Letter to Our Readers
The Prehospital Care Research Forum at UCLA believes that it is 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, lectures and workshops 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; Benefactor, SSCOR Inc.; and 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 2010 for the greater benefit of EMS.
Baxter Larmon, PhD, MICP
Director, Prehospital Care Research Forum
The Unfamiliar Broselow Pediatric Emergency Tape
Author:Christopher Shane Henderson, AS, EMT-P
Introduction:Many emergency medical providers rely exclusively on the Broselow¸ Tape for pediatric dosages and often overestimate the medications it contains. This device is a valuable piece of equipment and it is critical for providers to be familiar with its limitations. This survey was designed to evaluate paramedic familiarization with the Broselow_s¸ medication content. Achieving at least an 80% is defined by this study as adequate recognition.
Hypothesis:The majority of emergency medical providers are not adequately familiar with the medication contents of the Broselow¸.
Methods:Participants were selected by convenience. Fifty paramedics were asked to complete the survey as they were encountered on EMS calls, at fire stations or at hospitals. Participants responded to 10 questions with "yes" or "no," depending on whether they believed the medication and its stated purpose was found on Broselow¸ Tape. The survey contained five medications whose stated purpose was found on the Broselow¸ and five medications that were not.
Results:The paramedics surveyed had an overall mean score of 57%, with 8% having adequate recognition. Of the participants, 38% had adequate recognition of the medications contained on the tape, with a mean score of 64%, and 14% of participants had adequate recognition of medications not on the tape, with a mean score of 50%.
Conclusions:Participants were more successful recognizing medications contained on the tape, conceivably due to the belief that the tape is all-inclusive. Perhaps the most critical component of this survey is lacking the ability to recognize medication usages that are not contained on the equipment. This is because the impact of needing these dosages, and not having them, could potentially be life-threatening. These results illustrate the necessity to arm emergency providers with an education of the widely used Broselow¸ Tape. This can be achieved by incorporating this into primary pediatric education and pediatric provider courses. Equipment familiarization and increased knowledge of pediatric dosages, especially of medications not contained on the tape, can reduce the anxiety associated with treating these patients. Further research is needed to determine the national prevalence of this concern and to identify commonalities.
Direct correspondence to Christopher Shane Henderson AS, EMT-P, 3938 Porpoise Dr. SE, St. Petersburg, FL 37705.
An Analysis of the Paramedic Administration of Fentanyl
Author:Chris van Luen, EMT-P
Associate Authors:Bill Sugiyama; Jim Pointer, MD
Background:In most EMS jurisdictions nationwide, paramedics manage pain with intravenous or intramuscular morphine sulfate (MS). MS has numerous side effects. Little research exists regarding the use of fentanyl in the prehospital environment. Three transporting fire departments sought to determine if paramedics were able to adequately assess patient pain and safely utilize fentanyl to treat that pain in pediatric and adult patients.
Null Hypothesis:There is no reduction of pain from the time of initial patient assessment to the transfer of the patient care to emergency department staff.
Methods:This was a prospective non-randomized study that compared select data to historical controls. Data for the patients who received fentanyl was compared to the patients who received morphine sulfate from an identical time period exactly one year prior. Fentanyl is not a component of the state paramedic scope of practice. The California EMS Authority approved this investigation as a "pilot study."
Results:In this study, the onset of action for the reduction of patient pain was notably more rapid with fentanyl citrate than morphine sulfate. Of the patients who received fentanyl, 16.6% subjectively noted pain relief in under one minute, compared to 2% of patients who received morphine; 47% of fentanyl versus 14% of morphine at one to two minutes; 19.9% of fentanyl versus 36.0 % at two to three minutes; and 16.6% of fentanyl versus 48.0% of morphine at greater than three minutes. The reduction of pain, as noted on a 1-to-10 pain scale, was found to be almost double with fentanyl, as compared to morphine.
