Measuring the Effect of Audio Instructions on the Time and Effectiveness of Tourniquet Application by Laypeople.

OBJECTIVE: The "Stop the Bleed" campaign was created to educate laypeople about bleeding control and make bleeding control kits available in public locations. Unfortunately, previous research has indicated that up to half of all laypeople cannot effectively apply a tourniquet. The purpose of this study was to determine if laypeople could apply tourniquets more effectively with just-in-time training using combined audio-written instructions versus written-only instructions. METHODS: We conducted a prospective randomized study comparing the application of a tourniquet using a simulated bleeding arm. Participants were laypeople 18 years and older and excluded those with any previous tourniquet experience or training. Participants were randomized to just-in-time training using either audio-written or written-only instructions. Time in seconds to tourniquet application and the effectiveness of the tourniquet application was recorded. Effective application was defined as stopping the flow or significantly slowing the flow to a slow drip. Ineffective tourniquet placement was defined as not significantly changing the flow. Statistical analysis was performed using Fisher's exact, t-test, and linear regression. RESULTS: Eighty-two participants were included; 40 were in the audio-written instructions group, and 58.5% were male. The audio-written group's effective application rate was 92.5% and that of the written-only group was 76.2%. A significantly higher rate of ineffective tourniquet application was noted for the written-only group (23.8%), versus the audio-written group (7.5%), p = .04. Regardless of the type of instructions used, time to effective application of the tourniquet decreased as participant age increased (p = 0.02, 95%CI (-1.24, -0.13). There was no relationship between age and effective tourniquet application (p = 0.06). Time for tourniquet placement was not different between the audio-written (mean 100.4 seconds) and written-only (mean 106.1 seconds) groups (p = 0.58). CONCLUSION: This study suggests that combined audio-written instructions decrease the rate of ineffective tourniquet application by laypeople compared with written-only instructions. Further studies are needed to assess if audio instructions and just-in-time training can further maximize effective tourniquet application.

Prehospital Supraglottic Airways: An NAEMSP Position Statement and Resource Document.

Supraglottic airway (SGA) devices provide effective conduits for oxygenation and ventilation and may offer protection from gastric aspiration. SGA devices are widely used by EMS clinicians as both rescue and primary airway management devices. While in common use for more than four decades, major developments in SGA education, science, and technology have influenced clinical strategies of SGA insertion and use in prehospital airway management for patients of all ages. NAEMSP recommends:SGAs have utility as a primary or secondary EMS airway intervention. EMS agencies should select SGA strategies that best suit available resources and local clinician skillset, as well as the nature of their clinical practice setting.EMS agencies that perform endotracheal intubation must also equip their clinicians with SGA devices and ensure adequate training and competence.In select situations, drug-assisted airway management may be used by properly credentialed EMS clinicians to facilitate SGA insertion.Confirmation of initial and continuous SGA placement using waveform capnography is strongly encouraged as a best practice.When it is functioning properly, EMS clinicians should refrain from converting an SGA to an endotracheal tube. The decision to convert an SGA to an endotracheal tube must consider the patient's condition, the effectiveness of SGA ventilations, and the clinical context and course of initial SGA insertionSGA training, competency, and clinical use must be continuously evaluated by EMS agencies using focused quality management programs.

Characteristics and Diversity of ACGME Accredited Emergency Medical Services Fellowship Programs.

