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The Prehospital Care Research Forum Presents

Letter to Our Readers

Letter to Our Readers The Prehospital Care Research Forum at UCLA believes that it’s the responsibility of emergency medical professionals worldwide to develop a body of evidence that examines prehospital emergency care. Our mission is to assist, recognize and disseminate prehospital care research conducted at all provider levels. Each year, we acknowledge those authors who have contributed to the science of EMS through the publication of this supplement and their subsequent presentations. As part of our ongoing pledge, the Prehospital Care Research Forum at UCLA continues to educate the medical community through a variety of seminars and lectures throughout the country. These presentations are designed to demystify the research process and provide participants with the tools to conduct research in their community. I would like to thank our volunteer Board of Advisors and Associates. Without the dedication of these volunteers none of this would be possible. In addition to the hard work of many, many people, much of our success can be attributed to the commitment of several organizations dedicated to research in prehospital care. I would like to acknowledge our Founding Partner JEMS , Benefactors Laerdal Medical Corp. and SSCOR Inc., Friends Armstrong Medical and FISDAP. The generous support of these fine organizations and our affiliation with the National Association of EMS Educators and the National Association of EMTs are what enable the Research Forum to fulfill our mission. The future of EMS depends on the quality and quantity of research we produce. We invite you to take a stand, conduct research in your community and submit it in 2009 for the greater benefit of EMS. Sincerely, Baxter Larmon, PhD, MICP Director, Prehospital Care Research ForumWork-Family Conflict of Volunteer Firefighters/EMS Personnel >> Click here to download a PDF of all the abstracts. (Note: The corrected abstract that appears below is not included in the PDF.) Author: Dr. Ann McCarthy, CNP, NREMT-B Associate Author: Jennifer Averill Introduction: The purpose of this paper is to present an exploratory descriptive study conducted to determine if work-family conflict (WFC) and family-work conflict (FWC) are problems for volunteer rural firefighters who also serve as EMS providers. The study used a mixed-methods approach that involved three quantitative scales [the Netemeyer, Boles and McMurrian (1996) five-item WFC and FWC scales]; six qualitative, open-ended questions [six items chosen from the National Institute for Occupational Safety and Health (NIOSH) (2002) Quality of Worklife Questionnaire]; and a demographic survey. Research to date has primarily studied career firefighters and their occupational stress. One of the potential challenges facing volunteer firefighters is juggling roles as a family member and a volunteer firefighter. Hypothesis: WFC and FWC are problems for volunteer rural firefighters who also serve as EMS providers. Methods: This study’s mixed-methods approach encompassed quantitative methodology as the primary approach, with qualitative inquiry supplementation. A convenience sample of consenting adult members was taken from the San Juan County (N.M.) Fire Department. Results: The quantitative results demonstrated relatively low levels of WFC and FWC for the study sample. Reliability analysis of Netemeyer’s, et al. (1996) WFC and FWC scales produced Cronbach’s alpha levels that demonstrated high levels of internal consistency reliability. The qualitative results essentially supported those findings, with the following two final sets of code categories: identified strengths and specific stressors. Themes emerging from the codes and qualitative analysis centered on time and role conflict and family support for one’s firefighter role. Conclusions: This research concluded that the Netemeyer, et al., instrument was reliable for use with this population, and that WFC and FWC was not a significant problem or concern for the volunteer firefighters of San Juan County, N.M. Direct correspondence to: Dr. Ann McCarthy, P.O. Box 1015, Waterflow, NM 87421. Viewing Real-Time Video of Crash Scenes Might Not Alter ED Physicians’ Preparation for Patient Arrival Author: Jay Scott, BS, NREMT-P Associate Authors: Heramba Prasad, MD, & William Grant, EdD Introduction: Real-time images from closed-circuit television traffic cameras maintained by the New York State Department of Transportation are