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Emergency medical services: An annotated bibliography of the recent literature
Emergency MedicalServices: An Annotated Bibliography of the Recent literature JON R. KROHMER, MD,* HOWARD A. WERMAN, MD,t MEMBERS OF THE EMS EDUCATORS COMMITTEE, STEMS Emergency medical services (EMS) is a component of medical care that has changed significantly in the past 20 years. Much emphasis has been placed on physician involvement in medical control aspects of EMS activities. This has included more emphasis on training physicians about EMS, training which is now extending into emergency medicine residency programs. With this increased physician involvement has come a need for, and subsequent production of, a body of literature addressing EMS issues.
GENERAL Accidental death and disability: The neglected disease of modem society. National Academy of Sciences-National Research Council. Washington, DC, National Academy of Sciences, 1966. This is the classic “White Paper” which initiated national legislation leading to the development of EMS systems. It provides an overview of the care at the time and outlines the specific recommendations which were developed-A “must” for those really interested in the history of EMS. Emergency medical services: Problems, programs and policies. ACEP Committee on Public Policy. J Am Co11 Emerg Phys 1976$:285-l%. This is a revision of an earlier statement prepared by the Committee on Public Policy of the American College of Emergency Physicians (ACEP). It is a broadly encompassing review of the state of EMS (in 1976) and includes ACEP’s recommendations for improving overall standards. Now, with the perspective of 10 years it is still interesting reading to see where we were and where we still need to go. History of emergency medical services in the United States. Rockwood CA, Mann CM, Farrington JD, et al. J Trauma 1976;16:299-308. From the ‘Emergency Medicine Residency, Butterworth Hospital, Grand Rapids, MI; the TDivision of Emergency Medicine, Department of Preventive Medicine, Ohio State University, Columbus, OH; and the *EMS Educators Committee, Society of Teachers of Emergency Medicine (STEM), Dallas. Manuscript received July 25, 1988; accepted July 26, 1988. Address reprint requests to Dr Krohmer: Department of Emergency Medicine, Buttetworth Hospital, 100 Michigan NE, Grand Rapids, MI 49503. Key
Words:
Emergency medical services, EMS, bibliography.
0 1989 by W.B. Saunders Company. 07356757/89/0701-0023$5.00/O 110
This article affords a historical perspective of EMS in the United States from the mid-1960s until 1975. The article is a little disjointed in that it is not a chronological unfolding of major events, nor is it separated into specific subject areas. It is readable and interesting in providing background information about EMS development. Medical care in the streets. Caroline 43-46.
NL. JAMA 1977;237:
Dr Caroline provides descriptions of several field cases which she experienced while training and directing the Freedom House Ambulance (Pittsburgh) crews. The purpose of the discussion is to outline the unique skills and knowledge required of an EMS physician. Anyone who has spent time in the field can easily relate to the situations presented. Enjoyable and educational reading. Prehospital advanced life support: What color are the emperor’s clothes? Hoffer EP. J Am Coll Emerg Phys 1979;8:434436. The author likens the medical community’s ready acceptance of paramedic programs to the fairy tale in which no one dared to question the emperor’s new (nonexistent) clothing. A plea is made for controlled clinical trials to test the merits of the new system. The author also stresses the need for prehospital treatment of ventricular fibrillation and suggests a “load and go” approach for all other critically ill and injured persons. The conceptual development of EMS systems in the United States, part I. Boyd DR. Emerg Med Serv 1982;11(1): 19-23. The conceptual development of EMS systems in the United States, part II. Boyd DR: Emerg Med Serve 1982;11(2): 26-35. An overview of the history of EMS systems development in the United States is provided by these two articles. They briefly outline the phases of EMS system development, early activities and pioneering efforts, and financing of legislative activities. They provide a good, general overview. The impact of a physician-staffed mobile intensive care unit. Applebaum D. Am J Emerg Med 1985;3:15-18. This article describes the use of physicians in mobile intensive care units (MICUs) in a socialized medicine system in which it is important to control the costs of medical care and the large volume of emergency department (ED) visits that occur in the hospital designated by the city (Jerusalem, Israel) for emergency care. The author summarizes 1 year’s experience of a physician-attended MICU, which apparently helps maintain a reasonably good quality of health care in a society that rations its health care delivery.
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The urban paramedic’s scope of practice. Smith JP, Bodai BI. JAMA 1985;253:544-548.
general. It is well referenced for those training in EMS.
The goal of this article is to review “the available literature to delineate those areas where prehospital emergency services have been shown to be of value and to identify those areas where controversy exists to the scope of practice of paramedics.” The authors look specifically at airway management, defibrillation and cardiopulmonary resuscitation (CPR), hypovolemia, and the use of medications. They state they have looked at the available literature regarding field studies addressing these various issues. From these, they draw conclusions regarding appropriate practice of paramedics. Above all, the article points out the need for increased quality research into prehospital activities. (This article generated a number of follow-up letters to the editor questioning the conclusions of the article.--J.K.)
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Specialized urban EMS rescue. Freeman Set-v 1985;11(10):52-55.
A course in emergency care for f&-year medical students. McCally M, DeAtley C, Piemme TE. J Am Co11 Emerg Phys 1978;7:20-23.
RJ. J Emerg Med
This article discusses the implementation of specialized rescue/extrication services within a non-fire-based EMS system. It also examines the costs, benefits, and needs for such a system. The need for improved emergency medical services in Pitt County. Hunt RC, Allison EJ, Yates JG. NC Med J 1986;7:39-42. The current status of county (Pitt) is described EMS systems throughout ment in the resuscitation system is presented.
