Rapid Expansion and Adaptability of California Medical Disaster Teams.

The California Medical Assistance Team (CAL-MAT) program is coordinated by the California Emergency Medical Services Authority (EMSA). The program was developed to deploy and support medical personnel for disaster medical response. During the coronavirus disease (COVID-19) pandemic, the program and missions grew rapidly in response to medical surge, programs for testing and vaccination, and other concurrent disasters. CAL-MAT enrollment increased 10-fold from approximately 200 members at the beginning of 2020, to an estimated 2200 members by June 2021. This article describes the flexible use of a state-managed disaster medical response program within California and some of the challenges associated with rapid expansion and varied demands during the COVID-19 surges of March 2020-March 2022. CAL-MAT may serve as a model for development of similar state-sponsored or other disaster medical response teams.

EMS Care of Adult Hospice Patients- a Position Statement and Resource Document of NAEMSP and AAHPM.

Emergency medical services (EMS) systems are designed to provide care in the field and while transporting patients to a hospital; however, patients enrolled in hospice may not want invasive therapies nor benefit from hospitalization. For many reasons, encounters with hospice patients can be challenging for EMS systems, EMS clinicians, hospice clinicians, hospice patients, and their families.

EMS clinicians should receive hospice-focused education that fosters a basic understanding of hospice, palliative therapies, and advance care planning documents (e.g., Physician Orders for Life Sustaining Treatment). This education should emphasize the ongoing development of end-of-life communication skills.EMS medical directors and local hospice organizations should collaborate to develop hospice patient-centered EMS protocols that address symptom management and delineate appropriate and goal concordant clinical interventions, and that are within the agency-level scope of practice for local EMS clinicians. Partnerships between EMS and hospice organizations can facilitate access to hospice teams who can provide clear guidance on whether to treat-in-place with follow-up care or to transport hospice patients to the hospital.EMS medical directors and local hospice organizations should collaborate to perform needs assessments of hospice patient EMS utilization.EMS medical directors should consider including a focus on EMS care of hospice patients as part of their overall quality management program(s). Ideally these efforts should be collaborative with local hospice agencies in order to facilitate meaningful process improvement strategies that include both EMS and hospice stakeholders.Reimbursement programs should reasonably compensate EMS agencies for scene treatment in place, as well as transport to alternative destinations such as in-patient hospice facilities.

Emergency medical services clinicians in the United States are increasingly exposed to death.

Introduction: Exposure to patient death places healthcare workers at increased risk for burnout and traumatic stress, yet limited data exist exploring exposure to death among emergency medical services (EMS) clinicians. Our objective was to describe changes in EMS encounters involving on-scene death from 2018 to 2021. Methods: We retrospectively analyzed deidentified EMS records for 9-1-1 responses from the ESO Data Collaborative from 2018 to 2021. We identified cases where patient dispositions of death on scene, with or without attempted resuscitation, and without EMS transport. A non-parametric test of trend was used to assess for monotonic increase in agency-level encounters involving on-scene death and the proportion of EMS clinicians exposed to ≥1 on-scene death. Results: We analyzed records from 1109 EMS agencies. These agencies responded to 4,286,976 calls in 2018, 5,097,920 calls in 2019, 4,939,651 calls in 2020, and 5,347,340 calls in 2021.The total number of encounters with death on scene rose from 49,802 in 2018 to 60,542 in 2019 to 76,535 in 2020 and 80,388 in 2021. Agency-level annual counts of encounters involving death on scene rose from a median of 14 (interquartile range [IQR], 4-40) in 2018 to 2023 (IQR, 6-63) in 2021 (P-trend < 0.001). In 2018, 56% of EMS clinicians responded to a call with death on scene, and this number rose to 63% of EMS clinicians in 2021 (P-trend < 0.001). Conclusion: From 2018 to 2021, EMS clinicians were increasingly exposed to death. This trend may be driven by COVID-19 and its effects on the healthcare system and reinforces the need for evidence-based death notification training to support EMS clinicians.

Top Ten Tips Palliative Care Clinicians Should Know About Improving Partnerships With Emergency Medical Services.

Emergency medical services (EMS) clinicians increasingly encounter seriously ill patients and their caregivers in times of distress. When crises arise or care coordination falls short, these high-stakes interactions highlight opportunities to improve care experience and outcomes. Efforts must address wide educational gaps, absence of specialized care protocols, and systematic fragmentation leading to hyperlocal practice. The authors represent cross-sectional expertise in palliative care and EMS. This article describes unmet needs at the EMS-palliative interface, challenges with collaboration, and where directional progress exists.

