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Objective: Linking emergency medical services (EMS) data to hospital outcomes is important for quality assurance and research initiatives. However, non-linkage due to missing or incomplete patient information may increase the risk of bias and distort findings. The purpose of this study was to explore if an optimization strategy, in addition to an existing linkage process, improved the linkage rate and reduced selection and information bias. Methods: 4,150 transported patients in a metropolitan EMS system in Alberta, Canada from 2016/17 were linked to two Emergency Department (ED) databases by a standard strategy using a unique health care number, date/time of ED arrival, and hospital name. An optimized strategy added additional linkage steps incorporating last name, year of birth, and a manual search. The strategies were compared to assess the rate of linkage, and to describe event and patient-level characteristics of unlinked records. Results: The standard strategy resulted in 3,650 out of 4,150 (88.0%) linked records (95% CI 86.9%-88.9%). Of the 500 non-linked records, an additional 381 were linked by the optimized strategy (n = 4,031/4,150 [97.1%; 95% CI: 96.6%-97.6%]). There were no false positive linkages. The highest linkage failure was in 25 to 34 year-old patients (n = 93/478, 19.5%), males (n = 236/1975, 12.0%), Echo level events (n = 15/77, 19.5%), and emergency transport (45/231, 19.5%). The optimized strategy improved linkage in these groups by 68.8% (64/93), 79.2% (187/236), 40.0% (6/15), and 51.1% (23/45) respectively. For dispatch card, the highest linkage failure occurred in Card 24-Pregnancy/Childbirth/Miscarriage (n = 30/44, 68.2%), Card 27-Stab/Gunshot/Penetrating Trauma (n = 6/17, 35.3%), and Card 9-Cardiac/Respiratory Arrest/Death (n = 12/46, 26.1%). The optimized strategy improved linkage by 10.0% (3/30), 83.3% (5/6), and 41.7% (5/12) respectively. For the 119 unlinked records, 71 (59.7%) had sufficient information for linkage, but no appropriately matching records could be found. Conclusion: An optimized sequential deterministic strategy linking EMS data to ED outcomes improved the linkage rate without increasing the number of false positive links, and reduced the potential for bias. Even with adequate information, some records were not linked to their ED visit. This study underscores the importance of understanding how data are linked to hospital outcomes in EMS research and the potential for bias. [ABSTRACT FROM AUTHOR]

Introduction: The quality of an Emergency Medical Technician (EMT) or paramedic training program is likely one factor that contributes to a candidate's success on the National Registry Cognitive Examination. However, program pass rates and their associated geographic location have not previously been evaluated. Our objective was to evaluate the performance of EMT and paramedic programs in the United States, pass rates on the National Registry Cognitive Examinations, and relationship to geography. Methods: We conducted a cross-sectional evaluation of EMT and paramedic programs' first and cumulative third attempt pass rates on the National Registry Cognitive Examination in 2015. Included were civilian EMT and paramedic programs with >5 graduates testing for certification. Descriptive statistics were calculated for program pass rates, total graduates testing, and pass rates by National Association of State EMS Officials (NASEMSO) regions. Results: We included 1,939 EMT programs (6–1,892 graduates testing/program) and 602 paramedic programs (6–689 graduates testing/program). We excluded 262 (11.9%) EMT and 51 (7.8%) paramedic programs with ≤5 graduates testing annually due to unstable estimates of program pass rates. EMT programs in the highest quartile for total number of graduates testing outperformed the lowest quartile in both first attempt (65.7% vs. 61.9%, p < 0.001) and cumulative third attempt pass rates (79.1% vs 72.7%, p < 0.001). This difference was also seen for paramedic programs on first attempt (77.3% vs. 62.5%, p < 0.001) and cumulative third attempt (91.9% vs. 76.9%, p < 0.001). EMT program pass rates for first and cumulative third attempts also varied by NASEMSO region (first: 62–68%; third: 74–78%) with the Great Lakes and West regions outperforming the other regions. Paramedic program pass rates differed by NASEMSO regions as well (first: 65–83%; third: 81–95%) with highest pass rates in the West region. Conclusions Program performance for both EMT and paramedic programs varies by total number of graduates testing and geographic location. Graduates from larger EMT and paramedic programs have higher first and cumulative third attempt pass rates compared to graduates from smaller programs. Additionally, there is variability in program pass rates across NASEMSO regions for both certification levels. Further evaluation is necessary to better understand the variability in program performance in the United States. [ABSTRACT FROM AUTHOR]

Introduction: Compassion fatigue (CF) is defined as the acute or gradual loss of benevolence that occurs after exposure to critical incident stress. Colloquially referred to as the "cost of caring," CF can affect an individual's future response to stressful situations and is unhealthy for caregivers. Objective: To identify the prevalence and predictors of CF in EMS professionals. Methods: This was a cross-sectional survey of EMS personnel using one-stage area sampling. Nine EMS agencies recruited based on location and geographic region provided data on service area and call mix. Respondents were surveyed in-person during monthly training. The survey evaluated the relationship between CF and psychosocial factors using the Professional Quality of Life Scale (ProQOL). Parametric and non-parametric tests were used where appropriate for the univariate analysis. Those factors significant in the univariate analysis were included in the multivariable analysis. A logistic regression was conducted to determine predictors of CF while controlling for potential confounders. Results: A total of 686 EMS personnel completed the survey. Altogether, 48% had CF, of which 50.8% were male and 14% were minorities. Compared to those without CF, more than 4 times as many respondents with CF (n = 28[8.6%] v. 7[2.0%]) self-reported as currently in counseling and over a third (n = 109[33.1%]) had considered suicide. Irrespective of the presence of CF, one in two knew another EMS professional who had completed suicide. African-American EMS professionals were 3 times more likely to have CF (OR:3.1;p = 0.009). Mean scores on the ProQOL CF subscale were 10 points higher in those with CF compared to those without (27.1[±4.34] v. 17.04[±2.9]). EMS personnel were 48% more likely to have CF if they knew an EMS provider who completed suicide (p = 0.047). Additionally, those with concomitant traumatic stress syndromes, such as vicarious trauma and burnout, were 4.61 and 3.35 times more likely to have CF, respectively. Conclusions: CF is a considerable concern for EMS professionals and there are several modifiable factors that may reduce the prevalence of this cumulative stress syndrome. Additional research should focus on causal factors and mitigation strategies, as well as the individual and agency impact of CF on the prehospital work environment. [ABSTRACT FROM AUTHOR]

Objective: Shift work is an established risk factor for weight gain, cardiovascular disease, Type II diabetes mellitus, and impaired health-related quality of life (HRQoL). Prolonged exposure to shift work is common in paramedics and other emergency medical service (EMS) providers. Sub-populations of EMS workers may have varying health outcomes when exposed to shift work, but the reasons for this have not been investigated. We sought to describe cardiometabolic health, dietary patterns, physical activity, and health-related quality of life (HRQoL) in a sample of experienced intensive care flight paramedics (ICFPs) working for a Helicopter Emergency Medical Service (HEMS). Methods: Fifteen paramedics (median age 45, IQR 42–48 years) were recruited to undertake a range of health assessments. These included a food frequency questionnaire to assess dietary patterns, sampling of biomarkers to determine cardiometabolic health risk, maximal aerobic capacity assessment via treadmill running and assessment of HRQoL via the SF-36 survey. In an extension of the study protocol, ten of the fifteen participants wore a physical activity monitor for one year. Results: Median (IQR) weight was 79.9 (72.3–89.3) kg, body fat percentage 23.3 (21.9–26.5) %, body mass index (BMI) 25.1 (21.9–27.4) kg.m2, and waist to height ratio 0.48 (0.45–0.54). Dietary analyses showed high discretionary food intake. Biomarkers of cardiometabolic health risk were all within normal range. HRQoL was 86.2/100 for physical health and 85.1/100 for mental health. V̇O2max was 47.0 (43.0–54.6) mL.kg−1.min−1. The ten participants that wore activity monitors completed 11,235 (8334–15,380) steps per day and undertook 50 (12–98) minutes per day/350 (84–686) minutes per week of moderate to vigorous physical activity. The least amount of physical activity was conducted on day shifts. Conclusions: For ICFPs included in this study, HRQoL, cardiometabolic and physical activity outcomes are representative of good health. Although shift work influences the amount of physical activity, ICFPs exceeded minimum recommendations even when rostered to duty. Despite lengthy careers in EMS, ICFPs demonstrate an excellent health profile that is likely due to high physical activity levels and healthy BMI. This information may be useful in guiding health interventions in the wider EMS workforce. [ABSTRACT FROM AUTHOR]

Background: The EMS Practice Analysis provides a vision of current prehospital care by defining the work performed by EMS professionals. In this manuscript, we present the National Advanced Life Support (ALS) EMS Practice Analysis for the advanced EMT (AEMT) and paramedic levels of certification. The goal of the 2019 EMS Practice Analysis is to define the work performed by EMS professionals and present a new template for future practice analyses. Methods: The project was executed in three phases. Phase 1 defined the types/frequency of EMS clinical presentations using the 2016 National Emergency Medical Services Information System (NEMSIS) dataset. Phase 2 defined the criticality or potential for harm of these clinical presentations through a survey of a random sample of nationally certified EMS professionals and medical directors. Phase 3 defined the tasks and the associated knowledge, skills, and abilities (KSA) that encompass EMS care through focus groups of subject matter experts. Results: In Phase 1, the most common EMS adult impressions were traumatic injury, abdominal pain/problems, respiratory distress/arrest, behavioral/psychiatric disorder, and syncope/fainting. The most common pediatric impressions were traumatic injury, behavioral/psychiatric disorder, respiratory distress/arrest, seizure, and abdominal pain/problems. Criticality was defined in Phase 2 with the highest risk of harm for adults being airway obstruction, respiratory distress/arrest, cardiac arrest, hypovolemia/shock, allergic reaction, or stroke/CVA. In comparison, pediatric patients presenting with airway obstruction, respiratory distress/arrest, cardiac arrest, hypovolemia/shock, allergic reaction, stroke/CVA, and inhalation injury had the highest potential for harm. Finally, in Phase 3, task statements were generated for both paramedic and AEMT certification levels. A total of 425 tasks and 1,734 KSAs were defined for the paramedic level and 405 tasks and 1,636 KSAs were defined for the AEMT level. Conclusion: The 2019 ALS Practice Analysis describes prehospital practice at the AEMT and paramedic levels. This approach allows for a detailed and robust evaluation of EMS care while focusing on each task conducted at each level of certification in EMS. The data can be leveraged to inform the scope of practice, educational standards, and assist in validating the ALS levels of the certification examination. [ABSTRACT FROM AUTHOR]

