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Biomedical subjects

D C Cone

Publications and source records attributed to D C Cone.

At least 19 recordsLinked to original sources
PubMed1999

EMS systems: foundations for the future.

Emergency medical services (EMS) occupy a unique position in the continuum of emergency health care delivery. The role of EMS personnel is expanding beyond their traditional identity as out-of-hospital care providers, to include participation and active leadership in EMS administration, education, and research. With these roles come new challenges, as well as new responsibilities. This paper was developed by the SAEM EMS Task Force and provides a discussion of these new concepts as well as recommendations for the specialty of emergency medicine to foster the continued development of all of the potentials of EMS.

Emergency Medical Services↗
PubMed1999

Now that we have the Utstein style, are we using it?

OBJECTIVES: To examine the extent to which the Utstein style has been used for out-of-hospital cardiac arrest (OOHCA) research since its publication in 1991. The style was developed in an effort to standardize OOHCA research and reporting. METHODS: To locate all OOHCA research papers published between 1992 and 1997, all issues of six emergency medicine/emergency medical services (EM/ EMS) journals were examined manually, and papers from other journals were located using computerized searches. All located articles were examined by the first author to determine whether use of the Utstein style was indicated and if so, whether it had actually been used. When either of these was uncertain, all three authors reviewed the paper, and a consensus was reached. The Pearson chi-square test was used to compare rates of use from U.S. and non-U.S. institutions, and from the EM/EMS and non-EM/EMS literature, with significance set at p < 0.05. RESULTS: All 143 OOHCA research articles identified by the search were examined. The Utstein style was found to be not applicable to 41 (29%), and these were eliminated. The Utstein style was indicated for the remaining 102 studies. Of these, 41 (40%) used the Utstein style, and 61 (60%) did not. There was no difference in rates between papers from sites in the United States (18/48, 38%) and elsewhere (23/54, 43%), or between papers from the EM/EMS literature (17/44, 39%) and non-EM/EMS literature (25/59, 42%). Despite an upward trend in the use of the Utstein style seen from 1992 to 1994, use leveled off from 1994 to 1997, and has not exceeded 60% in any given calendar year studied. CONCLUSIONS: Six years after the release of the Utstein style for OOHCA research, fewer than 60% of OOHCA research articles actually use the style.

Bibliometrics↗
PubMed1998

EMS research.

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Clinical Protocols↗
PubMed1998

Medical student career advice related to emergency medicine.

OBJECTIVE: To describe the advisors and the advice given to residency candidate interviewees interested in specializing in emergency medicine (EM). METHODS: All interviewees at a university-based EM residency program were surveyed. Data were collected anonymously and included demographic information, characteristics of each applicant's medical school, career advice by non-EM faculty, and access to advisors who are residency-trained in and practicing EM. RESULTS: Of 114 interviewees, 104 (91%) completed the survey. Only 45% of the respondents reported they were assigned an emergency physician (EP) advisor by their school, and 38% sought advice informally from an EP. Of those students receiving advice from an EP, 70% reported their advisor was residency-trained in EM. Most (57%) respondents reported receiving negative advice concerning a career in EM from non-EM medical school faculty. Of the 59 students reporting negative advice, 18 (31%) received negative comments from non-EM residency program directors, 23 (39%) from non-EM department chairs, and 4 (7%) from medical school deans. The presence of a residency training program increased the chances of a student's being assigned an EP advisor, but neither an EP advisor nor the department status of EM within the students' institutions was associated with receipt of negative advice. CONCLUSIONS: Students considering specializing in EM often receive negative advice or have no assigned EP advisor. These factors may adversely affect entry into the field of EM.

Career Choice↗
PubMed1998

A time-motion study of the emergency medical services turnaround interval.

