Assessing EMS scope of practice for utility and risk: the New Mexico EMS Interventions Assessment Project, Phase One results.

INTRODUCTION: Few emergency medical services (EMS) interventions in New Mexico have been assessed for efficacy, potential harm, or potential benefit. There is concern that many interventions added over the years may be outdated, harmful, or ineffective in the EMS setting. A formal process for reviewing the state EMS scope of practice using literature review and expert consensus is discussed. In Phase One of the project, interventions in the New Mexico EMS scope of practice were prioritized for further review by surveying a national cadre of EMS experts to evaluate EMS interventions using a utilitarian harm/benefit metric. METHODS: An electronic survey based on the 2010 New Mexico EMS Scope of Practice statute was administered from March through June, 2011. A national cadre of 104 respondents was identified. Respondents were either State EMS medical directors or EMS fellowship directors. Respondents were asked to rate the potential harm and the potential benefit of specific EMS interventions on a 5-point ordinal scale. Median harm and benefit scores were calculated. RESULTS: A total of 88 completed surveys were received following 208 emailed invitations to 104 respondents (43% response rate). Twenty-two (22) highest-priority interventions (those with a harm/benefit median score ratio of >1) were identified. Seven additional second-priority interventions were also identified. These interventions will be advanced for formal literature review and expert consensus. CONCLUSIONS: The New Mexico EMS Interventions Project offers a novel model for assessing a prehospital scope of practice.

Value generation and health reform in emergency medical services.

American Emergency Medical Services (EMS) agencies largely have been untouched by the dramatic health care reform efforts underway, although change seems imminent. Clarifying the role of the modern EMS system, and the yardsticks used to evaluate its performance, will be a challenge.This paper introduces the concept of value (or outcomes to cost ratio) in EMS, and offers value assessment as a means by which reform decisions can be framed. The best reform decisions are those that optimize both costs and outcomes. This includes: (1) attention to the patient experience; (2) disallowing the provision of unhelpful, harmful or disproven prehospital care; and (3) expanding patient dispositions beyond Emergency Departments. Costs of care will need to be tracked carefully and acknowledged. Value generation should serve as the goal of ongoing EMS reform efforts.

Pine mouth (pine nut) syndrome: description of the toxidrome, preliminary case definition, and best evidence regarding an apparent etiology.

Pine mouth syndrome (PMS), otherwise known as pine nut syndrome, is a relatively new condition. At least several thousand cases have now been described in the literature. The author describes the PMS toxidrome, offers a preliminary case definition, and discusses current best evidence regarding the etiology and risk factors related to the development of PMS.A clinically compatible case of PMS must include taste disturbance, usually characterized as bitter or metallic, following the ingestion of affected pine nuts by 1 to 3 days. Affected nuts would appear to include all, or some portion, of nuts harvested from species Pinus armandii (Chinese white pine), but could include nuts from other species. The specific toxin that is apparently present in affected nuts has not yet been isolated, and the mechanism of toxicity and factors determining PMS susceptibility need to be further detailed. There are no proven therapies for PMS. The only treatment is to cease ingesting implicated nuts and to wait for symptoms to abate.

"Pine mouth" syndrome: cacogeusia following ingestion of pine nuts (genus: pinus). An emerging problem?

We report a case of cacogeusia, specifically metallogeusia (a perceived metallic or bitter taste) following pine nut ingestion. A 36-year-old male presented with cacogeusia one day following ingestion of 10-15 roasted pine nuts (genus: Pinus). Symptoms became worst on post-exposure day 2 and progressively improved without treatment over 5 days. There were no other symptoms and physical examination was unrevealing. All symptoms resolved without sequalae. We contemporaneously report a rise in pine nut-associated cacogeusia reported online during the first quarter of 2009, and a significant rise in online searches related to pine nut-associated cacogeusia (or what the online public has termed "pine mouth") during this time. Most online contributors note a similar cacogeusia 1-3 days following pine nut ingestion lasting for up to 2 weeks. All cases seem self-limited. Patients occasionally describe abdominal cramping and nausea after eating the nuts. Raw, cooked, and processed nuts (in pesto, for example) are implicated. While there appears to be an association between pine nut ingestion and cacogeusia, little is known about this condition, nor can any specific mechanism of specific cause be identified. It is not known if a specific species of pine nut can be implicated. "Pine mouth" appears to be an emerging problem.

Frequency and follow-up of incidental findings on trauma computed tomography scans: experience at a level one trauma center.