Introduction: There is a minimal amount of published data regarding to Emergency Medical Services (EMS) fellowship programs. The purpose of this study was to obtain program characteristics and diversity data regarding EMS fellowship programs. Methods: A survey was sent to program directors at all EMS fellowship programs accredited by the Accreditation Council of Graduate Medical Education (ACGME). Data collected included: year program started, year program accredited, unfilled fellow positions, number of EMS faculty, gender, and race/ethnicity. Gender and race/ethnicity data from EMS fellowships were compared to emergency medicine (EM) residencies using data from the American Association of Medical Colleges. Data were analyzed using IBM SPSS with descriptive statistics, and Chi-square tests. Results: The response rate for the survey was 88% (45/51) of all EMS fellowship programs that were accredited at the time of this survey. Most programs (71%) offer a one-year EMS fellowship, with the remaining offering an optional second year. The median number of physician response vehicles per program was 1.0 (IQR 0.0-2.0), with 24% (11/45) not having a dedicated physician response vehicle. This survey identified that 118 EMS fellows have graduated since inception of the accreditation process, while 34 positions went unfilled. The median number of EMS fellow positions per program was 2.0 (IQR 1.0-2.0), with a range of 1 to 4. It was noted that 31% of programs had no female EMS faculty, and 48% of programs had no under-represented minority EMS faculty. There was a significantly larger proportion of female faculty in EM residency programs (30.5%; 949/3,107) compared to EMS fellowships (19%; 53/274), OR = 1.8, 95% CI:1.3-2.5, p < 0.0001. There was a significantly larger proportion of female fellows in EMS (56%; 66/118) vs. female residents in EM (38%; 2,193/5,777), OR" = 2.1, 95% CI:1.4-3.0, p < 0.0001. There was a significantly larger proportion of under-represented minority faculty in EM residency programs (19.7%; 786/3,978) vs. EMS fellowships (12.0%, 33/274), OR = 1.8, 95% CI:1.2-2.6, p < 0.002. Conclusion: A significant number of EMS fellowship positions have remained unfilled since implementation of an accreditation process for EMS fellowships. The percentage of females and under-represented minority faculty in EMS programs was much lower than for EM residency programs.

Comparison Of The I-Gel Supraglottic And King Laryngotracheal Airways In A Simulated Tactical Environment.

BACKGROUND: When working in a tactical environment there are several different airway management options that exist. One published manuscript suggests that when compared to endotracheal intubation, the King LT laryngotracheal airway (KA) device minimizes time to successful tube placement and minimizes exposure in a tactical environment. However, comparison of two different blind insertion supraglottic airway devices in a tactical environment has not been performed. This study compared the I-Gel airway (IGA) to the KA in a simulated tactical environment, to determine if one device is superior in minimizing exposure and minimizing time to successful tube placement. METHODS: This prospective randomized cross over trial was performed using the same methods and tactical environment employed in a previously published study, which compared endotracheal intubation versus the KA in a tactical environment. The tactical environment was simulated with a one-foot vertical barrier. The participants were paramedic students who wore an Advanced Combat Helmet (ACH) and a ballistic vest (IIIA) during the study. Participants were then randomized to perform tactical airway management on an airway manikin with either the KA or the IGA, and then again using the alternate device. The participants performed a low military type crawl and remained in this low position during each tube placement. We evaluated the time to successful tube placement between the IGA and KA. During attempts, participants were videotaped to monitor their height exposure above the barrier. Following completion, participants were asked which airway device they preferred. Data was analyzed using Student's t-test across the groups for time to ventilation and height of exposure. RESULTS: In total 19 paramedic students who were already at the basic EMT level participated. Time to successful placement for the KA was 39.7 seconds (95%CI: 32.7-46.7) versus 14.4 seconds (95%CI: 12.0-16.9) for the IGA, p < 0.001. Maximum height exposure of the helmet above a one foot vertical barrier for the KA resulted in 1.42 inches of exposure (95%CI: 0.38-0.63) compared to the IGA with 1.42 inches, 95%CI:0.32-0.74, p = 0.99. On questioning 100% of the participants preferred the IGA device over the KA. CONCLUSION: In a simulated tactical environment placement of the IGA for airway management was faster than with the KA, but there was no difference in regard to exposure. Additionally, all the participants preferred using the IGA device over the KA.

Association between EMS Question Bank Completion and Passing Rates on the EMS Certification Examination.

