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• Pilot analysis of EMS Medical Director compensation performed via anonymous survey • Population and call volume positively influence EMS Medical Director compensation • The ratio of compensation was 1.05 per 10,000 increase in population [ABSTRACT FROM AUTHOR]

Emergency medical services (EMS) clinicians demonstrate a high prevalence of chronic medical conditions that place them at risk for early mortality. Workplace health promotion programs improve health outcomes, but the availably of such programs for EMS clinicians has not been described. We investigate the availability, scope, and participation of workplace health promotion programs available to EMS clinicians in North Carolina (NC). We administered an electronic survey based on the Centers for Disease Control and Prevention Worksite Health ScoreCard to key representatives of EMS agencies within NC that provide primarily transport-capable 9-1-1 response with ground ambulances. We collected information on agency size, rurality, elements of health promotion programs offered, incentives for participation, and participation rate. We calculated descriptive statistics using frequency and percentage for worksite and health promotion program characteristics. We compared the participation rate for agencies who did and did not incentivize participation using Fisher's exact test. Complete responses were received from 69 of 92 agencies (response = 75%) that collectively employ 6679 EMS clinicians [median employees per agency 71 (IQR 50–131)]. Most agencies (88.4%, 61/69) offered at least one element of a worksite health program, but only 13.0% (9/69) offered all elements of a worksite health program. In descending order, the availability of program elements were employee assistance programs (73.9%, 51/69), supportive physical and social environment (66.7%, 46/69), health education (62.3%, 43/69), health risk assessments (52.2%, 36/69), and organization culture of health promotion (20.3%, 14/69). Of agencies with programs, few (11.5%, 7/61) required participation, but most (59.0%, 36/61) offered incentives to participate. Participation rates were <25% among nearly all of the agencies that did not offer incentives, but >50% among most agencies that did offer incentives (p < 0.001). While most agencies offer at least one element of a worksite health promotion program, few agencies offer all elements and participation rates are low. [ABSTRACT FROM AUTHOR]

Objective: Use of point-of-care (POC) troponin (cTn) testing in the Emergency Department (ED) is well established. However, data examining POC cTn measurement in the prehospital setting, during ambulance transport, are limited. The objective of this study was to prospectively test the performance of POC cTn measurement by paramedics to detect myocardial infarction (MI) among patients transported to the ED for acute chest pain. Methods: A prospective cohort study of adults with non-traumatic chest pain was conducted in three Emergency Medical Services agencies (December 2016 to January 2018). Patients with ST-elevation MI on ECG were excluded. During ambulance transport paramedics initiated intravenous access, collected blood, and used a POC device (i-STAT; Abbott Laboratories) to measure cTn. Following ED arrival, participants received standard evaluations including clinical blood draws for cTn measurement in the hospital central lab (AccuTnI +3 assay; Beckman Coulter, or cTnI-Ultra assay; Siemens). Blood collected during ambulance transport was also analyzed for cTn in the central lab. Index visit MI was adjudicated by 3 experts using central lab cTn measures from the patient's clinical blood draws. Test characteristics (sensitivity, specificity, and predictive values) for detection of MI were calculated for POC and central lab cTn measurement of prehospital blood and compared with McNemar's test. Results: During the study period prehospital POC cTn results were obtained on 421 patients, of which 5.0% (21/421) had results >99th percentile upper reference limit. MI was adjudicated in 16.2% (68/421) during the index visit. The specificity and positive predictive value of the POC cTn measurement were 99.2% (95% CI 97.5–99.8%) and 85.7% (95% CI 63.7–97.0%) for MI. However, the sensitivity and NPV of prehospital POC cTn were 26.5% (95% CI 16.5–38.6%) and 87.5% (95% CI 83.9–90.6%). Compared to POC cTn, the central lab cTn measurement of prehospital blood resulted in a higher sensitivity of 67.9% (95% CI 53.7–80.1%, p < 0.0001), but lower specificity of 92.4% (95% CI 88.4–95.4%, p = 0.0001). Conclusions: Prehospital POC i-STAT cTn measurement in patients transported with acute chest pain was highly specific for MI but had low sensitivity. This suggests that prehospital i-STAT POC cTn could be useful to rule-in MI, but should not be used to exclude MI. [ABSTRACT FROM AUTHOR]

