Basic and Advanced EMS Providers Are Equally Effective in Naloxone Administration for Opioid Overdose in Northern New England.

OBJECTIVE: Overdose mortality from illicit and prescription opioids has reached epidemic proportions in the United States, especially in rural areas. Naloxone is a safe and effective agent that has been shown to successfully reverse the effects of opioid overdose in the prehospital setting. The National EMS Scope of Practice Model currently only recommends advanced life support (ALS) providers to administer naloxone; however, some individual states have expanded this scope of practice to include intranasal (IN) administration of naloxone by basic life support (BLS) providers, including the Northern New England states. This study compares the effectiveness and appropriateness of naloxone administration between BLS and ALS providers. METHODS: All Vermont, New Hampshire, and Maine EMS patient encounters between April 1, 2014 and December 31, 2016 where naloxone was administered were examined and 3,219 patients were identified. The proportion of successful reversals of opioid overdose, based on improvement in the Glasgow Coma Scale (GCS), respiratory rate (RR), and provider global assessment (GA) of response to medication was compared between BLS and ALS providers using a Chi-Squared statistic, Fisher's exact or Wilcoxon rank-sum test. RESULTS: There was no significant difference in the percent improvement in GCS between BLS and ALS (64% and 64% P = 0.94). There was no significant difference in the percentage of improvement in RR between BLS and ALS (45% and 48% P = 0.43). There was a significant difference in the percentage of improvement of GA between BLS and ALS (80% and 67% P < 0.001). There was no significant difference in determining appropriate cases to administer naloxone where RR < 12 and GCS < 15 between BLS and ALS (42% and 43% P = 0.94). CONCLUSIONS: BLS providers were as effective as ALS providers in improving patient outcome measures after naloxone administration and in identifying patients for whom administration of naloxone is appropriate. These findings support expanding the National EMS Scope of Practice Model to include BLS administration of intranasal naloxone for suspected opioid overdoses.

Adult Intraosseous Access by Advanced EMTs: A Statewide Non-Inferiority Study.

OBJECTIVE: Intraosseous (IO) access is increasingly being used as an alternative to peripheral intravenous access, which is often difficult or impossible to establish in critically ill patients in the prehospital setting. Until recently, only Paramedics performed adult IO access. In 2014, Vermont Emergency Medical Services (EMS) expanded the Advanced Emergency Medical Technicians (AEMTs) scope of practice to include IO access in adult patients. This study compares successful IO access in adults performed by AEMTs compared to Paramedics in the prehospital setting. METHODS: All Vermont EMS patient encounters between January 1, 2013 and November 30, 2015 were examined, and 543 adult patients with a documented IO access insertion attempt were identified. The proportion of successful IO insertions was compared between AEMTs and Paramedics using a Chi-Squared statistic and a non-inferiority test. RESULTS: There was no significant difference in the percentage of successful IO access between AEMTs and Paramedics [95.2% and 95.6%, respectively; P = 0.84]. The confidence interval around this 0.4% difference (95% confidence interval = -4.2, 3.2) was within a pre-specified delta of ±10% indicating non-inferiority of AEMTs compared to Paramedics. CONCLUSIONS: This study's finding that successful IO access was not different among AEMTs and Paramedics lends evidence in support of expanding the scope of practice of AEMTs to include establishing IO access in adults.

Cold Blooded: Evaluating Brain Temperature by MRI During Surface Cooling of Human Subjects.

BACKGROUND: Targeted temperature management (TTM) confers neurological and survival benefits for post-cardiac arrest patients with return of spontaneous circulation (ROSC) who remain comatose. Specialized equipment for induction of hypothermia is not available in the prehospital setting, and there are no reliable methods for emergency medical services personnel to initiate TTM. We hypothesized that the application of surface cooling elements to the neck will decrease brain temperature and act as initiators of TTM. METHODS: Magnetic resonance (MR) spectroscopy was used to evaluate the effect of a carotid surface cooling element on brain temperature in healthy adults. RESULTS: Six individuals completed this study. We measured a temperature drop of 0.69 ± 0.38 °C (95% CI) in the cortex of the brain following the application of the cooling element. Application of a room temperature element also caused a measurable decrease in brain temperature of 0.66 ± 0.41 °C (95% CI) which may be attributable to baroreceptor activation. CONCLUSION: The application of surface cooling elements to the neck decreased brain temperature and may serve as a method to initiate TTM in the prehospital setting.

Geographic Coverage and Verification of Trauma Centers in a Rural State: Highlighting the Utility of Location Allocationfor Trauma System Planning.

BACKGROUND: Care at verified trauma centers has improved survival and functional outcomes, yet determining the appropriate location of potential trauma centers is often driven by factors other than optimizing system-level patient care. Given the importance of transport time in trauma, we analyzed trauma transport patterns in a rural state lacking an organized trauma system and implemented a geographic information system to inform potential future trauma center locations. STUDY DESIGN: Data were collected on trauma ground transport during a 3-year period (2014 through 2016) from the Statewide Incident Reporting Network database. Geographic information system mapping and location-allocation modeling of the best-fit facility for trauma center verification was computed using trauma transport patterns, population density, road network layout, and 60-minute emergency medical services transport time based on current transport protocols. RESULTS: Location-allocation modeling identified 2 regional facilities positioned to become the next verified trauma centers. The proportion of the Vermont population without access to trauma center care within 60 minutes would be reduced from the current 29.68% to 5.81% if the identified facilities become verified centers. CONCLUSIONS: Through geospatial mapping and location-allocation modeling, we were able to identify gaps and suggest optimal trauma center locations to maximize population coverage in a rural state lacking a formal, organized trauma system. These findings could inform future decision-making for targeted capacity improvement and system design that emphasizes more equitable access to trauma center care in Vermont.

