with new and emerging communicable diseases. This is a concern, as when medical personnel are either unable or unwilling to take reasonable steps to protect themselves and their patients, it undermines the readiness of the essential service. To explore this situation in greater depth, the study examines the real-time responses from a sample of frontline personnel interviewed during the pandemic. The results indicate that there are a number of opportunities to improve workforce readiness to assure reliable continuity during the next outbreak, epidemic or pandemic.

Optimal weight-based epinephrine dosing for patients with a low likelihood of survival following out-of-hospital cardiac arrest.

INTRODUCTION: Cardiac arrest patients presenting with non-shockable rhythms have a low probability of survival, and epinephrine is one of the few pharmaceutical options for this group. The recommended 1.0 mg adult dose is extrapolated from early animal studies and lacks adjustment for patient weight. Although several prior studies have investigated "low-" and "high-" dose epinephrine, none have identified a benefit to either strategy. AIMS: To identify an optimal weight-based epinephrine dose for return-of-spontaneous-circulation (ROSC) after a single bolus among patients with low likelihood of survival. METHODS: Included were adult patients who experienced a witnessed, non-traumatic out-of-hospital cardiac arrest prior to EMS arrival. Patients with shockable presenting rhythms or receiving bystander CPR were excluded. The AUROC was used to assess the predictive value of epinephrine dose (mg/kg) for ROSC following a single bolus. From the ROC curve, the optimal threshold dosage (OTD) was determined using the Youden Index. A logistic regression model calculated the adjusted odds ratio of OTD on ROSC. RESULTS: A total of 2,463 patients met inclusion criteria, of which 190 (7.7%) attained ROSC after the first epinephrine administration. The dosage AUROC for ROSC was 0.603 (p < 0.01). As calculated by the Youden index, the OTD was 0.013 mg/kg. Patients receiving ≥ OTD were more likely to attain ROSC after a single epinephrine bolus (OR = 2.25,p < 0.001). CONCLUSIONS: Among patients with a low likelihood of survival, the optimal dose of epinephrine for attaining ROSC with a single bolus of epinephrine was 0.013 mg/kg. These findings should inspire further investigation into optimal dosing strategies for epinephrine.

Impact of delayed and infrequent administration of vasopressors on return of spontaneous circulation during out-of-hospital cardiac arrest.

INTRODUCTION: Epinephrine and vasopressin are the only vasopressors associated with return of spontaneous circulation (ROSC). While current guidelines recommend rapid and frequent vasopressor administration during cardiac arrest, delays in their administration in the out-of- hospital setting remain a concern. OBJECTIVE: This study evaluated delays in vasopressor administration and their effect on field ROSC. METHODS: This retrospective review included all adult patients who experienced cardiac arrest of medical origin and received field resuscitative efforts among 10 emergency medical services (EMS) systems. Data were abstracted from the EMS medical record and included response time intervals, calculated first-dose and interdosing intervals of vasopressors, and ROSC. Data were analyzed using Mann-Whitney tests, chi-square tests, and t-tests, survival analysis, and logistic regression, with p ≤ 0.05 indicating significance. RESULTS: A total of 660 cardiac arrest patients were enrolled in the study. The mean EMS response time was 8.8 minutes; 52.7% of patients had witnessed cardiac arrests, 46.2% received bystander cardiopulmonary resuscitation (CPR), 23.0% had shockable initial rhythms, and 19.5% experienced field ROSC. In total, 1,913 doses of epinephrine and 111 doses of vasopressin were administered, with mean and 90th-percentile scene arrival-to-first drug intervals of 9.5 and 17 minutes, respectively. The mean and 90th-percentile interdosing intervals were 6.1 and 10 minutes, respectively. Patients experiencing ROSC had shorter scene arrival-to-first drug intervals than those without ROSC (8.1 vs. 9.8 min, p < 0.01), but there was no difference in the mean interdosing interval (6.8 vs. 6.0 min, p = 0.57). In the logistic regression analysis of ROSC, the adjusted odds ratio for call receipt-to-first drug interval ≤10 minutes was 1.91 (p = 0.04). Patients receiving advanced airway control prior to vasopressor administration were less likely to have a call receipt-to-first drug interval within 10 minutes (4.0% vs. 17.3%, p < 0.01) and were less likely to attain ROSC (15.7% vs. 25.4%, p < 0.01). CONCLUSION: The interval between scene arrival and first administration of vasopressors is significantly shorter among patients who experience ROSC compared with those who do not. Airway control procedures delay vasopressor administration and reduce the likelihood of ROSC. Although the interdosing intervals of most patients were not consistent with current recommendations, there was no difference in the mean interdosing times between those who achieved ROSC and those who did not.

