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, 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 Partners: Jems Communications (now known as PennWell Public Safety), Friend: FISDAP and Donor: Armstrong Medical.
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 2013 for the greater benefit of EMS.
Baxter Larmon, PhD, MICP
Director, Prehospital Care Research Forum at UCLA
Decreasing Mortality of Cryptic Septic Shock in EMS Patients
By Ryan T. Mayfield, MS, NREMT-P; & Mary Meyers, MHA, EMT-P
Introduction: Patients in septic shock have been shown to have a high mortality rate. Patients who fall into the subset of cryptic septic shock—patients with a systolic blood pressure above 90 mmHg but with an elevated blood lactate—are at an even higher risk of mortality. Previous research has shown that EMS treatment can lower blood lactate levels before hospital arrival, but no studies to date have looked at the impact early identification by EMS might have on patient mortality
Hypothesis: The mortality rate of patients in cryptic septic shock identified by EMS before hospital arrival will be lower than if it is identified after hospital arrival.
Methods: This prospective study was IRB approved and given a waiver of informed consent. In November 2008, about 950 EMTs and paramedics were trained on identifying patients with septic shock and evaluating blood lactate levels. To measure blood lactate levels, the paramedics were provided with the Lactate Pro© blood lactate meter by Arkray Inc. Between May 1, 2009, and Dec. 31, 2011 patients more than 18 years old who were not pregnant with suspected septic shock underwent blood lactate readings by EMS. Septic patients with a lactate reading of ≥ 4.0 mmol/l were considered to be in cryptic septic shock if their corresponding systolic blood pressure was above 90 mmHg.
Results: During the study period, 167 patients with cryptic septic shock, confirmed by an emergency department physician diagnosis were transported by EMS. Out of the 167 patients, 82 (49.1%) were identified by EMS before arrival and 9 (0.5%) died in the hospital (Crude OR=0.061, CI 0.024 to 0.140, p=0.001). Of the 85 patients who were not identified, 57 (67.1%) died in the hospital (Crude OR=16.51, CI 6.78 to 41.41, p=0.001).
Conclusion: Many studies state the key to surviving septic shock is early identification. In this sample of cryptic septic shock it appears there is an almost 16 times greater chance of survival if patients are identified by EMS before arrival at a hospital. Further studies must be conducted to know if this can be replicated.
Probability of ROSC as a Function of Timing of Vasopressor Administration
By Christopher Johnson, EMT-B; Michael W. Hubble, PhD, NREMT-P; Jamie N. Blackwelder, EMT-B; William P. Bozeman, MD; Kevin T. Collopy, BA, CCEMT-P, FP-C; Sara Houston, BS, EMT-P; Melisa D. Martin, MHS, EMT-P; Delbert S. Wilkes, EMT-P; & Jonina D. Wiser, EMT-B
Introduction: Vasopressors (epinephrine and vasopressin) have been associated with return-of-spontaneous circulation (ROSC) but not long-term survival. A recent retrospective study reported a greater likelihood of ROSC when vasopressors were administered within the first 10 minutes of arrest. However, it is unlikely that the relationship between ROSC and the timing of vasopressor administration is a binary function (i.e., <10 vs. >10 minutes). More likely, this relationship is a function of time measured on a continuum, with diminishing effectiveness even within the first 10 minutes of arrest, and potentially, some lingering benefit beyond 10 minutes. However, this relationship remains undefined.
Objective: To develop a model describing the likelihood of ROSC as a function of the time interval between call-receipt and first vasopressor administration measured on a continuum.
Methods: This retrospective study of cardiac arrest was conducted using the North Carolina Prehospital Care Reporting System (PREMIS). Inclusionary criteria were all adult patients suffering witnessed, non-traumatic arrests between Jan. 1, 2012, and June 30, 2012. Chi-square and t-tests were used to analyze the relationships between ROSC and call receipt-to-vasopressor-interval (CRTVI); patient age, race, and gender; endotracheal intubation; AED use; first presenting cardiac rhythm; and bystander CPR. A multivariate logistic regression model calculated the odds ratio of ROSC as a function of CRTVI while controlling for statistically significant variables from the univariate analyses.
