Influence of Personal and Work Environments on Work-Life Balance Among Emergency Medical Technicians.

Introduction Work-life balance (WLB) is a critical concern for emergency medical technicians (EMTs) because it significantly affects the provision of comprehensive emergency medical services (EMS). This study investigated personal and work-related factors influencing work-to-family negative spillover (WFNS), a key element of WLB, among EMTs. Methods A web-based survey was conducted from July 26 to September 13, 2021, among EMTs in Hokkaido, Japan. The study included 21 facilities that were randomly selected from 42 fire stations. The Japanese version of the Survey Work-Home Interaction-NijmeGen (SWING-J) was used to measure WFNS. Personal background factors, such as age, sex, years of work experience, and education, were surveyed. We also evaluated work environment factors, such as weekly working hours, monthly night shifts, monthly overtime hours, and yearly paid vacation days. Unpaired Student's t-tests, one-way analysis of variance (ANOVA), and multilevel generalized linear model (MGLM) analyses were used to explore the relationships between WFNS and personal and work-related factors. Results A total of 912 respondents were included in our analysis. They were predominantly male (98.2%), with an average EMT work experience of 12.7 years and a mean WFNS score of 1.16 (standard deviation (SD) = 1.67). MGLM analysis, adjusting for covariates, identified years of work experience (ß = -0.129, p = 0.001), monthly overtime hours (ß = 0.184, p < 0.001), and yearly paid vacation days (ß = -0.170, p < 0.001) as independent factors associated with WFNS. Conclusion This study suggested that adjusting WFNS among EMTs could be achieved by reducing overtime hours and fostering an organized approach to paid leave within the work environment.

Prehospital emergency care patient satisfaction scale [PECPSS] for care provided by emergency medical teams: Scale development and validation.

The purpose of this study was to develop and validate an emergency medical technician (EMT) care patient satisfaction scale to measure patient satisfaction with prehospital emergency care. To date, patient satisfaction surveys of EMTs have been performed subjectively, e using each facility's questionnaire, without the use of a validated patient satisfaction scale. However, no specific scale has been devised to assess patient satisfaction with EMTs. The study population comprised patients who used an ambulance between November 2020 and May 2021 (N = 202). A survey instrument was administered to participants who provided informed consent. In the process of validating the patient satisfaction scale, an exploratory factor analysis (EFA) of construct validity was performed. The results of the EFA showed a factor structure consisting of five factors: "teamwork", "explanation and communication", "physical treatment and psychological support", "quickness of transport", and "environment in the ambulance". In addition, domain and summary scores showed good internal reliability (Cronbach's range = 0.82-0.94). The patient satisfaction scale developed in this study was designed and validated considering the role of EMTs and patients' needs for prehospital care. This scale may be useful in the development of assessments and interventions to improve patient satisfaction with EMTs.

Influence of work and family environment on burnout among emergency medical technicians.

OBJECTIVE: Burnout among emergency medical technicians is a serious problem affecting delivery of quality emergency medical services. Although the repetitive nature of the job and lower education level requirements for technicians have been reported as risk factors, little is known about the influence of burden of responsibility, degree of supervisor support, and home environment on burnout among emergency medical technicians. This study aimed to test the hypothesis that burden of responsibility, degree of supervisor support, and home environment increase burnout probability. METHODS: A web-based survey was conducted among emergency medical technicians in Hokkaido, Japan from July 26, 2021 to September 13, 2021. A total of 21 facilities were randomly selected from 42 fire stations. Prevalence of burnout was measured using the Maslach Burnout-Human Services Survey Inventory (MBI-HSS). Burden of responsibility was measured using a visual analog scale. Occupational background was also measured. Supervisor support was measured using the Brief Job Stress Questionnaire (BJSQ). Family-work negative spillover was measured using the Japanese version of Survey Work-Home Interaction-NijmeGen (SWING). The cutoff value for burnout syndrome was defined as emotional exhaustion≥27 and/or depersonalization≥10. RESULTS: A total of 700 survey respondents were included, and 27 surveys with missing data were excluded. The suspected burnout frequency was 25.6%. Covariates were adjusted using multilevel logistic regression model analysis. Low supervisor support (odds ratio, 1.421; 95% confidence interval, 1.136-1.406; P<0.001) and high family-work negative spillover (odds ratio, 1.264; 95% confidence interval, 1.285-1.571; P<0.001) were independent factors associated with higher probability of burnout. CONCLUSION: This study indicated that focusing on improvement of supervisor support for emergency medical technicians and creating supportive home environments may assist in reducing burnout frequency.

