Spatial Methods to Enhance Public Health Surveillance and Resource Deployment in the Opioid Epidemic.

OBJECTIVES: To improve public health surveillance and response by using spatial optimization. METHODS: We identified cases of suspected nonfatal opioid overdose events in which naloxone was administered from April 2013 through December 2016 treated by the city of Pittsburgh, Pennsylvania, Bureau of Emergency Medical Services. We used spatial modeling to identify areas hardest hit to spatially optimize naloxone distribution among pharmacies in Pittsburgh. RESULTS: We identified 3182 opioid overdose events with our classification approach, which generated spatial patterns of opioid overdoses within Pittsburgh. We then used overdose location to spatially optimize accessibility to naloxone via pharmacies in the city. Only 24 pharmacies offered naloxone at the time, and only 3 matched with our optimized solution. CONCLUSIONS: Our methodology rapidly identified communities hardest hit by the opioid epidemic with standard public health data. Naloxone accessibility can be optimized with established location-allocation approaches. Public Health Implications. Our methodology can be easily implemented by public health departments for automated surveillance of the opioid epidemic and has the flexibility to optimize a variety of intervention strategies.

Exertional heat illness: emerging concepts and advances in prehospital care.

Exertional heat illness is a classification of disease with clinical presentations that are not always diagnosed easily. Exertional heat stroke is a significant cause of death in competitive sports, and the increasing popularity of marathons races and ultra-endurance competitions will make treating many heat illnesses more common for Emergency Medical Services (EMS) providers. Although evidence is available primarily from case series and healthy volunteer studies, the consensus for treating exertional heat illness, coupled with altered mental status, is whole body rapid cooling. Cold or ice water immersion remains the most effective treatment to achieve this goal. External thermometry is unreliable in the context of heat stress and direct internal temperature measurement by rectal or esophageal probes must be used when diagnosing heat illness and during cooling. With rapid recognition and implementation of effective cooling, most patients suffering from exertional heat stroke will recover quickly and can be discharged home with instructions to rest and to avoid heat stress and exercise for a minimum of 48 hours; although, further research pertaining to return to activity is warranted.

Recognition and treatment of exertional heat illness at a marathon race.

Exertional heat illness is rarely encountered by individual EMS providers but can be common in certain settings and events. The notion that significantly altered mental status must accompany elevated core temperature in heat illness may delay recognition and treatment. We report on a series of marathon and half-marathon runners who suffered exertional heat illness during a marathon race in relatively mild conditions. Altered mental status was not uniformly present. All patients were treated in the finish line medical tent and responded well to cooling. More than half were discharged from the medical tent without being transported to the hospital. This case series demonstrates that many runners respond to early identification and treatment of exertional heat illness. Significant preparation is required by the medical providers to handle the rapid influx of patients at the conclusion of the event.

Measuring adverse events in helicopter emergency medical services: establishing content validity.

INTRODUCTION: We sought to create a valid framework for detecting adverse events (AEs) in the high-risk setting of helicopter emergency medical services (HEMS). METHODS: We assembled a panel of 10 expert clinicians (n = 6 emergency medicine physicians and n = 4 prehospital nurses and flight paramedics) affiliated with a large multistate HEMS organization in the Northeast US. We used a modified Delphi technique to develop a framework for detecting AEs associated with the treatment of critically ill or injured patients. We used a widely applied measure, the content validity index (CVI), to quantify the validity of the framework's content. RESULTS: The expert panel of 10 clinicians reached consensus on a common AE definition and four-step protocol/process for AE detection in HEMS. The consensus-based framework is composed of three main components: (1) a trigger tool, (2) a method for rating proximal cause, and (3) a method for rating AE severity. The CVI findings isolate components of the framework considered content valid. CONCLUSIONS: We demonstrate a standardized process for the development of a content-valid framework for AE detection. The framework is a model for the development of a method for AE identification in other settings, including ground-based EMS.

A comparative assessment of adverse event classification in the out-of-hospital setting.

