Utilisation of WhatsApp for Emergency Medical Services in Garissa, Kenya.

Garissa county, Kenya is a geographically large county with a mobile pastoralist population that has developed a method for emergency medical services (EMS) coordination using the WhatsApp communication platform. This work was based on a site visit, to better understand and describe the current operations, strengths, and weaknesses of the EMS communication system in Garissa. The use of WhatsApp in Garissa county seems to work well in the local context and has the potential to serve as a cost-effective solution for other EMS systems in Kenya, Africa, and other LMICs.

The Value of Songs for Teaching and Learning Cardiopulmonary Resuscitation (CPR) Competencies: A Systematic Review.

We sought to summarize, in a systematic review, the effectiveness of songs to support learning, performance, and recall of quality characteristics of cardiopulmonary resuscitation (CPR) compression rate, and depth. We systematically reviewed the literature from eight academic indexes from the fields of medicine, nursing, allied health, and education, from 2014 to 2020 to identify studies that evaluated an intervention of song use during CPR training against control and reported outcomes of compression rate and depth. There were 185 studies initially identified for review, eight met criteria for inclusion and analysis. For the critical outcome of compression depth, a pooled song group (n=446) when compared to a non-song group (n=443) demonstrated higher odds of being in the recommended range (OR 3.47). All studies, however, performed an average compression depth shallower than recommended guidelines in each arm. The available literature, we found, utilized heterogenous methodology and was at high risk of bias. When pooled, there were trends towards improved CPR metric performance in groups who were exposed to songs during treatment, though this only reached significance when groups were tested at >30 days from initial exposure. Findings of lower compression rates in the song groups suggest that song selection should favor beats per minute closer to the midpoint of the 100-120 ideal range to allow for variation when used as mental metronomes.

A Cross-sectional Survey on the Use of Tranexamic Acid in the Pre-hospital Setting.

STUDY OBJECTIVE: Tranexamic Acid (TXA), an anti- fibrinolytic, has been used in military trauma cases and civilian Emergency Departments for several years. This study aims to evaluate protocols for the administration of TXA across Emergency Medical Services (EMS) regions in the United States. METHODS: An anonymous survey was distributed by the National Association of Emergency Medical Technicians (NAEMT) to its members. RESULTS: A total of 264 eligible responses were received. Respondents included paramedics (62.5%), emergency medical technicians (EMTs) (9%), critical care paramedics (11%), and other health care professionals (19%). The majority of protocols included criteria for blood pressure (67%), heart rate (53%), and age (66%). Notable variations included TXA dilution and indications for traumatic brain injury. CONCLUSION: TXA has been widely implemented in EMS protocols since the CRASH (Clinical Randomization of an Antifibrinolytic in Significant Hemorrhage) trials. However, there remains significant variations in indications and dose concentrations.

Increased Temperatures Are Associated with Increased Utilization of Emergency Medical Services in Rhode Island.

BACKGROUND: Increasing temperatures negatively impact health and increases demands on healthcare systems. However, this has been poorly studied in Rhode Island (RI). Here we characterize the impact of heat on emergency medical services (EMS) utilization in RI. METHODS: The Rhode Island National Emergency Services Information System V3 dataset was merged with data from the National Center for Environmental Information of the National Oceanic and Atmospheric Administration from the summers of 2018 and 2019. The outcome of daily mean EMS runs were compared against the exposure increasing daily temperatures, measured as daily maximum, minimum and daily average °F, using Poisson regressions. Patient characteristics were included across temperature models. RESULTS: Increasing daily temperatures were associated with increasing EMS encounters. The adjusted incident rate ratio (IRR) for mean daily EMS encounters by increasing maximum daily temperature was 1.006 (95% CI 1.004-1.007, Table 3). This resulted in a projected 17.2% increase in EMS runs on days with a maximum temperature of 65°F compared to days with a maximum temperature of 95°F. The adjusted IRR for mean daily EMS encounters by the daily minimum temperature was 1.004 (1.003-1.006) and the adjusted IRR for the mean daily EMS encounters by the daily average temperature was 1.006 (1.005-1.008). CONCLUSIONS: Increasing minimum, maximum, and average daily temperatures were associated with increasing EMS utilization across Rhode Island in the summers of 2018 and 2019. Further research into these trends may help with planning and resource allocation as summer temperatures continue to rise.

Pediatric Out-of-Hospital Cardiac Arrest in Rhode Island: Concepts and Controversies.