EMS in a rural North Carolina and compared with other types of the nation. A plan for improverate experienced with the existing
Emergency medical services in the 1980’s (commentary). Stewart RD. NY State J Med 1986;86:405-407. This commentary, accompanying the article by Mustalish (following), is an excellent brief summary of the challenge facing EMS systems in the next decade. Dr Stewart strongly advocates high-quality, vigorous research to determine the efficacy of many of the previously accepted procedures and field care. He makes an excellent argument for assumption of full medical control of EMS systems by physicians. He states that without tight medical accountability and further research “they will find themselves still shuffling along the dusty road, oil and wine in their packs, kindly seeking to help the victims of thieves, their donkeys trotting along behind them.” The National Association of EMS Physicians is mentioned as a new organization whose goal is to foster better prehospital care and take us beyond the care of the Good Samaritan. Emergency medical services: Twenty years of growth and development. Mustalish AC. NY State J Med 1986;86:414420. This article is an excellent historical review of the past 20 years in the growth and development of EMS, including not only emergency medical technicians (EMT@ and paramedics, but also emergency physicians, emergency nurses, and changes in the ED. It is an excellent resource for EMS in
and should be standard reading
Self-instructional emergency medicine program for medical students. Block FE, Beville C, Cook H, et al. J Am Co11 Emerg Phys 1977;6:13-15. A freshman medical school course in emergency medicine offered at the University of Virginia is presented. With seven hours of didactic instruction and the effective use of selfinstructional videotapes, students were able to successfully complete testing in both cognitive and psychomotor objectives. The article provides a useful model for efficiently introducing emergency medicine into the medical school curriculum.
This article describes the successful implementation of a 52-hour course in emergency medicine for first-year medical students at George Washington University School of Medicine. The course content is described, detailing those topics taught by lecture, demonstration, and practicum. Audiovisual references, as well as supply and equipment lists, are included. Involving and educating base station physicians in paramedic programs. Cooper MA, Ornato JP. Ann Emerg Med 1980;9:524-526. According to these authors, much attention is focused on paramedic training but little education is given to emergency physicians who will interact with paramedics over the radio and in the ED. They describe a four-part education process that they use in the region of Omaha, Nebraska. These four parts are participation in the Paramedic Policy and Procedures Committee, participation in the clinical training of paramedics, riding with the paramedics, and a base-station course. A general EMS curriculum for residency training. Lowry JW, Lauro AJ. Ann Emerg Med 1980;9:250-252. The authors provide a broad overview of the 2-year EMS curriculum at Charity Hospital’s emergency medicine residency program in 1980. The course included EMT instruction, didactic lectures (a list of topics is included in the article), prehospital experience, and participation on community EMS committees. This program was developed using guidelines provided by ACEP, JCAH, DHEW, and program alumni. Reassessing training levels for prehospital Briese GL. J Emerg Med 1983;1:67-71.
EMS personnel.
This article discusses intermediate levels of training for prehospital care personnel. Levels of training between EMT and paramedic include “EMT-intermediate” and EMTs trained in defibrillation, intravenous (IV) therapy, military 111
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antishock trouser (MAST) use. The author points out propriate level of training effective EMS system in a
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application, and/or EOA/EGTA the need for determining the apthat will provide the most costparticular community.
The evolution of a rural EMT-intermediate Williamson JE, Landis SS, Allison 1983;44:737-742.
training program. EJ. NC Med J
This article presents a model training program for intermediate level EMTs in the area. It includes the organizational structure of the EMS system, the training objectives, and content of the course. An emergency medical services curriculum for emergency medicine residencies. Kallsen G, Merritt-Lindgren M. Ann Emerg Med 1984;13:912-915. The fully integrated EMS curriculum used at the Valley Medical Center and Highland Hospital emergency medicine residencies is detailed in this article. The purpose of the training is to insure competency in off-line and on-line medical control. The overall structure of the program, as well as detailed descriptions of the individual components, is provided. Statewide prehospital mobile intensive care treatment protocols for advanced Lifesupport units in North Carolina. Shepherd SM, Allison EJ, Sayers DG, et al. NC Med J 1985;46:579-602. Advanced life support (ALS) treatment protocols for both pediatric and adult patients that may be used as standing orders at the discretion of the medical director are provided. The format includes both outlines and algorithms. It provides a solid structure from which to construct protocols for those faced with developing an entire program. (Many of the ALS protocols should be updated based on more recent AHA recommendations.--J.K.) Curriculum for training residents in EMS (a&r). Ann Emerg Med 1986;15:654.
Otten EJ.
This abstract outlines a poster session presentation at the UA/EM meeting in 1986. The 4-year program of EMS education developed at the University of Cincinnati is described. The program begins with orientation lectures on basic EMS configuration and systems design for PGY I residents. These residents are assigned to local EMS squads to gain prehospital experience. PGY II residents take a communications course before handling all telemetry calls for the county. They also receive flight training and participate as flight physicians in the air medical program. PGY III residents participate on the area disaster response team. A 4week course for PGY IV residents covers administrative aspects of EMS. Design of a resident In-field experience for an emergency medicine residency curriculum. Stewart RD. Paris PM, Heller MB. Ann Emerg Med 1987;16:175-179. This discussion delineates a resident experience for onscene attendance at selected EMS incidents. The 6-month 112
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period reviewed included 158 cardiac arrests, 58 difficult intubations, 49 central or peripheral lines, and 24 severely injured patients. Residents were surveyed and subsequently supported the program on the basis that it enriched their learning experience of EMS in the field. Department of Transportation Serv 1987;16(10):195-201.
(DOT) guidelines. Emerg Med
This summary provides a comprehensive and useful look at the current DOT guidelines for EMT-ambulance, EMTintermediate, EMT-paramedic, EMT-dispatcher, and EMS instructor training programs. In outline fashion, the suggested curriculum for each of these courses is defined. DOT guidelines for EMS air ambulances are also included.