A suicide attempt by intramuscular injection of pentobarbital sodium into rectus abdominis suggested by computed tomography.

Suicide attempts in humans due to injections of the veterinary drug pentobarbital sodium have been rarely reported. Herein, we present a case of a suicide attempt by intramuscular injection of pentobarbital sodium into the rectus abdominis muscle, which was suggested by computed tomography (CT). A 73-year-old man was brought to the emergency department with GCS 3 (E1V1M1) and an incised wound on the right side of the neck. A bottle of Somnopentyl® (pentobarbital sodium, 64.8 mg/ml), a 20-ml empty syringe with an 18-mm needle, and no. 10 scalpel were present at the scene. At the emergency department, the patient was intubated and was admitted to the intensive care unit. A urine drug screen test by SIGNIFY® ER was positive for benzodiazepines and barbiturates, and continuous veno-venous hemofiltration (CHF) was initiated. The route of drug administration was initially unknown; however, a CT scan revealed swelling of the left rectus abdominis muscle with a wound suggestive of a needle puncture, and the CT analysis suggested 38.16 ml as the maximum dose of pentobarbital sodium. On day 3, the patient's consciousness improved, and he was weaned off CHF and mechanical ventilation. There have been several reports of postmortem CT yielding information on the site of administration of intoxicants, but there have been none for surviving intoxicated patients. This is the first report of the usefulness of CT to identify the site of administration of the causative agent of intoxication while the patient is still alive.

A 48-Year-Old Previously Healthy Man Presenting with Acute Respiratory Distress Syndrome (ARDS), Negative Tests for SARS-CoV-2, and Positive Serology for Parainfluenza Virus Type 3 (PIV-3).

BACKGROUND Human parainfluenza viruses (PIVs) belong to the Paramyxoviridae family. PIVs cause lower respiratory tract infections in children and the elderly. In addition, severe pneumonia due to PIVs has been reported in immunocompromised adults. However, no reports have described PIV infections leading to acute respiratory distress syndrome (ARDS) in immunocompetent hosts. CASE REPORT A 48-year-old otherwise healthy man was transported to our hospital due to worsening dyspnea. On arrival, strong effortful breathing was observed and results of arterial blood gas analysis revealed severe hypoxia. On the basis of the clinical presentation, we intubated the patient for mechanical ventilation. However, mechanical ventilation provided inadequate oxygenation. Finally, veno-venous extracorporeal membrane oxygenation was initiated. Pneumonia was considered to be a cause of the ARDS, based on the patient's history and blood examination. Repeated reverse transcription-polymerase chain reaction tests for the novel coronavirus were performed, and endotracheal aspirate specimens were cultured for bacteria and fungus; however, the results were all negative. On day 2, the PIV-3-specific antibody titer was elevated. Two weeks later, the PIV-3-specific antibody titer had increased 4-fold. On the basis of these results, we diagnosed pneumonia induced by PIV-3 infection. CONCLUSIONS ARDS can occur because of severe pneumonia induced by PIV-3. In cases of unexplained severe pneumonia or ARDS, PIV infection should be included in the differential diagnosis.

Veno-venous extracorporeal membrane oxygenation and prone ventilation for therapeutic management of COVID-19.

BACKGROUND: The efficacy and safety of the combined use of veno-venous extracorporeal membrane oxygenation (ECMO) and prone ventilation are currently not known for coronavirus disease 2019 (COVID-19). CASE PRESENTATION: We report two cases in which the combination of veno-venous ECMO and prone ventilation for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia were successfully carried out. Both patients had developed severe respiratory failure due to SARS-CoV-2 pneumonia, thus requiring veno-venous ECMO. Prone ventilation was also administered safely. CONCLUSION: Oxygenation and lung compliance gradually improved during prone ventilation, and both patients were successfully extubated. For patients with severe SARS-CoV-2 pneumonia who require veno-venous ECMO, the use of prone ventilation could be beneficial, and should be considered.

Delayed retroperitoneal hemorrhage during veno-venous extracorporeal membrane oxygenation: a case report.

CASE: There are several reports of retroperitoneal hemorrhage induced by percutaneous femoral cannulation for extracorporeal membrane oxygenation (ECMO). However, there are no reports of delayed retroperitoneal hemorrhage, which develops a few days after ECMO initiation and is unrelated to the ECMO cannulation. Herein, we report a rare case of delayed retroperitoneal hemorrhage during veno-venous extracorporeal membrane oxygenation (VV-ECMO). OUTCOME: A 54-year-old man was referred to our hospital because of severe acute respiratory distress syndrome. We initiated VV-ECMO. The patient had severe delirium and was confined to a long-term supine position to maintain circuit safety. On day 13, computed tomography unexpectedly revealed a large retroperitoneal hemorrhage spreading around the psoas muscle. CONCLUSION: Delayed retroperitoneal hemorrhage can develop during VV-ECMO management a few days after its initiation. Anticoagulant use and forceful muscular strain could be risk factors of delayed retroperitoneal hemorrhage.

