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This board is owned by Matt Holland, LKS ASE, Librarian. Contact Matt.Holland@nwas.nhs.uk.


Hosts recent articles from research based journals. Pinboard started in September 2016.


This board collates published research on the prehospital and paramedic Practice.


The board is aimed at those working in Ambulance Services and Prehospital Care. Anyone can look.


The board is updated regularly. Somewhere between daily and weekly depending on the volume of publication.

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This board is maintained and run by Matt Holland, Librarian LKS ASE Matt.Holland@nwas.nhs.uk.

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Check the LKS ASE website to find out more about us. Follow us on Twitter, our Twitter handle is @NWASLibrary.


Evaluation of a Novel Wireless Transmission System for Trauma Ultrasound Examinations From Moving Ambulances.

Abstract: To determine if physicians trained in ultrasound interpretation perceive a difference in image quality and usefulness between Extended Focused Assessment with Sonography ultrasound examinations performed at bedside in a hospital vs. by emergency medical technicians minimally trained in medical ultrasound on a moving ambulance and transmitted to the hospital via a novel wireless system. In particular, we sought to demonstrate that useful images could be obtained from patients in less than optimal imaging conditions; that is, while they were in transport. Emergency medical technicians performed the examinations during transport of blunt trauma patients. Upon patient arrival at the hospital, a bedside Extended Focused Assessment with Sonography examination was performed by a physician. Both examinations were recorded and later reviewed by physicians trained in ultrasound interpretation. Data were collected on 20 blunt trauma patients over a period of 13 mo. Twenty ultrasound-trained physicians blindly compared transmitted vs. bedside images using 11 Questionnaire for User Interaction Satisfaction scales. Four paired samples t-tests were conducted to assess mean differences between ratings for ambulatory and base images. Although there is a slight tendency for the average rating across all subjects and raters to be slightly higher in the base than in the ambulatory condition, none of these differences are statistically significant. These results suggest that the quality of the ambulatory images was viewed as essentially as good as the quality of the base images.

Pub.: 11 Apr '18, Pinned: 13 Apr '18

Utilizing Propensity Score Analyses in Prehospital Blood Product Transfusion Studies: Lessons Learned and Moving Toward Best Practice.

Abstract: Recently, observational studies analyzing prehospital blood product transfusions (PHT) for trauma have become more widespread in both military and civilian communities. Due to these studies' non-random treatment assignment, propensity score (PS) methodologies are often used to determine an intervention's effectiveness. However, there are no guidelines on how to appropriately conduct PS analyses in prehospital studies. Such analyses are complicated when treatments are given in emergent settings as the ability to administer treatment early, often before hospital admission, can interfere with assumptions of PS modeling. This study conducts a systematic review of literature from military and civilian populations to assess current practice of PS methodology in PHT analyses. The decision-making process from the multicenter Prehospital Resuscitation on Helicopter Study (PROHS) is discussed and used as a motivating example. Results show that researchers often omit or incorrectly assess variable balance between treatment groups and include inappropriate variables in the propensity model. When used correctly, PS methodology is an effective statistical technique to show that aggressive en route resuscitation strategies, including PHT, can reduce mortality in individuals with severe trauma. This review provides guidelines for best practices in study design and analyses that will advance trauma care.

Pub.: 11 Apr '18, Pinned: 13 Apr '18

Advanced airway management in hoist and longline operations in mountain HEMS – considerations in austere environments: a narrative review This review is endorsed by the International Commission for Mountain Emergency Medicine (ICAR MEDCOM)

Abstract: Providing sufficient oxygenation and ventilation is of paramount importance for the survival of emergency patients. Therefore, advanced airway management is one of the core tasks for every rescue team. Endotracheal intubation is the gold standard to secure the airway in the prehospital setting. This review aims to highlight special considerations for advanced airway management preceding human external cargo (HEC) evacuations.We systematically searched MEDLINE, EMBASE, and PubMed in August 2017 for articles on airway management and ventilation in patients before hoist or longline operation in HEMS. Relevant reference lists were hand-searched.Three articles with regard to advanced airway management and five articles concerning the epidemiology of advanced airway management in hoist or longline rescue missions were included. We found one case report regarding ventilation during hoist operations.The exact incidence of advanced airway management before evacuation of a patient by HEC is unknown but seems to be very low (< 5%). There are several hazards which can impede mechanical ventilation of patients during HEC extractions: loss of equipment, hyperventilation, inability to ventilate and consequent hypoxia, as well as inadequacy of monitoring.Advanced airway management prior to HEC operation is rarely performed. If intubation before helicopter hoist operations (HHO) and human cargo sling (HCS) extraction is considered by the rescue team, a risk/benefit analysis should be performed and a clear standard operating procedure (SOP) should be defined. Continuous and rigorous training including the whole crew is required. An international registry on airway management during HEC extraction would be desirable.

Pub.: 03 Apr '18, Pinned: 10 Apr '18

Analysis of Prehospital Scene Times and Interventions on Mortality Outcomes in a National Cohort of Penetrating and Blunt Trauma Patients.

