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The overarching mission of prehospital emergency medical services (EMS) is to deliver lifesaving care for people when their needs are greatest. Fulfilling this mission is challenged by threats to patient and provider safety. The EMS setting is a high-risk one because care is delivered rapidly in the out-of-hospital setting where resources of benefit to patients are limited. There is growing evidence that safety culture varies widely across EMS agencies. A poor safety culture may manifest as error in medication, back injuries, and other poor outcomes for patient and provider. Recently, federal and national leaders of EMS (ie, the National Highway Traffic Safety Administration) have made improving EMS safety culture a national priority. Unfortunately, few initiatives can help local EMS leaders achieve that priority. The authors describe the successful EMS Champs Fellowship program, supported by the Jewish Healthcare Foundation, designed to train EMS leaders to improve safety for patients and providers.

Although tuberculosis has declined throughout this century, it has recently made a resurgence in our society. A major step in proper control measures is effective tuberculosis screening programs. Up to this point, prehospital care personnel have had a limited role in preventive medicine. In this article, it is proposed that prehospital care personnel can be a factor in the fight against tuberculosis through the conducting of tuberculin skin testing. The epidemiology of tuberculosis, tuberculosis control strategies, the current role of prehospital care in public health, the administration and interpretation of the tuberculin skin test, and tuberculosis high-risk groups are also reviewed.

High-quality EMS systems that are safe for both providers and patients are essential to providing optimal care to the acutely ill and injured and are also necessary to provide the first line of care for victims of natural and manmade disasters.1 The EMS industry must achieve a culture of safety and high reliability if it is to meet the expectations of the new millennium. A national center to gather and organize information pertaining to provider and patient safety would advance the interests of our public and providers. Since the publication of To Err is Human, hundreds of publications and thousands of patient safety programs have been created.2 While hospitals and other care facilities function under legislative and oversight body regulations (including The Joint Commission) requiring reporting and cause analysis, similar requirements and programs are largely absent for prehospital care. Our challenge is to design systems that decrease the likelihood of patient or provider harm. How safe is EMS? The truth is, we simply do not know. Aside from a small series of reports and anecdotes, we know very little about national patient safety in EMS. It is clear that prehospital care is challenged by many factors known to augment error: time urgency, interruptions, an uncontrolled environment, stress, variable initial training, and inconstant continuing ed-

A common proverb applies well to emergency care: He who relieves pain is blessed but he who causes none is double so. Emergency physicians have invested much effort to improve acute pain management with education and research. Old paradigms once taught and practiced—“no one ever died of pain” or “analgesics obscure diagnoses”—are melting, albeit more slowly than we may like. 1 Rupp T. Delaney K.A. Inadequate analgesia in emergency medicine. Ann Emerg Med. 2004; 43: 494-502 Abstract Full Text Full Text PDF PubMed Scopus (399) Google Scholar , 2 Todd K.H. Crandall C. Choiniere M. et al. Pain in the emergency department: a multicenter study. Acad Emerg Med. 2006; 13: 88-89 Crossref Google Scholar Fasting and Emergency Department Procedural Sedation and Analgesia: A Consensus-Based Clinical Practice AdvisoryAnnals of Emergency MedicineVol. 49Issue 4PreviewEmergency physicians frequently administer procedural sedation and analgesia to nonfasted patients; however, they currently have no specific guidelines to aid them in preprocedural risk stratification. We assembled a committee of leading emergency physician sedation researchers to develop a consensus-based clinical practice advisory for this purpose. Our goal was to create a tool to permit emergency physicians to identify prudent limits of sedation depth and timing in light of fasting status and individual patient risk factors. Full-Text PDF Aspiration Pneumonitis Requiring Intubation After Procedural Sedation and Analgesia: A Case ReportAnnals of Emergency MedicineVol. 49Issue 4PreviewEmergency department (ED) procedural sedation and analgesia is widely and routinely performed; serious complications are rare. We describe the first reported case of aspiration during procedural sedation in the ED. Although our patient required endotracheal intubation and critical care admission, there was no adverse long-term outcome. Given that there were no apparent predisposing factors, we believe it is crucial for emergency physicians to routinely anticipate the possibility of such a complication during each sedation event. Full-Text PDF