STUDY OBJECTIVE: Because overall EMS system response depends on ambulance availability, we conducted a prospective study of the EMS turnaround interval. This interval represents the time elapsed from ambulance arrival at the hospital until the ambulance reports back in service. METHODS: An on-site observer, while monitoring EMS radio traffic, recorded the delivery and recovery activities of personnel from a large urban EMS system at a university hospital emergency department. System policy permitted a maximum turnaround interval of 30 minutes. Prospectively defined subintervals were analyzed. RESULTS: A convenience sample of 122 patient deliveries was collected. Observed and radio-reported times of arrival at the hospital differed by -1'24" to +11'08". In 18.9% of cases, arrival was reported on radio more than 5 minutes after the observed arrival. Time from arrival to removal of the patient from the ambulance averaged 59" (range, 13" to 2'53"), and time from patient removal to emergency department entry averaged 42" (range, 10" to 5'22"). Time from ED entry to placement of the patient on an ED bed averaged 2'11" (range, 33" to 9'35"). Although the mean interval for the verbal report to ED staff was 33" (range, 13" to 2'53"). it was 15" or less in 36% of cases. Writing the ambulance call report took an average of 17'12" (range, 5'20" to 52'11"). The mean time off radio was 29'51" (range, 11'43" to 53'37"), and the mean time the ambulance was actually at the ED was 30'01" (range, 11'25" to 1 degree 17'53"). Observed and radio-reported ambulance departure times differed by -4'31" to +23'32". In 22% of cases, departure times differed by -4'31" to +23'32". In 22% of cases, departure was reported by radio more than 5' after actual departure. CONCLUSION: In this system, ambulance call report documentation required the greatest subinterval of turnaround interval. The turnaround interval and its subintervals varied widely, and radio contact times correlated poorly with observed times at the ED. Attempts at improvement of overall system response through active management of the turnaround interval may be frustrated by reliance on radio-reported availability.

Ambulances↗
PubMed1996

Material safety data sheet: a useful resource for the emergency physician.

The large number of hazardous chemicals manufactured, transported, and stored in the United States creates the potential for significant toxic exposures to workers in industry today. Emergency physicians are likely to be called upon to evaluate many of these exposures when they occur in the acute setting. In addition to single-patient exposure, significant potential exists for such exposures in the setting of mass casualties. Emergency physicians need a source of readily available information regarding chemical hazards that can be helpful in the diagnosis and treatment of such exposures. The Material Safety Data Sheet (MSDS) is reviewed herein, with special attention given to the sort of information that can be found on the MSDS and how such information can be clinically helpful to emergency physicians. The significant drawbacks and limitations of MSDS documents are also reviewed.

Documentation↗
PubMed1996

Number of patches.

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Clinical Competence↗
PubMed1995

Proper depth placement of oral endotracheal tubes in adults prior to radiographic confirmation.

OBJECTIVE: To determine whether a certain distance measurement on the oral endotracheal tube (ETT) at the corner of the mouth could reasonably ensure proper depth of placement in critically ill patients, without the immediate need for a confirming chest x-ray (CXR). METHODS: A prospective observational cross-sectional design was used to compare ETT mark distance and radiographic location of the ETT tip. The measurement marking on the ETT at the level of the corner of the mouth was noted at the time of intubation. The relationship of the tip of the ETT to the tracheal carina on the postintubation CXR was then determined. The ETT placement was deemed correct if the tip was at least 2 cm cephalad to the carina on the CXR. RESULTS: Of 83 intubated patients assessed, 52 were men and 31 women. The mean measurement of the ETT at the corner of the mouth was 22.2 cm for the women and 23.1 cm for the men. The mean distance from the tip of the ETT to the carina was 3.45 cm for the women and 4.13 cm for the men. Seventy-five of the 83 patients (90.4%; 95% CI 81.9-95.7%) had correct ETT positions on the initial CXR. If the ETT position had been adjusted at the corner of the mouth to 21 cm for the women and 23 cm for the men, the ETT would have been in correct position for 81 of the 83 patients (97.6%; 95% CI 89.6-95.7%). This represents a significant improvement in tube placement (p < 0.025; the McNemar chi-square). CONCLUSION: Proper depth of ETT placement in the critically ill adult patient can be estimated by the technique of this study. In this adult patient population, corner-of-the-mouth placement of the ETT using the 21-cm tube mark for the women and the 23-cm mark for the men would have led to proper placement for most patients.

Adult↗
PubMed1992

Lead screening and follow-up in an urban pediatric clinic.