Abstract: Recent studies have suggested improved outcomes in victims of penetrating trauma managed with shorter prehospital times and limited interventions. The purpose of the current study was to perform an outcome analysis of patients transported following penetrating and blunt traumatic injuries. We performed a descriptive retrospective analysis of the 2014 National Emergency Medical Services Information System (NEMSIS) public release research data set for patients presenting after acute traumatic injury. A total of 2,018,141 patient encounters met criteria, of which 3.9% were penetrating trauma. Prehospital cardiac arrest occurred in 0.5% blunt and 4.2% penetrating trauma patients. Emergency department (ED) mortality was higher in penetrating than blunt trauma patients (4.1% vs. 0.8%). Scene times were 18.1 ± 36.5 minutes for blunt and 16.0 ± 45.3 minutes for penetrating trauma. Mean scene time for blunt trauma patients who died in the ED was 24.9 ± 58.0 minutes compared with 18.8 ± 38.5 minutes for those admitted; for penetrating trauma, scene times were 17.9 ± 23.5 and 13.4 ± 11.6 minutes, respectively. Mean number of procedures performed for blunt trauma patients who died in the ED was 6.5 ± 4.3 compared with 3.1 ± 2.3 for those who survived until admission; for penetrating trauma, the numbers of procedures performed were 5.7 ± 3.4 and 2.6 ± 2.0, respectively. Although less frequent than blunt trauma, penetrating trauma is associated with significantly higher prehospital and ED mortality. Increased scene time and number of procedures was associated with greater mortality for both blunt and penetrating trauma. Further study is required to better understand any causal relationships between prehospital times and interventions and patient outcomes.

Pub.: 05 Apr '18, Pinned: 10 Apr '18

Prehospital triage of patients diagnosed with perforated peptic ulcer or peptic ulcer bleeding: an observational study of patients calling 1-1-2

Abstract: Triage systems are used in emergency medical services to systematically prioritize prehospital resources according to individual patient conditions. Previous studies have shown cases of preventable deaths in emergency medical services even when triage systems are used, indicating a potential undertriage among some conditions. The aim of this study was to investigate the triage level among patients diagnosed with perforated peptic ulcer (PPU) or peptic ulcer bleeding (PUB).In a three-year period in Central Denmark Region, all patients hospitalized within 24 h after a 1-1-2 emergency call and who subsequently received either a PPU or a PUB (hereinafter combined and referred to as PPU/PUB) or a First Hour Quintet (FHQ: respiratory failure, stroke, trauma, cardiac chest pain, and cardiac arrest) diagnosis were investigated. A modified Poisson regression was used to estimate the relative risk of receiving the highest and lowest prehospital response level. Also, a linear regression analysis was used to estimate the relative risk of 30-day mortality.Of 8658 evaluated patients, 263 were diagnosed with PPU/PUB. After adjusting for relevant confounding variables, patients diagnosed with PPU/PUB were less likely to receive ambulance transportation compared to patients diagnosed with stroke, RR = 1.41 (CI: 1.28–1.56); trauma, RR = 1.28 (CI: 1.15–1.42); cardiac chest pain, RR = 1.47 (CI: 1.33–1.62); and cardiac arrest, RR = 1.44 (CI: 1.31–1.42). Among patients diagnosed with PPU/PUB, 6.5% (CI: 3.3–9.7) did not receive ambulance transportation. The proportion of patients not receiving ambulance transportation was higher among patients diagnosed with PPU/PUB compared to patients diagnosed with an FHQ diagnosis. The 30-day mortality rate among patients diagnosed with PPU/PUB was 7.8% (CI: 4.2–11.1). This was lower than the 30-day mortality rate among patients diagnosed with respiratory failure (P = 0.010), stroke (P = 0.001), and cardiac arrest (P < 0.001), but comparable to the 30-day mortality among patients diagnosed with cardiac chest pain (P = 0.080) and trauma (P = 0.281).Among patients calling 1-1-2, fewer patients diagnosed with PPU/PUB received ambulance transportation than patients diagnosed with FHQ diagnoses, despite a high mortality among patients diagnosed with PPU/PUB.

Pub.: 05 Apr '18, Pinned: 10 Apr '18

#FOAMems: Engaging paramedics with free, online open-access education.

Abstract: Twitteruse among paramedics and other prehospital care clinicians is on the rise and is increasingly being used as a platform for continuing education and international collaboration. In 2014, the hashtag #FOAMems was registered. It is used for the sharing of emergency medical services, paramedicine, and prehospital care-related content. It is a component of the 'free open-access meducation' (FOAM) movement. The aim of this study was to characterize and evaluate the content of #FOAMems tweets since registration. An analytical report for #FOAMems was generated on symplur.com from February 4, 2014, to April 30, 2017. A transcript of all #FOAMems tweets for a randomly selected 1 month period (October 2015) was generated, and quantitative content analysis was performed by two reviewers. Tweets were categorized according to source (original tweet/retweet) and whether referenced. The top 92 tweeters were analyzed for professional identity. During the study period, there were over 99,000 tweets containing #FOAMems, by over 9,200 participants. These resulted in almost 144 million impressions. Of the top 92 tweeters, 50 were paramedics (54%). Tweets were mainly related to cardiac (23%), leadership (19%), and trauma (14%). The 1-month period resulted in 649 original tweets, with 2110 retweets; 1070 of these were referenced. Paramedics are engaging with both clinical and nonclinical content on Twitterusing #FOAMems. Social media resources are widely shared, which is in line with the FOAM movement's philosophy. However, opportunities exist for paramedics to share further diverse resources supported by referenced material.