monitored at a dedicated workstation in the State University of New York Upstate University Hospital Emergency Department. Emergency department (ED) physicians can directly view crash scene and rescue efforts. This IRB-exempt study sought to determine if the ability to view the live feed altered the ED physician’s preparation for reception of motor vehicle crash (MVC) victims in the ED. Methods: DOT personnel alert SUNY Upstate ED physicians when a crash occurs. Using a structured data collection form, information was gathered on the physician’s ability to determine: the nature of the crash, number of vehicles involved, number of victims, extent of damage, and other hazards, such as fire or entrapment. The physicians were asked to document if the live feed altered preparation for victim arrival at the ED, including activation of a trauma code, determination of ED assignment, suggested EMS treatment and determination of need for ALS care. Data were entered into a MS Excel spreadsheet and analyzed using MedCalc TM v9.3.9.0. Results: Data were available for 22 incidents. Using tests for single proportions, it was clear that the physicians could identify numbers of vehicles (z=6.4, p<0.0001, 95%CI 67.2-94.1); extent of damage (z=33.4, p<0.0001, 95%CI 16.2-51); other hazards (z=29.1, p<0.0001, 95%CI 23.1-59.61); nature of the crash (z=31, p<0.0001, 95%CI 20.2-55.8); and number of people involved (z=46, p<0.0001, 95%CI 69-20). In contrast, in only one case was it reported that the physician used the information to determine hospital assignment and in one other case to determine the need for advanced EMS care. Conclusions: Live-feed video images from MVC scenes provide data regarding nature and severity of the incident, but did not alter ED preparation for victim arrival. Direct correspondence to: Jay Scott, 750 East Adam St, Syracuse, NY 13210. Emergency Medical Technicians’ Attitudes Regarding the Prehospital Administration of Nebulized Albuterol Before and After Using the Drug Author: Matthew Deluhery, BS Associate Authors: Christine Stake, MA; Vicki Bacidor, ANP; Michael Kinder, BS; & Mark Cichon, DO Introduction: Study objectives were to determine EMT-Bs’ self-perceived comfort level with administering nebulized albuterol and if giving nebulized medication modifies their stance on scope of practice. Methods: A fire department swas enrolled to dispense albuterol. Before any medication dispensing, EMT-Bs completed a 14-question survey. The same survey was re-administered six months later. Results: All 21 EMT-Bs participated in the baseline and a repeat survey. Self-assessed competency in giving albuterol was determined via questions on a Likert scale (1–below average, 2–average for EMT-B, 3–above average), evaluating confidence assessing lung sounds, indications/contraindications for beta-agonists and assembly of the nebulizer. Baseline means were 2.38, 2.52 and 2.62, respectively, and after six months of albuterol dispensing, the means were 2.58 (p=.236), 2.73 (p=.266), 2.85 (p=.176), respectively, with no EMT-B stating "below average" for any of the three questions on the follow-up survey. Participants were also asked on a 5-point scale (1–strongly disagree, 2–somewhat disagree, 3–undecided, 4–somewhat agree, 5–strongly agree) whether a large number of their calls involved bronchospasm. This yielded a baseline mean of 3.96 and 4.24 (p=.049) six months later. On the same 5-point scale (baseline mean, six-month mean), EMT-Bs were asked if paramedics should handle all respiratory distress calls (3.45, 1.88, p<.001), and if on-line medical control should be contacted before albuterol is given (2.57, 2.38, p=.136). Lastly, EMT-Bs responded on the same 5-point scale if EMT-Bs nationwide should be trained to administer albuterol (3.62, 3.77, p=.603). Conclusions: After dispensing albuterol for six months, EMT-Bs’ self-perceived ability to assess lung sounds and administer albuterol were at or above average for an EMT-B but did not significantly increase from baseline. There was a significant change in realization of the amount of bronchospasm calls and in the attitudes about ALS back-up. Feelings about on-line medical control and the EMT-B scope of practice did not vary with the ability to dispense albuterol. Direct correspondence to: Matthew Deluhery, 1151 South Oak Park, Ave Apt 3, Oak Park, Il 60304. Administration of Nebulized Albuterol by EMT-Basic Providers Author: Christine Stake, MA Associate Authors: Susan Siorek, RN, BSN; Vicki Bacidore, APN; Mark Cichon, DO; Matthew Deluhery, MD; & Michael