Primary palliative care education in emergency medicine residency: A mixed-methods analysis of a yearlong, multimodal intervention.

Background: Emergency medicine (EM) physicians frequently care for seriously ill patients at the end of life. Palliative care initiated in the emergency department (ED) can improve symptom management and quality of life, align treatments with patient preferences, and reduce length of hospitalization. We evaluated an educational intervention with digital tools for palliative care discussions in an urban EM residency using the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework. Methods: Our intervention, conducted from July 2020 to August 2021, included education on palliative care techniques, digital tools, and incentives for participation. We tracked goals of care conversations and palliative care consults using electronic medical record data, conducted pre- and posttraining surveys, and used semistructured interviews to assess resident perspectives on palliative care conversations in the ED. Outcomes included number of goals of care conversations recorded by EM residents, consults to palliative care from the ED, and resident perspectives on palliative care in EM. Results: The results were as follows: reach-45 residents participated in the intervention; effectiveness-89 goals of care conversations were documented by 23 ED residents, and palliative care consults increased from approximately four to 10 monthly; adoption-over half the residents who participated in the intervention documented goals of care discussions using an electronic dotphrase; implementation-by the completion of the intervention, residents reported increased comfort with goals of care conversations, saw palliative care as part of their responsibility as EM physicians, and effectively documented goals of care discussions; and maintenance-at 2-month follow up, palliative care consults from the ED remained at approximately 10 monthly, and digital tools to prompt and track palliative care discussions remained in use. Conclusions: An integrated palliative care training for EM residents with technological assists was successful in facilitating goals of care discussions and increasing palliative care consults from the ED.

Paramedic use of the Physician Order for Life-Sustaining Treatment (POLST) for medical intervention and transportation decisions.

BACKGROUND: Physician Order for Life-Sustaining Treatment forms (POLST) exist in some format in all 50 states. The objective of this study is to determine paramedic interpretation and application of the California POLST for medical intervention and transportation decisions. METHODS: This study used a prospective, convenience sample of California Bay Area paramedics who reviewed six fictional scenarios of patients and accompanying mock POLST forms. Based on the clinical case and POLST, paramedics identified medical interventions that were appropriate (i.e. non-invasive positive pressure airway) as well as transportation decisions (i.e. non-transport to the hospital against medical advice). EMS provider confidence in their POLST interpretation was also assessed. RESULTS: There were 118 paramedic participants with a mean of 13.3 years of EMS experience that completed the survey. Paramedics routinely identified the selected medical intervention on a patients POLST correctly as either comfort focused, selective or full treatment (113-118;96%-100%). For many clinical scenarios, particularly when a patient's POLST indicated comfort focused treatment, paramedics chose to use online medical oversight through base physician contact (68-73;58%-62%). In one case, a POLST indicated "transport to hospital only if comfort needs cannot be met in current location", 13 (14%) paramedics elected to transport the patient anyway and 51 (43%) chose "Non-transport, Against Medical Advice". The majority of paramedics agreed or strongly agreed that they knew how to use a POLST to decide which medical interventions to provide (106;90%) and how to transport a patient (74;67%). However, after completing the cases, similar proportions of paramedics agreed (42;36%), disagreed (43;36%) or were neutral (30;25%) when asked if they find the POLST confusing. CONCLUSION: The POLST is a powerful tool for paramedics when caring patients with serious illness. Although paramedics are confident in their ability to use a POLST to decide appropriate medical interventions, many still find the POLST confusing particularly when making transportation decisions. Some paramedics rely on online medical oversight to provide guidance in challenging situations. Authors recommend further research of EMS POLST utilization and goal concordant care, dedicated paramedic POLST education, specific EMS hospice and palliative care protocols and better nomenclature for non-transport in order to improve care for patients with serious illness.

Emergency medical service interpretation of Physician Orders for Life-Sustaining Treatment (POLST) in cardiopulmonary arrest.

