RESUMO
OBJECTIVES: To determine whether the skill performance and psychomotor agility, as measured by the endotracheal intubation success rate, of air ambulance medical personnel would be affected by the potential fatigue incurred when increasing the length of their shifts from 12 to 24 hours. METHODS: This was a retrospective review of all flight and intubation records from a large air medical transport system from 1997, when 24-hour shifts were in place, and six months (March-August) of 1996, during which 12-hour shifts were scheduled. Records of all intubation efforts during both periods, including multiple attempts per patient, and outcomes of all attempts, were recorded. Results of successes and failures were tabulated for both ultimate intubation outcome per patient and all attempts per patient for each calendar day and for the 12 hours between 19:00 and 07:00 when fatigue might play a role. Results from the two study periods were compared using Fisher's exact test. RESULTS: During the six months of 1996, 190 of 199 (95.5%) patients were ultimately successfully intubated. These patients required 237 attempts (80.1% successful). During 1997, 362 of 376 (96.3%) patients were successfully intubated, and required 438 attempts (82.6% successful). There was no statistically significant difference in the number of ultimately successful intubations (p = 0.66) or total intubation attempts (p = 0.37) between 1996 and 1997. Analysis of intubations between 19:00 and 07:00 revealed 81 of 84 (96.4%) patients successfully intubated in 1996, with 81 of 103 (78.6%) attempts successful. During 1997, 173 of 180 (96.1%) patients were ultimately successfully intubated, with 173 of 212 (81.6%) attempts successful. Again, there was no significant difference in the number of successful intubations (p = 0.99) or intubation attempts (p = 0.55) between 1996 and 1997. CONCLUSION: Psychomotor agility of air ambulance medical personnel, as measured by the success rate of endotracheal intubation, was not affected by the potential additional fatigue incurred as a result of increasing shift length from 12 to 24 hours.
Assuntos
Resgate Aéreo , Auxiliares de Emergência/normas , Fadiga , Intubação Intratraqueal/normas , Desempenho Psicomotor/fisiologia , Tolerância ao Trabalho Programado , Competência Clínica , Auxiliares de Emergência/psicologia , Fadiga/complicações , Humanos , Avaliação de Resultados em Cuidados de Saúde , Estados Unidos , Tolerância ao Trabalho Programado/fisiologia , Tolerância ao Trabalho Programado/psicologia , Recursos HumanosRESUMO
Airway management and optimal ventilation are crucial aspects of managing out-of-hospital medical emergencies. The goals in these situations are controlled ventilation and optimized inspiratory time, expiratory time, and airflow. Numerous techniques and devices are available to deliver oxygen-enriched air to patients during resuscitation. The bag-valve-mask (BVM) is one of the most common devices used to provide ventilation, although the American Heart Association ranks BVM devices lower in preference than other ventilation adjuncts, such as emergency and transport ventilators (ETVs) and pocket masks. The clearly documented limitations of BVM ventilation and its widespread use in the United States underscore the need to improve ventilation practices during care provided by emergency medical services (EMS) personnel. As part of that improvement, ETVs clearly have a role in the prehospital setting. These devices should be available on every ambulance, and the ability to use ETVs should be part of each EMS provider's skill set. Furthermore, all patients requiring emergency ventilation must be adequately monitored, including continuous monitoring of end-tidal carbon dioxide concentrations. As with any other skill, ventilation requires attention during initial training, continuing education and skill reinforcement, and quality review.
Assuntos
Serviços Médicos de Emergência , Insuficiência Respiratória/terapia , Ventiladores Mecânicos , Dióxido de Carbono/análise , Humanos , Intubação Intratraqueal , Monitorização Fisiológica , Estados UnidosRESUMO
During the past 30 years, emergency medical services (EMS) in the United States have experienced explosive growth. The American health care system is now transforming, providing an opportune time to examine what we have learned over the past three decades in order to create a vision for the future of EMS. Over the course of several months, a multidisciplinary steering committee collaborated with hundreds of EMS-interested individuals, organizations, and agencies to develop the EMS Agenda for the Future. Fourteen EMS attributes were identified as requiring continued development in order to realize the vision established within the Agenda. They are integration of health services, EMS research, legislation and regulation, system finance, human resources, medical direction, education systems, public education, prevention, public access, communication systems, clinical care, information systems, and evaluation. Discussion of these attributes provides important guidance for achieving a vision for the future of EMS that emphasizes its critical role in American health care.