Pediatric out-of-hospital cardiac arrest (POHCA) is an infrequently encountered event by emergency medical providers, both across Rhode Island and nationally. The etiologies of these events differ from those in adult cardiac arrests and overall outcomes remain poor. The skills required by emergency medical providers to care for these patients are performed and practiced infrequently. Pediatric patients are also at further risk of serious adverse events secondary to challenges with airway management and variation in equipment sizing and weight-based medication dosing. Recent changes to Rhode Island Emergency Medical Services protocols, particularly the requirement for all non-traumatic cardiac arrests to be managed on scene for a minimum of 30 minutes, have led to discussion and controversy. As we aim to improve the quality of care delivered during these resuscitations through education, research and collaborative protocol development, it is important to recognize and remain focused on the unique aspects of these pediatric patients.

Pilot Study of the Effect of a Protocol of 30 Minutes of Scene Care in Out-of-Hospital Cardiac Arrest in Rhode Island.

BACKGROUND: Improved outcomes in out-of-hospital cardiac arrest (OHCA) have been demonstrated with increased focus on high-quality CPR. In 2017, the RI Department of Health mandated 30 minutes of on-scene CPR for atraumatic cardiac arrest victims. The effects of this intervention are unknown. METHODS: An EMR query was performed to identify OHCA cases presenting to a Lifespan hospital during the months of March 2016 (pre-intervention) and March 2017 (post-intervention) with an estimated severity index of 1 or cardiac arrest. Primary Results: 63 cases of OHCA were identified. ROSC at ED presentation increased in the post-intervention period, though it was not statistically significant (12% vs 22%, CI = -0.01,0.25 vs. 0.09,0.35). Endotracheal intubation and ACLS medication use increased as well. CONCLUSIONS: This pilot study of a protocol emphasizing on-scene CPR in urban Rhode Island resulted in changes in pre-hospital OHCA management and there was a trend toward increased ROSC in the post-intervention period.

Comparison of EMS Provider In-Transit Performance and Exertion with Standard and Experimental Resuscitation Protocols during Simulated Out-of-Hospital Cardiac Arrest.

OBJECTIVE: To assess the effect of a device-assisted out- of-hospital cardiac arrest (OHCA) resuscitation approach on provider performance during simulated transport. METHODS: BLS and ALS providers were randomized into control and experimental teams. Subjects were fitted with wireless heart rate (HR) monitors. Control teams simulated with standard protocols and equipment; experimental teams with resuscitation-automating devices and goal-directed protocols. Chest compression quality, pulmonary ventilation, defibrillation, and medication administration tasks were monitored; subjects' HR's were continuously recorded. RESULTS: Ten control and ten experimental teams completed the study (20 EMT-B's; 1 EMT-I, 8 EMT-C's, 11 EMT-P's) with similar resting HR's and age-predicted maximal HR's (mHR). All exhibited suboptimal in-transit resuscitation quality during initial simulations; HR did not differ significantly between the groups. Experimental teams exhibited improved chest compression and ventilation quality during transport along with lower subject HR. CONCLUSION: OHCA resuscitation automation improved the in-simulation quality of critical in-transit tasks and reduced provider exertion.

Health Information Exchange in Emergency Medical Services.

BACKGROUND: The Office of the National Coordinator for Health Information Technology has outlined the benefits of health information exchange in emergency medical services (EMSs) according to the SAFR model-search, alert, file, and reconcile-developed in collaboration with the California Emergency Medical Services Authority. OBJECTIVE: This scoping review aims to identify and characterize progress toward the adoption of prehospital health information exchange, as reported in the peer-reviewed literature. METHODS: A structured review of literature in MEDLINE-indexed journals was conducted using the "Electronic Health Records" topic-specific query, the "Emergency Medical Services" Medical Subject Headings descriptor, and a prehospital identifier. RESULTS: Our initial search yielded 368 nonduplicative, English-language articles; 131 articles underwent full-text review and 11 were selected for analysis according to pre-established inclusion criteria. Original research was thematically grouped according to the SAFR model. CONCLUSION: Within isolated systems, there has been limited progress toward the adoption of prehospital health information exchange. Interoperability, accurate match algorithms, security, and wireless connectivity have been identified as potential barriers to adoption. Additional research is required to evaluate the role of health information exchange within EMSs.

Comparative Analysis of Emergency Medical Service Provider Workload During Simulated Out-of-Hospital Cardiac Arrest Resuscitation Using Standard Versus Experimental Protocols and Equipment.

