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Background: Uncontrolled external hemorrhage is a common cause of preventable death. The Hartford Consensus recommendations presented the concept of a continuum of care, in which police officers should be considered an integral component of the emergency medical response to active shooter incidents. Recent publications have reported individual cases of tourniquet application by police officers. This report analyzed all documented cases of hemorrhage control using tourniquets applied by police officers in a single large metropolitan police department., Methods: A retrospective computerized search of all public safety communications center reports and police officer documentation for cases of tourniquet application was conducted by searching for the word "tourniquet." Each case was evaluated for indication and appropriateness using Stop The Bleed criteria for tourniquet placement. In addition, police response time was compared to emergency medical services (EMS) response time in an effort to determine if there was a time difference in response to the bleeding patient that could potentially impact patient outcomes., Results: Forty- three cases were identified over the 6-year period ending in December 2019. The majority of cases involved gunshot wounds and most were civilian victims. Injured police officers accounted for two cases (gunshot wound and dog bite). Review of the officers' narratives indicated that most applications appeared justified using the Stop The Bleed criteria (two cases were questionable if a tourniquet was necessary and one may have been placed in an incorrect location). On average, police arrived 4 minutes sooner than EMS did., Conclusion: Several reports in the literature document the success of police officer application of tourniquets to control limb hemorrhage. Most of the reports involved a small number of case reports. This is the largest case series to date from a single urban police department., (2021.)

Importance: Trauma is the leading cause of death for US individuals younger than 45 years, and uncontrolled hemorrhage is a major cause of trauma mortality. The US military's medical advancements in the field of prehospital hemorrhage control have reduced battlefield mortality by 44%. However, despite support from many national health care organizations, no integrated approach to research has been made regarding implementation, epidemiology, education, and logistics of prehospital hemorrhage control by layperson immediate responders in the civilian sector., Objective: To create a national research agenda to help guide future work for prehospital hemorrhage control by laypersons., Evidence Review: The 2-day, in-person, National Stop the Bleed (STB) Research Consensus Conference was conducted on February 27 to 28, 2019, to identify and achieve consensus on research gaps. Participants included (1) subject matter experts, (2) professional society-designated leaders, (3) representatives from the federal government, and (4) representatives from private foundations. Before the conference, participants were provided a scoping review on layperson prehospital hemorrhage control. A 3-round modified Delphi consensus process was conducted to determine high-priority research questions. The top items, with median rating of 8 or more on a Likert scale of 1 to 9 points, were identified and became part of the national STB research agenda., Findings: Forty-five participants attended the conference. In round 1, participants submitted 487 research questions. After deduplication and sorting, 162 questions remained across 5 a priori-defined themes. Two subsequent rounds of rating generated consensus on 113 high-priority, 27 uncertain-priority, and 22 low-priority questions. The final prioritized research agenda included the top 24 questions, including 8 for epidemiology and effectiveness, 4 for materials, 9 for education, 2 for global health, and 1 for health policy., Conclusions and Relevance: The National STB Research Consensus Conference identified and prioritized a national research agenda to support laypersons in reducing preventable deaths due to life-threatening hemorrhage. Investigators and funding agencies can use this agenda to guide their future work and funding priorities.

On March 13, 2019 the EMS Examination Committee of the American Board of Emergency Medicine (ABEM) approved modifications to the Core Content of EMS Medicine. The Core Content is used to define the subspecialty of EMS Medicine, provides the basis for questions to be used during written examinations, and leads to development of a certification examination blueprint. The Core Content defines the universe of knowledge for the treatment of prehospital patients that is necessary to practice EMS Medicine. It informs fellowship directors and candidates for certification of the full range of content that might appear on certification examinations.

