Dermoid cysts of the nose in children.
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Child↗
Biomedical subjects
L H Brown
Publications and source records attributed to L H Brown.
A simplified synthesis of 1-beta-d-arabinofuranosyl-5-fluorouracil.
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Chemistry, Organic↗
Surgical treatment of ptosis of the eyelid.
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Adult↗
Do pulse checks delay semiautomatic defibrillation by EMT-defibrillators?
Advanced cardiac life support (ACLS) guidelines from the American Heart Association (AHA) now recommend not checking for a pulse between the initial three defibrillations for pulseless patients in ventricular tachycardia or fibrillation. The AHA asserts that checking for a pulse needlessly delays defibrillation. This study was undertaken to determine if pulse checks delay defibrillation by EMT-Defibrillators (EMT-Ds) using a semiautomatic defibrillator (SAED). Twenty-seven EMT-Ds demonstrated delivery of three successive defibrillations during two test scenarios: once with and once without pulse checks after the first and second defibrillations. The time from the first to third defibrillation was recorded. The mean time to deliver the defibrillations was 60.2 +/- 6.2 seconds with pulse checks and 57.5 +/- 4.6 seconds without pulse checks. The difference, 2.7 +/- 5.9 seconds, was statistically significant (P = 0.026). Pulse checks by EMT-Ds do delay administration of defibrillations, but consideration should be given to reinstating pulse checks as a part of the AHA guidelines, since this delay is of questionable clinical significance.
Electric Countershock↗
Use of local climatic data to determine if weather precludes the operation of an air medical system.
INTRODUCTION: Weather is one of many factors that affect safety in an air medical program. Syracuse, New York, has notoriously bad weather, and some have questioned whether an air medical service is practical given central New York's climate. This study was undertaken to determine the extent to which the area's climate could be expected to limit the availability of an air medical service. METHODS: CAMTS weather minimums for rotor-wing programs were compared with 1996-1997 hourly weather observations from the Northeastern Regional Climate Center (NRCC) and sunrise/sunset data from the United States Naval Observatory to determine how frequently weather conditions could be expected to preclude an air medical response in the greater Syracuse area. RESULTS: Exactly 17,544 hourly observations were made. CAMTS weather minimums would have precluded local flights for 606 (3.5%) of these hours and cross-country flights for 1111 (6.3%) hours. Cross-country flights were more likely to be precluded than local flights (P = .001), and both local and cross-country flights were more likely to be precluded at nighttime than in the daytime (P = .001). All flights were more likely to be precluded during winter months than during summer months (P = .000). CONCLUSION: The weather in central New York generally does not preclude the operation of an air medical services system.
Air Ambulances↗
Public perceptions of a rural emergency medical services system.
INTRODUCTION: To determine the awareness of citizens and physicians concerning the capabilities of a rural emergency medical services (EMS) system. HYPOTHESIS: Citizens and physicians are unaware of the capabilities of the EMS system. METHODS: Residents were selected randomly from the local telephone directory and asked a series of structured questions about their EMS agency. A written survey was distributed to area physicians. Chi-square analysis was used to compare the proportion of respondents who knew the available interventions in their community with the proportion of those who did not. Statistical significance was inferred at p < 0.01. RESULTS: A total of 49% of the citizens were able to identify available skills, and 41.4% of the physicians were able to identify available skills. Physicians were less likely than were the citizens to be able to identify the skills performed by each provider (p < 0.001). CONCLUSION: This study indicates that both physicians and the lay public have little understanding of the capabilities of their EMS system.
Attitude of Health Personnel↗
Mistaken identity: the effect of badges on EMT recognition.