MEDICALCONTROL Medical control of paramedic services. Amey BD, Straub EJ, Harrison EE. Emerg Med Serv 1978;7(4):20-24. This article describes integrated medical control for an EMS system serving the city of Tampa, Florida and the surrounding county. Quality control issues including the care of cardiac arrest patients, trauma victims, and pediatric cases are the responsibility of the Prehospital Care Committee. Medical leadership of the system is provided by two medical directors, 12 on-line medical advisors, and a number of consultants covering a spectrum of medical specialties. Finally, data for the system are collected and stored on a microcomputer for analysis of the system’s performance. The article describes a valuable model for regional EMS system development. Developing medical control in a rural EMS system. Riner RM. Emerg Med Serv 1981;10(2):22-28. This article begins with an introduction to the specific elements of medical control for an EMS system. The author describes the application of these principles of medical control to a rural county in Hawaii. A contractual relationship exists between the district EMS medical director and the Hawaii Department of Health (EMS systems branch) which specifies that he/she is to provide audits of high-risk cardiac and trauma cases, case reviews, involvement in continuing medical education, written protocols, and quality assurance. An important component of medical control is a continued assessment of paramedic skills. Other components include chart audits, continuing medical education, and testing and risk management. Effectiveness of a prehospital medical control system: An analysis of the interaction between emergency room physician and paramedic. Pozen MW, D’Agostino RB, Sytkowski PA, et al. Circulation 1981;61:442-447. The accuracy of paramedics’ and telemetry physicians’ interpretation of rhythm strips, as compared with that of a cardiologist, is examined. The appropriateness of treatment administered is also examined based on the rhythm interpretation and the paramedics’ treatment protocols. The authors found major variations in the accuracy of interpretations by
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paramedics and telemetry physicians and in the appropriateness of treatment. The article strongly questions the effectiveness of present systems to respond to life-threatening dysrhythmias and calls for greater medical control. The crisis of control. 1981;6(11):30-35.
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This article discusses the problems of the EMS state agency in Georgia, which is a branch of the Department of Human Resources. The author points out several conflicts that have developed under the existing state EMS structure. These problems include difficulty in the agency’s functioning as both regulator of EMS activities and a representative of EMS, the existence of EMS as a “nonpreventive” agency in the Department of Health, and the organizational ambiguity in the Georgia EMS system at all levels. The author proposes that an Gflice of Emergency Medical Services be established and that this body be responsible for statewide development of EMS services. A separate EMS professional review board would be charged with issues such as certification and decertification of prehospital providers, vehicle inspection, and appeals. The article provides an excellent discussion of potential problems that must be considered when the EMS lead agency is a branch of the state health department. Medical control and the volunteer rescue squad. Edwards BW. J Emerg Med Serv 1981;6(11):38-42. The problem of implementing medical control in an existing system of volunteer rescue squads is discussed. The development of the EMS system in Virginia Beach, Virginia is traced from its inception in the 194Os, including a discussion of the role of medical direction in that system. In 1979 a municipal ordinance was passed formalizing the relationship between the physician directors and the volunteer rescuers in the system and creating an Office of Emergency Medical Services. The structure of this body is discussed. The article describes an interesting approach to establishing strong medical control in an existing EMS system. Physician qualification for medical control in emergency medical services systems. Raucher LA, Fahmey PM. National Academy Press, Washington, DC, 1981, pp 129-134. This document outlines the physician qualifications and responsibilities for on-line and off-line medical control functions. This is only a portion of the book, that contains the proceedings and summary report of the National Academy of Sciences Conference on Medical Control held in Washington, DC on May 12-13, 1980. This entire book contains a lot of interesting information. Medical control of prehospital emergency medical services. EMS Committee of the American College of Emergency Physicians. Ann Emerg Med 1982;11:387. This is the position paper of ACEP, addressing medical control. The position paper was approved by the Board of Directors on April 24, 1982.
Standing orders vs voice control. Hunt RC, Bass RR, Graham RG, et al. J Merg Med Serv 1982;11:26-30. The authors describe a study that looked at the use of standing orders as a medical control device in advanced cardiac life support. The study compares the outcome of cardiac arrest victims who were treated initially using standing orders only with victims who were treated with direct physician orders only. No statistical difference was found between the two groups in the number of arrest victims with a palpable pulse on arrival in the emergency department. Paramedics reported a subjective improvement in the efficiency of care with the use of standing orders. Medical control of emergency medical services: An overview for emergency physicians. Page JR, Krentz MJ, Aranosian RD, et al. Dallas, TX, EMS Committee of the American College of Emergency Physicians, 1984 This off-line control, section views.
overview outlines the role of the medical director, (administrative) medical control, on-line medical and qualifications of medical directors. It also has a on review and audit, including individual case re-
Medical control of prehospital care. McSwain NJ. J Trauma 1984;24: 172. Dr McSwain’s editorial emphasizes the necessity of physician involvement in prehospital care, with the discussion centering around the treatment of trauma patients. The author places the burden of responsibility for an effective EMS system on the physicians involved in medical control. Rx for medical control. 1984;9(4):39-41.
