- Email: [email protected]
Effectiveness of a simple web-based disaster triage educational tool, directed towards latin-american EMS providers
NAEMSP ANNUAL MEETING ABSTRACTS
Adjusted for head/neck AIS, Injury Severity Score, other significant injury (any other AIS 3-6), mechanism of injury (penetrating vs. blunt), mode of transport (ground vs. helicopter), age, sex, use of prehospital paralytics, and the propensity score, risk of death was higher for OOH-ETI than ED-ETI (OR 4.93; 95% CI: 3.20–7.59). Of survivors, neurological status was poor in 211 and good in 1,098. Adjusted for the same covariates, risk of poor neurological status was higher for OOH-ETI than ED-ETI (OR 1.55; 95% CI: 1.01–2.37). The Horton test indicated good fit for both models (p = 0.99 and 0.58, respectively). Conclusions: OOH-ETI is associated with higher adjusted risk of death and poor neurological status after severe TBI. The nature of these associations and their impacts upon current clinical care remain undefined.
14 OUTCOME FOLLOWING MAJOR HEMORRHAGE: THE CONFOUNDING VARIABLE OF VENTILATORY MANAGEMENT Paul E. Pepe, Keith Lurie, Jane Wigginton, Ahamed Idris, City of Dallas Introduction: The detrimental hemodynamic effects of positive pressure ventilation in hypovolemic states have been well-described for more than 60 years. Nevertheless, typical paramedic training programs and applicable prehospital trauma protocols often call for ‘‘hyperventilation’’ therapy (e.g., rates .15/min), particularly in moribund trauma patients. Typically, paramedics are trained to do so because of the rote rationale that they will ‘‘pump in more oxygen’’ and better ‘‘compensate for metabolic acidosis.’’ Therefore, a study was performed to demonstrate that slower than ‘‘normal’’ respiratory rates (RRs) still preserve adequate oxygenation and acid–base status in hemorrhagic states, while ‘‘normal’’ (or higher RRs) worsen hemodynamics, even in cases of mild to moderate hemorrhage. Methods: Eight pigs, ventilated with 12 mL/kg tidal volume; 28% FiO2; RR = 12/min, were hemorrhaged to , 65 mm Hg systolic arterial blood pressure (SABP). RRs were then sequentially changed every 10 min to 6/min, 20/min, 30/min, and then 6/min again. Results: With RRs at 6/min, the animals maintained pH .7.25 and SaO2 .99%, but increased mean SABP (65 to 84 mm Hg; p , 0.05), time-averaged coronary perfusion pressure (CPP; 50 6 2 to 60 6 4 mm Hg; p , 0.05) and cardiac output (Qt; 2.4 to 2.8 L/m; p , 0.05). With RRs = 20 and 30, SABP (73 and 66 mm Hg), CPP (47 6 3 and 42 6 4 mm Hg) and Qt (2.5 and 2.4 L/min) decreased as did PaO2 and PaCO2 ( , 30 mm Hg) with p , 0.05 for each comparison, respectively. When RR returned to 6/min, SABP rose to 95 mm Hg, CPP (to 71 6 6 mm Hg), and Qt (3.0) also improved significantly (p , 0.05). Conclusion: Following moderate hemorrhage, animals can maintain adequate oxygenation and ventilation with lower RRs, while higher RRs progressively impair hemodynamics. Current resuscitative protocols for trauma involving provision of positive pressure ventilation should be re-examined, both in medical protocols and training.