Background: The geographic distribution and access to paramedic education programs is unclear but often cited as a reason for emergency medical services (EMS) workforce shortages. Our aims were: 1) to examine the spatial distribution of accredited paramedic programs and 2) to compare characteristics of communities with and without existing programs. Methods: We performed a cross-sectional study of US paramedic education programs accredited by the Commission on Accreditation of Allied Health Education Programs as of April 2020. Program locations were geocoded to county, and population estimates from the US Census Bureau were used to determine the adult population within the program's potential catchment area (30, 50, and 100 miles). Clustering of programs was examined using Moran's I. We compared community characteristics obtained from the 2018 American Community Survey, 2018–2019 Area Health Resources Files, and 2018 National Emergency Department Inventory between counties with and without programs. Logistic regression models were used to determine associations of community characteristics and existence of a paramedic program, controlling for urbanicity. Results: There were 790 paramedic program locations in the US, located in 596/3142 (19%) counties. Every state, except Rhode Island and Washington, DC, had at least one paramedic program site. The population within potential catchment areas ranged from 182 million (30 miles) to 248 million (100 miles), representing 73% to 99% of the US adult population, respectively. However, among counties classified as rural (n = 644), this decreased to 22% (30 miles) to 95% (100 miles). There was significant clustering of programs (p < 0.001). There were significantly higher odds of having a paramedic program for counties classified as metro compared to non-metro (OR 4.42, 95% CI 3.60–5.42) and with the presence of healthcare resources (e.g., emergency department in the county: OR 2.42, 95% CI 1.87–3.14). Conclusions: Approximately 73% of the US adult population lives within 30 miles of an existing paramedic education program; however, this decreases to 22% in rural areas. Geographic barriers to accessing paramedic education remain a challenge for ongoing efforts to address the rural EMS workforce shortage. [ABSTRACT FROM AUTHOR]

Primary postpartum hemorrhage (PPH) is a life-threatening obstetric emergency that can be mitigated through the administration of a uterotonic to actively manage the third stage of labor. This study describes the prehospital administration of oxytocin by paramedics following attendance of out-of-hospital (OOH) births. A retrospective analysis was undertaken of all OOH births between the 1st January 2018 and 31st December 2018 attended by the Queensland Ambulance Service. The demographic and epidemiological characteristics of patients that were administered oxytocin and the occurrence of adverse side effects were described. In total, 350 OOH births were included in this study with the majority involving multigravidas women (94.3%) and all but two involving singleton pregnancies. Oxytocin was administered following 222 births (63.4%), while 67 patients (19.1%) declined administration preferring a physiological third stage of labor, and in 61 cases (17.4%) oxytocin was withheld by the attending paramedic. There were no documented adverse events or side effects following administration. Oxytocin administration occurred on average 14 minutes (interquartile range 9-25) following the time of birth. The median time from oxytocin administration to placenta delivery was 10 minutes (interquartile range 5-22). Oxytocin is well accepted and safe treatment adjunct for the management of the third stage of labor in OOH births and should be considered for routine practice by other emergency medical services. [ABSTRACT FROM AUTHOR]

Background: For those patients who receive fibrinolysis in the treatment of ST-elevation myocardial infarction (STEMI), early treatment, i.e., within 2 hours of symptom onset, confers the greatest clinical benefit. This rationale underpins paramedic-delivered fibrinolysis in the prehospital setting. However, the current New Zealand approach requiring paramedics to first gain physician authorization, has proved inefficient and time consuming, particularly due to technological failings. Therefore, this study aimed to trial a new autonomous paramedic-delivered fibrinolysis model, examining the impact on time-to-treatment, paramedic diagnostic accuracy and patient outcomes. Methods: Utilizing a prospective observational approach, over a 24-month period, paramedics identified patients with a clinical presentation and electrocardiogram features consistent with STEMI, and initiated fibrinolysis. These patients were compared to a historic cohort who received fibrinolysis by paramedics within the same regions but following physician authorization. The main outcome measures were pain-to-needle (PTN) time and accuracy of paramedic diagnosis. A secondary end-point was 30-day and 6-month mortality and hospital length of stay (LOS). Results: A total of 174 patients received fibrinolysis (mean age, 64 years, SD ± 11.2). Median PTN time was 87 minutes (IQR = 58) for the historic cohort (n = 96), versus 65 minutes (IQR = 31) for the experimental cohort (n = 78), (p = 0.007). Autonomous paramedic diagnosis showed a sensitivity of 96% (95% CI 89–99) and specificity of 91% (95% CI 76–98). A significant reduction in both 30-day mortality and hospital LOS was observed among the experimental cohort (p = 0.04 and <0.001, respectively). No significant difference was observed between groups in terms of 6-month mortality. Conclusions: Prehospital fibrinolysis provided autonomously by paramedics without direct physician oversight is safe and feasible. Moreover, this independent approach can significantly improve time-to-treatment, resulting in short term mortality benefit and reduced hospital LOS. [ABSTRACT FROM AUTHOR]

Background: The endotracheal tube (ETT) is considered the gold standard in emergency airway management, although supraglottic airway devices, especially the laryngeal tube (LT), have recently gained in importance. Although regarded as an emergency device in case of failure of endotracheal intubation in most systems, we investigated the dynamics of the use of the LT in a metropolitan ambulance service without any regulations on the choice of airway device. Methods: A retrospective, observational study on all patients from the Municipal Ambulance Service, Vienna in need of advanced airway management over a 5-year period. Differences between years were compared; influencing factors for the use of the LT were analyzed using multivariable logistic regression. Results: In total 5,175 patients (mean age 62 ± 20 years, 36.6% female) underwent advanced airway management. Of these, 15.6% received the LT. LT use increased from 20 out of 1,001 (2.0%) in 2009 to 292 of 1,085 (26.9%) in 2013 (p < 0.001). The increase between each consecutive year was also significant. Paramedics more frequently inserted the LT than physicians (RR 1.80 (95%CI 1.48–2.16); p < 0.001). Female patients received a LT less frequently (RR 0.84 (95%CI 0.72–0.97), p = 0.013). There was no difference regarding airway device due to underlying causes requiring airway management and no relationship to the NACA-score. Conclusion: In a European EMS system of physician and paramedic response, the proportion of airway managed by LT over ETT rose considerably over five years. Although the ET is still the gold standard, the LT is gaining in importance for EMS physicians and paramedics. [ABSTRACT FROM AUTHOR]

Objective: Previous research indicates that 9-1-1 response to incidents involving children is particularly distressing for emergency medical services (EMS) clinicians. This qualitative study was conducted to increase understanding about the difficulties of responding to pediatric calls and to obtain information about how organizations can better support EMS providers in managing potentially difficult calls. Methods: Paramedics and emergency medical technicians from a single U.S. ambulance service were invited to participate in focus groups about responding to 9-1-1 calls involving pediatric patients. A total of 17 providers from both rural and metro service regions participated in six focus groups held in community meeting spaces. A semi-structured focus group guide was used to explore (1) elements that make pediatric calls difficult, (2) pre-arrival preparation practices, (3) experiences with coping after difficult pediatric calls, and (4) perspectives about offered and desired resources or support. Focus groups were audio recorded and transcripts were analyzed using standard coding, memoing, and content analysis methods in qualitative analysis software (NVivo). Results: Responses about elements that make pediatric calls difficult were organized into the following themes: (1) special social value of children, (2) clinical difficulties with pediatric patients, (3) added acuity to already challenging calls, (4) caregivers as secondary patient, and (5) identifying with patient or patient's family. Pre-arrival preparation methods included mental or verbal review of hypothetical scenarios and refocusing nerves or emotions back to the technical aspect of the job. Participants described using available resources that largely took the form of social support. Suggestions for additional resources included: increased opportunities for external feedback; more frequent pediatric clinical training; institutionalization of recovery time after difficult calls; and improved storage and labeling of pediatric equipment. Conclusions: This study provides qualitative data about the difficulties of responding to pediatric calls and resources needed to support clinicians. Findings from this study can be used to guide EMS leaders in designing and implementing institutional initiatives to enhance training and support for prehospital clinicians providing care to children. [ABSTRACT FROM AUTHOR]

The National Association of EMS Educators, the National EMS Management Association, and the International Association of Flight and Critical Care Paramedics believe the time has come for paramedics to be trained through a formal education process that culminates with an associate degree. Once implemented a degree requirement will improve the care delivered by paramedics and enhance paramedicine as a heath profession. [ABSTRACT FROM AUTHOR]

Background: In 2016, nearly 45,000 deaths in the United States were attributed to suicide making this the 10th leading cause of death for all ages. National survey data suggest that among Emergency Medical Technicians (EMTs), including firefighters and Paramedics, rates of suicide are significantly higher than among the general public. EMTs face high levels of acute and chronic stress as well as high rates of depression and substance abuse, which increase their risk of suicide. Objective/Aim: To determine the statewide Mortality Odds Ratio (MOR) of suicide completion among EMTs as compared to non-EMTs in Arizona. Methods: We analyzed the Arizona Vital Statistics Information Management System Electronic Death Registry of all adult (≥18) deaths between January 1, 2009 and December 31, 2015. Manual review of decedent occupation was performed to identify the EMT cohort; all other deaths were included in the non-EMT cohort. Using the underlying cause of death as the outcome, we calculated the MOR of both the EMT and non-EMT cohorts. Results: There were a total of 350,998 deaths during the study period with 7,838 categorized as suicide. The proportion of deaths attributed to suicide among EMTs was 5.2% (63 of 1,205 total deaths) while the percentage among non-EMTs was 2.2% (7,775/349,793) (p < 0.0001). The crude Mortality Odds Ratio for EMTs compared with non-EMTs was [cMOR 2.43; 95% CI (1.88–3.13)]. After adjusting for gender, age, race, and ethnicity, EMTs had higher odds that their death was by suicide than non-EMTs [aMOR: 1.39; 95% CI (1.06–1.82)]. Conclusion: In this statewide analysis, we found that EMTs had a significantly higher Mortality Odds Ratio due to suicide compared to non-EMTs. Further research is necessary to identify the underlying causes of suicide among EMTs and to develop effective prevention strategies. [ABSTRACT FROM AUTHOR]

Background: Incivility, defined as negative interpersonal acts that violate workplace and social norms, has been linked to negative outcomes in healthcare settings. A minimal amount is known regarding workplace incivility among emergency medical services (EMS) professionals. Our objectives were to (1) evaluate the prevalence of incivility and factors associated with experiencing workplace incivility; (2) describe the association between incivility and workforce-reducing factors (stress, career satisfaction, turnover intentions, and workplace absences); and (3) quantify the association between incivility and the organizational culture of an EMS agency. Methods: A random sample of 38,000 nationally-certified EMS professionals received an electronic questionnaire with an EMS-adapted Workplace Incivility Scale, the Competing Values Framework organizational culture scale, and factors that may negatively impact the EMS workforce. All completed surveys from nonmilitary EMS professionals currently providing patient care at the EMT level or higher were included in these analyses. We constructed multivariable logistic regression models (OR, 95% CI) to identify factors associated with experiencing workplace incivility and to examine the associations between experiencing incivility and workforce-reducing factors. We calculated univariable odds ratios to assess the association between organizational culture type and incivility. Results: A total of 3,741 EMS professionals responded to the survey (response rate =10.3%), with 2,815 (75.2%) meeting inclusion criteria. Incivility from supervisors or coworkers was experienced at least once a week by 47.4% of respondents. Factors associated with increased odds of experiencing incivility included female sex, AEMT/paramedic certification level, increasing years of EMS experience, service types other than 9-1-1 response, and higher weekly call volumes. Exposure to regular incivility was associated with increased odds of dissatisfaction with EMS, a main EMS job or a main supervisor; moderate or higher stress levels; intent to leave one's job and EMS in the next 12 months; and 10 or more workplace absences in the past 12 months. The organizational culture type "market" was associated with the greatest odds of incivility. Conclusions: Nearly half of respondents experienced incivility once a week or more, and incivility was associated with potential workforce-reducing factors. Further research is needed to understand how organizational climate and interpersonal behaviors in the workplace affect the EMS workforce. [ABSTRACT FROM AUTHOR]