Kinder, BS, CCEMTP Introduction: Research has demonstrated that using nebulized albuterol in a prehospital setting for asthma is an effective treatment and leads to better clinical outcomes. However, administration of nebulized albuterol has often been limited to paramedics. Earlier research has demonstrated that with proper training, EMT-Bs can effectively administer albuterol, which has been shown to improve patient outcomes (Richmond, 2005, Markenson, 2004). Study objectives were: 1) Demonstrate EMT-Bs can effectively administer nebulized beta-agonists; 2) Assess patient outcomes based on defined criteria; 3) Assess number of refusals of transport; and 4) Based on results, refine education as needed and expand study protocol to additional EMT-B municipal departments. Methods: A municipal EMT-B fire department with a large population of asthma patients was selected for the study. Permission to expand the scope of care for EMT-Bs and acceptance of the study protocol was received from the appropriate governing bodies. IRB approval was received. A three-hour mandatory continuing education program was developed and taught to all providers. Providers administering albuterol were required to complete a data sheet in addition to the run report. Results: During the 18-month study (April 2006 to October 2007), 118 patients received nebulized albuterol. The age range of patients was one to 81 years old, and 16 (13.6%) were pediatric patients. Average scene time to hospital was 12 minutes. Average scene time to albuterol administration was seven minutes. For medications taken before arrival, 10% administered oxygen, 64% used an inhaler and 19% had a nebulizer treatment. For 83% (n=93) of patients, final diagnosis was determined following hospital chart review: 76% (n=71) had a final diagnosis of asthma, 10% (n=9) were respiratory, and 14% (n=13) were other. Hospital admitting status was obtained for 84% (n=78) of patients: 58% (n=45) were discharged, 33% (n=26) were admitted to the hospital, 5% (n=4) left the ED before treatment was completed, and one patient expired due to cardiac arrest en route to hospital. One refusal of transport to a hospital was reported. Data review identified six runs in which albuterol should have been administered and was not; re-education with the municipality was completed. Conclusions: An EMT-B municipal department was able to effectively administer albuterol. Chart and run sheet review identified instances when albuterol should have been given and was not. Follow-up should be completed by sponsoring institution. Direct correspondence to: Christine Stake, 2160 S First Ave., Building 110/LL Room 0243, Maywood, Il 60153. Cardiac Arrest After Prehospital Rapid Sequence Induction Author: Robert Bauter, BA, CPM, NREMT-P Associate Authors: Scott Matin, MBA, NREMT-P; Peter Dworsky, MPH, NREMT-P; Philip Shepherd, AAB, NREMT-P; & Charles Livezey, MICP Introduction: MONOC EMS has been performing rapid sequence induction (RSI) since April 2006. The RSI protocol is regulated by the New Jersey Office of Emergency Medical Services and is only performed with on-line medical control. Hypothesis: Common comorbidity factors exist in patients who go into cardiac arrest after undergoing RSI. Methods: MONOC EMS has had 513 occasions to use RSI on patients between April 2006 and July 2008. Twenty-six (5.1%) patients have gone into cardiac arrest. A retrospective review of these 26 patients was completed. The following data were evaluated and compared in order to determine common factors of the cardiac arrest: age, gender, past medical history, initial SpO, intubation attempts, method of airway control and time to advanced airway placement. Results: Of the 26 patients who went into cardiac arrest, 10 (38.5%) had respiratory complaints, nine (34.6%) were unconscious, and seven (26.9%) had traumatic injuries. After reviewing the data, we eliminated the trauma victims due to the nature of the injuries. We then concentrated on the remaining 19 patients (3.7% of the original 513). The medical histories of the unconscious patients were significant for cardiac and respiratory disease. The remaining were significant for respiratory failure. The initial median SpO reading for both groups was 87%. All patients received successful airway control: 11 endotracheal intubations, seven Combitubes and one oral pharyngeal airway. Advanced airways were confirmed patent by both a colorimetric device and capnography. Conclusions: Patients over the age of 75 with significant respiratory and cardiac disease who are extremely hypoxic may not be good candidates for the RSI procedure. A number of factors could affect the findings: 1. The patient’s existing medical condition could inhibit the patient from being sufficiently oxygenated to perform the procedure. 