INTRODUCTION: Many emergency medical services (EMS) providers wear badges with their uniforms. This study was undertaken to determine whether emergency medical technicians (EMTs) who wear badges with their uniforms are more likely to be mistaken for law enforcement personnel than are those who do not wear badges. HYPOTHESIS: Emergency medical services providers who wear badges are more likely to be mistaken for law enforcement personnel than are those who do not wear badges. METHODS: High school students, college students, civic organizations, and church groups were shown slides of different uniforms and badges/insignia and asked to identify the person portrayed. Responses were categorized as "EMS," "law enforcement," or "other." Frequency of responses for each uniform and insignia were compared with chi-square analysis. RESULTS: Fifty-nine percent of the uniforms with badges were identified as law enforcement personnel. Only 5.5% of the uniforms with badges were identified as "EMS," compared with 74% of the uniforms with a Star of Life (p < 0.001). CONCLUSION: Individuals wearing uniforms with badges are more likely to be identified as law enforcement personnel than are EMS personnel. Emergency medical services providers who do not wish to be mistaken for law enforcement personnel should wear the Star of Life, not a badge, with their uniform.
Adolescent↗
Does the ambulance environment adversely affect the ability to perform oral endotracheal intubation?
OBJECTIVE: Oral endotracheal intubation (ETI) is the preferred method of controlling the airway in critically ill or injured patients. It was postulated that time could be saved if intubation was performed in the ambulance en route to the hospital. This study was designed to determine whether the ambulance environment adversely affected the ability of emergency medical technicians at the advanced-intermediate level (EMT-AI) to perform oral ETI. HYPOTHESIS: The restrictive environment of a moving ambulance would affect adversely the ability of EMT-AIs to perform ETI compared with a controlled setting. This would result in a significant increase in the time necessary to perform ETI in the ambulance compared with a controlled setting not complicated by restrictive space and motion. METHODS: Twenty on-duty EMT-AIs were recruited to volunteer for this prospective, nonrandomized, nonblinded trial. All participants performed three consecutive oral ETIs on an airway mannequin in two settings: 1) in the back of a moving ambulance; and 2) on a table in the rescue squad station. Of the participants, 10 performed the intubations in the ambulance first; the remainder performed the intubations at the station first. Time for intubation with the mannequin was recorded by stopwatch. The mean times for intubation in both settings were compared by Student's t-test (p < 0.05). RESULTS: All intubation attempts were successful. The mean time for intubation in the station was 13.0 +/- 3.4 seconds. The mean time in the ambulance setting was 13.2 +/- 5.3 seconds. There was no significant difference between the intubation times in the two settings (p = 0.88). CONCLUSION: The environment of a moving ambulance does not appear to hinder the ability of EMT-AIs to perform oral ETI in a laboratory setting with a mannequin model.
Ambulances↗
Does ambulance crew size affect on-scene time or number of prehospital interventions?
INTRODUCTION: While large cities typically staff ambulances with two emergency medical services (EMS) professionals, some EMS agencies use three people for ambulance crews. The Greenville, North Carolina, EMS agency converted from three-person to two-person EMS crews in July 1993. There are no published reports investigating the best crew size for out-of-hospital emergency care. HYPOTHESIS: Two-person EMS crews perform the same number and types of interventions as three-person EMS crews. Two-person EMS crews do not have longer on-scene times than do three-person EMS crews. METHODS: Data for the two most common advanced life support calls in this system--seizures and chest pains--were collected for the months of June and August 1993. Three-person EMS crews responded to both types of calls in June. In August, two-person EMS crews responded to seizure calls; two-person EMS crews accompanied by a fire department engine (pumper) with additional manpower responded to chest pain calls. The frequency of specific interventions, number of total interventions, and scene times for the August calls were compared to their historical control groups, the June calls. RESULTS: One hundred twenty-six patient contacts were included in the study. There were no significant differences in total number or types of procedures performed for the two patient groups. Mean on-scene time for patients with seizures was 11.0 +/- 4.2 minutes for three-person crews and 19.4 +/- 8.3 minutes for two-person crews (p < 0.001). Mean on-scene time for patients with chest pain was 13.6 +/- 4.9 minutes for three-person crews, and 15.4 +/- 3.2 minutes for two-person crews assisted by fire department personnel (p > 0.05). CONCLUSION: Two-person EMS crews perform the same number of procedures as do three-person EMS crews. However, without the assistance of additional responders, two-person EMS crews may have statistically significantly longer on-scene times than three-person EMS crews.
Ambulances↗
EMS knowledge and skills in rural North Carolina: a comparison with the National EMS Education and Practice Blueprint.