Background: With increasing active shooter and intentional mass casualty events, as well as everyday injuries resulting in severe bleeding, there have been calls for the public to learn bleeding control techniques. The aims of this project were to offer bleeding control training to surgeons attending the Clinical Congress of the American College of Surgeons (ACS), to determine if the trained surgeons believe that teaching bleeding control to the public should be a priority of the ACS, and to assess the surgeon trainees' perceptions regarding the appropriateness of the course for a public audience., Study Design: This was an educational program with a post-course evaluation to determine if the bleeding control course is appropriate for a public audience., Results: Three hundred forty-one surgeons were trained. All were trained and successfully performed a return demonstration. Regarding perceptions of the participating surgeons that teaching bleeding control to the public should be a priority of the ACS, 93.79% of the 322 surgeons responding indicated agreement with this proposition. Regarding whether or not the training was at an appropriate level of difficulty for the public, 93.13% of the 320 respondents to this item agreed that it was appropriate., Conclusions: The surgeons who were trained were very much in favor of making training the public a priority of the ACS. With additional training of surgeons and other health care professionals as trainers, and the engagement of the public, the goal of having a citizenry prepared to stop bleeding can be achieved., (Copyright © 2017 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Active shooter incidents have led to the recognition that the traditional response paradigm of sequential response and scene entry by law enforcement, first responders, and emergency medical service (EMS) personnel produced delays in care and suboptimal victim outcomes. The Hartford Consensus Group developed recommendations to improve the response to and outcomes from active shooter events and urged that a continuum of care be implemented that incorporates not only EMS response, but also the initiation of care by law enforcement officers and potentially by lay bystanders., Objective: To develop and implement tiered educational programs designed to teach police officers and lay bystanders the principles of initial trauma care and bleeding control using as a foundation the U.S. military's Tactical Combat Casualty Care course and the guidelines of the Committee on Tactical Emergency Casualty Care., Discussion: The Tactical Casualty Care for Law Enforcement and First Responders course is a 1-day program combining didactic lecture, hands-on skills stations, and clinical scenarios designed primarily for police officers. The Bleeding Control for the Injured is a 2- to 3-h program for the potential citizen responder in the skills of hemorrhage control. In addition, we document the application of these skills by law enforcement officers and first responders in several real-life incidents involving major hemorrhage., Conclusions: Developing and implementing tiered educational programs for hemorrhage control will improve response by police officers and the lay public. Educating law enforcement officers in these skills has been demonstrated to improve trauma victim survival., (Copyright © 2015 Elsevier Inc. All rights reserved.)

On September 23, 2010, the American Board of Medical Specialties (ABMS) approved emergency medical services (EMS) as a subspecialty of emergency medicine. As a result, the American Board of Emergency Medicine (ABEM) is planning to award the first certificates in EMS medicine in the fall of 2013. The purpose of subspecialty certification in EMS, as defined by ABEM, is to standardize physician training and qualifications for EMS practice, to improve patient safety and enhance the quality of emergency medical care provided to patients in the prehospital environment, and to facilitate integration of prehospital patient treatment into the continuum of patient care. In February 2011, ABEM established the EMS Examination Task Force to develop the Core Content of EMS Medicine (Core Content) that would be used to define the subspecialty and from which questions would be written for the examinations, to develop a blueprint for the examinations, and to develop a bank of test questions for use on the examinations. The Core Content defines the training parameters, resources, and knowledge of the treatment of prehospital patients necessary to practice EMS medicine. Additionally, it is intended to inform fellowship directors and candidates for certification of the full range of content that might appear on the examinations. This article describes the development of the Core Content and presents the Core Content in its entirety.

Health-care providers are increasingly faced with the possibility of needing to care for people injured in explosions, but can often, however, feel undertrained for the unique aspects of the patient's presentation and management. Although most blast-related injuries (eg, fragmentation injuries from improvised explosive devices and standard military explosives) can be managed in a similar manner to typical penetrating or blunt traumatic injuries, injuries caused by the blast pressure wave itself cannot. The blast pressure wave exerts forces mainly at air-tissue interfaces within the body, and the pulmonary, gastrointestinal, and auditory systems are at greatest risk. Arterial air emboli arising from severe pulmonary injury can cause ischaemic complications-especially in the brain, heart, and intestinal tract. Attributable, in part, to the scene chaos that undoubtedly exists, poor triage and missed diagnosis of blast injuries are substantial concerns because injuries can be subtle or their presentation can be delayed. Management of these injuries can be a challenge, compounded by potentially conflicting treatment goals. This Seminar aims to provide a thorough overview of these unique primary blast injuries and their management.