2. The paramedics might not be raising the patient’s SpOenough by pre-oxygenation to keep the patient oxygenated during the procedure. 3. In the cases in which more than one intubation attempt was necessary, the paramedics might not be re-oxygenating patients effectively between intubation attempts. Further study is necessary to investigate these issues. Direct correspondence to: Robert Bauter, 4806 Megill Rd., Neptune, NJ 07753. Analysis of Safety Experiences and Behaviors of EMS Providers Author: Paul Bishop, MPA, EMT-P Associate Author: Rollin Fairbanks, MD, MS Introduction: EMS providers have been shown to be at high risk for on-the-job injuries and death. In particular, EMS providers are susceptible to injuries in motor vehicle crashes (MVCs), including during transport of patients. Earlier research has indicated EMS providers are unlikely to wear proper restraint devices while working in the rear of the ambulance. To determine how best to target education, a study was conducted to determine which EMS providers were more likely to disregard safety restraint recommendations. Methods: A survey instrument was developed to determine EMS providers’ safety experiences, practices and attitudes. The 26-item survey was distributed at the state EMS conference in a large northeastern state. The questions included demographic information, experiences related to injuries and several Likert scale safety-behavior questions. Results: For the study, 468 surveys were completed and returned. The demographics of respondents were similar to those of the state’s EMS providers, except for having more advanced providers. In all, 86% (n=402) reported always or frequently wearing their seatbelts while in the front of the ambulance, and 79% (n=370) reported securing equipment always or frequently. However, only 22% (n=103) indicated always or frequently wearing a seatbelt in the rear of the ambulance except when "providing essential care such as airway management, CPR or medication administration." There was no significant difference in these findings based on age, length of service, certification, gender, work status or history of MVCs. However, respondents injured in an MVC (n=22; 4.7%) were significantly more likely to wear their seatbelts in the back (n=8; 1.7%) than those who were not injured (42 of 446) (p<.01). Also, full-time EMS providers (n=99; 21.2%) were significantly more likely than volunteer only (n=304; 65%) to report minor injuries (67% vs. 40%, p<.01 [67]% ), MVCs (40% vs. 14%, p<.01), and injuries from MVCs (12% vs.5%, p<.05). Conclusions: Only 22% (n=103) of respondents wear restraints while riding in the patient compartment of ambulances, although the rates of seatbelt use in front and the rates of restraining equipment were much higher. This trend did not seem to vary among subgroups studied except those injured in crashes. Full-time EMS workers report more injuries from on-duty MVCs. Direct correspondence to: Paul Bishop, 1190 Scottsville Rd., Suite 216, Rochester, NY 14624. Characteristics Associated with Latex Sensitivity Among Nationally Certified EMS Professionals Author: Melissa Bentley, BS, NREMT-P Associate Authors: Jonathan Studnek, PhD, NREMT-P, & Antonio Fernandez, MS, NREMT-P Introduction: The Centers for Disease Control and Prevention state an increase in exposure to latex increases the risk of developing latex hypersensitivity. Each time EMS professionals come into contact with a patient, they are required to wear personal protective equipment (PPE). This PPE often contains latex. The objective of this study was to determine characteristics of EMS professionals associated with reporting latex sensitivity. Hypothesis: Individual and work-life characteristics are associated with latex sensitivity among EMS professionals. Methods: Data used for this analysis were obtained from a survey of nationally registered EMS professionals. Latex sensitivity was defined as the report of a rash on the hands after wearing latex gloves. Characteristics assessed include gender, EMS call volume, certification level, community size and service type. Analysis included only currently practicing EMS professionals. Chi-squared analyses were preformed to determine associations between characteristics of EMS professionals and the report of latex sensitivity. Results: There