INTRODUCTION: Many state and local emergency medical services (EMS) systems may wish to modify provider levels and their scope of practice to align their systems with the recommendations of the National Emergency Medical Services Education and Practice Blueprint. To determine any changes that may be needed in a typical EMS system, the knowledge and skills of EMS providers in one rural area of North Carolina were compared with the knowledge and skills recommended in the National Emergency Medical Services Education and Practice Blueprint. METHODS: A survey listing 175 items of patient care-oriented knowledge and skills described in the National Emergency Medical Services Education and Practice Blueprint was developed. EMS providers from five rural eastern North Carolina counties were asked to identify on the survey those items of knowledge and skills they believed they possessed. The skills and knowledge selected by the respondents at the five different North Carolina levels of certification were compared with the knowledge and skills listed for comparable provider levels delineated by the National Emergency Medical Services Education and Practice Blueprint. The proportions of the recommended skills reported to be possessed by the respondents were compared to determine which North Carolina certification levels best correlate with the Blueprint. RESULTS: One hundred forty-five EMS providers completed the survey. The proportion of recommended skills and knowledge reported to be possessed by Emergency Medical Technicians (EMTs) ranked significantly lower than did the skills and knowledge reported to be possessed by respondents at other levels in five of the 10 Blueprint elements. The proportion of recommended skills and knowledge reported to be possessed by EMT-Defibrillator-level personnel ranked lower than did those reported to be possessed by respondents at other levels in seven of the 10 Blueprint elements. The proportion of recommended skills and knowledge reported to be possessed by EMT-Intermediates ranked lower than did those reported to be possessed by respondents at other levels in nine of the 10 Blueprint elements. The proportion of recommended skills and knowledge reported to be possessed by EMT-Advanced Intermediates ranked lower than were the skills and knowledge reported to be possessed by respondents at other levels in two of the 10 Blueprint elements. Finally, the proportion of recommended skills and knowledge reported to be possessed by EMT-Paramedics ranked lower than were those reported to be possessed by respondents at other levels in one of the 10 Blueprint elements. CONCLUSION: In North Carolina, combining the EMT and EMT-Defibrillator levels and eliminating the EMT-Intermediate level would create three levels of certification, which would be more consistent with levels recommended by the Blueprint. The results of this study should be considered in any effort to revise the levels of EMS certification in North Carolina and in planning the training curricula for bridging those levels. Other states may require similar action to align with the National Emergency Medical Services Education and Practice Blueprint.
Certification↗
Does basic life support in a rural EMS system influence the outcome of patients with respiratory distress?
PURPOSE: The purpose of this study was to determine whether basic life support, prehospital emergency medical care in a rural area affects the hospital course of patients with respiratory distress. METHODS: Medical records for patients admitted from the emergency department with a discharge diagnosis related to respiratory disease were reviewed. Data collected included: 1) mode of arrival; 2) initial symptom; 3) vital signs; 4) prehospital interventions applied; 5) hospital days; 6) discharge status; and 7) principal diagnosis. Multiple logistic regression analysis was used to predict length of hospital stay. RESULTS: Charts for 603 patients were reviewed. Complete data for all variables included in the logistic regression analysis were available for 471 patients (78.1%). Because 55 patients died, only 416 (69.0%) were included in the multiple regression analysis conducted to predict length of hospital stay. Logistic regression analysis demonstrated that patients who arrived by ambulance and older patients were more likely to die; patients with higher systolic blood pressures were more likely to survive. Only patient age predicted length of hospital stay, with older patients having longer stays. CONCLUSIONS: Basic life support prehospital care in this rural emergency medical services system does not result in a lower mortality rate or a shorter hospital stay for a broad group of patients with respiratory distress who require hospital admission. Although this study is limited to a single population and a single emergency medical services system, it is one of only a few studies of outcome in basic life support systems.
Aged↗
Rural vs urban motor vehicle crash death rates: 20 years of FARS data.