Results: Of the 1,150 patients meeting inclusion criteria, 518 (45.0%) experienced ROSC. ROSC was less likely with increasing CRTVI (OR=0.95,p<0.01). Compared to patients with shockable rhythms, patients with asystole (OR=0.36,p<0.01) and PEA (OR=0.57,p<0.01) were less likely to achieve ROSC. Bystander CPR was a predictor of ROSC (OR=2.4,p<0.01), whereas race, age and AED were not.
Conclusion: The study found that time to vasopressor administration is significantly associated with ROSC, and that for every one-minute delay between call-receipt and vasopressor administration, the odds of ROSC declined by 5%. Similar to previous studies, the study observed an increased likelihood of ROSC among patients presenting with shockable rhythms and receiving bystander CPR. These results support the notion of a time-dependent function of vasopressor effectiveness across the entire range of administration delays rather than just the first 10 minutes.
The Accuracy of Emergency Medical Dispatcher-Assisted Layperson-Caller Pulse Check Using the Medical Priority Dispatch System Protocol
By Greg Scott, MBA, EMDQ-I; Jeff Clawson, MD; Mark Rector; Dave Massengale; Mike Thompson; Brett Patterson; & Christopher Olola, HO, PhD
Introduction: Knowing the pulse rate of a patient in a medical emergency can help determine patient acuity and the level of medical care required. Little evidence exists regarding the ability of a layperson 9-1-1 caller to accurately determine a conscious patient’s pulse rate.
Hypothesis: When instructed by a trained emergency medical dispatcher (EMD) using the scripted Medical Priority Dispatch System protocol Pulse Check Diagnostic Tool, a layperson-caller can detect a carotid pulse and accurately determine the pulse rate in a conscious person.
Methods: This nonrandomized and noncontrolled prospective study was conducted at three different public locations in the state of Utah. A healthy, mock patient’s pulse rate was obtained using an electrocardiogram monitor. Laypeople initiated a simulated 9-1-1 phone call to an EMD call-taker who provided instructions for determining the pulse rate of the patient. Layperson accuracy was assessed using correlations between the layperson’s finding and the ECG reading.
Results: Two hundred sixty-eight laypeople participated; 248 (92.5%) found the pulse of the mock patient. There was a high correlation between pulse rates obtained using the ECG monitor and those found by the laypeople , overall (94.6%, P<.001), and by site, gender, and age.
Conclusions: Laypeople, when provided with expert, scripted instructions from a trained 9-1-1 dispatcher over the phone, can accurately determine the pulse rate of a conscious and healthy person. Improvements to the 9-1-1 instructions may further increase layperson accuracy.
Probability of a Shockable Presenting Rhythm as a Function of EMS Response Time
By Ginny O’Brien, BS, EMT-P; Michael W. Hubble, PhD, NREMT-P; Daniel R. Wesley, AS, EMT-B; Patricia A. Dorian, EMT-B; Matt J. Losh, EMT-B; Robert Swain, EMT-P; & Stephen Taylor, BS, EMT-P
Introduction: Survival from cardiac arrest is associated with having a shockable presenting rhythm (VF/pulseless VT) on EMS arrival. A concern is that several studies have reported a decline in the incidence of SPR over the past few decades. One plausible explanation is that contemporary cardiovascular therapies, such as increased use of statin and beta blocker drugs, may shorten the duration of VF/VT after arrest. As a result, EMS response time would become an increasingly important factor in the likelihood of a shockable presenting rhythm, and consequently, cardiac arrest survival.
Objective: To develop a model describing the likelihood of shockable presenting rhythm as a function of EMS response time.
Methods: This study conducted a retrospective observational study of cardiac arrest using the North Carolina Prehospital Care Reporting System (PREMIS). Inclusionary criteria consisted of all adult patients suffering nontraumatic cardiac arrest witnessed by a layperson between Jan. 1, 2012, and June 30, 2012. Patients defibrillated before EMS arrival were excluded. Chi-square and t-tests were used to analyze the relationship between shockable presenting rhythm and patient age, gender and race; response time measured as elapsed minutes between 9-1-1 call receipt and scene arrival and the presence of bystander CPR. A multivariate logistic regression model was used to calculate the odds ratio of a shockable presenting rhythm as a function of response time while controlling for statistically significant variables identified by the univariate analyses. Due to the risk of bias from small sample sizes, all response time categories with less than five patients were excluded.
