The policy case for designating EMS teams for vulnerable patient populations: Evidence from an intervention in Boston.

This study documents more than five years of analysis that drove the policy case, deployment, and retrospective evaluation for an innovative service model that enables Boston Emergency Medical Services (EMS) to respond quickly and effectively to investigation incidents in an area of heavy need in Boston. These investigation incidents are typically calls for service from passers-by or other third-party callers requesting that Boston EMS check in on individuals, often those who may appear to have an altered mental status or to be unhoused. First, this study reports the pre-intervention analytics in 2017 that built the policy case for service segmentation, a new Community Assistance Team designated "Squad 80" that primarily responds to investigation incidents in one broad area of the city with high rates of substance abuse and homelessness, helping patients who often refuse ambulance transport connect to social services. Second, this study reports a post-intervention, observational evaluation of its operational advantages and trade-offs. We observe that incidents involving the Community Assistance Team have significantly shorter response times and result in fewer transports to emergency departments than investigation incidents not involving the unit, leading to fewer ambulance unit-hours utilized across the system. This study documents the descriptive analytics that built the successful policy case for a substantive change in the healthcare-delivery supply chain in Boston and how this change offers operational advantages. It is written to be an accessible guide to the analysts and policy makers considering emergency services segmentation, an important frontier in equitable public-service delivery.

Policy-Relevant Indicators of Urban Emergency Medical Services COVID-19-Patient Encounters.

In the first two years of the COVID-19 pandemic, members of Boston Emergency Medical Services, the City of Boston's municipal ambulance service, had 7,689 encounters with confirmed-positive Boston residents. As COVID-19 virus strains continue to infect residents in Boston and across the country, understanding the correlation between population positivity, EMS encounters, and hospitalizations can inform healthcare response. This study examines urban virus-surveillance indicators that can serve as an early warning of the volume of Emergency Medical Services (EMS) encounters with COVID-19 positive patients and subsequently how EMS encounters with confirmed COVID-19 patients can serve as an early indicator of future hospital-demand surges. With daily data from Boston EMS and three other public agencies, we evaluate the relationship between five indicators and confirmed Boston EMS COVID-19 encounters by estimating separate Auto Regressive Integrated Moving Average models and cross-correlating their residuals. This study finds a significant and positive correlation between new COVID-19 cases citywide and EMS encounters 6 days later (p < 0.01), as well as between confirmed EMS encounters with COVID-19 patients and the number of intensive care unit beds occupied 7- and 18 -days later (p < 0.01). This study provides city health leadership needed clarity on the specific ordering and associated time lag in which infections in the population increase, EMS members encounter positive patients, and hospitals deliver care.

Worse Cardiac Arrest Outcomes During The COVID-19 Pandemic In Boston Can Be Attributed To Patient Reluctance To Seek Care.

Delays in seeking emergency care stemming from patient reluctance may explain the rise in cases of out-of-hospital cardiac arrest and associated poor health outcomes during the COVID-19 pandemic. In this study we used emergency medical services (EMS) call data from the Boston, Massachusetts, area to describe the association between patients' reluctance to call EMS for cardiac-related care and both excess out-of-hospital cardiac arrest incidence and related outcomes during the pandemic. During the initial COVID-19 wave, cardiac-related EMS calls decreased (-27.2 percent), calls with hospital transportation refusal increased (+32.5 percent), and out-of-hospital cardiac arrest incidence increased (+35.5 percent) compared with historical baselines. After the initial wave, although cardiac-related calls remained lower (-17.2 percent), out-of-hospital cardiac arrest incidence remained elevated (+24.8 percent) despite fewer COVID-19 infections and relaxed public health advisories. Throughout Boston's fourteen neighborhoods, out-of-hospital cardiac arrest incidence was significantly associated with decreased cardiac-related calls, but not with COVID-19 infection rates. These findings suggest that patients were reluctant to obtain emergency care. Efforts are needed to ensure that patients seek timely care both during and after the pandemic to reduce potentially avoidable excess cardiovascular disease deaths.

The 2019 Core Content of Emergency Medical Services Medicine.