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EM. J Emerg Med Serv
This is a brief article on medical control which incorporates Dr Norman McSwain’s components of prospective, immediate, and retrospective control. It incorporates a quality assurance design which demonstrates that prospective and immediate medical control is much simpler than retrospective control. The article also includes two forms, employee performance appraisal and crew performance evaluation, which are helpful for on-line evaluation. The emergency physicians and medical control ln advanced life support. Ponter JE. J Emerg Med 1985;3:31-35. This article is a description on how a large urban EMS district in California set certification, recertification, and continuing education standards for advanced life support physician medical radio operators (MROs). At the time of publication they had certified nearly 50 physician MROs and felt that they had achieved a high level of ongoing medical control. Medical control+nality assurance ln prehospital care. Holroyd BR, Knopp R, Kallsen G. JAMA 1986;256:10271031. The authors provide a very good overview of medical control aspects of prehospital care. They include historical and 113
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legislative background, organization of medical control (prospective, immediate, and retrospective), and types of medical control. Current trends concerning medical control also are included in the article. Role of the physician in the prehospital setting. Pepe PE, Stewart RD. Ann Emerg Med 1986;15:1480-1483. This article outlines the critical role physicians must play in assuring adequate medical control of the activities of prehospital care providers. As outlined, physicians should be involved in initial training of personnel, field supervision, policy decisions, system assessment, quality assurance, and research. The need for dedicated, competent physicians as leaders in insuring the credibility of prehospital care is discussed. This is an excellent article addressing medical control issues. Medical direction in emergency medical services: the role of the physician. Stewart RD. Emerg Med Clin North Am 1987;5:119-132. Dr Stewart begins this discussion with historical considerations of emergency medical services. After presenting the philosophy of prehospital care, he outlines the role of the physician by expanding the role and responsibilities of the EMS physician as outlined by ACEP to include system planning and design, protocol development, personnel education, medical control, quality assurance, research, and field care. Finally, the qualifications of an EMS medical director are discussed. This article provides an excellent overview of the components of physician involvement in EMS.
EVALUATION/QUALITYASSURANCE Recurrent themes in ambulance critique review sessions over eight years. Pilcher DB, Gettinger CE, Seligson D. J Trauma 1979;19:324-328. This article outlines a quality assurance program involving biweekly ambulance critique review sessions used over an eight year period at the University of Vermont College of Medicine. It points out common problems of the system which can be avoided through prehospital personnel education. An additional benefit of the program is the good relations that develop between prehospital providers and ED personnel participating in the review sessions. Evaluation of an EMS regional referral system using a tracer methodology. Egges J, Turnock BJ. Ann Emerg Med 1980;9:918-923. This study followed five tracer conditions (multiple trauma, head trauma, spinal cord injury, bums, and low birth weight infants) in one region of the Illinois EMS system to determine whether the patients were treated in the appropriate regional center designated for the condition. It showed that only about half of the patients were moved to the appropriate center. An analysis of some of the transfer patterns is provided. The conclusions of the article are interesting but are too specific to be readily applicable to the general problem of EMS regionalization. 114
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JEMS staff report: Standardized skills testing: A new program for evaluating EMT’s, paramedics and medical radio operators. J Emerg Med Serv 1980;6(12):36-39. This article is a moderately in-depth review of skills testing for EMTs and radio resource personnel. An overview of a comprehensive testing process is provided. Resources for more detailed information and standardized testing materials are included. A method for reviewing radio-telemetry paramedic calls. Rottman SJ, Fitzgerald-Westby K. Ann Emerg Med 1981;10:36-38. The authors describe a method used at Los Angeles County/University of Southern California base station for reviewing taped paramedic telemetry calls. Emergency medicine residents who are rotating on a 2-week prehospital care rotation review the tapes of all telemetry paramedic calls. Using a specific review form, the residents critique the prehospital and ED physician assessments and treatments. Communication techniques are also evaluated. Using this review process, specific problems or exemplary runs are identified for presentation at tape review conferences. This program is felt to be very beneficial in the education of residents in telemetry protocol and communications procedures. Measuring your system. 1983;9(1):84-91.
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Mr Stout presents a method by which an EMS system can be objectively evaluated on performance. Ten areas of importance to EMS function are outlined: clinical performance; medical accountability; dispatching and system status management; access, first responder, and citizen CPR; disaster capability; personnel management practices; stability, reliability, and fail-safes; pricing policies, billing, and collection practices; response time performance; and public accountability. The method allows for the calculation of a numerical score to judge performance. It helps identify problem areas in the EMS system and suggests possible solutions. A computer-assisted quality assurance system for an emergency medical service. Stewart RD, Burgman J, Cannon GM, et al. Ann Emerg Med 1985;14:25-29. This article describes the effectiveness of using a full-time quality assurance officer and a computer program designed for error detection to significantly improve the identification of documentation and performance errors that occur in a busy urban EMS system. The core of information necessary for developing a realistic, meaningful, quality assurance program essential for the prehospital phase of all local or regional EMS systems is contained in the article. The field instructor program: Quality control of prehoapital care, the Grst step. Pons PT, Dinerman N, Rosen P, et al. J Emerg Med 1985;2:421-427. The authors present the system used in the Denver paramedic system to orient new paramedics to their program and
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evaluate the quality of care provided by these new personnel. The bulk of the orientation, training, and evaluation is done by paramedic field instructors while they are providing actual patient care. The successes, assets, and liabilities of the system as discussed. Prehospital assessment and scoring. Ramzy AI, Warren GT. Trauma Q 1986;3:1-13. This is a nice review of the current status of prehospital trauma scoring. The authors also describe the use of trauma scoring in the Maryland EMS system.