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

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

Quantifying the prevalence and predictors of burnout in emergency medical services personnel.

INTRODUCTION: Recently, burnout has amassed considerable attention because of deleterious effects on workers and the work environment. Frequently, EMS clinicians find themselves prone to experiencing burnout, yet little is known about etiologies in this population. OBJECTIVE: To estimate prevalence and predictors of burnout in EMS clinicians. METHODS: This was a cross-sectional survey study of nine EMS agencies from North Carolina selected based on geography and population. Emergency medical technicians (EMTs), advanced EMTs, and paramedics were included. Emergency medical responders and air medical personnel were excluded if those positions were a primary occupational function. The Professional Quality of Life (ProQOL) Scale was used to assess burnout. Parametric and nonparametric testing was used to assess factors potentially affecting burnout. Factors significant in univariate analyses were included in a hierarchical linear regression model to determine unique predictors of burnout while controlling for confounders. The area under the curve (AUC) of the receiver operating characteristic (ROC) was used to determine model predictability. RESULTS: A total of 686 EMS clinicians completed the survey. Overall, 57.3% (n = 393) were likely to have burnout. Of the 328 respondents who were likely to have burnout, 254 (77.4%) and 211 (75.1%) also were identified as likely to suffer from compassion fatigue or vicarious trauma, respectively. Overall, 152 (22.2%) were likely to suffer from all three stress disorders, 118 (56.5%) of which scored high enough to potentially produce immune system dysregulation. Prior suicidal thoughts ((sr2 = 0.042, p < 0.001), attempts (sr2 = 0.025, p < 0.001) or the presence of vicarious trauma (sr2 = 0.040, p < 0.001) accounted for 4.2%, 2.5%, and 4.0% of model variance, respectively. Years of field experience (sr2 = 0.035, p < 0.001) and credential level (sr2 = 0.011, p = 0.005) accounted for 4.6% of model variance. Finally, a respondent's experience or knowledge of debriefing (sr2 = 0.008, p = 0.023); experiencing adversity in childhood in the form of familial mental illness, depression, or suicide (sr2 = 0.009, p = 0.016); or the incarceration of a family member (sr2 = 0.010, p = 0.011) accounted for a combined 2.7% of model variance. Model predictability showed an AUCROC of 81.5%. CONCLUSIONS: This study showed a nearly 60% prevalence of occupational burnout in the group of EMS clinicians surveyed, making burnout of considerable concern in this population. Further study is needed to address occupational factors that contribute to burnout in EMS clinicians.

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

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

Time to first compression using Medical Priority Dispatch System compression-first dispatcher-assisted cardiopulmonary resuscitation protocols.