Objective. Despite the widespread use of standard treatment protocols, there are few published data regarding paramedic protocol adherence. In this descriptive study, the authors sought to assess the frequency andnature of deviations from a standardized treatment protocol for the chief complaint of chest pain. They also sought to quantify any time delays in treatment of potential ischemic cardiac chest pain. Methods. A retrospective review of written documentation obtained from four ambulance services in a mid-Atlantic state was completed. A convenience sample of consecutive emergency medical services (EMS) records was obtained from January 2001 to May 2002, and75 calls were selected from each service (N = 300). Results. Neither the median scene times nor the response times varied among the four services in the study. However, the suburban ambulance service (service 1) did have a significantly longer transport time (19 minutes) than the rural (14 minutes) andthe urban (11 and10 minutes) services (p < 0.05). Documentation of history andphysical characteristics varied widely for each service. The patient took aspirin 10% of the time prior to EMS arrival, yet paramedics gave it additionally 50% of the time, while nitroglycerin was given in 73% of cases of suspected cardiac ischemia. Posttreatment vital signs for nitroglycerin were documented 30% of the time for three of the four services, while the other service documented these 75% of the time. Medical command contact varied by agency (80–100%), as did the receipt andcompletion of medical orders. Conclusions. Paramedics may delay transport of patients with potential cardiac ischemia. Deviations from protocol occur frequently andthe care documented for prehospital patients with chest pain is variable. The expected care described by written protocols does not correlate with the treatment documented.

Objective. To identify a set of clinical factors most strongly associated with the use of drug-facilitated intubation (DFI) in the out-of-hospital setting. Method. The authors used data from a prospective, multicentered endotracheal intubation (ETI) observational cohort trial, including patients from 45 emergency medical services in Pennsylvania. Providers reported clinical, physiologic, and anatomic factors associated with each ETI effort. The authors included only data from the 23 services using DFI. They identified all non-arrest (presence of a pulse) adult patients. They included both successful and failed ETIs. They defined DFI cases as patients who received a sedative or neuromuscular-blocking agent to facilitate ETI. The authors also classified patients who underwent nasotracheal intubation as DFI. They defined control subjects as patients undergoing conventional oral ETI. They performed multivariate logistic regression to identify the clinical, physiologic, and anatomic factors characteristic of DFI. They examined alternate forms of the final prediction model. Results. The authors analyzed data from 208 nonarrest patients, including 92 DFIs and 116 control subjects. Of 34 factors potentially related to DFI, 17 were excluded on univariate analysis (likelihood ratio p > 0.25). Multivariate logistic regression revealed the following as positively associated with DFI: presence of clenched jaw/trismus (odds ratio [OR], 2.33; 95% confidence interval [CI], 1.10–4.95; p=0.026); increased verbal Glasgow Coma Scale score (OR, 1.71; 95% CI, 1.29–2.26; p < 0.001); use of cervical spine precautions (OR, 2.30; 95% CI, 1.15–4.62; p = 0.018). Anterior vocal cords (OR, 0.27; 95% CI, 0.10–0.71; p = 0.004) and laryngospasm (OR, 0.14; 95% CI, 0.02-1.17; p = 0.025) were negatively associated with DFI. The model showed good fit (Hosmer-Lemeshow p = 0.75) and discrimination (area under the curve = 0.76). Conclusions. The authors identified a set of predictors strongly associated with DFI. These data offer insight into the current use of DFI and support the development of consensus-based guidelines for this procedure.