OBJECTIVES: Historically, motor vehicle crash (MVC)-related mortality is higher in rural areas than in urban areas. The authors evaluated whether the difference in rural and urban MVC deaths is persisting, and whether the frequency of patients being found dead at the scene, particularly in rural areas, is increasing. METHODS: Fatal Accident Reporting System (FARS) data for 1977 through 1996 were reviewed. The authors determined the frequency with which crash deaths occurred, and calculated population-based and vehicle-miles-traveled-based crash death rates. They compared rates for urban and rural areas. RESULTS: A total of 875,405 crash deaths were included in the analysis. Both population-based and vehicle-miles-traveled-based MVC deaths have decreased over the last 20 years, but rural rates remain significantly higher than urban rates. Dead-at-scene rates may be increasing, and the rural dead-at-scene rate is higher than the urban rate. CONCLUSION: While MVC death rates are declining, the rural MVC death rate is still higher than the urban rate. Although these data may indicate some positive movement in the area of MVC-related deaths, differences in the rural and urban rates and the number of patients found dead on-scene remain as issues that require attention.
Accidents, Traffic↗
Do warning lights and sirens reduce ambulance response times?
OBJECTIVE: To determine the time saving associated with lights and siren (L&S) use during emergency response in an urban EMS system. METHODS: This prospective study evaluated ambulance response times from the location at time of dispatch to the scene of an emergency in an urban area. A control group of responses using L&S was compared with an experimental group that did not use L&S. An observer was assigned to ride along with ambulance crews and record actual times for all L&S responses. At a later date, an observer and an off-duty paramedic in an identical ambulance retraced the route--at the same time of day on the same day of the week--without using L&S and recorded the travel time. Response times for the two groups were compared using paired t-test. RESULTS: The 32 responses with L&S averaged 105.8 seconds (1 minute, 46 seconds) faster than those without (95% confidence interval: 60.2 to 151.5 seconds, p = 0.0001). The time difference ranged from 425 seconds (7 minutes, 5 seconds) faster with L&S to 210 seconds (3 minutes, 30 seconds) slower with L&S. CONCLUSION: In this urban EMS system, L&S reduce ambulance response times by an average of 1 minute, 46 seconds. Although statistically significant, this time saving is likely to be clinically relevant in only a very few cases. A large-scale multicenter L&S trial may help address this issue on a national level.
Ambulances↗
Paramedic use of endotracheal tube introducers for the difficult airway.
OBJECTIVE: To evaluate the ability of paramedics to learn and apply the skill of introducer-aided oral intubation in the setting of the simulated "difficult airway." The authors hypothesized that, following a brief introduction to the device, intubation success rates would not differ for traditional and introducer-aided intubations of an immobilized airway mannequin. METHODS: During a paramedic recertification class, experienced paramedics were given a brief didactic introduction to the "bougie-like" Flex Guide endotracheal tube introducer (ETTI). The participants were then asked to intubate adult mannequins immobilized in the head-neutral position, with and without the ETTI. "Successful placement" was defined as completion of the procedure within 30 seconds and endotracheal tube position confirmed by the investigator with direct visualization. RESULTS: For both traditional and ETTI intubations, 34 (97%) of the 35 paramedics successfully intubated within 30 seconds. The two unsuccessful intubation attempts were recognized by the paramedic as esophageal intubations, and correct tube placement was obtained within an additional 30 seconds. CONCLUSION: In this study, use of the ETTI was mastered by the participants after only a brief didactic introduction to the device, with their ability to intubate an immobilized mannequin using the ETTI being equal to their ability to perform traditional intubation. These results suggest that use of the ETTI is easily learned, and may support the device's role in the prehospital management of the difficult airway.
Emergency Medical Technicians↗
Which emergency medicine journals should EMS professionals read?
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Bibliometrics↗
Potential time savings by prehospital administration of activated charcoal.