COMMUNICATION Telemetry-Medical command ln coronary and other mobile emergency care systems. Nagel EL, Hirschman JC, Nussenfeld SR, et al. JAMA 1970;214:332-338. This article is of historical interest. It describes one of the first large-scale EMS experiences with telemetry, in the city of Miami. The conclusion from the 2-year experience was that telemetry provided a mechanism for delivery of advanced care in the streets by paramedical personnel. The EMTs in the city were trained to defibrillate but were not using any other advanced life support skills, including IV or drug therapy. The authors conclude “telemetry of electrocardiograms is not new; and the use of paramedics to carry out a physician’s advise is not new. What is novel and exciting for the future of mobile emergency medical care is the combining of these techniques into one diagnostic treatment system with great economy of the physician’s time and utilization of strategically located and specially trained rescue squads to minimize the time lag between the receipt of the alarm and the actual delivery of medical services on the spot.” Prehospital care telemetry--How essential? Hitt JM, Sanders AB. J Emerg Med 1984;1:417-420. The authors examine the pilot use of ECG telemetry in Tucson, Arizona. A cost and use analysis suggests performance standards outlining situations in which telemetry may be helpful. The authors also suggest the value of intangibles that telemetry may provide a system: improved esprit de corps, in-service training and evaluation, and increased performance security when new personnel are introduced. They acknowledge that each EMS system must decide the value of telemetry in its system. A survey of prehospital care paramedic/physician communication for Multnomah County (Portland), Oregon. Thompson SJ, Schriver JA. J Emerg Med 1984;1:421-428. The authors review a trial implementation of a radio communications system between field paramedics and emergency physicians over a 6month period. The survey demonstrated that 16% of the calls involved requests for physician consultation, 1% involved physician-initiated advice, and 83% were for information only. The relative importance (concerning patient care) of physician radio intervention is discussed.
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Development and Implementation of emergency CPR lnstruction via telephone. Carter WB, Eisenberg MS, Hallstrom AP, et al. Ann Emerg Med 1984;13:695-700. In King County, Washington a CPR telephone message to be delivered to bystanders of cardiac arrest was developed based on review of taped cardiac arrest calls and the observation of the CPR performance of 60 community volunteers undergoing CPR training. It was then tested using 143 volunteers (without prior CPR training) in simulated cardiac arrest. The quality of CPR was comparable to CPR performed by individuals with formal CPR training. The wording of the message directly determined the adequacy of performance. Specific telephone CPR instructions are included in the article. Emergency CPR instruction via telephone. Eisenberg MS, Hallstrom AP, Carter WB, et al. Am J Public Health 1985;75:47-50. This study reports the results of a program conducted in suburban King County, Washington in which the emergency dispatcher provided bystander instruction in CPR. The study concludes that the telephone CPR program increased the percentage of cases in which bystander CPR was initiated (from 45% to 56% of cardiac arrests) and that such CPR was safe, increased survival, and was positively received by those involved. The small number of patients studied make significant statistical analysis difficult and, therefore, make sweeping conclusions impossible.
DISASTERMANAGEMENT Revising the rural hospital disaster plan: A role for the EMS system in managing the multiple casualty Incident. Melton RJ, Riner RM. Ann Emerg Med 1981;10:39-44. These authors believe that many rural communities use a military/civil defense model for disaster planning, which is inappropriate for the most probable types of disasters. The civil defense model involves large numbers of victims treated for long periods of time in the field setting. The authors propose that an EMS system model that relies on an EMS system working closely with the local hospitals is more effective and realistic. The EMS model is described in detail with lists of important responsibilities of various components of the system. Disaster medicine training in France. Feldstein B, Dufeu N, Handal K, et al. Ann Emerg Med 1983;12:49-51. This article describes the curriculum of a disaster medicine training program developed and conducted in France. The course is a 71-hour comprehensive didactic program that is followed by field experience lasting two days to 1 week. The curriculum is outlined. Disaster training for emergency physicians ln the United States: A systems approach. Feldstein BD, Gallery ME, Sanner PH, et al. Ann Emerg Med 1985;14:91-95. This is a description of the course, “Disaster Management in Planning for Emergency Physicians,” that was designed jointly by ACEP and the Federal Emergency Management 115
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Agency (FEMA). The 16-hour course was first conducted in September 1983. Topics covered include disaster elements, general planning and organization, victim flow, communication, evacuation modalities, field and hospital management, documentation, public relations, and applications to the local community. The psychological impact of disaster on rescue personnel. Durham TW, McCammon SL, Allison EJ. Ann Emerg Med 1985;14:73-77. This was a study of 79 health care workers involved in the care of victims of an apartment building explosion. A questionnaire was administered to all healthcare workers to assess the incidence of posttraumatic stress disorder (PTSD). Eighty percent of the interviewees were found to have at least one symptom of PTSD. These data support the need for a plan to address the emotional sequelae occurring in disaster careworkers. Disaster Medical Services. Disaster Committee, American College of Emergency Physicians. Ann Emerg Med 1985;14: 1026. The roles of emergency physicians in the medical aspects of disaster planning, management, and patient care are described in this document developed by the disaster committee and approved by the board of directors of ACEP on June 24, 1985. A prehospital approach to multiple-victim incidents. Haynes BE, Dahlen RD, Pratt FD, et al. Ann Emerg Med 1986;15:458-462. This article reviews an EMS system’s experience with multiple-casualty incidents, defined as four or more patients per incident. Forty-seven incidents were reviewed. Little tabulated data and no statistical analysis are provided. Identified as major problems in such incidents were field management, paramedic assessment, radio communications, and base hospital management. This article is an important review for physicians who train and supervise paramedics. The national disaster medical system: A concept ln large-scale emergency medical care. Moritsugu KP, Reutershan TP. Ann Emerg Med 1986;15:1496-1498. This is a description of the background and purpose of the National Disaster Medical System (NDMS), including rapid response, patient evacuation, and definitive medical care. This comprehensive program is designed to involve federal, state and community resources. The article describes how local communities may participate. SPECIAL EVENTS Emergency medical services at the 1984 Democratic national convention. (letter). Auerbach PS, Gelb AM, Turns JE. Ann Emerg Med 1985;14:709-711. This letter provides a description of the medical care system that was developed for the convention. It addresses security considerations, provides an overview of the responses during the convention, and makes recommendations for those involved in future similar activities. 116
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Special event medical care: The 1984 Los Angeles Summer Olympics experience. Baker WM, Simone BM, Niemann JT, et al. Ann Emerg Med 1986;15:185-190. A review of the medical care rendered on scene at the 1984 Summer Olympics, which was attended by 3.5 million people, is detailed. Care was provided for 5,516 patients. Medical problems were most frequently musculoskeletal, cutaneous, or environmental problems. Only 91 patients were transferred to a hospital for further care. The authors’ review would be helpful for physicians planning medical care for special events.