The purpose of this study was to examine screening and follow-up procedures used in testing for lead toxicity at an urban pediatric clinic. A retrospective chart review of all patients with elevated zinc protoporphyrin levels was undertaken. In the first four months of 1990, 66 of 438 patients screened (15.1%) had elevated zinc protoporphyrin levels. Sixty charts were located and reviewed to evaluate five key interventional strategies. Iron therapy was implemented in 31 (51.2%), and follow-up was scheduled in 21 (35.0%). Two exposure histories and two dietary histories were documented (3.3% each). Only 26 children (43.3%) had venous blood drawn for lead-level determination. Eleven patients (18.3%) had none of these five steps documented, and an additional 26 (43.3%) received only one. Fifteen children (25.0%) received two interventions, six (10.0%) received three, and two (3.3%) received four. No patients received all five steps. Better procedures are needed at this site to ensure the implementation and documentation of diagnostic and therapeutic interventions in children with elevated zinc protoporphyrin levels. Other screening programs may benefit from examination for similar methodologic problems.

Child↗
PubMedDate not supplied

Patient-initiated refusals of prehospital care: ambulance call report documentation, patient outcome, and on-line medical command.

INTRODUCTION: There is a growing interest in cases in which emergency medical services (EMS) providers evaluate a patient, but do not transport the patient to a hospital. A subset of these cases, the patient-initiated refusal (PIR) in which the patient refused care and transport, was studied and evaluated. The objectives of the study were to examine the adequacy of ambulance call report documentation in PIR, to examine the clinical outcome of these patients in one hospital-based, suburban EMS system, and to assess the potential impact of on-line medical command (OLMC) on cases of PIR. METHODS: The system studied is a hospital-based, transport-capable, advanced life support service in a suburban EMS system, with an annual call volume of 4,200 runs. During the 6-month study period, all ambulance call reports completed by the paramedics and medical command control forms completed by medical command physicians were examined, and cases of PIR collected. Each ambulance call report was examined for adequacy of documentation. Patient outcome was determined from emergency department records and telephone follow-up. RESULTS: Eighty-five PIRs were documented during the study period. Four cases were excluded because of a missing ambulance call reports and/or medical command control forms, leaving 81 PIRs for analysis. Despite policy requiring OLMC in cases of PIR, OLMC was established in only 23 PIRs (28%). Of these, two (9%) had inadequate ambulance call report documentation. Of the 58 PIR in which OLMC was not established, 25 (43%) had inadequate ambulance call report documentation (p < 0.001, Fisher's exact test). Follow-up was obtained for 54 (67%) PIR. Of these, 37 (68%) did not subsequently see a physician, and all needed no further medical care. Seven (13%) saw their own physicians within a few days of the initial refusal of prehospital care, and had no further problems. Ten patients were seen in an emergency department within a few days. Three (6%) were discharged, and did well. Seven (13%) were admitted to the hospital, with four (7%) admitted to monitored beds, and three (6%) to unmonitored beds. There were no deaths. CONCLUSIONS: Ambulance call report documentation is better with OLMC than without. Patients who initially refuse care may be ill, and some ultimately will be hospitalized. Further research may elucidate a role for OLMC in preventing refusals by incompetent patients, convincing patients who are competent but appear ill to accept transport, and assisting paramedics with other difficult or unusual circumstances.

Adult↗
PubMedDate not supplied

A survey of emergency medical services systems on college and university campuses.

INTRODUCTION: Many colleges and universities appear to exist in relative isolation from community-based emergency medical services (EMS) systems. In response, some have developed their own EMS systems. OBJECTIVE: To determine the extent of this phenomenon and to delineate the characteristics of these systems. DESIGN/METHODS: Questionnaires were mailed to 1,503 colleges/universities in the United States and Canada. The questionnaire asked whether the institution had an EMS system and included 19 questions about the characteristics of the system. RESULTS: A total of 919 (61%) responses were received. Of the institutions responding, 234 (25%) had an EMS system and 31 (3.4%) were considering starting a system. Characteristics of the systems were as follows: 1) Types of patients-the two most common call types were medical and trauma/surgical; 134 (57%) reported one-fourth of calls to be medical and 91 (39%) reported one-fourth of calls to be trauma/surgical. 2) Type of service-133 (57%) services transport patients; 195 (83%) respond only to the campus or other university property; the remainder also respond to the community; and 135 (58%) function all year. 3) Dispatch-178 (76%) are dispatched by the campus police, although most services are dispatched by several sources; 46 (20%) use 9-1-1. 4) Personnel-two systems (0.85%) exclusively employ paramedics; 141 systems (60%) have at least one emergency medical technician; the remainder use emergency care attendants and first-aid providers; 118 (50%) have medical directors, of these 76 (64%) are student health physicians and 21 (18%) are community physicians. 5) Demographic Information-The majority of the campus-based EMS systems exist on small campuses in urban areas. CONCLUSIONS: A significant number of colleges/universities have EMS systems and one-half transport patients. However, the level of training of the personnel and medical direction may be below the standard for the EMS systems in the communities in which these campus-based systems exist.

