The Prehospital Care Research Forum Presents Selected Abstracts

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 2012 for the greater benefit of EMS.

Baxter Larmon, PhD, MICP
Director, Prehospital Care Research Forum

High Frequency Use of EMS in an Urban Inner City
By Dr. Amy Knowlton, ScD; Brian Weir, MS; Frank Hazzard, BS; Brenna Hughes BS; & Wade Gaasch, MD
Objective: Research suggests that frequent use of EMS might be an indication of ineffective health care or treatment, patient nonadherence to medical regimens, or patients’ needs for services not adequately met by EMS or other health care delivery systems. As healthcare policymakers seek to reduce costs and improve outcomes, identifying demographic characteristics and health issues of high frequency users of EMS systems will inform the development of targeted interventions to more effectively address these patients’ health concerns and service needs.
Methods: The study reviewed Baltimore City Fire Department’s 9-1-1 call dispatch data and EMS electronic patient records during a 23-month period from2008 to 2010. Frequent use was defined as six or more EMS incidents in the 23-month period. Analyses used electronic health records to compare demographics and health issues of frequent to nonfrequent EMS patients, and to the city population.
Results: Frequent users (n=1,990) had a range of six to 199 incidents (mean=11.2) during the observational period. While these they accounted for less than 1% of EMS users, they were involved in 8.7% of EMS incidents. Frequent users as compared to nonfrequent users were more likely to be middle aged males, and had an 11 times higher odds of indication of mental illness (52% vs. 9%), seven times higher odds of indication of substance use (35% vs. 7%), seven times higher odds of asthma (39% vs. 9%), and a six times higher odds of diabetes (39% vs. 10%), among other chronic conditions. Almost two-thirds (66%) had mental illness or substance use indications.
Conclusion: The study found frequent users of this urban EMS system had high prevalence of behavioral health and somatic health conditions. Results suggest the need for fire department linkage to public health and behavioral health agencies to provide coordinated assessment and service delivery. Such intervention is important in addressing frequent users’ unmet care or service needs, and promoting their adherence to medical regimens of chronic conditions. Linking EMS frequent users to comprehensive primary care might have implications to health outcomes as well as EMS and ED use and health care costs.

Gender Pay Disparities within EMS
By Cornelia Bryan, MHHS, NREMT-P; Salvatore A. Sanders, PhD; Joseph J. Mistovitch, MEd, NREMT-P; & John M. Hazy, PhD
Introduction: Previous research has identified that despite awareness and advancements made to reduce gender disparities in occupational settings, EMS has not been exempt from gender-based pay differences. To date, research targeting the analysis of specific factors that might contribute to any wage differences between male and female EMS professionals is lacking.
Purpose: To identify if gender pay disparities exist within EMS and to identify if specific factors contribute to any pay discrepancies between male and female EMS professionals.
Hypotheses: Female EMS professionals are paid less than male EMS professionals. Factors such as education, level of certification, experience, community size, and type of employer contribute to the gender pay gap between EMS professionals.
Methods: A secondary analysis of 2008 Longitudinal EMT Attributes and Demographics Study (LEADS) data was performed and used to examine potential factors (education, level of certification, experience, community size, and type of employer) that were hypothesized to contribute to wage differences between male and female EMS professionals.
Results: The sample consisted of 1,610 randomly selected EMS professionals who were nationally registered. Gender wage disparities in EMS were found to exist. The level of certification (Beta=.318, p=.000), years of experience (Beta=.256, p=.000), number of hours worked per week (Beta=.230, p=.000), community size (Beta=.181, p=.000), type of employer (Beta=.180, p=.000), and gender (which had a negative relationship with Beta=-.064, p=.006) of the EMS professional were all found to significantly influence the earnings of EMS providers. Similarities in educational attainment for both men and women led to the omission of education as a factor in the regression model (p=.780). Only 48.8% of the earnings of EMS professionals could be attributed to the years of experience, hours worked, type of employer, community size, level of certification, and gender of the EMS professional. Gender attributed to 4.4% of the EMS earnings difference between male and female EMS professionals.
Conclusion: The findings from the present study might provide a basis for understanding and reducing the gender pay disparities that exist within EMS.