were 1,058 (51.4%) responses to the survey, with 933 (88.2%) meeting inclusion criteria. Of those, 142 (15.2%) EMS professionals were classified as having a latex sensitivity. More females reported having a latex sensitivity (21.5% vs. 12.8%, p=0.001). As the reported number of calls per week increased, there was an increase in the frequency of latex sensitivity (0–1 call=4.0%; 2–29 calls=15.7%; 30+ calls=20.5%; p=0.001). Those working for a county or municipal service reported the lowest frequency of latex sensitivity, while those who worked for a private service had the highest (county/municipal=11.9%; fire=12.7%; other=14.1%; private=22.4%; p=0.010). More paramedics (17.6%) reported a latex sensitivity than basics (10.8%) or intermediates (10.0%, p=0.025). There was no statistically significant difference in the report of latex sensitivity found when assessing the number of EMS jobs or community size (p=0.23 and p=0.068, respectfully). Conclusions: From the study population, 15.2% were classified as having a latex sensitivity. Latex sensitivity was significantly associated with gender, number of calls in one week, certification level and service type. Further research needs to be conducted to determine ways to decrease exposure to latex products in this workforce. Direct correspondence to: Melissa Bentley, 6610 Busch Blvd., Columbus, OH 43229. Delay in Application of Mechanical CPR Device Author: Dana Sellner, NREMT-B Associate Authors: Carl Aronson, NREMT-B; Paul Satterlee, MD; & David Page, MS, NREMT-P Introduction: Current AHA guidelines emphasize minimal interruptions to chest compressions during CPR. Mechanical devices might provide improved chest compressions but might cause delay in the initiation or cause interruption to CPR. Objective: To determine how quickly a mechanical CPR device can be applied. Methods: Several dates were selected at random, and EMS clinicians reporting for duty at a centralized base were asked to assemble and apply the LUCAS® device (Medtronic Inc.) to an 81 kg Rescue Randy (Simulaids Inc.) as quickly as possible. The clinicians had previous training on the device and had the device for clinical use for at least 12 months. The manikin was lying on the ground with a jacket lying on top. Two observers timed the crews. Results: Eighteen crews were approached, and 14 agreed to participate. One crew did not follow directions in applying the device as they would in the field and was excluded. The remaining 13 crews averaged 67 seconds (range of 31 seconds to 134 seconds). Conclusions: In this small sample, crews took an average of 67 seconds to apply a mechanical device to assist with CPR compressions. More research is needed to determine if 67 seconds (range of 31 seconds to 134 seconds) can be decreased with training or design changes. Research is also needed to determine if the benefit of mechanized compressions outweighs the danger of CPR interruptions. Direct correspondence to: Dana Sellner, 1045 E 5th St., Saint Paul, MN 55106. Has the Proportion of EMS-Related Research Authored by Paramedics Changed During the Last 10 years? Author: Attila Hertelendy, PhD, MS, MHSM, NREMT-P Associate Author: Lawrence Brown, EMT-P, MPH & TM Introduction: For the past 15 to 20 years, the Prehospital Care Research Forum, National Association of EMS Physicians and National Association of EMS Educators have promoted the expansion of EMS research, including research conducted by EMS professionals. This study was undertaken to determine whether the proportion of EMS research authored by EMS professionals has increased over the past decade. Hypothesis: The proportion of EMS-related original research that has an EMS professional listed as an author did not change between 1997 and 2007. Methods: Seven leading emergency medicine/EMS journals ( Annals of Emergency Medicine , Academic Emergency Medicine , The American Journal of Emergency Medicine , The Journal of Emergency Medicine , Clinical Pediatric Emergency Medicine , Prehospital and Disaster Medicine and Prehospital Emergency Care ) were hand searched to identify EMS-related original research published in 1997 and 2007. Editorials, commentaries, reviews and other non-research articles were excluded. Data gathered included whether the first author, or any author, had EMS credentials listed; however, MD/EMT-P or similar physician credentials were not considered an EMS professional. The frequency of first authors and any author having EMS credentials for the two study years were compared using chi-square, with p<.05 considered