Canada↗
PubMedDate not supplied

Termination of resuscitation in the prehospital setting for adult patients suffering nontraumatic cardiac arrest. National Association of EMS Physicians Standards and Clinical Practice Committee.

The National Association of EMS Physicians (NAEMSP) supports out-of-hospital termination of resuscitation for adult, nontraumatic cardiac arrest patients who have not responded to full resuscitative efforts. The following factors should be considered in establishing termination of resuscitation protocols: 1) Termination of resuscitation may be considered for any adult patient who suffers sudden cardiac death that is likely to be medical. 2) Unwitnessed cardiac arrest with delayed initiation of cardiopulmonary resuscitation (CPR) beyond 6 minutes and delayed defibrillation beyond 8 minutes has a poor prognosis. 3) In the absence of "do not resuscitate" or advanced directives, a full resuscitative effort including CPR, definitive airway management, medication administration, defibrillation if necessary, and at least 20 minutes of treatment following Advanced Cardiac Life Support (ACLS) guidelines should be performed prior to declaring the patient dead. 4) A patient whose rhythm changes to, or remains in, ventricular fibrillation or ventricular tachycardia should have continued resuscitative efforts. Patients in asystole or pulseless electrical activity should be strongly considered for out-of-hospital termination of resuscitation. 5) Logistic factors should be considered, such as collapse in a public place, family wishes, and safety of the crew and public. 6) Online medical direction should be established prior to termination of resuscitation. The decision to terminate efforts should be a consensus between the on-scene paramedic and the online physician. 7) The on-scene providers and family should have access to resources, such as clergy, crisis workers, and social workers. 8) Quality review is necessary to ensure appropriate application of the termination protocol, law enforcement notification, medical examiner or coroner involvement, and family counseling.

Adult↗
PubMedDate not supplied

Hazardous materials preparedness in the emergency department.

INTRODUCTION: This study was conducted to examine the preparedness of emergency departments (EDs) to safely receive, decontaminate, and treat chemically contaminated patients. METHODS: The safety officers of all 58 acute-care hospitals in the five-county philadelphia metropolitan region were surveyed by mail, with a repeat mailing to nonresponders followed by telephone contact. The 16 survey questions addressed the ability of EDs to safely decontaminate and treat chemically contaminated patients. RESULTS: Thirty-eight of 58 hospitals (66%) returned usable surveys. Of these, 24 (63%) have a written plan for decontamination and treatment of chemically contaminated patients in the ED, and 19 (50%) have a hospital-wide disaster plan that includes contingencies for decontamination and treatment of one or more chemically contaminated patients. Thirteen hospitals (34%) conducted a drill of either of these plans in 1994. Twenty (53%) EDs have a specific treatment area for chemically contaminated patients. A stock of supplies for protecting the ED from secondary contamination is maintained by 16 (42%). While 24 (63%) store personal protective equipment, most of these involve only gowns, gloves, and surgical masks; only 13 provide any type of respiratory protection. Nine respondents were certain that patients brought in by local EMS would have been adequately decontaminated in the field, eight stated that they believed or felt decontamination would be adequate, and 12 were concerned that field decontamination might not be adequate. Eighteen hospitals (47%) reported treating one or more chemically contaminated patients in 1994. The authors believe the return rate reflects reluctance to commit hospital policies to paper. This was confirmed during telephone follow-up of nonrespondents when, for example, one safety officer discussed hazardous materials (hazmat) principles for 40 minutes, but refused to complete the survey. CONCLUSIONS: Hospital hazmat preparedness in this area varies tremendously. A significant proportion of hospitals lack a written plan and equipment to allow the ED to safely and effectively handle the chemically contaminated patient. There is reluctance to discuss this topic.

Data Collection↗