Evidence-Based Guideline for Prehospital Airway Management.

Airway management is a cornerstone of emergency medical care. This project aimed to create evidence-based guidelines based on the systematic review recently conducted by the Agency for Healthcare Research and Quality (AHRQ). A technical expert panel was assembled to review the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The panel made specific recommendations on the different PICO (population, intervention, comparison, outcome) questions reviewed in the AHRQ review and created good practice statements that summarize and operationalize these recommendations. The recommendations address the use of ventilation with bag-valve mask ventilation alone vs. supraglottic airways vs. endotracheal intubation for adults and children with cardiac arrest, medical emergencies, and trauma. Additional recommendations address the use of video laryngoscopy and drug-assisted airway management. These recommendations, and the associated good practice statements, offer EMS agencies and clinicians an opportunity to review the available evidence and incorporate it into their airway management strategies.

Learning the Language of Medical Device Innovation: A Longitudinal Interdisciplinary Elective for Medical Students.

PROBLEM: Physicians are playing a growing role as clinician-innovators. Academic physicians are well positioned to contribute to the medical device innovation process, yet few medical school curricula provide students opportunities to learn the conceptual framework for clinical needs finding, needs screening, concept generation and iterative prototyping, and intellectual property management. This framework supports innovation and encourages the development of valuable interdisciplinary communication skills and collaborative learning strategies. APPROACH: Our university offers a novel 3-year-long medical student Longitudinal Interdisciplinary Elective in Biodesign (MSLIEB) that teaches medical device innovation in 4 stages: (1) seminars and small-group work, (2) shared clinical experiences for needs finding, (3) concept generation and product development by serving as consultants for biomedical engineering capstone projects, and (4) reflection and mentorship. The MSLIEB objectives are to: create a longitudinal interdisciplinary peer mentorship relationship between undergraduate biomedical engineering students and medical students, and encourage codevelopment of professional identities in relation to medical device innovation. OUTCOMES: The MSLIEB enrolled 5 entering cohorts from 2017 to 2021 with a total of 37 medical student participants. The first full entering cohort of 12 medical students produced 8 mentored biomedical engineering capstone projects, 7 of which were based on clinical needs statements derived from earlier in the elective. Medical student participants have coauthored poster and oral presentations; contributed to projects that won WolfieTank, a university-wide competition modeled after the television show Shark Tank; and participated in the filing of provisional patents. Students reflecting on the course reported a change in their attitude towards existing medical problems, felt better-equipped to collaboratively design solutions for clinical needs, and considered a potential career path in device design. NEXT STEPS: The MSLIEB will be scaled up by recruiting additional faculty, broadening clinical opportunities to include the outpatient setting, and increasing medical student access to rapid prototyping equipment.

Disparity in Gender Representation of Speakers at National Emergency Medical Services Conferences: A Current Assessment and Proposed Path Forward.

INTRODUCTION: Gender disparities between Emergency Medicine physicians with regards to salary, promotion, and scholarly recognition as national conference speakers have been well-documented. However, little is known if similar gender disparities impact their out-of-hospital Emergency Medical Services (EMS) colleagues. Although there have been improvements in the ratio of women entering the EMS workforce, gender representation has improved at a slower rate for paramedics compared to emergency medical technicians (EMTs). Since recruitment, retention, and advancement of females within a specialty have been associated with the visibility of prominent, respected female leaders, gender disparity of these leaders as national conference speakers may contribute to the "leaky pipeline effect" seen within the EMS profession. Gender representation of these speakers has yet to be described objectively. STUDY OBJECTIVE: The primary objective of this study was to determine if disparity exists in gender representation of speakers at well-known national EMS conferences and trade shows in the United States (US) from 2016-2020. The secondary objective was to determine if males were more likely than females to return to a conference as a speaker in subsequent years. METHODS: A cross-sectional analysis of programs from well-known national conferences, specifically for EMS providers, which were held in the US from 2016-2020 was performed. Programs were abstracted for type of conference session (pre-conference, keynote, main conference) and speakers' names. Speaker gender (male, female) was confirmed via internet search. RESULTS: Seventeen conference programs were obtained with 1,709 conference sessions that had a total of 2,731 listed speaker names, of whom 537 (20%) were female. A total of 30 keynote addresses had 39 listed speaker names of whom six (15%) were female. No significant difference was observed in the number of years males returned to present at the same conference as compared to females. CONCLUSION: Gender representation of speakers at national EMS conferences in the US is not reflective of the current best estimate of the US EMS workforce. This disparity exists not only in the overall percent of female names listed as speakers, but also in the percent of individual female speakers, and is most pronounced within keynote speakers. Online lecture platforms, as an unintentional consequent of the COVID-19 pandemic, coupled with intentional speaker development and mentorship initiatives, may reduce barriers to facilitating a new pipeline for more females to become speakers at national EMS conferences.