Background: A minimal amount of research exists examining the extent to which patient safety events occur within paramedicine and even fewer studies investigating patient safety systems for self-reporting by paramedics. The purpose of this study was to identify barriers to paramedic self-reporting of patient safety incidents (PSIs). Methods: We randomly distributed paper-based surveys among 1,153 paramedics in an Ontario region in Canada. The survey described one of 5 different PSI clinical scenarios (near miss, adverse event, and minor, major or critical patient care variances) and listed 18 potential barriers to self-reporting PSIs as statements presented for rating on a 5-point Likert scale (very significant = 1 - very insignificant = 5). We invited comments on PSI self-reporting with 2 open-ended questions. We analyzed data with descriptive statistics, chi-square tests and Kruskal-Wallis H test. We used an inductive approach to qualitatively analyze emerging themes. Results: We received responses from 1,133 paramedics (98.3%). Almost one third (28.4%) were Advanced Care Paramedics and 45.1% had >10 years' experience. The top 5 barriers to PSI self-reporting (very significant or significant, %) were the fear of being: punished (81.4%), suspended (79.6%), terminated (79.1%), investigated by Ministry of Health and Long-Term Care (78.4%), and decertified (78.0%). Overall, 64.1% responded they would self-report a given PSI. Intention to self-report a PSI varied according to scenario (22.8% near miss, 46.6% adverse event, 74.4% minor, 92.6% major, 95.6% critical). No association was found between level of training (p = 0.55) or years of experience (p = 0.10) and intention to self-report a PSI. Seven themes to improve PSI self-reporting by paramedics emerged from the qualitative data. Conclusions: A high proportion of fear-based barriers to self-reporting of PSIs exist among this study population. This suggests that a culture change is needed to facilitate the identification of future patient safety threats. [ABSTRACT FROM AUTHOR]

Objective: Strokes are a leading cause of morbidity and mortality in the United States, especially in the “stroke belt” of the southeast. Up to 65% of stroke patients access care by calling 9-1-1. The primary objective of this study is to measure the accuracy of emergency medical dispatchers (EMD) and paramedics, in the prehospital identification of stroke. Methods: The study was based at Grady Emergency Medical Services, which is Atlanta, Georgia's public emergency medical services (EMS) provider. A retrospective analysis of all medically related 9-1-1 calls to Grady EMS classified as “stroke” between January 1, 2012, and December 31, 2012 was performed. A database was created using deterministic linkage between records from Grady EMS, Grady Hospital Emergency Department (ED), and the Grady Hospital Stroke Registry. Patients excluded were less than 18 years of age, had previous or concurrent head injuries, were transferred from another inpatient facility, and/or had incomplete patient records in any one of the three databases. Descriptive analysis, linear regression, and logistic multivariable regression were performed to discover the accuracy of stroke identification and contributory prehospital factors. Results: A total of 548 patients were included: 475 were transported with EMS impression of stroke and 73 with an impression other than stroke. The median age was 59 years, 87.4% were black, and 52.6% were female. Paramedics adhered to all seven elements of the Grady EMS stroke protocol in 76.4% (n = 363) of suspected stroke cases. Sensitivity and positive predictive value for paramedic stroke identification was 76.2% and 49.3%, respectively, and for EMD, was 48.9% and 24%, respectively. Identification of hemorrhagic strokes had a relatively lower sensitivity. Paramedics were more likely to positively identify strokes when the Cincinnati Prehospital Stroke Scale (CPSS) screen was positive, or when classified by EMD as stroke. Paramedics were less likely to identify stroke in female patients. Paramedics' diagnostic accuracy was similar regardless of their adherence to the EMS stroke care protocol. Conclusions: EMD and EMS personnel in a large city in the Southeastern United States, with high stroke prevalence, had a relatively high sensitivity in identifying acute stroke patients. Paramedic accuracy was augmented by positive CPSS screening and by EMD recognition of stroke. [ABSTRACT FROM AUTHOR]

Objective: Outcomes of Out-of-Hospital Cardiac Arrest (OHCA) are influenced by many factors. We postulate that paramedics who have participated in a greater number of OHCA resuscitations will have improved patient outcomes when compared to paramedics who participated in fewer resuscitations. Methods: We conducted a retrospective analysis of prospectively collected data abstracted from the cardiac arrest database of a large urban EMS system. All OHCA cases where resuscitation was attempted during the year 2014 were reviewed. Our outcome of interest was the rate of sustained Return of Spontaneous Circulation (ROSC), which is defined as ROSC for five continuous minutes or greater. The rate of sustained ROSC was calculated from cases when paramedics served in the role of the lead medic. These rates were then analyzed using the Chi-Square test. Results: A total of 1,145 cases of OHCA met criteria for inclusion in this study, of which 343 paramedics participated in at least one cardiac arrest in 2014. The median number of resuscitations was 10 with a range from 1 to 26 resuscitations. The paramedics were dichotomized into two groups; those who participated in <10 OHCAs (120/343), labeled “less experienced,” and those who participated in ≥10 OHCAs (223/343), labeled “more experienced.” Paramedics in the less experienced group had a sustained ROSC rate of 22.2% for resuscitations in which they were the lead medic, while those in the more experienced group had a rate of 28.9% (p-value = 0.047), RR 1.30 (95% CI 1.001, 1.692). Conclusions: This study demonstrated that more experienced paramedics had a statistically significant increase in achieving sustained ROSC when they were functioning in a lead role compared to less experienced paramedics. We found no other clinically significant patient outcomes related to the provider's experience. [ABSTRACT FROM AUTHOR]

Background: When working in a tactical environment there are several different airway management options that exist. One published manuscript suggests that when compared to endotracheal intubation, the King LT laryngotracheal airway (KA) device minimizes time to successful tube placement and minimizes exposure in a tactical environment. However, comparison of two different blind insertion supraglottic airway devices in a tactical environment has not been performed. This study compared the I-Gel airway (IGA) to the KA in a simulated tactical environment, to determine if one device is superior in minimizing exposure and minimizing time to successful tube placement. Methods: This prospective randomized cross over trial was performed using the same methods and tactical environment employed in a previously published study, which compared endotracheal intubation versus the KA in a tactical environment. The tactical environment was simulated with a one-foot vertical barrier. The participants were paramedic students who wore an Advanced Combat Helmet (ACH) and a ballistic vest (IIIA) during the study. Participants were then randomized to perform tactical airway management on an airway manikin with either the KA or the IGA, and then again using the alternate device. The participants performed a low military type crawl and remained in this low position during each tube placement. We evaluated the time to successful tube placement between the IGA and KA. During attempts, participants were videotaped to monitor their height exposure above the barrier. Following completion, participants were asked which airway device they preferred. Data was analyzed using Student's t-test across the groups for time to ventilation and height of exposure. Results: In total 19 paramedic students who were already at the basic EMT level participated. Time to successful placement for the KA was 39.7 seconds (95%CI: 32.7-46.7) versus 14.4 seconds (95%CI: 12.0-16.9) for the IGA, p < 0.001. Maximum height exposure of the helmet above a one foot vertical barrier for the KA resulted in 1.42 inches of exposure (95%CI: 0.38-0.63) compared to the IGA with 1.42 inches, 95%CI:0.32-0.74, p = 0.99. On questioning 100% of the participants preferred the IGA device over the KA. Conclusion: In a simulated tactical environment placement of the IGA for airway management was faster than with the KA, but there was no difference in regard to exposure. Additionally, all the participants preferred using the IGA device over the KA. [ABSTRACT FROM AUTHOR]

Objective: Physiologic alterations during rapid sequence intubation (RSI) have been studied in several emergency airway management settings, but few data exist to describe physiologic alterations during prehospital RSI performed by ground-based paramedics. To address this evidence gap and provide guidance for future quality improvement initiatives in our EMS system, we collected electronic monitoring data to evaluate peri-intubation vital signs changes occurring during prehospital RSI. Methods: Electronic patient monitor data files from cases in which paramedic RSI was attempted were prospectively collected over a 15-month study period to supplement the standard EMS patient care documentation. Cases were analyzed to identify peri-intubation changes in oxygen saturation, heart rate, and blood pressure. Results: Data from 134 RSI cases were available for analysis. Paramedic-assigned prehospital diagnostic impression categories included neurologic (42%), respiratory (26%), toxicologic (22%), trauma (9%), and cardiac (1%). The overall intubation success rate (95%) and first-attempt success rate (82%) did not differ across diagnostic impression categories. Peri-intubation desaturation (SpO2 decrease to below 90%) occurred in 43% of cases, and 70% of desaturation episodes occurred on first-attempt success. The incidence of desaturation varied among patient categories, with a respiratory diagnostic impression associated with more frequent, more severe, and more prolonged desaturations, as well as a higher incidence of accompanying cardiovascular instability. Bradycardia (HR decrease to below 60 bpm) occurred in 13% of cases, and 60% of bradycardia episodes occurred on first-attempt success. Hypotension (systolic blood pressure decrease to below 90 mmHg) occurred in 7% of cases, and 63% of hypotension episodes occurred on first-attempt success. Peri-intubation cardiac arrest occurred in 2 cases, one of which was on first-attempt success. Only 11% of desaturations and no instances of bradycardia were reflected in the standard EMS patient care documentation. Conclusions: In this study, the majority of peri-intubation physiologic alterations occurred on first-attempt success, highlighting that first-attempt success is an incomplete and potentially deceptive measure of intubation quality. Supplementing the standard patient care documentation with electronic monitoring data can identify unrecognized physiologic instability during prehospital RSI and provide valuable guidance for quality improvement interventions. [ABSTRACT FROM AUTHOR]

Background: Intimate partner violence (IPV) refers to abuse transpiring between people in an intimate relationship. Intimate partner violence is a leading cause of morbidity and mortality for women that paramedics frequently report encountering and yet paramedics rarely receive formal education or training to manage. The response of paramedics to IPV is likely to be directed by their individual knowledge, attitudes, and preparedness; all of which are currently unknown. This study aimed to measure paramedic students' knowledge, attitudes, and preparedness tomanage IPV patients, and provides baseline data to inform the development of contemporary curricula. Methods: We surveyed a cohort of paramedic students from two Australian universities using the Modified Physician REadiness to Manage Intimate partner violence Survey (PREMIS). Internal consistency of previously identified scales was calculated and multiple linear regression was used to measure the association between previous training, knowledge, attitudes, and preparation. Results: We received 260 surveys (80.5% response rate). Results show that actual knowledge, perceived knowledge, and preparedness to manage IPV patients were low. Students with previous training reported higher perceived knowledge (p < .05) and preparedness (p < .01). Participants reported low self-efficacy, confidence, and preparation to manage IPV patients and demonstrated mostly neutral attitudes toward women and patients. Conclusions: Results indicate students require increased IPV education. Education should improve knowledge and preparedness to recognize and refer IPV patients, as well as change neutral and inappropriate attitudes. Incorporating such education and training into the paramedic curricula may improve the preparedness of practitioners, resulting in an improved response to IPV patients. [ABSTRACT FROM AUTHOR]