Assuntos
Serviços Médicos de Emergência/tendências , Diretrizes para o Planejamento em Saúde , Prestação Integrada de Cuidados de Saúde , Prioridades em Saúde , Humanos , Estados UnidosRESUMO
During the past 30 years, emergency medical services (EMS) in the United States have experienced explosive growth. The American health care system is now transforming, providing an opportune time to examine what we have learned over the past three decades in order to create a vision for the future of EMS. Over the course of several months, a multidisciplinary steering committee collaborated with hundreds of EMS-interested individuals, organizations, and agencies to develop the "EMS Agenda for the Future." Fourteen EMS attributes were identified as requiring continued development in order to realize the vision established within the Agenda. They are Integration of Health Services, EMS Research, Legislation and Regulation, System Finance, Human Resources, Medical Direction, Education Systems, Public Education, Prevention, Public Access, Communication Systems, Clinical Care, Information Systems, and Evaluation. Discussion of these attributes provides important guidance for achieving a vision for the future of EMS that emphasizes its critical role in American health care.
Assuntos
Serviços Médicos de Emergência/tendências , Sistemas de Comunicação entre Serviços de Emergência/tendências , Serviços Médicos de Emergência/legislação & jurisprudência , Serviços Médicos de Emergência/organização & administração , Auxiliares de Emergência/educação , Previsões , Humanos , Pesquisa/tendências , Estados UnidosRESUMO
STUDY OBJECTIVE: We sought to assess the involvement of law enforcement agencies in out-of-hospital emergency medical care and their attitudes toward expanded roles in emergency medical services (EMS) systems. METHODS: We mailed a 20-question survey to 800 police chiefs and sheriffs randomly selected from a list of all law enforcement agencies in the United States. The questions focused on the characteristics of each law enforcement agency, its current level of involvement in providing out-of-hospital emergency medical care, and the characteristics of its associated community and local EMS system. The survey concluded with four statements to assess officer attitudes toward an expanded role in EMS-related activities. We used the chi 2 or Fisher exact test to analyze differences in proportions. The alpha-error rate was set at .05. RESULTS: Seventeen surveys were returned as undeliverable. Of the remaining 783 surveys, we received 602 responses (77%). Five hundred forty-nine (70.1%) of the respondents were the primary law enforcement agencies in their communities; they make up the final sample. The median number of officers per agency was 12 (range, 1 to 2,623), and the median population served was 6,936 (range, 150 to 1,500,000). Responses indicated that 442 (80.7%) agencies responded to one or more specific types of medical emergencies and 263 (50.3%) provided some level of patient care. Law enforcement officers frequently arrived at the scene of medical emergencies before EMS personnel (81.5%), with a roll-time interval of less than 8 minutes (87.2%). Only 14 agencies (2.6%) used automatic external defibrillators. Fifty-three percent agreed with the statement that EMS-related activities would interfere with their law enforcement duties. However, more than 60% of respondents agreed that law enforcement agencies should be involved in providing emergency medical services for life-threatening emergencies, that their officers would be willing to undertake extra medical training and that EMS-related activities would improve their public images. CONCLUSION: Many law enforcement agencies are involved to some extent in providing out-of-hospital emergency medical care, and most of the agencies we surveyed would support additional medical training and new or expanded roles for themselves in EMS systems.
Assuntos
Serviços Médicos de Emergência , Cuidados para Prolongar a Vida , Polícia , Atitude , Cardioversão Elétrica , Medicina de Emergência/educação , Primeiros Socorros , Parada Cardíaca/terapia , Humanos , Polícia/educação , Estudos de Amostragem , Transporte de Pacientes , Estados Unidos , Recursos HumanosRESUMO
Policies regarding ambulance diversion are critical to ensuring that EMS providers are aware of appropriate patient destinations, even before patients enter the system. Field EMS personnel should never be requested to prolong transport time intervals to search for an available hospital at the potential expense of patients' conditions and the immediate availability of out-of-hospital emergency care for the community. The responsibility for providing efficient emergency care to the community rests with all those who contribute to EMS structures and processes. All EMS system participants, including hospitals, EMS providers, local and regional lead agencies, and medical oversight authorities, must work together to create comprehensive ambulance diversion policies that satisfactorily meet each other's needs, while maintaining the highest regard for the needs of EMS patients and the entire community.
