The reliability of prehospital clinical evaluation for potential spinal injury is not affected by the mechanism of injury.

INTRODUCTION: Traditional EMS teaching identifies mechanism of injury as an important predictor of spinal injury. Clinical criteria to select patients for immobilization are being studied in Michigan and have been implemented in Maine. Maine requires automatic immobilization of patients with "a positive mechanism" clearly capable of producing spinal injury. OBJECTIVE: To determine whether mechanism of injury affects the ability of clinical criteria to identify patients with spinal injury. METHODS: In this multicenter prospective cohort study, EMS personnel completed a check-off data sheet for prehospital spine-immobilized patients. Data included mechanism of injury and yes/no determinations of the clinical criteria: altered mental status, neurologic deficit, evidence of intoxication, spinal pain or tenderness, and suspected extremity fracture. Hospital outcome data included confirmation of spinal injury and treatment required. Mechanisms of injury were tabulated and rates of spinal injury for each mechanism were calculated. The patients were divided into three different high-risk and low-risk groups. RESULTS: Data were collected for 6,500 patients. There were 209 (3.2%) patients with spinal injuries identified. There were 1,058 patients with 100 (9.4%) injuries in the first high-risk mechanism group, and 5,423 patients with 109 (2%) injuries in the first low-risk group. Criteria identified 97 of 100 (97%) injuries in the high-risk group and 102 of 109 (94%) in the low-risk group. Two additional data divisions yielded identical results. CONCLUSION: Mechanism of injury does not affect the ability of clinical criteria to predict spinal injury in this population.

Can melatonin improve adaptation to night shift?

This study was undertaken to determine whether melatonin (N-acetyl-5 methoxytryptamine) is effective in helping emergency medical services (EMS) personnel who work rotating night shifts reset their biological clocks and minimize circadian rhythm disruption. A double-blinded, randomized, crossover study was performed using 22 volunteers. Participants were working a span of consecutive night (2300 to 0700 hours) shifts and received either a melatonin capsule (6 mg) or placebo to be taken before each of the consecutive day sleeps. Each participant completed a total of 4 spans of consecutive night shifts (2 melatonin, 2 placebo). Collected data included daily sleep diaries, quantification of alcohol/caffeine consumed, and drug side effects. Assessment of sleep quality, posttreatment mood, and workload ratings were measured daily by 10-cm visual analog scale (VAS). Analysis of sleep diaries found no significant difference (P > .05) between the two treatments with respect to mean sleep latency, duration, and efficiency, and subjectively rated sleep quality. Similarly, no significant benefits were noted between the median VAS scores for daily posttreatment mood or workload ratings. Adverse effects were rare; one patient taking melatonin reported a prolonged sedative effect. Despite recent interest in melatonin for treatment of circadian-based sleep disorders, no clinical benefits were noted in EMS personnel working rotating night shifts.

Elder mistreatment: national survey of emergency physicians.

To determine the perceived magnitude of elder mistreatment, physician awareness of applicable state laws, and the barriers to reporting suspected cases, we surveyed a random sample of 3,000 members of the American College of Emergency Physicians in the United States. Survey questions included practice characteristics, number and type of suspected cases of elder mistreatment seen in the ED, number of cases actually reported, and reasons for not reporting abuse. Physicians were also asked about the availability of elder-mistreatment protocols and their familiarity with local laws and reporting requirements. We received 705 completed surveys, for a response rate of 24%. Most physicians (52%) described elder mistreatment as prevalent but less so than spouse or child abuse. The respondents had evaluated a mean of 4 +/- 8 (range, 0 to 93) suspected cases of elder mistreatment in the preceding 12 months; approximately 50% were reported. Only 31% of emergency physicians reported having a written protocol for the reporting of elder mistreatment, and physicians were generally not familiar with applicable state laws. Twenty-five percent were able to recall educational content pertaining to elder mistreatment during their emergency medicine residencies. Most physicians were not certain or did not believe that clear-cut medical definitions of elder abuse or neglect exist (74%); that emergency physicians can accurately identify cases of mistreatment (58%); or that their states had sufficient resources to meet the needs of victims (92%). These results suggest that practicing emergency physicians are not confident in identifying or reporting geriatric victims of abuse or neglect. This lack of confidence may reflect inadequacies of training, research, and continuing education with regard to mistreatment of older people.