Introduction: Rapid sequence intubation (RSI) is not only used in traumatic brain injuries in the out-of-hospital setting, but also for non-traumatic brain pathologies (NTBP) such as brain tumors, meningitis, encephalitis, hypoxic/anoxic brain injury, stroke, arteriovenous malformations, tumors, aneurysms, brain hemorrhage, as well as brain injury due to diabetes, seizures and toxicity, metabolic conditions, and alcohol and drug overdose. Previous research suggests that RSI is common in non-traumatic coma, but with an unknown prevalence of NTBP in those that receive RSI. If NTBP is common and if brain trauma RSI evidence is not valid for NTBP then a sizable proportion of NTBP receive this treatment without evidence of benefit. This study calculated the outof- hospital NTBP prevalence in patients that had received RSI and explored factors that predicted survival. Methods: A retrospective cohort study based on data collected from an ambulance service and seven hospitals based in Melbourne, Australia. Non-traumatic brain pathologieswere defined using ICD10-AM codes for the calculation of NTBP prevalence. Logistic regression modelled out-of-hospital predictors of survival to hospital discharge after adjustment for comorbidities. Results: The seven participating hospitals treated 2,277 patients that received paramedic RSI for all illnesses and indications from January 1, 2008 to December 31, 2015, with survival data available for 1,940 (85%). Of the 1,940, 1,125 (58%) patients had at least one hospitaldiagnosed NTBP. Sixty-nine percent all of NTBP survived to hospital discharge, compared to 65% for traumatic intracranial injury. Strokes were the most common and had poor survival to discharge (37%) compared to the second most common NTBP toxicity/toxic encephalopathy that had very high survival (98%). No out-of-hospital clinical intervention or prehospital time interval predicted survival. Factors that did predict survival include Glasgow Coma Scale (GCS), duration of mechanical ventilation, age, ICU length of stay, and comorbidities. Conclusions: Non-traumatic brain pathologies are seven times more prevalent than traumatic brain injuries in patients that underwent out-of-hospital RSI in Victoria, Australia. Since the mechanisms through which RSI impacts mortality might differ between traumatic brain injuries and NTBP, and given that NTBP is very prevalent, it follows that the use of RSI in NTBP could be unsupported. [ABSTRACT FROM AUTHOR]

Objectives: Emergency departments (ED) continue to be overburdened, leading to crowding and elevated risk of negative clinical outcomes. Extending clinical services to paramedics may support efforts to improve ED burdens by promoting health care access and capacity during times of patient crisis. The objective of this study was to identify the clinical course and most responsible diagnosis of patients transported by paramedic services to local EDs to then evaluate impact of various augmented 9-1-1/paramedic clinical service models on the need for additional ED services. Methods: A retrospective cohort and model-simulation based study. We retrieved clinical data from hospital records for a random selection of 3,000 patients who engaged 9-1- 1/paramedic services and were transported to a regional ED to identify their clinical course (interventions, diagnostics) disposition and most responsible admitting/discharge diagnosis. We used this data to establish, simulate and test numerous paramedic service models on the need for ED services. Results: A random selection of 3,000 patients was reviewed across 3 hospitals. The majority were female (57.2%) with a mean age of 65 (SD = 21.3). The majority (n = 1954; 65.1%) were discharged directly from ED of which 3.6% (n = 108) received no intervention or diagnostic, 20.4% (n = 611) received only a diagnostic, 4.8% (n = 143) received only an intervention and 36.4% (n = 1092) received both an intervention and diagnostic. The proportion of nonadmitted patients rose to 82.2% and 77.2% when considering lower priority patients and age greater than 65, respectively. Patient types were identified based on frequency and association with discharge directly from ED. Twelve simulated augmented paramedic clinical service models are reported with estimated gains in the number of patients who may no longer require ED services ranging from 7.5% (n = 146) to 35.4% (n = 691). Conclusions: This study suggests a reduction in need for ED services may be achieved through innovative models of paramedic services at the time of crisis. Identifying and confirming patient types/events to target and clinical services to include in the model requires ongoing investigation. Future research will be needed to evaluate the accuracy and impact of the models presented. [ABSTRACT FROM AUTHOR]

Background: High quality cardiopulmonary resuscitation (CPR) has produced a relatively new phenomenon of consciousness in patients with vital signs absent. Further research is necessary to produce a viable treatment strategy during and post resuscitation.Objective: To provide a case study done by paramedics in the field illustrating the need for sedation in a patient whose presentation was consistent with CPR induced consciousness. Resuscitative challenges are provided as well as potential future treatment options to minimize harm to both patients and prehospital providers.Case Report: A 52-year-old male presented as a witnessed out-of-hospital cardiac arrest (OHCA). During CPR the patient began to exhibit signs of life including severe agitation and thrashing of his limbs while CPR was ongoing for ventricular fibrillation prior to defibrillation. Resuscitation became considerably more complicated due to the violent and counterintuitive motions done by the patient during their own resuscitation. Despite the atypical presentation of cardiac arrest the patient was successfully resuscitated employing high quality CPR, standard advanced life support (ALS) care as well as two double sequential external defibrillation shocks. The patient underwent emergency percutaneous coronary intervention (PCI) for a 100% occlusion of his left anterior descending artery (LAD). The patient returned home 3 days later fully recovered with a Cerebral Performance Score of 1.Conclusion: CPR induced consciousness is emerging as a new phenomenon challenging providers of high quality CPR during cardiac arrest resuscitation. Our case report describes the manifestations of CPR induced consciousness as well as the resuscitative challenges which occur during resuscitation. Further research is required to determine the true frequency of this condition as well as treatment algorithms that would allow for appropriate and safe management for both the patient and EMS providers. [ABSTRACT FROM PUBLISHER]

Objective: Intraosseous (IO) access is increasingly being used as an alternative to peripheral intravenous access, which is often difficult or impossible to establish in critically ill patients in the prehospital setting. Until recently, only Paramedics performed adult IO access. In 2014, Vermont Emergency Medical Services (EMS) expanded the Advanced Emergency Medical Technicians (AEMTs) scope of practice to include IO access in adult patients. This study compares successful IO access in adults performed by AEMTs compared to Paramedics in the prehospital setting. Methods: All Vermont EMS patient encounters between January 1, 2013 and November 30, 2015 were examined, and 543 adult patients with a documented IO access insertion attempt were identified. The proportion of successful IO insertions was compared between AEMTs and Paramedics using a Chi-Squared statistic and a non-inferiority test. Results: There was no significant difference in the percentage of successful IO access between AEMTs and Paramedics [95.2% and 95.6%, respectively; P = 0.84]. The confidence interval around this 0.4% difference (95% confidence interval = –4.2, 3.2) was within a pre-specified delta of ±10% indicating non-inferiority of AEMTs compared to Paramedics. Conclusions: This study's finding that successful IO access was not different among AEMTs and Paramedics lends evidence in support of expanding the scope of practice of AEMTs to include establishing IO access in adults. [ABSTRACT FROM AUTHOR]

Objective:This study aims to determine the number and reasons for emergency paramedic attendances to older adults in Victoria, Australia. A second aim is to investigate the prevalence of psychosocial factors that may contribute to older patients requiring emergency paramedic attendance.Methods:This descriptive retrospective study analyzed all emergency paramedic attendances to patients aged 65 or older between July 1, 2011 and June 30, 2014 in Victoria, Australia. Fully de-identified data were extracted from the Ambulance Victoria Data Warehouse. Data included demographic and clinical variables such as age, gender, case nature (cause), past history, management and transportation, paramedic final assessment (diagnosis), social situation, past history; as well as free text case descriptions.Results:A total of 596,579 patients 65 years or older were attended by emergency paramedics during the study period. This accounted for 24.1% of Ambulance Victoria workload during that period. The mean (SD) age of patients was 79.8(8.2). The majority (70.7%) of cases involved patients at private residences. The most common final assessments were pain (18.7%), cardiac problem (7.2%), infection (6.9%), trauma (6.7%), other/unknown (6.4%), and respiratory problem (5.7%). The vast majority of patients were transported to hospital (82.8%). Psychosocial issues were evident in the free text case descriptions of more than 91,000 cases.Conclusion:Paramedics attended almost 600,000 patients 65 years and older during the study period. Patients suffered from conditions including, pain, trauma, infections, cardiac complaints, and respiratory problems. Free text case descriptions provided more detail and insight into the reasons for emergency paramedic attendance. Psychosocial problems were far more prevalent than indicated by the “final assessment” field. Further research is required to determine the reasons and implications of this. [ABSTRACT FROM PUBLISHER]

Background: Patients who present in ventricular fibrillation are typically treated with cardiopulmonary resuscitation (CPR), epinephrine, antiarrhythmic medications, and defibrillation. Although these therapies have shown to be effective, some patients remain in a shockable rhythm. Double sequential external defibrillation has been described as a viable option for patients in refractory ventricular fibrillation. Objective: To describe the innovative use of two defibrillators used to deliver double sequential external defibrillation by paramedics in a case of refractory ventricular fibrillation resulting in prehospital return of spontaneous circulation and survival to hospital discharge with good neurologic function. Case: A 28-year-old female sustained a witnessed out-of-hospital cardiac arrest (OHCA). Bystander CPR was performed by her husband followed by paramedics providing high-quality CPR, antiarrhythmic medication, and 6 biphasic defibrillations using standard energy levels. Double sequential external defibrillation was applied and a return of spontaneous circulation was attained on scene and maintained through to arrival to the emergency department. Following admission to hospital the patient was diagnosed with long QT syndrome. An implantable cardioverter defibrillator was placed and the patient was discharged with a Cerebral Performance Category of 2 as well as a modified Rankin Scale of 2 after an 18-day hospital stay. The patient's functional status continued to improve post discharge. Conclusion: The addition of double sequential external defibrillation as part of a well-organized resuscitation effort may be a valid treatment option for OHCA patients who present in refractory ventricular fibrillation. [ABSTRACT FROM AUTHOR]

Objective: To report on clinical and socio-demographic factors of a one-year caseload of women attended by a statewide ambulance service in Australia, who presented during pregnancy, prior to the commencement of labor. Methods: Retrospective clinical data collected via in-field electronic patient care record (VACIS®) by paramedics during clinical management was provided by Ambulance Victoria. Cases were electronically extracted from the Ambulance Victoria Clinical Data Warehouse via comprehensive filtering followed by case review. Results: Over a 12-month period, paramedics were called to 2,098 women with pregnancy as a primary or non-primary clinical consideration. Women's ages ranged from 14 to 48 years. The majority were multigravidas (86%). There was a greater chance that ambulance services would be required during business hours than any other time of the day. Paramedics noted pregnant women required ambulance services for a range of primary presenting symptoms both obstetric (n = 1137) and non-obstetric (n = 961). Some women had pre-existing conditions including asthma, hypertension, and diabetes potentially complicating their pregnancies. Paramedics administered analgesia to one third of the women. Paired t-tests revealed significant improvement in the pain relief and overall vital signs of the women encountered. Less than half the women (n = 986, 47%) required interventions. Conclusions: This is a unique population wide analysis of ambulance service resource use exploring the clinical profile of pregnant women requiring ambulance services in one calendar year. To manage obstetric and non-obstetric complications in this population safely and effectively, paramedics require an understanding of the unique physiological adaptions during pregnancy. This study therefore has both educational and practice implications. [ABSTRACT FROM AUTHOR]