Objective: Physician Orders for Life-Sustaining Treatment (POLST) forms exist in some form in all 50 states. This study evaluates emergency medical service (EMS) practitioners interpretation of the POLST in cardiopulmonary arrest. Methods: This study used a prospective convenience sample of California Bay Area EMS practitioners who reviewed 6 fictional scenarios of patients in cardiopulmonary arrest and accompanying California POLST forms. Based on the cases and POLST, EMS practitioners identified patient preference for "attempt resuscitation," "do not attempt resuscitation/DNR," or "unsure" and subsequently selected medical interventions (ie, chest compressions, defibrillation, and so on). They also rated their confidence in POLST use and interpretation. Results: In scenarios of cardiopulmonary arrest and POLST that indicated do not resuscitate (DNR)/do not attempt resuscitation (DNAR) and full treatment, only 45%-65% of EMS practitioners correctly identified the patient as DNR/DNAR. EMS practitioners were more likely to interpret the POLST correctly in scenarios where patients were DNR/DNAR but indicated selective treatment (86%; 168/196) or comfort-focused treatment (86%; 169/196). In cardiopulmonary arrest scenarios where the patient was correctly identified as DNR/DNAR, EMS practitioners frequently selected defibrillation, advanced airway, or epinephrine as appropriate treatment. For all 6 scenarios, there was no statistical difference in response selection with level of training (emergency medical technician/paramedics) or type of EMS personnel (fire based/private). Conclusion: The POLST is a powerful tool to convey medical treatment preferences; however, there is significant variation in the interpretation and application by EMS practitioners. To improve the POLST effectiveness, the authors suggest more EMS input into POLST development, concise language that defines resuscitation, and more EMS education about clinical application.

EMS Experience Caring and Communicating with Patients and Families with a Life-Limiting-Illness.

Introduction: The emergency medical services (EMS) system was designed to reduce death and disability and EMS training focuses on saving lives through resuscitation, aggressive treatment and transportation to the emergency department. EMS providers commonly care for patients who have life-limiting illnesses. The objective was to explore EMS provider challenges, self-perceived roles and training experiences caring for patients and families with life-limiting illness. Methods: Qualitative content analysis of semi-structured interviews with EMS providers (n = 15) in Alameda County, CA. Purposive sampling was used to ensure a variety of perspectives including provider age, years of EMS experience, emergency medical technicians and paramedics, fire-based versus private, transport versus non-transporting. Recorded and transcribed interviews were analyzed using a thematic approach. Results: In their work with patients with life-limiting illness, participating EMS providers were interviewed and reported challenges for which their formal training had not prepared them: responding to grief and emotion expressed by families during traumatic events or death notification, and performing in the moment decision-making to determine the course of action after acute, unexpected, and traumatic events. Many participants reported becoming comfortable with grief counseling and death notification after acquiring some clinical experience. In the moment decision-making was eased when patients and families had had advance care planning discussions, however many patients, especially those from vulnerable and underserved populations, lacked advance care planning. In the face of situations where the course of action was not immediately clear, EMS providers voiced two frames for their role in caring for patients with life-limiting illness: transportation only ("transport people") versus a more "holistic" view, where EMS providers provided counseling and information about available resources. Conclusions: EMS providers interface with patients who have life-limiting illness and their families in the setting of traumatic events where the course of action is often unclear. There is an opportunity to provide formal training to EMS providers around grief counseling as well as how they can assist patients and families in in the moment decision-making to support previously identified goals and align care with patient goals and preferences.

Hospice and Comfort Care Patient Utilization of Emergency Medical Services.

Introduction: Emergency medical services (EMS) were designed to prevent death and disability. When hospice patients call 9-1-1, it can create challenging scenarios for EMS providers, patients, and families. The objective of this investigation is to understand the characteristics of hospice and comfort care patient EMS utilization in Alameda County, California. Methods: This is a 15-month (7/1/2019-10/1/2020) retrospective observational study in Alameda County using electronic patient care reports (PCRs). The search terms "hospice" and "comfort measures only" were applied to PCR narratives. Results: Of the 237,493 EMS provider response calls, 534 (0.2%) were for hospice and comfort care patients. One hundred seventy-four (32.6%) calls were from skilled nursing facilities versus 343 (64.2%) from private residences. Among the most common primary impressions were respiratory complaints (96; 18.0%), altered mental status (96; 18.0%), weakness (58; 10.9%), and cardiac arrest (45; 8.4%). The most common interventions included blood glucose (244; 45.7%), electrocardiogram (181; 33.9%), and intravenous placement (170; 31.8%). Of note, eight (1.5%) patients received cardiopulmonary resuscitation, and an additional eight (1.5%) patients were intubated endotracheally or received a supraglottic airway device for intubation. Sixty-eight (12.7%) patients received medications, the most common of which were fentanyl (17; 3.2%) and albuterol (16; 3.0%). Of note, five (0.9%) patients received naloxone. Ultimately, 468 (87.6%) patients were transported by EMS. Of the 33 (6.1%) patients who died on the scene, three received resuscitation attempts. Conclusion: Although EMS providers encounter hospice and comfort care patients infrequently, awareness of hospice services and comprehensive end-of-life care communication skills with patients and family should be an important part of EMS.