MEDICOLEGAL The ten-year malpractice experience of a large urban EMS system. Solar JM, Montes MF, Ego1 AB, et al. Ann Emerg Med 1985;14:87-90. The Dade County (Miami) area of Florida has 339 certified paramedics serving a population of 1.7 million persons and handling 265,060 incidents during the decade of 1972 to 1982. Sixteen malpractice claims from 11 incidents (1 per 24,096 incidents) were filed; 87% occurred in the second 5-year period. The average annual rate of claims per 100 paramedics increased from 0.38 in the first 5 years to 1.68 in the second 5 years. Cases are presented to demonstrate that inadequate record keeping and “gray zone” patients who do not fit any particular protocol present the greatest risk.
TRAUMA Utilization of medical care in Orange County: The impact of implementation of a regional trauma system. Cales RH, Anderson PG, Heilf RW. Ann Emerg Med 1985;14:853858. This article attempts to catalogue the impact of a countywide prehospital and hospital trauma system, based on mortality statistics, ambulance runs, and ED visits/hospital days. Data collected before and after implementation of the system are examined. The authors draw some useful, pragmatic conclusions and suggest some areas for improvement. Prehospital management of trauma: A tale of three cities. Pepe PE, Stewart RD, Copass MK. Ann Emerg Med 1986;15: 1484-1490. This is a survey of three major cities referable to the prehospital management of trauma victims. The section on categorization of trauma patients includes penetrating injuries, blunt trauma, major bums, and isolated extremity and head injuries. Rural EMS care is considered a unique entity, deserving of special consideration. The authors call for closer scrutiny of the role of aeromedical evacuation. Direct inacademically oriented physivolvement of “street-wise,” cians is obligatory to provide leadership, management, and research of field trauma. Other issues covered are trauma center referrals, high-risk patients, the continuum of medical care, outcome data, and pain relief. Note: The comments and opinions in these annotations are those of the reviewers (committee members) and not necessarily those of the STEM Board of Directors.
GENERAL Accidental death and disability: The neglected disease of modem society. National Academy of Sciences-National Research Council. Washington, DC, National Academy of Sciences, 1966. This is the classic “White Paper” which initiated national legislation leading to the development of EMS systems. It provides an overview of the care at the time and outlines the specific recommendations which were developed-A “must” for those really interested in the history of EMS. Emergency medical services: Problems, programs and policies. ACEP Committee on Public Policy. J Am Co11 Emerg Phys 1976$:285-l%. This is a revision of an earlier statement prepared by the Committee on Public Policy of the American College of Emergency Physicians (ACEP). It is a broadly encompassing review of the state of EMS (in 1976) and includes ACEP’s recommendations for improving overall standards. Now, with the perspective of 10 years it is still interesting reading to see where we were and where we still need to go. History of emergency medical services in the United States. Rockwood CA, Mann CM, Farrington JD, et al. J Trauma 1976;16:299-308. From the ‘Emergency Medicine Residency, Butterworth Hospital, Grand Rapids, MI; the TDivision of Emergency Medicine, Department of Preventive Medicine, Ohio State University, Columbus, OH; and the *EMS Educators Committee, Society of Teachers of Emergency Medicine (STEM), Dallas. Manuscript received July 25, 1988; accepted July 26, 1988. Address reprint requests to Dr Krohmer: Department of Emergency Medicine, Buttetworth Hospital, 100 Michigan NE, Grand Rapids, MI 49503. Key
Words:
Emergency medical services, EMS, bibliography.
0 1989 by W.B. Saunders Company. 07356757/89/0701-0023$5.00/O 110
This article affords a historical perspective of EMS in the United States from the mid-1960s until 1975. The article is a little disjointed in that it is not a chronological unfolding of major events, nor is it separated into specific subject areas. It is readable and interesting in providing background information about EMS development. Medical care in the streets. Caroline 43-46.
NL. JAMA 1977;237:
Dr Caroline provides descriptions of several field cases which she experienced while training and directing the Freedom House Ambulance (Pittsburgh) crews. The purpose of the discussion is to outline the unique skills and knowledge required of an EMS physician. Anyone who has spent time in the field can easily relate to the situations presented. Enjoyable and educational reading. Prehospital advanced life support: What color are the emperor’s clothes? Hoffer EP. J Am Coll Emerg Phys 1979;8:434436. The author likens the medical community’s ready acceptance of paramedic programs to the fairy tale in which no one dared to question the emperor’s new (nonexistent) clothing. A plea is made for controlled clinical trials to test the merits of the new system. The author also stresses the need for prehospital treatment of ventricular fibrillation and suggests a “load and go” approach for all other critically ill and injured persons. The conceptual development of EMS systems in the United States, part I. Boyd DR. Emerg Med Serv 1982;11(1): 19-23. The conceptual development of EMS systems in the United States, part II. Boyd DR: Emerg Med Serve 1982;11(2): 26-35. An overview of the history of EMS systems development in the United States is provided by these two articles. They briefly outline the phases of EMS system development, early activities and pioneering efforts, and financing of legislative activities. They provide a good, general overview. The impact of a physician-staffed mobile intensive care unit. Applebaum D. Am J Emerg Med 1985;3:15-18. This article describes the use of physicians in mobile intensive care units (MICUs) in a socialized medicine system in which it is important to control the costs of medical care and the large volume of emergency department (ED) visits that occur in the hospital designated by the city (Jerusalem, Israel) for emergency care. The author summarizes 1 year’s experience of a physician-attended MICU, which apparently helps maintain a reasonably good quality of health care in a society that rations its health care delivery.