Control of End-Tidal CO2
By Robert Kohler, EMT-P
Introduction: With the ability to monitor end tidal CO2, EMS professionals are responsible for maintaining specific levels providing the patient is sufficiently oxygenated. This study will compare the efficacy of two methods of maintaining ETCO2 in a narrow range during the prehospital phase.
Methods: Paramedics were given the choice of methods for positive pressure ventilation the bag-valve mask (BVM) by Allied LSP (control) or a disposable peek inspiratory pressure cycled resuscitator (VAR) model VAR-Plus-PCM by VORTRAN Technology 1 Inc. (study). Twenty paramedics from a ground-based 9-1-1 service participated in 40 hours of training developed from manufacturer’s requirements and the FCCS course curriculum. Clinical targets were an FiO2=100%, rate of 10 to 12 bpm, PIP from 15 to 25 cm/H20 and EtCO2 of 35—45 mm/Hg. Selected patients were at least 15 years old, intubated, in respiratory arrest and not post-cardiac arrest. In all, 1,017 ambulance calls from January through September 2010 were reviewed and 152 (14.9% intubated patients were evaluated; Forty-five (29.6%) cases met the criteria. The control group (23 cases) had 1,012 EtCO2 readings. The study group (22 cases) had 1,270 readings. Paramedics were not restricted as to the method of ventilation for each case and all contributed data from both groups. The first four minutes of recordings from all cases were excluded to account for procedural anomalies while securing the airway. EtCO2 was monitored via Side-Stream Capnography available on the LIFEPAK 12s.
The standard deviation of EtCO2 values were calculated for each patient and the results charted. Additionally, all data in each group were combined and the standard deviation calculated and compared. The difference in the quantity of records between the groups had no significant effect on results in a test analysis.
Results: After nine months of recorded data, the study group trended toward a lower standard deviation as time progressed while the control group did not. Combined EtCO2 values in the study group reflected a standard deviation of 14.09 and in the control 16.97.
Conclusion: Although data are still being collected, these initial values indicate that a paramedic can effectively and more accurately control the range of EtCO2 with a VAR than a BVM.

Do Extended Shift Lengths and Sleepiness Negatively Impact EMS Professionals’ Relationships With Family, Friends and Co-workers?
By Antonio Fernandez, PhD, NREMT-P; Melissa A. Bentley, MS, NREMT-P; & Jon R. Studnek, PhD, NREMT-P
Introduction: EMS professionals are often subjected to shifts with extended work hours. There is limited research describing how these work patterns impact the personal and professional relationships of these workers.The goal of this study is to examine the association between extended shift lengths, sleepiness, and the negative impact on personal and professional relationships among nationally certified EMS professionals.
Hypothesis: Working extended shifts and self-reported sleepiness are significantly associated with a negative impact on personal and professional relationships.
Methods: In 2009, people who previously responded to the Longitudinal EMT Attributes and Demographics study were mailed a questionnaire. Respondents were asked if their personal (family and friends) or professional (coworkers) relationships had been negatively affected due to being sleepy or tired during the previous 12 months. Questions regarding shift length and work hours, as well as the Epworth Sleepiness Scale (ESS) were included in the questionnaire. Two multiple logistic regression models were used to measure the effect of work hours and sleepiness on relationships.
Results: The questionnaire was received by 1,603 people with 1,078 (67.2%) complete responses. When examining negative impacts on personal relationships, extended shift length and ESS were significantly associated. Due to a statistical interaction, the association between shift length and negative impacts on personal relationships was assessed in the presence of reported overtime. Among those people who indicated that they worked mandatory overtime, the odds of reporting negative impacts on personal relationships was 1.94 (95%CI=1.15-3.29) times greater for those who worked more than 24 hours compared to those who worked less than 24 hours. This association was not present for those who indicated that they did not work mandatory overtime. For every one-point increase in ESS, the odds of reporting negative impacts on personal relationships increased 17% (OR=1.17; 95%CI=1.10—1.24). When examining negative impacts on professional relationships, ESS was significantly associated (OR=1.17; 95%CI=1.12—1.22) but extended shift length was not (OR=1.16; 95%CI=0.72—1.87).
Conclusion: This study revealed significant associations between the report of negative impacts on personal relationships, extended shift length when working mandatory overtime and sleepiness. Extended shift length did not appear to impact professional relationships however; sleepiness was significantly associated with the report of negative impacts on relationships with coworkers.

Demographic and Work-Life Characteristics Associated with Overall Job Satisfaction Among Nationally Certified EMS Professionals
By Jennifer Eggerichs-Purcell, MS, CHES, NREMT-P; & Melissa A. Bentley, MS, NREMT-P
Introduction: The Institute of Medicine states that the overall job satisfaction is often low n EMS. The objective of this study was to determine if overall job satisfaction was associated with demographic and work-life characteristics among nationally certified EMS professionals.
Hypothesis: There are individual and work-life characteristics associated with overall job satisfaction among EMS professionals.
Methods: Data used for this analysis were obtained from the 2009 Longitudinal EMT Attributes and Demographics Study (LEADS). Overall job satisfaction was estimated as a dichotomous outcome of satisfied or dissatisfied. Characteristics assessed included overall health, age, service type of EMS, education level, sex, call volume, and call type. Analysis included only currently practicing EMS personnel. Chi-Squared and t-test analyses were performed to determine associations between characteristics and overall job satisfaction.
Results: Of 1,504 responses, 734 (48.8%) people responded to the survey, with 675 (91.9%) meeting inclusion criteria. There were 593 (87.9%) EMS professionals classified as satisfied with their overall job. When looking at overall general health, 363 (62.4%, p=0.001) of the people that were satisfied also had good health. With respect to service type, job satisfaction was highest (60.9%, p=0.036) in governmental versus nongovernmental services. Those working primarily emergency calls were most satisfied when compared to those working scheduled transports and both emergency and scheduled calls, (85.9% versus 5.6% and 8.9%, respectively, p=0.001). Age was found to be statistically related to job satisfaction with an average age of those reporting satisfaction of 40.5 years (SD=11.5) and those unsatisfied average age of 36.3 years (SD=10.4). There was no statistical significance found when assessing the association between job satisfaction and education, gender, call volume, or the number of organizations worked.
Conclusion: It was found that overall job satisfaction is influenced by demographics and work-life characteristics. Further research would be beneficial in how best to apply these findings to EMS health, wellness, and educational programs.