There is a need for emergency planners to accurately plan for and accommodate a potentially significant increase in patient volume in response to a disaster. In addition, an equally large political demand exists for leaders in government and the healthcare sector to develop these capabilities in a financially feasible and evidence-based manner. However, it is important to begin with a clear understanding of this concept on a theoretical level to create this capacity. Intuitively, it is easy to understand that surge capacity describes the ability of a healthcare facility or system to expand beyond its regular operations and accommodate a greater number of patients in response to a multiple casualty-producing event. The way a response to this need is implemented will, of course, vary dramatically depending on numerous issues, including the type of event that has transpired, the planning that has occurred before its occurrence, and the resources that are available. Much has been written on strategies for developing and implementing surge capacity. However, despite the frequency with which the term is used in the medical literature and by the lay press, a clear description of surge capacity as a concept is lacking. The following article will provide this foundation. A conceptual framework of surge capacity will be described, and some new nomenclature will be proposed. This is done to provide the reader with a comprehensive yet simplified view of the various elements that make up the concept of surge capacity. This framework will cover the types of events that can cause a surge of patients, the general ways in which healthcare facilities respond to these events, and the categories of people who would make up the population of affected victims.

A study was designed to determine whether paramedics accurately predict which patients will require admission to the hospital, and in those requiring admission, whether they will need a ward bed or intensive care unit (ICU) monitoring. This prospective, cross-sectional study of consecutive Emergency Medical Service (EMS) transport patients was conducted at an urban city hospital. Paramedics were asked to predict if the patient they were transporting would require admission to the hospital, and if so, whether that patient would be admitted to a ward bed or require an ICU bed. Predictions were compared to actual patient disposition. During the study period, 1349 patients were transported to our hospital. Questionnaires were submitted in 985 cases (73%) and complete data were available for 952 (97%) of these patients. Paramedics predicted 202 (22%) patients would be admitted to the hospital, of whom 124 (61%) would go the ward and 78 (39%) would require intensive care. The actual overall admission rate was 21%, although the sensitivity of predicting any admission was 62% with a positive prediction value (PPV) of 59%. Further, the paramedics were able to predict admission to intensive care with a sensitivity of 68% and PPV of 50%. It is concluded that paramedics have very limited ability to predict whether transported patients require admission and the level of required care. In our EMS system, the prehospital diversion policies should not be based solely on paramedic determination.

Background: Aspirin (ASA) has unquestioned benefit to patients with cardiac ischemia. Previous studies indicate health care providers may not adequately treat patients experiencing cardiac ischemia with ASA., Objective: To determine the rate of ASA use for patients being treated for chest pain suggestive of cardiac ischemia in the prehospital setting., Methods: This was a retrospective study of paramedic encounters identified through billing records for all patients receiving the combination of an intravenous catheter, supplemental oxygen, and cardiac monitoring from November 2001 to January 2002. Prehospital medical records were reviewed in order to determine the proportion of patients with suspected cardiac ischemia who received ASA. The setting was a single prehospital emergency medical services system serving an urban population., Results: A total of 2,457 paramedic encounters were reviewed over a three-month period. Two hundred thirty-two patients were assessed as having cardiac ischemia, of whom 169 (73%) had no absolute or relative contraindication to ASA. Of the 169 patients, only 92 (54%) received ASA. Of the 99 patients, who received nitroglycerin for presumed cardiac ischemia and had no contraindication to receiving ASA, only 78 (79%) received ASA. Of the 453 patients complaining of nontraumatic chest pain and without a contraindication, 157 (35%) received ASA., Conclusions: Paramedics do not use ASA optimally and may choose therapies with less proven benefit.

