Bystander CPR--discouragement or reaffirmation?
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Death, Sudden↗
Biomedical subjects
T D Valenzuela
Publications and source records attributed to T D Valenzuela.
Implementation of a computerized management information system in an urban fire department.
An important aspect in the effective management of an emergency medical services system is the ability to monitor system performance. To provide this information on a timely basis, a comprehensive data collection system is required. We describe the design, implementation, use, and effect of a comprehensive, computerized data retrieval system within an urban fire department. Building on a data collection system already in place, it was possible to minimize the cost and accelerate the training process. A comparison is included between the different type of systems available for use with prehospital providers. Use of prehospital data collection systems results in more in-depth understanding of system operations and the status of prehospital medical care provided to the community.
Data Collection↗
Pulmonary embolism.
The incidence and mortality of acute pulmonary embolism (PE) remain ill defined, particularly in the setting of the emergency department. However, high-risk groups can be identified based on medical conditions known to predispose patients to venous thrombosis. Recent research into the physiologic regulation of coagulation and thrombolysis reveals that recurrent venous thrombosis and PE may be caused by heritable deficiencies and abnormalities of plasma proteins. To decide among options for evaluation and treatment of patients suspected of PE, physicians combine clinical assessment with patterns observed on radionuclide ventilation-perfusion (V/Q) scans. However, the prevalence of PE among patients with "low probability" V/Q scans suggests that current physician behavior may be imprudent. Heparin anticoagulation continues to be standard therapy for acute PE, but newer clot-specific thrombolytic drugs may offer superior benefits with acceptable complication rates in carefully selected patients.
Humans↗
A new model for providing prehospital medical care in large stadiums.
To determine proper priorities for the provision of health care in large stadiums, we studied the medical incident patterns occurring in a major college facility and combined this with previously reported information from four other large stadiums. Medical incidents were an uncommon occurrence (1.20 to 5.23 per 10,000 people) with true medical emergencies being even more unusual (0.09 to 0.31 per 10,000 people). Cardiac arrest was rare (0.01 to 0.04 events per 10,000 people). However, the rates of successful resuscitation in three studies were 85% or higher. The previous studies were descriptive in nature and failed to provide specific recommendations for medical aid system configuration or response times. A model is proposed to provide rapid response of advanced life support care to victims of cardiac arrest. We believe that the use of this model in large stadiums throughout the United States could save as many as 100 lives during each football season.
Adolescent↗
Pulmonary embolism.
Pulmonary embolism remains a challenging problem in diagnosis and management for the emergency physician. Although its clinical presentation is protean and often ambiguous, risk stratification can be accomplished based on the predictive power of a limited number of physical and historical characteristics. Ventilation-perfusion lung scanning occupies a central position in the work-up of suspected PE; however, evidence exists that it may be misused by many physicians. A low probability V-Q scan does not exclude the diagnosis of PE. Patients with other than normal- or high-probability patterns of pulmonary ventilation and perfusion on lung scanning require further investigation. Noninvasive venous studies are useful when indicative of proximal deep venous thrombosis, but are normal in many patients with acute PE. Heparin remains the standard of treatment for most patients with PE. Vena cava filters effectively reduce the incidence of recurrent PE in patients with contraindications to anticoagulation. Thrombolytic therapy offers potential advantages in the treatment of patients with shock due to their PE. Case reports of PE treated with tissue-type plasminogen activator, a new thrombus-specific fibrinolytic agent, are encouraging but preliminary.
Algorithms↗
Air transport following surgical stabilization: an extension of regionalized trauma care.
A 30-month retrospective review was performed of all trauma patients initially evaluated and operatively stabilized at Level III hospitals, with subsequent specialized air transport within 48 hours of injury to the regional Level I trauma center in Seattle. Nineteen patients were identified, with a mean ISS of 44 (range, 20-66). Mean transport time and distance were 2.4 hours and 456 miles, respectively. The estimated average ground transport time for the same patients was 23.8 hours. No deaths occurred during transport, and the overall survival rate was 58%. Transport charges averaged $4,162, which was 14% of the complete hospitalization cost. We conclude that: 1) patient survival after air transport was no different than that predicted for trauma victims with immediate access to a trauma center; 2) postoperative hemodynamic instability predicted a poor outcome; 3) the higher cost of air relative to ground transport is outweighed by significant time savings in these critically injured patients; and 4) air transport following operative stabilization represents an extension of regionalized trauma care to the isolated areas of Washington and Alaska.
Adolescent↗
Occupational exposure to hepatitis B in paramedics.
To determine their occupational risk for hepatitis B infection, 59 Seattle paramedics were tested for hepatitis B serum markers. Evidence of antibody to hepatitis B surface antigen (anti-HBs) or antibody to hepatitis B core antigen (anti-HBc) was found in 25%, a rate five times that of a similar Seattle population. Seropositivity did not correlate with age, race, clinical history, or length of service. Of the 15 paramedics with seropositivity to hepatitis B virus six initially had low titers of either anti-HBs or anti-HBc. Four of the six demonstrated persistent low-grade seropositivity on retesting. Paramedics are at increased risk of hepatitis B infection. The high frequency of low-titer anti-HBs suggests that frequent low-level exposure to hepatitis B virus occurs in this population; hepatitis B vaccine should be strongly considered for paramedics.