Pub.: 06 Apr '18, Pinned: 10 Apr '18

Clinician tasking in ambulance control improves the identification of major trauma patients and pre-hospital critical care team tasking.

Abstract: Trauma remains the fourth leading cause of death in western countries and is the leading cause of death in the first four decades of life. NICE guidance in 2016 advocated the attendance of pre-hospital critical care trauma team (PHCCT) in the pre-hospital stage of the care of patients with major trauma. Previous publications support dispatch by clinicians who are also actively involved in the delivery of the PHCCT service; however there is a lack of objective outcome measures across the current reviewed evidence base. In this study, we aimed to assess the accuracy of PHCCT clinician led dispatch, when measured by Injury Severity Score (ISS). A retrospective cohort study over a 2 year period pre and post implementation of a PHCCT clinician led dispatch of PHCCT for potential major trauma patients, using national ambulance data combined with national trauma registry data. A total of 99,702 trauma related calls were made to SAS including 495 major trauma patients with an ISS >15, and a total of 454 dispatches of a PHCCT. Following the introduction of a PHCCT clinician staffed trauma desk, the sensitivity for major trauma was increased from 11.3% to 25.9%. The difference in sensitivity between the pre and post trauma desk group was significant at 14.6% (95% CI 7.4%-21.4%, p < .001). The results from the study support the results from other studies recommending that a PHCCT clinician should be located in ambulance control to identify major trauma patients as early as possible and co-ordinate the response. Copyright © 2018. Published by Elsevier Ltd.

Pub.: 07 Apr '18, Pinned: 10 Apr '18

Intrastate Variation in Treatment and Outcomes of Out-of-Hospital Cardiac Arrest.

Abstract: Our objective was to analyze and compare out-of-hospital cardiac arrest (OHCA) system of care performance and outcomes at the Medical Control Authority (MCA) level in the state of Michigan. We hypothesized that clinically and statistically significant variations in treatment and outcomes of OHCA exists within a single U.S. state. We performed a retrospective, observational study of all non-traumatic EMS-treated OHCA from the state of Michigan CARES registry for 2014-2015. Geocoding of the OHCA incident address was used to assign records to individual MCAs. MCA-based demographics, arrest characteristics, system of care performance and outcomes were quantified and compared. Associations between demographics, system of care parameters, and outcomes were examined at the MCA level. A total of 8,115 records with complete data were available for analysis. Eleven MCAs met study inclusion criteria of >100 cases, producing a final sample size of 7,788 records (96%). Statistically significant variations in survival to hospital discharge ranged from 4.5% to 15% (p < 0.001) (Adjusted odds ratio [AOR] range 0.6-2.0) and survival with good neurologic outcome 2.7-12.5% (p < 0.001; AOR range 0.5-2.2,) were observed across MCAs. Bystander CPR ranged from 32% to 53% (p < 0.001) and bystander AED application ranged from 3.5% 11.5% (p < 0.05). Of patients admitted to the hospital alive, 29-68% received targeted temperature management. In hospital mortality ranged from 53.1% to 73.9% (p < 0.05). Significant intrastate variability in OHCA system of care performance and outcomes currently exist and are similar to what has been previously reported across North America almost a decade ago. This degree of variability highlights the opportunity to optimize modifiable factors within local systems of care to improve OHCA outcomes.

Pub.: 07 Apr '18, Pinned: 10 Apr '18

Out-of-hospital Cardiac Arrest with Do-Not-Resuscitate Orders Signed in Hospital: Who are the Survivors?

Abstract: Signing Do-Not-Resuscitate orders is an important element contributing to a worse prognosis for out-of-hospital cardiac arrest (OHCA). However, our data showed that some of those OHCA patients with Do-Not-Resuscitate orders signed in hospital survived to hospital discharge, and even recovered with favorable neurological function. In this study, we described their clinical features and identified those factors that were associated with better outcomes. A retrospective, observational analysis was performed on all adult non-traumatic OHCA who were enrolled in the Resuscitation OUTCOMES: Consortium (ROC) PRIMED study but signed Do-Not-Resuscitate orders in hospital after admission. We reported their demographics, characteristics, interventions and outcomes of all enrolled cases. Patients surviving and not surviving to hospital discharge, as well as those who did and did not obtain favorable neurological recovery, were compared. Logistic regression models assessed those factors which might be prognostic to survival and favorable neurological outcomes at discharge. Of 2289 admitted patients with Do-Not-Resuscitate order signed in hospital, 132(5.8%) survived to hospital discharge and 28(1.2%) achieved favorable neurological recovery. Those factors, including witnessed arrest, prehospital shock delivered, Return of Spontaneous Circulation (ROSC) obtained in the field, cardiovascular interventions or procedures applied, and no prehospital adrenaline administered, were independently associated with better outcomes. We suggest that some factors should be taken into considerations before Do-Not-Resuscitate decisions are made in hospital for those admitted OHCA patients. Copyright © 2018. Published by Elsevier B.V.