The HEART Pathway is a validated risk stratification protocol for Emergency Department patients with chest pain that has yet to be tested in the prehospital setting. This study seeks to test the performance of a prehospital modified HEART Pathway (PMHP). A prospective cohort study of adults with chest pain without ST-segment elevation myocardial infarction was conducted at three EMS agencies between 12/2016-1/2018. To complete a PMHP assessment, paramedics drew blood, measured point-of-care (POC) troponin (i-STAT; Abbott Point of Care) and calculated a HEAR score. Patients were stratified into three groups: high-risk based on an elevated troponin, low-risk based on a HEAR score <4 with a negative troponin, or moderate risk for a HEAR score ≥4 with a negative troponin. Sensitivity, specificity, negative and positive predictive values of the PMHP for detection of major adverse cardiac events (MACE: cardiac death, MI, or coronary revascularization) at 30-days were calculated. A total of 506 patients were accrued, with PMHP completed in 78.1% (395/506). MACE at 30-days occurred in 18.7% (74/395). Among these patients, 7.1% (28/395) were high risk yielding a specificity and PPV for 30-day MACE of 96.6% (95%CI: 94.0–98.3%) and 60.7% (95%CI: 40.6–78.6%) respectively. Low-risk assessments occurred in 31.4% (124/395), which were 90.5% (95%CI: 81.5–96.1%) sensitive for 30-day MACE with a NPV of 94.4% (95%CI: 88.7–97.7%). Moderate-risk assessments occurred in 61.5% (243/395), of which 20.6% had 30-day MACE. The PMHP is able to identify high-risk and low-risk groups with high specificity and negative predictive value for 30-day MACE. Clinical trial registration: clinicaltrials.gov (NCT02709135). [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to characterize key health indicators in Emergency Medical Services (EMS) personnel and identify areas for intervention in order to ensure a strong and capable emergency health workforce. Methods: Participants were EMS personnel delivering patients to 4 regional tertiary care emergency departments within North Carolina (NC). After transferring patient care and agreeing to participate, height, weight, and blood pressure (BP) measurements were recorded and each participant completed a questionnaire regarding demographics, activity levels, alcohol consumption, smoking, and medical history. Data were analyzed descriptively. Results: A sample of 452 EMS personnel from across NC was enrolled. The cohort was predominantly male (74.1%) and employed full-time (85.5%). The prevalence of overweight and obesity (80.3%) among EMS personnel was higher than the NC population (65.6%) and the general United States (US) population (70.8%). A previous diagnosis of high BP was reported by only 18.3% of participants, but 65.1% had elevated BP at the time of measurement. Alcohol consumption in the past 30 days among participants (55.4%) was slightly higher than state estimates (48.0%) and similar to national estimates (57.1%). However, heavy drinking (22.2%) and binge drinking (28.8%) were reported at much higher rates than state (5.6% and 15.2%, respectively) and national (6.6% and 18.3%, respectively) estimates. The prevalence of current smoking (21.5%) and quit attempts (48.8%) in the cohort was similar to state (21.8% and 55.0%, respectively) and national (21.2% and 55.7%, respectively) estimates. Likewise, the proportion of EMS providers meeting the Center for Disease Control's activity guidelines (49.6%) was similar to that found in the NC (46.8%) and the general US (48.0%) populations. Conclusions: These findings suggest a high prevalence of overweight and obesity, heavy drinking, binge drinking, and high BP among NC EMS personnel. Similar to fire service personnel, these rates are higher than the general US population. As such, they suggest areas where intervention would have the greatest positive impact on the health and performance of the EMS workforce. [ABSTRACT FROM AUTHOR]