15 EMERGENCE OF SARS, SARS-LIKE SYMPTOMS, AND REASONS FOR QUARANTINE OF PARAMEDICS DURING A SARS OUTBREAK P. Richard Verbeek, Ian W. McClelland, Alexis C. Silverman, Robert J. Burgess, Sunnybrook Health Sciences Centre
85 Objective: To describe the emergence of suspect and probable SARS, the development of SARS-like symptoms, and reasons for quarantine in paramedics of a large urban EMS system during a SARS outbreak. Methods: During a SARS outbreak in a large North American city, an EMS/base hospital medical support unit (MSU) was developed to provide medical surveillance including quarantine advice and support to approximately 800 paramedics. Paramedics were placed on quarantine according to recommendations from the provincial SARS operating centre and municipal public health departments. Paramedics reporting for duty were screened daily for SARS-like symptoms. Paramedics on quarantine were required to self-screen daily and were required to report SARS-like symptoms (myalgia, severe headache, extreme fatigue, fever, cough, shortness of breath) to the MSU. Results: There were four cases of probable SARS and four cases of suspect SARS. Three of the cases of probable SARS resulted from direct contact with a single patient with probable SARS who was part of an original cohort of cases previously published. All four probable cases occurred before medical surveillance could be implemented. Overall, 526 paramedics were quarantined during the SARS outbreak. The primary reasons for quarantine were unprotected exposure to a health care institution experiencing a SARS outbreak (389 [74%]), unprotected exposure to either of two paramedic colleagues who had SARS-like symptoms on duty (75 [14%]), failed daily screening (43 [8%]), unprotected exposure to patients with SARS-like symptoms (19 [4%]). While under quarantine, SARS-like symptoms developed in 68 (13%) of paramedics only 5 of whom were diagnosed with suspect SARS. The following SARS-like symptoms developed in the 68 symptomatic paramedics: cough (53 [78%]), myalgia (33 [48%]), fatigue (30 [44%]), headache (29 [43%]), fever (11 [16%]), shortness of breath (7 [10%]). Conclusions: Probable SARS can develop early in a paramedic population during a SARS outbreak. Most paramedics required quarantine due to unprotected exposure to health care institutions with a SARS outbreak. A number of paramedics will develop SARS-like symptoms while under quarantine without being diagnosed with suspect or probable SARS. These findings suggest that early protection of paramedics is required during a SARS outbreak.
16 EFFECTIVENESS OF A SIMPLE WEB-BASED DISASTER TRIAGE EDUCATIONAL TOOL, DIRECTED TOWARDS LATIN-AMERICAN EMS PROVIDERS Amado Baez, Matthew Sztajnkrycer, Pablo Smester, Mayo Graduate School of Medicine Objective: A previous survey demonstrated a lack of standardization related to disaster triage among Latin American providers. Our objective was to assess the effectiveness of a short Web-based educational intervention in disaster and mass casualty triage. Methods: The tool consisted of two Web-based educational modules: an introduction to disaster triage and a START (Simple Triage and Rapid Treatment) module. Each had a maximum completion time of 15 minutes. Pre- and post-intervention tests were administered, each consisting of five standardized scenarios based on the START system. Factorial analysis was used to measure the weight of each scenario. For intra-class
86
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correlation the first and fifth scenarios were identical. Using three Spanish Internet EMS forums, Latin American providers were invited to participate in the study. For skills retention assessment a one month follow up survey was administered. For analysis chi-square and Fisher’s exact were used. Results: A total of 55 EMS providers participated in the study; 24 were first responders and 31 advanced providers. With a mean of 5.9 years of EMS experience, 20 had real disaster experience and 19 had previous knowledge of the START system. Five participants correctly answered four or more scenarios on the pre-test intervention, compared with 53 post-test [p , 0.001 RR 10.60 (4.59–24.49)]. Similar findings were obtained for those accurately triaging all 5 scenarios, with none found on the pre-test compared with 49 on the post test (p , 0.001). When assessing intra-rater reliability, 14 scored the duplicate scenarios correctly on the pre-test, compared to all 55 on the post-test [p , 0.001 RR 3.93 (2.50– 6.18)]. When asked about the color designation for contaminated patients, 13 correctly chose the color blue on the pre-test survey, whereas 55 chose this color post-intervention (p , 0.001). Follow-up at one month was 69%. 34 of 38 respondents correctly answered four or more scenarios. No significant difference was noted compared with the immediate post-course survey (p 0.18). Conclusion: Initial ability of a cohort of Latin American EMS providers to accurately triage patients was sub-optimal. A short Web-based educational tool significantly impacted the cohort’s ability to triage in a simulated patient environment, and this improvement was maintained after one month. d