INTRODUCTION: Without bystander cardiopulmonary resuscitation (CPR), cardiac arrest survival decreases 7%-10% for every minute of delay until defibrillation. Dispatcher-assisted CPR (D-CPR) has been shown to increase the rates of bystander CPR and cardiac arrest survival. Other reports suggest that the most critical component of bystander CPR is chest compressions with minimal interruption. Beginning with version 11.2 of the Medical Priority Dispatch System (MPDS) protocols, instructions for mouth-to-mouth ventilation (MTMV) and pulse check were removed and a compression-first pathway was introduced to facilitate rapid delivery of compressions. Additionally, unconscious choking and third-trimester pregnancy decision-making criteria were added in versions 11.3 and 12.0, respectively. However, the effects of these changes on time to first compression (TTFC) have not been evaluated. OBJECTIVE: We sought to quantify the TTFC of MPDS versions 11.2, 11.3, and 12.0 for all calls identified as cardiac arrest on call intake that did not require MTMV instruction. METHODS: Audio recordings of all D-CPR events for October 2005 through May 2010 were analyzed for TTFC. Differences in TTFC across versions were compared using the Kruskal-Wallis test. RESULTS: A total of 778 cases received D-CPR. Of these, 259 were excluded because they met criteria for MTMV (pediatric patients, allergic reaction, etc.), were missing data, or were not initially identified as cardiac arrest. Of the remaining 519 calls, the mean TTFC was 240 seconds, with no significant variation across the MPDS versions (p = 0.08). CONCLUSIONS: Following the removal of instructions for pulse check and MTMV, as well as other minor changes in the MPDS protocols, we found the overall TTFC to be 240 seconds with little variation across the three versions evaluated. This represents an improvement in TTFC compared with reports of an earlier version of MPDS that included pulse checks and MTMV instructions (315 seconds). However, the MPDS TTFC does not compare favorably with reports of older, non-MPDS protocols that included pulse checks and MTMV. Efforts should continue to focus on improving this key, and modifiable, determinant of cardiac arrest survival.

Interevaluator reliability of a mock paramedic practical examination.

INTRODUCTION: Prior to graduation, paramedic students must be assessed for terminal competency and preparedness for national credentialing examinations. Although the procedures for determining competency vary, many academic programs use a practical and/or oral examination, often scored using skill sheets, for evaluating psychomotor skills. However, even with validated testing instruments, the interevaluator reliability of this process is unknown. Objective. We sought to estimate the interevaluator reliability of a subset of paramedic skills as commonly applied in terminal competency testing. METHODS: A mock examinee was videotaped performing staged examinations mimicking adult ventilatory management, oral board, and static and dynamic cardiac stations during which the examinee committed a series of prespecified errors. The videotaped performances were then evaluated by a group of qualified evaluators using standardized skill sheets. Interevaluator variability was measured by standard deviation and range, and reliability was evaluated using Krippendorff's alpha. Correlation between scores and evaluator demographics was assessed by Pearson correlation. RESULTS: Total scores and critical errors varied considerably across all evaluators and stations. The mean (± standard deviation) scores were 24.77 (±2.37) out of a possible 27 points for the adult ventilatory management station, 11.69 (±2.71) out of a possible 15 points for the oral board station, 7.79 (±3.05) out of a possible 12 points for the static cardiology station, and 22.08 (±1.46) out of a possible 24 points for the dynamic cardiology station. Scores ranged from 18 to 27 for adult ventilatory management, 7 to 15 for the oral board, 2 to 12 for static cardiology, and 19 to 24 for dynamic cardiology. Krippendorff's alpha coefficients were 0.30 for adult ventilatory management, 0.01 for the oral board, 0.10 for static cardiology, and 0.48 for dynamic cardiology. Critical criteria errors were assigned by 10 (38.5%) evaluators for adult ventilatory management, five (19.2%) for the oral board, and nine (34.6%) for dynamic cardiology. Total scores were not correlated with evaluator demographics. CONCLUSIONS: There was high variability and low reliability among qualified evaluators using skill sheets as a scoring tool in the evaluation of a mock terminal competency assessment. Further research is needed to determine the true overall interevaluator reliability of this commonly used approach, as well as the ideal number, training, and characteristics of prospective evaluators.

Association between poor sleep, fatigue, and safety outcomes in emergency medical services providers.

