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Controversy in EMS


Waveform capnography 23% misplaced when not used 0% when used What about outcomes? 830 pediatric patients Prospective trial No outcome advantage from ETI San Diego ... – PowerPoint PPT presentation

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Title: Controversy in EMS

Controversy in EMS
What is controversy?
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How to choose a topic? Risk vs. Frequency
  • Low risk / Infrequent
  • High risk / Infrequent
  • Low risk / Frequent
  • High risk / Frequent

What are the biggest controversies in EMS today?
Three questions Three controversies Three
different styles of answer
The three for today
  • Intubation
  • High risk / Infrequent
  • Analgesia administration
  • Low risk / Frequent (At least it should be...)
  • Lights and siren use
  • High risk / Frequent

A is for Airway
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We could do it
  • Jacobs LM, Berrizbeitia LD, Bennett B, et al.
  • intubation in the prehospital phase of emergency
    medical care.
  • JAMA. 19832502175-2177.
  • Stewart RD, Paris PM, Winter PM, et al. Field
  • intubation by paramedical personnel success
    rates and
  • complications. Chest. 198485341-345.
  • DeLeo BC. Endotracheal intubation by rescue squad
  • Heart Lung. 19776851-854.
  • Guss DA, Posluszny M. Paramedic orotracheal
    intubation a
  • feasibility study. Am J Emerg Med.

Can we still?
  • 25 misplaced
  • 12 misplaced

Katz SH, Falk JL. Misplaced endotracheal tubes by
paramedics in an urban emergency medical services
system. Ann Emerg Med. 20013732-37.
Jemmett ME, Kendal KM, Fourre MW, et al.
Unrecognized misplacement of endotracheal tubes
in a mixed urban to rural emergency medical
services setting. Acad Emerg Med. 200310
What can help us do it right?
  • Waveform capnography
  • 23 misplaced when not used
  • 0 when used

Silvestri S, Ralls GA, Krauss B, et al. The
effectiveness of out-of hospital use of
continuous end-tidal carbon dioxide monitoring on
the rate of unrecognized misplaced intubation
within a regional emergency medical services
system. Ann Emerg Med. 200545497-503.
What about outcomes?
  • 830 pediatric patients
  • Prospective trial
  • No outcome advantage from ETI

Gausche M, Lewis RJ, Stratton SJ, et al. Effect
of out-of-hospital pediatric endotracheal
intubation on survival and neurological outcome
a controlled clinical trial. JAMA.
San Diego
Ochs M, Davis D, Hoyt D, et al.
Paramedic-performed rapid sequence intubation of
patients with severe head injuries. Ann Emerg
Med. 200240159-167.
Davis DP, Hoyt DB, Ochs M, et al. The effect of
paramedic rapid sequence intubation on outcome in
patients with severe traumatic brain injury. J
Trauma. 200354444-453. Davis DP, Peay J, Sise
MJ, et al. The impact of prehospital endotracheal
intubation on outcome in moderate to
severe traumatic brain injury. J Trauma.
Dunford JV, Davis DP, Ochs M, et al. Incidence of
transient hypoxia and pulse rate reactivity
during paramedic rapid sequence intubation. Ann
Emerg Med. 200342721-728.
Davis DP, Valentine C, Ochs M, et al. The
Combitube as a salvage airway device for
paramedic rapid sequence intubation. Ann Emerg
Med. 200342697-704.
The review and the rebuttal
  • Out-of-hospital endotracheal intubation may
    inadvertently interact with other key physiologic
    processes key to optimizing resuscitation
  • Resounding thunderclaps in a storm of debate
    about out-of-hospital endotracheal intubation

Wang HE, Yealy DM, Out of hospital endotracheal
intubation Where are we? Annals of EM 2006476,
Burton JH, Out of hospital endotracheal
intubation Half empty or half full? Annals of EM
2006476, 542-4
What we know
  • Hypoxia increases mortality and morbidity
  • Hypocarbia increases mortality and morbidity
  • Paramedics interpret airway interventions
    differently than physicians
  • Waveform capnography is the gold standard in LIVE

  • Few misplaced endotracheal tubes reported
  • Recent survey (non-scientific)
  • People who took airway course gt80 success
  • Average number of intubations 5
  • People who did not lt70
  • Average number of intubations 1/2
  • Most providers do not intubate each year

Answers we still need
  • What about medical patients?
  • Is outcome better with a combitube or LMA?
  • How will we train paramedics to intubate as ACLS
    de-emphasizes intubation?
  • Should paramedics intubate?