INTRODUCTION: A board review question bank was created to assist candidates in their preparation for the 2015 EMS certification examination. We aimed to describe the development of this question bank and evaluate its successes in preparing candidates to obtain EMS subspecialty board certification. METHODS: An online question bank was developed by 13 subject matter experts who participated as item writers, representing eight different EMS fellowship programs. The online question bank consisted of four practice tests, with each of the tests comprised of 100 questions. The number of candidates who participated in and completed the question bank was calculated. The passing rate among candidates who completed the question bank was calculated and compared to the publicly reported statistics for all candidates. The relationship between candidates' performance on the question bank and subspecialty exam pass rates was determined. RESULTS: A total of 252 candidates took at least one practice test and, of those, 225 candidates completed all four 100-question practice tests. The pass rate on the 2015 EMS certification exam was 79% (95%CI 74-85%) among candidates who completed the question bank, which is 12% higher than the overall pass rate (p = 0.003). Candidates' performance on the question bank was positively associated with overall success on the exam (X2 = 75.8, p < 0.0001). Achieving a score of ≥ 70% on the question bank was associated with a higher likelihood of passing the exam (OR = 17.8; 95% CI: 8.0-39.6). CONCLUSION: Completing the question bank program was associated with improved pass rates on the EMS certification exam. Strong performance on the question bank correlated with success on the exam.

An innovative arrangement for in-vial membrane-assisted liquid-liquid microextraction: application to the determination of esters of phthalic acid in alcoholic beverages by gas chromatography-mass spectrometry.

A new arrangement for membrane-assisted liquid-liquid microextraction is presented. The extracting organic solvent was placed into a chromatographic microvial, compatible with the chromatograph autosampler, whose septum was replaced by a disc of porous hydrophobic membrane. This extraction device was completely immersed into the analytical sample contained in a cylindrical container subjected to rotary and basculant movement. Then, the extraction of analytes took place from the sample to the organic solvent contained in the vial through the membrane. Esters of the phthalic acid have been selected as model analytes to determine the performance characteristics of the extraction system. The limits of detection, limits of quantification and relative standard deviations (%) were in the range 0.1-0.4, 0.3-1 and 4-7, respectively. Esters of phthalic acid have been successfully analysed in alcoholic beverages. The main operational advantages of this arrangement consisted of minimal required handling, minimal risk of cross contamination and its simplicity.

Prehospital care of traumatic brain injury in North Carolina.

Traumatic brain injury results in more than 140,000 visits to North Carolina emergency departments annually. North Carolina first implemented a systematically organized approach to brain injury management in 1967, and the state's emergency medical services community continues to optimize patient care by incorporating evolving knowledge into protocols and procedures.

North Carolina College of Emergency Physicians' Guidance Document on Emergency Medical Services.

The North Carolina College of Emergency Physicians (NCCEP) Emergency Medical Services (EMS) Committee uses an evidence-based approach in writing its protocols and procedures. The most recent revision of the NCCEP document, which was started in late 2010, lasted for more than 1 year and utilized committee members from across the state. Four meetings were held at locations across North Carolina. In addition, 2 surveys were sent to get input from EMS providers. Since 2010, the document has been updated on an ongoing basis, aligning it with the latest evidence-based medicine.

Development of a new three-phase membrane-assisted liquid-phase microextraction method: determination of nitrite in tap water samples as model analytical application.

A novel and simple device for membrane-assisted liquid-phase microextraction is used for the first time in a three-phase system. The device consists of a glass vial containing the aqueous acceptor phase, whose septum of its screw stopper has been replaced by a sized piece of polytetrafluoroethylene membrane impregnated with n-decane. The vial is assembled to a volumetric flask containing the aqueous donor phase, and the membrane comes in contact alternatively with both donor and acceptor aqueous phases by orbital agitation. The device has been tested for the determination of nitrite in tap water samples, which is extensively carried out in routine analysis, as model analytical application. Experimental variables, such as the organic solvent used to form the supported liquid membrane, the volumes of both donor and acceptor phases, the orbital agitation rate, and the extraction time were studied and optimized in terms of enrichment factor. Under the selected working conditions, the analytical figures of merit for nitrite determination were a linearity range up to 50 ng mL(-1), limits of detection and quantification of 0.15 and 0.50 ng mL(-1), respectively, and a good repeatability (RSD < 10%). The method has been applied to four tap water samples of different origins, and accurate and precise results were achieved. Besides, the very low volume of organic solvent used, its low cost and the no-risk of cross-contamination are significant operational advantages.

Emergency medical services education research priorities during COVID-19: A modified Delphi study.