OBJECTIVES: Incidental findings found on computed tomography (CT) scan during the Emergency Department evaluation of trauma patients are often benign, but their presence must always be communicated to patients, who should be referred for follow-up care. Our objective was to quantify the frequency of these incidental CT findings in trauma patients. A secondary goal was to determine how often these lesions were communicated to patients and how often patients were referred for follow-up. METHODS: We performed a retrospective chart review of 500 consecutive patients presenting as trauma activations. Subjects received head, chest, or abdomen/pelvis CT scans at our hospital. Patients were identified using our trauma registry. Final CT reports were examined and discharge summaries were reviewed for basic demographics. Scans with incidental findings prompted detailed secondary review of discharge summaries to determine follow-up. Investigators reviewed incidental findings and classified them into three groups by clinical importance, using predetermined criteria. RESULTS: Of the 500 patient charts identified for review, 480 (96%) were available, yielding 1930 CT reports for analysis. Incidental findings were noted in 211 of 480 (43%) patients and on 285 (15%) of the 1930 CT studies performed for the 480 patients. Of available patient records, only 27% of patient charts had mention of the finding in the discharge summary, had documentation of an in-hospital workup, or had documentation of a referral for follow-up. Most-concerning lesions, such as suspected malignancies or aortic aneurysms, accounted for 15% of all incidental findings and were referred for follow-up in only 49% of cases. CONCLUSIONS: Incidental findings were noted in 15% of trauma CT scans. Follow-up was poor, even for potentially serious findings. Further studies should examine the long-term outcome of patients with these findings.

Physician medical direction and clinical performance at an established emergency medical services system.

OBJECTIVE: Few developed emergency medical services (EMS) systems operate without dedicated medical direction. We describe the experience of Hamad Medical Corporation (HMC) EMS, which in 2007 first engaged an EMS medical director to develop and implement medical direction and quality assurance programs. We report subsequent changes to system performance over time. METHODS: Over one year, changes to the service's clinical infrastructure were made: Policies were revised, paramedic scopes of practice were adjusted, evidence-based clinical protocols were developed, and skills maintenance and education programs were implemented. Credentialing, physician chart auditing, clinical remediation, and online medical command/hospital notification systems were introduced. RESULTS: Following these interventions, we report associated improvements to key indicators: Chart reviews revealed significant improvements in clinical quality. A comparison of pre- and post-intervention audited charts reveals a decrease in cases requiring remediation (11% to 5%, odds ratio [OR] 0.43 [95% confidence interval (CI) 0.20-0.85], p = 0.01). The proportion of charts rated as clinically acceptable rose from 48% to 84% (OR 6 [95% CI 3.9-9.1], p < 0.001). The proportion of misplaced endotracheal tubes fell (3.8% baseline to 0.6%, OR 0.16 [95% CI 0.004-1.06], (exact) p = 0.05), corresponding to improved adherence to an airway placement policy mandating use of airway confirmation devices and securing devices (0.7% compliance to 98%, OR 714 [95% CI 64-29,334], (exact) p < 0.001). Intravenous catheter insertion in unstable cases increased from 67% of cases to 92% (OR 1.31 [95% CI 1.09-1.71], p = 0.004). EMS administration of aspirin to patients with suspected ischemic chest pain improved from 2% to 77% (OR 178 [95% CI 35-1,604], p < 0.001). CONCLUSIONS: We suggest that implementation of a physician medical direction is associated with improved clinical indicators and overall quality of care at an established EMS system.

Seatbelt use in Qatar in association with severe injuries and death in the prehospital setting.

INTRODUCTION: Road traffic crashes (RTCs) are common in Qatar, and are now considered the third leading cause of mortality. In this study, the safety devices used by the Qatari public at the time of RTCs were assessed and the association between seatbelt use by vehicle occupants involved in RTCs and severe injury/death in the prehospital setting was determined. METHODS: This study was a retrospective case-control investigation. A Hamad Medical Corporation Emergency Medical Services (EMS) database of RTCs occurring from January 2006 to April 2007 was utilized for this study, providing a total of 5,267 patient records (83.5% male, 16.5% female, median age = 28 years). Patient demographics, crash characteristics, prehospital assessments, and interventions were identified, and use of safety devices was determined. Univariate analysis including chi-square, Student's t-test, and analysis of variance (ANOVA) was performed as appropriate. "Case" patients are defined as those who had specific, critical prehospital assessments, or who received advanced cardio-respiratory life support measures in the field. Logistic regression modeling was used to predict the probability of a case being unbelted, controlling for confounders. RESULTS: Seatbelt use in Qatar was low: 33.9% of males and 32.6% of females wore seatbelts at the time of the RTC. Victims involved in a vehicle rollover crash were less likely to be belted than were those involved in a non-rollover incident (26.2% belted vs. 37.8%; OR = 0.59; 95% CI = 0.50-0.68). Case patients-those with defined critical assessment findings or resuscitation in the field-and control patients were similar in age (30 years vs. 28 years median). Case patients were disproportionately male (89.1% vs. 83.2%; OR = 1.65; 95% CI = 1.01-2.83) and were more likely to be victims of a vehicle rollover crash (44.7% vs. 23.8%; OR = 2.57; 95% CI = 1.84-3.59). Seatbelt use was significantly lower among cases than controls: 19.7% of cases were reported to have worn seatbelts compared to 34.2% of controls (OR = 0.47; 95% CI = 0.31-0.69). This relationship also persisted (OR = 0.51; 95% CI = 0.33-0.76) after controlling for confounders. CONCLUSIONS: Seatbelt use in Qatar is low. Seatbelts are protective: in the prehospital setting unbelted vehicle occupants involved in RTCs were nearly twice as likely to suffer severe injury or death compared to belted patients. Prehospital morbidity and mortality appears to be reduced significantly by the consistent use of seatbelts by the motoring population in Qatar.