On March 13, 2019 the EMS Examination Committee of the American Board of Emergency Medicine (ABEM) approved modifications to the Core Content of EMS Medicine. The Core Content is used to define the subspecialty of EMS Medicine, provides the basis for questions to be used during written examinations, and leads to development of a certification examination blueprint. The Core Content defines the universe of knowledge for the treatment of prehospital patients that is necessary to practice EMS Medicine. It informs fellowship directors and candidates for certification of the full range of content that might appear on certification examinations.

Influence of statins on distinct circulating microRNAs during prolonged aerobic exercise.

Statins exacerbate exercise-induced skeletal muscle injury. Muscle-specific microRNAs (myomiRs) increase in plasma after prolonged exercise, but the patterns of myomiRs release after statin-associated muscle injury have not been examined. We examined the relationships between statin exposure, in vitro and in vivo muscle contraction, and expression of candidate circulating myomiRs. We measured plasma levels of myomiRs, circulating microRNA-1 (c-miR-1), c-miR-133a, c-miR-206, and c-miR-499-5p from 28 statin-using and 28 nonstatin-using runners before (PRE), immediately after (FINISH), and 24 h after they ran a 42-km footrace (the 2011 Boston marathon) (POST-24). To examine these cellular-regulation myomiRs, we used contracting mouse C2C12 myotubes in culture with and without statin exposure to compare intracellular and extracellular expression of these molecules. In marathoners, c-miR-1, c-miR-133a, and c-miR-206 increased at FINISH, returned to baseline at POST-24, and were unaffected by statin use. In contrast, c-miR-499-5p was unchanged at FINISH but increased at POST-24 among statin users compared with PRE and runners who did not take statins. In cultured C2C12 myotubes, extracellular c-miR-1, c-miR-133a, and c-miR-206 were significantly increased by muscle contraction regardless of statin use. In contrast, extracellular miR-499-5p was unaffected by either isolated statin exposure or isolated carbachol exposure but it was increased when muscle contraction was combined with statin exposure. In summary, we found that statin-potentiated muscle injury during exercise is accompanied by augmented extracellular release of miR-499-5p. Thus c-miR-499-5p may serve as a biomarker of statin-potentiated muscle damage.

Tourniquet Use in a Civilian Emergency Medical Services Setting: A Descriptive Analysis of the Boston EMS Experience.

INTRODUCTION: Despite the resurgence of early tourniquet use for control of exsanguinating limb hemorrhage in the military setting, its appropriate role in civilian emergency medical services (EMS) has been less clear. OBJECTIVE: To describe the experience of prehospital tourniquet use in an urban, civilian EMS setting. METHODS: A retrospective review of EMS prehospital care reports was performed from January 1, 2005 to December 1, 2012. Data, including the time duration of prehospital tourniquet placement, EMS scene time, mechanisms of injury, and patient demographics, underwent descriptive analysis. Outcomes data for participating receiving hospitals were also reviewed. RESULTS: Ninety-eight cases of prehospital tourniquet use were identified. The most common causes of injury were penetrating gunshot or stabbing wounds (67.4%, 66/98); 7.1% (7/98) of cases were due to blunt trauma; 23.5% (23/98) of cases were from nontraumatic hemorrhage related to uncontrolled hemodialysis shunt or wound bleeding; 45.4% (44/97) of cases were placed on a lower extremity; 54.6% (53/97) were placed on an upper extremity. Placement was successful in hemorrhage control in 91% (87/95, 95%CI: 85.9-97.3%) of cases. The average prehospital tourniquet placement time was 14.9 minutes. Half of all tourniquet placements were performed by basic life support providers. Hospital follow-up was available for 96.9% (95/98) of cases. Of these, the tourniquet was removed by EMS in 3.2% (3/95), the emergency department in 54.7% (52/95), or in the operating room (OR) in 31.6% (30/95) of the time; 46.7% (14/30) of these OR cases had a documented vascular injury needing repair. Ten deaths with hospital follow-up data were identified, none of which were due to tourniquet use. There was one case of forearm numbness potentially due to nerve injury and one case with potential vascular complication, representing an overall complication rate of 2.1% (2/95). CONCLUSION: The early use of tourniquets for extremity hemorrhage in an urban civilian EMS setting appears to be safe, with complications occurring infrequently.