Conclusion:The study reviewed the administration of fentanyl to 317 patients with findings similar to that of Kanowitz et al. Only three patients displayed an adverse reaction, none experienced vital sign abnormalities, and none required recovery intervention. There were no admissions to the hospital, nor patient deaths attributed to the prehospital use of fentanyl. Our conclusions echo that of Kanowitz et al: IV fentanyl can be used safely and effectively in the prehospital arena without causing significant hypotension, respiratory depression, hypoxemia or sedation.
Direct correspondence to Chris van Luen, EMT-P, 8446 Lombard Way, Rohnert Park, CA 94928.
EMS Under- Triage of Elderly Fall Victims by Current Trauma Triage Guidelines
Author:Robert Bauter, MAS, CPM, NREMT-P
Associate Authors:Carolyn A. Fernandez, RN, MSN, APRN-BC, CCRN, CEN; Scott Matin, MBA, NREMT-P; Peter Dworsky, MPH, NREMT-P; Brian O_Neill, RN, AA; Paul Scalzo, NREMT-P; Charles Livezey, NJMICP; James Knight, JD
Introduction:With our aging population, the increasing numbers of elderly trauma victims will change the way EMS triages these patients. Studies have shown that age and other co-morbidity factors increase the severity of injury. The CDC released their revised Guidelines for Triage of Injured Patients in January 2009 that addresses these issues. Under current New Jersey trauma triage guidelines, age and co-morbidity issues are not included.
Hypothesis:Adherence to New Jersey trauma triage guidelines results in under-triage of elderly fall victims.
Methods:A retrospective chart review was conducted from June 1, 2008 to May 31, 2009 of elderly fall victims (> 65 years of age) in Ocean County, N.J., who a) were transferred to the regional trauma center from local hospitals, b) suffered head injuries secondary to falls and c) were on anti-coagulants. As the sole provider of ALS in the county, we compared those numbers to our ALS dispatch and treatment records.
Results:In the study time frame, the regional trauma center reported 32 patients > 65 years of age from Ocean County who were transferred from local hospitals, had suffered a head injury secondary to a fall and who were on anti-coagulants. In the same time frame, our ALS units were dispatched to 295 calls for fall victims, treating 15 patients. We were cancelled prior to arrival on 280 calls. Only one patient meeting the three study criteria was treated and transported to the trauma center by ALS. The other 14 patients who were assessed or treated by ALS did not meet the criteria for a trauma center nor for the study criteria. ALS was not dispatched or was cancelled on the 32 patients who were transferred.
Conclusions:With 32 patients being transferred to the trauma center without ALS intervention (100%), 280 of 295 patients having ALS cancelled prior to arrival (95%) and only one patient (0.34%) of the 15 assessed by ALS and transported to the trauma center, EMS does under-triage elderly fall victims using current N.J. trauma triage guidelines.
Direct correspondence to Robert Bauter, MAS, CPM, NREMT-P, 4806 Megill Rd., Neptune, NJ 07753.
Difference in Prehospital Interventions Based on Crew Configuration
Author:Jeffery Schultz, NREMT-P
Associate Authors:Lucas A. Myers, NREMT-P; Christopher S. Russi, DO, FACEP
Introduction:In the state of Minnesota, regulations allow ambulance services to mix crews with paramedics and EMT-basics while maintaining Advanced Life Support (ALS) status. Hiring EMTs for full-time positions is cost beneficial for ambulance services. Little has been researched in care provided by these mixed crews to a large array of patient conditions. The aim of this study is to examine interventional differences in crew configurations in 9-1-1 calls.
Methods:A single ambulance service employing 12 satellite sites was used in the analysis. This service consists mainly of paramedic/paramedic (P/P) crews, but does employ EMT-basic and paramedic crews (P/E). Patient records were examined for both crew configurations to identify differences in treatments patients receive. ALS intervention is defined as that which is in accordance with state and local laws, beyond the scope of practice of an EMT-basic, such as IV medication administration, ECG monitoring and advanced airway management. This study was approved by the Mayo Clinic Institutional Review Board.