Identifying victims of elder abuse and neglect: a training video for prehospital personnel.

INTRODUCTION: The majority of prehospital emergency medical services (EMS) personnel lack specific training relating to elder abuse and neglect. OBJECTIVES: To develop and test an audio-visual training program that focuses on the identification and reporting of domestic violence in the elderly. METHODS: A videotape was designed to be used as a 45-minute training course for prehospital personnel using one-half inch, super-VHS recording. A convenience sample of 60 EMS personnel working in Kent County then were asked to evaluate the videotape program. Each volunteer completed a pre-test on elder abuse and neglect, watched the 45-minute videotape, and then answered 12 questions on a post-test. RESULTS: Participants had an average of 12.4 years (range: 1-30 years) prehospital emergency-care experience. Only four (7%) could recall any previous training relating to elder abuse or neglect during their careers. Although the prevalence of elder abuse in their community was described as "rather rare" by most (60%) of the subjects, 85% (51/60) had seen a suspected case of elder abuse or neglect during their careers; 47% (28/60) had seen a case during the past six months. Only 29% of these suspected cases were reported to county authorities. Approximately 40% of the questions on the pre-test were answered correctly (mean score, 4.8 +/- 3.0). In comparison, 83% of the questions on the post-test were answered correctly (10.0 +/- 3.0). Although participants had a number of suggestions to improve the video program, 78% (47/60) expected this material to change the way they will evaluate elderly patients in the future. CONCLUSION: Prehospital personnel do not feel confident identifying or reporting victims of elder abuse or neglect. A videotape training program may be an effective way of presenting this information as a means of continuing education.

Photograph documentation of motor vehicle damage by EMTs at the scene: a prospective multicenter study in the United States.

The purpose of this study was to determine if emergency medical service (EMS) personnel could take instant photographs of motor vehicle damage at crash scenes depicting the area and severity of damage of the crash under adverse weather conditions, in different lighting, and quickly enough so as not to interfere with patient care. This prospective multicenter trial involved 35 ambulances responding to motor vehicle crash scenes in rural, suburban, and urban areas in five centers in four states. Emergency medical technicians (EMTs) reported their experience implementing a protocol for use of an instant camera to photograph vehicle damage at crash scenes. Time reported by EMTs to take the photographs was 1 minute or less in 204 of 288 (70.9%) of motor vehicle crashes and 2 minutes or longer in 12 of 288 (4.2%) of motor vehicle crashes. From one EMS agency in the study, 48 scene times during which photographs were taken were, on average, 1.5 minutes shorter than 48 scene times immediately before implementation of on-scene crash photography. Photographs were taken in different weather and lighting conditions. EMTs reported they were able to determine both area and severity of damage in 260 of 290 (92.5%) crash photographs, but they were unable to determine area and severity of damage in only 2 of 290 (0.7%) crash photographs.

Regional variation of nonrural pediatric ambulance transport rates: an ecological study.

STUDY OBJECTIVE: To determine the relationship of pediatric transport rates per hundred thousand pediatric population (RATE) to socioeconomic status (SES) factors and also mortality in Emergency Medical Services (EMS) systems. DESIGN: Retrospective ecological study. SETTING: Four EMS Medical Control Authorities (MCAs) in Michigan. PARTICIPANTS: Patients (3,792), 0-19 years of age, responded to as a nonscheduled emergency response and transported to a hospital by ambulance. METHODS AND MEASUREMENTS: RATE, economic status (INCOME), private transportation status (VEHICLE), educational status (EDUC), primary care physician availability (PHYS), and EMS disease death rate (EMSDD) were determined for each MCA and analyzed using Spearman rank correlation. RESULTS: RATE between MCAs varied from 325 to 750. RATE was highest in the most urban MCA: its 0-4 RATE was fourfold larger than any other MCA. INCOME, EDUC, and VEHICLE were inversely correlated with transport rate: -1.00, -1.00, -1.00; P < 0.001. Rate was positively correlated with EMSDD: 1.00; P < 0.001. CONCLUSIONS: Substantial variation in RATE between MCAs may be primarily due to the high 0-4 transport rate in the most urban MCA. This study also suggests that higher pediatric EMS system utilization rates may be correlated to higher mortality and also to unavailability of personal transportation.