OBJECTIVE: To determine the association between poor sleep quality, fatigue, and self-reported safety outcomes among emergency medical services (EMS) workers. METHODS: We used convenience sampling of EMS agencies and a cross-sectional survey design. We administered the 19-item Pittsburgh Sleep Quality Index (PSQI), 11-item Chalder Fatigue Questionnaire (CFQ), and 44-item EMS Safety Inventory (EMS-SI) to measure sleep quality, fatigue, and safety outcomes, respectively. We used a consensus process to develop the EMS-SI, which was designed to capture three composite measurements of EMS worker injury, medical errors and adverse events (AEs), and safety-compromising behaviors. We used hierarchical logistic regression to test the association between poor sleep quality, fatigue, and three composite measures of EMS worker safety outcomes. RESULTS: We received 547 surveys from 30 EMS agencies (a 35.6% mean agency response rate). The mean PSQI score exceeded the benchmark for poor sleep (6.9, 95% confidence interval [CI] 6.6, 7.2). More than half of the respondents were classified as fatigued (55%, 95% CI 50.7, 59.3). Eighteen percent of the respondents reported an injury (17.8%, 95% CI 13.5, 22.1), 41% reported a medical error or AE (41.1%, 95% CI 36.8, 45.4), and 90% reported a safety-compromising behavior (89.6%, 95% CI 87, 92). After controlling for confounding, we identified 1.9 greater odds of injury (95% CI 1.1, 3.3), 2.2 greater odds of medical error or AE (95% CI 1.4, 3.3), and 3.6 greater odds of safety-compromising behavior (95% CI 1.5, 8.3) among fatigued respondents versus nonfatigued respondents. CONCLUSIONS: In this sample of EMS workers, poor sleep quality and fatigue are common. We provide preliminary evidence of an association between sleep quality, fatigue, and safety outcomes.

High school allied health students and their exposure to the profession of EMS.

INTRODUCTION: Ensuring a stable Emergency Medical Services (EMS) workforce is a growing concern, and effective recruiting strategies are needed to expose young adults to the EMS profession. The objective of this study was to assess the exposure of high school allied health students to EMS as a career option, as well as measure their attitudes and beliefs about the EMS profession. Hypothesis Few high school allied health students are exposed to EMS educational and career opportunities. METHODS: A convenience sample of allied health students in a rural high school system was surveyed about exposure to EMS, career intentions, factors impacting career decisions, and attitudes and beliefs about EMS. Descriptive statistics were calculated, and intention to pursue an EMS career was modeled using logistic regression. RESULTS: Of 171 students enrolled in allied health courses across six high schools, 135 (78.9%) agreed to participate; 85.2% were female. Almost all (92.6%) respondents intended to pursue a health career, but only 43.0% reported that their allied health course exposed them to EMS as a profession. Few participants (37.7%) were knowledgeable about EMS associate degree or baccalaureate degree (27.4%) programs. Only 20.7% of the respondents intended to pursue EMS as a career, although 46.0% wanted to learn more about the profession. Most (68.2%) students expressed interest in an emergency medical technician (EMT) course if one were offered, and 80.0% were interested in a ride-along program. Independent predictors of pursuing an EMS career included exposure to EMS outside of high school (OR = 7.4, 95% CI = 1.7-30.4); media influence on career choice (OR = 9.6, 95% CI = 1.8-50.1); and the belief that EMS was mentally challenging (OR = 15.9, 95% CI = 1.1-216.6). Negative predictors included the beliefs that an EMS career was stimulating (OR = 0.05, 95% CI = 0.00-0.53) and physically challenging (OR = 0.06, 95% CI = 0.00-0.63); as well as prior exposure to an EMS job advertisement (OR = 0.14, 0.03-0.53). CONCLUSIONS: Overall, there was a lack of exposure to career and educational options in EMS among allied health students in the school system studied, and few students intended to pursue an EMS career after graduation. However, the majority of students indicated they would like to learn more about EMS, and would enroll in an EMT course and ride-along program if available. These findings suggest that, with exposure to the profession, more allied health students could choose EMS as a career.

Predictors of COVID-19 Vaccination Among EMS Personnel.

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