OBJECTIVE: Activated charcoal (AC) has been proven useful in many toxic ingestions. Theoretically, administration of AC in the prehospital environment could save valuable time in the treatment of patients who have sustained potentially toxic oral ingestions. The purpose of this study was to determine the frequency of prehospital AC administration and to identify time savings that could potentially result from field AC administration. METHODS: Adult patients with a chief complaint of toxic ingestion who had complete emergency medical services (EMS) and emergency department (ED) records and no medical treatment (gastric emptying, AC administration) prior to EMS arrival were eligible for inclusion. Data obtained from EMS and ED records included time of EMS departure from the scene, time of EMS arrival at the ED, and time of administration of AC in the ED. Since most EMS agencies in this system do not insert gastric tubes, patients requiring gastric tube placement for administration of AC were excluded. RESULTS: Twenty-nine of 117 (24.8%) adult patients received oral AC with no other intervention. None of the 117 patients received AC in the prehospital setting. The EMS transport time for these patients ranged from 5 to 43 minutes (mean 16.2 +/- 9.7 minutes). The delay from ED arrival to AC administration ranged from 5 to 94 minutes (mean 48.8 +/- 24.1 minutes), and was more than 60 minutes for 14 (48.2%) of the patients. The total time interval from scene departure to ED AC administration ranged from 17 to 111 minutes (mean 65.0 +/- 25.9 minutes). CONCLUSIONS: In a selected subset of patients who tolerate oral AC, prehospital administration of AC could result in earlier and potentially more efficacious AC therapy. Prospective study of the benefits and feasibility of prehospital AC administration is indicated.
Antidotes↗
Effect of vital signs on advanced life support interventions for prehospital patients.
OBJECTIVE: Routine vital signs assessment is considered a fundamental component of patient assessment. This study was undertaken to determine whether advanced life support (ALS) emergency medical services (EMS) providers depend on vital signs information in managing their patients. METHODS: Emergency medical technician-paramedics (EMT-Ps) and EMT-Intermediates (EMT-Is) were presented with 20 randomized patient scenarios that did not included vital signs information. The participants were asked to identify all of the interventions they would perform for each hypothetical patient. At least six weeks later the same scenarios were presented in a new order, with vital signs information, and the participants again identified the interventions they would perform. The participants' estimations of the patients' blood pressures, as well as the frequencies with which 18 specific interventions were performed, were compared for the no-vital signs and the vital signs groups using chi-square of Fisher's exact test, with an alpha value of 0.05 considered significant. RESULTS: Fourteen EMT-Ps and 16 EMT-Is completed both the no-vital signs and vital signs portions of the study, for a total of 1,160 hypothetical patient encounters. When vital signs were given, the EMT-Is were more likely to apply a cardiac monitor (65.2% vs 80.1%, p = 0.000), more likely to start at least one intravenous (i.v.) line (82.1% vs 87.8%, p = 0.038), and more likely to administer a medication (1.3% vs 5.6%, p = 0.003). The EMT-Ps were also more likely to apply a cardiac monitor (84.4% vs 90.3%, p = 0.041), more likely to run an i.v. at a "wide open" rate (9.5% vs 19.0%, p = 0.004), and less likely to identify patients as being hypotensive (39.9% vs 26.4%, p = 0.004). CONCLUSION: The presence or absence of vital signs information does influence some of the patient care decisions of EMS providers; however, the clinical implications of these decisions are unclear. Further studies are needed to determine whether ALS providers can adequately manage actual patients without obtaining vital signs.
Blood Pressure↗
Accuracy of rural EMS provider interpretation of three-lead ECG rhythm strips.
OBJECTIVE: To measure the accuracy of lead II rhythm strip interpretations performed by advanced life support (ALS) emergency medical technicians (EMTs) in a rural emergency medical services (EMS) system. METHODS: An electronic rhythm simulator was used to produce 24 three-lead electrocardiogram (ECG) rhythm strips. The rhythms were shown to 57 ALS EMTs participating in regularly scheduled continuing education classes. The participants were asked to identify the rhythms. RESULTS: The three-lead ECG interpretations were generally accurate, although there was some difficulty in distinguishing between specific types of tachydysrhythmia and atrioventricular (AV) block. The overall accuracy of the rhythm interpretations was 79.2%, ranging from 45.6% (second-degree type II heart block) to 98.2% (sinus bradycardia). The sensitivity for specific tachydysrhythmias ranged from 68.4% (supraventricular tachycardia) to 86.0% (atrial fibrillation); the sensitivity for specific types of AV block ranged from 45.6% (second-degree, type II) to 71.9% (third-degree). CONCLUSION: In this EMS system, ECG interpretations are generally accurate, with tachydysrhythmias and AV blocks being the source of most discrepancies.
Clinical Competence↗