The relationship of large city out-of-hospital cardiac arrests and the prevalence of COVID-19.

BACKGROUND: Though variable, many major metropolitan cities reported profound and unprecedented increases in out-of-hospital cardiac arrest (OHCA) in early 2020. This study examined the relative magnitude of those increases and their relationship to COVID-19 prevalence. METHODS: EMS (9-1-1 system) medical directors for 50 of the largest U.S. cities agreed to provide the aggregate, de-identified, pre-existing monthly tallies of OHCA among adults (age >18 years) occurring between January and June 2020 within their respective jurisdictions. Identical comparison data were also provided for corresponding time periods in 2018 and 2019.  Equivalent data were obtained from the largest cities in Italy, United Kingdom and France, as well as Perth, Australia and Auckland, New Zealand. FINDINGS: Significant OHCA escalations generally paralleled local prevalence of COVID-19. During April, most U.S. cities (34/50) had >20% increases in OHCA versus 2018-2019 which reflected high local COVID-19 prevalence. Thirteen observed 1·5-fold increases in OHCA and three COVID-19 epicenters had >100% increases (2·5-fold in New York City). Conversely, cities with lesser COVID-19 impact observed unchanged (or even diminished) OHCA numbers. Altogether (n = 50), on average, OHCA cases/city rose 59% during April (p = 0·03). By June, however, after mitigating COVID-19 spread, cities with the highest OHCA escalations returned to (or approached) pre-COVID OHCA numbers while cities minimally affected by COVID-19 during April (and not experiencing OHCA increases), then had marked OHCA escalations when COVID-19 began to surge locally. European, Australian, and New Zealand cities mirrored the U.S. experience. INTERPRETATION: Most metropolitan cities experienced profound escalations of OHCA generally paralleling local prevalence of COVID-19.  Most of these patients were pronounced dead without COVID-19 testing. FUNDING: No funding was involved. Cities provided de-identified aggregate data collected routinely for standard quality assurance functions.

An Evolving Clinical Need: Discordant Oxygenation Measurements of Intubated COVID-19 Patients.