Results: A total of 563 patients met inclusion criteria. Overall, a shockable presenting rhythm was observed in 159 patients (28.2%). A shockable presenting rhythm was less likely with increasing EMS response time (OR=0.92,p<0.01) and age (OR= 0.98,p<0.01), while males were more likely to have a shockable presenting rhythm (OR=1.87,p<0.01). Race and bystander CPR were not associated with a shockable presenting rhythm, although EMS response time was longer among patients with bystander CPR compared to those without bystander CPR (9.83 vs. 8.83 minutes, p<0.01).
Conclusions: This study found that for every 1 minute of added ambulance response time, the odds of a shockable presenting rhythm declined by 8%. This information could prove useful for EMS managers tasked with developing EMS system response strategies for cardiac arrest management.
Estimates of Cost-Effectiveness of a Comprehensive Influenza Vaccination Program for Emergency Medical Services Personnel
By John Deal, BS, NREMT-P, FP-C; Michael W. Hubble, PhD, NREMT-P
Introduction: Because of their frequent contact with vulnerable patients, vaccination against influenza is recommended for all health care workers. Vaccination has been shown to decrease influenza transmission to patients as well as reduce worker illness and absenteeism. However, the vaccination rate among EMS workers remains low and most EMS agencies are reluctant to mandate vaccination because of the unknown economic consequences of mandatory, employer-provided vaccination programs.
Objective: To estimate the cost-effectiveness of a mandatory, employer-provided influenza vaccination program for EMS
Methods: Using estimates from published reports on influenza vaccination, a cost-effectiveness model of an employer-provided vaccination program in an urban EMS system of 100 employees was developed from the perspective of the EMS employer. Model inputs included vaccination costs, vaccination rate, infection rate, and costs associated with absenteeism, lost productivity due to working while ill (presenteeism), and medical care for treating illness (medical office visits and prescription drugs). To assess the robustness of the model, a series of univariate and multivariate sensitivity analyses were performed on the input variables.
Results: In the base case scenario, the proportion of employees contracting influenza or influenza-like illness was estimated to be 19% (19) among vaccinated employees compared to 26% among nonvaccinated employees. The costs of vaccine, consumables and employee time for vaccination totaled $40.86 per vaccinated employee. For a theoretical EMS system of 100 employees, the cost of mandatory vaccination was estimated to be $4,086. Compared to no vaccination, a mandatory vaccination program would save $20,122 (or $16,036 in net savings). The total savings were 4.9 times the cost of the vaccination program as derived from avoided absenteeism ($7,241), avoided presenteeism ($10,963), and avoided medical costs of treating influenza/influenza-like illness ($1,918). Through sensitivity analyses the model was verified to be robust across a wide range of input variable assumptions. The net monetary benefits were positive across all ranges of input assumptions, but cost savings were most sensitive to the vaccination uptake rate.
Conclusions: This cost-benefit analysis suggests that an employer-provided influenza vaccination program is a cost-effective strategy for reducing EMS employee absenteeism, presenteeism, and influenza/influenza-like illnesss health care costs.
Influence of Vasopressin on Achieving Out-of-Hospital Return of Spontaneous Circulation
By Brittany McCormick, EMT-B; Casey Schmidt, EMT-B; Emily Wilkes, DH, AA, AS, NREMT-P; Kim Woodward, BS, BA, EMT-P; Benjamin Young, EMT-B; Evelyn Wilson, MHS, NREMT-P; Melisa Martin, MHS, EMT-P; & Michael Hubble, PhD, NREMT-P
Introduction: Epinephrine has been used since 1906 in the treatment of cardiac arrest. However, recent clinical trials have not been able to demonstrate a clear benefit compared to a placebo. More recently, vasopressin has been suggested as an alternative to epinephrine. However, previous investigations of vasopressin have provided mixed and inconclusive results when compared to epinephrine.
Objective: To compare the rate of return of spontaneous circulation (ROSC) between patients receiving vasopressin plus epinephrine vs. epinephrine alone in out-of-hospital cardiac arrest.