Lethal cardiac arrhythmias such as ventricular fibrillation and pulseless ventricular tachycardia (VF/pVT) complicate up to 6% of all out-of-hospital STEMIs. Typically, paramedics respond to this by applying defibrillation pads and delivering a shock as soon as possible. A recently introduced “pads-on” protocol directed paramedics to apply defibrillation pads to all STEMI patients (regardless of clinical stability) with the aim of decreasing time to first shock. In this article we present two cases of prehospital STEMI complicated by VF to illustrate times to first shock for the two different protocols. One case each of a STEMI complicated by VF before implementation of the pads-on protocol and after the implementation of the protocol is presented. An important difference in the time to first shock is noted between the two patients with STEMI complicated by VF. While it took 2 min 43 s for the pads-off patient to be defibrillated, only 27 s elapsed before the pads-on patient was defibrillated. These two cases demonstrate that the application of defibrillation pads immediately following the diagnosis of prehospital STEMI has the potential to decrease the time to shock in patients suffering VF/pVT. [ABSTRACT FROM PUBLISHER]

Emergency medical services (EMS) must provide a wide range of care for patients in the out-of-hospital setting. Although previous work has detailed that EMS providers rarely perform certain procedures, (e.g., endotracheal intubation) there are limited data detailing the frequency of procedures across the breadth of EMS providers’ scope of practice. We sought to characterize procedures performed by EMS in the United States. We conducted an analysis of the 2011 National Emergency Medical Services Information System (NEMSIS) research data set, encompassing EMS emergency response data from 40 states and two territories. From these data, we report the number and incidence of EMS procedures. We also characterize procedures performed. There were 14,371,941 submitted EMS responses, of which 7,680,559 had complete information on procedures performed on adults. Of these, 4,206,360 EMS responses had procedures performed totaling 11,407,396 procedures. The most common procedures performed were peripheral venous access (28.4%), cardiac monitoring (16.1%) pulse oximetry (13.5%), and blood glucose analysis (10.4%). Procedures were performed most often in patients with traumatic injury (20.0%) followed by chest pain/discomfort (14.0%). Critical procedures (cardioversion, defibrillation, endotracheal intubation, etc.) were infrequently performed (n= 277,785, 2.4%). These data highlight the frequency with which EMS providers perform procedures across the United States. This may help to guide future EMS training and education efforts by highlighting the relative frequency and infrequency of specific procedures. [ABSTRACT FROM PUBLISHER]

Introduction. Separate clinical practice guidelines (CPG) for asthma and chronic obstructive pulmonary disease (COPD) often guide prehospital care. However, having distinct CPGs implies that paramedics can accurately differentiate these conditions. We compared the accuracy of paramedic identification of these two conditions against the emergency department (ED) discharge diagnosis.Methods. A retrospective cohort of all patients transported to ED by ambulance in Perth, Western Australia between July 2012 and June 2013; and identified as “asthma” or “COPD” by paramedics. We linked ambulance data to emergency department discharge diagnosis.Results. Of 1,067 patients identified by paramedics as having asthma, 41% had an ED discharge diagnosis of asthma, i.e., positive predictive value (PPV) = 41% (95% CI 38–44%). Of 1,048 patients recorded as COPD, 57% had an ED discharge diagnosis of COPD (PPV 57%; 95% CI 54–60%). Sensitivity for the paramedic identification of patients diagnosed with asthma or COPD in the ED was 66% for asthma (95% CI 63–70%) and 39% for COPD (95% CI 36–41%). Paramedics reported wheezing in 86% of asthma and 55% of COPD patients.Conclusion. Differentiating between asthma and COPD in the prehospital setting is difficult. A single CPG for respiratory distress would be more useful for the clinical management of these patients by paramedics [ABSTRACT FROM PUBLISHER]

Objectives. The purpose of this research was to characterize the use of simulation in initial paramedic education programs in order assist stakeholders' efforts to target educational initiatives and resources. This group sought to provide a snapshot of what simulation resources programs have or have access to and how they are used; faculty perceptions about simulation; whether program characteristics, resources, or faculty training influence simulation use; and if simulation resources are uniform for patients of all ages. Methods. This was a cross-sectional census survey of paramedic programs that were accredited or had a Letter of Review from the Committee on Accreditation of Educational Programs for the EMS Professions at the time of the study. The data were analyzed using descriptive statistics and chi-square analyses. Results. Of the 638 surveys sent, 389 valid responses (61%) were analyzed. Paramedic programs reported they have or have access to a wide range of simulation resources (task trainers [100%], simple manikins [100%], intermediate manikins [99%], advanced/fully programmable manikins [91%], live simulated patients [83%], computer-based [71%], and virtual reality [19%]); however, they do not consistently use them, particularly advanced (71%), live simulated patients (66%), computer-based (games, scenarios) (31%), and virtual reality (4%). Simulation equipment (of any type) reportedly sits idle and unused in (31%) of programs. Lack of training was cited as the most common reason. Personnel support specific to simulation was available in 44% of programs. Programs reported using simulation to replace skills more frequently than to replace field or clinical hours. Simulation goals included assessment, critical thinking, and problem-solving most frequently, and patient and crew safety least often. Programs using advanced manikins report manufacturers as their primary means of training (87%) and that 19% of faculty had no training specific to those manikins. Many (78%) respondents felt they should use more simulation. Conclusions. Paramedic programs have and have access to diverse simulation resources; however, faculty training and other program resources appear to influence their use. [ABSTRACT FROM AUTHOR]

Objectives. The purpose of this study was to examine trends in oxygen administration following the 2010 American Heart Association guidelines recommendation to withhold oxygen therapy for patients with uncomplicated presentations of ACS whose SpO2 is 94% or higher. Methods. Following IRB review and approval, we performed a retrospective analysis of data obtained from FisdapTM, a national, clinical skills tracking system for paramedic students between June 2010 and December 2012. Inclusion criteria included: 1) student consent for research, 2) cardiac chest pain recorded as the chief complaint, and 3) SpO2 data available for review. O2 administration, route, and dose were abstracted, and the percent of patient encounters with oxygen administration was calculated for each year. Unadjusted logistic regression was used to determine if O2 administration rates changed significantly over the study period. Unadjusted logistic regression was also used to determine if there was a difference in the odds of receiving oxygen based on a patient's SpO2 value. Results. 10,552 patient encounters by 2,447 paramedic students from 195 paramedic programs representing 49 states were included for analysis. Prior to release of the new guidelines (2010), 71.9% (95% CI 69.8-74.0%) of patients with SpO2 ≥ 94% received supplemental O2. Rates of O2 administration were significantly lower in 2011 (64%; 95% CI 62.7-65.3%) and in 2012 (53.1%; 95% CI 51.5-54.7). The odds of a hemodynamically stable chest pain patient with SpO2 ≥ 94% receiving supplemental oxygen in 2011 were 1.4 times lower compared to patients in 2010 (95% CI 1.3-1.6). Similarly, the odds of patients in 2012 receiving supplemental oxygen were 2.3 times lower compared to patients in 2010 (95% CI 2.0-2.6). The odds of receiving supplemental oxygen decreased by 4% for each 1% increase in SpO2 beyond the 94% threshold (OR = 0.96; 95% CI 0.94-0.98). Conclusions. The prehospital administration of supplemental O2 decreased significantly following release of the 2010 updated guidelines; however, our data revealed that 50% of patients not meeting criteria for administration still received supplemental O2. [ABSTRACT FROM AUTHOR]

Introduction. Studies from Australia, Sweden, the United States, and elsewhere have found that paramedics experience violence in the emergency medical services (EMS) workplace. The objective of this study was to describe and explore violence experienced by paramedics in the ground ambulance setting, including types of violence experienced, by whom the violence was perpetrated, actions taken by paramedics, and effects of these episodes. Method. A cross-sectional study utilizing a mixed-methods paper survey was provided to a convenience sample of rural, suburban, and urban-based ground ambulance paramedics in two Canadian provinces. Paramedics were asked to describe episodes of verbal assault, intimidation, physical assault, sexual harassment, and sexual assault they were exposed to during the past 12 months. Qualitative questions inquired about the impact of these experiences. Response selections were analyzed using descriptive statistics and regression analysis, and qualitative data was analyzed using descriptive content analysis. Results. A total of 1,884 paramedics were invited to participate and 1,676 responded (89.0%). Most participants (75%) reported experiencing violence in the past 12 months. The most common form of violence reported was verbal assault (67%), followed by intimidation (41%), physical assault (26%), sexual harassment (14%), and sexual assault (3%). Patients were identified as the most common perpetrators of violence. Serious sequellae were qualitatively reported. Conclusion. The majority of Canadian paramedics surveyed experience violence in the workplace, which can lead to serious personal and professional sequellae. Strategies should be devised and studied to reduce violent events toward paramedics and to mitigate the impact such events have on the wellbeing of paramedics. [ABSTRACT FROM AUTHOR]

Objective. We sought to characterize and estimate the frequency of mass casualty incidents (MCIs) occurring in the United States during the year 2010, as reported by emergency medical services (EMS) personnel. Methods. Using the 2010 National EMS Database of the National Emergency Medical Services Information System (NEMSIS), containing data from 32 states and territories, we estimated and weighted the frequency of MCIs documented by EMS personnel based on their perception of the event to produce incidence rates of MCIs per 100,000 population and MCIs per 1,000 9-1-1 calls requesting EMS service. We conducted descriptive analyses to characterize the MCIs by geographic location, incident type, and time of day as well as the MCI patients by demographic and health information. We used chi-squared tests to compare response delays and two-tailed t-tests to compare system response times between EMS responses documented as MCIs and those not. Results. Among the 9,776,094 EMS responses in the 2010 National EMS Database, 14,504 entries were documented as MCI. These entries represented an estimated 9,913 unique MCIs from the National EMS Database: 39.1% occurred in the South Atlantic region of the United States where only 19.1% of the population resides, 60.9% occurred in an urban setting, and 58.4% occurred on a street or highway. There were an estimated 13,677 MCI patients. The prehospital EMS personnel's primary impressions of the patients ranged from electrocution (0.01%) to traumatic injury (40.7%). Of the patients with a primary impression of injury ( N = 7,960), motor vehicle traffic crash was the cause of injury for 62.7%. Among the MCI EMS responses, 47.6% documented experiencing a response delay compared to only 12.3% of non-MCI EMS responses. Conclusions. This study demonstrates the range of health conditions and characteristics of EMS responses that EMS personnel perceive as MCIs, suggests that response delays are common during MCIs, and indicates there may be underreporting of all persons involved in an MCI. The National EMS Database is useful for describing MCIs and may help guide national leadership in strengthening EMS system preparedness for MCIs. [ABSTRACT FROM AUTHOR]