Pub.: 10 Apr '18, Pinned: 10 Apr '18

The relationship between elevated prehospital point-of-care lactate measurements, intensive care unit admission, and mortality: A retrospective review of adult patients.

Abstract: To determine whether prehospital point-of-care lactate (pLA) is associated with mortality, admission, and duration of hospital stay. A retrospective clinical audit, where elevated lactate was defined as ≥2 mmol/L. The ambulance service and primary referral hospital in the Australian Capital Territory from 1st July 2014 to 30th June 2015. Adult patients (≥18 years) who had pLA measured and were transported to the primary referral hospital. Mortality, admission, and duration of hospital stay. Two hundred fifty-three patients with a median pLA of 2.5 mmol/L (interquartile range [IQR]: 1.5-3.7) were analysed. Overall mortality was 8.3%; 68% were admitted to the hospital; 8.3% to the intensive care unit (ICU). pLA was non-significantly higher in those who died compared to survivors (3.5 [IQR: 2.75-5.85] vs 2.4 [1.5-3.6]; W = 1631.5; p = 0.053). pLA was higher for those admitted to the hospital (2.9 [1.9-3.9] vs 2.0 [1.4-3.1]; W = 5094.5, p = 0.001) and the ICU (3.2 [2.4-5.7] vs 2.4 [1.5-3.6]; W = 1578.5; p = 0.008). There was no relationship between pLA and duration of stay. Considered as a screening tool, at a cut-off of 2.5 mmol/L, pLA had a likelihood ratio+ of 1.61 for mortality and 1.44 for ICU admission; the odds ratio for mortality was 3.76 (95% confidence interval = 1.30, 13.89). Elevated prehospital lactate was associated with significantly increased ICU and hospital admissions. There may be value in pLA as a screening tool. Copyright © 2018 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.

Pub.: 01 Apr '18, Pinned: 03 Apr '18

Civilian Prehospital Tourniquet Use Is Associated with Improved Survival in Patients with Peripheral Vascular Injuries.

Abstract: Tourniquet use has been proven to reduce mortality on the battlefield. Although empirically transitioned to the civilian environment, data substantiating survival benefit attributable to civilian tourniquet use is lacking. We hypothesized that civilian prehospital tourniquet use is associated with reduced mortality in patients with peripheral vascular injuries. Multicenter retrospective review of all patients sustaining peripheral vascular injuries admitted to 11 Level I trauma centers (Jan/2011-Dec/2016). The study population was divided into two groups based on prehospital tourniquet use. Baseline characteristics were compared and factors associated with mortality identified. Logistic regression, adjusting for demographic, physiologic and injury-related parameters was used to evaluate the association between prehospital tourniquet use and mortality. Delayed amputation was the secondary outcome. Over 6 years, 1,026 patients with peripheral vascular injuries were admitted. Prehospital tourniquets were used in 181(17.6%) patients. Tourniquet time averaged 77.3±63.3min (IQR: 39.0-92.3 min). Traumatic amputations occurred in 98 patients (35.7% had a tourniquet). Mortality was 5.2% in the Non-Tourniquet group compared to 3.9% in the Tourniquet group [OR(95%CI):1.36(0.60-1.65), p=0.452]. After multivariable analysis, the use of tourniquets was found to be independently associated with survival [Adjusted OR(95%CI): 5.86(1.41-24.47), Adjusted p=0.015]. Delayed amputation rates were not significantly different between the two groups [1.1% vs. 1.1%, Adjusted OR(95% CI):1.82(0.36-9.99), Adjusted p=0.473]. Although still underutilized, civilian prehospital tourniquet application was independently associated with a six-fold mortality reduction in patients with peripheral vascular injuries. More aggressive prehospital application of extremity tourniquets in civilian trauma patients with extremity hemorrhage and traumatic amputation is warranted. Copyright © 2018. Published by Elsevier Inc.