Assuntos
Ambulâncias/normas , Serviço Hospitalar de Emergência/estatística & dados numéricos , Transporte de Pacientes/normas , Área Programática de Saúde , Tomada de Decisões , Humanos , Sociedades Médicas , Fatores de Tempo , Viagem , Estados UnidosRESUMO
OBJECTIVE: Out-of-hospital emergency medical services (EMS) need relevant and measurable indicators of quality. Those front-line workers who provide service directly to the customer are integral to the process of defining quality. The authors' objective was to obtain from paramedics, the front-line workers in the EMS system, their perspective on quality of care. METHODS: During regularly scheduled education sessions, 102 of the 140 field paramedics from a large municipal EMS system attended a presentation on total quality management. The paramedics were then assigned to focus groups and asked to identify quality indicators and provide recommendations for how they should be measured. RESULTS: Eighteen different quality indicators were identified. In addition, the paramedics suggested 17 ways to measure these proposed quality indicators. CONCLUSIONS: From the perspective of the study participants, indicators of the quality of out-of-hospital care differ from many used in traditional EMS quality assurance programs. Future studies should investigate the applicability of these indicators to the total quality management of EMS systems.
Assuntos
Atitude do Pessoal de Saúde , Serviços Médicos de Emergência/normas , Auxiliares de Emergência/psicologia , Indicadores de Qualidade em Assistência à Saúde/normas , Auxiliares de Emergência/educação , Grupos Focais , Humanos , Pennsylvania , Gestão da Qualidade Total , Saúde da População UrbanaAssuntos
Tratamento de Emergência/normas , Trajes Gravitacionais/normas , Seleção de Pacientes , Choque/terapia , Medicina de Emergência , Tratamento de Emergência/métodos , Trajes Gravitacionais/estatística & dados numéricos , Humanos , Reprodutibilidade dos Testes , Projetos de Pesquisa/normas , Sociedades Médicas , Estados UnidosRESUMO
STUDY OBJECTIVE: To determine whether family members accept field termination of unsuccessful out-of-hospital cardiac arrest resuscitation. METHODS: We carried out a prospective cohort study, using a structured interview, in an urban, municipal, advanced life support emergency medical services (EMS) system. The interview subjects were family members present at the scene in a consecutive series of unsuccessful out-of-hospital resuscitation attempts. RESULTS: During the 4-month study period, 140 out-of-hospital cardiac arrests occurred. Follow-up with a family member was performed in 42 of the 53 cardiac arrests that met the inclusion criteria (79%). When resuscitation was terminated in the field (n = 25), 24 family members (96%) reported satisfaction with the decision. When resuscitation was terminated in the emergency department (n = 17), 14 family members (82%) reported satisfaction with the decision to transport the victim to the hospital. However, responses indicated that 13 of the family members (76%) might have accepted termination of resuscitation in the home. In all cases, relatives reported satisfaction with the paramedics' care and with the manner in which they were informed of the victims' deaths. CONCLUSION: Family members accept termination of unsuccessful out-of-hospital cardiac arrest resuscitation in the field.
Assuntos
Atitude Frente a Morte , Reanimação Cardiopulmonar , Serviços Médicos de Emergência/métodos , Família/psicologia , Parada Cardíaca/terapia , Idoso , Tomada de Decisões , Feminino , Pesquisa sobre Serviços de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Pennsylvania , Estudos Prospectivos , Inquéritos e Questionários , Falha de TratamentoRESUMO
OBJECTIVE: To evaluate the success rate, intubation time, and complication rate of transillumination-guided intubation following two hours of instruction in the use of the Trachlight (TL) device. METHODS: A prospective, randomized crossover laboratory trial was conducted at an emergency medical service training site with 30 nonpaid volunteer paramedic students, one month prior to their graduation. The students were instructed in the use of the TL in a standardized curriculum consisting of didactic, video, and demonstration sessions. Each student was required to successfully intubate a training manikin with the TL five times. Approximately three weeks later, the students were asked to intubate the manikin 20 times, alternating between direct laryngoscopy (DL) and TL. RESULTS: The success rates were 94% for DL and 63% for TL (p < 0.0001). The mean intubation times were 14.6 seconds for DL and 16.8 seconds for TL (p < 0.001). The incidences of trauma were 7.3% for DL and 1.4% for TL (p < 0.001). CONCLUSION: A two-hour training session, including five successful light-guided intubations using the TL, was inadequate for producing acceptable success rates during manikin intubations by paramedic students. While TL intubation intervals were shorter when successful, the 2.2-second difference was not clinically meaningful. The incidence of trauma in our manikin model during TL intubations was significantly lower than that with DL.
