Biomedical subjects
Publications and source records attributed to P T Pons.
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 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.
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)
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.
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.
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.
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.
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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.
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)
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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.
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.
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)
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.
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.