Methods: This study conducted a retrospective observational study of cardiac arrest using the North Carolina Prehospital Care Reporting System (PREMIS), a statewide EMS patient database. Inclusionary criteria consisted of all adult patients suffering nontraumatic cardiac arrests in North Carolina between Jan. 1, 2012, and June 30, 2012, who received at least one dose of vasopressin and/or epinephrine. Chi-square and t-tests were used to analyze the relationship between ROSC and vasopressin use; patient age, gender, and race; witnessed arrest; EMS response time; shockable presenting rhythm; endotracheal intubation; and the presence of bystander CPR. A multivariate logistic regression model was used to calculate the odds ratio of ROSC as a function of vasopressin use while controlling for statistically significant variables identified by the univariate analyses.
Results: A total of 1,831 patients met the inclusion criteria, of which 19.6% (359) received vasopressin. Overall, 28.2% (516) achieved ROSC. Vasopressin was not associated with increased rate of ROSC (OR1.0,p=0.74). ROSC was more likely among females (OR=1.3,p=0.01), witnessed arrests (OR=1.6,p<0.01), and shockable presenting rhythm (OR1.9,p<0.01), endotracheal intubation (OR=0.5,p<0.01) and bystander CPR (OR=0.6,p<0.01) were negatively associated with ROSC, although EMS response time was longer among patients with bystander CPR compared to those without (10.5 vs. 8.7 minutes, p<0.01).
Conclusion: In this statewide, retrospective analysis, vasopressin made no difference in the rate of ROSC compared to epinephrine alone.
Estimation of Patient Weight and Laryngoscopic Grade of View Achieved By Paramedics Performing Endotracheal Intubation
By Bradley Demeter, MD; Emily Guhl, BA; Peter Lazzara, BS, EMT-P; Leslee Stein-Spencer, RN, MS; James Walter, MD; & Eric Beck, DO, EMT-P
Introduction: Field intubations are frequently complicated by challenging patients, austere environments and limited equipment, although as with hospital intubations, safe and expeditious airway management is expected. A common metric in the literature for such a standard is the “first pass” success rate.
Objective: To identify demographic, environmental and technical variables that might predict first-pass success of field endotracheal intubation
Method: This study retrospectively reviewed 137 field intubations reported by paramedics in a large, urban, fire-based EMS system for variables that might predict first pass success, including a provider’s estimation of patient weight and a novel data point in the literature on prehospital airway management: the Cormack-Lehane laryngoscopic grade of view.
Results: The maximal grade of view achieved on first attempt was significantly greater in cases of first pass success compared to intubation that required a second attempt (C-L Grade 1.41±0.6 v. 3.47±0.7, p<0.01). The care providers’ estimation of patient weight also correlated with first pass success (mean 82.1±31.3kg v. 97±34.9, p=0.05). There was a stepwise progression in mean weight from an unimpeded view of the glottic opening (C-L Grade 1, 79.7±32.1kg, n=69); to visualization of some of the vocal cords (C-L Grade 2, 82.2±21, n=29); to visualization of only the epiglottis (C-L Grade 3, 89.9±40.5; n=14; to inability to visualize either the glottis or epiglottis (C-L Grade 4, 102±30.2, n=11).
Conclusion: These data suggest that an estimation of patient weight might correlate with airway difficulty, as increases in weight appear to predict less favorable views of the glottis during direct laryngoscopy and correspond with lower rates of first pass success.
Work Exhaustion Associated with Personal and Work-Related Characteristics among NREMTs
By Jennifer Eggerichs, MS, CHES, NREMT-P; & Melissa A. Bentley, MS, NREMT-P
Introduction: Work exhaustion is the depletion of emotional and mental energy needed to meet job demands, and the impact of work exhaustion in EMS is a growing concern. The objectives of this study were to characterize work exhaustion in a cohort of nationally certified EMS professionals and to determine if work exhaustion was associated with personal and work-related characteristics among nationally certified EMS professionals.
Hypothesis: There are personal and work-related characteristics associated with work exhaustion among EMS professionals.
Methods: In 2010, a questionnaire was sent to all nationally certified EMS professionals eligible for recertification. A 3-item work exhaustion scale was used to assess work exhaustion (Strongly Agree=1 to Strongly Disagree=6). A summation of all three items divided by three was used to compute the outcome variable. This questionnaire also contained previously validated demographic and work-life characteristics. Multivariable linear regression modeling was used to test the study hypothesis (á=0.05).