Impact of statin use on exercise-induced cardiac troponin elevations.

Marathon running commonly causes a transient elevation of creatine kinase and cardiac troponin I (cTnI). The use of statins before marathon running exacerbates the release of creatine kinase from skeletal muscle, but the effect of statin use on exercise-induced cTnI release is unknown. We therefore measured cTnI concentrations in statin-using (n = 30) and nonstatin-using (n = 41) runners who participated in the 2011 Boston Marathon. All runners provided venous blood samples the day before, within an hour of finishing, and 24 hours after the marathon. cTnI was assessed at each time point via both a contemporary cTnI and high-sensitivity cTnI (hsTnI) assay. Before the marathon, cTnI was detectable in 99% of runners with the use of the hsTnI assay. All participants completed the marathon (finish time: 4:04:09 ± 0:41:10), and none had symptoms of an acute coronary syndrome. cTnI increased in all runners (p <0.001) immediately after the marathon, and half (hsTnI = 54% vs contemporary cTnI = 47%) exceeded the diagnostic cut-point for an acute myocardial infarction. Statin use did not affect the magnitude of cTnI release (group*time p = 0.47) or the incidence of runners with cTnI elevation greater than the diagnostic cut-point for myocardial infarction (57% vs 51%, p = 0.65). In addition, there was no significant association between statin potency and cTnI release (r = 0.09, p = 0.65). In conclusion, marathon-induced cTnI increases are not altered by statin use.

Rapid upregulation and clearance of distinct circulating microRNAs after prolonged aerobic exercise.

Short nonprotein coding RNA molecules, known as microRNAs (miRNAs), are intracellular mediators of adaptive processes, including muscle hypertrophy, contractile force generation, and inflammation. During basal conditions and tissue injury, miRNAs are released into the bloodstream as "circulating" miRNAs (c-miRNAs). To date, the impact of extended-duration, submaximal aerobic exercise on plasma concentrations of c-miRNAs remains incompletely characterized. We hypothesized that specific c-miRNAs are differentially upregulated following prolonged aerobic exercise. To test this hypothesis, we measured concentrations of c-miRNAs enriched in muscle (miR-1, miR-133a, miR-499-5p), cardiac tissue (miR-208a), and the vascular endothelium (miR-126), as well as those important in inflammation (miR-146a) in healthy male marathon runners (N = 21) at rest, immediately after a marathon (42-km foot race), and 24 h after the race. In addition, we compared c-miRNA profiles to those of conventional protein biomarkers reflective of skeletal muscle damage, cardiac stress and necrosis, and systemic inflammation. Candidate c-miRNAs increased immediately after the marathon and declined to prerace levels or lower after 24 h of race completion. However, the magnitude of change for each c-miRNA differed, even when originating from the same tissue type. In contrast, traditional biomarkers increased after exercise but remained elevated 24 h postexercise. Thus c-miRNAs respond differentially to prolonged exercise, suggesting the existence of specific mechanisms of c-miRNA release and clearance not fully explained by generalized cellular injury. Furthermore, c-miRNA expression patterns differ in a temporal fashion from corollary conventional tissue-specific biomarkers, emphasizing the potential of c-miRNAs as unique, real-time markers of exercise-induced tissue adaptation.

Older adult falls at a metropolitan airport: 2009-2010.

INTRODUCTION: We investigated falls at a metropolitan airport to determine fall incidence, identify potential causes of these falls, and suggest opportunities for mitigation. METHODS: We used deidentified incident reports of all falls requiring EMS response that occurred at the airport during 2009 and 2010. RESULTS: On average, one fall occurred every 2.3days. Ninety-six percent (96%) of falls occurred in terminals. Of all falls, 44% occurred on escalators, making escalators the most common location. Seventy-two percent (72%) of fallers were females; 43% were ≥65years; 92% of all falls resulted in a documented injury; 37% of falls resulted in transport to hospital emergency departments. Escalator fall risks include carrying bags (due to changes in baggage fees), using cells phones, not using handrails, and compromised strength and balance. CONCLUSIONS AND IMPACT: Diverting at-risk passengers to elevators could significantly reduce the overall falls. Interventions targeting escalator falls have the greatest promise for reducing falls at this airport.

