Search

INTRODUCTION: Illicitly manufactured fentanyl (IMF) is responsible for a growing number of deaths. Some case series have suggested that IMF overdoses require significantly higher naloxone doses than heroin overdoses. Our objective was to determine if the naloxone dose required to treat an opioid overdose is associated with the finding of fentanyl, opiates, or both on urine drug screen (UDS). METHODS: A retrospective chart review was conducted at a single emergency department and its affiliated emergency medical services (EMS) agency. The charts of all patients who received naloxone through this EMS from 1/1/2017 to 6/15/2018 were reviewed. The study included patients diagnosed with a non-suicidal opioid overdose whose UDS was positive for opiates, fentanyl, or both. Data collected included demographics, vital signs, initial GCS, EMS and ED naloxone administrations, response to treatment, laboratory findings, and ED disposition. The fentanyl-only and fentanyl + opiate groups were compared to the opiate-only group using the stratified (by ED provider) variant of the Mann-Whitney U test. RESULTS: Eight hundred and thirty-seven charts were reviewed, and 121 subjects were included in the final analysis. The median age of included subjects was 38 years and 75% were male. In the naloxone dose analysis, neither the fentanyl-only (median 0.8 mg, IQR 0.4–1.6; p = 0.68) nor the fentanyl + opiate (median 0.8 mg, IQR 0.4–1.2; p = 0.56) groups differed from the opiate-only group (median 0.58 mg, IQR 0.4–1.6). CONCLUSION: Our findings refute the notion that high potency synthetic opioids like illicitly manufactured fentanyl require increased doses of naloxone to successfully treat an overdose. There were no significant differences in the dose of naloxone required to treat opioid overdose patients with UDS evidence of exposure to fentanyl, opiates, or both. Further evaluation of naloxone stocking and dosing protocols is needed. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s13181-019-00735-w) contains supplementary material, which is available to authorized users.

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.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.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.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.

Growing numbers of emergency medical services (EMS) providers respond to patients who receive hospice care. The objective of this investigation was to assess the knowledge, attitudes, and experiences of EMS providers in the care of patients enrolled in hospice care.We conducted a survey study of EMS providers regarding hospice care. We collected quantitative and qualitative data on EMS provider's knowledge, attitudes, and experiences in responding to the care needs of patients in hospice care. We used Chi-squared tests to compare EMS provider's responses by credential (Emergency Medical Technician [EMT] vs. Paramedic) and years of experience (0-5 vs. 5+). We conducted a thematic analysis to examine open-ended responses to qualitative questions.Of the 182 EMS providers who completed the survey (100% response rate), 84.1% had cared for a hospice patient one or more times. Respondents included 86 (47.3%) EMTs with Intermediate and Advanced training and 96 (52.7%) Paramedics. Respondent's years of experience ranged from 0-10+ years, with 99 (54.3%) providers having 0-5 years of experience and 83 (45.7%) providers having 5+ years of experience. There were no significant differences between EMTs and Paramedics in their knowledge of the care of these patients, nor were there significant differences (p0.05) between those with 0-5 and 5+ years of experience. Furthermore, 53 (29.1%) EMS providers reported receiving formal education on the care of hospice patients. A total of 36% respondents felt that patients in hospice care required a DNR order. In EMS providers' open-ended responses on challenges in responding to the care needs of hospice patients, common themes were family-related challenges, and the need for more education.While the majority of EMS providers have responded to patients enrolled in hospice care, few providers received formal training on how to care for this population. EMS providers have expressed a need for a formal curriculum on the care of the patient receiving hospice.