Pub.: 02 Apr '18, Pinned: 03 Apr '18

Stop the Bleed: The Effect of Hemorrhage Control Education on Laypersons’ Willingness to Respond During a Traumatic Medical Emergency

Abstract: Background The “Stop the Bleed” campaign advocates for non-medical personnel to be trained in basic hemorrhage control. However, it is not clear what type of education or the duration of instruction needed to meet that requirement. The objective of this study was to determine the impact of a brief hemorrhage control educational curriculum on the willingness of laypersons to respond during a traumatic emergency. Methods This “Stop the Bleed” education initiative was conducted by the University of Texas Health San Antonio Office of the Medical Director (San Antonio, Texas USA) between September 2016 and March 2017. Individuals with formal medical certification were excluded from this analysis. Trainers used a pre-event questionnaire to assess participants knowledge and attitudes about tourniquets and responding to traumatic emergencies. Each training course included an individual evaluation of tourniquet placement, 20 minutes of didactic instruction on hemorrhage control techniques, and hands-on instruction with tourniquet application on both adult and child mannequins. The primary outcome in this study was the willingness to use a tourniquet in response to a traumatic medical emergency. Results Of 236 participants, 218 met the eligibility criteria. When initially asked if they would use a tourniquet in real life, 64.2% (140/218) responded “Yes.” Following training, 95.6% (194/203) of participants responded that they would use a tourniquet in real life. When participants were asked about their comfort level with using a tourniquet in real life, there was a statistically significant improvement between their initial response and their response post training (2.5 versus 4.0, based on 5-point Likert scale; P<.001). Conclusion In this hemorrhage control education study, it was found that a short educational intervention can improve laypersons’ self-efficacy and reported willingness to use a tourniquet in an emergency. Identified barriers to act should be addressed when designing future hemorrhage control public health education campaigns. Community education should continue to be a priority of the “Stop the Bleed” campaign. Ross EM , Redman TT , Mapp JG , Brown DJ , Tanaka K , Cooley CW , Kharod CU , Wampler DA . Stop the Bleed: The Effect of Hemorrhage Control Education on Laypersons’ Willingness to Respond During a Traumatic Medical Emergency. Prehosp Disaster Med. 2018;33(2):127–132.

Pub.: 01 Apr '18, Pinned: 03 Apr '18

Incidence and outcomes of out-of-hospital cardiac arrest: A New Zealand perspective.

Abstract: To describe the incidence and outcomes from out-of-hospital cardiac arrest (OHCA) in the New Zealand population served by the St John Ambulance Service. A retrospective observational study was conducted using data from the St John New Zealand OHCA registry, which serves a population of around 4 million. The incidence and outcomes of adult patients who were treated for an OHCA between 1 October 2013 and 30 September 2015 are reported. A total of 7996 adult OHCA cases were attended, resuscitation was attempted in 3862 cases (60 per 100 000 person-years). The median response time was 9 min (interquartile range 7-12), the median age was 66 (interquartile range 53-77) and 69% were men. Most events occurred in the home (67%), bystanders witnessed 53%, EMS witnessed 16% and 31% were unwitnessed. Bystander CPR was administered in 62% of cases and 8% were defibrillated prior to EMS arrival. Most events had a presumed cardiac aetiology (77%) and 38% presented in a shockable rhythm. Of those who had attempted resuscitation, a return of spontaneous circulation sustained to hospital handover occurred in 30% of events and 15% survived to 30 days. Adjusted survival outcomes demonstrated differences according to ethnicity. This is the first study to describe the epidemiology and outcomes of OHCA in New Zealand. Our findings provide important baseline data to monitor temporal trends, investigate the impact of changes in the management of OHCA and demonstrate that there are opportunities for improvement across the system of care. © 2018 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.

Pub.: 24 Mar '18, Pinned: 30 Mar '18

The association between hospital arrival time, transport method, prehospital time intervals, and in-hospital mortality in trauma patients presenting to Khayelitsha Hospital, Cape Town

Abstract: Publication date: Available online 20 March 2018 Source:African Journal of Emergency Medicine Author(s): Anders Möller, Luke Hunter, Lisa Kurland, Sa'ad Lahri, Daniël J. van Hoving Introduction Trauma is a leading cause of unnatural death and disability in South Africa. The aim of the study was to determine whether method of transport, hospital arrival time or prehospital transport time intervals were associated with in-hospital mortality among trauma patients presenting to Khayelitsha Hospital, a district-level hospital on the outskirts of Cape Town, South Africa. Methods The Khayelitsha Hospital Emergency Centre database was retrospectively analysed for trauma-related patients presenting to the resuscitation area between 1 November 2014 and 30 April 2015. Missing data and additional variables were collected by means of a chart review. Eligible patients’ folders were scrutinised for hospital arrival time, transport time intervals, transport method and in-hospital mortality. Descriptive statistics were presented for all variables. Categorical data were analysed using the Fisher’s Exact test and Chi-square, continuous data by logistic regression and the Mann Whitney test. A confidence interval of 95% was used to describe variance and a p-value of <0.05 was deemed significant. Results The majority of patients were 19–44 year old males (n = 427, 80.3%) and penetrating trauma the most frequent mechanism of injury (n = 343, 64.5%). In total, 258 (48.5%) patients arrived with their own transport, 254 (47.7%) by ambulance and 20 (3.8%) by the police service. The arrival of trauma patients peaked during the weekend, and was especially noticeable between midnight and six a.m. In-hospital mortality (n = 18, 3.4%) was not significantly affected by transport method (p = 0.26), hospital arrival time (p = 0.22) or prehospital transport time intervals (all p-values >0.09). Discussion Method of transport, hospital arrival time and prehospital transport time intervals did not have a substantially measurable effect on in-hospital mortality. More studies with larger samples are suggested due to the small event rate.