Since the first appearance of the severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) earlier this year, clinicians and researchers alike have been faced with dynamic, daily challenges of recognizing, understanding, and treating the coronavirus disease 2019 (COVID-19) due to SARS-CoV-2. Those who are moderately to severely ill with COVID-19 are likely to develop acute hypoxemic respiratory failure and require administration of supplemental oxygen. Assessing the need to initiate or titrate oxygen therapy is largely dependent on evaluating the patient's existing blood oxygenation status, either by direct arterial blood sampling or by transcutaneous arterial oxygen saturation monitoring, also referred to as pulse oximetry. While the sampling of arterial blood for measurement of dissolved gases provides a direct measurement, it is technically challenging to obtain, is painful to the patient, and can be time and resource intensive. Pulse oximetry allows for non-invasive, real-time, continuous monitoring of the percent of hemoglobin molecules that are saturated with oxygen, and usually closely predicts the arterial oxygen content. As such, it was particularly concerning when patients with severe COVID-19 requiring endotracheal intubation and mechanical ventilation within one of our intensive care units were observed to have significant discordance between their predicted arterial oxygen content via pulse oximetry and their actual measured oxygen content. We offer these preliminary observations along with our speculative causes as a timely, urgent clinical need. In the setting of a COVID-19 intensive care unit, entering a patient room to obtain a fresh arterial blood gas sample not only takes exponentially longer to do given the time required for donning and doffing of personal protective equipment (PPE), it involves the consumption of already sparce PPE, and it increases the risk of viral exposure to the nurse, physician, or respiratory therapist entering the room to obtain the sample. As such, technology similar to pulse oximetry which can be applied to a patients finger, and then continuously monitored from outside the room is essential in preventing a particularly dangerous situation of unrealized hypoxia in this critically-ill patient population. Additionally, it would appear that conventional two-wavelength pulse oximetry may not accurately predict the arterial oxygen content of blood in these patients. This discordance of oxygenation measurements poses a critical concern in the evaluation and management of the acute hypoxemic respiratory failure seen in patients with COVID-19.

Utility of Different Lung Ultrasound Simulation Modalities Used by Paramedics during Varied Ambulance Driving Conditions.

INTRODUCTION: Prehospital use of lung ultrasound (LUS) by paramedics to guide the diagnoses and treatment of patients has expanded over the past several years. However, almost all of this education has occurred in a classroom or hospital setting. No published prehospital use of LUS simulation software within an ambulance currently exists. STUDY OBJECTIVE: The objective of this study was to determine if various ambulance driving conditions (stationary, constant acceleration, serpentine, and start-stop) would impact paramedics' abilities to perform LUS on a standardized patient (SP) using breath-holding to simulate lung pathology, or to perform LUS using ultrasound (US) simulation software. Primary endpoints included the participating paramedics': (1) time to acquiring a satisfactory simulated LUS image; and (2) accuracy of image recognition and interpretation. Secondary endpoints for the breath-holding portion included: (1) the agreement between image interpretation by paramedic versus blinded expert reviewers; and (2) the quality of captured LUS image as determined by two blinded expert reviewers. Finally, a paramedic LUS training session was evaluated by comparing pre-test to post-test scores on a 25-item assessment requiring the recognition of a clinical interpretation of prerecorded LUS images. METHODS: Seventeen paramedics received a 45-minute LUS lecture. They then performed 25 LUS exams on both SPs and using simulation software, in each case looking for lung sliding, A and B lines, and seashore or barcode signs. Pre- and post-training, they completed a 25-question test consisting of still images and videos requiring pathology recognition and formulation of a clinical diagnosis. Sixteen paramedics performed the same exams in an ambulance during different driving conditions (stationary, constant acceleration, serpentines, and abrupt start-stops). Lung pathology was block randomized based on driving condition. RESULTS: Paramedics demonstrated improved post-test scores compared to pre-test scores (P <.001). No significant difference existed across driving conditions for: time needed to obtain a simulated image; clinical interpretation of simulated LUS images; quality of saved images; or agreement of image interpretation between paramedics and blinded emergency physicians (EPs). Image acquisition time while parked was significantly greater than while the ambulance was driving in serpentines (Z = -2.898; P = .008). Technical challenges for both simulation techniques were noted. CONCLUSION: Paramedics can correctly acquire and interpret simulated LUS images during different ambulance driving conditions. However, simulation techniques better adapted to this unique work environment are needed.

12-Lead Electrocardiograms Acquired and Transmitted by Emergency Medical Technicians are of Diagnostic Quality and Positively Impact Patient Care.