Results:There were a total of 33,067 patients > 18 years of age meeting inclusion criteria for this study. P/P crews accounted for 27,257 (82.4%) patients, and the P/E crews accounted for the remaining 5,810 (17.6%) patients. At least one intervention was performed on the P/P crews 70.3% (8,106/27,257) of the time, and the P/E crews performed an intervention 79.3% (1,202/5,810) of the time, a 9.0% difference (p<.0001). In the entire group, P/P crews treated 9,982 (36.6%) patients with ALS interventions while the P/E crew treated 2,459 (42.3%) patients with ALS interventions. This is a 5.7% difference (p<.0001).
Conclusions:These data suggest paramedics treat with BLS and ALS interventions at a higher rate when partnered with an EMT-basic rather than with another paramedic. Further research is necessary to determine what impact these differences have on patient outcome.
Direct correspondence to Jeffret Schultz, NREMT-P, 501 6 Avenue NW, Rochester, MN 55901.
An Assessment of Undergraduate Paramedic Students'Empathy Levels to Patient's Medical Condition
International Winner, Australia
Author:Malcolm Boyle, ADipBus, ADipHSc(Amb Off), MICA Cert, BInfoTech, MClinEpi, PhD, MACAP
Associate Author:Brett Williams, Intensive Care Paramedic Cert, MICA Cert, BAVEd, GCert ICP, GDip EmergHlth, MHlthSc, MACAP
Introduction:Paramedics rely on establishing a health provider-patient relationship with patients they attend, thereby promoting two-way communication and patient satisfaction in delivering appropriate patient assessment and treatment. Paramedics must also have an ability to empathize with the patient and their family members in order to understand a patient_s perspective when developing a successful health provider-patient relationship.
Objective:To assess the extent of empathy in paramedic students at Monash University.
Methods:A cross-sectional study consisting of two paper-based questionnaires using a convenience sample of first, second and third year undergraduate paramedic students studying at Monash University. Student empathy levels were measured using two standardized self-reporting instruments; first was the Jefferson Scale of Physician Empathy (JSPE), and second, the Medical Condition Regard Scale (MCRS).
Results:A total of 94 students participated in the study, of which 63% were females. The maximum JSPE score was 140. Males had greater mean JSPE empathy scores than females, 113.25 v 107.5, p=0.042. The JSPE also identified that first year undergraduate paramedic mean empathy levels were the lowest, 107.53, with second year_s being the highest at 110.4, and student age having no significant affect on empathy scores. The MCRS maximum score was 66. The MCRS produced low mean scores in relation to student compassion for a patient with substance abuse, 46.42, and non-English speaking background patients, 49.17. Mean MCRS scores decreased significantly from first year to third year.
Conclusions:This study suggests that Monash University undergraduate paramedics improve their empathy towards patients over the duration of the course and that they lack compassion.
Direct correspondence to Dr. Malcom Boyle, Monash University, Department of Community Emergency Health and Paramedic Practice, P.O. Box 527, Victoria, VIC 3199.
Prehospital Intravenous Cannulation: Reducing the Risks and Rate from Inapproriate Venous Accessby Paramedics
International Winner, United Kingdom
Associate Authors:Dr. Smita Banerjee, Anne Spaight, Dr. John Stephenson, Prof A Niroshan Siriwardena
Introduction:Prehospital intravenous (IV) cannulation by paramedics is a key intervention that enables administration of fluids and drugs in the prehospital setting. Inappropriate use and poor technique of IV cannulation carry potential risks for patients, such as pain and infection. Cannulation rates vary widely between paramedics and ambulance stations, and rates have increased over the past decade. A baseline audit carried out in Lincolnshire division of EMAS in 2006 found that paramedics cannulated 14.2% of transported patients and cannulation rates varied considerably between ambulance stations, with a mean rate of 13.4% (range 5.8% to 19%). An estimated 15.6% of these cannulations could have been avoided.