Objective: Timely administration of epinephrine is critical in the treatment of anaphylaxis. This study sought to determine the frequency of administration of epinephrine by EMS providers caring for pediatric patients in the prehospital setting. Methods: We examined data from the NC EMS database (PreMIS) from 2010-3 to determine frequency of epinephrine administration in pediatric patients with anaphylaxis. We studied patients <18 years of age with an EMS provider impression of “allergic reaction.” Anaphylaxis was present if there was hypotension (defined as SBP < 90 or DBP < 45 for patients age 11 and older, and SBP < 70 + (2 × age) for patients ages 0-10), or impaired respirations (defined as description of labored or absent respirations, or RR < 12 or > 30). We determined the overall frequency of epinephrine administration. A multivariate logistic regression was then constructed to examine the impact of the following variables on appropriate epinephrine administration: age < 10, non-white race, rural county of case origin, duration of transportation from scene, and presence of a paramedic. Results: A total of 504 patients met inclusion criteria, of which 471 demonstrated anaphylaxis as previously defined. A total of 153 patients with anaphylaxis received epinephrine (32.4%, 95% CI 28.3-36.9%). Age < 10 was associated with increased odds of not receiving epinephrine appropriately (OR 2.90, 95% CI 1.85-4.54, p < 0.001). Other variables did not have statistically significant impact on epinephrine administration. Conclusion: There are missed opportunities for prehospital administration of epinephrine in pediatric patients with anaphylaxis. Very young children (age < 10) had increased odds for not receiving epinephrine. [ABSTRACT FROM AUTHOR]

Introduction The History, Electrocardiogram (ECG), Age, Risk Factors, and Troponin (HEART) score is a decision aid designed to risk stratify emergency department (ED) patients with acute chest pain. It has been validated for ED use, but it has yet to be evaluated in a prehospital setting. Hypothesis A prehospital modified HEART score can predict major adverse cardiac events (MACE) among undifferentiated chest pain patients transported to the ED.Methods: A retrospective cohort study of patients with chest pain transported by two county-based Emergency Medical Service (EMS) agencies to a tertiary care center was conducted. Adults without ST-elevation myocardial infarction (STEMI) were included. Inter-facility transfers and those without a prehospital 12-lead ECG or an ED troponin measurement were excluded. Modified HEART scores were calculated by study investigators using a standardized data collection tool for each patient. All MACE (death, myocardial infarction [MI], or coronary revascularization) were determined by record review at 30 days. The sensitivity and negative predictive values (NPVs) for MACE at 30 days were calculated.Results: Over the study period, 794 patients met inclusion criteria. A MACE at 30 days was present in 10.7% (85/794) of patients with 12 deaths (1.5%), 66 MIs (8.3%), and 12 coronary revascularizations without MI (1.5%). The modified HEART score identified 33.2% (264/794) of patients as low risk. Among low-risk patients, 1.9% (5/264) had MACE (two MIs and three revascularizations without MI). The sensitivity and NPV for 30-day MACE was 94.1% (95% CI, 86.8-98.1) and 98.1% (95% CI, 95.6-99.4), respectively.Conclusions: Prehospital modified HEART scores have a high NPV for MACE at 30 days. A study in which prehospital providers prospectively apply this decision aid is warranted. Stopyra JP , Harper WS , Higgins TJ , Prokesova JV , Winslow JE , Nelson RD , Alson RL , Davis CA , Russell GB , Miller CD , Mahler SA . Prehospital modified HEART score predictive of 30-day adverse cardiac events. Prehosp Disaster Med. 2018;33(1):58-62. [ABSTRACT FROM AUTHOR]