Model curriculum in emergency medical services for emergency medicine residency programs. SAEM Emergency Medical Services Committee.

An emergency medical services (EMS) curriculum, as developed by the SAEM Emergency Medical Services Committee, is provided for the training of emergency medicine residents in EMS.

Into the fray: integration of emergency medical services and special weapons and tactics (SWAT) teams.

INTRODUCTION: The purpose of this study was to determine current experience and training of emergency medical support personnel for special weapons and tactics (SWAT) teams in North America. METHODS: This cross-sectional, epidemiologic survey was sent to SWAT unit commanders from the 200 largest metropolitan areas. Questions included basic demographics, specialized training of emergency medical services (EMS) personnel, and where such personnel are deployed during tactical operations. Unit commanders also were asked to estimate the number and type of injuries sustained during tactical operations and to list any recommendations to improve the EMS response. RESULTS: A total of 150 surveys was completed, for a response rate of 75%. The most common medical support (69%) was a civilian ambulance on standby at a predesignated location. Ninety-four percent of these prehospital care providers had no specialized training, and could not enter an area that was not secured tactically. Police officers with first aid or EMT training comprised the next largest group of medical support. Overall, 31% of SWAT commanders depended on remote EMS dispatch by radio to the scene when injuries occurred. Thirty-eight percent of respondents reported a significant injury had occurred during their tactical operations within the past 24 months. Common injuries included gunshot wounds, chemical exposure, and fractures. However, 78% (117/150) of respondents did not have a medical director, and 23% (35/150) of teams did not have an EMS preplan or protocol. CONCLUSION: The results suggest a need for established EMS protocols, medical direction, and specialized tactical medical training, especially in large metropolitan areas.

In-field extremity amputation: prevalence and protocols in emergency medical services.

OBJECTIVE: To determine current experience, attitudes, and training concerning the performance of in-field extremity amputations in North America. DESIGN: Cross-sectional, epidemiological survey. PARTICIPANTS: Emergency medical services (EMS) directors from the 200 largest metropolitan areas in North America and attendees at the 1992 Mid-Year National Association of EMS Physicians Meeting. INTERVENTIONS: The survey consisted of five questions focusing on demographic and operational data, the frequency of occurrence of the performance of in-field amputations, personnel responsible for performing the procedure, existing written protocols for the procedure, and the scope of training provided. RESULTS: A total of 143 surveys was completed. Eighteen respondents (13%) reported a total of 26 in-field extremity amputations in the past five years. The most common cause for the injuries requiring amputations was motor-vehicle accidents. In the majority of cases (53.2%), trauma surgeons were responsible for performing the amputation, followed by emergency physicians (36.4%). Of respondents, 96% stated that there was no training available through their EMS agencies related to the performance of in-field extremity amputations. Only two EMS systems had an existing protocol regarding in-field amputations. CONCLUSIONS: The results suggest a need for established protocols to make the procedure easily accessible when needed, especially in large metropolitan EMS systems. This information should be emphasized during EMS training and reinforced through continuing education.

To report or not to report: emergency services response to elder abuse.