OBJECTIVE: Our objective was to identify research priorities to understand the impact of COVID-19 on initial emergency medical services (EMS) education. METHODS: We used a modified Delphi method with an expert panel (n = 15) of EMS stakeholders to develop consensus on the research priorities that are most important and feasible to understand the impact of the COVID-19 pandemic on initial EMS education. Data were collected from August 2020 to February 2021 over 5 rounds (3 electronic surveys and 2 live virtual meetings). In Round 1, participants submitted research priorities over 9 specific areas. Responses were thematically analyzed to develop a list of research priorities reviewed in Round 2. In Round 3, participants rated the priorities by importance and feasibility, with a weighted score (2/3*importance+1/3*feasibility) used for preliminary prioritization. In Round 4, participants ranked the priorities. In Round 5, participants provided their agreement or disagreement with the group's consensus of the top 8 research priorities. RESULTS: During Rounds 1 and 2, 135 ideas were submitted by the panel, leading to a preliminary list of 27 research priorities after thematic analysis. The top 4 research priorities identified by the expert panel were prehospital internship access, impact of lack of field and clinical experience, student health and safety, and EMS education program availability and accessibility. Consensus was reached with 10/11 (91%) participants in Round 5 agreeing. CONCLUSIONS: The identified research priorities are an important first step to begin evaluating the EMS educational infrastructure, processes, and outcomes that were affected or threatened through the pandemic.

Application of Different Commercial Tourniquets by Laypersons: Would Public-access Tourniquets Work Without Training?

BACKGROUND: The White House "Stop the Bleed" campaign has renewed interest in public-access bleeding kits and the use of tourniquets by the lay public. The objective of this study was to determine which type of tourniquet could be applied most effectively by the lay public using only manufacturer instructions included with each tourniquet. METHODS: This prospective study randomized participants to one of four different tourniquets (SOFTT-W, CAT, RMT, SWAT-T). Participants were all over 18 years of age. Individuals with prior military, EMS, or patient-care medical experience were excluded. Using only the manufacturer's packaging instructions, participants were asked to apply a tourniquet on a simulated bleeding arm. A trained observer noted if tourniquet application by the participant was effective, partially effective, or ineffective based on reduction or cessation of simulated blood flow. Participant's application of the tourniquet was also timed (in seconds) by the observer. The primary outcome of our study was the effectiveness of application for each of the four tourniquets. Secondary outcome was time to effective application. RESULTS: A total of 176 participants were enrolled. For untrained laypersons the RMT had the highest effective application rate of 64.4% and was also the most rapidly applied at 100.9 ± 8.8 seconds (95% confidence interval [CI] = 83.1 to 118.6). The SWAT-T had the highest ineffective application rate (55.5%) than any other tourniquet type (p = 0.002). There was no effect of age or education on time to application for any tourniquet type. Effective applications were performed significantly faster than partially effective or ineffective applications (93.4 ± 5.8 [95% CI = 81.7 to 104.9] vs. 136.7 ± 8.7 [95% CI = 118.8 to 154.7] vs. 151.9 ± 8.3 [95% CI = 135.2 to 168.6]; p ≤ 0.001). There was no difference in time between partial and ineffective applications (p = 0.261). CONCLUSIONS: Our study suggests that laypersons could benefit from prior training to effectively apply tourniquets in emergency situations. Of the tourniquets studied, the RMT was the most effectively and most rapidly applied.

Willingness of Emergency Medical Services Professionals to Respond to an Active Shooter Incident.