OBJECTIVES: We sought to test reliability of two approaches to classify adverse events (AEs) associated with helicopter EMS (HEMS) transport. METHODS: The first approach for AE classification involved flight nurses and paramedics (RN/Medics) and mid-career emergency physicians (MC-EMPs) independently reviewing 50 randomly selected HEMS medical records. The second approach involved RN/Medics and MC-EMPs meeting as a group to openly discuss 20 additional medical records and reach consensus-based AE decision. We compared all AE decisions to a reference criterion based on the decision of three senior emergency physicians (Sr-EMPs). We designed a study to detect an improvement in agreement (reliability) from fair (kappa = 0.2) to moderate (kappa = 0.5). We calculated sensitivity, specificity, percent agreement, and positive and negative predictive values (PPV/NPV). RESULTS: For the independent reviews, the Sr-EMP group identified 26 AEs while individual clinician reviewers identified between 19 and 50 AEs. Agreement on the presence/absence of an AE between Sr-EMPs and three MC-EMPs ranged from κ = 0.20 to κ = 0.25. Agreement between Sr-EMPs and three RN/Medics ranged from κ = 0.11 to κ = 0.19. For the consensus/open-discussion approach, the Sr-EMPs identified 13 AEs, the MC-EMP group identified 18 AEs, and RN/medic group identified 36 AEs. Agreement between Sr-EMPs and MC-EMP group was (κ = 0.30 95%CI -0.12, 0.72), whereas agreement between Sr-EMPs and RN/medic group was (κ = 0.40 95%CI 0.01, 0.79). Agreement between all three groups was fair (κ = 0.33, 95%CI 0.06, 0.66). Percent agreement (58-68%) and NPV (63-76%) was moderately dissimilar between clinicians, while sensitivity (25-80%), specificity (43-97%), and PPV (48-83%) varied. CONCLUSIONS: We identified a higher level of agreement/reliability in AE decisions utilizing a consensus-based approach for review rather than independent reviews.

Characterization of electrocardiogram changes throughout a marathon.

PURPOSE: There are few data examining cardiovascular physiology throughout a marathon. This study was devised to characterize electrocardiographic activity continuously throughout a marathon. METHODS: Cardiac activity was recorded from 19 subjects wearing a Holter monitor during a marathon. The 19 subjects (14 men and 5 women) were aged 39 ± 16 years (mean ± SD) and completed a marathon in 4:32:16 ± 1:23:35. Heart rate (HR), heart rate variability (HRV), T-wave amplitude, T-wave amplitude variability, and T-wave alternans (TWA) were evaluated continuously throughout the marathon. RESULTS: Averaged across all subjects, HRV, T-wave amplitude variability, and TWA increased throughout the marathon. Increased variability in T-wave amplitude occurred in 86 % of subjects, characterized by complex oscillatory patterns and TWA. Three min after the marathon, HR was elevated and HRV was suppressed relative to the pre-marathon state. CONCLUSION: HRV and T-wave amplitude variability, especially in the form of TWA, increase throughout a marathon. Increasing TWA as a marathon progresses likely represents a physiologic process as no arrhythmias or cardiac events were observed.

A Worksheet to Quantify Social and Digital Media Content as Scholarly Products for Academic Promotion.

PROBLEM: Social and digital media contributions are a timely way of adding to the public discourse, serve as an online footprint of public contributions that a faculty member has made on behalf of their institution, can increase community trust, and serve as a public commitment to diversity, equity, and inclusion (DEI) work. Thus, such contributions should be considered significant and meritorious in a promotion package. APPROACH: A diverse group of 6 University of Pittsburgh School of Medicine academics from varying specialties, training pathways, and academic ranks was assembled to create a consensus worksheet for the inclusion of social and digital media contributions in a promotion package. They reviewed existing literature on the quantification of social and digital media impact and current promotion practices within their institution. This review, combined with expert opinion, was used to pilot and vet the social and digital media worksheet, January 2022-March 2023. OUTCOMES: The worksheet is comprised of 4 sections: Scholarship Philosophy; Reputation, Influence, and Leadership; Digital Content; and Media Appearances, Quotes, and Other (i.e., content or notable digital contributions not otherwise listed). It helps to clearly document for the faculty promotions and appointments committee that the faculty member is contributing to patient education, advocacy, epidemiology, research, health care professions education, or DEI via their social and digital media presence. The strengths of the metrics in the worksheet are that they are based on existing evidence, they include objective third-party metrics, and the benchmarks used for them skew conservative in their capture of the effort, quality, and influence of contributions. NEXT STEPS: The social and digital media worksheet is designed to be adaptable to a rapidly changing social and digital media landscape, and the metrics used in it are likely to be iterative and ever evolving. Transparency will be imperative when assessing candidates' promotion portfolios.

Resident field response in an emergency medicine prehospital care rotation.