Risk factors for acute pancreatitis in patients with accidental hypothermia.

BACKGROUND: Pancreatic damage is commonly observed as a consequence of accidental hypothermia (core body temperature below 35 °C). We aimed to investigate the risk factors for pancreatic damage and the causal relationship in patients with accidental hypothermia. METHODS: This retrospective, single-center, observational case-control study was conducted in the emergency department of a tertiary care medical center. We investigated patients who were admitted for accidental hypothermia over a course of ten years (January 2008 to December 2017). RESULTS: Of the 138 enrolled patients, 70 had elevated serum amylase levels (51%). We observed a correlation between initial core body temperature and serum amylase level (Spearman's rank correlation coefficient -0.302, p < 0.001). Patients who developed acute pancreatitis had a significantly lower initial core body temperature than those who did not develop it (odds ratio = 0.76; 95% confidence interval [CI] = 0.61-0.94; p = 0.011). Receiver operating characteristic analysis showed that a body temperature lower than 28.5 °C at the time of visit was predictive of acute pancreatitis (area under the curve = 0.71, 95% CI = 0.54-0.88, sensitivity = 0.67, specificity = 0.69, p = 0.017). CONCLUSIONS: We concluded that an initial core body temperature lower than 28.5 °C was a risk factor for acute pancreatitis in accidental hypothermia cases. In such situations, careful follow-up is necessary.

Traumatic Basilar Artery Entrapment without Longitudinal Clivus Fracture: A Case Report and Review of the Literature.

In blunt cerebrovascular injury, reported traumatic basilar artery occlusions have involved dissection of the basilar artery, distal embolization due to traumatic vertebral artery dissection, or entrapment of the basilar artery into the clivus fracture. To date, however, there are no reports of traumatic basilar artery entrapment without a clivus fracture. Here, we report the first case of traumatic basilar artery occlusion caused by entrapment into an originally existing bone defect. A 67-year-old man with a history of treatment for intracranial aneurysm suffered multiple traumatic injuries in a fall. On arrival at our hospital, he presented with neurogenic shock with quadriplegia. Computed tomography (CT) showed small epidural hematoma, C4-6 cervical spinous process fracture, and Th2-3 vertebral body fracture. CT angiography revealed occlusion of the basilar artery trunk. As vertebrobasilar artery dissections and clivus fracture were not observed; however, we could not elucidate the pathology of the basilar artery occlusion. On day 4, after surgery for the cervical and thoracic lesions, he exhibited consciousness disturbance. Diffusion-weighted imaging on day 5 showed hyperintensities in the brainstem and cerebellum. Basi-parallel anatomic scanning magnetic resonance imaging showed that the basilar artery, while lacking vascular wall injuries, was tethered into the clivus. Antithrombotic therapy was performed, but the patient progressed to a locked-in state. Previous head CT before the trauma revealed a bone defect already present in the clivus. We speculated basilar artery entrapment into this preexisting bone defect. We must look for basilar artery injury in trauma patients even in the absence of clivus fracture.

Successful resuscitation for cardiac arrest due to severe accidental hypothermia accompanied by mandibular rigidity: a case of cold stiffening mimicking rigor mortis.

BACKGROUND: In cases of severe accidental hypothermia, it was recommended that resuscitation should be continued until the patient has rewarmed, as hypothermia itself can preserve cerebral function, and hypothermic cardiac arrest is reversible. During cardiopulmonary resuscitation for normothermic patients, muscle rigidity suggests the initiation of postmortem changes such as rigor mortis and can lead to the termination of resuscitation. Currently, the prognosis of cardiac arrest due to severe accidental hypothermia accompanied by rigidity is unknown. CASE PRESENTATION: A 29-year-old woman was found unresponsive near a snowy mountain trail. Upon discovery, she was found to be in cardiac arrest with an initial asystole rhythm and exhibited mandibular rigidity. On admission, her core temperature was 22 °C. Although cardiac arrest continued, and she showed no response to normal resuscitation, blood gas analysis revealed that her initial serum potassium level was 5.4 mmol/L. Extracorporeal membrane oxygenation (ECMO) for systemic perfusion and rewarming was initiated. After ECMO was introduced, return of spontaneous circulation was achieved. She showed no neurological impairments at discharge. CONCLUSIONS: Muscle rigidity does not rule out the possibility of resuscitation in patients with severe accidental hypothermia under cardiac arrest. Serum potassium levels may assist in deciding whether ECMO should be introduced, even if a patient is in asystole. This knowledge may help emergency physicians to save the lives of such patients.