statistically significant. Results: In 1997, the seven journals published 405 original research articles, of which 93 (22.9%) were EMS-related. Thirty-four (36.6%) of those had at least one author with EMS credentials. For 14 (15.1%), the first author had EMS credentials. In 2007, the seven journals published 556 original research articles, of which 85 (15.3%) were EMS-related. Of those, 27 (31.7%) had at least one author with EMS credentials. Four (4.7%) had a first author with EMS credentials. The proportion of articles with at least one EMS professional author did not change significantly between the 10-year period; however, the proportion of articles with an EMS professional as first author was significantly smaller in 2007 than in 1997 (X2=5.23, p=.02). Conclusions: Although the proportion of EMS-related research articles with an EMS professional listed as an author has not changed over the pastdecade, the proportion with an EMS professional listed as the first author has decreased significantly. This finding requires further investigation. Direct correspondence to: Attila Hertelendy, PO Box 2000, Roswell, NM 88202. Making Noise: Is the Siren on When the Warning Lights Are Used? Author: Alexander Trembley, NREMT-B Associate Author: David Page, MS, NREMT-P Introduction: Safety guidelines and legislative statutes state that the siren should always be used when the warning lights are on. In Hennepin County, Minn., a Code3 response is defined as "an ambulance response that utilizes red lights and siren." Anecdotal observation reveals that emergency medical providers are not using their sirens as often as their warning lights, but how often does it actually happen? Is there a difference between day and night responses? Hypothesis: Warning lights and siren are both used 100% of the time when responding to a call in both day and night responses. Methods: For this study, paramedic students were given a sheet to record the time of call, the response request and the percentage of time in which warning lights and sirens were used on the calls they participated in during their field clinicals. The students also recorded their preceptors and other paramedics driving the ambulance during their clinical. The students recorded it in secret to prevent a Hawthorne effect. Results: A total of 96 runs were collected. In daytime responses (n=56; 58.3), collected between 0600 and 1800, warning lights were used for response in 54 (96.4%) of the calls. Once the warning lights were on, they were left on for an average of 94% of the response time. The siren was used in 52 (92.9%) of the calls. Once the siren was on, it was left on for an average of 67% of the response time. In night responses, (n=36; 64.2%) warning lights were used in 34 (94.4%) of the calls. Once the warning lights were on, they remained on for an average of 89% of the response time. The siren was used for night response in 26 (72.2%) of the calls. Once the siren was on, it remained on for an average of 43% of the response time. Conclusions: More research must be conducted to see if this data is a good fit for all response data. Direct correspondence to: Alexander Trembley, 301 E Burnsville Pkwy., Apt. 118, Burnsville, MN 55337. Efficacy and Compliance of a Prehospital Clinical Clearance Spinal Immobilization Guideline Author: Lukas Myers, NREMT-P Associate Authors: Christopher S. Russi, DO, FACEP; Daniel Hankins, MD, FACEP; Kathleen Berns, RN, MS, CNS; & Scott Zietlow, MD (Editor's note: The following abstract is the corrected version.) Introduction: Prehospital spinal immobilization criteria are useful in identifying those at risk for spinal fractures, while reducing the number of patients who are unnecessarily immobilized. The use of a selective spinal immobilization set of criteria, without regard to mechanism of injury, has been shown to accomplish this task. Methods: The purpose of this study was to examine the effectiveness of a prehospital spinal clearance guideline as well as that of the triage and management of these injuries. This was a retrospective study of traumatically injured patients and their subsequent care based on a clinical clearance spinal immobilization guideline between January 2006 and January 2007. Two gold standards were used in the analysis (radiographic findings and physician clearance without radiographs). Data was collected and analyzed using JMP software. This project was approved by the Mayo Clinic IRB. Results: The study included 942 patients who were documented to have a traumatic injury. Of the total number of patients, 