Effect of a Mobile Integrated Hospice Healthcare Program on Emergency Medical Services Transport to the Emergency Department.

Objective: To evaluate the effect of a Mobile Integrated Hospice Healthcare (MIHH) program including hospice education and expansion of paramedic scope of practice to use hospice medication kits. Primary outcome was the effect on hospice patient transport to the Emergency Department. Secondary outcomes included reasons for patient transport and review of MIHH kit utilization. Methods: In 2015, the project was implemented in Ventura County, California in collaboration with county emergency medical services (EMS) agency, first response/transport organizations, and hospice programs. Paramedic supervisors received 30 hours of hospice training focusing on palliative care, grief and crisis counseling. When 9-1-1 was called for a patient, EMS first responders arrived on scene, determined a patient was enrolled in hospice and then contacted trained MIHH. Results: Six months (2/2015-7/2015) prior to project implementation the percentage of hospice patients transported to the ED averaged 80.3% (98/122). During the first (8/2015-7/2016), second (8/2016-7/2017) and third year (8/2017-7/2018) after project implementation, the percentage of hospice patients transported to the ED was 36.2% (68/188), 33.2% (63/190) and 24.8% (36/145) respectively. A total of 523 hospice patients were cared for by MIHH during this three-year interval. Of those hospice patients transported, the most common reason for transport was fall/trauma. The MIHH hospice kit was only used once in the field. Odds ratio for hospice transportation to the ED before and after project implementation was 0.125 (95% Confidence Interval: 0.077 to 0.201; p < 0.0001). This represents an absolute reduction risk of 46.6% (95% Confidence Interval: 38.53% to 54.72%). Conclusion: MIHH decreased the transportation of hospice patients to the ED. MIHH provided hospice education, provided family grief support and developed treatment plans with hospice nurses. An expanded scope of practice, including a paramedic hospice kit, was not contributory to this decrease.

Centralized Ambulance Destination Determination: A Retrospective Data Analysis to Determine Impact on EMS System Distribution, Surge Events, and Diversion Status.

INTRODUCTION: Emergency medical services (EMS) systems can become impacted by sudden surges that can occur throughout the day, as well as by natural disasters and the current pandemic. Because of this, emergency department crowding and ambulance "bunching," or surges in ambulance-transported patients at receiving hospitals, can have a detrimental effect on patient care and financial implications for an EMS system. The Centralized Ambulance Destination Determination (CAD-D) project was initially created as a pilot project to look at the impact of an active, online base hospital physician and paramedic supervisor to direct patient destination and distribution, as a way to improve ambulance distribution, decrease surges at hospitals, and decrease diversion status. METHODS: The project was initiated March 17, 2020, with a six-week baseline period; it had three additional study phases where the CAD-D was recommended (Phase 1), mandatory (Phase 2), and modified (Phase 3), respectively. We used coefficients of variation (CV) statistical analysis to measure the relative variability between datasets (eg, CAD-D phases), with a lower variation showing better and more even distribution across the different hospitals. We used analysis of co-variability for the CV to determine whether level loading was improved systemwide across the three phases against the baseline period. The primary outcomes of this study were the following: to determine the impact of ambulance distribution across a geographical area by using the CV; to determine whether there was a decrease in surge rates at the busiest hospital in this area; and the effects on diversion. RESULTS: We calculated the CV of all ratios and used them as a measure of EMS patient distribution among hospitals. Mean CV was lower in Phase 2 as compared to baseline (1.56 vs 0.80 P < 0.05), and to baseline and Phase 3 (1.56 vs. 0.93, P <0.05). A lower CV indicates better distribution across more hospitals, instead of the EMS transports bunching at a few hospitals. Furthermore, the proportion of surge events was shown to be lower between baseline and Phase 1 (1.43 vs 0.77, P <0.05), baseline and Phase 2 (1.43 vs. 0.33, P < 0.05), and baseline and Phase 3 (1.43 vs 0.42, P < 0.05). Diversion was shown to increase over the system as a whole, despite decreased diversion rates at the busiest hospital in the system. CONCLUSION: In this retrospective study, we found that ambulance distribution increased across the system with the implementation of CAD-D, leading to better level loading. The surge rates decreased at some of the most impacted hospitals, while the rates of hospitals going on diversion paradoxically increased overall. Specifically, the results of this study showed that there was an improvement when comparing the CAD-D implementation vs the baseline period for both the ambulance distribution across the system (level loading/CV), and for surge events at three of the busiest hospitals in the system.