Background. Specially trained tactical emergency medical support (TEMS) personnel provide support to law enforcement special weapons and tactics (SWAT) teams. These programs benefit law enforcement agencies, officers, suspects, and citizens. TEMS programs are increasingly popular, but there are wide variations in their organization and operation and no recent data on their prevalence. Objective. We sought to measure the current prevalence and specific characteristics of TEMS programs in a comprehensive fashion in a single southeastern state. Methods. North Carolina emergency medical services (EMS) systems have county-based central EMS oversight; each system was surveyed by phone and e-mail. The presence and selected characteristics of TEMS programs were recorded. U.S. Census data were used to measure the population impact of the programs. Results. All of the 101 EMS systems statewide were successfully contacted. Thirty-three counties (33%) have TEMS programs providing medical support to 56 local law enforcement agencies as well as state and federal agencies. TEMS programs tend to be located in more populated urban and suburban areas, serving a population base of 5.9 million people, or 64% of the state's population. Tactical medics in the majority of these programs (29/33; 88%) are not sworn law enforcement officers. Conclusions. Approximately one-third of county-based EMS systems in North Carolina have TEMS programs. These programs serve almost two-thirds of the state's population base, using primarily nonsworn tactical medics. Comparison with other regions of the country will be useful to demonstrate differences in prevalence and program characteristics. Serial surveillance will help track trends and measure the growth and impact of this growing subspecialty field. [ABSTRACT FROM AUTHOR]

The article presents information on an inexpensive miniature electrocardiographic (ECG) device that have application in tactical medicine use. The device is marketed as a cardiac event recorder. The device can be placed directly on a patient's chest with electrical contact provided by sensors on the back of the instrument case, or it can be attached via a cable to standard ECG electrodes. It displays the ECG waveform on a small liquid crystal display screen. Tactical medical providers must be equipped and prepared to manage numerous traumatic injuries and medical conditions that may occur in unsecured areas where standard emergency medical services providers are not permitted.

Abstract: Background: TASER (TASER International, Scottsdale, AZ) conducted electrical weapons (CEWs) are commonly used by law enforcement officers. Although animal studies have suggested that transcardiac CEW discharges may produce direct cardiac effects, this has not been demonstrated in human studies. Objectives: This study sought to determine the incidence and outcomes of transcardiac CEW probe impact locations in a large series of actual CEW deployments. Methods: A multi-center database of consecutive CEW uses by law enforcement officers was retrospectively reviewed. Case report forms were independently reviewed by three investigators to identify cases with paired probe configurations potentially producing a transcardiac discharge vector. Descriptive analysis was performed and inter-rater reliability was assessed. Results: Among 1201 total CEW uses, 813 included probe deployments and 178 cases had paired anterior probe impacts potentially capable of producing a transcardiac discharge vector. This represents 14.8% of all CEW uses (95% confidence interval [CI] 12.9–16.9%) and 21.9% of CEW uses in probe mode (95% CI 19.1–24.9%). Inter-rater agreement was very good, with kappa = 0.82. There were no immediate deaths in any cases (97.5% CI 0.0–0.3%) to suggest a cardiac dysrhythmia, including those with transcardiac discharge vector. Conclusion: CEW deployments with probe impact configurations capable of producing a transcardiac discharge occur in a minority of cases in field use conditions. None of these cases, transcardiac or otherwise, produced immediately fatal dysrhythmias. These data support the overall safety of CEWs and provide a benchmark estimate of the likelihood of transcardiac discharge vectors occurring in field use of CEWs. [Copyright &y& Elsevier]

Abstract: Background: Excited delirium is increasingly recognized as a risk factor for sudden death, though the specific pathophysiology of these deaths is typically unclear. Objectives: We describe a survivor of excited delirium that displayed a transient severe prolongation of the QT interval, suggesting unmasking of long QT syndrome as a possible mechanism of sudden death. Case Report: A 30-year-old man was arrested by police for violent assaultive behavior. Officers at the scene noted confusion, nonsensical speech, sweating, and bizarre agitated behavior; he was transported to the Emergency Department for medical evaluation of possible excited delirium. His initial electrocardiogram revealed a markedly prolonged corrected QT interval of over 600 ms. Intravenous hydration and sodium bicarbonate were administered, with normalization of the QT; he was admitted and recovered uneventfully. Conclusions: We discuss the possible association between long QT syndrome and unexplained sudden deaths seen with excited delirium. Sodium bicarbonate may be considered when long QT syndrome is identified during or after agitated delirium, though its routine use cannot be recommended based on a case report. [Copyright &y& Elsevier]