Prehospital pearls, pitfalls, and updates.

The rapid proliferation of emergency medical services in the United States has led to numerous controversies concerning delivery, interventions, and efficacy. This article presents a brief overview of the important literature in this expanding field. Important clinical topics, including first-responder defibrillation, rapid sequence intubation, and airway management, are reviewed. In addition, several important medicolegal topics pertaining to pre-hospital care are analyzed.

ExacTech blood glucose meter clinical trial.

INTRODUCTION: Current prehospital protocols for the management of patients with altered mental status include the empiric administration of hypertonic glucose, naloxone, and thiamine. The injudicious use of 50% dextrose (D50W) may result in hyperosmolarity, a worsening of hypokalemia, and unwarranted additional health-care costs for the patient. The administration of D50W also may worsen the neurological outcome of patients with local or generalized ischemia. OBJECTIVE: To evaluate the ExacTech blood glucose meter's ability to estimate blood glucose levels accurately and rapidly. METHODS: Emergency medical technicians (EMTs) from selected advanced life support (ALS) units in the Portland, Ore., metropolitan area participated in a prospective clinical trial of the ExacTech blood glucose meter. A convenience sample was drawn from emergency medical services (EMS) patients with suspected diabetic emergencies, altered mental status, and other neurological deficits. Venous blood samples were drawn from these populations at the same time as the ExacTech readings were obtained. The venous blood was submitted to the receiving hospitals for laboratory analysis of blood glucose levels, and a comparison was made between the results of the two methods. RESULTS: A total of 80 matched sets of data were obtained from 1 April 1990 through 6 May 1991. The hospital blood glucose values ranged from 8 to 1233 mg/dl. Sixteen (20%) of the patients were hypoglycemic (&.lt.60 mg/dl) and 23 (28.8%) were hyperglycemic ( greater than 180 mg/dl). The ExacTech device sensitivity and specificity for hypoglycemia using venous samples were 94.6% and 89.2%, respectively. For hyperglycemia, these same parameters were 87.5% and 97.1%. Pearson's r over the range of the instrument (40-450 mg/dl) was 0.8656 (p less than .001). If the prehospital "definition" of hypoglycemia (for threshold-to-treat) is raised to 65 mg/dl, the device has 100% sensitivity in the sample population. CONCLUSION: The device functioned accurately and consistently in the prehospital environment over a wide range of temperatures, and in the hands of many different individuals.

Analysis of hospital ability to provide trauma services: a comparison between teaching and community hospitals.

HYPOTHESIS: Teaching hospitals (TH) can maintain the American College of Surgeons Committee on Trauma (ACSCOT) criteria for Level II trauma care more consistently than can community hospitals (CH). METHODS: A retrospective analysis of 2,091 trauma system patients was done to determine if TH in an urban area are better able to meet the criteria for Level II trauma care than are CH. During the study period, a voluntary trauma plan existed among five hospitals; two TH and three CH. A hospital could accept patients that met trauma system entry criteria as long as, at that moment, it could provide the resources specified by ACSCOT. Hospitals were required to report their current resources accurately. A centralized communications center maintained a computerized, inter-hospital link which continuously monitored the availability of all participating hospitals. Trauma system protocols required paramedics to transport system patients to the closest available trauma hospital that had all the required resources available. Nine of the required ACSCOT Level II trauma center criteria were monitored for each institution emergency department (ED); trauma surgeon (TS); operating room (OR); angiography (ANG); anesthesiologist (ANE); intensive care unit (ICU); on-call surgeon (OCS); neurosurgeon (NS); and CT scanner (CT) available at the time of each trauma system entry. RESULTS: With the exception of OR, TH generally maintained the required staff and services more successfully than did CH. Further, less day to night variation in the available resources occurred at the TH. Specifically, ANE, ICU, TS, NS, and CT were available more often both day and night, at TH than CH. However, OR was less available at TH than CH during both day and night (p less than .01). CONCLUSIONS: In this community, TH provided a greater availability of trauma services than did CH. This study supports the designation of TH as trauma centers. A similar availability can be performed in other communities to help guide trauma center designation.

The effect of base station contact on ambulance destination.

Concern has been raised that a single medical control base station serving a metropolitan area may preferentially divert ambulance patients to the base station hospital. Such concern may discourage the development of regional medical control systems. During the first six months of 1988, a retrospective cross-sectional analysis was made of all advanced life support (ALS) ambulance transports and all contacts to the single base station, known as Medical Resource Hospital (MRH). Destinations of all ALS ambulance calls dispatched through the county's 911 dispatch center were analyzed to determine whether the destinations were affected by MRH contact. There were 12,396 transports to 17 area hospitals with 1,272 (10.3%) of these requiring MRH contact. We hypothesized that if MRH contact did not affect destination, the proportion of all non-MRH ALS ambulance patients received by each hospital from the 911-dispatched group would equal the proportion of patients received by each hospital after MRH contact. Five hospitals received a statistically significant (P less than .003) different percentage of MRH contact patients than their proportion of 911-dispatched patients would have predicted. The three that received more were community hospitals in outlying areas. The remaining two were a large referral hospital and a smaller community hospital located in the urban area. The MRH hospital did not have a significantly different percentage of 911-dispatched patients after MRH contact. Similarly, destinations of specific ALS ambulances (two serving in the MRH ambulance catchment area and four in distant catchment areas) were evaluated.(ABSTRACT TRUNCATED AT 250 WORDS)

Preparing the trauma patient for transfer.

Rapid preparation of the trauma patient for early transfer is crucial for optimal outcome. Working together with the staff of the receiving trauma center will ensure that a consistent treatment approach is given to all injured patients. A pretransfer checklist is often helpful (Table 3), and can be made in partnership with your regional trauma center. Preparing a patient for transfer will not vary much from normal practice, but it must be done promptly. You make the difference.