Poster Presentations 17 WHERE IS THE EMS-C LITERATURE? John E. Gough, James M. Callahan, Lawrence H. Brown, East Carolina University Objective: Although there is an EMS-specific peer-reviewed journal, Prehospital Emergency Care, we have previously demonstrated that a large proportion of EMS-related research is published in the general emergency medicine (EM) literature. This study was undertaken to determine which peerreviewed journals publish the largest proportion of EMS-C related research. Methods: A commercial Medline search tool (Ovid Technologies, Salt Lake City, UT) was used to identify EMS-C related articles during the 10-year period of 1993 through 2002. We defined EMS-C articles as those indexed by the MeSH terms (‘‘pediatrics/’’ OR ‘‘child health services/’’) AND (‘‘emergency medical services/’’ OR ‘‘air ambulances/’’ OR ‘‘ambulances/’’ OR ‘‘transportation of patients/’’ OR ‘‘emergencies’’). We included only those articles published in English language and in Index Medicus journals. We report the frequency with 95% confidence intervals (95% CI) of publications in specific journals. Results: A total of 326 EMSC publications were identified; 246 were published in English language Index Medicus journals. Five journals, Pediatric Emergency Care (N = 56, 22.8%, 95% CI: 18–28%), Pediatrics (N = 31, 12.6%, 95% CI: 8–17%), Annals of Emergency Medicine (N = 14, 5.7%, 95% CI: 3–9%), Pediatric Clinics of North America (N = 12, 4.9%, 95% CI: 2–8%), and Archives of Pediatrics and Adolescent Medicine (N = 11, 4.5%, 95% CI: 2–
VOLUME 8 / NUMBER 1
7%) published just over half (50.4%, 95% CI: 44–57%) of all the EMS-C related articles. The remaining 122 articles, accounting for 49.6% (95% CI: 43–56%) of the publications, were published in 64 different journals that each published less than ten EMS-C related articles over the 10-year period; 43 of them published only one EMS-C related article. Conclusion: The majority of the EMS-C related articles are not published in EMS or general EM journals; the greatest concentration of EMS-C articles is in the journals Pediatric Emergency Care and Pediatrics, with Annals of Emergency Medicine being the only general EM journal with a meaningful number of EMS-C related articles. EMS medical directors charged with understanding and addressing EMS-C related issues should not depend solely upon the EMS or general EM literature.
18 EMS PROVIDER ATTITUDES AND BARRIERS TOWARDS PEDIATRIC RESEARCH Tasmeen Singh, James Chamberlain, Joseph Wright, Children’s National Medical Center Objective: There are limited randomized clinical trials conducted in the EMS setting, with only one pediatric randomized clinical trial conducted in 20 years. Traditionally, EMS personnel are not trained in research methodology. As a result, there is a perception of EMS resistance towards research. This study was designed to 1) evaluate the attitudes of EMS personnel towards pediatric emergency medicine research and 2) determine the barriers to conducting EMS research. Methods: A voluntary, written survey was administered to EMS personnel attending CME classes and educational conferences in Maryland. Results: Data from 220 surveys have been collected. Sixty-eight percent reported never participating in research, 16% completed additional paperwork for a study, 8% participated in testing a new protocol or equipment, and 2% participated in a clinical drug trial. Fifty-one percent agreed that EMS research for children is lacking, and 44% were interested in pediatric research. Respondents were least interested in studies that involved additional paperwork or patient interviews (48%), followed by clinical trials (32%). When queried for the reasons EMS providers have refused to participate in a research study, 47% reported they were not interested in the research and 11% did not agree with the project. When asked about the amount of time they would spend on study related paperwork, 56% were willing to spend less than 5 minutes (mean minutes reported = 7.2). Sixty-three percent were willing to undergo additional training for a research study if they were paid, but only 29% were willing if time was not paid (p = 0.001). Only 34% were willing to participate in a blinded clinical trial. Providers who had a level of education equal to or higher than a bachelor’s degree were more likely to be interested in research (OR = 29.45, CI = 3.9–216). Additional data are being collected for further stratified analyses. Conclusion: Most EMS providers do not have experience in structured research and are reluctant to be involved in pediatric research, particularly on a voluntary basis. Major barriers include a lack of interest and knowledge about the purpose of research. Educational opportunities, including mandatory research training, may be necessary to secure more global EMS commitment to research.