Public Perception and Value of EMS Compared to Other Public Service Entities
By Jennifer Eggerichs-Purcell, MS, CHES, NREMT-P; & Gregory Gibson, PhD, PRC, NREMT-B
Introduction: Scant empirical evidence exists on the public’s value of EMS. The objective of this study is to assess the public’s perception and value of EMS as compared to other public service entities.
Hypothesis: The public will value EMS more than other public service entities. Methods: A random-digitdial telephone survey was conducted by selecting adults from a geographic probability sample of the continental United States. Study participants were asked about their willingness to pay for EMS and value of EMS, when compared to both fire and police services. Participants were also asked to choose between EMS or public service entities for funding cuts. Descriptive statistics were used.
Results: A total of 1,041 respondents completed the survey. The majority of individuals were willing to pay the same for EMS when compared to both police and fire services (663 or 63.7% and 726 or 69.7%, respectively). The majority of respondents also reported that EMS is equally important when compared to police and fire (775 or 74.4% and 898 or 79.5%, respectively). See Table 1 (to access, click on the March 2012 cover and “PCRF” at for a reduction in spending were mandated, which public service entity the respondents would cut first.
Conclusion: While the public acknowledges EMS is as equally important as fire and police services, they are more willing to cut funding to EMS before fire and police.

Decreasing Door to Antibiotic Time in Septic Shock Patients Using an EMS Sepsis Alert
By T. Ryan Mayfield, MS, NREMT-P; Mary Meyers, MHA, EMT-P; & Wayne Guerra, MD, MBA
Introduction: One of the goals for treatment of patients with sepsis is to reduce the delay in antibiotic administration. Studies have shown that for each hour of delay after identification the mortality rate increases by 7.6%. One of the areas that has been overlooked in the past is the role EMS personnel can play in the identification and treatment of these patients.
Hypothesis: Identification of EMS patients in severe sepsis and septic shock and hospital notification before arrival in the ED will decrease the door-to-antibiotic time.
Methods: In November 2008, about 900 EMTs and paramedics were trained on identification of patients with severe sepsis/septic shock, and the criteria for a prehospital sepsis alert. All patients at least 18 years old and not pregnant who were transported by EMS with severe sepsis or septic shock between Jan. 1, 2009, and Dec. 31, 2010, were included in this study.
Results: During the study period, 212 patients with confirmed severe sepsis or septic shock were transported by EMS. Out of the 212 patients, 82 (38.7%) were identified by EMS as meeting the criteria for severe sepsis or septic shock and had a sepsis alert initiated before arrival at the ED. The other 130 (61.3%) patients were not identified by EMS before arrival due largely to being transported by agencies not participating in the sepsis alert study. Patients with an alert had a median arrival to antibiotic time of 49 minutes while patients with no alert called had a median time of 73 minutes (p=0.0147).
Conclusion: Early identification by EMS and notification before arrival at the ED significantly decreases door-to-antibiotic time in patients with severe sepsis and septic shock.

Are Paramedics Allowing Patients to Inappropriately Influence Transport Destination?
By T. Ryan Mayfield, MS, NREMT-P; & Mary Meyers, MHA, EMT-P
Introduction: In areas with a large number of hospitals, determining transport destination often falls to the treating paramedic. Factors including distance, special resources available, and patient or family requests have to be balanced with the patient’s best interest. However, all things being equal, it is unclear if paramedics allow a patient, or the patient’s family, to dictate transport to a facility that is not appropriated for the patient’s severity.
Hypothesis: Paramedics are not allowing the patient or patient’s family to influence transport to an inappropriate destination.
Methods: For this study, records for 5,636 patient transports were analyzed from a large EMS system with urban, suburban and rural coverage areas. Transport distance, transport mode and destination reason were analyzed for significant differences.
Results: There were no significant difference between mean transport distance for a patient transported emergently to a destination chosen by the patient or patient’s family and the mean distance transported to the closest facility (5.78 miles vs. 5.71 miles, p=0.792). There was a significant difference (p=0.000) between emergent transport to a specialty resource center (12.75 miles), emergent transport to closest facility (5.71 miles), and emergent transport to a facility of the patient or patient’s family choosing (5.78 miles).
Conclusion: Paramedics are willing to take a critical patient to the facility chosen by the patient or patient’s family only if there is no difference in distance between that and the closest facility. When the patient is believed to need a facility with a special resource, the paramedics are willing to travel a significantly farther distance.