43 (4.6%) had acute spinal fractures identified upon hospital radiography. The guideline allowed 558 (59.2%) patients to be cleared; 1.3% (7/558) had spinal fractures. The remaining 384 did not meet clearance criteria, and accounted for the remaining 36 (9.4% - 36/384) spinal fractures. The guideline correctly predicted 36 of 43 (95% Confidence Interval [CI] 86.9% to 92.9%) spinal fractures. The median age of the seven fractures not immobilized was 82 years, while the 36 patients with fractures that were immobilized was 48 years. When immobilization was indicated, the caregivers were compliant 77.6% (298/384) of the time. Of the non-compliant 22.4% (86/384), there were nine spinal fractures found. The guideline failed to predict 16.3% (7/43) of fractures. Of the fractures, 20.9% (9/43) failed clearance criteria but were not immobilized by ambulance staff. In all, 37.2% of patients who were identified to have a spinal fracture by hospital radiography were not immobilized. Conclusions: This spinal guideline demonstrates efficacy in identifying those at risk for spinal fractures. The use of an age extreme criteria may enhance this already effective guideline. Further analysis of the compliance failures may also add to the guidelines ability for fracture prediction. Direct correspondence to: Lukas Myers, 200 First St. SW, Rochester MN 55905. Focusing the Management of Out-of-Hospital Hypoglycemia on Restoring Homeostasis Author: Christopher Shane Henderson, AS, EMT-P Introduction: The research seeks to evaluate out-of-hospital hypoglycemic treatment modalities in an effort to determine which treatment is the most effective mimic of normal function and is the most practical for routine use. Methods: This is a prospective observational study conducted during an eight-month period (June 2005–February 2006) on all diabetic patients treated for hypoglycemia in the out-of-hospital setting. The department consists of 13 ALS units and responded to about 30,000 9-1-1 calls during this eight-month period. The treatment of hypoglycemic patients included the administration of glucose orally (25.0 g), intravenously (12.5–25.0 g), and the use of glucagon intramuscularly. Researching the effects of out-of-hospital hypoglycemic emergencies on final serum glucose levels will provide quantifiable evidence that clinicians can use when making treatment decisions. Results: During the study period, 270 patients received out-of-hospital management for hypoglycemia. Of those, 215 (79.6%) of the patients were treated with 25 g of glucose administered intravenously and had a final serum glucose of 202 +/- 61.8 mg/dL. Twenty-four (8.9%) of the patients were treated with 12.5 g of glucose administered intravenously and had a final serum glucose of 148 +/- 47.8 mg/dL. Another 24 (8.9%) of the patients were treated with 25 g of glucose administered orally and had a final serum glucose of 97 +/- 15.7 mg/dL. Finally, seven (2.6%) of the patients were treated with intramuscular glucagon and had a final serum glucose of 94 +/- 52.0 mg/dL (see Table 1, March 2009 JEMS, pg. 66). Conclusions: Out-of-hospital treatment of diabetic hypoglycemia can be effectively managed with the administration of 12.5 g of glucose administered intravenously. The final blood glucose levels remained at an average of 148 +/-61.8 mg/dL, which is reasonably close to the expected 140 mg/dL in the presence of a meal. The traditional treatment of an amp of dextrose (25 g) intravenously has the affect of postprandial, or after-meal, hyperglycemia. Maintaining a constant, normal internal environment should be a primary concern for health-care providers. Direct correspondence to: Christopher Shane Henderson, 400 9th St. South, St. Petersburg, FL 33701. Cardiopulmonary Resuscitation by EMS: Measuring Performance, Reducing Errors and Increasing Patient Safety Author: Angelo Salvucci, MD Associate Authors: Christopher McNicoll, MA, MPH; Amy Kaji, MD, PhD; Marianne Gausche-Hill, MD; James Niemann, MD; Benjamin Squire, MD; William Koenig, MD; & David Chase, MD Introduction: The likelihood of surviving a sudden cardiac arrest is increased if the victim receives properly performed CPR. Historically, however, acquisition and retention of CPR skills has not been adequate, resulting in performance errors and patient safety concerns. The 2005 American Heart Association Guidelines for CPR attempted to address these deficiencies by emphasizing chest compressions. How well EMS personnel meet the 2005 AHA Guidelines is unknown. Objective: To measure adequacy of chest compression