BACKGROUND: Historically, staging of civilian emergency medical services (EMS) during an active shooter incident was in the cold zone while these professionals awaited the scene to be completely secured by multiple waves of law enforcement. This delay in EMS response has led to the development of a more effective method: the Rescue Task Force (RTF). The RTF concept has the second wave of law enforcement escorting civilian EMS into the warm zone, thus decreasing EMS response time. To our knowledge, there are no data regarding the willingness of EMS professionals to enter a warm zone as part of an RTF. In this study, we assessed the willingness of EMS providers to respond to an active shooter incident as part of an RTF. METHODS: A survey was distributed at an annual, educational EMS conference in North Carolina. The surveys were distributed on the first day of the conference at the beginning of a general session that focused on EMS stress and wellness. Total attendance was measured using identification badges and scanners on exiting the session. Data were assessed using χ2 analysis, as were associations between demographics of interest and willingness to respond under certain conditions. A p value < .01 indicated statistical significance. RESULTS: The overall response rate was 76% (n = 391 of 515 session attendees). Most surveys were completed by paramedics (74%; n = 288 of 391). Most EMS professionals (75%; n = 293 of 391) stated they would respond to the given active shooter scenario as part of an RTF (escorted by the second wave of law enforcement) if they were given only ballistic gear. However, most EMS professionals (61%; n = 239 of 391) stated they would not respond if they were provided no ballistic gear and no firearm. Those with tactical or military training were more willing to respond with no ballistic gear and no firearm (49.6%; n = 68 of 137) versus those without such training (31%; n = 79 of 250; odds ratio, 2.2; 95% confidence interval, 1.4-3.3; p < .001). CONCLUSION: EMS professionals are willing to put themselves in harm's way by entering a warm zone if they are simply provided the proper training and ballistic equipment.

Motor vehicle crash fatalities among Hispanics in rural North Carolina.

OBJECTIVES: Deaths from motor vehicle crashes (MVCs) have decreased significantly over the past three decades. Unfortunately, few data have been collected regarding death rates for MVCs in minority populations. The purpose of this study was to compare the death rate of whites versus Hispanics for MVCs in a rural environment. METHODS: This study examined one rural county in North Carolina from January 1, 1999, to December 31, 1999. A retrospective cohort study was performed using the North Carolina State Highway Patrol computerized database of MVCs. Data regarding the total number of MVCs, fatalities, alcohol-related deaths, seatbelt usage, and cause of the collision were analyzed for both whites and Hispanics. Census information regarding population in this region also was obtained from the U.S. Bureau of Census. Data were analyzed using a chi-square test, with an alpha value of 0.05 used to establish statistical significance. RESULTS: During the study period, whites were involved in 2,689 MVCs, compared with 158 MVCs for Hispanics. Whites were involved in ten fatal MVCs, compared with seven fatal MVCs involving Hispanics. The percent of fatal MVCs for whites was 0.3%, or 10 deaths per 2,689 MVCs. In contrast, the percent of fatal MVCs for Hispanics was 4.4%, or 7 deaths per 158 MVCs; odds ratio (OR) = 12.4, 95% CI = 4.7 to 33.1. The 2000 Census Report for Pitt County noted a white population of 81,613 and a Hispanic population of 4,216. Based on these population data, the death rate for MVCs per 100,000 population was 12.3 for whites versus 166.0 for Hispanics, OR = 13.6, 95% CI = 5.2 to 35.6. Although the cause for this disparity was not determined, previous studies suggest that alcohol and decreased seatbelt usage are contributing factors. CONCLUSIONS: In this study, the death rates among Hispanics for rural MVCs were significantly higher than for whites. The causes of this disparity are not clear but are important to define. Only by understanding this disparity can we begin to develop appropriate interventions that may prevent these deaths.

Enzymatic determination of pyrophosphate in urine by flow methods.

Two flow methods for the enzymatic determination of pyrophosphate are described that are used to diminish the consumption of reagents. One method is based on the use of an open-close circuit with manual injection using a syringe. The other is a sequential injection method. The analytical features of both methods are: a linear range of 0.4 - 20 mg L(-1), an LOD of 0.38 mg L(-1), and a CV of 2.0% for the sequential injection method, and a linear range of 0.3 - 15 mg L(-1), an LOD of 0.29 mg L(-1), and CV of 2.2% for the open-close circuit method. The methods were applied to the determination of pyrophosphate in urine. The pyrophosphate concentration determined in urine samples varied from 1.26 to 6.67 mg L(-1).

A sensitive extracto-photometric method for determination of residual chlorine in greywater.

A new photometric method for chlorine determination based on the oxidative transformation of iodide to iodine and subsequent extraction in ethyl acetate has been developed. The effects of several chemical variables (pH, ionic strength, and iodide concentration) have been studied. Characteristics of the method were linear range 0-0.6 mg C12/L, limit of detection 5 microg Cl2/L, and coefficient of variation 0.6%. The method has been applied to greywater without previous sample treatment.