Background. Preemployment testing is utilized by many ambulance services. Surprisingly, there is limited published research on the efficacy of this testing in determining an employee's ability to complete the requirements of this physically demanding occupation. Objectives. The purpose of this study was to analyze the preemployment fitness test results from a 4-year cohort of paramedic students from an Australian university. To date, no published studies have reported on the fitness test scores for paramedic students or on whether overall test score is biased toward any particular test components. Similarly, no data have been presented on whether there are gender differences in scores for individual test components or overall test score. Methods. Retrospective cohort study of de-identified data from 4 years of data from Paramedic Science students ( n = 251) (mean age = 24.9 years). Data were recorded from the Queensland Ambulance Service (QAS) Health Related Fitness Test (HRFT), a preemployment fitness test used by an Australian state ambulance service. HRFT score is calculated out of a possible 100 points and is based on performance scores in nine component fitness tests. Raw test scores for each of these component tests are ranked on a 0-4 scale prior to these data being scaled and summed to generate the overall HRFT score. An overall score >24.99 is awarded a 'Pass.' Results. Five individuals failed to 'Pass' the HRFT. Overall HRFT scores were influenced significantly by performance in the strength tests, with males also recording significantly ( p < 0.005) higher scores in all of the strength tests than females. Similarly, approximately 40% of the female participants, compared to 6% of males, achieved an overall test 'Pass' and yet gained a ranked score of 0 in at least three of the component tests. Conclusions. It was concluded that the scoring system did not exclude participants with poor fitness levels, as many participants recorded low scores in several test components yet still passed the test. We recommend that before redesigning the HRFT, studies should be first conducted on the occupational demands and physical standards required for this important profession. [ABSTRACT FROM AUTHOR]

Objective. The objective of this study was to seek validity evidence for simulation-based assessments (SBA) of paramedics by asking to what extent the measurements obtained in SBA of clinical competence are associated with measurements obtained in actual paramedic contexts, with real patients. Methods. This prospective observational study involved analyzing the assessment of paramedic trainees at the entry-to-practice level in both simulation- and workplace-based settings. The SBA followed an OSCE structure involving full clinical cases from initial patient contact to transport or transfer of care. The workplace-based assessment (WBA) involved rating samples of clinical performance during real clinical encounters while assigned to an emergency medical service. For each candidate, both assessments were completed during a 3-week period at the end of their training. Raters in the SBA and WBA settings used the same paramedic-specific seven-dimension global rating scale. Reliability was calculated and decision studies were completed using generalizability theory. Associations between settings (overall and by dimension) were calculated using Pearson's correlation. Results. A total of 49 paramedic trainees were assessed using both a SBA and WBA. The mean score in the SBA and WBA settings were 4.88 (SD = 0.68) and 5.39 (SD = 0.48), respectively, out of a possible 7. Reliability for the SBA and WBA settings reached 0.55 and 0.49, respectively. A decision study revealed 10 and 13 cases would be needed to reach a reliability of 0.7 for the SBA and WBA settings. Pearson correlation reached 0.37 ( p = 0.01) between settings, which rose to 0.73 when controlling for imperfect reliability; five of seven dimensions (situation awareness, history gathering, patient assessment, decision making, and communication) reaching significance. Two dimensions (resource utilization and procedural skills) did not reach significance. Conclusion. For five of the seven dimensions believed to represent the construct of paramedic clinical performance, scores obtained in the SBA were associated with scores obtained in real clinical contexts with real patients. As SBAs are often used to infer clinical competence and predict future clinical performance, this study contributes validity evidence to support these claims as long as the importance of sampling performance broadly and extensively is appreciated and implemented. [ABSTRACT FROM AUTHOR]

Background. Identifying ST-segment elevation myocardial infarctions (STEMIs) by paramedics can decrease door-to-balloon times. While many paramedics are trained to obtain and interpret electrocardiograms (ECGs), it is unknown how accurately they can identify STEMIs. Objective. This study evaluated paramedics' accuracy in recognizing STEMI on ECGs when faced with potential STEMI mimics. Methods. This was a descriptive cohort study using a survey administered to paramedics. The survey contained questions about training, experience, and confidence, along with 10 ECGs: three demonstrating STEMIs (inferior, anterior, and lateral), two with normal results, and five STEMI mimics (left ventricular hypertrophy [LVH], ventricular pacing, left and right bundle branch blocks [LBBB, RBBB], and supraventricular tachycardia [SVT]). We calculated the overall sensitivity and specificity and the proportion correct with 95% confidence intervals (CIs).  Results. We obtained 472 surveys from 30 municipal emergency medical services (EMS) agencies in five counties with 15 medical directors from seven hospitals. The majority (69%) reported ECG training within the preceding year, 31% within six months; and 74% were confident in recognizing STEMIs. The overall sensitivity and specificity for STEMI detection were 75% and 53% (95% CI 73%-77%, 51%-55%), respectively. Ninety-six percent (453/472, 95% CI 94%-98%) correctly identified the inferior myocardial infarction (MI), but only 78% (368/472, 94% CI 74%-82%) identified the anterior MI and 51% (241/472, 46%-56%) the lateral MI. Thirty-seven percent (173/472, 95% CI 32%-41%) of the paramedics correctly recognized LVH, 39% (184/472, 95% CI 35%-44%) LBBB, and 53% (249/472, 95% CI 48%-57%) ventricular pacing as not a STEMI. Thirty-nine percent (185/472, 95% CI 35%-44%) correctly identified all three STEMIs; however, only 3% of the paramedics were correct in all interpretations. The two normal ECGs were recognized as not a STEMI by 97% (459/472, 95% CI 95%-99%) and 100% (472/472, 95% CI 99%-100%). There was no correlation between training, experience, or confidence and accuracy in recognizing STEMIs. Conclusions. Despite training and a high level of confidence, the paramedics in our study were only able to identify an inferior STEMI and two normal ECGs. Given the paramedics' low sensitivity and specificity, we cannot rely solely on their ECG interpretation to activate the cardiac catheterization laboratory. Future research should involve the evaluation of training programs that include assessment, initial training, testing, feedback, and repeat training. [ABSTRACT FROM AUTHOR]

Introduction. Epinephrine and vasopressin are the only vasopressors associated with return of spontaneous circulation (ROSC). While current guidelines recommend rapid and frequent vasopressor administration during cardiac arrest, delays in their administration in the out-of- hospital setting remain a concern. Objective. This study evaluated delays in vasopressor administration and their effect on field ROSC. Methods. This retrospective review included all adult patients who experienced cardiac arrest of medical origin and received field resuscitative efforts among 10 emergency medical services (EMS) systems. Data were abstracted from the EMS medical record and included response time intervals, calculated first-dose and interdosing intervals of vasopressors, and ROSC. Data were analyzed using Mann-Whitney tests, chi-square tests, and t-tests, survival analysis, and logistic regression, with p ≤ 0.05 indicating significance. Results. A total of 660 cardiac arrest patients were enrolled in the study. The mean EMS response time was 8.8 minutes; 52.7% of patients had witnessed cardiac arrests, 46.2% received bystander cardiopulmonary resuscitation (CPR), 23.0% had shockable initial rhythms, and 19.5% experienced field ROSC. In total, 1,913 doses of epinephrine and 111 doses of vasopressin were administered, with mean and 90th-percentile scene arrival-to-first drug intervals of 9.5 and 17 minutes, respectively. The mean and 90th-percentile interdosing intervals were 6.1 and 10 minutes, respectively. Patients experiencing ROSC had shorter scene arrival-to-first drug intervals than those without ROSC (8.1 vs. 9.8 min, p < 0.01), but there was no difference in the mean interdosing interval (6.8 vs. 6.0 min, p = 0.57). In the logistic regression analysis of ROSC, the adjusted odds ratio for call receipt-to-first drug interval ≤10 minutes was 1.91 (p = 0.04). Patients receiving advanced airway control prior to vasopressor administration were less likely to have a call receipt-to-first drug interval within 10 minutes (4.0% vs. 17.3%, p < 0.01) and were less likely to attain ROSC (15.7% vs. 25.4%, p < 0.01). Conclusion. The interval between scene arrival and first administration of vasopressors is significantly shorter among patients who experience ROSC compared with those who do not. Airway control procedures delay vasopressor administration and reduce the likelihood of ROSC. Although the interdosing intervals of most patients were not consistent with current recommendations, there was no difference in the mean interdosing times between those who achieved ROSC and those who did not. [ABSTRACT FROM AUTHOR]

Introduction. Continuous positive airway pressure (CPAP) has been used effectively in the prehospital environment for a wide range of respiratory emergencies. The feasibility of CPAP when used by primary care paramedics (PCPs) has not been established. Objective. We sought to study the feasibility of prehospital CPAP when used by paramedics trained to the primary care paramedic (PCP) level compared with those trained to the advanced care paramedic (ACP) level. Our hypothesis was that the feasibility of CPAP use by paramedics trained to the PCP level is similar to that of paramedics trained to the ACP level. Methods. We conducted an observational study of 302 consecutive cases of CPAP use over one year beginning June 25, 2009. We defined compliant use as 100% adherence to the provincial CPAP medical directive. The criteria for compliance included specifics of patient presentation, vital signs, and appropriate documentation by the paramedic, as well as proper use, titration, and discontinuation of CPAP equipment according to protocol. Data were abstracted from ambulance call reports. Results. Using the criteria set out for compliant CPAP use, the highest level of compliance among the ACPs and the PCPs was 98.6% and 98.9%, respectively, for documenting indication for CPAP use. The lowest level of compliance among the ACPs was 84.4% for titration of CPAP during treatment, and the lowest level of compliance among the PCPs was 90% for adherence to criteria for CPAP application according to patients' vital signs. Overall, the criteria for compliant use of CPAP were met for 76.8% (232/302) of the call reports examined. The rate of compliant use of CPAP was 75.9% (161/212) for ACP calls and 78.9% (71/90) for PCP calls. The difference between rates of compliant use for ACP calls versus PCP calls was not statistically significant (χ2 [1 df] = 0.31, p = 0.66). Conclusions. This study found no significant difference in the compliant use of prehospital CPAP between paramedics trained to the PCP level and those trained to the ACP level. This study suggests that CPAP use by PCP-level paramedics may be feasible. Further study is required to determine whether compliance translates to safe use of prehospital CPAP by PCP-level paramedics. [ABSTRACT FROM AUTHOR]