Complaints against Emergency Medical Services (EMS) agencies represent a concerning and potentially time-consuming problem for all involved in the delivery of prehospital emergency medical care. The objective of this study was to identify the source of complaints against an EMS system to help focus quality and performance improvement and customer service efforts. We conducted a retrospective review of complaints filed against a busy urban EMS agency over a 6-year period. All complaints were included, totaled by season and by year, and categorized by originator and nature of the complaint. A total of 286 complaints were registered during the 6-year period, with an average of 48 per year and 9.3 per 10,000 responses. The most common originators of complaints were patients (53%) followed by medical personnel (19%) and family members or friends (12%). Rude behavior accounted for 23% of the complaints registered, followed by technical skills (20%), transport problems (18%), and loss of belongings (13%). The identification of areas of dissatisfaction will allow focused quality and performance improvement programs directed at customer service and risk management.

Emergency Medical Services (EMS) agencies are increasingly being held to an ambulance response time (RT) criterion of responding to a medical emergency within 8 min for at least 90% of calls. This recommendation resulted from one study of outcome after nontraumatic cardiac arrest and has never been studied for any other emergency. This retrospective study evaluates the effect of exceeding the 8 min RT guideline on patient survival for victims of traumatic injury treated by an urban paramedic ambulance EMS system and transported to a single Level I trauma center. Of 3576 patients identified by the hospital trauma registry, 3490 (97.6%) had complete records available. Patients were grouped according to ambulance RT: < or = 8 min (n = 2450) or > 8 min (n = 1040). After controlling for other significant predictors, there was no difference in survival after traumatic injury when the 8 min ambulance RT criteria was exceeded (mortality odds ratio 0.81, 95% CI 0.43-1.52). There was also no significant difference in survival when patients were stratified by injury severity score group. Exceeding the ambulance industry response time criterion of 8 min does not affect patient survival after traumatic injury.

Study Objective: The task force assessed the needs, demands, feasibility, and content of training for US civilian emergency medical responders (paramedics, nurses, and physicians) for nuclear/biological/chemical (NBC) terrorism., Methods: A task force representing key professional organizations, stakeholders, and disciplines involved in emergency medical response conducted an iterated instructional-design analysis on the feasibility and content of such training with input from educational professionals. We then analyzed 6 previously developed training courses for their congruence with our recommendations., Results: The task force produced descriptions of learning groups, content and learning objectives, and barriers and challenges to NBC education. Access to training and sustainment of learning (retention of knowledge) represent the significant barriers. The courses analyzed by the task force did not meet all objectives and challenges addressed., Conclusion: The task force recommends training programs and materials need to be developed to overcome the identified barriers and challenges to learning for these audiences. Furthermore, the task force recommends incorporating NBC training into standard training programs for emergency medical professionals.

Wound botulism is a rare and potentially fatal disease. The use of black tar heroin has spawned an increase in the incidence of the disease, with the majority of cases occurring in California. The use of botulism antitoxin and surgical debridement are recommended to decrease hospital stay. For this to be effective, the diagnosis of wound botulism first must be considered, followed by an aggressive search for any area of infection that may be debrided. This case report demonstrates several factors to consider in patients presenting with symptoms of botulism poisoning: occurrence away from the Mexico border, no obvious abscess, and the need for prolonged ventilatory support. This case report documents a prolonged hospital stay, possibly caused by delay in administration of antitoxin in a patient with cellulitis that was not considered appropriate for debridement.

We evaluated the effects of Emergency Medicine (EM) residency training, EM board certification, and physician experience on the occurrence of malpractice claims and indemnity payments. This was a retrospective review of closed malpractice claims from a single insurer. Outcome measures included the occurrence of claims resulting in indemnity, indemnity amounts, and defense costs. Differences in the outcome measures were compared based on: EM residency training, EM board certification, EM residency training versus other residency training, and physician experience using both univariate and multivariate analyses. There were 428 closed EM claims with indemnity paid in 81 (18.9%). Indemnity was paid in 22. 4% of closed claims against non-EM residency-trained physicians, and in only 13.3% against EM residency-trained physicians (p = 0.04). The total indemnity was $6,214,475. Non-EM trained physicians accounted for $4,440,951 (71.5%), EM residency-trained physicians accounted for $1,773,524 (28.5%). The average indemnity was $76,721 and the average defense cost was $17,775. There were no significant differences in the mean indemnity paid per closed claim or the mean cost to defend a closed claim when comparing EM-trained and non-EM residency-trained physicians. The total cost (indemnity + defense costs) per physician-year of malpractice coverage was $4,905 for non-EM residency-trained physicians and $2,212 for EM residency-trained physicians. EM residency-trained physicians account for significantly less malpractice indemnity than non-EM residency-trained physicians. This difference is not due to differences in the average indemnity but is due to significantly fewer closed claims against EM residency-trained physicians with indemnity paid. This results in a cost per physician-year of malpractice coverage for non-EM residency-trained physicians that is over twice that of EM residency-trained physicians.

