First responder in personal protective equipment with unknown illness during a disaster drill.
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Dehydration↗
Biomedical subjects
David Hostler
Publications and source records attributed to David Hostler.
A randomized, controlled comparison of cardiopulmonary resuscitation performed on the floor and on a moving ambulance stretcher.
BACKGROUND: Recent studies have demonstrated that cardiopulmonary resuscitation (CPR) of poor quality is associated with worsened outcomes. OBJECTIVE: To compare the quality of CPR delivered on the floor with the quality of CPR delivered on a moving stretcher. The authors hypothesized that CPR performed on the floor would be superior to that performed on a moving stretcher. METHODS: A randomized, crossover experimental design was used. Subjects included emergency medical technician students, paramedic students, and emergency medicine residents. Two-member teams were randomly assigned to perform two-rescuer CPR on a manikin either on the floor or on a moving stretcher. After a 5-minute rest, the teams performed CPR under the opposite condition. Compression and ventilation data were collected using a recording resuscitation manikin. Dependent variables were compression depth, compression rate per minute, percentage of correct chest compressions, tidal volume, and percentage of correct ventilations. Data were compared using two-tailed paired t-test. RESULTS: Sixty-two subjects completed the study. The mean compression depth performed on the floor (39 +/- 9 mm) was greater than that on a moving stretcher (28 +/- 9 mm) (p < 0.001). The mean rates of chest compressions on the floor (110 +/- 17 beats/min) and on a moving stretcher (113 +/- 21 beats/min) were not different (p = 0.49). The percentage of correct compressions performed on the floor (54% +/- 40%) exceeded that on a moving stretcher (21% +/- 29%)(p < 0.001). The percentage of correct ventilations performed on the floor (43% +/- 26%) was greater than that on a moving stretcher (24% +/- 21%)(p < 0.04). CONCLUSIONS: Chest compression and ventilation quality of CPR performed on the floor was superior to that of CPR performed on a moving stretcher in this manikin model. The quality of CPR while moving was significantly compromised.
Adolescent↗
Program accreditation effect on paramedic credentialing examination success rate.
OBJECTIVES: Program accreditation is used to ensure the delivery of quality education and training for allied health providers. However, accreditation is not mandated for paramedic education programs. This study examined if there is a relationship between completion of an accredited paramedic education program and achieving a passing score on the National Registry Paramedic Certification Examination. METHODS: We used data from the National Registry Paramedic Certification Examination for calendar year 2002. Successful completion (passing) of the examination was defined as correctly answering a minimum of 126 out of 180 (70%) of the questions and meeting or exceeding the individual subtest passing scores. Accredited paramedic training programs were certified by the Committee on Accreditation of Educational Programs for the Emergency Medical Services Professions (CoAEMSP) on or before January 1, 2002. Candidates reported demographic characteristics including age, gender, self-reported race and ethnicity, education, and employer type. We examined the relationship between passing the examination and attendance at an accredited paramedic training program. RESULTS: A total of 12,773 students completed the examination. Students who attended an accredited program were more likely to pass the examination (OR = 1.65, 95% CI: 1.51-1.81). Attendance at an accredited training program was independently associated with passing the examination (OR = 1.58, 95% CI = 1.43-1.74) even after accounting for confounding demographic factors. CONCLUSION: Students who attended an accredited paramedic program were more likely to achieve a passing score on a national paramedic credentialing examination. Additional studies are needed to identify the aspects of program accreditation that lead to improved examination success.
Accreditation↗
The effect of a voice assist manikin (VAM) system on CPR quality among prehospital providers.
UNLABELLED: Numerous studies have documented poor cardiopulmonary resuscitation (CPR) performance among prehospital providers during both simulated and actual resuscitations. Previous studies have shown that a real-time, voice assist manikin (VAM) system may improve CPR performance. OBJECTIVE: To determine whether VAM prompting would improve CPR performance by prehospital providers during simulated resuscitation. METHODS: In this prospective, randomized, crossover design, 114 prehospital providers performed two 3-minute sessions of one-rescuer CPR on a VAM-resuscitation manikin: one round with the VAM feature turned on and one with the feature turned off. The primary outcomes were measured at 15-second intervals and included the fraction of correct compressions, the mean compression depth, the fraction of correct ventilations, and the mean ventilation tidal volume. Generalized estimating equations were used to analyze the repeated measures. RESULTS: The VAM prompting was not directly associated with correct compressions during one-rescuer CPR in a cohort of subjects naïve to the system. However, the general decay in correct compressions seen over 3 minutes was attenuated with VAM prompting. Neither the compression depth nor the decay in compression depth over time was affected by VAM prompting. In contrast, VAM prompting did affect the fraction of correct ventilations and attenuated the time-dependent decline in correct ventilations in tidal volume. CONCLUSIONS: Use of VAM did not directly improve compression or ventilation rate or quality in this cohort of prehospital providers. However, use of VAM did prevent decay of compression and ventilation performance over time.
Adult↗
An algorithmic approach to prehospital airway management.
Airway management, including endotracheal intubation, is considered one of the most important aspects of prehospital medical care. This concept paper proposes a systematic algorithm for performing prehospital airway management. The algorithm may be valuable as a tool for ensuring patient safety and reducing errors as well as for training rescuers in airway management.
Airway Obstruction↗
Defining the learning curve for paramedic student endotracheal intubation.