Pub.: 21 Mar '18, Pinned: 30 Mar '18

A cross-sectional survey of child abuse management knowledge among emergency medicine personnel in Cape Town, South Africa

Abstract: Publication date: Available online 20 March 2018 Source:African Journal of Emergency Medicine Author(s): Bruna Dessena, Paul C. Mullan Introduction Child abuse is a common condition in the emergency centres of South Africa. It is critical for both prehospital emergency care practitioners and emergency centre-based emergency medicine registrars to be competent in screening, diagnosing, treating, and documenting child abuse. Our goal was to assess the knowledge of child abuse management in a sample of prehospital emergency care practitioners and emergency medicine registrars in Cape Town, South Africa. Methods A mixed-methods approach of quantitative and qualitative data was used to survey a sample of 120 participants (30 emergency medicine registrars and 90 prehospital emergency care practitioners: 30 Basic Life Support, 30 Intermediate Life Support, and 30 Advanced Life Support). An expert panel created the survey to ensure content validity and survey questions were designed to assess the perceived and actual knowledge of participants. We hypothesised that there would be significantly higher levels of perceived and actual knowledge in emergency medicine registrars compared to emergency care practitioners. An open-ended question on how participants felt dealing with child abuse was qualitatively analysed using thematic analysis. Results There were significant differences in the levels of perceived knowledge (58% of emergency medicine registrars agreed that they felt adequately trained overall, versus 39% of emergency care practitioners; −19% difference, 95% CI −26% to −12%) and actual knowledge (83% of emergency medicine registrars with correct answers, versus 62% of emergency care practitioners; −21% difference, 95% CI −26% to −16%) among participants. Themes that emerged from qualitative analysis included personal distress, retaliation, frustration, medical system frustration, and personal competence concerns. Discussion Significant perceived and actual knowledge deficits of child abuse management exist among both emergency care practitioners and emergency medicine registrars in this setting. Future interventions should address the need for guidelines and increased training opportunities to ensure the health and safety of abused children.

Pub.: 21 Mar '18, Pinned: 30 Mar '18

Naloxone access for Emergency Medical Technicians: An evaluation of a training program in rural communities.

Abstract: Opioid-related overdose death rates in rural communities in the United States are much higher than their urban counterparts. However, basic life support (BLS) personnel, who are more common in rural areas, have much lower rates of naloxone administration than other levels of emergency medical services (EMS). Training and equipping basic level Emergency Medical Technician (EMTs) to administer naloxone for an opioid overdose could yield positive outcomes. Following a legislative change that allowed EMTs to administer naloxone in one rural state, we evaluated an EMT training program by examining EMTs' opioid overdose knowledge and attitudes before and after the training. One-hundred-seventeen rural EMTs participated the training. They demonstrated statistically significant improvements on almost all of the knowledge questions after the training (p's = 0.0469 to <0.0001). The opioid overdose competency and concern scales showed statistically significant improvement (p < 0.0001) and reduction (p < 0.0001), respectively. Furthermore, statistically significant changes in knowledge and opinions of state law regarding naloxone administration were observed. Significantly more EMTs supported the idea of expanding naloxone to people at risk for overdose (p = 0.0026) after the training. At a time when states are passing legislation to expand first responders' access to naloxone, this study provides evidence about authorizing EMTs to administer naloxone. Copyright © 2018 Elsevier Ltd. All rights reserved.

Pub.: 25 Mar '18, Pinned: 30 Mar '18

A tale of two cities: prehospital intubation with or without paralysing agents for traumatic brain injury.

Abstract: The role of prehospital endotracheal intubation (PETI) for traumatic brain injury is unclear. In Victoria, paramedics use rapid sequence induction (RSI) drugs to facilitate PETI, while in New South Wales (NSW) they do not have access to paralysing agents. We hypothesized that RSI would both increase PETI rates and improve mortality. Retrospective comparison of adult primary admissions (Glasgow Coma Scale <9 and abbreviated injury scale head and neck >2) to either Victorian or NSW trauma centre, which were compared with univariate and logistic regression analysis to estimate odds ratio for mortality and intensive care unit (ICU) length of stay. One hundred and ninety-two Victorian and 91 NSW patients did not differ in: demographics (males: 77% versus 79%; P = 0.7 and age: 34 (18-88) versus 33 (18-85); P = 0.7), Glasgow Coma Scale (3 (3-8) versus 5 (3-8); P = 0.07), and injury severity score (38 (26-75) versus 35 (18-75); P = 0.09), prehospital hypotension (15.4% versus 11.7%; P = 0.5) and desaturation (14.6% versus 17.5%; P = 0.5). Victorians had higher abbreviated injury scale head and neck (5 (4-5) versus 5 (3-6); P = 0.04) and more often successful PETI (85% versus 22%; P < 0.05). On logistic regression analysis, mortality did not differ among groups (31.7% versus 26.3%; P = 0.34; OR = 0.84; 95% CI: 0.38-1.86; P = 0.67). Among survivors, Victorians had longer stay in ICU (364 (231-486) versus 144 (60-336) h), a difference that persisted on gamma regression (effect = 1.58; 95% CI: 1.30-1.92; P < 0.05). Paramedics using RSI to obtain PETI in patients with traumatic brain injury had a higher success rate. This increase in successful PETI rate was not associated with an improvement in either mortality rate or ICU length of stay. © 2018 Royal Australasian College of Surgeons.