Study Objective: Previous out-of-hospital airway management data are limited by small, single-site designs. We sought to evaluate the feasibility of performing a prospective, multi-centered evaluation of out-of-hospital endotracheal intubation (ETI) using a standardized data collection tool. Methods: We designed a prospective multi-centered observational study involving 45 advanced life support (ALS) services from a mid-Atlantic state. Using a standardized data form, prehospital personnel reported details of each attempted ETI, including patient demographics, methods used, difficulties encountered, and initial patient outcomes. We calculated and assessed data form return rates (using independent queries of the number of ETI attempted by each EMS service) and missing data entry rates. We also performed preliminary cross-sectional assessments of factors of current interest in out-of-hospital ETI. Accuracy and validity of responses were not evaluated. Data were stored centrally and analyzed using descriptive techniques. Results: Participants included 8 urban, 15 suburban, 20 rural, and 2 air medical services. Data forms were received on 783 adults receiving ETI attempts during the study period June 1, 2001–November 30, 2001. The pooled data form return rate was 72.7%. Per-service return rates ranged from 0 to 100% and the median per-service return rate was 75%. Non-response (data form not returned for attempted intubation) was problematic, with nine services demonstrating data return rates less than 50%. Data return rates could not be calculated for an additional nine services. The missing data entry rate was 0.5–22.2%. The overall reported ETI success rate was 86.8% (92.8% for cardiac arrests and 76.8% for non-arrests) and did not appear to vary between population settings. There were two cases of delayed recognition of esophageal intubation, one case of unrecognized esophageal intubation, and 22 cases of tube dislodgement during patient care or transport. Bag-valve-mask ventilation was used as the rescue airway technique in the majority of failed ETI. When stratified for cardiac arrests vs. non-arrests, ETI success was not associated with field or initial ED survival. Conclusions: We successfully obtained complete data for the majority of ETI attempted across multiple EMS services. Our data also indicate the need to address problems with non-response. Preliminary cross-sectional data highlight areas of current interest in out-of-hospital airway management.

This report examines the literature regarding pneumococcal disease and the current state of pneumococcal vaccination. Improvements in medical care have reduced the number of deaths from pneumococcal disease. However, vaccination is still the most effective measure. The U.S. Department of Health and Human Services, through the Healthy People 2000 and Healthy People 2010 reports, have recommended widespread pneumococcal vaccination practices. In spite of this, vaccination rates remain low among all segments of the population, with minorities and groups at risk for pneumococcal disease the most neglected. The authors propose implementation of emergency medical services (EMS)-delivered vaccination against pneumococcal disease. The epidemiology of pneumococcal disease is presented. The efficacy, availability, and use recommendations for the vaccine are described within this report. Finally, the benefits and possible implementation strategies for EMS delivery are detailed.

OBJECTIVE:Emergency medical services (EMS) agencies may be an underutilized resource for provision of preventive health services. This study sought to demonstrate the feasibility for EMS agencies to provide influenza immunizations.METHODS:This prospective, observational cohort study was conducted with urban, suburban, and rural EMS agencies that volunteered to participate. EMS managers and paramedics attended an orientation program, and then developed and implemented recruitment strategies. Adult volunteer subjects who met Centers for Disease Control and Prevention criteria for influenza vaccination were enrolled. Paramedics obtained informed consent, determined subject eligibility, administered the vaccine, and observed each subject for 10 minutes. Paramedics, EMS managers, and subjects completed surveys; EMS managers reported costs and resource utilization. Data were analyzed descriptively.RESULTS:Ninety paramedics from 15 EMS agencies in three counties participated. Subjects were recruited by print and broadcast media and enrolled at 73 events held at retail establishments, community events, EMS stations, churches, senior citizen complexes, and private residences. Of the 2,075 adults immunized, 1,014 (49%) did not receive influenza vaccination in the previous year. Seven hundred five (34%) reported that they probably would not have been vaccinated elsewhere. Fixed cost for each immunization was $3.42. The EMS managers estimated their variable costs to range from zero dollars (volunteer agencies with all donated expenses) to $15.31 per immunization. No adverse events were reported. Subjects, paramedics, and EMS managers indicated a high level of satisfaction with the project.CONCLUSION:The MEDICVAX Project demonstrated the feasibility of EMS agencies to safely provide influenza immunizations. The project reached some adults who likely would not have been immunized.