Establishment of an Alternate Care Site (ACS) in Imperial County During COVID-19.

Imperial County is in southern California, one of the state's two counties at the international United States-Mexico border. The county is one of the most resource-limited in the state, with only two hospitals serving its 180,000 citizens, and no tertiary care centers. A significant portion of the population cared for at the local hospitals commutes from Mexicali, a large city of 1.2 million persons, just south of Imperial County's ports of entry. Since May 2020, following an outbreak in Mexicali, Imperial County has seen a significant increase in the number of COVID-19 patients, quickly outpacing its local resources. In response to this surge an alternate care site (ACS) was created as part of a collaboration between the California State Emergency Medical Service Authority (EMSA) and the county. In the first month of operations (May 26-June 26, 2020) the ACS received 106 patients with an average length of stay of 3.6 days. The average patient age was 55.5 years old with a range of 19-95 years. Disposition of patients included 25.5% sent to the emergency department for acute care needs, 1.8% who left against medical advice, and 72.7% who were discharged home or to a skilled nursing facility. There were no deaths on site. This study shares early experiences, challenges, and innovations created with the implementation of this ACS. Improving communication with local partners was the single most significant step in overcoming initial barriers.

Adult Patients with Respiratory Distress: Current Evidence-based Recommendations for Prehospital Care.

INTRODUCTION: We developed evidence-based recommendations for prehospital evaluation and treatment of adult patients with respiratory distress. These recommendations are compared with current protocols used by the 33 local emergency medical services agencies (LEMSA) in California. METHODS: We performed a review of the evidence in the prehospital treatment of adult patients with respiratory distress. The quality of evidence was rated and used to form guidelines. We then compared the respiratory distress protocols of each of the 33 LEMSAs for consistency with these recommendations. RESULTS: PICO (population/problem, intervention, control group, outcome) questions investigated were treatment with oxygen, albuterol, ipratropium, steroids, nitroglycerin, furosemide, and non-invasive ventilation. Literature review revealed that oxygen titration to no more than 94-96% for most acutely ill medical patients and to 88-92% in patients with acute chronic obstructive pulmonary disease (COPD) exacerbation is associated with decreased mortality. In patients with bronchospastic disease, the data shows improved symptoms and peak flow rates after the administration of albuterol. There is limited data regarding prehospital use of ipratropium, and the benefit is less clear. The literature supports the use of systemic steroids in those with asthma and COPD to improve symptoms and decrease hospital admissions. There is weak evidence to support the use of nitrates in critically ill, hypertensive patients with acute pulmonary edema (APE) and moderate evidence that furosemide may be harmful if administered prehospital to patients with suspected APE. Non-invasive positive pressure ventilation (NIPPV) is shown in the literature to be safe and effective in the treatment of respiratory distress due to acute pulmonary edema, bronchospasm, and other conditions. It decreases both mortality and the need for intubation. Albuterol, nitroglycerin, and NIPPV were found in the protocols of every LEMSA. Ipratropium, furosemide, and oxygen titration were found in a proportion of the protocols, and steroids were not prescribed in any LEMSA protocol. CONCLUSION: Prehospital treatment of adult patients with respiratory distress varies widely across California. We present evidence-based recommendations for the prehospital treatment of undifferentiated adult patients with respiratory distress that will assist with standardizing management and may be useful for EMS medical directors when creating and revising protocols.

Skin and Soft Tissue Infections in the Emergency Department.

This article covers the diagnosis and treatment of skin and soft tissue infections commonly encountered in the emergency department: impetigo, cutaneous abscesses, purulent cellulitis, nonpurulent cellulitis, and necrotizing skin and soft tissue infections. Most purulent infections in the United States are caused by methicillin-resistant Staphylococcus aureus. For abscesses, we emphasize the importance of incision and drainage. Nonpurulent infections are usually caused by streptococcal species and initial empiric antibiotics need not cover methicillin-resistant Staphylococcus aureus. For uncommon but potentially lethal necrotizing skin and soft tissue infections, the challenge is rapid diagnosis in the emergency department and prompt surgical exploration and debridement.

Diabetes prevalence in rural Indigenous Guatemala: A geographic-randomized cross-sectional analysis of risk.