Assuntos
Educação Médica , Avaliação Educacional , Intubação Intratraqueal , Estudos Cross-Over , Coleta de Dados , Humanos , Intubação Intratraqueal/efeitos adversos , Intubação Intratraqueal/instrumentação , Intubação Intratraqueal/métodos , Avaliação de Programas e Projetos de Saúde , Estudos Prospectivos , Fatores de TempoRESUMO
Wide complex tachycardias present diagnostic challenges for emergency physicians. The history, physical examination, and ECG provide information required to arrive at the correct diagnosis. When a previous history of heart disease exists, VT should be suspected; however, no single clinical feature is sufficiently reliable for distinguishing VT from SVT. Patients with VT may tolerate their dysrhythmias for several hours and maintain hemodynamic stability. ECG analysis is the most useful process in differentiating SVT and VT. Characteristics suggestive of VT include evidence of AV dissociation, QRS duration of longer than 0.16 seconds, and QRS axis between -90 degrees +/- 180 degrees. Predictive QRS morphologic criteria also have been established for VT. A four-step approach to ECG analysis has been reported to accurately identify patients with VT, but prospective validation in an ED setting is lacking. The initial approach to treating patients with wide QRS tachycardias depends on hemodynamic stability. Until the identify of a dysrhythmia is certain, consider all patients to be suffering from VT. Unstable patients require immediate cardioversion. Acute treatment of stable patients includes lidocaine or procainamide. Adenosine is appropriate when wide QRS SVT is the diagnosis, and it also has been used as a diagnostic aid to identify dysrhythmias. Reports of complications with the use of adenosine as a diagnostic agent have not yet appeared but may occur after sufficient numbers of cases have accumulated. Magnesium sulfate may be useful in refractory cases of VT and torsades de pointes. Chronic treatment of patients prone to VT may include complex pharmacotherapy and AICDs. Development of new class III agents and enhancement of AICD technology may result in improved patient outcomes and the availability of more choices for emergent therapy of wide QRS tachycardias.
Assuntos
Eletrocardiografia , Taquicardia , Árvores de Decisões , Desfibriladores Implantáveis , Diagnóstico Diferencial , Serviços Médicos de Emergência , Humanos , Taquicardia/diagnóstico , Taquicardia/etiologia , Taquicardia/terapiaRESUMO
A case of intentional massive insulin overdose requiring prolonged glycemic support is presented. Suicidal insulin overdose may be more common than generally appreciated. Because hypoglycemic reactions are evaluated routinely in the ED, emergency physicians should maintain a high degree of suspicion regarding suicidal intent or foul play in diabetics with hypoglycemia who respond minimally to the administration of concentrated glucose solutions or in hypoglycemic presentations by nondiabetics who have access to diabetic medications. Fingerstick glucose evaluations or serum glucose levels should be obtained routinely at 15 to 30 minutes after glucose administration in any hypoglycemic patient to gauge the intensity of glucose use. Inability to maintain euglycemia following glucose administration suggests excessive insulin and requires further workup. Evaluation of serum insulin and C-peptide levels is useful in confirming intentional overdoses in cases that are not clear-cut. Glucose infusion rates must be tailored individually to each overdose situation as great individual variability exists in insulin absorption and effects. The clinician should anticipate the possible need for prolonged glycemic support in this setting.
Assuntos
Hipoglicemia/induzido quimicamente , Insulina/intoxicação , Adulto , Glicemia/análise , Overdose de Drogas/diagnóstico , Emergências , Glucose/uso terapêutico , Humanos , Hipoglicemia/sangue , Hipoglicemia/tratamento farmacológico , MasculinoRESUMO
This article presents specific uses of the portable chest film. The specific utility, borderline utility, and pitfalls in interpretation of films that are often taken to investigate a number of diagnostic problems common to the practice of emergency medicine are discussed.