Pain Management
College Position Papers
  • American College of Emergency Physicians
  • American Academy of Pediatrics
  • American Medical Association
  • American College of OB and Gyn
  • American College of Surgeons

NAEMSP Position Paper
  • Mandatory pain assessment
  • Indications for pain management
  • Alternatives for pain management
  • Patient monitoring
  • Transfer of patient information
  • Quality improvement and medical oversight

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Why is pain undertreated?
  • 5. Lack of medical training
  • 4. Misunderstandings about addiction
  • 3. Lack of routine assessment
  • 2. Misunderstanding about adverse events
  • 1. Fear of regulatory oversight

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New York Stories
Time Frames
  • Mean time to medication 24 minutes
  • Range 3-61 minutes
  • Females, mean 25.6 minutes
  • Males, mean 23 minutes

  • Precedent for standing order treatment for
    seizures with controlled substances
  • No history of diversions in REMO
  • Protocol and systems review by NYS DOH Bureau of
    Narcotics Enforcement and Bureau of EMS
  • We dont want our concerns about a few
    diversions to stand between your patients and
    pain management. Jim Giglio, Director,
    Narcotics Enforcement

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What is the right agent?
  • A medication with a rapid onset of action
  • Easily titrated to effect
  • A medication with a short half-life
  • Rapidly metabolized for exam in ED
  • A medication that is easily dosed
  • 1 unit per kilogram

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Galinski M. A randomized, double-blind study
comparing morphine with fentanyl in prehospital
analgesia. Am J Emerg Med. 2005
National trends
  • 14 States require physician contact for
    administration of narcotics
  • 37 States allow STANDING ORDER pain management
  • 16 States allow the use of Fentanyl for pain
    management all on STANDING ORDER

(For extremity fractures and burns)
Lights and sirens
  • Please note that editing has been done to
    abstracts presented to allow for space. Intent
    and content have not been altered

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Is ambulance transport time with lights and siren
  • OBJECTIVE To determine whether ambulance
    transport time from the scene to the emergency
    department is faster with warning lights and
    siren than that without.
  • DESIGN In a convenience sample, transport times
    and routes of ambulances using lights and sirens
    were recorded by an observer. The time also was
    recorded by a paramedic who drove an ambulance
    without lights and siren over identical routes
    during simulated transports at the same time of
    day and on the same day of the week as the
    corresponding lights-and-siren transport.

RC Hunt, LH Brown et al. Ann Emerg Med 1995
Is ambulance transport time with lights and siren
  • SETTING An emergency medical service system in a
    city with a population of 46,000.
  • RESULTS Fifty transport times with lights and
    siren averaged 43.5 seconds faster without lights
    and siren t 4.21, P .0001.
  • CONCLUSION In this setting, the 43.5-second mean
    time savings does not warrant the use of lights
    and siren during ambulance transport, except in
    rare situations or clinical circumstances.

RC Hunt, LH Brown et al. Ann Emerg Med 1995
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Do Warning Lights And Sirens Reduce Ambulance
Response Times?
  • OBJECTIVE To determine the time saving
    associated with lights and siren (LS) use during
    emergency response in an urban EMS system.
  • METHODS This study evaluated response times to
    the scene of an emergency in an urban area...At a
    later date, they retraced the route--at the
    same time of day on the same day of the
    week--without using LS and recorded the travel

LH Brown, RC Hunt, et al, Prehospital Emergency
Care  2000 January-March  4170 - 74
Do Warning Lights And Sirens Reduce Ambulance
Response Times?
  • RESULTS The 32 responses with LS 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 LS to 210 seconds (3 minutes, 30 seconds)
    slower with LS.
  • CONCLUSION In this urban EMS system, LS 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 LS trial may help
    address this issue on a national level.

LH Brown, RC Hunt, et al, Prehospital Emergency
Care  2000 January-March  4170 - 74
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Time saved with the use of lights and siren in a
rural environment
  • OBJECTIVE To determine whether the use of
    warning lights and siren saves a significant
    amount of time for ambulances responding to
    requests for emergency medical aid in a rural
    emergency medical services (EMS) setting.
  • METHODS A prospective design was used to
    determine run times for ambulances responding to
    calls with lights and siren (code 3) and for a
    similarly equipped "chase" ambulance traveling to
    the same destination via the same route without
    lights and siren, while obeying all traffic laws
    (code 2) within a rural setting. Data were
    collected for run time intervals, distance
    traveled, visibility, road surface conditions,
    time of day, and day of the week.