PURPOSE: Prehospital emergency medical services (EMS) personnel, as initial responders to calls for assistance, are in an ideal position to identify abused or neglected elderly. A survey of prehospital personnel in Michigan was conducted to determine the scope of this problem, levels of awareness, and willingness to report cases of elder abuse. METHODS: The study population was a random sample of 500 prehospital personnel throughout one state. A blinded, self-administered survey was completed by emergency medical technicians (EMTs) and paramedics outlining their practice characteristics, prevalence of abuse in their community, and training available specific to elder abuse. Attitudes concerning the understanding and reporting of geriatric abuse were measured using a Likert-type scale. RESULTS: A total of 156 surveys (31%) was completed; 68% of the respondents were paramedics. Respondents had an average of 8.7 years (range: 9 months-30 years) of prehospital emergency-care experience, and evaluated an average of 11 patients (range: 1-59) older than 65 years of age each week. Seventy-eight percent had seen a suspected case of elder abuse or negligence during their careers; 68% had seen a case during the past 12 months (mean: 2.3 cases/yr; range: 0-24 cases/yr). However, surveyed personnel reported only 27% of suspected cases to authorities last year (mean: 0.62 cases/yr). Reasons for not reporting included 1) unsure which authorities take reports; 2) unclear definitions; 3) unaware of mandatory reporting laws; and 4) lack of anonymity. Ninety-five percent of respondents stated that training related to elder abuse was not available through their EMS agency. CONCLUSION: Paramedics and EMTs lack complete understanding of their role in the identification and reporting of elder abuse. This information should be emphasized during EMS training and reinforced through continuing education.

Guidelines for the prehospital use of thrombolytic agents.

Recognizing that prehospital thrombolytic therapy may provide benefit to certain subsets of patients, the routine prehospital use of thrombolytic agents should be discouraged pending further scientific delineation and documentation of those subgroups. ACEP encourages further investigation to document feasibility, efficacy, cost-effectiveness, and safety of use of these agents in this environment. Detailed education is needed in such areas as contraindications and the mechanics of drug administration. Online medical direction is paramount to the successful use of these agents in the prehospital setting.

Accuracy of the Prehospital Index in identifying major hemorrhage in trauma victims.

PURPOSE: To determine the sensitivity of the Prehospital Index (PHI) in identifying patients with severe blood loss, a one-year review was conducted at a regional trauma facility. METHODS: The study population consisted of 217 consecutive trauma admissions (ages 3 to 88 years). Patients were managed using standard resuscitation techniques; blood transfusions were ordered at the discretion of attending physicians and did not follow any preplanned protocol. Medical records were examined to determine total blood requirements for each patient during the first 12 hours of hospitalization, the emergency department (ED) disposition, and final outcome of treatment. The following clinical variables were analyzed (unpaired t-test) to determine their value as predictors of blood loss: age, gender, mechanism of injury, initial vital signs, revised trauma score, PHI, and injury severity score. RESULTS: Forty-two percent (92 patients) received transfusions during the first 12 hours of hospitalization. The best predictor of blood loss was the Prehospital Index. Of the total group, 45% had a PHI greater than 3; 77% (75/98) of these patients required transfusion and received an average of 7.1 units of packed cells. Fifty-five percent (119/217) had a PHI less than or equal to 3; 86% (102/119) of these patients did not require transfusion. CONCLUSION: The data suggest that patients with PHI scores greater than 3 require close hemodynamic monitoring to rule out significant blood loss and may warrant immediate cross-matching on arrival to the ED.

Comparison of motor vehicle damage documentation in emergency medical services run reports compared with photographic documentation.

STUDY OBJECTIVE: To determine whether emergency medical services (EMS) run reports adequately document vehicle damage when compared with vehicle photographs by using a traffic accident scoring system. DESIGN: A prospective study consisting of three phases: photographing motor vehicle collisions and collecting their respective EMS run reports, traffic accident damage score development, and comparison of photographs to the run reports by emergency medical technicians using the traffic accident damage score. SETTING: Data were collected in North Carolina and Ohio from motor vehicle crashes to which nine different EMS squads responded during a three-year period. TYPE OF PARTICIPANTS: EMS squads ranged from basic to paramedic levels of training. MEASUREMENTS AND MAIN RESULTS: Three emergency medical technicians were unable to determine the area of vehicle damage in 48% and the severity of damage in 61% of the EMS run reports. In contrast, there were no instances in which all three emergency medical technicians were unable to determine both area and severity of damage from the photographs. CONCLUSION: Most EMS run reports do not document vehicle damage adequately.