Study Objective: Emergency department records are an important source of injury surveillance data. However, documentation regarding intentional assault has not been studied and may be suboptimal. The purpose of this study was to analyze physician documentation of assailant, site, and object used in intentional assault., Methods: The ED log of an urban Level I trauma center was retrospectively reviewed to identify eligible patients presenting consecutively in November 1996. All acutely injured patients not involved in a motorized vehicle crash were identified., Results: From the ED log, 1, 483 patients were identified as possible study subjects; 1,457 (98%) charts were located and reviewed and 971 (67%) met inclusion criteria. Of these, 288 (30%) cases resulted from intentional assault. In 67% of patients, there was no documentation of the identity of the assailant. For 13% of cases, there was no documentation regarding the object or force used in the assault. In 79% of cases there was no documentation regarding the site of assault. For 24 cases (8%), the assailant was documented as an intimate partner or ex-partner. Police involvement in these cases was documented 54% of the time, despite the fact that this state mandates police reports for cases of acute partner violence. Social service involvement and shelter referrals were documented in less than one fourth of domestic violence cases., Conclusion: Although the ED commonly treats patients who have been assaulted, basic surveillance data are often omitted from the chart. Structured charting may provide more complete data collection.

Droperidol is used for sedating combative patients in the emergency department (ED). We performed a randomized, prospective, double-blind study to evaluate the efficacy of droperidol in the management of combative patients in the prehospital setting. Forty-six patients intravenously received the contents of 2-cc vials of saline or droperidol (5 mg). Paramedics used a 5-point scale to quantify agitation levels prior to and 5 and 10 min after administration of the vials. Twenty-three patients received droperidol and 23 received saline. At 5 min, patients in the droperidol group were significantly less agitated than were patients in the saline group. At 10 min, this difference was highly significant. Eleven patients in the saline group (48%) required more sedation after arrival in the ED versus 3 patients (13%) in the droperidol group. We conclude that droperidol is effective in sedating combative patients in the prehospital setting.

We performed a prospective crossover study to determine the cervical spine immobilization and comfort level of healthy subjects on a full-body vacuum splint in comparison with a standard backboard, with and without cervical spine collars. Twenty-six healthy volunteers were immobilized on a backboard (BB) and a full-body vacuum splint (VS), both with and without a cervical collar (CC). Pre- and post-immobilization cervical spine range-of-motion measurements were made using an electronic digital inclinometer and a standard handheld goniometer. Subjects were also asked to subjectively grade their immobilization and discomfort both overall and in seven specific body regions. No statistically significant difference was found between the VS+CC and the BB+CC for flexion and rotation, although the VS+CC combination provided significantly superior immobilization to the BB+CC for extension and lateral bending. The VS alone, in all cases except extension, provided superior immobilization to the BB alone. A statistically significant difference in subjective perception of immobilization was noted, with the BB being less effective than the other three alternatives and the VS+CC providing the best immobilization. A significant difference in overall comfort and occipital region comfort, favoring the vacuum splint, was found. In conclusion, the vacuum splint is an effective and more comfortable alternative to the background for cervical spine immobilization.