KROHMER AND WERMAN H EMS: ANNOTATED BIBLIOGRAPHY
The urban paramedic’s scope of practice. Smith JP, Bodai BI. JAMA 1985;253:544-548.
general. It is well referenced for those training in EMS.
The goal of this article is to review “the available literature to delineate those areas where prehospital emergency services have been shown to be of value and to identify those areas where controversy exists to the scope of practice of paramedics.” The authors look specifically at airway management, defibrillation and cardiopulmonary resuscitation (CPR), hypovolemia, and the use of medications. They state they have looked at the available literature regarding field studies addressing these various issues. From these, they draw conclusions regarding appropriate practice of paramedics. Above all, the article points out the need for increased quality research into prehospital activities. (This article generated a number of follow-up letters to the editor questioning the conclusions of the article.--J.K.)
TRAINING
Specialized urban EMS rescue. Freeman Set-v 1985;11(10):52-55.
A course in emergency care for f&-year medical students. McCally M, DeAtley C, Piemme TE. J Am Co11 Emerg Phys 1978;7:20-23.
RJ. J Emerg Med
This article discusses the implementation of specialized rescue/extrication services within a non-fire-based EMS system. It also examines the costs, benefits, and needs for such a system. The need for improved emergency medical services in Pitt County. Hunt RC, Allison EJ, Yates JG. NC Med J 1986;7:39-42. The current status of county (Pitt) is described EMS systems throughout ment in the resuscitation system is presented.
EMS in a rural North Carolina and compared with other types of the nation. A plan for improverate experienced with the existing
Emergency medical services in the 1980’s (commentary). Stewart RD. NY State J Med 1986;86:405-407. This commentary, accompanying the article by Mustalish (following), is an excellent brief summary of the challenge facing EMS systems in the next decade. Dr Stewart strongly advocates high-quality, vigorous research to determine the efficacy of many of the previously accepted procedures and field care. He makes an excellent argument for assumption of full medical control of EMS systems by physicians. He states that without tight medical accountability and further research “they will find themselves still shuffling along the dusty road, oil and wine in their packs, kindly seeking to help the victims of thieves, their donkeys trotting along behind them.” The National Association of EMS Physicians is mentioned as a new organization whose goal is to foster better prehospital care and take us beyond the care of the Good Samaritan. Emergency medical services: Twenty years of growth and development. Mustalish AC. NY State J Med 1986;86:414420. This article is an excellent historical review of the past 20 years in the growth and development of EMS, including not only emergency medical technicians (EMT@ and paramedics, but also emergency physicians, emergency nurses, and changes in the ED. It is an excellent resource for EMS in
and should be standard reading
Self-instructional emergency medicine program for medical students. Block FE, Beville C, Cook H, et al. J Am Co11 Emerg Phys 1977;6:13-15. A freshman medical school course in emergency medicine offered at the University of Virginia is presented. With seven hours of didactic instruction and the effective use of selfinstructional videotapes, students were able to successfully complete testing in both cognitive and psychomotor objectives. The article provides a useful model for efficiently introducing emergency medicine into the medical school curriculum.
This article describes the successful implementation of a 52-hour course in emergency medicine for first-year medical students at George Washington University School of Medicine. The course content is described, detailing those topics taught by lecture, demonstration, and practicum. Audiovisual references, as well as supply and equipment lists, are included. Involving and educating base station physicians in paramedic programs. Cooper MA, Ornato JP. Ann Emerg Med 1980;9:524-526. According to these authors, much attention is focused on paramedic training but little education is given to emergency physicians who will interact with paramedics over the radio and in the ED. They describe a four-part education process that they use in the region of Omaha, Nebraska. These four parts are participation in the Paramedic Policy and Procedures Committee, participation in the clinical training of paramedics, riding with the paramedics, and a base-station course. A general EMS curriculum for residency training. Lowry JW, Lauro AJ. Ann Emerg Med 1980;9:250-252. The authors provide a broad overview of the 2-year EMS curriculum at Charity Hospital’s emergency medicine residency program in 1980. The course included EMT instruction, didactic lectures (a list of topics is included in the article), prehospital experience, and participation on community EMS committees. This program was developed using guidelines provided by ACEP, JCAH, DHEW, and program alumni. Reassessing training levels for prehospital Briese GL. J Emerg Med 1983;1:67-71.
EMS personnel.
This article discusses intermediate levels of training for prehospital care personnel. Levels of training between EMT and paramedic include “EMT-intermediate” and EMTs trained in defibrillation, intravenous (IV) therapy, military 111
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antishock trouser (MAST) use. The author points out propriate level of training effective EMS system in a
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application, and/or EOA/EGTA the need for determining the apthat will provide the most costparticular community.
The evolution of a rural EMT-intermediate Williamson JE, Landis SS, Allison 1983;44:737-742.
training program. EJ. NC Med J
This article presents a model training program for intermediate level EMTs in the area. It includes the organizational structure of the EMS system, the training objectives, and content of the course. An emergency medical services curriculum for emergency medicine residencies. Kallsen G, Merritt-Lindgren M. Ann Emerg Med 1984;13:912-915. The fully integrated EMS curriculum used at the Valley Medical Center and Highland Hospital emergency medicine residencies is detailed in this article. The purpose of the training is to insure competency in off-line and on-line medical control. The overall structure of the program, as well as detailed descriptions of the individual components, is provided. Statewide prehospital mobile intensive care treatment protocols for advanced Lifesupport units in North Carolina. Shepherd SM, Allison EJ, Sayers DG, et al. NC Med J 1985;46:579-602. Advanced life support (ALS) treatment protocols for both pediatric and adult patients that may be used as standing orders at the discretion of the medical director are provided. The format includes both outlines and algorithms. It provides a solid structure from which to construct protocols for those faced with developing an entire program. (Many of the ALS protocols should be updated based on more recent AHA recommendations.--J.K.) Curriculum for training residents in EMS (a&r). Ann Emerg Med 1986;15:654.