Decontamination of Prehospital Equipment by EMS Providers
By Mary Meyers, MHA, EMT-P; & Anne Clouatre, MHS, EMT-P
Introduction: EMS equipment is exposed to blood and body fluids. With the growth of more antibiotic-resistant infections and virulent strains of viruses, paramedics should perform the maximum amount of decontamination possible. EMS crews are particularly vulnerable in emergency situations, as their equipment is in direct contact with patients and body fluids without the benefit of maximum protective gear. The purpose of this study was to observe if EMS providers decontaminated equipment routinely. Since this is a cross-sectional study, there is no hypothesis. It seeks to describe the behavior of a population of paramedics with respect to the risk factor of contamination and disease.
Methods: Between April and October 2011 after patient hand off in the emergency department, paramedics were observed at random for decontamination of equipment. For this study, recommended decontamination processes are bundled. The bundle is defined by three essential procedures: 1) use of either a germicidal agent present in the ED or an agent stocked routinely by ambulances and designated for decontamination; 2) use of gloves by the providers while cleaning; and 3) decontamination of the stretcher on which the patient was transported and equipment used by the crew for care of the patient. Decontamination is defined as the use of user-ready cleaning agents present in the ED (wipes) or agents stocked in ambulances specifically for decontamination purposes. All the procedures described in the bundle must be followed for the score to be tabulated as a 1. If any procedure is not followed, the bundle score is 0.
Results: Out of a sample of 55 patient hand-offs, only 21.1% of paramedic ambulance crews fulfilled the requirements of the bundle. Less than 1% performed even one of the three steps necessary for decontamination. Most common behavior was removal of used sheet and replacement with clean sheet from the hospital (79%).
Conclusion: Based on these results, paramedics might be inadequately decontaminating equipment. More research is necessary to determine prevalence of this practice, and to develop protocols that will guide paramedics and EMTs in following decontamination procedures.

The Effect of Resting Between Compression Cycles on CPR Chest Compressions
By Robert Curran, DC
Introduction: The American Heart Association recommends that when feasible, rescuers should frequently alternate “compressor” duties during CPR–regardless of whether they feel fatigued–to ensure that fatigue does not interfere with delivery of adequate chest compressions. Several studies indicated dramatic decrease in CPR chest compression depth after one minute of compressions
Methods: Volunteers were recruited by announcements in Exercise Science classes. The Physical Activity Readiness Questionnaire (PAR-Q) was administered and excluded those who would be at a higher risk of injury or illness by participating in the study. Each subject was advised of a standard set of instructions based on “calling” 911 for assistance. The subjects were advised to: “Place the heel of one hand in the middle of the chest, approximately at the mid-nipple line. Place the other hand on top of the first hand, interlocking the fingers. Press down trying to compress the breastbone approximately 2 inches down at a rate of about 100 times per minute. Push hard, push fast, until help arrives.” The subjects were not told how long they were expected to continue compressions, but were advised to stop if they were exhausted or suffering pain. A Laerdal CPR Recording Resusci-Annie (Norway) was used to evaluate compression depth and rate. Each subject was allowed to perform compressions for one minute and then instructed to rest for one minute until a full five minutes of chest compressions were performed or the subject stopped due to fatigue or pain.
Results: Average compression depth per minute performing compressions was 32 mm, 31 mm, 31 mm, 31 mm and 30 mm.
Conclusion: While there was no improvement in compression depth with rest intervals, the depth stayed relatively consistent without the significant drop off as seen in continuous compression studies. In addition, the subjects reported no fatigue at the end of five minutes and the ability to continue if necessary.