Objective: Recognizing the impact of the 1977 San Francisco study of trauma deaths in trauma care, our purpose was to reassess those findings in a contemporary trauma system., Design: Cross-sectional., Material and Methods: All trauma deaths occurring in Denver City and County during 1992 were reviewed; data were obtained by cross-referencing four databases: paramedic trip reports, trauma registries, coroner autopsy reports and police reports., Measurements and Main Results: There were 289 postinjury fatalities; mean age was 36.8 +/- 1.2 years and mean Injury Severity Score (ISS) was 35.7 +/- 1.2. Predominant injury mechanisms were gunshot wounds in 121 (42%), motorvehicle accidents in 75 (38%) and falls in 23 (8%) cases. Seven (2%) individuals sustained lethal burns. Ninety eight (34%) deaths occurred in the pre-hospital setting. The remaining 191 (66%) patients were transported to the hospital. Of these, 154 (81%) died in the first 48 hours (acute), 11 (6%) within three to seven days (early) and 26 (14%) after seven days (late). Central nervous system injuries were the most frequent cause of death (42%), followed by exsanguination (39%) and organ failure (7%). While acute and early deaths were mostly due to the first two causes, organ failure was the most common cause of late death (61%)., Conclusions: In comparison with the previous report, we observed similar injury mechanisms, demographics and causes of death. However, in our experience, there was an improved access to the medical system, greater proportion of late deaths due to brain injury and lack of the classic trimodal distribution.

The prehospital care of the pregnant patient is aimed at expeditious transport of the patient to an appropriate facility combined with rapid intervention to stabilize the mother, including oxygen administration and fluid resuscitation. Optimal care of the fetus is dependent on appropriate management of the mother.

A progressive color-coded light activation panel is described that enhances in-hospital activation of the trauma team. This communication system creates a network among the resuscitation suite of the emergency department, the operating room, the anesthesiology department, and the surgery department.

Prehospital care has undergone a significant evolution during the past two decades and has been transformed from a transportation service into an advanced life support (ALS) delivery system. Crucial to the quality of such a program is physician knowledge and medical control. We describe a formal, one-month prehospital rotation for emergency medicine residents. The resident physician is exposed to a number of varying emergency medical services (EMS) systems, administrative experiences, and most uniquely, functions as a paramedic within our own ALS EMS system. In this manner, we believe the resident best obtains an understanding of the environment, attitudes, and behavior of prehospital personnel.

Prehospital advanced trauma life support (ATLS) is controversial because the risks, benefits, and time required to accomplish it remain unknown. We studied 70 consecutive patients with penetrating cardiac injuries to determine the relationships among prehospital procedures, time consumed in the field, and ultimate patient outcome. Thirty-one patients sustained gunshot wounds, and 39 had stab wounds. The mean Revised Trauma Score was 2.8 +/- 0.5. Paramedics spent an average of 10.7 +/- 0.5 minutes at the scene. Seventy-one percent of the patients underwent endotracheal intubation; 93% had at least one IV line inserted; and 57% had two IV lines inserted. Twenty-one (30%) survived. There was no correlation between on-scene time and either the total number of procedures performed (r = .17, P = .17) or IV lines established (r = .06, P = .6). On-scene times did not differ regardless of whether endotracheal intubation or pneumatic antishock garment applications occurred. We conclude that well-trained urban paramedics can perform multiple life-support procedures with very short on-scene times and a high rate of patient survival and that prehospital trauma systems require a minimum obligatory on-scene time to locate patients and prepare them for transport.

The esophageal obturator airway has been in use for the past 20 years. It is promoted as being easy to use and can be rapidly inserted blindly; however, numerous complications have been noted. The device is reviewed in this article and compared to endotracheal intubation.

On December 14, 1985, the Teller chairlift at the Keystone, Colorado, ski area collapsed, throwing 60 of the 372 people aboard to the ground from heights up to 50 feet. Initial triage and management of the victims was carried out by the local ski patrol, the on-duty physician at the area's Snake River Health Services Clinic, and by volunteer physicians and nurses present at the scene. Thirty-three people required immediate evacuation to hospitals, most of them being transported 75 miles by helicopter air ambulance to level I and II trauma centers in the Denver metropolitan area. Eighteen of these air-evacuated patients were in serious or critical condition. Less seriously injured victims were treated at local medical facilities. The scene evacuation was carried out by helicopter and ground vehicles in accordance with an existing disaster plan coordinated by the Colorado Trauma Institute (CTI). The unique problems posed by a mass casualty incident in a remote mountain location are emphasized by this tragedy. Patient salvage due to the efficacy of a regionally organized trauma system is clearly demonstrated.