J Ho, M Lindquist, Prehosp Emerg Care. 2001
Time saved with the use of lights and siren in a
rural environment
  • RESULTS Sixty-seven runs were timed during a
    21-month period. The average code 3 response
    interval was 8.51 minutes. The average code 2
    response interval was 12.14 minutes. The 3.63
    minutes saved on average represents significant
    time savings of 30.9 (p lt 0.01). Shorter runs
    had higher time savings per mile than the longer
    runs. Run distance was the only variable that was
    statistically significant in affecting time saved
    during a code 3 response.
  • CONCLUSION Code 3 operation by EMS personnel in
    a rural EMS setting saved significant time over
    code 2 operation when traveling to a call.

J Ho, M Lindquist, Prehosp Emerg Care. 2001
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Emergency medical vehicle collisions in an urban
  • INTRODUCTION Emergency medical services
    collisions (EMVCs) are a largely unexplored area
    of emergency medical services (EMS) research.
    Factors that might contribute to an EMVC are
    numerous and include use of warning lights and
    siren (WLS).
  • METHODS Retrospective study of all collisions
    involving vehicles assigned to the EMS Division
    of the Houston Fire Department in calendar year
    1993. Fifty-one ambulances were operational 24
    hours per day during calendar year 1993. Houston
    EMS received 150,000 requests for assistance,
    made 180,000 vehicular responses, and accrued
    2,651,760 miles in 1993.

WA Biggers Jr, BS Zachariah,et al, Prehospital
Disaster Med. 1996 Jul-Sep11(3)195-201
Emergency medical vehicle collisions in an urban
  • RESULTS Eighty-six EMVCs were identified during
    the study period. The gross incidence rate was
    therefore 3.2 EMVC/100,000 miles driven or 4.8
    collisions/10,000 responses. Major collisions,
    determined according to injuries or vehicular
    damage, accounted for 10.8 of all EMVCs. There
    were 17 persons transported to hospitals from EMS
    collisions, yielding an injury incidence of 0.64
    injuries/100,000 miles driven or 0.94
    injuries/10,000 responses. There were no
    fatalities. The majority of collisions (85.1)
    occurred at some site other than an intersection.
    Drivers with a history of previous EMVCs were
    involved in 33 of all collisions. The presence
    of prior EMVCs was associated (p lt 0.001) with
    the number of persons transported from the
    collision to a local hospital. Five drivers, all
    with previous EMVCs, accounted for 88.2 (15/17)
    of all injuries.
  • CONCLUSIONS A few drivers with previous EMVCs
    account for a disproportionate number of EMVCs
    and nearly 90 of all injuries. This risk
    factor--history of previous EMVC--has not been
    reported in the EMS literature. It is postulated
    that this factor ultimately will prove to be the
    major determinant of EMVCs. Data collection of
    EMS collisions needs to be standardized and a
    proposed collection tool is provided.

WA Biggers Jr, BS Zachariah,et al, Prehospital
Disaster Med. 1996 Jul-Sep11(3)195-201
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The wake-effect--emergency vehicle-related
  • INTRODUCTION Experience suggests "wake-effect"
    collisions occur as a result of an EMS vehicle's
    transit, but do not involve the emergency medical
    vehicle (EMV). Substantiating the existence and
    magnitude of wake-effect collisions may have
    major implications regarding the manner of EMV
  • METHODS Survey analysis. Participants Thirty
    paramedics employed by the Salt Lake City (Utah)
    Fire Department and 45 paramedics employed by
    Salt Lake County Fire Department. The survey
    consisted of three open-ended questions
    concerning years on the job, EMVCs, and
    wake-effect collisions.