INTRODUCTION: Existing peer-reviewed literature describing emergency medical technician (EMT) acquisition and transmission of 12-lead electrocardiograms (12L-ECGs), in the absence of a paramedic, is largely limited to feasibility studies. STUDY OBJECTIVE: The objective of this retrospective observational study was to describe the impact of EMT-acquired 12L-ECGs in Suffolk County, New York (USA), both in terms of the diagnostic quality of the transmitted 12L-ECGs and the number of prehospital percutaneous coronary intervention (PCI)-center notifications made as a result of transmitted 12L-ECGs demonstrating a ST-elevation myocardial infarction (STEMI). METHODS: A pre-existing database was queried for Emergency Medical Services (EMS) calls on which an EMT acquired a 12L-ECG from program initiation (January 2017) through December 31, 2019. Scanned copies of the 12L-ECGs were requested in order to be reviewed by a blinded emergency physician. RESULTS: Of the 665 calls, 99 had no 12L-ECG available within the database. For 543 (96%) of the available 12L-ECGs, the quality was sufficient to diagnose the presence or absence of a STEMI. Eighteen notifications were made to PCI-centers about a concern for STEMI. The median time spent on scene and transporting to the hospital were 18 and 11 minutes, respectively. The median time from PCI-center notification to EMS arrival at the emergency department (ED) was seven minutes (IQR 5-14). CONCLUSION: In the event a cardiac monitor is available, after a limited educational intervention, EMTs are capable of acquiring a diagnostically useful 12L-ECG and transmitting it to a remote medical control physician for interpretation. This allows for prehospital PCI-center activation for a concern of a 12L-ECG with a STEMI, in the event that a paramedic is not available to care for the patient.

Prehospital Naloxone and Emergency Department Adverse Events: A Dose-Dependent Relationship.

BACKGROUND: The purpose of this study was to evaluate prehospital and emergency department (ED) interventions and outcomes of patients who received prehospital naloxone for a suspected opioid overdose. OBJECTIVES: The primary objective was to evaluate if the individual dose, individual route, total dose, number of prehospital naloxone administrations, or occurrence of a prehospital adverse event (AE) were associated with the occurrence of AEs in the ED. Secondary objectives included a subset analysis of patients who received additional naloxone while in the ED, or were admitted to an intensive care or step-down unit (ICU). METHODS: This was a retrospective, observational chart review of adult patients who received prehospital naloxone and were transported by ambulance to a suburban academic tertiary care center between 2014 and 2017. Descriptive, univariate, and multivariate statistics were used, with p < 0.05 indicating significance. RESULTS: There were 513 patients included in the analysis, with a median age of 29 years, and median total prehospital naloxone dose of 2 mg. An increasing number of prehospital naloxone doses, an occurrence of a prehospital AE, and a route of administration other than intranasally for the first dose of prehospital naloxone were significantly associated with an increased likelihood of an ED AE. Patients who received < 2 mg of prehospital naloxone had the least likelihood of being admitted to an ICU, whereas patients who received at least 6 mg had a dramatically increased likelihood of ICU admission. CONCLUSIONS: Our results suggest that an increasing number of prehospital naloxone doses was significantly associated with an increased likelihood of an ED adverse event.

A COVID-19 Airway Management Innovation with Pragmatic Efficacy Evaluation: The Patient Particle Containment Chamber.

The unique resource constraints, urgency, and virulence of the coronavirus disease 2019 pandemic has sparked immense innovation in the development of barrier devices to protect healthcare providers from infectious airborne particles generated by patients during airway management interventions. Of the existing devices, all have shortcomings which render them ineffective and impractical in out-of-hospital environments. Therefore, we propose a new design for such a device, along with a pragmatic evaluation of its efficacy. Must-have criteria for the device included: reduction of aerosol transmission by at least 90% as measured by pragmatic testing; construction from readily available, inexpensive materials; easy to clean; and compatibility with common EMS stretchers. The Patient Particle Containment Chamber (PPCC) consists of a standard shower liner draped over a modified octagonal PVC pipe frame and secured with binder clips. 3D printed sleeve portals were used to secure plastic sleeves to the shower liner wall. A weighted tube sealed the exterior base of the chamber with the contours of the patient's body and stretcher. Upon testing, the PPCC contained 99% of spray-paint particles sprayed over a 90s period. Overall, the PPCC provides a compact, affordable option that can be used in both the in-hospital and out-of-hospital environments.