Background. The Broselow tape is widely used to rapidly estimate weight and facilitate proper medication dosing in pediatric patients. Objective. We aimed to determine the accuracy of prehospital use of the Broselow tape. Methods. We prospectively enrolled a consecutive sample of pediatric patients transported to the emergency department (ED) at Harbor-UCLA Medical Center from February 2008 to January 2009. Eligible subjects arrived via ambulance and were less than 145 cm tall, the upper limit of height for Broselow measurements. Subjects were excluded if they had a medical condition preventing proper measurement (e.g., contractures). Per Los Angeles County protocol, paramedics obtained a Broselow weight on all pediatric patients. The paramedic Broselow weight was compared with the ED Broselow weight and the ED scale weight, which was obtained unless mobilization was contraindicated. Accuracy was determined by assessing Bland-Altman plots and the Pearson correlation coefficient. As part of a sensitivity analysis, multiple imputation was used to account for missing data. Results. There were 572 subjects enrolled. The median age was 24 months (interquartile range [IQR] 10 to 49 months); 316 (55%) of the subjects were male. The weighted Cohen's kappa assessing agreement between the paramedic and ED Broselow colors was 0.74 (95% confidence interval [CI] 0.68 to 0.79). The median difference between the paramedic Broselow weight and the scale weight was -0.10 kg (IQR -1.7 to 0.7). The accuracy of the paramedic Broselow weight when compared with the ED scale weight and the ED Broselow weight as defined by Pearson's correlation coefficient was 0.92 (95% CI 0.90 to 0.93) and 0.97 (95% CI 0.97 to 0.98), respectively. Multiple imputation for missing data did not alter the results. Conclusion. Paramedic Broselow weight correlates well with scale weight and ED Broselow weight. Paramedics can use the Broselow tape to accurately determine weight for pediatric patients in the prehospital setting. [ABSTRACT FROM AUTHOR]

Introduction. Prior to graduation, paramedic students must be assessed for terminal competency and preparedness for national credentialing examinations. Although the procedures for determining competency vary, many academic programs use a practical and/or oral examination, often scored using skill sheets, for evaluating psychomotor skills. However, even with validated testing instruments, the interevaluator reliability of this process is unknown. Objective. We sought to estimate the interevaluator reliability of a subset of paramedic skills as commonly applied in terminal competency testing. Methods. A mock examinee was videotaped performing staged examinations mimicking adult ventilatory management, oral board, and static and dynamic cardiac stations during which the examinee committed a series of prespecified errors. The videotaped performances were then evaluated by a group of qualified evaluators using standardized skill sheets. Interevaluator variability was measured by standard deviation and range, and reliability was evaluated using Krippendorff's alpha. Correlation between scores and evaluator demographics was assessed by Pearson correlation. Results. Total scores and critical errors varied considerably across all evaluators and stations. The mean (± standard deviation) scores were 24.77 (±2.37) out of a possible 27 points for the adult ventilatory management station, 11.69 (±2.71) out of a possible 15 points for the oral board station, 7.79 (±3.05) out of a possible 12 points for the static cardiology station, and 22.08 (±1.46) out of a possible 24 points for the dynamic cardiology station. Scores ranged from 18 to 27 for adult ventilatory management, 7 to 15 for the oral board, 2 to 12 for static cardiology, and 19 to 24 for dynamic cardiology. Krippendorff's alpha coefficients were 0.30 for adult ventilatory management, 0.01 for the oral board, 0.10 for static cardiology, and 0.48 for dynamic cardiology. Critical criteria errors were assigned by 10 (38.5%%) evaluators for adult ventilatory management, five (19.2%%) for the oral board, and nine (34.6%%) for dynamic cardiology. Total scores were not correlated with evaluator demographics. Conclusions. There was high variability and low reliability among qualified evaluators using skill sheets as a scoring tool in the evaluation of a mock terminal competency assessment. Further research is needed to determine the true overall interevaluator reliability of this commonly used approach, as well as the ideal number, training, and characteristics of prospective evaluators. [ABSTRACT FROM AUTHOR]

Introduction. In the setting of ST-segment elevation myocardial infarction (STEMI), early reperfusion yields better patient outcomes. Emergency medical services (EMS) is the first medical contact for half of the afflicted population, and prehospital thrombolysis may result in considerably faster reperfusion compared with percutaneous coronary intervention (PCI) in rural settings. However, there are few reports of prehospital thrombolysis in rural EMS systems. Objective. To describe a rural EMS system's experience with tenecteplase in STEMI. Methods. Data were retrospectively abstracted from the medical records of patients receiving tenecteplase using standard chart review guidelines. Primary outcomes included time saved by EMS-initiated thrombolysis, aborted infarctions, serious bleeding events, and in-hospital mortality. Secondary outcomes included reinfarction, rescue angioplasty, and appropriateness of treatment. Time savings was defined as transport time after tenecteplase administration plus 90 minutes, which is the typical door-to-balloon time for PCI laboratories. Aborted infarction was defined as resolution of the cumulative ST-segment elevation to ≤50%% of that on the initial electrocardiogram (ECG) within two hours after treatment, and peak creatine kinase (CK)/CK-MB levels less than or equal to twice the upper limit of normal. Results. Seventy-three patients received prehospital tenecteplase; this treatment was determined to be appropriate in 86.4%% of cases. The mean patient age was 59 years, and 71.6%% of the patients were male. Mean (± standard deviation) scene-arrival-to-drug time was 26.2 (±11.4) minutes, the mean scene-arrival-to-hospital-arrival time was 73.0 (±20.6) minutes, and the mean transport time was 46.0 (± 11.1) minutes. Tenecteplase was administered 35.9 (±25.0) minutes prior to hospital arrival, and the estimated reperfusion time savings over PCI was 125.9 (±25.0) minutes. Aborted infarctions were observed in 24.1%% of patients, whereas 9.6%% suffered reinfarction, 47.9%% underwent rescue angioplasty, and 16.7%% required coronary artery bypass grafting (CABG). Serious bleeding events occurred in 15 patients (20.5%%), and four (5.5%%) died. Conclusion. In this retrospective review of rural STEMI patients, tenecteplase was administered 36 minutes prior to hospital arrival, saving approximately two hours over typical PCI strategies and resulting in aborted infarctions in one-fourth of patients. In a rural setting with lengthy transport times to PCI facilities, tenecteplase appears to be a feasible prehospital intervention. Randomized controlled trials are needed to fully evaluate the safety and effectiveness of this intervention prior to widespread adoption. [ABSTRACT FROM AUTHOR]

Background. Various alternative airway devices have been developed in the last several years. Among these is the Supraglottic Airway Laryngopharyngeal Tube (SALT), which was designed to function as a basic mechanical airway and as an endotracheal tube (ET) introducer for blind endotracheal intubation (ETI). Objective. To determine the rate of successful placement of the SALT and the success rate of subsequent blind ET insertion by a cohort of emergency medical services (EMS) providers of varying levels of EMS certification. Methods. This study was a two-phase, two-group nonblinded, prospective time trial using a convenience cohort of prehospital providers to determine the success rate for SALT placement (i.e., the basic life support [[ BLS]] phase) and ET placement using the SALT (i.e., the advanced life support [[ ALS]] phase) in an unembalmed human cadaver model. The part 1 cohort ( group 1) comprised predominantly basic and intermediate emergency medical technician (EMT)-level providers, whereas the part 2 cohort ( group 2) comprised exclusively paramedic-level providers. Results. In group 1, 51 (98%%) of the subjects were able to successfully place the SALT and ventilate the cadaver (BLS phase), with 48 (92.3%%) subjects successfully placing it on the first attempt. In group 2, 21 (96%%) of the subjects were able to successfully place the SALT, with 19 (86%%) placing the SALT on the first attempt. Successful blind placement of an ET through the SALT (ALS phase) by group 1 was 48.1%% (95%% confidence interval [[CI]]: 34--62), with 37%% (95%% CI: 24--51) placing the ET on the first attempt. In group 2, 20 subjects (91%% [[95%% CI: 71--99]]) were able to successfully place an ET through the SALT, with 13 (59%% [[95%% CI: 36--79]]) doing so on the first attempt. Conclusions. Emergency medical services providers of varying levels can successfully and rapidly place the SALT and ventilate a cadaver specimen. The success rate for blind placement of an ET through the SALT was suboptimal. [ABSTRACT FROM AUTHOR]

Background. Because of their frequent patient interactions, particularly with patients in long-term care facilities, emergency medical services (EMS) professionals are at risk of contracting and spreading influenza. However, influenza vaccination rates among EMS professionals are poorly quantified. Objectives. We sought to document vaccination rates of EMS professionals and identify predictors of vaccination uptake. Methods. We conducted a cross-sectional survey of North Carolina EMS professionals after the 2007--2008 influenza season. The survey assessed vaccination status as well as beliefs regarding influenza illness and vaccine effectiveness similar to the constructs of the Health Belief Model. Prediction of vaccine uptake was modeled using logistic regression. Results. A total of 601 EMS professionals completed the survey. Among the respondents, 47.9%% reported receiving the influenza vaccination; vaccination rates varied among rural, suburban, and urban respondents (p == 0.01). Significant differences were found between the vaccinated and unvaccinated groups regarding employer vaccine recommendation (odds ratio [[OR]] == 3.6, p < 0.01), employer-offered influenza training (OR == 1.5, p < 0.01), employer-offered vaccination (OR == 3.3, p < 0.01), and belief in vaccine safety (OR == 27.5, p < 0.01) and effectiveness (OR == 9.5, p < 0.01). Most respondents believed they were at higher risk for influenza, the risk of adverse reactions was outweighed by prevention of disease, the vaccine was safe and effective, and vaccination protected themselves and their patients; however, only 9.1%% supported mandatory vaccination. Those who were not vaccinated cited reasons such as belief in personal health as a protector against influenza, concerns about vaccine effectiveness, and the lack of an employer mandate. Predictors of vaccination included previous influenza diagnosis, perceived higher risk compared with that in the general population, belief in vaccine effectiveness, belief of favorable risk--benefit ratio, employer vaccine recommendation, and age. Conclusion. In this multicenter evaluation of EMS professionals, influenza vaccination rates were unacceptably low. Previous influenza infection, employer vaccine recommendation, a perception of increased risk for contracting the illness, and favorable beliefs about vaccine effectiveness were all predictive of vaccination acceptance. Emergency medical services systems should focus their efforts on combating misinformation through employee educational campaigns as well as develop policies regarding immunization requirements and working while ill. [ABSTRACT FROM AUTHOR]

Obective. The objectives were to evaluate the safety and efficacy of ondansetron in the out-of-hospital treatment of undifferentiated nausea or vomiting. Methods. Patients with severe nausea or intractable vomiting who were transported by paramedic-staffed ambulances in eight California counties were treated with intravenous (IV), intramuscular (IM), or oral dissolving tablet (ODT) administration of ondansetron. Data were collected prospectively for a six-month period using an online database. Prospectively defined outcome measures were 1) efficacy as measured by a quantitative visual analog nausea scale and 2) incidence of adverse effects. There were no control or placebo groups. Results. Data was collected for 2072 patients, but one patient did not receive the medication. Therefore, Ondansetron was administered to 2,071 patients (3.7% of transported patients). Most patients were adult, with only 66 patients less than 18 years old. Of the 2,071 patients, 1,320 (64%) received IV administration, 77 (4%) received IM administration, and 674 (33%) received ODT administration of ondansetron. Intravenous administration resulted in the largest improvements in nausea scores (mean 4.4; 95% confidence interval [CI] 4.2, 4.5), followed by IM (mean 3.6; 95% CI 3.0, 4.3) and ODT (mean 3.3; 95% CI 3.1, 3.5). Overall, the mean decrease in nausea score was 4.0 (95% CI 3.9, 4.1; p < 0.001) on a 10-point scale. After medication administration, four patients had mild hypotension, one had hypertension, two had itching or rash, and one had a brief episode of supraventricular tachycardia that resolved spontaneously. Conclusions. Ondansetron is safe and effective for out-of-hospital treatment of nausea and vomiting when administered by paramedics via the IV, IM, or oral route. When available to paramedics, ondansetron is used frequently. [ABSTRACT FROM AUTHOR]

