Does the emperor of CPR wear clothes?
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Cardiopulmonary Resuscitation↗
Biomedical subjects
Thomas D Rea
Publications and source records attributed to Thomas D Rea.
The effect of pulse oximetry on emergency medical technician decision making.
OBJECTIVE: Relatively little is known about the use of pulse oximetry in the prehospital setting. The purpose of this study was to determine how emergency medical technicians (EMTs) use pulse oximetry information to influence their decisions regarding the involvement of advanced life support (ALS) personnel in a two-tiered emergency medical services (EMS) system. METHODS: EMTs were trained and authorized to use pulse oximetry in predefined clinical situations. The EMTs completed a questionnaire describing the influence of the oximetry information on their decision making regarding the involvement of ALS units. RESULTS: The EMTs reported an influence on their decisions whether to involve ALS care in 35 (12%) of 302 cases. The addition of the pulse oximetry information caused the EMTs to request ALS dispatch in 11 cases, to cancel a previously dispatched ALS response in eight cases, and not to request an ALS response from the scene when they otherwise would have requested it in 16 cases. CONCLUSION: Prehospital pulse oximetry has a measurable influence on EMT decisions concerning ALS involvement in a two-tiered EMS system. It improves system efficiency by helping to match patients to an appropriate level of care.
Advanced Cardiac Life Support↗
Epinephrine use by emergency medical technicians for presumed anaphylaxis.
OBJECTIVE: The use of epinephrine for the treatment of anaphylaxis by emergency medical technicians (EMTs) has not been rigorously evaluated. The aim of this study was to determine whether first-tier EMTs use epinephrine safely and appropriately for anaphylactic reactions. METHODS: The study used a case-control design. Cases were persons treated by EMTs with epinephrine for presumed anaphylaxis from January 1, 2000, through January 31, 2003, in King County, Washington (n = 22). Controls were emergency medical services (EMS)-treated persons matched to cases by diagnosis category, patient age, fire department, and year, but who had not been administered epinephrine by EMTs (n = 44). Cases and controls were compared with regard to history, symptoms, and examination characteristics. In a second assessment, physicians blinded to treatment (case/control) status reviewed events to determine whether they would have treated the patient with epinephrine RESULTS: When cases were compared with controls, cases were more likely to report a history of anaphylaxis (27% vs. 2%), upper airway symptoms (59% vs. 18%), and shortness of breath (77% vs. 27%). Cases were also more likely to have tachypnea (32% vs. 5%), hypotension (41% vs. 9%), decreased level of consciousness (32% vs. 2%), abnormal breath sounds (46% vs. 16%), and rash (50% vs. 23%) (p < or = 0.01 for all comparisons). The physicians agreed with the EMTs' decisions regarding epinephrine use (or nonuse) in 86% (57/66) of events: 86% (19/22) in which the EMTs used epinephrine and 86% (38/44) in which the EMTs did not use epinephrine. CONCLUSION: In this EMS system, the EMTs used epinephrine for presumed anaphylaxis in a discriminating manner that typically agreed with physician review.
Adult↗
Time to intubation and survival in prehospital cardiac arrest.
OBJECTIVE: To examine the correlation between time to paramedic intubation and survival after prehospital cardiac arrest. METHODS: This was a retrospective cohort study of 693 patients who had paramedic endotracheal intubation for prehospital cardiac arrest in King County, Washington (excluding Seattle), between January 1991 and May 2003. Based on the time from patient collapse until intubation, cases were divided into quartiles. Survival in the slower three quartiles (defined as "slow intubation") was compared with survival in the fastest quartile (defined as "quick intubation"). RESULTS: In the quick intubation group (intubation time < or = 12 minutes), 46% of the patients survived; in the slow intubation group (intubation time > or = 13 minutes), 23% of the patients survived. Logistic regression was used to adjust for possible confounders that affect survival: age, gender, location, bystander cardiopulmonary resuscitation, cardiac rhythm, emergency medical technician response time, and paramedic response time. The fully adjusted odds ratio of survival for the slow intubation group compared with the quick intubation group was 0.42 (95% confidence interval 0.26, 0.69). CONCLUSIONS: This study is the first of its kind to compare survival with the time interval until an aspect of advanced life support is performed. These findings suggest that faster intubation times may increase odds of survival in prehospital cardiac arrest. Future prospective studies are merited to further understand this association.
Aged↗
Intentions to use an automated external defibrillator during a cardiac emergency among a group of seniors trained in its operation.
OBJECTIVE: By decreasing the time to defibrillation, automated external defibrillators (AEDs) provide an opportunity for lay people to improve survival in out-of-hospital sudden cardiac arrest. We examined how beliefs, expectations, and actual performance are related to intentions to use an AED during a future heart emergency among a group of seniors. DESIGN AND OUTCOME MEASURES: One hundred fifty-nine seniors who had been previously trained in the operation of an AED were tested on their AED skills and asked about their perceptions regarding their AED skills; their expectations that an AED would save the life of a cardiac arrest victim; and their intentions to use an AED during a future cardiac event. RESULTS: Logistic regression analyses showed that greater self-perceived ability to use an AED better actual performance on skills assessment but not expectations regarding the efficacy of AED treatment were independently associated with positive intentions to use an AED in a future heart emergency. CONCLUSIONS: The likelihood that an elderly lay bystander will actually use an AED during a cardiac event may be closely tied to perceptions of his or her ability to operate an AED.
Aged↗
Time to first shock by emergency medical technicians with automated external defibrillators.