BACKGROUND: Emergency medical services (EMS) is an important component of emergency medicine residency curricula. For over 20 years, residents at a university-affiliated program have staffed a physician response vehicle and responded to selected calls in an urban EMS system with online faculty backup. OBJECTIVES: To describe the prehospital educational experience and patient care provided through this unique program and to assess residents' perceptions. METHODS: This was a three-year retrospective study of patient care records for all prehospital resident responses. Information obtained included complaint, disposition, procedures performed, and medications administered. The number of EMS radio consultations provided by residents during this rotation was also sought. We surveyed 43 current and recently graduated residents to assess their perceptions of this experience. RESULTS: Residents treated 1,434 patients during 1,381 scene responses (16.7 field patient contacts per resident-year). Complaints included cardiac arrest (788, 55.0%) and neurologic (230, 16.0%), traumatic (194, 13.5%), respiratory (144, 10.0%), and other cardiac (40, 2.8%) emergencies. Most patients (1,022; 71.3%) were transported to the hospital, including 82 of 143 patients (57.3%) who initially refused EMS transport. Residents performed procedures on 546 responses (39.5%), including 123 successful intubations, 115 central lines, 43 peripheral (IV) lines, and 10 intraosseous lines. EMS radio consultation records were available for only the second half of the study period. Residents provided 11,583 consultations during this one-and-a-half-year period (264 radio consultations per resident-year). Of the 40 returned surveys (93.0%), autonomy (n = 21), medical decision making (n = 10), and management of high-acuity patients (n = 7) were the most important perceived benefits of this program. CONCLUSION: Our prehospital training program incorporates emergency medicine residents as in-field physicians and allows hands-on opportunity to provide patient care for a variety of conditions in the EMS environment, as well as extensive experience in online medical direction. The trainees believed it had a strong positive impact on their acquisition of important emergency medicine abilities.

Tree of Life Synagogue Shooting in Pittsburgh: Preparedness, Prehospital Care, and Lessons Learned.

On Saturday, October 27, 2018, a man with anti-Semitic motivations entered Tree of Life synagogue in the Squirrel Hill section of Pittsburgh, Pennsylvania; he had an AR-15 semi-automatic rifle and three handguns, opening fire upon worshippers. Eventually 11 civilians died at the scene and eight people sustained non-fatal injuries, including five police officers. Each person injured but alive at the scene received care at one of three local level-one trauma centers. The injured had wounds often seen in war-settings, with the signature of high velocity weaponry. We describe the scene response, specific elements of our hospital plans, the overall out-of-hospital preparedness in Pittsburgh, and the lessons learned.

Community lessons to understand resuscitation excellence (culture): Association between emergency medical services (EMS) culture and outcome after out-of-hospital cardiac arrest.

BACKGROUND: The large geographic variation in outcome after out-of-hospital cardiac arrest (OHCA) is not well explained by traditional patient and emergency medical services (EMS) characteristics. A 'culture of excellence' in resuscitation within an EMS is believed to be an important factor that influences quality of care and outcome in patients with OHCA. However, whether a culture of excellence is associated with improved survival after OHCA is not known. METHODOLOGY: We linked survey responses from EMS agency medical directors related to resuscitation culture to a retrospective analysis of prospectively collected data from the Resuscitation Outcomes Consortium (ROC) Epistry - Cardiac Arrest. We used a multivariable random effects model to assess whether EMS culture strategies were associated with OHCA survival to hospital discharge. RESULTS: Of the 46 EMS medical directors surveyed, 35 (76%) provided a complete response. Included were n = 66,597 cases of OHCA who received attempted resuscitation by one of n = 123 EMS agencies from July 1, 2010, through June 30, 2015. Overall survival to discharge was 11%. Organizational values and goals were independently associated with survival to hospital discharge in all OHCAs (adjusted odds ratio [AOR] 1.27, 95% confidence interval [CI] 1.09-1.48) and the subgroup restricted to bystander witnessed OHCAs with initial shockable rhythm (AOR 1.55, 95% CI 1.21-1.99). CONCLUSIONS: An organizational goal to improve OHCA survival was independently associated with improved survival to discharge. EMS agencies looking to improve OHCA survival should consider implementing an organizational goal to improve OHCA survival and empower quality improvement personnel to drive that goal.

Management of prehospital seizure patients by paramedics.