JJ Clawson, RL Martin, et al, Prehospital
Disaster Med. 1997 Oct-Dec12(4)274-7.
The wake-effect--emergency vehicle-related
  • RESULTS Seventy-three surveys were analyzed.
    Sixty EMVCs and 255 wake-effect collisions were
    reported. Overall, the mean value for the number
    EMVCs per respondent was 0.82 (0.60-1.05) and for
    wake-effect collisions 3.49 (2.42-4.55). The mean
    values for EMVC's for each service were 0.86
    (0.50-1.38) 0.80 (0.50-11.0). For wake-effect
    collisions the mean values were 4.59 (2.83-6.35)
    and 2.76 (1.46-4.06) respectively.
  • CONCLUSIONS This study suggests that the
    wake-effect collision is real and may occur with
    greater frequency than do EMVCs. Significant
    limitations of this study are recall bias and
    misclassification bias. Future studies are needed
    to define more precisely wake-effect collision
    prevalence and the resulting "cost" in regards to
    injury and vehicle/property damage.

JJ Clawson, RL Martin, et al, Prehospital
Disaster Med. 1997 Oct-Dec12(4)274-7.
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The effectiveness of lights and siren use during
ambulance transport by paramedics
  • OBJECTIVES To determine whether lights and siren
    (LS) use during transport in the authors' EMS
    system results in reduced transport time to the
    hospital. Second, to determine whether LS use
    results in any emergency department critical
    interventions in the time saved.
  • METHOD A convenience sample of transport times
    were measured for 75 ambulances traveling to the
    hospital with LS and compared with measured
    simultaneous transport times for a personal
    observer vehicle traveling the same route as the
    ambulance. Upon hospital arrival, the driver of
    the observer vehicle proceeded to the patients'
    locations and noted the medical interventions
    accomplished at the hospital prior to his
    arrival. Interventions were reviewed to identify
    time-critical interventions that would have been
    delayed without LS use.

DJ OBrien, TG Price, et al. Prehosp Emerg Care.
1999 Apr Jun3(2)127-30
The effectiveness of lights and siren use during
ambulance transport by paramedics
  • RESULTS The mean ambulance transit time was 666
    seconds and the mean observer transit time was
    896 seconds. The mean difference in ambulance
    (LS) transit time and the observer (no LS)
    transit time was 230 seconds (3 min, 50 sec).
    There was a statistically significant correlation
    between transit time difference and number of
    stoplights encountered, traffic intensity, and
    distance traveled. Of the 75 patients
    transported, four patients were felt to have
    benefited clinically by the time saved.
  • CONCLUSIONS Use of LS significantly shortens
    transport time. In this series of patients
    transported under the care of a paramedic, the
    time saved by the use of LS was not usually
    associated with immediately apparent clinical

DJ OBrien, TG Price, et al. Prehosp Emerg Care.
1999 Apr Jun3(2)127-30
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Patient outcome using medical protocol to limit
"lights and siren" transport.
  • INTRODUCTION Emergency medical services vehicle
    collisions (EMVCs) associated with the use of
    warning "lights and siren" (LS) are responsible
    for injuries and death to emergency medical
    services (EMS) personnel and patients. This study
    examines patient outcome when medical protocol
    directs LS transport.
  • DESIGN During four months, all EMS calls
    initiated as an emergency request for service and
    culminating in transport to an emergency
    department (ED) were included. Medical criteria
    determined emergent (LS) versus non-emergent
    transport. Patients with worsened conditions, as
    reported by EMS providers, were reviewed.

DF Kupas, DJ Dula, et l, Prehospital Disaster
Med. 1994 Oct-Dec9(4)226-9.
The effectiveness of lights and siren use during
ambulance transport by paramedics
  • RESULTS Ninety-two percent (1,495 of 1,625) of
    patients were transported non-emergently.
    Thirteen (1) of these were reported to have
    worsened during transport, and none of them
    suffered any worsened outcome related to the
    non-LS transport.
  • CONCLUSION This medical protocol directing the
    use of warning LS during patient transport
    results in infrequent LS transport. In this
    study, no adverse outcomes were found related to
    non-LS transports.

DF Kupas, DJ Dula, et l, Prehospital Disaster
Med. 1994 Oct-Dec9(4)226-9.
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Take home message
  • EMS is a key intersection between public safety
    and public health
  • EMS is dynamic and we must study outcomes to
    determine appropriate protocols
  • We must demand system development and access to
    information so that EMS outcomes can be measured
  • Physicians must drive the development of
    protocols for EMS that balance public and
    provider safety
  • Because we always have, should never be the

Thank you.
Additional references
  • Thanks to
  • Kate Nelson
  • David Neubert
  • Dan Gerard