Adjusted for head/neck AIS, Injury Severity Score, other significant injury (any other AIS 3-6), mechanism of injury (penetrating vs. blunt), mode of transport (ground vs. helicopter), age, sex, use of prehospital paralytics, and the propensity score, risk of death was higher for OOH-ETI than ED-ETI (OR 4.93; 95% CI: 3.20–7.59). Of survivors, neurological status was poor in 211 and good in 1,098. Adjusted for the same covariates, risk of poor neurological status was higher for OOH-ETI than ED-ETI (OR 1.55; 95% CI: 1.01–2.37). The Horton test indicated good fit for both models (p = 0.99 and 0.58, respectively). Conclusions: OOH-ETI is associated with higher adjusted risk of death and poor neurological status after severe TBI. The nature of these associations and their impacts upon current clinical care remain undefined.
14 OUTCOME FOLLOWING MAJOR HEMORRHAGE: THE CONFOUNDING VARIABLE OF VENTILATORY MANAGEMENT Paul E. Pepe, Keith Lurie, Jane Wigginton, Ahamed Idris, City of Dallas Introduction: The detrimental hemodynamic effects of positive pressure ventilation in hypovolemic states have been well-described for more than 60 years. Nevertheless, typical paramedic training programs and applicable prehospital trauma protocols often call for ‘‘hyperventilation’’ therapy (e.g., rates .15/min), particularly in moribund trauma patients. Typically, paramedics are trained to do so because of the rote rationale that they will ‘‘pump in more oxygen’’ and better ‘‘compensate for metabolic acidosis.’’ Therefore, a study was performed to demonstrate that slower than ‘‘normal’’ respiratory rates (RRs) still preserve adequate oxygenation and acid–base status in hemorrhagic states, while ‘‘normal’’ (or higher RRs) worsen hemodynamics, even in cases of mild to moderate hemorrhage. Methods: Eight pigs, ventilated with 12 mL/kg tidal volume; 28% FiO2; RR = 12/min, were hemorrhaged to , 65 mm Hg systolic arterial blood pressure (SABP). RRs were then sequentially changed every 10 min to 6/min, 20/min, 30/min, and then 6/min again. Results: With RRs at 6/min, the animals maintained pH .7.25 and SaO2 .99%, but increased mean SABP (65 to 84 mm Hg; p , 0.05), time-averaged coronary perfusion pressure (CPP; 50 6 2 to 60 6 4 mm Hg; p , 0.05) and cardiac output (Qt; 2.4 to 2.8 L/m; p , 0.05). With RRs = 20 and 30, SABP (73 and 66 mm Hg), CPP (47 6 3 and 42 6 4 mm Hg) and Qt (2.5 and 2.4 L/min) decreased as did PaO2 and PaCO2 ( , 30 mm Hg) with p , 0.05 for each comparison, respectively. When RR returned to 6/min, SABP rose to 95 mm Hg, CPP (to 71 6 6 mm Hg), and Qt (3.0) also improved significantly (p , 0.05). Conclusion: Following moderate hemorrhage, animals can maintain adequate oxygenation and ventilation with lower RRs, while higher RRs progressively impair hemodynamics. Current resuscitative protocols for trauma involving provision of positive pressure ventilation should be re-examined, both in medical protocols and training.