UNLABELLED: The interval from collapse to electrical rescue shock is a critical determinant of successful defibrillation in cardiac arrest. In order to achieve the earliest possible defibrillation, many emergency medical services (EMS) systems equip first-responding units with an automated external defibrillator (AED). OBJECTIVE: To measure the time from on-scene emergency medical technician (EMT) recognition of cardiac arrest to AED application and shock in ventricular fibrillation (VF) arrest. In addition, the authors sought to understand the reasons for delays. METHODS: Using the AED recordings and written EMS reports, the authors conducted a retrospective cohort study of all persons who experienced an EMS-attended VF cardiac arrest in which an AED was applied and a shock delivered by an EMT, from January 1999 through December 2000 (n = 177). Based on the bimodal distribution of times, two groups were assembled: no delay (time to shock < or = 90 seconds) and delayed (time to shock > 90 seconds). Patient and event characteristics associated with delay status were determined using Mantel-Haenszel methods. RESULTS: The median (25th, 75th percentile) time from cardiac arrest recognition to shock was 51 (43, 64) seconds. Ninety-four percent (n = 166) of the cohort received a shock within 90 seconds. Delayed shock was associated with unwitnessed arrest status (odds ratio = 9.3, 95% confidence interval = 2.3, 36.8) and nursing home location (odds ratio = 10.0, 95% confidence interval = 2.1, 47.5). CONCLUSION: The findings suggest that a 1-minute goal and a 90-second minimum standard for time to first shock are appropriate for EMT AED defibrillation in the field.
Aged↗
An emergency medical services program of alternate destination of patient care.
OBJECTIVE: The emergency department (ED) is ideally reserved for urgent health needs. The ED, however, is often the site of care for nonurgent conditions. The authors investigated whether emergency medical technicians could decrease ED use by patients with nonurgent concerns who use 911 by appropriately identifying and triaging them to alternate care destinations. METHODS: From August 2000 through January 2001, two King County fire-based emergency medical services (EMS) agencies participated in an alternate care destination program for patients with specific low-acuity diagnosis codes (intervention group). Eligible patients were offered care at a clinic-based destination as an alternate to the ED (n = 1,016). The frequency of the destination of care (ED, clinic, or home) for the intervention group was compared with a matched control group that was comprised of a preintervention historical cohort of EMS encounters from the same two fire-based agencies and with the same acuity and diagnosis criteria and seasonal interval (n = 2,617). RESULTS: Compared with the preintervention group, a smaller proportion of patients in the intervention group received care in the ED (44.6% vs. 51.8%, p = 0.001), while a greater proportion of patients in the intervention group received clinic care (8.0% vs. 4.5%, p = 0.001) or home care (no transport) (47.4 vs. 43.7%, p = 0.043). Results were comparable when adjusted for other patient characteristics. Similar relationships were not evident among nonparticipating King County EMS agencies. Based on physician review and patient interview, the alternate care intervention appeared to be safe and satisfactory. CONCLUSION: An EMS-based program may represent one approach to limiting nonurgent ED use.
Adult↗
Resuscitation of residents with do not resuscitate orders in long-term care facilities.
BACKGROUND: A considerable number of emergency medical services (EMS) responses for cardiac arrest occur in long-term care facilities. In some instances, these responses are for residents who have expressed wishes not to be resuscitated by signing a do not resuscitate (DNR) order. OBJECTIVES: To assess the magnitude of EMS use for cardiac arrest in long-term care facilities for residents with DNR orders and to determine reasons why EMS is called. METHODS: A retrospective study was conducted using data collected from medical incident reports between July 1999 and December 2000 for all persons experiencing cardiac arrest in long-term care facilities defined as nursing homes, adult family homes, and assisted-living centers in King County, Washington, excluding Seattle. The authors also surveyed facilities to determine their policies for calling 9-1-1 in the event of cardiac arrest. Results. Of the 392 cardiac arrests in long-term care facilities to which EMS responded, 139 (35%) of the residents had DNR orders. Of these 139, 29 (21%) received attempted resuscitation by EMS. The problem appeared to be greater among nursing homes and adult family homes than in assisted-living centers. Among nursing homes, the primary reason for an EMS call was concern for validity of the DNR order, whereas among adult family homes, the primary concern was appropriate medical authority to declare death. CONCLUSION: Efforts to clarify existing regulations, streamline the DNR transfer process, and improve communication between EMS and long-term care facilities may result in better fulfillment of residents' end-of-life wishes and a saving of EMS resources.
Aged↗
Web-based training for EMT continuing education.
OBJECTIVE: New Internet technologies offer the opportunity to delivery quality instruction to emergency medical technicians (EMTs) in a cost-effective manner. The purpose of this study was to determine whether web-based continuing education (CE) could be developed at a low cost and provide a high level of satisfaction and acceptance among EMTs. METHODS: EMTs completed web-based CE modules in place of traditional instructor-led instruction. The EMTs in the study completed a questionnaire that assessed acceptance and satisfaction. Expenses for producing and delivering web-based instruction and delivering instructor-led instruction were tracked for all aspects of the project. RESULTS: Seventy-four percent of the EMTs strongly preferred the web-based modules over instructor-led modules. Other survey items indicated a high level of acceptance of the format (87%). The web-based modules in this study were produced and delivered at a cost of dollar 3 per EMT/module, which is less than the costs of traditional instructor-led training, ranging from dollar 21 to dollar 82 per EMT/module. CONCLUSION: Although not a replacement for all instructor-led training, web-based training can be a cost-effective and acceptable alternative for achieving instructional objectives within the cognitive domain. It offers other benefits such as improved administration of training records and consistent delivery of content.
Attitude of Health Personnel↗