Can Female College Students Perform CPR Chest Compressions?
By Robert Curran, DC
Introduction: Untrained bystanders who observe a person in cardiac arrest are advised to “push hard and push fast” to perform chest compression-only CPR by EMS dispatchers. This study analyzes whether female college students could perform adequate continuous chest compressions on an adult mannikin.
Methods: Volunteers were recruited by announcements in Exercise Science classes. The Physical Activity Readiness Questionnaire (PAR-Q) was administered and excluded those who would be at a higher risk of injury or illness by participating. Each subject was advised of a standard set of instructions based on “calling” 9-1-1 for assistance. The subjects were advised to: “Place the heel of one hand in the middle of the chest, approximately at the mid-nipple line. Place the other hand on top of the first hand, interlocking the fingers. Press down trying to compress the breastbone approximately 2 inches down at a rate of about 100 times per minute. Push hard, push fast, until help arrives.” The subjects were not told how long they were expected to continue compressions, but were advised to stop if they were exhausted or suffering pain. A Laerdal CPR Recording Resusci-Annie (Norway) was used to evaluate compression depth and rate.
Results: Of the 15 volunteers, mean age=25.5 years, seven (46.7%) performed adequate chest compressions for at least one minute, dropping minute by minute to four (26.7%), three (20%) , one (6.7%) and one (6.7%).
Conclusion: Only four (27%) of the female college students assessed in this small study were able to perform adequate rate and depth chest compressions for more than one minute.

Fist CPR Compressions: Evaluation of an Alternative Compression Technique
By Robert Curran, DC
Introduction: Recent literature supports the susceptibility of wrist tissues (particularly the scapholunate ligament) to damage when load is applied to an extended wrist, as in performing “normal” hand-over-hand chest compressions. This study investigates the chest compression depth achievable by female college students, comparing “ hand-over-hand compressions with a novel straight wrist, or “fist,” technique which mightdecrease such injury susceptibility.
Methods: Volunteers were recruited by announcements in Exercise Science classes. The Physical Activity Readiness Questionnaire (PAR-Q) was administered and excluded those who would be at a higher risk of injury or illness by participating. Each subject was advised of a standard set of instructions based on “calling” 9-1-1 for assistance. Volunteers were randomly assigned to perform “ hand-over-hand compressions or fist compressions on their first lab visit and then assigned the other type on their second lab visit, at least 48 hours later. For the fist compressions, subjects were advised to: “Make a fist with each hand, put them side by side, knuckles on the chest, in the middle of the chest. Press down trying to compress the breastbone approximately 2 inches down at a rate of about 100 times per minute. Push hard, push fast, until help arrives.” The subjects were not told how long they were expected to continue compressions, but were advised to stop if they were exhausted or suffering pain. A Laerdal CPR Recording Resusci-Annie (Norway) was used to evaluate compression depth and rate. Subjects performed hand-over-hand chest compressions on the same mannikin on a different day
Results: Thirty-two minute samples of comparative data were available from 14 volunteers. Mean compression depth of fist compressions was 31.5 mm. Mean compression depth of normal compressions was 32.6 mm.
Conclusion: The performance of fist compressions by female college students did not result in clinically unacceptable loss of compression depth vs. normal hand-over-hand chest compressions on a mannikin. Further study of this technique, and variations, are warranted in different populations in light of evidence of potential wrist injury especially to a professional rescuer, by using current chest compression technique.

What Makes for a Good EMS Team? Characteristics of Good Team Leadership and Good Team Membership
By Gregory Gibson, PhD, PRC, NREMT-B; Robert Wagoner, BSAS, NREMT-P; & Richard Walker, MD
Introduction: In EMS, it is generally accepted that a good team consisting of a team leader and one or more team members facilitates the delivery of quality patient care. However, little research exits on the characteristics of effective team leaders and team members. The purpose of the present study was to discern characteristics of good team leadership and membership in EMS providers.
Methods: Data were collected in a seven-step nominal group technique seeking answers to the research question: “What are the specific components of team leadership and team membership on a single patient call in which multiple EMS providers are present?” Nine EMS experts participated and were recruited from these EMS service types: two from fire-based; two from county/municipal; three from hospital-based; one from private, not-for-profit; and one affiliated with a large university-based EMS service.
Findings: Eight characteristics of good team leadership were discerned: 1) Creates action plan; 2) Communicates accurately and concisely, listens intently and encourages feedback; 3) Receives, processes, verifies, and prioritizes information; 4) Reconciles incongruent information; 5) Demonstrates confidence, compassion, maturity and command presence; 6) Takes charge; 7) Maintains accountability for team’s actions/outcomes; and 8) Assesses the situation and resources and modifies accordingly. Eight characteristics were also discerned for good team membership: 1) Demonstrates followership–is receptive to leadership; 2) Performs functions using situational awareness and maintains it; 3) Utilizes appreciative inquiry; 4) Avoids freelance activity; (5 Listens actively by using closed-loop communication and reports progress on tasks; 6) Performs tasks accurately and in a timely manner; 7) Advocates for safety and is safety conscious at all times; and 8) Leaves ego/rank at the door.
Conclusion: This study discerned eight primary characteristics for both team leadership and team membership. By identifying these attributes, EMS providers can focus on strategies that enhance team function and improve team resource management. Ultimately, improvements in managing the EMS team should further enhance the delivery of out-of-hospital patient care in the United States.