15 EMERGENCE OF SARS, SARS-LIKE SYMPTOMS, AND REASONS FOR QUARANTINE OF PARAMEDICS DURING A SARS OUTBREAK P. Richard Verbeek, Ian W. McClelland, Alexis C. Silverman, Robert J. Burgess, Sunnybrook Health Sciences Centre
85 Objective: To describe the emergence of suspect and probable SARS, the development of SARS-like symptoms, and reasons for quarantine in paramedics of a large urban EMS system during a SARS outbreak. Methods: During a SARS outbreak in a large North American city, an EMS/base hospital medical support unit (MSU) was developed to provide medical surveillance including quarantine advice and support to approximately 800 paramedics. Paramedics were placed on quarantine according to recommendations from the provincial SARS operating centre and municipal public health departments. Paramedics reporting for duty were screened daily for SARS-like symptoms. Paramedics on quarantine were required to self-screen daily and were required to report SARS-like symptoms (myalgia, severe headache, extreme fatigue, fever, cough, shortness of breath) to the MSU. Results: There were four cases of probable SARS and four cases of suspect SARS. Three of the cases of probable SARS resulted from direct contact with a single patient with probable SARS who was part of an original cohort of cases previously published. All four probable cases occurred before medical surveillance could be implemented. Overall, 526 paramedics were quarantined during the SARS outbreak. The primary reasons for quarantine were unprotected exposure to a health care institution experiencing a SARS outbreak (389 [74%]), unprotected exposure to either of two paramedic colleagues who had SARS-like symptoms on duty (75 [14%]), failed daily screening (43 [8%]), unprotected exposure to patients with SARS-like symptoms (19 [4%]). While under quarantine, SARS-like symptoms developed in 68 (13%) of paramedics only 5 of whom were diagnosed with suspect SARS. The following SARS-like symptoms developed in the 68 symptomatic paramedics: cough (53 [78%]), myalgia (33 [48%]), fatigue (30 [44%]), headache (29 [43%]), fever (11 [16%]), shortness of breath (7 [10%]). Conclusions: Probable SARS can develop early in a paramedic population during a SARS outbreak. Most paramedics required quarantine due to unprotected exposure to health care institutions with a SARS outbreak. A number of paramedics will develop SARS-like symptoms while under quarantine without being diagnosed with suspect or probable SARS. These findings suggest that early protection of paramedics is required during a SARS outbreak.
16 EFFECTIVENESS OF A SIMPLE WEB-BASED DISASTER TRIAGE EDUCATIONAL TOOL, DIRECTED TOWARDS LATIN-AMERICAN EMS PROVIDERS Amado Baez, Matthew Sztajnkrycer, Pablo Smester, Mayo Graduate School of Medicine Objective: A previous survey demonstrated a lack of standardization related to disaster triage among Latin American providers. Our objective was to assess the effectiveness of a short Web-based educational intervention in disaster and mass casualty triage. Methods: The tool consisted of two Web-based educational modules: an introduction to disaster triage and a START (Simple Triage and Rapid Treatment) module. Each had a maximum completion time of 15 minutes. Pre- and post-intervention tests were administered, each consisting of five standardized scenarios based on the START system. Factorial analysis was used to measure the weight of each scenario. For intra-class
86
PREHOSPITAL EMERGENCY CARE JANUARY / MARCH 2004
correlation the first and fifth scenarios were identical. Using three Spanish Internet EMS forums, Latin American providers were invited to participate in the study. For skills retention assessment a one month follow up survey was administered. For analysis chi-square and Fisher’s exact were used. Results: A total of 55 EMS providers participated in the study; 24 were first responders and 31 advanced providers. With a mean of 5.9 years of EMS experience, 20 had real disaster experience and 19 had previous knowledge of the START system. Five participants correctly answered four or more scenarios on the pre-test intervention, compared with 53 post-test [p , 0.001 RR 10.60 (4.59–24.49)]. Similar findings were obtained for those accurately triaging all 5 scenarios, with none found on the pre-test compared with 49 on the post test (p , 0.001). When assessing intra-rater reliability, 14 scored the duplicate scenarios correctly on the pre-test, compared to all 55 on the post-test [p , 0.001 RR 3.93 (2.50– 6.18)]. When asked about the color designation for contaminated patients, 13 correctly chose the color blue on the pre-test survey, whereas 55 chose this color post-intervention (p , 0.001). Follow-up at one month was 69%. 34 of 38 respondents correctly answered four or more scenarios. No significant difference was noted compared with the immediate post-course survey (p 0.18). Conclusion: Initial ability of a cohort of Latin American EMS providers to accurately triage patients was sub-optimal. A short Web-based educational tool significantly impacted the cohort’s ability to triage in a simulated patient environment, and this improvement was maintained after one month. d