Use of gelatin puzzle phantoms to teach medical students isolated ultrasound transducer movements and fundamental concepts.

BACKGROUND: Psychomotor skills related to the use of medical ultrasound are a fundamental, but often overlooked component of this ubiquitous medical imaging technology. Although discussions of image production/orientation, sonographic planes, and imaging/scanning techniques are common in existing literature, these discussions rarely address practical skills related to these basic concepts. The cognitive load of transducer movements and machine operation, in conjunction with learning the ultrasound representation of anatomy, may overwhelm a novice learner. Our goal was to develop and evaluate a set of ultrasound puzzle phantoms for students to use as they learn isolated, specific transducer movements and sonographic concepts. We intentionally created phantoms that contain objects that are likely familiar to students to reduce the cognitive load associated with simultaneously learning the ultrasound interpretation of anatomy. METHODS: This preliminary evaluation of our novel, homemade, gelatin ultrasound puzzle phantoms was performed using pretests and posttests obtained by scanning an assessment phantom, and student questionnaires. Two phases of training and testing occurred with feedback from Phase 1 allowing for refinement of the puzzles and techniques for testing. Skills taught and evaluated included probe rotation, depth assessment, sliding, and tilting. RESULTS: Twenty-eight students attended the Phase 1 training session with positive trends in students' abilities to use rotation, sliding, and tilting to answer questions, while only depth showed statistically significant improvements (p = 0.021). Overall students agreed the experience a productive use of time (86%), was beneficial (93%), and would recommend to others (93%). Fifteen (54%) students returned 3 months later. There was no significant decay in skills obtained from the prior training session. In Phase 2, 134 medical students participated, and 76 (57%) completed an online questionnaire. A majority of students agreed they had a better understanding of rotation (83%), depth (80%), sliding (88%) and tilting (55%). Similar to Phase 1, many students (75%) felt the experience was beneficial. CONCLUSIONS: This preliminary study gave us insight into student opinions, as well as information to guide future scalability and development of additional ultrasound puzzle phantoms to aid in medical student education of isolated transducer movements and sonographic concepts prior to imaging human anatomy.

Using a Journal Club Series to Introduce Paramedic Students to Research Fundamentals and Critical Appraisal of Medical Literature.

INTRODUCTION: Despite United States national learning objectives referencing research fundamentals and the critical appraisal of medical literature, many paramedic programs are not meeting these objectives with substantive content. PROBLEM: The objective was to develop and implement a journal club educational module for paramedic training programs, which is all-inclusive and could be distributed to Emergency Medical Services (EMS) educators and EMS medical directors to use as a framework to adapt to their program. METHODS: Four two-hour long journal club sessions were designed. First, the educator provided students with four types of articles on a student-chosen topic and discussed differences in methodology and structures. Next, after a lecture about peer-review, students used search engines to verify references of a trade magazine article. Third, the educator gave a statistics lecture and critiqued the results section of several articles found by students on a topic. Finally, students found an article on a topic of personal interest and presented it to their classmates, as if telling their paramedic partner about it at work. Before and after the series, students from two cohorts (2017, 2018) completed a survey with questions about demographics and perceptions of research. Students from one cohort (2017) received a follow-up survey one year later. RESULTS: For the 2016 cohort, 13 students participated and provided qualitative feedback. For the 2017 and 2018 cohorts, 33 students participated. After the series, there was an increased self-reported ability to find, evaluate, and apply medical research articles, as well as overall positive trending opinions of participating in and the importance of prehospital research. This ability was demonstrated by every student during the final journal club session. McNemar's and Related-Samples Cochran's Q testing of questionnaire responses suggested a statistically significant improvement in student approval of exceptions from informed consent. CONCLUSION: The framework for this paramedic journal club series could be adapted by EMS educators and medical directors to enable paramedics to search for, critically appraise, and discuss the findings of medical literature.