BACKGROUND: Developing countries and Indigenous populations are disproportionately affected by global trends in diabetes (T2DM), but inconsistent data are available to corroborate this pattern in Guatemala and indigenous communities in Central America. Historic estimates of T2DM, using a variety of sampling techniques and diagnostic methods, in Guatemala include a T2DM prevalence of: 4·2% (1970) and 8·4% (2003). Objectives of this geographically randomized, cross-sectional analysis of risk include: (1) use HbA1c to determine prevalence of T2DM and prediabetes in rural Indigenous community of Atitlán (2) identify risk factors for T2DM including age, BMI and gender. METHODS: A spatially random sampling method was used to identify 400 subjects. Prevalence was compared using the confidence interval method, and logistic regression and linear regression were used to assess association between diabetes and risk factors. FINDINGS: The overall prevalence of T2DM using HbA1c was 13·81% and prediabetes was also 13·81% in Atitlán, representing a tripling in diabetes from historic estimates and a large population with pre-diabetes. The probability of diabetes increased dramatically with increasing age, however no significant overall relationship existed with gender or BMI. CONCLUSIONS: Diabetes is a larger epidemic than previously expected and appears to be related to ageing rather than BMI. Our proposed explanations for these findings include: possible Indigenous unique genetic susceptibility to T2DM, shortcomings in BMI as a metric for adiposity in assessing risk, changes in lifestyle and diet, and an overall aging population. The conclusion of this study suggest that (1) T2DM in rural regions of Guatemala may be of epidemic proportion. With pre-diabetes, more than 25% of the population will be diabetic in the very near future; (2) Age is a significant risk factor in the Indigenous population but BMI is not. This suggests that in some populations diabetes may be a disease of ageing.

A Case of Acute Ischemic Monomelic Neuropathy and Review of the Literature.

Ischemia monomelic neuropathy is rare and underrecognized complication of hemodialysis access (HA), characterized by diffuse multiple mononeuropathies in the absence of significant clinical ischemia. It is important to diagnose this syndrome early because ligation of the HA is the most accepted treatment to prevent or at least halt irreversible neural dysfunction and therefore, chronic pain and disability. Literature describing this fistulae-related pathology is rare, and we attempt to increase its awareness.

Case of acute lead toxicity associated with Ayurvedic supplements.

Use of traditional folkloric remedies not disclosed to the physician may be difficult to identify as a source of lead toxicity. This report illustrates the presentation of a 26-year-old man who, during his 1 month vacation in India, was treated for low back pain with Ayurvedic herbal medicine. On his return to the USA, he presented to the emergency department with epigastric pain, weight loss, dark stools, nausea and vomiting. He was admitted and noted to be anaemic with a blood lead level (BLL) of 94.8 µg/dL. Peripheral blood smear demonstrated basophilic stippling. Chelation therapy with succimer was initiated. The patient became asymptomatic within months. Three years later, he remained asymptomatic with BLL <20 µg/dL. Physicians should be cognisant of potential toxicity from these Ayurvedic medications and have a heightened level of suspicion for lead toxicity in the face of anaemia and abdominal pain without obvious cause.

Ulnar neuropathy at the elbow in computer keyboard operators.

OBJECTIVE: This case series sought to determine the prevalence of ulnar neuropathy at the elbow (UNE) by using electrophysiologic criteria among all computer keyboard operators (CKOs) referred over a four-year period (1995-1999) for electrodiagnosis (EDX) due to clinical suspicion of focal upper limb neuropathies. PARTICIPANTS: All CKOs referred to an EDX laboratory for suspicion of focal upper limb neuropathies primarily from private practice physicians, mostly hand surgeons, and an occupational medicine clinic. METHODS: All 148 CKOs underwent NCV studies of the upper limbs, which included segmental studies of the ulnar nerve and were questioned for the presence and distribution pattern of paresthesias in the symptomatic upper limb(s). The CKOs provided the electromyographer with subjective descriptions of their workstation configuration, layout, and basic office equipment. RESULTS: Focal ulnar neuropathy at the elbow (UNE) was identified in 105 out of 148 CKOs referred to an EDX laboratory for clinical suspicion of upper limb focal neuropathies. CONCLUSIONS: Compared with the more prevalent diagnosis of carpal tunnel syndrome (CTS), ulnar neuropathy at the elbow should also be considered among CKOs referred for EDX testing because of suspicion of focal upper limb neuropathies. Clinicians evaluating CKOs for suspicion of focal upper limb neuropathies should routinely ask about symptoms of ulnar neuropathy.