Glidescope Enables 90% Reduction in EMS Field Intubation Failures
By Kenneth Rothfield, MD; Kevin G. Seaman, MD; Michelle Duell, CRNA; & Joseph E. Pellegrini, PhD, CRNA
Introduction: Emergency prehospital intubation may be associated with high failure rates. The GlideScope video laryngoscope (Verathon) requires less training than traditional laryngoscopy, and hospital-based studies have demonstrated increased efficacy and decreased complications and failures. A recent EMS study reported similar intubation success rates with the GlideScope (97%) and traditional laryngoscopy (95%). However, this traditional layrngoscopy success rate is well above the national norm. For example, in Howard County, Md., the 2008 to2009 overall intubation success rate by EMS personnel was approximately 64%, with a 59% first-pass success rate. The purpose of this prospective, descriptive study was to determine the impact of implementation of GlideScope by the Howard County (Md.) Department of Fire & Rescue.
Methods: After IRB and Maryland State EMS Board approval, GlideScope Ranger units were placed on 12 EMS vehicles. Before implementation 150 paramedics received didactics and simulator training on the Glidescope. Nineteen providers received supplemental live operating room training. Measured variables included overall and first-pass success rates, complications and time to intubation.
Results: In all, 103 emergency intubations were evaluated. The most common indication for intubation was cardiac arrest, followed by airway protection. The GlideScope was used for 87 (84.5%) cases for first pass whereas traditional laryngoscopy was used in 14 (13.6%) cases. Overall intubation success was 98% (p<0.05), with 69% first-pass success for the GlideScope, and 7% for traditional laryngoscopy. All unsuccessful traditional laryngoscopies except one case were subsequently intubated using the GlideScope. Two patients could not be intubated. The King LT-D supraglottic airway (King Systems) was used successfully in one patient, and the other was transported without a secured airway. Average time for a successful intubation attempt was about 25 seconds. There were no reported cases of esophageal intubations, dental or soft tissue injuries.
Conclusion: Prehospital providers intubate with a dramatically higher success rate when the GlideScope is available. These results should prompt further evaluation of videolaryngoscopy by EMS systems.
Get references on To access, click on the March 2012 cover and “PCRF” at

Protecting the Public: Public Perceptions of EMS Workforce Screening and License Removal
By Gregory Gibson, PhD, PRC, NREMT-B; & Jennifer Eggerichs-Purcell, MS, CHES, NREMT-P
Introduction: Americans rely on the efforts of trained EMS professionals, but little research exists on the public’s expectations regarding pre-employment screening and license removal for EMS professionals. This study examined those expectations.
Hypotheses: 1) The public will report high agreement for prehire screening of EMS professionals. 2) Certain legal convictions will receive higher agreement from the public for licensure removal.
Methods: Data were collected by telephone survey using a stratified, clustered, random digit dial, national telephone sample. Cell phone users were excluded, presenting a potential coverage bias. Four areas of pre-employment screening (illegal drug use, a criminal background, mental health problems, and physical fitness) were scaled from 1 (strongly disagree) to 10 (strongly agree). Five legal convictions (illegal use of a narcotic drug or other drugs meant to treat a patient, violations of a patient’s confidentiality, stealing from a patient, deliberately withholding of or providing negligent care, and improper care that did not harm a patient) were scaled from 1 (very uncomfortable) to 10 (very comfortable). Descriptive statistics were generated. See Table 1 online (to access, click on the March 2012 cover and “PCRF” at for public perception of prehire screening and license removal for EMS professionals.
Results: In all, 1,051 respondents completed the survey (response rate = 62.3% of calls made). Highest agreement on prehire screening was for illegal drug use, and the lowest was physical fitness. Highest agreement for license removal was for stealing from a patient, and the lowest was for improper patient care. Table 1 presents public perception agreement levels for these scales.
Conclusion: Findings indicate public support for prehire screening and for licensure removal. The results of this study show the public expects a fully vetted EMS workforce absent legal convictions.