BACKGROUND: Seizure patients are frequently encountered in the prehospital environment and have the potential to need advanced interventions, though the utility of advanced life support (ALS) interventions in many of these patients has not been proven. OBJECTIVE: Our goals were to assess the management of prehospital seizure patients by paramedics in an urban EMS system with an existing ALS-based prehospital seizure protocol and to assess characteristics and short-term outcomes that may aid in addressing the utility of specific ALS interventions. METHODS: This was a retrospective study of 97 EMS cases with the chief complaint of seizure. Prehospital records were reviewed for patient and event characteristics, including past seizure history, seizure timing, level of consciousness, on-scene and transport times, and EMS interventions. Emergency department (ED) records were reviewed for recurrence of seizure activity, ED evaluation, and disposition. Data were analyzed using descriptive statistics and Student t-test. RESULTS: Of 87 patients meeting the protocol inclusion criteria for all ALS interventions, 11 (12.6%) received cardiac monitoring, 55 (63.2%) had intravenous (IV) access attempted, and 56 (64.4%) had blood glucose determination. Average on-scene time was 5.9 minutes longer if IV access was attempted (p = 0.001), though transport times were not significantly different (11.6 versus 11.3 minutes, respectively; p = 0.851). Additional seizure activity occurred in the prehospital and/or ED settings in 28 patients (28.9% of all cases), including 17 in the prehospital setting and 15 in the ED. Diazepam was administered by EMS for half of the eight (8.2%) patients who had seizures lasting more than 1 minute, while the remainder had seizures that were focal or spontaneously resolved. CONCLUSION: This study showed a lower-than-anticipated level of compliance with an ALS-based prehospital seizure protocol, though patient-specific care appeared appropriate. Prehospital seizure patients have the potential for seizure recurrence and may benefit from focused ALS interventions, but their heterogeneity makes uniform protocols difficult to develop and follow.

Increased chest compression to ventilation ratio improves delivery of CPR.

OBJECTIVE: Chest compressions are interrupted during cardiopulmonary resuscitation (CPR) due to human error, for ventilation, for rhythm analysis and for rescue shocks. Earlier data suggest that the recommended 15:2 compression to ventilation (C:V) ratio results in frequent interruptions of compressions during CPR. We evaluated a protocol change from the recommended C:V ratio of 15:2-30:2 during CPR in our municipal emergency medical system. METHODS: Municipal firefighters (N=875) from a single city received didactic and practical training emphasizing the importance of continuous chest compressions and recommending a 30:2 C:V ratio. Both before and after the training, digital ECG and voice records from all first-responder cases of out-of-hospital cardiac arrest were examined off-line to quantify chest compressions. The number of chest compressions delivered and the number and duration of pauses in chest compressions were compared by t-test for the first three 1min intervals when CPR was recommended. RESULTS: More compressions were delivered during minutes 1, 2, and 3 during CPR with the 30:2 C:V ratio (78+/-29, 80+/-30, 74+/-26) than with the 15:2C:V ratio (53+/-24, 57+/-24, 51+/-26) (p<0.001). Fewer pauses for ventilation occurred during each minute with the 30:2 C:V ratio (1.7+/-1.2, 2.2+/-1.2, 1.8+/-1.0) than with the 15:2C:V ratio (3.4+/-2.6, 4.7+/-7.2, 4.0+/-2.9) (p< or =0.01). Degradation of the final ECG to asystole occurred less frequently after the protocol change (asystole pre 67.1%, post 56.8%, p<0.05). The incidence of return of spontaneous circulation was not altered following the protocol change. CONCLUSIONS: Retraining first responders to use a C:V ratio of 30:2 instead of the traditional 15:2 during out-of-hospital cardiac arrest increased the number of compressions delivered per minute and decreased the number of pauses for ventilation. These data are new as they produced persistent and quantifiable changes in practitioner behavior during actual resuscitations.

Usefulness of vasopressin administered with epinephrine during out-of-hospital cardiac arrest.

Vasopressin administration has been suggested during cardiopulmonary resuscitation, and a previous clinical trial has suggested that vasopressin is most effective when administered with epinephrine. Adult subjects (n = 325) who received > or =1 dose of intravenous epinephrine during cardiopulmonary resuscitation for nontraumatic, out-of-hospital cardiac arrest were randomly assigned to receive 40 IU of vasopressin (n = 167) or placebo (n = 158) as soon as possible after the first dose of epinephrine. The rate of return of pulses was similar between the vasopressin and placebo groups (31% vs 30%), as was the presence of pulses at the emergency department (19% vs 23%). No subgroup appeared to be differentially affected, and no effect of vasopressin was evident after adjustment for other clinical variables. Additional open-label vasopressin was administered by a physician after the study drug for 19 subjects in the placebo group and 27 subjects in the vasopressin group. Results were similar if these subjects were excluded or were assigned to an actual drug received. Survival duration for subjects admitted to the hospital did not differ between groups. In conclusion, vasopressin administered with epinephrine does not increase the rate of return of spontaneous circulation.

Inter-rater reliability for witnessed collapse and presence of bystander CPR.