Pub.: 25 Mar '18, Pinned: 30 Mar '18

Geographical variation of diabetic emergencies attended by prehospital Emergency Medical Services is associated with measures of ethnicity and socioeconomic status.

Abstract: Geographical variation of diabetic emergencies attended by prehospital emergency medical services (EMS) and the relationship between area-level social and demographic factors and risk of a diabetic emergency were examined. All cases of hypoglycaemia and hyperglycaemia attended by Ambulance Victoria between 1/01/2009 and 31/12/2015 were tabulated by Local Government Area (LGA). Conditional autoregressive models were used to create smoothed maps of age and gender standardised incidence ratio (SIR) of prehospital EMS attendance for a diabetic emergency. Spatial regression models were used to examine the relationship between risk of a diabetic emergency and area-level factors. The areas with the greatest risk of prehospital EMS attendance for a diabetic emergency were disperse. Area-level factors associated with risk of a prehospital EMS-attended diabetic emergency were socioeconomic status (SIR 0.70 95% CrI [0.51, 0.96]), proportion of overseas-born residents (SIR 2.02 95% CrI [1.37, 2.91]) and motor vehicle access (SIR 1.47 95% CrI [1.08, 1.99]). Recognition of areas of increased risk of prehospital EMS-attended diabetic emergencies may be used to assist prehospital EMS resource planning to meet increased need. In addition, identification of associated factors can be used to target preventative interventions tailored to individual regions to reduce demand.

Pub.: 25 Mar '18, Pinned: 30 Mar '18

Violence against ambulance personnel: a retrospective cohort study of national data from Safe Work Australia.

Abstract: Objectives and importance: Paramedics have high rates of occupational injury and fatality. The objective of this study is to describe their specific risks of violence-related injury. This retrospective cohort study is an examination of retrospective data provided by Safe Work Australia (SWA). An examination of the 300 cases of serious claims of injury related to assaults, violence, harassment and bullying that occurred among individuals identified as ambulance officers and paramedics in Australia from 2001 to 2014. Paramedic risks likely vary by exposures such as hours worked and call volume. To examine how those exposures may influence risk, the available data were used to estimate rates based on hours worked and call volume. The data show that, for serious injuries among paramedics in Australia between 2001 and 2014, the total number of violence-related cases increased from 5 to 40 per year; the number of cases of injury secondary to assault tripled from 10 to 30; and the rate of cases by call volume doubled from 6 to 12. The cost of these injuries was approximately AUD$250 000 for the year 2013-14. The median time at work lost per individual case of 'work-related harassment and/or workplace bullying' was 9.6 weeks. Although females comprised 32% of the paramedic workforce, they were the victims in 42% of cases of exposure to violence and 40% of harassment cases. Although anecdotal reports indicate that some interventions have been attempted, violence against paramedics continues to be a growing problem in Australia. The data presented in this study allow for a better understanding of the problem and can support efforts by ambulance service administrators, physicians, paramedics and university researchers to work together to develop and publish evidence based, cost-effective solutions to reduce the risk of workplace violence. Effective solutions will likely be multifaceted and include training, engineering changes, community education and adjustments to agency policies. Because of the widespread nature of the risks, a national commission should be empowered to address this growing problem.

Pub.: 28 Mar '18, Pinned: 30 Mar '18

Neighbourhood alcohol environment and injury risk: a spatial analysis of pedestrian injury in Baltimore City.

Abstract: The purpose of this study was to investigate the contribution of neighbourhood disorder around alcohol outlets to pedestrian injury risk. A spatial analysis was conducted on census block groups in Baltimore City. Data included pedestrian injury EMS records from 1 January 2014 to 15 April 2015 (n=858), off-premise alcohol outlet locations for 2014 (n=693) and neighbourhood disorder indicators and demographics. Negative binomial regression models were used to determine the relationship between alcohol outlet count and pedestrian injuries at the block group level, controlling for other neighbourhood factors. Attributable risk was calculated by comparing the total population count per census block group to the injured pedestrian count. Each one-unit increase in the number of alcohol outlets was associated with a 14.2% (95% CI 1.099 to 1.192, P<0.001) increase in the RR of neighbourhood pedestrian injury, adjusting for traffic volume, pedestrian volume, population density, per cent of vacant lots and median household income. The attributable risk was 10.4% (95% CI 7.7 to 12.7) or 88 extra injuries. Vacant lots was the only significant neighbourhood disorder indicator in the final adjusted model (RR=1.016, 95% CI 1.007 to 1.026, P=0.003). Vacant lots have not been previously investigated as possible risk factors for pedestrian injury. This study identifies modifiable risk factors for pedestrian injury previously unexplored in the literature and may provide evidence for alcohol control strategies (eg, liquor store licencing, zoning and enforcement). © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Pub.: 29 Mar '18, Pinned: 30 Mar '18

The utilization of automated external defibrillators in Taiwan.