Results: A total of 24,586 (33.9%) people completed the questionnaire. The majority of respondents were EMT-Basics (50.9%; 12,514), male (73.3%; 18,021) and had an average age of 40 (SD=10.5). Respondents reported high disagreement of work exhaustion (mean=5.28, SD=0.93). Statically significant predictors of work exhaustion included highest level of education completed (high school diploma/GED â=1; some college â= -0.006, SE=0.02; Associates or Bachelors â=-0.053, SE=0.02; Graduate Degree â=-0.057, SE=0.03); excellent overall health (agree â=1; disagree â=-.127, SE=0.03); excellent overall physical fitness (agree â=1; disagree â=-.388, SE=0.02); years of experience (less than 1 year â=1; 1-4 years â=-0.041, SE=0.19; 5-10 years â=-0.198, SE=0.19; 11-20 years â=-0.346, SE=0.19; 21 or more years â=-0.458, SE=0.19); volunteering (yes â=1; no â=0.039, SE=0.01); and job satisfaction (agree â=1; disagree â=-1.385, SE=0.03). The overall model fit was R2=0.195.
Conclusion: This is the first study that has assessed work exhaustion in EMS professionals. As years of experience increased and job satisfaction decreased, work exhaustion increased in this population. Likewise, those people who did not volunteer reported less work exhaustion. Key EMS stakeholders should focus attention on these predictors to monitor those people at a higher risk of work exhaustion.
Out-of-Hospital Cardiac Arrest in North Carolina: Epidemiology and patient factors associated with return of spontaneous circulation
By Emily Wilikins, EMT-B; Stephen Taylor, BS, EMT-P; Caitlyn Boyles, EMT-B; Doran A Grossman-Orr, EMT-B; Lennie Cooper, EMT-P; & Michael W. Hubble, PhD, NREMT-P
Introduction: Although the epidemiology and outcome of out-of-hospital cardiac arrest are known to vary geographically, published descriptions of out-of-hospital cardiac arrest are limited to those of EMS systems in urbanized areas. Larger-scale studies are needed to better describe the epidemiology of out-of-hospital cardiac arrest and factors associated with return of spontaneous circulation (ROSC) in nonurban areas.
Objective: To perform a statewide, population-based, retrospective study of the epidemiology of out-of-hospital cardiac arrest and patient factors associated with ROSC.
Methods: The PREMIS system, a comprehensive and mandated data collection system for all North Carolina EMS systems, was queried for out-of-hospital cardiac arrest occurring between Jan. 1, 2012, and June 30, 2012. Descriptive statistics, Chi-square and t-tests were used to summarize the epidemiology of out-of-hospital cardiac arrest.
Results: During the study period, North Carolina EMS agencies responded to 4,111 out-of-hospital cardiac arrests, of which 5.6% (230) were of traumatic origin, 39.1% (1,607) were female patients, and 3.8% (156) were pediatric patients (<18 years). Arrests were witnessed by laypeople in 49.4% (2,030) of cases, 18.0% (740) presented with a shockable rhythm on EMS arrival, and 44.7% (1,838) achieved ROSC. Males were more likely to present with a shockable rhythm (21.2% vs. 13.1%, p<0.01) and more likely to experience a traumatic arrest (7.3% vs. 3.1%, p<0.01). Those with ROSC were more likely to be female (47.7% vs. 42.6%, p<0.01), present with a shockable rhythm (62.4% vs. 41.9%, p<0.01), have a witnessed arrest (50.3% vs. 41.6%, p<0.01), and experience a nontraumatic arrest (48.0% vs. 29.2%, p<0.01). There was no difference in age (61.9 vs. 60.7 years, p=0.10) or EMS response time (10.4 vs. 10.0 minutes, p=0.14) between patients with and without ROSC.
Conclusion: Compared to reports from mostly urbanized EMS systems, out-of-hospital cardiac arrest s in North Carolina were similar in terms of age, gender, cause of arrest, frequency of witnessed arrest, and rate of ROSC, while EMS response times were comparatively longer and fewer patients presented with a shockable rhythm. Patient factors associated with ROSC included being female, witnessed arrest, nontraumatic arrest, and shockable presenting rhythm. These findings describe out-of-hospital cardiac arrests in North Carolina which includes a mixture of urban, suburban and rural areas and offers a broader depiction of OHCA than some other studies.