Adaptive Cross-Resistance to Aminoglycoside Antibiotics in Pseudomonas aeruginosa Induced by Topical Dosage of Neomycin.

BACKGROUND: Topical antimicrobial formulations containing neomycin are commonly used to prevent and treat burn infections. However, Pseudomonas aeruginosa shows rapid acquisition of adaptive resistance to neomycin. This study aimed to evaluate the survival of P. aeruginosa during exposure to neomycin at high concentrations comparable to those used in topical formulations, and to investigate the effect of adaptive resistance to neomycin on the susceptibility to other aminoglycosides. METHODS: Strain IID1130 [neomycin minimal inhibitory concentration (MIC) = 4 µg/ml] was incubated on an agar medium containing neomycin at high concentrations (8-4,096 µg/ml), and growing colonies were macroscopically observed. Acquisition of adaptive resistance was examined for 5 P. aeruginosa strains. Cells were sequentially passaged on agar medium containing neomycin with step-wise increased concentrations (8-2,048 µg/ml). To assess reversion of antibiotic susceptibility, the resulting colonies were repeatedly subcultured on antibiotic-free agar plates. RESULTS: Growing IID1130 colonies were macroscopically detected on a neomycin-containing (2,048 µg/ml) agar plate for 48 h. These cells showed increasing MIC for not only neomycin, but also gentamicin and amikacin; the MIC values were occasionally higher than the breakpoints. When the adapted cells were subcultured on antibiotic-free agar, several passages were required for reversion of susceptibility. CONCLUSIONS: Our findings suggest that P. aeruginosa can survive in the presence of neomycin with a concentration typically used in topical dosage forms, and that the acquired adaptive resistance is persistent and is accompanied by cross-resistance to other aminoglycosides.

Effects of epinephrine administration in out-of-hospital cardiac arrest based on a propensity analysis.

BACKGROUND: Epinephrine administration has been advocated for cardiopulmonary resuscitation (CPR) for decades. Despite the fact that epinephrine administration during CPR is internationally accepted, the effects of the prehospital epinephrine administration still remain controversial. We investigated the effects of epinephrine administration on patients with out-of-hospital cardiac arrest based on a propensity analysis with regard to the 'CPR time'. METHODS: From April 1, 2007, to December 31, 2009, 633 out-of-hospital cardiac arrest patients with bystander witnesses were included in the present study. To rule out any survival bias, we used the propensity scores, which included CPR time. CPR time was defined as the time span from when the emergency medical technicians started CPR until either the return of spontaneous circulation or arrival at the hospital. After performing propensity score matching, the epinephrine and no-drug groups each included 141 patients. The primary study endpoint was a favorable neurological outcome at 30 days after cardiac arrest. RESULTS: After propensity score matching, the frequency of the return of spontaneous circulation before arrival at the hospital in the matched epinephrine group was higher than that in the matched no-drug group (27% vs. 13%, P = 0.002). However, the frequency of a favorable neurological state did not differ between the two groups. With regard to the frequency of a favorable neurological state in the patients, the adjusted odds ratio of the time span from cardiac arrest to the first epinephrine administration was 0.917 (95% confidence interval 0.850-0.988, P = 0.023) per minute. CONCLUSIONS: In patients with witnessed out-of-hospital cardiac arrest, prehospital epinephrine administration was associated with increase of the return of spontaneous circulation before arrival at the hospital. Moreover, the early administration of epinephrine might improve the overall neurological outcome.

Acquisition of a transposon encoding extended-spectrum beta-lactamase SHV-12 by Pseudomonas aeruginosa isolates during the clinical course of a burn patient.

Three of seven clonally related Pseudomonas aeruginosa strains isolated from a burn patient produced the extended-spectrum beta-lactamase (ESBL) SHV-12. Its gene was flanked by two IS26 elements with a large transposon (>24 kb). The transposon also contained at least five IS26 elements and a gene encoding the amikacin resistance determinant aminoglycoside 6'-N-acetyltransferase type Ib [aac(6')-Ib]. It was inserted into the gene PA5317 in the P. aeruginosa chromosome.