INTRODUCTION: Protocolized automation of critical, labor-intensive tasks for out-of-hospital cardiac arrest (OHCA) resuscitation may decrease Emergency Medical Services (EMS) provider workload. A simulation-based assessment method incorporating objective and self-reported metrics was developed and used to quantify workloads associated with standard and experimental approaches to OHCA resuscitation. METHODS: Emergency Medical Services-Basic (EMT-B) and advanced life support (ALS) providers were randomized into two-provider mixed-level teams and fitted with heart rate (HR) monitors for continuous HR and energy expenditure (EE) monitoring. Subjects' resting salivary α-amylase (sAA) levels were measured along with Borg perceived exertion scores and multidimensional workload assessments (NASA-TLX). Each team engaged in the following three OHCA simulations: (1) baseline simulation in standard BLS/ALS roles; (2) repeat simulation in standard roles; and then (3) repeat simulation in reversed roles, ie, EMT-B provider performing ALS tasks. Control teams operated with standard state protocols and equipment; experimental teams used resuscitation-automating devices and accompanying goal-directed algorithmic protocol for simulations 2 and 3. Investigators video-recorded resuscitations and analyzed subjects' percent attained of maximal age-predicted HR (%mHR), EE, sAA, Borg, and NASA-TLX measurements. RESULTS: Ten control and ten experimental teams completed the study (20 EMT-Basic; 1 EMT-Intermediate, 8 EMT-Cardiac, 11 EMT-Paramedic). Median %mHR, EE, sAA, Borg, and NASA-TLX scores did not differ between groups at rest. Overall multivariate analyses of variance did not detect significant differences; univariate analyses of variance for changes in %mHR, Borg, and NASA-TLX from resting state detected significant differences across simulations (workload reductions in experimental groups for simulations 2 and 3). CONCLUSIONS: A simulation-based OHCA resuscitation performance and workload assessment method compared protocolized automation-assisted resuscitation with standard response. During exploratory application of the assessment method, subjects using the experimental approach appeared to experience reduced levels of physical exertion and perceived workload than control subjects.

Circus disaster: Case report, response, and review of injuries.

Circus acts with human artists performing acrobatic feats are a popular spectator pastime in the United States and in international venues. There is little data in the literature regarding injuries sustained during circus acts. Some injuries are minor, but others can be serious, or even fatal. This article describes a recent circus disaster, a review of the relevant literature, and an analysis of the disaster response.

Simulation-based Randomized Comparative Assessment of Out-of-Hospital Cardiac Arrest Resuscitation Bundle Completion by Emergency Medical Service Teams Using Standard Life Support or an Experimental Automation-assisted Approach.

INTRODUCTION: Effective resuscitation of out-of-hospital cardiac arrest (OHCA) patients is challenging. Alternative resuscitative approaches using electromechanical adjuncts may improve provider performance. Investigators applied simulation to study the effect of an experimental automation-assisted, goal-directed OHCA management protocol on EMS providers' resuscitation performance relative to standard protocols and equipment. METHODS: Two-provider (emergency medical technicians (EMT)-B and EMT-I/C/P) teams were randomized to control or experimental group. Each team engaged in 3 simulations: baseline simulation (standard roles); repeat simulation (standard roles); and abbreviated repeat simulation (reversed roles, i.e., basic life support provider performing ALS tasks). Control teams used standard OHCA protocols and equipment (with high-performance cardiopulmonary resuscitation training intervention); for second and third simulations, experimental teams performed chest compression, defibrillation, airway, pulmonary ventilation, vascular access, medication, and transport tasks with goal-directed protocol and resuscitation-automating devices. Videorecorders and simulator logs collected resuscitation data. RESULTS: Ten control and 10 experimental teams comprised 20 EMT-B's; 1 EMT-I, 8 EMT-C's, and 11 EMT-P's; study groups were not fully matched. Both groups suboptimally performed chest compressions and ventilations at baseline. For their second simulations, control teams performed similarly except for reduced on-scene time, and experimental teams improved their chest compressions (P=0.03), pulmonary ventilations (P<0.01), and medication administration (P=0.02); changes in their performance of chest compression, defibrillation, airway, and transport tasks did not attain significance against control teams' changes. Experimental teams maintained performance improvements during reversed-role simulations. CONCLUSION: Simulation-based investigation into OHCA resuscitation revealed considerable variability and improvable deficiencies in small EMS teams. Goal-directed, automation-assisted OHCA management augmented select resuscitation bundle element performance without comprehensive improvement.

False-negative chest radiographs in emergency department diagnosis of pneumonia.

BACKGROUND: Emergency department (ED) patients frequently undergo chest x-ray (CXR) to evaluate for pneumonia. The rate of false-negative CXR in patients with pneumonia is unclear. OBJECTIVES: Identify patients admitted with pneumonia who were diagnosed by CT despite nondiagnostic CXR. METHODS: Retrospective analysis of quality improvement data on adult ED patients admitted with pneumonia over 21 months. Primary outcome was percent of patients diagnosed by CT despite normal CXR. Patients were classified as CXR-diagnosed if they had CXR and no CT, or if antibiotics were ordered after CXR and before CT. CT-based diagnosis was indicated by administration of antibiotics only after CT was completed. RESULTS: 49 patients (11.4%) were diagnosed by CT (p<0.001). These patients were younger (p<0.001) and more often complained of chest pain (p<0.001). CONCLUSIONS: Patients with pneumonia may present with normal or nondiagnostic CXR, although false negatives may be less common than previously reported.