Background. Airway management is a key component of prehospital care for seriously ill and injured patients. Oral endotracheal intubation (OETI) is the definitive airway of choice in most emergency medical services (EMS) systems. However, OETI may not be an approved skill for some clinicians or may prove problematic in certain patients because of anatomic abnormalities, trauma, or inadequate relaxation. In these situations alternative airways are frequently employed. However, the reported success rates for these devices vary widely, and established benchmarks are lacking. Objective. We sought to determine pooled estimates of the success rates of alternative airway devices (AADs) and needle cricothyrotomy (NCRIC) and surgical cricothyrotomy (SCRIC) placement through a meta-analysis of the literature. Methods. We performed a systematic literature search for all English-language articles reporting success rates for AADs, SCRIC, and NCRIC. Studies of field procedures performed by prehospital personnel from any nation were included. All titles were reviewed independently by two authors using prespecified inclusion criteria. Pooled estimates of success rates for each airway technique were calculated using a random-effects meta-analysis model. Results. Of 2,005 prehospital airway titles identified, 35 unique studies were retained for analysis of AAD success rates, encompassing a total of 10,172 prehospital patients. The success rates for SCRIC and NCRIC were analyzed across an additional 21 studies totaling 512 patients. The pooled estimates (and 95% confidence intervals [CIs]) for intervention success across all clinicians and patients were as follows: esophageal obturator airway–esophageal gastric tube airway (EOA-EGTA) 92.6% (90.1%–94.5%); pharyngeotracheal lumen airway (PTLA) 82.1% (74.0%–88.0%); esophageal-tracheal Combitube (ETC) 85.4% (77.3%–91.0%); laryngeal mask airway (LMA) 87.4% (79.0%–92.8%); King Laryngeal Tube airway (King LT) 96.5% (71.2%–99.7%); NCRIC 65.8% (42.3%–83.59%); and SCRIC 90.5% (84.8%–94.2%). Conclusions. We provide pooled estimates for prehospital AAD, NCRIC, and SCRIC airway interventions. Of the AADs, the King LT demonstrated the highest insertion success rate (96.5%), although this estimate is based on limited data, and data regarding its ventilatory effectiveness are lacking; more data are available for the ETC and LMA. The ETC, LMA, and PTLA all had similar—but lower—success rates (82.1%–87.4%). NCRIC has a low rate of success (65.8%); SCRIC has a much higher success rate (90.5%) and should be considered the preferred percutaneous rescue airway. [ABSTRACT FROM AUTHOR]

Objective. To examine the effects of adding close concurrent and retrospective physician oversight, consistent with National Association of EMS Physicians (NAEMSP) recommendations, to an existing regional prehospital rapid-sequence intubation (RSI) program. Methods. This study involved a retrospective cohort of patients receiving RSI between January 1, 2004, and July 31, 2008. On January 1, 2007, an updated program including additional concurrent and retrospective physician oversight, increased RSI-specific continuing medical education, and cadaver laboratory training was implemented. Study patients were divided into a preintervention group (group 1) and a postintervention group (group 2) based on date of medical care. Data regarding baseline characteristics, airway management, medication usage, and performance factors were compared between the groups. A retrospective review by two emergency medical services (EMS) physicians assessed whether the RSI was “clearly indicated” based on a predetermined set of criteria. Results. There were 109 RSIs performed in group 1 and 54 in group 2. Absolute increases in the use of both basic life support (BLS) (5%, p = 0.2) and advanced life support (ALS) (41%, p = 0.001) airway techniques were observed. Increases in postintubation administration of midazolam (30%, p = 0.001) and morphine (24%, p = 0.001) and a decrease for vecuronium (–28%, p = 0.001) were observed. There was no statistically significant difference in the intubation success rates (92% vs. 94%) and the frequencies of recognized esophageal endotracheal tube (ETT) placement (5% vs. 6%). The number of unrecognized esophageal ETT placements remained zero. Physician chart review demonstrated an absolute increase in “clearly indicated” RSIs (17%, p = 0.01). Conclusions. Close concurrent and retrospective physician oversight consistent with recommendations from the NAEMSP is associated with improved cognitive skills in paramedics, including appropriate patient selection for RSI. Further research is warranted to validate this model and optimize where resources are best used to enhance patient safety and improve clinical management for this controversial paramedic skill. [ABSTRACT FROM AUTHOR]

Background. Airway management is a key component of prehospital care for seriously ill and injured patients. Although endotracheal intubation has been a commonly performed prehospital procedure for nearly three decades, the safety and efficacy profile of prehospital intubation has been challenged in the last decade. Reported intubation success rates vary widely, and established benchmarks are lacking. Objective. We sought to determine pooled estimates for oral endotracheal intubation (OETI) and nasotracheal intubation (NTI) placement success rates through a meta-analysis of the literature. Methods. We performed a systematic literature search for all English-language articles reporting placement success rates for prehospital intubation. Studies of field procedures performed by prehospital personnel from any nation were included. All titles were reviewed independently by two authors using prespecified inclusion criteria. Pooled estimates of success rates for each airway technique, including drug-facilitated intubation (DFI) and rapid-sequence intubation (RSI), were calculated using a random-effects model. Historical trends were evaluated using meta-regression. Results. Of 2,005 identified titles reviewed, 117 studies addressed OETI and 23 addressed NTI, encompassing a total of 57,132 prehospital patients. There was substantial interrater reliability in the review process (kappa = 0.81). The pooled estimates (and 95% confidence intervals [CIs]) for intervention success for nonphysician clinicians were as follows: overall non-RSI/non-DFI OETI success rate: 86.3% (82.6%–89.4%); OETI for non–cardiac arrest patients: 69.8% (50.9%–83.8%); DFI 86.8% (80.2%–91.4%); and RSI 96.7% (94.7%–98.0%). For pediatric patients, the paramedic OETI success rate was 83.2% (55.2%–95.2%). The overall NTI success rate for nonphysician clinicians was 75.9% (65.9%–83.7%). The historical trend of OETI reflects a 0.49% decline in success rates per year. Conclusions. We provide pooled estimates of placement success rates for prehospital airway interventions. For some patient and clinician characteristics, OETI has relatively low success rates. For nonarrest patients, DFI and RSI appear to increase success rates. Across all clinicians, NTI has a low rate of success, raising questions about the safety and efficacy of this procedure. [ABSTRACT FROM AUTHOR]

Background. Emergency airway management is an important component of resuscitation of critically ill patients. Multiple studies demonstrate variable endotracheal intubation (ETI) success by prehospital providers. Data describing how many ETI training experiences are required to achieve high success rates are sparse. Objectives. To describe the relationship between the number of prehospital ETI experiences and the likelihood of success on subsequent ETI and to specifically look at uncomplicated first-pass ETI in a university-based training program with substantial resources. Methods. We conducted a secondary analysis of a prospectively collected cohort of paramedic student prehospital intubation attempts. Data collected on prehospital ETIs included indication, induction agents, number of direct laryngoscopy attempts, and advanced airway procedures performed. We used multivariable generalized estimating equations (GEE) analysis to determine the effect of cumulative ETI experience on first-pass and overall ETI success rates. Results. Over a period of three years, 56 paramedic students attempted 576 prehospital ETIs. The odds of overall ETI success were associated with cumulative ETI experience (odds ratio [OR] 1.097 per encounter, 95% confidence interval [CI] = 1.026–1.173, p = 0.006). The odds of first-pass ETI success were associated with cumulative ETI experience (OR 1.061 per encounter, 95% CI = 1.014–1.109, p = 0.009). Conclusion. In a training program with substantial clinical opportunities and resources, increased ETI success rates were associated with increasing clinical exposure. However, first-pass placement of the ETT with a high success rate requires high numbers of ETI training experiences that may exceed the number available in many training programs. [ABSTRACT FROM AUTHOR]

Objective. To identify the specific educational strategies used by paramedic educational programs that have attained consistently high success rates on the National Registry of Emergency Medical Technicians (NREMT) examination. Methods. NREMT data from 2003-2007 were analyzed to identify consistently high-performing paramedic educational programs. Representatives from 12 programs that have maintained a 75% first-attempt pass rate for at least four of five years and had more than 20 graduates per year were invited to participate in a focus group. Using the nominal group technique (NGT), participants were asked to answer the following question: “What are specific strategies that lead to a successful paramedic educational program?” Results. All 12 emergency medical services (EMS) educational programs meeting the eligibility requirements participated. After completing the seven-step NGT process, 12 strategies were identified as leading to a successful paramedic educational program: 1) achieve and maintain national accreditation; 2) maintain high-level entry requirements and prerequisites; 3) provide students with a clear idea of expectations for student success; 4) establish a philosophy and foster a culture that values continuous review and improvement; 5) create your own examinations, lesson plans, presentations, and course materials using multiple current references; 6) emphasize emergency medical technician (EMT)-Basic concepts throughout the class; 7) use frequent case-based classroom scenarios; 8) expose students to as many prehospital advanced life support (ALS) patient contacts as possible, preferably where they are in charge; 9) create and administer valid examinations that have been through a review process (such as qualitative analysis); 10) provide students with frequent detailed feedback regarding their performance (such as formal examination reviews); 11) incorporate critical thinking and problem solving into all testing; and 12) deploy predictive testing with analysis prior to certification. Conclusion. Twelve specific strategies were identified by representatives from high-performing paramedic education programs. Further study should be conducted to determine whether implementation of these recommendations would improve program pass rates on the NREMT credentialing examination and improve entry-level paramedic field performance. [ABSTRACT FROM AUTHOR]

Objective. To determine whether the interval between the arrival of basic life support (BLS) providers and the arrival of advanced life support (ALS) providers is associated with patient outcome after cardiac arrest. Methods. We conducted a retrospective cohort study of all witnessed, out-of-hospital ventricular fibrillation (VF) cardiac arrests between January 1, 1991, and December 31, 2007. Eligible patients (n = 1,781) received full resuscitation efforts from both BLS and ALS providers. Results. The BLS-to-ALS arrival interval was a significant predictor of survival to hospital discharge (odds ratio [OR] 0.96, 95% confidence interval [CI] 0.93-0.99); the likelihood of survival decreased by 4% for every minute that ALS arrival was delayed following BLS arrival. Other significant predictors of survival were whether the arrest occurred in public (OR 1.48, 95% CI 1.19-1.85), whether a bystander administered cardiopulmonary resuscitation (CPR) (OR 1.34, 95% CI 1.07-1.68), and the interval between the 9-1-1 call and BLS arrival (OR 0.78, 95% CI 0.73-0.83). Conclusions. We found that a shorter BLS-to-ALS arrival interval increased the likelihood of survival to hospital discharge after a witnessed, out-of-hospital VF cardiac arrest. We conclude that ALS interventions may provide additional benefits over BLS interventions alone when utilized in a well-established, two-tiered emergency medical services (EMS) system already optimized for rapid defibrillation. The highest priorities in any EMS system should still be early CPR and early defibrillation, but timely ALS services can supplement these crucial interventions. [ABSTRACT FROM AUTHOR]