OBJECTIVE: Witnessed collapse and bystander CPR are the variables most frequently associated with good outcome from out-of-hospital cardiac arrest (OOHCA). The reliability of abstracting witnessed collapse and bystander CPR from prehospital Emergency Medical Services (EMS) patient care records (PCRs) is not known. We sought to determine the inter-rater reliability for different methods of ascertaining and defining witnessed collapse and performance of bystander CPR. METHODS: A sample of 100 PCRs for patients with OOHCA was selected at random from a pool of 325 PCRs between May 2003 and January 2005. Paramedics used a drop down menu to indicate witnessed collapse and bystander CPR, and completed a narrative description of the event. An on-scene EMS physician also completed a data sheet. The PCR was examined by two separate evaluators to determine the presence of witnessed collapse and bystander CPR. A consensus was reached by three other reviewers using all available data sources. Inter-rater agreement was quantified using the unweighted kappa statistic. RESULTS: For witnessed collapse, there is substantial agreement between the following: individual evaluators (kappa=0.76, S.D.=0.07), individual evaluators and consensus group (kappa=0.61, S.D.=0.07 and 0.66, S.D.=0.07), and physician and consensus group (kappa=0.68, S.D.=0.08). Agreement between individual evaluators and the physician was fair to moderate (kappa=0.38, S.D.=0.07 and 0.44, S.D.=0.07). Agreement between individual evaluators, physician, consensus group and the PCR drop down menu was fair to moderate (kappa range 0.33, S.D.=0.09 to 0.54, S.D.=0.09). For bystander CPR, there is substantial agreement between the individual evaluators and the consensus group (kappa=0.64, S.D.=0.07 and 0.63, S.D.=0.06) and between the physician and the consensus group (kappa=0.61, S.D.=0.08). Agreement between the two individual evaluators is moderate (kappa=0.59, S.D.=0.07). Agreement between the physician and individual evaluators is fair (kappa=0.36, S.D.=0.07 and 0.38, S.D.=0.07). The PCR drop down menu had moderate to substantial agreement with the individual evaluators, physician, and consensus group (kappa range 0.50, S.D.=0.09 to 0.75, S.D.=0.09). CONCLUSIONS: Determination of witnessed collapse and bystander CPR during OOHCA may be less reliable than previously thought, and differences between methods of rating could influence study results.

Hyponatremia in runners requiring on-site medical treatment at a single marathon.

STUDY OBJECTIVE: Literature reports indicate an increasing number of cases of hyponatremia in athletes participating in moderate endurance events such as standard marathons. In this study, we evaluated the incidence of hyponatremia in marathon finishers requiring medical treatment on-site and attempted to assess the contribution of fluid type ingested and nonsteroidal antiinflammatory drug (NSAID) use to the development of hyponatremia. METHODS: We examined a prospective, convenience sample of runners requiring intravenous hydration at the final medical tent of a standard marathon course and a comparison group of finishers who did not require intravenous hydration. After giving informed consent, subjects had blood drawn and answered a questionnaire regarding fluid intake on the course and NSAID use before the race. Blood samples were analyzed on-site for serum sodium values as well as other hematologic parameters. RESULTS: Fifty-one subjects requiring intravenous hydration as well as 11 subjects who did not were enrolled. Three subjects (5.6%; 95% CI, 0-11.9%; missing = 8) in the intravenous hydration group had serum sodium less than 130 mEq/L. None of the three runners suffered neurologic or pulmonary consequences and only one required overnight hospital admission for hydration. The small number of hyponatremic subjects precluded the analysis of the role of fluid type or NSAID use in the development of hyponatremia or the development of a model for prediction. CONCLUSION: This study found a 5.6% incidence of hyponatremia in marathon runners requiring medical treatment.

Identification of adverse events in ground transport emergency medical services.

The purpose of this study was to develop a method to define and rate the severity of adverse events (AEs) in emergency medical services (EMS) safety research. They used a modified Delphi technique to develop a consensus definition of an AE. The consensus definition was as follows: "An adverse event in EMS is a harmful or potentially harmful event occurring during the continuum of EMS care that is potentially preventable and thus independent of the progression of the patient's condition." Physicians reviewed 250 charts from 3 EMS agencies for AEs. The authors examined physician agreement using κ, Fleiss's κ, and corresponding 95% confidence intervals (CIs). Overall physician agreement on presence of an AE per chart was fair (κ = 0.24; 95% CI = 0.19, 0.29). These findings should serve as a basis for refining and implementing an AE evaluation instrument.