IntroductionLittle is known about the existence, distribution, and characteristics of Emergency Medical Services (EMS) systems in Africa, or the corresponding epidemiology of prehospital illness and injury.MethodsA survey was conducted between 2013 and 2014 by distributing a detailed EMS system questionnaire to experts in paper and electronic versions. The questionnaire ascertained EMS systems’ jurisdiction, operations, finance, clinical care, resources, and regulatory environment. The discovery of respondents with requisite expertise occurred in multiple phases, including snowball sampling, a review of published scientific literature, and a rigorous search of the Internet.ResultsThe survey response rate was 46%, and data represented 49 of 54 (91%) African countries. Twenty-five EMS systems were identified and distributed among 16 countries (30% of African countries). There was no evidence of EMS systems in 33 (61%) countries. A total of 98,574,731 (8.7%) of the African population were serviced by at least one EMS system in 2012. The leading causes of EMS transport were (in order of decreasing frequency): injury, obstetric, respiratory, cardiovascular, and gastrointestinal complaints. Nineteen percent of African countries had government-financed EMS systems and 26% had a toll-free public access telephone number. Basic emergency medical technicians (EMTs) and Basic Life Support (BLS)-equipped ambulances were the most common cadre of provider and ambulance level, respectively (84% each).ConclusionEmergency Medical Services systems exist in one-third of African countries. Injury and obstetric complaints are the leading African prehospital conditions. Only a minority (Mould-MillmanNK, DixonJM, SefaN, YanceyA, HollongBG, HagahmedM, GindeAA, WallisLA. The state of Emergency Medical Services (EMS) systems in Africa. Prehosp Disaster Med. 2017;32(3):273–283.

Emergency medical dispatch (EMD) systems are a crucial component of effective Emergency Medical Services (EMS) systems. They provide a means of public access to emergency care information and out-of-hospital emergency care resources and expertise. EMD systems also link various components of EMS, thereby improving efficiency and performance. As EMS systems are rapidly developing across many parts of Africa, EMD systems which are context appropriate are in great need, but are mostly absent despite the wide availability of telecommunications technology. To facilitate the development of EMD systems appropriate for the African setting, the African Federation for Emergency Medicine (AFEM) and the International Academies of Emergency Dispatch (IAED) convened a working group in November 2014 to provide conceptual, technical, and innovative recommendations for contextually appropriate EMD systems for African settings. It is hoped that these recommendations will augment efficiency, effectiveness, and standardisation within and among African EMD systems, thereby improving health outcomes for sufferers of acute illness or injury.

Background and Purpose— The Emergency Medical Services field triage to stroke centers has gained considerable complexity with the recent demonstration of clinical benefit of endovascular treatment for acute ischemic stroke. We sought to describe a new smartphone freeware application designed to assist Emergency Medical Services professionals with the field assessment and destination triage of patients with acute ischemic stroke. Methods— Review of the application’s platform and its development as well as the different variables, assessments, algorithms, and assumptions involved. Results— The FAST-ED (Field Assessment Stroke Triage for Emergency Destination) application is based on a built-in automated decision-making algorithm that relies on (1) a brief series of questions assessing patient’s age, anticoagulant usage, time last known normal, motor weakness, gaze deviation, aphasia, and hemineglect; (2) a database of all regional stroke centers according to their capability to provide endovascular treatment; and (3) Global Positioning System technology with real-time traffic information to compute the patient’s eligibility for intravenous tissue-type plasminogen activator or endovascular treatment as well as the distances/transportation times to the different neighboring stroke centers in order to assist Emergency Medical Services professionals with the decision about the most suitable destination for any given patient with acute ischemic stroke. Conclusions— The FAST-ED smartphone application has great potential to improve the triage of patients with acute ischemic stroke, as it seems capable to optimize resources, reduce hospital arrivals times, and maximize the use of both intravenous tissue-type plasminogen activator and endovascular treatment ultimately leading to better clinical outcomes. Future field studies are needed to properly evaluate the impact of this tool in stroke outcomes and resource utilization.

Background: Emergency medical care is performed in an uncontrolled environment and involves invasive procedures and life support measures. The performance of these duties places emergency care practitioners (ECPs) at risk of occupationally acquired injuries and communicable diseases. Although legislative guidelines exist for the protection of healthcare workers, little is known about the protective measures available for and utilised by ECPs in the pre-hospital environment in South Africa. Objectives: To review the availability and implementation of emergency medical services (EMS)-specific infection control policies and standard operating procedures in the pre-hospital environment. Methods: Interviews with key informants were used to collect data concerning policies on communicable diseases and infection control in the EMS, the operational aspects of these policies, and educational programmes on communicable diseases and infection control for ECPs. Results: There is no national policy on communicable diseases and infection control in EMS. Only KwaZulu-Natal, Eastern Cape and Gauteng have EMS-specific standard operating procedures for communicable diseases and infection control. Formal education and in-service training is limited. Conclusions: A national communicable disease and infection control policy specific to the EMS needs to be developed together with an accredited training module on communicable diseases and infection control for EMS in the pre-hospital environment.