Physiologic and Clinical Management Factors Associated with Patients Experiencing Cardiac Arrest after EMS Contact
By Mark Pinchalk, MS, EMT-P; & Ronald N. Roth, MD
ypothesis: Cardiac arrest occurring in prehospital patients after EMS contact is associated with measurable physiological deraignment and the failure of EMS providers to provide key prehospital interventions.
Methods: Retrospective chart review in a single urban ALS EMS system of medical patients who experienced a cardiac arrest after EMS contact and on whom an advanced airway (endotracheal intubation or King Airway) was attempted. Trauma cases were excluded. This was a retrospective chart review that only included cases in which advanced airway placement was attempted.
Results: Forty-four cases were identified from Jan, 1, 2010, to Sept. 30, 2012. The mean time from EMS contact to the patient arresting was 15.8 +/- 7.8 minutes. The mean Glasgow Coma Score was 10.1 +/- 5.0. The ECG was abnormal (tachycardia or bradycardia) 50% (22/44) of the time. In all, 57.7% (15/26) of patients had an initial SpO2 of < 90% and 44.8% (13/29) were hypotensive with a systolic blood pressure of < 90. For clinical management, 75.0% (33) of the patients were moved to the ambulance before the arrest. Of the patients, 72.7% (32) were documented to have been placed on oxygen; 26.3% (5/19) of patients with respiratory complaints were placed in CPAP; 40.9% (18) received positive pressure ventilation via bag valve mask (BVM); 25.0% (11) of patients had a successful IV or IO line placed; 46.2% (6/13) of hypotensive patients received an fluid bolus; and 31.6% (6/19) of respiratory patients received a respiratory medication.
Conclusion: Altered mental status, hypoxia, initial tachycardia or bradycardia, and hypotension appear to be physiological findings associated with cardiac arrest after EMS patient contact. Early movement of the patient to the ambulance; failure to manage respiratory problems with CPAP or BVM ventilation; failure to obtain IV access; and failure to administer fluids for hypotension appear to be clinical management issues associated with cardiac arrest after EMS contact. An educational program targeted to early identification of dangerous physiological findings and critical clinical early interventions might improve patient outcomes.
Short Board MVC Extrications: Current Practices and Opinions of New Hampshire EMS Providers
By Angela Shepard, MD, MPH; & Chief Clay Odell, NRP, RN
Introduction: Many currently accepted practices in EMS are supported only by historical practice or professional consensus. Spinal immobilization is one area in which long-held beliefs are being called into question. Anecdotal evidence implies that short board devices are used less frequently than EMS training programs teach and many protocols direct. To assess practice patterns and opinions in New Hampshire, the New Hamphsire Bureau of EMS surveyed providers about their use of short boards during motor vehicle collision extrications.
Methods: A short survey was distributed at two regional EMS conferences and a required EMS instructor training. Participation was voluntary and anonymous.
Results: Two hundred and three completed surveys were returned.
Most providers reported using short boards infrequently during MVC extrications that met standard criteria for short board use. Of respondents who reported a short board usage rate, 62.6% (127) of the responses were for rates of 25% or lower. In fact the most frequently chosen response, selected by 45.8% (93) of respondents, was 0 to 5%. Only 14.3% (29) of respondents reported using a short board 95 to 100% of the time.
While 78.8% (160) of respondents were “very confident” in their ability to apply a short board during extrication, their confidence in the device itself was significantly lower. Only 23.6% (48) of respondents indicated they were “very confident” the device effectively immobilized the spine during extrication. One hundred and four respondents (51.2%) chose to write comments. Most frequent comments included: time consuming, difficult to apply in many cars, and application increases movement of patient. Many respondents questioned the value in MVCs noting the lack of evidence to support its use or preferring to use only c-collar and manual stabilization. Nine respondents voiced strong support for short board usage in MVC extrications.
Conclusion: Short board usage for MVC extrication is low among New Hampshire EMS providers responding to our survey. Providers feel confident in their ability to apply the device but are unsure it provides effective spinal protection during extrication. Additional study of short board devices is recommended to determine the clinical relevance of this practice.