Allied Health Personnel↗
Reperfusion revisited.
The field of thrombolytic treatment for a variety of clinical conditions has progressed extremely rapidly over the past decade. Unfortunately, answers to questions of the greatest interest to practicing physicians remain ambiguous. They include the following: For which problems should thrombolytic treatment be the treatment of choice? Which patients should receive thrombolytic treatment, and which should not? Which of the available thrombolytic agents is "best" for which problem in which patient? In this situation of clinical ambiguity, our experience with thrombolysis in AMI is instructive. The problems for which thrombolytic treatment are indicated have in common the attribute that they are "time-sensitive"; that is, optimal benefit is achieved with earlier initiation of treatment. We have learned that to minimize delay, emergency physicians must proactively agree with our colleagues in cardiology, family practice, internal medicine, pulmonary medicine, etc., on issues of patient selection, drug selection, and ancillary therapy. It is too late to argue such issues once the patient with a thrombotic or embolic disorder has arrived in the emergency department. By cooperating in advance, we can ensure our patients the maximum benefit from timely administration of this potent therapy while protecting them from avoidable complications and expense from its medically inappropriate use.
Emergencies↗
Physician in-field observation of prehospital advanced life support personnel: a statewide evaluation.
STUDY HYPOTHESIS: Direct physician observation of advanced life support (ALS) personnel is rare in a demographically diverse state. STUDY POPULATION: Twenty ALS agencies from throughout Arizona. METHODS: A board-certified emergency physician performed on-site interviews with the emergency medical services (EMS) supervisor of each agency to approximate the number of days per year that physicians observe ALS personnel in the field. RESULTS: Only 11 agencies (55%) reported that physicians ever observed ALS personnel. Among all agencies, an estimated total of 84 observer-days occurred per year. The agencies staffed a total of 86 ALS units, resulting in an estimated 0.98 observer-days/unit/year (84/86). On the average, it took 3.4 ALS personnel to staff a given unit over time and the probability that an ALS provider would be on a unit on any given day was 0.29 (1/3.4). The probability of a given provider being observed during one year was approximately 0.29 (0.98 x 0.29). Thus, on the average, an ALS provider would be observed by a physician approximately once every 3.5 years (1/0.29). Among urban agencies, the "average" ALS provider would be observed once every 2.9 years. This compared to a likelihood of in-field observation of only once every 6.7 years for non-urban providers (p = .036). CONCLUSIONS: The skills of ALS providers in Arizona are observed by a physician in the field very infrequently. Although an uncommon occurrence in urban agencies, observation of non-urban ALS personnel occurs even less frequently. In addition, nearly one-half of the agencies surveyed never had a physician-observer. Although a variety of skills evaluation methods exist, it remains unclear whether any method is as useful as direct observation. Future investigations are needed to evaluate whether in-field physician observation impacts skills, patient care, or outcome in EMS systems.
Arizona↗
Use of emergency medical services by children with special health care needs.
OBJECTIVE: This study describes emergency medical services (EMS) responses for children with special health care needs (CSHCN) in an urban area over a one-year period. METHODS: A prospective surveillance system was established to identify EMS responses for children, 21 years of age or younger, with a congenital or acquired condition or a chronic physical or mental illness. Responses related to the special health care needs of the child were compared with unrelated responses. RESULTS: During a one-year period, 924 responses were identified. Fewer than half of the responses were related to the child's special health care need. Younger children were significantly more likely to have a response related to their special needs than older children. Among related responses, seizure disorder was the most common diagnosis, while asthma was more common for unrelated responses. Almost 58% of the responses resulted in transport of the child to a hospital. CONCLUSIONS: Emergency medical services responses related to a child's special health care needs differ from unrelated responses. The most common special health care needs of children did not require treatment beyond the prehospital care provider's usual standard of care. These results are relevant for communities providing EMS services for CSHCN.
Adolescent↗
Development of an electronic emergency medical services patient care record.
OBJECTIVE: The need for valid and reliable emergency medical services (EMS) data has long been recognized. EMS data are useful for monitoring resources and operations, documenting patient care and outcome, and evaluating injury prevention strategies. The goal of this project was to develop a computerized data set with the capability to generate a patient care record (PCR) to overcome some of the current EMS data limitations. METHODS: The authors discuss developing an electronic PCR and analysis data set containing 233 variables. Data are collected for the following: incident, response, scene, patient, history, primary survey (including vital signs), physical examination, physiologic scores, diagnostics, plan (medications and procedures), assessment, and reevaluation. Software on a portable computer installed in an EMS response unit utilizes a graphical user interface for data collection by prehospital emergency care providers. A data set stores codes corresponding to user's selections. This data set supports data storage and analysis. The electronic PCR and data set can be useful to EMS agencies for collecting, storing, reporting, and analyzing information. RESULTS: Variables are categorized into 12 main categories to categorize the variables and to drive data collection. The system provides the user with the ability to print out a record (using a portable printer installed in an ambulance) and analyze data stored in the data set. CONCLUSION: This computerized approach overcomes many limitations inherent with using paper-based systems for research. Linked with emergency department, hospital discharge, and mortality data, EMS data can be used in systems analyses related to patient outcome.
Arizona↗