Objective:This evaluation was aimed at investigating the effect of a complex educational intervention to reduce the rate of cannulation and improve cannulation technique in East Midlands Ambulance Service (EMAS) NHS Trust, which provides emergency and unscheduled care in six counties of the United Kingdom.
Method:A non-randomized control group (before and after) design was used to evaluate the effect of the educational intervention. Two geographical areas of EMAS were involved in the study; an intervention area (Nottinghamshire) was compared with a control area (Lincolnshire). The educational intervention was based on current guidance (JRCALC) and delivered to paramedic team leaders who cascaded it to their teams. Comparisons between the areas were made by analyzing cannulation rates two months before and after intervention. Paramedics, 50 in each group, were assessed on technique, appropriateness and attitude towards cannulation.
Results: Preliminary results showed that there was a reduction in cannulation rates in the intervention area from 9.1% to 6.5% compared with an increase in the control area from 13.8 to 19.1%. Paramedics in the intervention group were significantly more likely to use correct consent and hand-washing techniques following the intervention.
Conclusion:An educational intervention to clinical team leaders was effective in bringing about change leading to enhanced quality and safety in aspects of prehospital cannulation.JEMS
Direct correspondence to Mohammed Iqbal, East Midlands Ambulance Service, Lines Division HQ, Cross O_Cliff Court, Lincoln, Lines LN42HL, United Kingdom.
UCLA Center for Prehospital Care
ZOLL Medical Corp.
National Association of EMS Educators
National Association of EMTs
Board of Advisors
Lawrence H. Brown, MPH, TM
Edward Dickinson, MD, FACEP, EMT-P
William J. Koenig, MD, FACEP
Todd F. LeGassick, MPH
Mark L. Marchetta, BS, RN, NREMT-P
Gregg Margolis, PhD, NREMT-P
David I. Page, MS, NREMT-P
Marv Birnbaum, MD, PhD
Elizabeth Criss, RN, MEd
Baxter Larmon, PHD, MICP
David A. Skibo
Paul Bishop, MPA, EMT-P
Scott Bourn, PhD, RN, EMT-P
Dwayne Clayden, MEM, BHSc, EMT-P
Megan Corry, MA, EMT-P
Twink Dalton, RN, NREMT-P, MS
Robert De Lorenzo, MD, MSM, FACEP
Phillip Dickison, MD, NREMT-P, FACEP
Thomas Dunn, PhD, EMT-B
Mic Gunderson, EMT-P
Nancy Hays, MPH
Christopher Shane Henderson, AS, EMT-P
David Hostler, PhD, CSCS
Billy James, PhD, EMT-P
Todd LeDuc, MS, CFO, CEM
Jeffrey Lindsey, PhD, EMT-P, CFO, EFO
Mary Kay Margolis, MHA, MPH
Richard Narad, DPA, JD
Madeleine O_Donnell, BN, BEd, MEd
Robert J. Philip, MPH, NREMT-P
Louise Reynolds, PhD
Chris Thos Ryther, MS, NREMT-P
Andrew W. Stern, MPA, MA, NREMT-P
Ronald Stewart, MD
Walt Alan Stoy, PhD, EMT-P, CCEMT-P
Johathan Studnek, PhD, NREMT-P
Mike Taigman, EMT-P
William F. Toon, MEd, NREMT-P
Atilla —ner, MD, MPH, FAAEM
Donald Walsh, PhD, EMT-P
Paul A. Werfel, MS, NREMT-P
David M. Williams, PhD
EMS Research Fellows
Melissa Bently, BS, NREMT-P
Antonio R. Fernandez, BS, NREMT-P
2010 Call for Abstracts
Deadline: March 31, 2010
This article originally appeared in March 2010 JEMS as "The Prehospital Care Research Forum Presents: Selected abstracts for presentation at the 27th Annual EMS Today."