Factors Affecting Prehospital Pain Treatment
By T. Ryan Mayfield, MS, NREMT-P; Mary Meyers, MHA, EMT-P; & Wayne Guerra, MD, MBA
Introduction: Inadequate pain control is a major source patient dissatisfaction and delay in initiating pain relief can result in larger quantities of medicine needed to gain relief. This study attempted to identify patient characteristics that would lead a paramedic to more likely treat a patient’s pain with a narcotic analgesic.
Hypothesis: Pain treatment is not affected by distance traveled, location of pain, organ system, medical vs. traumatic cause, age, transport mode, cause of injury, severity of pain, or treating paramedic.
Methods: Prehospital medical care reports of patients transported between Jan. 1, 2010, and Dec. 31, 2010, were reviewed, and all patients with a Glasgow Coma Score of 13 and above with a documented complaint of pain on a 0—10 scale were analyzed.
Results: A total of 5,778 patients were transported during the study period with 1,789 (31%) patients having a documented complaint of pain. Of the patients complaining of pain, 474 (26.4%) patients were treated with narcotics. There was a statistically significant greater chance of receiving narcotics if the patients were transported more than 6.6 miles (t=2.89, p=0.004); complained of abdominal pain (p=0.042); or complained of pain greater than or equal to 7 out of 10 (p=0.000). There was no significant difference based of patient age, transport mode, organ system, medical vs. traumatic pain, or cause of injury. There was no significant difference in prevalence of pain treatment by individual paramedics as a model; however, outliers were seen on both ends of the spectrum when looking at individual paramedic odds ratios.
Conclusions: Administration of narcotic medication for pain control is more prevalent for abdominal pain, pain reported to be greater than or equal to 7, and for longer transports. Further investigation needs to be conducted to determine the cause of the variation among individual paramedics.

Incidence of Cryptic Septic Shock in EMS Patients
By T. Ryan Mayfield, MS, NREMT-P; Mary Meyers, MHA, EMT-P; & Wayne Guerra, MD, MBA
Introduction: Patients with severe sepsis and septic shock have been shown to have a high mortality rate. Patients who fall into the subset of cryptic septic shock, that is patients with a normal blood pressure but an elevated blood lactate, are at an even higher risk of mortality. Previous research has shown that EMS can lower blood lactate levels before hospital arrival, but no studies to date have looked at how prevalent cryptic sepsis is among EMS patients.
Hypothesis: The prevalence of cryptic septic shock in EMS patients will be less than 30% of the total number of patients in septic shock.
Methods: Paramedics were provided with, and given training on, the Lactate Pro LT-710 blood lactate meter by Arkray Inc. (Japan). This meter is FDA-approved and CLIA-waived, and it has shown a good correlation to hospital lactate tests. Between May 1, 2009, and Dec. 31, 2010, patients with suspected severe sepsis or septic shock underwent blood lactate readings by EMS. Patients with a lactate reading of ≥4.0 mg/dL were considered to be in cryptic septic shock regardless of their corresponding blood pressure.
Results: During the study period, 220 patients with confirmed severe sepsis or septic shock underwent blood lactate measurements by EMS. Out of the 220 patients, 94 (42.7%) had blood lactate levels ≥4.0 mg/dL in the absence of hypotension. Of the 126 patients who were hypotensive (57.3%), 35 (15.9%) also had a blood lactate level ≥4.0 mg/dL. Overall 58.3% of EMS patients with severe sepsis or septic shock had blood lactate readings ≥4.0 mg/dL.
Conclusions: Multiple studies have shown that the earlier patients in septic shock are identified, the lower the mortality rate. The ability of EMS to identify patients in cryptic septic shock before arrival at the hospital and thus initiate prehospitaltreatment might lead to lower mortality rates. Furthermore, EMS treatment might lower lactate levels unknowingly during transport. If this, occurs the treating physician will lose a vital clue as to the patient’s severity.

Cultural Competency in EMS
By Sean Kivlehan, MD, MPH, NREMT-P; & April M. Tantillo, MD, MPH
Introduction: EMS providers encounter challenging and unpredictable situations daily in which rapid assessments and actions need to be taken. This study will evaluate the frequency with which cultural, language and religious barriers are encountered in practice and whether these barriers are perceived to impede care.
Methods: A survey was distributed to EMS providers in a diverse suburban county of New York state. Responses were collected anonymously and compiled for analysis.
Results: A larger than expected number of providers responded of which only 68 met primary inclusion criteria based on practice setting. Of these, every respondent indicated experiencing difficulty in communicating with a patient due to language, cultural, racial, gender or religious differences, with language being the most common. Almost half (33; 48.5%) reported difficulty in more than one of these categories. Interestingly, more than 54 (80%) of respondents felt that their partner had exhibited biases while only 18 (27%) reported exhibiting biases themselves. A majority (52/ 76.4%) agreed that EMS providers would benefit from a program in cultural competency
Conclusion: This study identifies a need for cultural competency curriculum development and training in EMS . Further research is needed to externally validate these findings; however EMS managers and education providers should consider expanding existing cultural competency training and awareness.