Poster Presentations 17 WHERE IS THE EMS-C LITERATURE? John E. Gough, James M. Callahan, Lawrence H. Brown, East Carolina University Objective: Although there is an EMS-specific peer-reviewed journal, Prehospital Emergency Care, we have previously demonstrated that a large proportion of EMS-related research is published in the general emergency medicine (EM) literature. This study was undertaken to determine which peerreviewed journals publish the largest proportion of EMS-C related research. Methods: A commercial Medline search tool (Ovid Technologies, Salt Lake City, UT) was used to identify EMS-C related articles during the 10-year period of 1993 through 2002. We defined EMS-C articles as those indexed by the MeSH terms (‘‘pediatrics/’’ OR ‘‘child health services/’’) AND (‘‘emergency medical services/’’ OR ‘‘air ambulances/’’ OR ‘‘ambulances/’’ OR ‘‘transportation of patients/’’ OR ‘‘emergencies’’). We included only those articles published in English language and in Index Medicus journals. We report the frequency with 95% confidence intervals (95% CI) of publications in specific journals. Results: A total of 326 EMSC publications were identified; 246 were published in English language Index Medicus journals. Five journals, Pediatric Emergency Care (N = 56, 22.8%, 95% CI: 18–28%), Pediatrics (N = 31, 12.6%, 95% CI: 8–17%), Annals of Emergency Medicine (N = 14, 5.7%, 95% CI: 3–9%), Pediatric Clinics of North America (N = 12, 4.9%, 95% CI: 2–8%), and Archives of Pediatrics and Adolescent Medicine (N = 11, 4.5%, 95% CI: 2–
VOLUME 8 / NUMBER 1
7%) published just over half (50.4%, 95% CI: 44–57%) of all the EMS-C related articles. The remaining 122 articles, accounting for 49.6% (95% CI: 43–56%) of the publications, were published in 64 different journals that each published less than ten EMS-C related articles over the 10-year period; 43 of them published only one EMS-C related article. Conclusion: The majority of the EMS-C related articles are not published in EMS or general EM journals; the greatest concentration of EMS-C articles is in the journals Pediatric Emergency Care and Pediatrics, with Annals of Emergency Medicine being the only general EM journal with a meaningful number of EMS-C related articles. EMS medical directors charged with understanding and addressing EMS-C related issues should not depend solely upon the EMS or general EM literature.
18 EMS PROVIDER ATTITUDES AND BARRIERS TOWARDS PEDIATRIC RESEARCH Tasmeen Singh, James Chamberlain, Joseph Wright, Children’s National Medical Center Objective: There are limited randomized clinical trials conducted in the EMS setting, with only one pediatric randomized clinical trial conducted in 20 years. Traditionally, EMS personnel are not trained in research methodology. As a result, there is a perception of EMS resistance towards research. This study was designed to 1) evaluate the attitudes of EMS personnel towards pediatric emergency medicine research and 2) determine the barriers to conducting EMS research. Methods: A voluntary, written survey was administered to EMS personnel attending CME classes and educational conferences in Maryland. Results: Data from 220 surveys have been collected. Sixty-eight percent reported never participating in research, 16% completed additional paperwork for a study, 8% participated in testing a new protocol or equipment, and 2% participated in a clinical drug trial. Fifty-one percent agreed that EMS research for children is lacking, and 44% were interested in pediatric research. Respondents were least interested in studies that involved additional paperwork or patient interviews (48%), followed by clinical trials (32%). When queried for the reasons EMS providers have refused to participate in a research study, 47% reported they were not interested in the research and 11% did not agree with the project. When asked about the amount of time they would spend on study related paperwork, 56% were willing to spend less than 5 minutes (mean minutes reported = 7.2). Sixty-three percent were willing to undergo additional training for a research study if they were paid, but only 29% were willing if time was not paid (p = 0.001). Only 34% were willing to participate in a blinded clinical trial. Providers who had a level of education equal to or higher than a bachelor’s degree were more likely to be interested in research (OR = 29.45, CI = 3.9–216). Additional data are being collected for further stratified analyses. Conclusion: Most EMS providers do not have experience in structured research and are reluctant to be involved in pediatric research, particularly on a voluntary basis. Major barriers include a lack of interest and knowledge about the purpose of research. Educational opportunities, including mandatory research training, may be necessary to secure more global EMS commitment to research.