Prescription opioid policies and associations with opioid overdose and related adverse effects.

BACKGROUND: United States (US) policies to mitigate the opioid epidemic focus on reducing access to prescription opioids to prevent overdoses. We examined the impact of state policies in Vermont (July 2017) and Maine (July 2016) on opioid overdoses and opioid-related adverse effects. METHODS: Study population included patients 15 years and older in all-payer claims of Vermont (N = 597,683; Jan.2016-Dec.2018) and Maine (N = 1,370,960; Oct.2015-Dec.2017). We used interrupted time series analyses to assess the impact of opioid prescribing policies on monthly opioid overdose rate and opioid-related adverse effects rate. We used the International Classification of Disease-10-CM to identify overdoses (T40.0 × 1-T40.4 × 4, T40.601-T40.604, T40.691-T40.694) and adverse effects (T40.0 × 5, T40.2 × 5-T40.4 × 5, T40.605, T40.695). RESULTS: Immediately after the policy, the level of Vermont's opioid overdose rate increased by 34% (95% confidence interval, CI: 1.09, 1.65) while the level of opioid-related adverse effects rate decreased by 29% (95% CI: 0.58, 0.87). In Maine, there was no level change in opioid overdose rate, but the slope of the adverse effects rate after the policy decreased by 3.5% (95% CI: 0.94, 0.99). These results varied within age and rurality subgroups in both states. CONCLUSION: While the decrease in rate of adverse effects following the policy changes is promising, the increase in Vermont's opioid overdose rate may suggest there is an association between policy implementation and short-term risk to public health.

Gastric Varices in Absence of Splenic Vein Thrombosis: A Rare Entity of Idiopathic Non-Cirrhotic Portal Hypertension.

Idiopathic non-cirrhotic portal hypertension (INCPH) is portal hypertension (PHT) without cirrhosis and other identifiable causes. Esophageal and gastric varices are seen in INCPH which are mostly asymptomatic. We present a rare case of symptomatic isolated gastric varices (IGV) in the setting of INCPH. We report a case of a 60-year-old man who presented with an acute onset of hematemesis and no identifiable history. Upon further evaluation, he was found to have non-bleeding dilated gastric varices on esophagogastroduodenoscopy (EGD) and PHT without cirrhosis. Our patient is unique because he has symptomatic IGV and INCPH.

Implementation of the universal BLS termination of resuscitation rule in a rural EMS system.

BACKGROUND: Emergency Medical Services (EMS) are often the first medical providers to begin resuscitation of out-of-hospital cardiac arrest (OHCA) victims. The universal Basic Life Support Termination of Resuscitation (BLS-TOR) rule is a validated clinical prediction tool used to identify patients in which continued resuscitation efforts are futile. OBJECTIVE: The primary aim is to compare the rate of transport of OHCA cases before and after the implementation of a BLS-TOR protocol and to determine the compliance rate of EMS personnel with the new protocol in a largely volunteer, rural system. METHODS: A retrospective cohort study was conducted using the statewide EMS electronic patient care report system. Cases were identified by searching for any incident that had a primary impression of "cardiac arrest" or a primary symptom of "cardiorespiratory arrest" or "death." Data were collected from the two years prior to and following implementation of the BLS-TOR rule from January 1, 2012 through March 31, 2016. RESULTS: There were 702 OHCA cases were identified, with 329 cases meeting inclusion criteria. The transport rate was 91.1% in the pre-intervention group compared with 69.4% in the post-intervention group (χ2=24.8; p<0.001). EMS compliance rate with the BLS-TOR rule was 66.7%. Of the 265 patients transported during the study, 87 patients met (post-intervention group; n=22) or retrospectively met (pre-intervention group; n=65) the BLS-TOR requirements for field termination of resuscitation. None of these patients survived to hospital discharge. CONCLUSION: Rural EMS systems may benefit from implementation and utilization of the universal BLS-TOR rule.

Pharmacist input into statewide treatment protocols for emergency medical services.

PURPOSE: A pharmacist's role in helping Vermont health officials standardize pharmacotherapy-related protocols used by emergency medical services (EMS) personnel across the state is described. SUMMARY: Pharmacists with expertise in emergency medicine (EM) or critical care are ideally positioned to provide guidance on optimizing and standardizing medication-use aspects of state and local EMS protocols. In 2012, the medical director of the EMS division of the Vermont Department of Health requested that an EM pharmacist at a Burlington academic medical center review draft EMS protocols designed to replace the existing patchwork of local protocols with statewide standards of care; among the 92 draft protocols reviewed, 62 pertained to medication use. The pharmacist provided a wide range of suggestions on 33 protocols, including (1) evidence-based recommendations on use of vasopressor agents for septic shock, (2) recommendations to optimize medication ordering and preparation in the prehospital setting, (3) recommendations on prehospital management of pediatric shock and appropriate use of chemical restraints, and (4) recommendations to promote use of smart infusion pumps by EMS personnel. All of the pharmacist's suggestions were incorporated into the final protocols, which took effect in March 2014. The protocols have helped standardize care for patients receiving EMS services throughout Vermont while reducing the potential for medication errors. CONCLUSION: An EM pharmacist participated in the review and development of statewide EMS treatment protocols that focused on choice of medication therapy, dosage, administration, and identification and minimization of potential risks of medication errors.