BACKGROUND:The nature of the trauma patient's injuries may compromise the airway and ultimately lead to death or neurological devastation. The same injuries complicate protecting the airway in these patients by preventing manipulation of the cervical spine for direct laryngoscopy. A recent study has shown that misplaced endotracheal tubes occur significantly more often in trauma patients than in medical patients.OBJECTIVES:The authors hypothesized that elevating the long spine board would reduce the amount of time required for paramedics to intubate a simulated trauma patient.METHODS:Paramedics from an urban emergency medical services division were given up to two opportunities to intubate a manikin in a type I ambulance in each of two positions in random order: supine and with the head elevated. The manikin was secured to a long spine board with three straps, a semi-rigid cervical collar, and a cervical immobilization device. An investigator maintained cervical spine alignment and provided cricoid pressure. The elevated position was accomplished by raising the head of the stretcher 27 degrees, resulting in 7 degrees of spine board elevation. Each attempt was timed. If the first attempt was unsuccessful, the times for both the first and second attempts were totaled to determine the total time required for intubation. Times for successful intubation in each position were compared with a Mann-Whitney test. First-attempt success rates for each position were compared with chi2 analysis. Multinomial regression was used to determine whether experience, paramedic height, or previous intubation success influenced intubation time in either position.RESULTS:Fifty-five paramedics provided informed consent and completed the study. Average time to intubate the supine manikin was significantly longer than needed to intubate the head-elevated manikin (35.6 +/- 19.0 seconds vs 27.9 +/- 12.8 seconds, p = 0.025). The manikin was successfully intubated on the first attempt 84% in the supine position and 95% in the head-elevated position (p = 0.200). Regression analysis identified intubation position as the only significant predictor of intubation time (p = 0.007).CONCLUSIONS:Modest elevation of the head of an immobilized patient appears to allow more rapid intubation. With the spine board properly secured to the stretcher, this technique potentially offers improved intubation time without additional cost or equipment.

OBJECTIVES:Conventionally trained out-of-hospital rescuers (such as paramedics) often fail to accomplish endotracheal intubation (ETI) in patients requiring invasive airway management. Previous studies have identified univariate variables associated with failed out-of-hospital ETI but have not examined the interaction between the numerous factors impacting ETI success. This study sought to use multivariate logistic regression to identify a set of factors associated with failed adult out-of-hospital ETI.METHODS:The authors obtained clinical and demographic data from the Prehospital Airway Collaborative Evaluation, a prospective, multicentered observational study involving advanced life support (ALS) emergency medical services (EMS) systems in the Commonwealth of Pennsylvania. Providers used standard forms to report details of attempted ETI, including system and patient demographics, methods used, difficulties encountered, and initial outcomes. The authors excluded data from sedation-facilitated and neuromuscular blockade-assisted intubations. The main outcome measure was ETI failure, defined as failure to successfully place an endotracheal tube on the last out-of-hospital laryngoscopy attempt. Logistic regression was performed to develop a multivariate model identifying factors associated with failed ETI.RESULTS:Data were used from 45 ALS systems on 663 adult ETIs attempted during the period June 1, 2001, to November 30, 2001. There were 89 cases of failed ETI (failure rate 13.4%). Of 61 factors potentially related to ETI failure, multivariate logistic regression revealed the following significant covariates associated with ETI failure (odds ratio; 95% confidence interval; likelihood ratio p-value): presence of clenched jaw/trismus (9.718; 95% CI = 4.594 to 20.558; p < 0.0001); inability to pass the endotracheal tube through the vocal cords (7.653; 95% CI = 3.561 to 16.447; p < 0.0001); inability to visualize the vocal cords (7.638; 95% CI = 3.966 to 14.707; p < 0.0001); intact gag reflex (7.060; 95% CI = 3.552 to 14.033; p < 0.0001); intravenous access established prior to ETI attempt (3.180; 95% CI = 1.640 to 6.164; p = 0.0005); increased weight (ordinal scale) (1.555; 95% CI = 1.242 to 1.947; p = 0.0001); and electrocardiographic monitoring established prior to ETI attempt (0.199; 95% CI = 0.084 to 0.469; p = 0.0003). This model was the most parsimonious of the models evaluated and demonstrated good fit (Hosmer-Lemeshow test p = 0.471) and discrimination (area under ROC curve = 0.906). There were no significant interaction terms.CONCLUSIONS:The authors used multivariate logistic regression to identify a set of factors associated with failure to accomplish ETI in adult out-of-hospital patients. Findings from this analysis could provide the basis for clinical protocols or decision rules aimed at minimizing the incidence of out-of-hospital ETI failure.

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position statement and best practices recommendations from the National Center for Early Defibrillation , Mary M. Newman *, Vincent N. Mosesso, Jr. , Joseph P. Ornato , Paul M. Paris , National Center for Early Defibrillation Police AED Issues Forum 1 a National Center for Early Defibrillation, Department of Emergency Medicine, University of Pittsburgh, 230 McKee Place, Pittsburgh, PA 15213, USA b Medical College of Virginia, Richmond, VA, USA