Mass gatherings are heterogeneous in terms of size, duration, type of event, crowd behavior, demographics of the participants and spectators, use of recreational substances, weather, and environment. The goals of health and medical services should be the provision of care for participants and spectators consistent with local standards of care, protection of continuing medical service to the populations surrounding the event venue, and preparation for surge to respond to extraordinary events. Pre-event planning among jurisdictional public health and EMS, acute care hospitals, and event EMS is essential, but should also include, at a minimum, event security services, public relations, facility maintenance, communications technicians, and the event planners and organizers. Previous documented experience with similar events has been shown to most accurately predict future needs. Future work in and guidance for mass gathering medical care should include the consistent use and further development of universally accepted consistent metrics, such as Patient Presentation Rate and Transfer to Hospital Rate. Only by standardizing data collection can evaluations be performed that link interventions with outcomes to enhance evidence-based EMS services at mass gatherings. Research is needed to evaluate the skills and interventions required by EMS providers to achieve desired outcomes. The event-dedicated EMS Medical Director is integral to acceptable quality medical care provided at mass gatherings; hence, he/she must be included in all aspects of mass gathering medical care planning, preparations, response, and recovery. Incorporation of jurisdictional EMS and community hospital medical leadership, and emergency practitioners into these processes will ensure that on-site care, transport, and transition to acute care at appropriate receiving facilities is consistent with, and fully integrated into the community's medical care system, while fulfilling the needs of event participants.

Most respondents thought the number of ambulances insufficient and said they would rather use a taxi—perceived to be faster—in a medical emergency. Nevertheless, people generally had favorable attitudes of existing public ambulance services, although few knew of the toll-free emergency number and many thought it appropriate to use ambulances to transport corpses. Targeted public education, along with improved capacity of ambulance agencies to handle increased caseload, could improve use., Background: Emergency medical services (EMS) systems provide professional prehospital emergency medical care and transportation to help improve outcomes from emergency conditions. Ghana’s national ambulance service has relatively low public utilization in comparison with the large burden of acute disease. Methods: A survey instrument was developed using Pechansky and Thomas’s model of access covering 5 dimensions of availability, accessibility, accommodation, affordability, and acceptability. The instrument was used in a cross-sectional survey in 2013 in Accra, Ghana; eligible participants were those 18 years and older who spoke English, French, or Twi. Although the analysis was mainly descriptive, logistic regression was used to identify factors associated with reported intention to call for an ambulance in the case of a medical emergency. Results: 468 participants completed surveys, with a response rate of 78.4%. Few (4.5%) respondents had ever used an ambulance in prior emergency situations. A substantial proportion (43.8%) knew about the public access medical emergency telephone number, but of those only 37.1% knew it was a toll-free call. Most (54.7%) respondents believed EMTs offered high-quality care, but 78.0% believed taxis were faster than ambulances and 69.2% thought the number of ambulances in Accra insufficient. Many (23.4%) thought using ambulances to transport corpses would be appropriate. In two hypothetical emergency scenarios, respondents most commonly reported taxis as the preferred transportation (63.6% if a family member were burned in a house fire, 64.7% if a pedestrian were struck by a vehicle). About 1 in 5 respondents said they would call an ambulance in either scenario (20.7% if a family member were burned in a house fire, 23.3% if a pedestrian were struck by a vehicle) while 15.5% and 10.2%, respectively, would use any available vehicle. Those aged 18–35 years were more likely than older respondents to prefer an ambulance (odds ratio [OR], 2.27; confidence interval [CI], 1.47 to 3.68), as were those with prior ambulance experience (OR, 1.75; CI, 0.98 to 3.09) (compared with those with no prior experience) and those who believed ambulances were safer than taxis (OR, 2.17; CI, 1.1 to 4.2) (compared with those who did not hold such beliefs). Conclusions: Perceptions of public ambulance services in Accra, Ghana, are generally favorable, although use is low. Public health education to improve awareness of the toll-free medical emergency number and about appropriate use of ambulances while simultaneously improving the capacity of ambulance agencies to receive increased caseload could improve use of the EMS system.

