The ‘Lift-Assist’ Call
Cone DC, Ahern J, Lee CH, et al. A descriptive study of the ‘lift-assist’ call. Prehosp Emerg Care. 2012;17(1):51–56. doi: 10.3109/10903127.2012.717168. Epub 2012 Sep 12.
As I write these words, my radio is crackling with Ladder 7 being dispatched routine for a “lift-assist” (LA). Will this be a transport? Probably not.
My hope is that this new study might prompt a long overdue revision of how EMS handles these cases.
This study reviewed 1,087 LA responses (5% of all calls in this Brandford, Conn., fire-based EMS system) to 535 unique addresses from 2004 to 2009. The authors report that in half of these cases, EMS was called back to the same address within 30 days. Although data was incomplete for the early years of the study, it appears that many callbacks were for the same patient (85%) and that half of these (55%) were transported during the second call.
Such data confirms a London Ambulance Service study showing that 47% of elderly (more than 65 years old) fall patients not transported initially summoned help again with two weeks, and half of these were then transported. The authors reference several studies where EMS crews have screened elderly patients to receive home-based case management to prevent falls. They note that the “move away from reflexive, response-based intervention and toward proactive preventive measures reflects a general interest in the EMS community."
One major limitation of this new study, which the authors acknowledge, is a lack of outcomes data for these patients. Without this data we don’t know if the non-transport was helpful or hurtful. Still, Cone and co-authors should be commended for tackling the difficult issue of lift-assists.
At minimum, we should all be asking ourselves, “Is this the ONE—a lift-assist where we will return to find a patient whose weakness, illness, injury or failure to care for themselves has resulted in a much worse problem?” From this study we know that more than one quarter of these patients will end up in the hospital anyway, and that EMS spent an average of 21 minutes responding to these cases. From a risk/cost-benefit ratio, transport may be a better solution for the EMS system—but we don’t know if this is the best bet for the patient until we study their outcomes.
The bottom line: Evaluate those LA patients very carefully. You (or your EMS system) will be called back to at least half of them.
ECG Interpretation Accuracy
Bhalla MC, Mencl F, Gist MA, et al. Prehospital electrocardiographic computer identification of ST-segment elevation myocardial infarction. Prehosp Emerg Care. doi:10.3109/10903127.2012.722176. Epub ahead of print 2012 Oct 15.
Why learn to interpret ECGs if the machine will do a better job? Congratulations to Bhalla and co-authors, who reviewed 200 12-lead ECGs to double-check the accuracy of the machine’s interpretation. The results were predictable, based on previous studies: The machine’s specificity was 100%. All ECGs labeled “acute MI suspected” were correctly diagnosed.
No earth-shattering news here. Unfortunately, however, sensitivity was 58%. This means 42 patients with ST-elevation myocardial infarction (STEMI) would have been missed if we rely only on the machine’s interpretation. Interestingly, half of the missed STEMIs had an interpretation of “data quality prohibits interpretation.” The authors astutely point out that obtaining ECGs en route to the hospital and artifact in general may be causing the machine to hiccup.
This will no doubt sound familiar to those of us with some experience in the field. At times, it takes some fiddling around with cables, patches, patient coaching and especially patience to settle everything down for the tracing to be good enough for machine interpretation. It should also be noted that 131 STEMI ECGs were excluded from this sample due to transmission problems, or the first ECG did not show STEMI.
The authors also point out that this study was the catalyst to allow field activation of catheterization labs. Way to go.
Running Hot & Cold
McMullan JT, Pinnawin A, Jones E, et al. The 60-day temperature-dependent degradation of midazolam and lorazepam in the prehospital environment. Prehosp Emerg Care. 2011;17(1):1–7. Epub 2012 Nov 13.
Do you ever wonder if the temperature variations in your hot/freezing ambulance will cause some of our medications to inactivate? Kudos to McMullan and co-authors for studying this with two critical medications: midazolam (Versed) and lorazepam (Ativan). Refrigerated storage is recommended for lorazepam.
This study involved 14 metropolitan EMS systems and a special study box that measured temperature every minute. Chromatography was used to determine drug concentrations in a single lab after 60 days.
Results for 229 samples: Midazolam had no degradation and lorazepam had a 0.01 drop in concentration that was not statistically significant.
One has to wonder what the temperature variation was in these boxes, as well as their storage locations (jump bags by a door versus cabinets near an air conditioner). The study did not document which vehicles had temperature-controlled drug compartments. The chart provided in the article shows lorazepam is clearly affected by temperatures above 75° F. We don’t know whether this degradation may have a clinically significant effect, especially in time periods longer than 60 days or high heat.