Orientation and evaluation of the new paramedic employee are areas that are frequently overlooked or not performed in a consistent manner. In order to evaluate skills of new employees in a standardized fashion and provide a formal structured orientation, the field instructor program was instituted. Since 1978, 78 people have gone through the program. Sixty-nine (88.5%) successfully completed the course. All of those released in "poor standing" were subsequently dismissed from the paramedic division because of poor medical performance. This program has provided orientation of new paramedics and identified those with serious deficiencies in their practice.

Great strides have been made in the prehospital and Emergency Department management of patients, yet the relief of pain and suffering is something that is often forgotten or, if not overlooked, provided in a suboptimal fashion. It is too easy not to feel the pain the patient has or that is is produced while one is seeking to help. The optimal analgesic should have rapid onset, short duration, few side effects, and no major adverse reactions. Nitrous oxide, known since 1776, is perhaps the drug that comes closest to meeting that ideal.

These four examples of technology and its relationship to pre-hospital care will be reviewed: portable defibrillators, pneumatic antishock garment, 911 systems with computer-aided dispatch, and aeromedical transport.

Prehospital intravenous access has been central to the debate of paramedic intervention during management of trauma in the field. Some have suggested that excessive time requirements for IV access are detrimental to patient salvage. This prospective study objectively quantified the time required to place a peripheral IV line in our urban paramedic system. A third-party observer, nonparamedic, timed the procedure on scene with a stopwatch. Total intravenous time, including obtaining a 30-cc blood sample, was defined as the period from removal of the catheter cover until the catheter was taped. The study group included 125 patients (51 trauma and 74 nontrauma). The average total time to obtain IV access and sample blood was 2.20 +/- 0.20 and 2.71 +/- 0.18 minutes in trauma and nontrauma patients, respectively. In a subset of 63 patients in whom blood sampling time was determined separately, subtracting that from total IV time provided a net of 0.58 +/- 0.09 minutes to obtain access. Fourteen patients had a second IV line started (without blood sampling), requiring 1.25 +/- 0.38 and 0.70 +/- 0.24 minutes, respectively, for trauma and nontrauma patients. Paramedics were successful on their first IV attempt in 90% of trauma and 84% of nontrauma patients; ultimate success was 100%. This on scene study documents the time required for prehospital IV access, performed by a well-trained paramedic in an E.M.S. system with strong medical control, is less than 90 seconds.

The ability of paramedics to deliver advanced trauma life support (ATLS) in an expedient fashion for victims of trauma has been strongly challenged. In this study, the records of 114 consecutive victims of blunt trauma who underwent laparotomy or thoracotomy were reviewed. Prehospital care was rendered by paramedics operating under strict protocols. The mean response time (minutes +/- SEM) to the scene was 5.6 +/- 0.27. On-scene time was 13.9 +/- 0.62. The time to return to the hospital was 8.0 +/- 0.4. On-scene time included assessing hazards at the scene, patient extrication, spine immobilization (n = 98), application of oxygen (n = 94), measurement of vital signs (n = 114), splinting of 59 limbs, and the following ATLS procedures: endotracheal intubation (n = 31), IV access (n = 106), ECG monitoring (n = 69), procurement of blood for tests including type and cross (n = 58), and application of a pneumatic antishock garment (PASG) (n = 31). On-scene times were analyzed according to the number of ATLS procedures performed: insertion of one IV line (n = 46), 14.8 +/- 1.03 minutes; two IV lines (n = 28), 13.4 +/- 0.92; one IV line plus intubation (n = 7), 14.0 +/- 2.94; two IV lines plus intubation (n = 9), 17.0 +/- 2.38; and two IV lines plus intubation plus PASG (n = 13), 12.4 +/- 1.36. Of the 161 IV attempts, 94% were completed successfully. Of 36 attempts at endotracheal intubation, 89% were successful.(ABSTRACT TRUNCATED AT 250 WORDS)

A mileage population death index (MPDI) was devised to compare the death rate from motor vehicle trauma in Florida counties. The MPDI was defined as the average death rate per one hundred million miles driven divided by the population of the particular county X 10(5). The resultant MPDI was correlated with the presence in a county of basic life support only and advanced life support. In addition, counties with large metropolitan hospitals which might possibly classify as Level I institutions were compared with other counties. A low MPDI was found to be highly correlated with the presence of an ALS system (p = 0.001). Counties with hospitals which might qualify as Level I also had a significantly lower MPDI (p = 0.04). We conclude that the presence of advanced life support and a sophisticated hospital is correlated with a significantly lower motor vehicle mortality.