depth, rate and release, and to evaluate the performance improvement impact of debriefing and real-time visual feedback in EMS personnel. Methods: In Ventura County, Calif., 84 on-duty EMTs and paramedics performed chest compressions on a SmartMan Adult CPR Manikin system from Ambu Inc. After the initial assessment, subjects viewed their performance on the system’s on-screen display and received guidance for improvement. Fifteen subjects then practiced 60 compressions using the SmartMan real-time on-screen feedback for each compression. A second assessment was done immediately afterward. The outcome measures studied were adequacy of depth, rate and release of chest compressions; performance differences before and after performance feedback; and effect of debriefing with and without real-time visual feedback. Results: Each assessment spanned five cycles of 30 chest compressions for a total of 150. At baseline, 20.2% (95% CI 14.1-26.3%) of the compressions met the 2005 AHA Guidelines for the three components: depth, rate and release. This improved to 43.7% (95% CI 34.8-52.7%, p < 0.0001) after post-assessment debriefing and to 77.1% (95% CI 68.7-85.4%, p < 0.0001) after debriefing plus real-time visual feedback. Conclusions: Despite the 2005 AHA Guidelines emphasizing chest compressions, only a small minority of chest compressions done by this cohort of EMS personnel achieved the correct depth, rate and release during an initial assessment. This is a previously reported, ongoing and substantial clinical error that worsens outcomes and negatively impacts patient safety. Given the importance of correct chest compressions, there should be greater emphasis on improving and maintaining competency. Provision of a brief training session using visual and verbal feedback significantly improved performance, and adding a brief real-time feedback practice session was superior to post-assessment debriefing alone. Direct correspondence to: Dr. Angelo Salvucci, 1679 Franceschi Rd., Santa Barbara, CA 93103. Call for Abstracts 2009 www.pcrf.mednet.ucla.edu FOUNDING PARTNERS UCLA Center for Prehospital Care JEMS BENEFACTORS Laerdal Medical Corp. SSCOR Inc. CONTRIBUTOR ZOLL Medical Corp. FRIENDS Armstrong Medical FISDAP AFFILIATES National Association of EMS Educators National Association of EMTs BOARD OF ADVISORS Lawrence H. Brown, EMT-P Edward Dickinson, MD, FACEP, EMT-P William J. Koenig, MD, FACEP Mark Marchetta, BS, RN, NREMT-P Todd F. LeGassick, MPH Gregg Margolis, MS, NREMT-P David I. Page, MS, NREMT-P ADVISOR EMERITUS Marv Birnbaum, MD, PhD DIRECTOR Baxter Larmon, PhD, MICP EMS RESEARCH FELLOWS Jonathan R. Studnek, BS, NREMT-P Antonio R. Fernandez, BS, NREMT-P ASSOCIATES Terry Abrams, MS, EMT-P Melissa Bentley, BS, NREMT-P Paul Bishop, MPA, EMT-P Scott Bourn, MSN, RN, REMT-P Elaine Christiansen, PhD, EMT-P Dwayne E. Clayden, MEM, EMT-P Harold C. Cohen, PhD, EMT-P Joseph Corley, BSHSS, EMT-P Megan Corry, MA, EMT-P Twink Dalton, RN, NREMT-P, MS Robert De Lorenzo, MD, FACEP Robert Delagi, MA, NREMT-P Phillip Dickinson, NREMT-P Thomas Dunn, PhD, EMT-B William Dunne, MS, NREMT-P Scott Eamer David Harrawood, RM, REMT-P Nancy Hays, MPH Attila Hertelendy, MS, MSHM, NREMT-P David Hostler, PhD, NREMT-P Billy James, PhD, EMT-P Todd Leduc, NREMT-P Thomas LeMaster, RN, REMT-P Jeffrey Lindsey, PhD, MS, EMT-P Wolfgang Maleck, MD Mary Kay Margolis, MHA, MPH Richard Nard, DPA David Nitch, NREMT-P Madeleine O’Donnell, BNg, BEd, MedS Robert J. Philip, MPH, NREMT-P Thomas Raithby, BS, EMT2 Louise Reynolds, BHSc Melissa N. Riley, PhD, NREMT-B, CFI Chris Thos. Ryther, MS. NREMT-P David L. Schriger, MD, MPH Jason B. Snider, MS, NRE


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West River Ambulance Receives New Rig

West River Ambulance in Hettinger, ND recently received a much-needed upgrade from their 1992 rig. A 2014 Ford/AEV Type III Custom Conversion rig with a 6.8 ...

Unlikely Pairing Leads to Health Care Education Wins

The University of Texas Health Science Center at Houston (UTHealth) School of Nursing and Harris County Emergency Corps (HCEC) have formed an unlikely pairin...

Know When and How Your Patient Can Legally Refuse Care

Refusal of care straddles the intersection of ethical, legal and scientific domains of prehospital practice.

Reflecting on 35 Years of Innovation in JEMS

Take a walk through the last 35 years of EMS in JEMS.

Readers Sound Off About Glove Use After Patient Care

How often are you susceptible to potentially unclean surfaces?

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