Objective To derive and validate a predictive model and novel emergency medical services (EMS) screening tool for severe sepsis (SS). Design Retrospective cohort study. Setting A single EMS system and an urban, public hospital. Patients Sequential adult, nontrauma, nonarrest, at-risk, EMS-transported patients between January 1, 2011, and December 31, 2012 were included in the study. At-risk patients were defined as having all 3 of the following criteria present in the EMS setting: (1) heart rate greater than 90 beats/min, (2) respiratory rate greater than 20 beats/min, and (3) systolic blood pressure less than 110 mm Hg. Interventions None. Measurements and Main Results Among 66,439 EMS encounters, 555 met the criteria for analysis. Fourteen percent (n = 75) of patients had SS, of which 19% (n = 14) were identified by EMS clinical judgment. In-hospital mortality for patients with SS was 31% (n = 23). Six EMS characteristics were found to be predictors of SS: older age, transport from nursing home, Emergency Medical Dispatch (EMD) 9-1-1 chief concern category of "sick person," hot tactile temperature assessment, low systolic blood pressure, and low oxygen saturation. The final predictive model showed good discrimination in derivation and validation subgroups (areas under curves, 0.843 and 0.820, respectively). Sensitivity of the final model was 91% in the derivation group and 78% in the validation group. At a predefined threshold of 2 or more points, prehospital severe sepsis (PRESS) score sensitivity was 86%. Conclusions The PRESS score is a novel EMS screening tool for SS that demonstrates a sensitivity of 86% and a specificity of 47%. Additional validation is needed before this tool can be recommended for widespread clinical use.

Background: International consensus guidelines now support the use of “chest compressions-only” cardiopulmonary resuscitation (CPR) instructions (CCOIs) by emergency medical dispatch (EMD) personnel providing telephone assistance to untrained bystanders at a cardiac arrest scene. These guidelines are based largely on evolving experimental data and a clinical trial conducted in one venue with distinct emergency medical services (EMS) system features. Accordingly, the Council of Standards for the National Academies of Emergency Dispatch was asked to adapt a modified telephone CPR protocol, and specifically one that could be applied more broadly to the spectrum of EMS systems. Methods: A group of international EMD specialists, researchers and professional association representatives analyzed available scientific data and considered variations in EMS systems, particularly those in Europe and North America. Results and conclusions: Several recommendations were established: (1) to avoid confusion, bystanders already providing CPR should continue those previously learned methods; (2) following a sudden collapse unlikely to be of respiratory etiology, CCOIs should be provided when the bystander is not CPR-trained, declining to perform mouth-to-mouth ventilation or unsure of actions to take; (3) following 4 min of CCOIs, ventilations can be provided, but, for now, only at a compression–ventilation ratio of 100:2 until EMS arrives; (4) until more data become available, dispatchers should follow existing compression–ventilation protocols for children and adult cases involving probable respiratory/trauma etiologies; (5) EMD CPR protocols should account for EMS system features and receive quality oversight and expert medical direction.

This report describes the rationale, purpose, structure, and content of the emergency medical services (EMS) injury prevention program "Accidents Aren't." The program is introduced with a review of injuries' toll professionally, epidemiologically, and economically in terms of the demand on medical care resources and the expense of care. With recognition that most EMS resources are expended on clinical care of non-critical but potentially catastrophic injuries, "Accidents Aren't" was designed to offer a more cost-effective means of care for this population and more efficient utilization of finite resources. The report describes the program's formulation process, its modular design, the instructor guidelines, the core training tool, the STARR mnemonic, and five clinical cases involving a wide array of injury mechanisms to which the mnemonic is applicable. Physician involvement in teaching and implementing the program is discussed. The relationship of the program to the future of EMS concludes the report.