Hepatic encephalopathy is a disease seen in this country most often secondary to the ravages of alcoholic liver disease. Although its presentation may be acute, fulminant, and obvious, it can also occur in a more subtle and less virulent form. Early recognition and aggressive intervention may alter the course of this disease.

Medical emergencies at a major metropolitan airport have a significant impact on prehospital care capabilities for the rest of the community in which the airport is located. Stapleton International Airport in Denver, Colorado, is a facility that in 1985 had 14.4 million passengers and a static employee population of 12,000 to 15,000. In 1981, there were 1,182 ambulance trips to the airport, 40.4% of which did not result in the transport of a patient. The expense of sending an ambulance and fire engine out on such calls was great, and paramedics were out of service for approximately 300 hours on these nontransport cases. In order to improve prehospital services to the airport and the city, a paramedic has been stationed in the concourse at the airport 16 hours a day since 1982. The records for airport paramedic services for the 12 months ending September 1985 were reviewed. Paramedic services were requested for 1,952 patients. Of these, 696 (35.7%) were transported to hospital by ambulance; 115 (5.9%) went by private car; 284 (14.6%) refused any paramedic care or transport; and 857 (43.9%) were released, after base station contact, with instructions to seek definitive care at the final destination. Presenting complaints were classified into 55 categories and the frequencies and dispositions are described. The most common presentations resulting in transport were chest pain, 110 (5.6%); syncope, 60 (3.1%); psychiatric, 57 (2.9%); abdominal pain, 49 (2.5%); seizure, 36 (1.8%); fracture, 31 (1.6%); and cardiac arrest, 29 (1.5%).(ABSTRACT TRUNCATED AT 250 WORDS)

An ongoing emergency medical care system involving paramedics and physicians at National Football League games is described. Medical converage was provided from three manned first aid stations in the stadium. During the 1978 football season 298 patients were seen by the medical team. Of those, 35 (11.75%) were sent to area hospitals. Two patients who sustained cardiac arrest were successfully resuscitated and eventually discharged home. There appeared to be a direct relationship between the recorded temperature during the game and the number of patients evaluated.

The role of advanced trauma life support (ATLS) in the prehospital care of the critically injured is highly controversial. This study analyzes the efficacy of ATLS in the management of critical penetrating wounds of the thorax and abdomen. In the 2 1/2-year period ending July 1984, 203 consecutive patients underwent emergency laparotomy or thoracotomy for gunshot and stab wounds. All patients were treated in the field by advanced paramedics (EMT-P). For gunshot wounds the mean time (+/- S.E.M.) responding to the scene was 4.5 (+/- 0.29) minutes, on the scene 10.1 (+/- 0.41) minutes, and returning to the hospital 6.4 (+/- 0.32) minutes. For stab wounds the mean time responding to the scene was 4.8 (+/- 0.21) minutes, on the scene 9.5 (+/- 0.37) minutes, and returning to the hospital 5.7 (+ 0.30) minutes. The number of intravenous lines started averaged 1.8 per patient. Eighty-one patients had PASG applied and 28 patients underwent endotracheal intubation (21 orally, seven nasally). Thirty-three patients had no obtainable blood pressure, of whom six survived (18%). One hundred sixty (94%) of the remaining 170 patients who had any initial blood pressure survived. One hundred nine (55%) patients had an increase in BP greater than or equal to 10 mm Hg (average, 35.6 mm Hg), 64 (32%) had no significant change, and 25 (13%) had a fall greater than or equal to 10 mm Hg (average, 24.2 mm Hg) from the field to the emergency department. Twenty (80%) of the 25 patients with a fall in blood pressure survived.(ABSTRACT TRUNCATED AT 250 WORDS)