Abstract: Increasing attention to care of patient succumbed to out-of-hospital cardiac arrest (OHCA) and evidence for improved survival have resulted in many countries to encourage the use automated external defibrillators (AEDs) by legislation. In Taiwan, the amendment of the Emergency Medical Services Act mandated the installation of AEDs in designated areas in 2013. Since then, 6151 AEDs have been installed and registered in mandated and non-mandated locations. The purpose of this study was to investigate the utilization of AEDs at mandated and non-mandated locations. This paper analyzed 217 cases in whom AEDs was used between July 11, 2013 and July 31, 2015. Descriptive statistics were used to analyze the data. The highest frequency of AEDs used was in long-term care facilities, accounting for 34 (15.7%) cases. The second and third highest was in schools and commuting stations. The highest utilization rate of registered AED was in long-term care facilities (73.9%), the second was in residential areas, and the third was in hot spring areas. Employees at the designated locations or medical personnel operated the AED in 143 cases (84.6%), and bystanders, relatives, friends or others operated the AEDs in 26 cases (15.4%). On-site Return of Spontaneous Circulation (ROSC) after applying AEDs occurred in 76 cases (45.8%). Long-term care facilities had the highest utilization of AEDs and government should pay more attention to enforce the installing of AEDs in these places. The government also needs to promote the education public on how to search the AEDs locations. Copyright © 2018. Published by Elsevier B.V.

Pub.: 29 Mar '18, Pinned: 30 Mar '18

Attitudes towards bystander cardiopulmonary resuscitation: Results from a cross-sectional general population survey.

Abstract: Survival from out-of-hospital cardiac arrest (OHCA) varies across the developed world. Although not all OHCA are recoverable, the survival rate in Scotland is lower than in comparable countries, with higher average survival rates of 7.9% in England and 9% across Europe. The purpose of this paper is to explore the barriers, facilitators and public attitudes to administering bystander cardiopulmonary resuscitation (CPR) which could inform future policy and initiatives to improve the rate of bystander CPR. Data was collected via a cross-sectional general population survey of 1027 adults in Scotland. 52% of respondents had been trained in CPR. Of those who were not trained, two fifths (42%) expressed a willingness to receive CPR training. Fewer than half (49%) felt confident administering CPR, rising to 82% if they were talked through it by a call handler. Multivariate analyses identified that people in social grade C2DE were less likely than those in social grade ABC1 to be CPR trained and less confident to administer CPR if talked through by a call handler. The older a person was, the less likely they were to be CPR trained, show willingness to be CPR trained or be confident to administer bystander CPR with or without instruction from an emergency call handler. These findings are particularly relevant considering that most OHCA happen in the homes of older people. In a developed country such as Scotland with widely available CPR training, only half of the adult population reported feeling confident about administering bystander CPR. Further efforts tailored specifically for people who are older, unemployed and have a lower social grade are required to increase knowledge, confidence and uptake of training in bystander CPR.

Pub.: 08 Mar '18, Pinned: 23 Mar '18

Posttraumatic Stress Disorder, Functional Impairment, and Subjective Distress in World Trade Center Disaster Workers

Abstract: Posttraumatic stress disorder (PTSD) is associated with functional deficits, poor physical health, and diminished quality of life. Limited research has examined PTSD symptom clusters and their associations with functioning and distress among disaster recovery workers, a population at high risk for PTSD due to potential for repeated trauma. The purpose of this study was to investigate associations between overall PTSD severity, as well as PTSD symptom clusters, and social and occupational functioning and subjective distress in World Trade Center (WTC) disaster workers after the terrorist attacks on September 11, 2001 (9/11). Disaster workers deployed to the site of the attacks completed assessments at three time points over approximately 5 years post-9/11. Our sample consisted of participants who met criteria for PTSD or subthreshold PTSD at baseline (n = 514), 1-year (n = 289), and 2-year follow-up (n = 179). Adjusted linear regression indicated that Clinician Administered PTSD Scale (CAPS)-rated PTSD severity was positively associated with subjective distress, and deficits in social and occupational functioning, over time, CAPS Criterion F items; βs = .20 to .62, ps < .001. The reexperiencing and avoidance/numbing symptom clusters were associated with increased subjective distress, the avoidance/numbing and hyperarousal clusters were associated with deficits in social functioning, and the reexperiencing and hyperarousal clusters were associated with worse occupational functioning. These associations were consistent across the study period. Findings point to the importance of targeting PTSD symptom clusters associated with specific areas of functional impairment, with the goal of improving global outcomes.

Pub.: 14 Mar '18, Pinned: 23 Mar '18