Paramedics’ Perceptions of Mechanical Chest Compression Devices for Use in Adult Out-of-Hospital Cardiac Arrest
By Darren Figgis, MSc, DIMC; Brian Carlin; Dr. Cathal O’Donnell; & Dr. Niamh Cummins
Introduction: The HSE National Ambulance Service (NAS) attends approximately 1,700 out-of-hospital cardiac arrests annually. Several devices for performing mechanical chest compressions (m-CPR) are being evaluated for possible future use. The opinion of paramedics regarding which device is most suited to their use has not yet been elicited.
Objective: This study was designed to ascertain paramedics’ perceptions of, and experience with, three m-CPR devices currently being used in Ireland.
Methods: Twenty-five members of the NAS participated in this study. Following a standardized instruction interval (video observation) in device assembly and application, subjects were asked to initiate mechanical chest compressions on the simulated victim (manikin) of out-of-hospital cardiac arrests (manikin). Assembly time was recorded using a stopwatch. Participants were then asked to complete a questionnaire regarding their experiences using each of the devices.
Results: Of the 25 participants (84% male), 40.0% (10) had no prior experience using any m-CPR device. 16.0% (4) reported previous clinical experience using the AutoPulse, 24% (6) reported having used the Life-Stat, and 12.0% (3) reported having used a version of the LUCAS device in clinical practice. More participants reported feeling either “comfortable” or “very comfortable” using the LUCAS2 (92.0%; 23), than either the AutoPulse (88.0%; 22) or the Life-Stat (72.0%; 18). Subjects reported the LUCAS2 device as being more portable (ease of carry), and easier to assemble and position on the manikin. Overall, 20.0% (5) rated their first preference for the AutoPulse, 12.0% (3) preferred the Life-Stat and 68.0% (17) preferred the LUCAS2 for use in their clinical work environment. However, more subjects required assistance with setting-up the LUCAS2 device (36.0%; 9) than either the Life-Stat (2.04%; 6) or the AutoPulse (20.0%; 5).
Conclusion: The LUCAS2 m-CPR device was chosen by NAS personnel as being easier to use in an EMS ambulance setting. However, more participants required assistance initiating mechanical chest compressions using this device than the others. The LUCAS2 also appears to have more consistent depth and rate of compressions in accordance with current international guidelines for provision of CPR.
Aspirin Administration by Emergency Medical Dispatchers Using a Protocol-Driven Aspirin Diagnostic and Instruction Tool
By Greg Scott, EMD-QI, MBA; Tracey Barron, BSc; Jeff Clawson, MD; Brett Patterson, EMD-I,; Ronald Shiner, AAS; Donald Robinson, BCA; Fenella Wrigley, FCEM; James Gummett; & Christopher Olola, PhD
Introduction: The American College of Cardiology and the American Heart Association recommend early aspirin administration to patients with symptoms of acute coronary syndrome (ACS)/acute myocardial infarction (AMI). The primary objective of this study was to determine if emergency medical dispatchers (EMDs) can provide chest pain/heart attack patients with standardized instructions effectively, using an Aspirin Diagnostic and Instruction Tool (ADxT) within the Medical Priority Dispatch System before arrival of an emergency response crew.
Methods: This retrospective study involved three dispatch centers in the United Kingdom and the United States. Six months of data were analyzed involving chest pain/heart attack symptoms taken using the MPDS Chest Pain and Heart Problems/Automated Internal Cardiac Defibrillator Protocols.
Results: The EMDs successfully completed the ADxT on 69.8% (30,810) of the 44,141 cases analyzed. The patient’s mean age was higher when the ADxT was completed, than when it was not (mean ±standard deviation (SD): 53.9±19.9 and 49.9±20.2; p<0.001, respectively). The ADxT completion rate was higher for second-party, than first-party calls (70.3% and 69.0%; p=0.024, respectively). A higher percentage of male patients took aspirin (91.3% and 88.9%; p=0.001). Patients who took aspirin were significantly younger than those who did not (mean±SD: 61.8±17.5 and 64.7±17.9, respectively). Unavailability of aspirin was the major reason (44.4%; 19,598) why eligible patients did not take aspirin when advised.
Conclusions: EMDs, using a standardized protocol, can enable early aspirin therapy to treat potential ACS/AMI prior to responders’ arrival. Further research is required to assess reasons for not using the protocol and the significance of the various associations discovered.