Purpose: To standardize the care of acute stroke patients who receive IV tPA being transported by ground EMS from a treating hospital to a stroke center. Background: National consensus guidelines exist for the hospital management of patients receiving IV tPA for acute ischemic stroke. Such patients require close monitoring and management to minimize risk of clinical deterioration. Although patients are often emergently transported from local hospitals to a stroke center, there are no treatment specific national guidelines for managing such patients enroute. As a result, there is a need to develop and implement a standardized approach to guide EMS personnel, particularly in states like Georgia where the public health burden of stroke is high. Methods: In 2012, the “Georgia EMS Interfacility Ground Transport Protocol for Patients during/after IV tPA Administration for Acute Ischemic Stroke” was developed in conjunction with the Georgia Coverdell Acute Stroke Registry, the Georgia State Office of EMS, a representative group of Georgia hospitals and EMS providers. Stakeholders were brought together with the goal of creating a unified statewide protocol. The intent was to create a streamlined protocol which could be readily implemented by pre-hospital care providers. Results: Stakeholders discussed challenges and opportunities to change the process of pre-hospital care. Challenges included recognition of the broad diversity of EMS providers representing over 250 agencies in the state. Opportunities included establishing the framework for greater collaboration across organizations and providers. The final protocol was endorsed by both the Georgia Coverdell Acute Stroke Registry and the State Office of EMS, and distributed to all EMS regions in Georgia. EMS agencies are currently implementing the protocol. Conclusion: Engaging a diverse group of statewide stakeholders to develop a new treatment protocol enhances success in implementation and serves to further the public health mission of improving care of acute stroke patients.

Introduction The use of Emergency Medical Services (EMS) for low-acuity pediatric problems is well documented. Attempts have been made to curb potentially unnecessary transports, including using EMS dispatch protocols, shown to predict acuity and needs of adults. However, there are limited data about this in children. The primary objective of this study is to determine the pediatric emergency department (PED) resource utilization (surrogate of acuity level) for pediatric patients categorized as “low-acuity” by initial EMS protocols. Methods Records of all pediatric patients classified as “low acuity” and transported to a PED in winter and summer of 2010 were reviewed. Details of the PED visit were recorded. Patients were categorized and compared based on chief complaint group. Resource utilization was defined as requiring any prescription medications, labs, procedures, consults, admission or transfer. “Under-triage” was defined as a “low-acuity” EMS transport subsequently requiring emergent interventions. Results Of the 876 eligible cases, 801 were included; 392/801 had no resource utilization while 409 of 801 had resource utilization. Most (737/801) were discharged to home; however, 64/801 were admitted, including 1 of 801 requiring emergent intervention (under-triage rate 0.12%). Gastroenterology and trauma groups had a significant increase in resource utilization, while infectious disease and ear-nose-throat groups had decreased resource utilization. Discussion While this EMS system did not well predict overall resource utilization, it safely identified most low-acuity patients, with a low under-triage rate. This study identifies subgroups of patients that could be managed without emergent transport and can be used to further refine current protocols or establish secondary triage systems.

Summary Objectives To present crucial stages of planning and the resources involved in the medical and health care that will address issues affecting the health and safety of all participants in the 2010 World Cup. Design Relevant literature reviews of mass gathering medical care supplemented experience of the authors in planning for previous similar events. Attention is focused on issues wherein effective planning requires the integration of public health practices with those of clinical emergency medical services. The tables that are included serve to illustrate the depth and breadth of planning as well as the organizational relationships required to execute care of a universally acceptable standard. Conclusions This article offers guidance in planning for the 2010 World Cup health and emergency medical care, emphasizing the need for integration of public health and medical practices. It depicts the span of planning envisioned, the organizational relationships crucial to it, and emphasizes the necessity of an early start.

Introduction: Temperature is one of the 4 SIRS criteria and is frequently abnormal in septic patients due to infectious and inflammatory pyrogens. However, core temperature does not always correlate with tactile assessment. Whether EMS assessment of tactile temperatures will predict sepsis is not kn