BACKGROUND: Proficiency in endotracheal intubation (ETI) is assumed to improve primarily with accumulated experience on live patients. While the National Standard Paramedic Curriculum recommends that paramedic students (PSs) perform at least five live ETIs, these training opportunities are limited. OBJECTIVE: To evaluate the effects of cumulative live ETI experience, elapsed duration of training, and clinical setting on PS ETI proficiency. METHODS: The authors used longitudinal, multicenter data from 60 paramedic training programs over a two-year period. The PSs reported outcomes (success/failure) for all live ETIs attempted in the operating room (OR), the emergency department (ED), the intensive care unit (ICU), and other hospital or prehospital settings. Fixed-effects logistic regression was used to model up to 30 consecutive ETI efforts by each PS, accounting for per-PS clustering. For each patient, the authors evaluated the association between ETI success and the PS's cumulative number of ETIs, adjusted for clinical setting, elapsed number of days from the first ETI encounter, and the interaction (cumulative ETIs x elapsed days). Predicted probability plots were constructed depicting the "learning curve" overall and for each clinical setting. Results. Between one and 74 ETIs (median 7; IQR 4-12) were performed by each of 802 PSs. Of 7,635 ETIs, 6,464 (87.4%) were successful. Stratified by clinical setting, 6,311 (82.7%) ETIs were performed in the OR, 271 (3.6%) in the ED, 64 (0.8%) in the ICU, 86 (1.1%) in other in-hospital settings, and 903 (11.8%) in the prehospital setting. For the 7,398 ETIs included in the multivariate analysis, cumulative number of ETI was associated with increased adjusted odds of ETI success (odds ratio 1.067 per ETI; 95% CI: 1.044-1.091). ETI learning curves were steepest for the ICU and prehospital settings but lower than for other clinical settings. CONCLUSIONS: Paramedic student ETI success improves with accumulated live experience but appears to vary across different clinical settings. Strategies for PS airway education must consider the volume of live ETIs as well as the clinical settings used for ETI training.
Allied Health Personnel↗
Feasibility of basic emergency medical technicians to perform selected advanced life support interventions.
OBJECTIVE: Emergency medical technician-basic (EMT-B) providers often provide the initial care to victims of out-of-hospital cardiac arrest. While automated external defibrillators enable EMT-B providers to deliver rescue shocks, patients in cardiac arrest may require additional interventions that EMT-B providers may not presently deliver. We sought to evaluate the feasibility of training EMT-B providers to provide additional cardiac resuscitation procedures using the laryngeal mask airway (LMA) and intraosseous (IO) access. METHODS: In this prospective observational study, we trained 18 EMT-B providers to use the LMA and IO drill (EZ-IO) in a three-hour educational session. Working in two-person teams, the rescuers performed a simulated ventricular fibrillation resuscitation. We evaluated placement success as well as elapsed time to placement of the LMA and EZ-IO. RESULTS: EMT-B providers successfully placed the LMA in 14 of 18 scenarios (78%; 95% confidence interval, 52% to 94%), with a mean of two attempts for placement. Subjects successfully placed the EZ-IO in 17 of 18 scenarios (94%; 95% confidence interval, 73% to 100%), all on the first attempt. The median time to LMA placement following the third shock was 109 seconds (interquartile range, 58-158) and the median time to EZ-IO placement was 72 seconds (interquartile range, 50-93) after LMA placement. CONCLUSIONS: EMT-B providers demonstrated moderate success in performing advanced-level cardiac resuscitation interventions. These observations suggest potential for expanding the role of basic-level rescuers in cardiopulmonary resuscitation.
Adult↗
Thrombin-antithrombin appearance in out-of-hospital cardiac arrest.
OBJECTIVE: Intravascular thrombosis induced during out-of-hospital cardiac arrest (OOHCA) may contribute to the pathophysiology of cardiac arrest and complicate resuscitation. We characterized the prevalence of thrombogenesis during OOHCA by measuring plasma levels of thrombin-antithrombin complexes (TAT). METHODS: An observational cohort study of medical OOHCA patients in an urban emergency medical services (EMS) system. Subjects were patients>or=18 years suffering medical OOHCA. Citrated blood samples were drawn in the prehospital setting either directly from venous blood or during the placement of a central venous catheter and frozen (-70 degrees C). The EMS physician documented age, gender, time intervals, return of spontaneous circulation (ROSC), therapies administered and time of blood draw. TAT assays were performed by commercial ELISA. RESULTS: Eighty-eight patients (58% male) aged 63.4+/-15.9 years were enrolled in the study. Median [interquartile range IQR] TAT values in 80 samples (8 samples were grossly clotted and excluded) were 159.2 [38, 2, 522, 8] and ranged from 0.79 to 1,343.9. Patients transported to the hospital had lower TAT levels than those pronounced in the field (p=0.014). Of four EMS-witnessed arrests, three had return of pulses with TAT values of 0.79, 6.8, and 17.9. The fourth had a TAT over 525 after a long unsuccessful resuscitation. For subjects with TAT below 50 (n=23), all but three were witnessed arrests or received bystander CPR. CONCLUSIONS: Except for a single case witnessed by EMS and immediately defibrillated into a perfusing rhythm, all cases of OOHCA exhibited increased thrombotic state. Intravascular thrombosis may represent a global barrier to resuscitation and ultimately, end-organ perfusion.
Aged↗