Impact of an emergency department closure on the local emergency medical services system.

BACKGROUND: On July 12, 2010, Boston Medical Center (BMC), the busiest emergency department (ED) in Massachusetts, with more than 100,000 adult patient visits per year, consolidated its two fully functional EDs into one. In preparation for this consolidation, BMC implemented systems changes to mitigate potential negative effects on both BMC and emergency medical services (EMS) providers, including Boston Emergency Medical Services (Boston EMS), the provider of 9-1-1 EMS to the City of Boston. OBJECTIVE: To examine the impact of the closure of an ED on an urban EMS system in a setting where ambulance diversion is not allowed. METHODS: We performed a before-and-after study that examined the effects of an ED closure on BMC and Boston EMS. We examined ED and Boston EMS volumes and ambulance turnaround intervals from June 1, 2010, to July 11, 2010 (preclosure) as compared with July 12, 2010, to August 26, 2010 (postclosure). Mean ED and Boston EMS volumes and Boston EMS turnaround intervals were calculated in four-hour shifts. We used multivariate analysis to analyze electronic medical systems data from BMC and Boston EMS and linear regression. We used autoregressive integrated moving average (ARIMA) models to determine the effect of the ED closure on turnaround intervals, ED volumes, and transport volumes. All analyses were adjusted for shift, ED volume, day of the week, and citywide EMS transport volumes. RESULTS: After ED closure, there was a statistically significant increase of 0.89 minutes (p = 0.02) in the mean EMS turnaround intervals. Additionally, the total ED volume decreased by 3.67 visits per shift (p < 0.001). The ratio of patients transported by Boston EMS to BMC remained unchanged (p = 0.11) for two weeks before and two weeks after the closure. CONCLUSIONS: The closure of one ED resulted in a statistically significant increase in turnaround intervals and a significant decrease in ED volume independent of EMS volumes. In the absence of ambulance diversion, ratios of EMS turnaround intervals and EMS volumes according to hospital destination can be used as alternatives to ambulance diversion times to examine the effects of system-level changes such as closure of an ED on an urban EMS system.

EMS providers' perceptions of safety climate and adherence to safe work practices.

BACKGROUND: Occupational injuries are an important source of morbidity for emergency medical services (EMS) providers. Previous work has shown that employee perceptions of an organization's commitment to safety (i.e., safety climate) correlate with adherence to safe practices. OBJECTIVE: To assess the association between perceived safety climate and compliance with safety procedures in an urban EMS system with >100,000 calls/year. METHODS: EMS providers were issued a self-administered survey that included questions on demographics, years of experience, perceived safety climate, and adherence to safety procedures. Safety climate was assessed with a 20-item validated instrument. Adherence to safety procedures was assessed with a nine-item list of safety behaviors. Strict adherence to safety procedures was defined as endorsing "agree" or "strongly agree" on 80% of items. The effect of safety climate on compliance with safe practices was estimated using multiple logistic regression. RESULTS: One hundred ninety-six of 221 providers (89%) completed surveys; 74% were male; the median age was 36-40 years; and the median amount of experience was 8 years. One hundred twenty-seven of 196 respondents (65%) reported strict adherence to safe work practice. Factor analysis confirmed the original six-factor grouping of questions; frequent safety-related feedback/training was significantly associated with safe practices (odds ratio [OR] = 2.14, 95% confidence interval [CI] = 1.01-4.51). CONCLUSION: EMS workers perceiving a high degree of perceived safety climate was associated with twofold greater odds of self-reported level of strict adherence to safe work practices. Frequent safety-related feedback/training was the one dimension of safety climate that had the strongest association with adherence to safe workplace behaviors.

Plant exposures: wilderness medicine.

This article discusses poisonous plants, the symptoms that might arise if they are ingested, and the treatments that should be administered to patients.