Influence of Shift Duration on Psychomotor and Cognitive Abilities of Paramedics: A Comparison of 12 vs. 24 Hour Shifts
By Randy Hamm, BS, RN, NREMT-P; Michael Hubble, PhD, NREMT-P; Ashley Chapman, BS, NREMT-P; & Cleveland Johnson, BS, NREMT-P
Introduction: EMS systems use extended shifts to provide around-the-clock emergency service. Typical EMS shift patterns include 24-hour continuous and 12-hour rotating and nonrotating day/night shifts which could result in disrupted sleep. Sleep deprivation is associated with impaired cognitive and psychomotor function, as well as medical errors. Although this association has been explored among physicians and nurses, few studies have explored this relationship among EMS personnel.This study examines the differences in sleepiness and cognitive and psychomotor performance among 12-hour day, 12-hour night, and 24-hour shifts.
Methods: A convenience sample of EMS personnel completed a demographic survey and a series of validated measures immediately following a 24-hour (24HS), 12-hour dayshift (12DS), or 12-hour nightshift (12NS). A self-administered Stanford Sleepiness Scale measured the participant’s degree of sleepiness while the Stroop Color-Word Test (“Stroop Task”) measured cognition, and the Lafayette Instrument Grooved Pegboard Test measured psychomotor performance. Differences among the groups were evaluated using analysis of variance
Results: Sixty-eight EMS personnel participated including 14 12DS, 22 12NS, and 32 24HS personnel. Males accounted for 47% of the sample and the mean age, years of experience, and stated hours of sleep immediately before their shift were 38.2, 12.5, and 5.7, respectively, and were statistically equivalent among the three shifts. The Stanford Sleepiness Scale score was 2.6 (±1.6), 3.0 (±1.5), and 1.8 (±1.5) for the 12DS, 12NS, and 24HS groups, respectively (p=0.01). The Stroop Task score was 6.64 (±12.4), -2.09 (±10.4), and -4.8 (±16.9) (p=0.04) and the Grooved Pegboard Test time was 61.9 (±8.8), 75.9 (±23.4), and 76.4(±14.5) seconds (p=0.02) for the 12DS, 12NS, and 24HS groups, respectively.
Conclusion: Using the Stanford Sleepiness Scale, the research found that 24HS personnel reported being less sleepy than their 12DS and 12NS co-workers. Despite a lower self-rated level of sleepiness, 24HS personnel scored considerably lower than 12DS personnel on cognitive and psychomotor abilities and lower than 12-hour personnel on psychomotor skills. In addition, 12NS personnel scored considerably lower than 12DS personnel on the same performance measures. These results suggest that 12NS and 24HS personnel suffer declines in cognitive and psychomotor abilities, yet may not be fully aware of their level of impairment.

EMS Utilization in a Busy Urban Area: Demographics and Health Conditions of the Patient Population
By Dr. Amy Knowlton, ScD; Brian Weir, MS; Frank Hazzard, BS; Brenna Hughes BS; & Wade Gaasch, MD
Introduction: Understanding EMS utilization rates and health and demographic characteristics of EMS patient populations can guide more efficient and effective EMS operations, and inform preventive intervention.
Methods: This study reviewed Baltimore City Fire Department EMS dispatch and EMS electronic medical records in 2008 through 2010, and coded health-related EMR data as per Munjal et al’s NYC EMS study (2011).
Results: Per 1,000 residents in Baltimore, the study found a yearly average of 202 calls with dispatch, 143 patient contacts and 130 patient transports. By contrast, prior studies found that per 1,000 residents/year, New York City had an average 135 calls with patient contact and 100 transports; Washington, D.C., had 202 calls with contact and 129 transports; and Memphis, Tenn., had 109 contacts and 88 transports. Of the calls in Baltimore with patient contact, the study classified 6% as life threatening, 30% nonlife threatening emergencies, 62% nonemergent, and 1% not requiring medical attention. Compared to Baltimore residents, Baltimore patients were older, more likely to be male and black, and less likely to be white. Preliminary analysis indicated that of health issues, 71% were medical/surgical, 13% trauma and 17% other/unknown. By comparison, the prior study found New York City calls consisted of 66% medical/surgical, 30% trauma and 5% other/unknown. More refined codes indicated 12% of the Baltimore EMS calls were psychiatric or substance related, 10% cardiovascular, 8% respiratory, 7% altered mental state and 3% violent trauma. By comparison, NYC EMS had 10% psychiatric/substance related, 7% cardiovascular, 15% respiratory, 7% altered mental state and 2% violent trauma.
Conclusion: Baltimore’s rates of EMS utilization and patient transports are high compared to New York City and a city with similar demographics, and the transport rate was comparably high as Washington, D.C. A substantial proportion of calls do not result in patient contact, and the majority that do are nonemergent. Compared to New York City, Baltimore had higher proportions of medical/surgical-related calls, lower proportions of trauma- and respiratory-related calls, and fairly similar proportions of behavioral, altered mental state, and violent trauma related calls. Further research is needed to examine health and demographic factors associated with suboptimal use of EMS, and to explore potential approaches to public health interventions to address it.

This article originally appeared in March 2012 JEMS as “The Prehospital Care Research Forum Presents “¦ : Selected abstracts for presentation at the 30th annual EMS Today Conference & Exposition in Baltimore, Feb. 28—March 3, 2012.”

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