Otten EJ.
This abstract outlines a poster session presentation at the UA/EM meeting in 1986. The 4-year program of EMS education developed at the University of Cincinnati is described. The program begins with orientation lectures on basic EMS configuration and systems design for PGY I residents. These residents are assigned to local EMS squads to gain prehospital experience. PGY II residents take a communications course before handling all telemetry calls for the county. They also receive flight training and participate as flight physicians in the air medical program. PGY III residents participate on the area disaster response team. A 4week course for PGY IV residents covers administrative aspects of EMS. Design of a resident In-field experience for an emergency medicine residency curriculum. Stewart RD. Paris PM, Heller MB. Ann Emerg Med 1987;16:175-179. This discussion delineates a resident experience for onscene attendance at selected EMS incidents. The 6-month 112
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period reviewed included 158 cardiac arrests, 58 difficult intubations, 49 central or peripheral lines, and 24 severely injured patients. Residents were surveyed and subsequently supported the program on the basis that it enriched their learning experience of EMS in the field. Department of Transportation Serv 1987;16(10):195-201.
(DOT) guidelines. Emerg Med
This summary provides a comprehensive and useful look at the current DOT guidelines for EMT-ambulance, EMTintermediate, EMT-paramedic, EMT-dispatcher, and EMS instructor training programs. In outline fashion, the suggested curriculum for each of these courses is defined. DOT guidelines for EMS air ambulances are also included.
MEDICALCONTROL Medical control of paramedic services. Amey BD, Straub EJ, Harrison EE. Emerg Med Serv 1978;7(4):20-24. This article describes integrated medical control for an EMS system serving the city of Tampa, Florida and the surrounding county. Quality control issues including the care of cardiac arrest patients, trauma victims, and pediatric cases are the responsibility of the Prehospital Care Committee. Medical leadership of the system is provided by two medical directors, 12 on-line medical advisors, and a number of consultants covering a spectrum of medical specialties. Finally, data for the system are collected and stored on a microcomputer for analysis of the system’s performance. The article describes a valuable model for regional EMS system development. Developing medical control in a rural EMS system. Riner RM. Emerg Med Serv 1981;10(2):22-28. This article begins with an introduction to the specific elements of medical control for an EMS system. The author describes the application of these principles of medical control to a rural county in Hawaii. A contractual relationship exists between the district EMS medical director and the Hawaii Department of Health (EMS systems branch) which specifies that he/she is to provide audits of high-risk cardiac and trauma cases, case reviews, involvement in continuing medical education, written protocols, and quality assurance. An important component of medical control is a continued assessment of paramedic skills. Other components include chart audits, continuing medical education, and testing and risk management. Effectiveness of a prehospital medical control system: An analysis of the interaction between emergency room physician and paramedic. Pozen MW, D’Agostino RB, Sytkowski PA, et al. Circulation 1981;61:442-447. The accuracy of paramedics’ and telemetry physicians’ interpretation of rhythm strips, as compared with that of a cardiologist, is examined. The appropriateness of treatment administered is also examined based on the rhythm interpretation and the paramedics’ treatment protocols. The authors found major variations in the accuracy of interpretations by
KROHMER AND WERMAN n EMS: ANNOTATED BIBLIOGRAPHY
paramedics and telemetry physicians and in the appropriateness of treatment. The article strongly questions the effectiveness of present systems to respond to life-threatening dysrhythmias and calls for greater medical control. The crisis of control. 1981;6(11):30-35.
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This article discusses the problems of the EMS state agency in Georgia, which is a branch of the Department of Human Resources. The author points out several conflicts that have developed under the existing state EMS structure. These problems include difficulty in the agency’s functioning as both regulator of EMS activities and a representative of EMS, the existence of EMS as a “nonpreventive” agency in the Department of Health, and the organizational ambiguity in the Georgia EMS system at all levels. The author proposes that an Gflice of Emergency Medical Services be established and that this body be responsible for statewide development of EMS services. A separate EMS professional review board would be charged with issues such as certification and decertification of prehospital providers, vehicle inspection, and appeals. The article provides an excellent discussion of potential problems that must be considered when the EMS lead agency is a branch of the state health department. Medical control and the volunteer rescue squad. Edwards BW. J Emerg Med Serv 1981;6(11):38-42. The problem of implementing medical control in an existing system of volunteer rescue squads is discussed. The development of the EMS system in Virginia Beach, Virginia is traced from its inception in the 194Os, including a discussion of the role of medical direction in that system. In 1979 a municipal ordinance was passed formalizing the relationship between the physician directors and the volunteer rescuers in the system and creating an Office of Emergency Medical Services. The structure of this body is discussed. The article describes an interesting approach to establishing strong medical control in an existing EMS system. Physician qualification for medical control in emergency medical services systems. Raucher LA, Fahmey PM. National Academy Press, Washington, DC, 1981, pp 129-134. This document outlines the physician qualifications and responsibilities for on-line and off-line medical control functions. This is only a portion of the book, that contains the proceedings and summary report of the National Academy of Sciences Conference on Medical Control held in Washington, DC on May 12-13, 1980. This entire book contains a lot of interesting information. Medical control of prehospital emergency medical services. EMS Committee of the American College of Emergency Physicians. Ann Emerg Med 1982;11:387. This is the position paper of ACEP, addressing medical control. The position paper was approved by the Board of Directors on April 24, 1982.
Standing orders vs voice control. Hunt RC, Bass RR, Graham RG, et al. J Merg Med Serv 1982;11:26-30. The authors describe a study that looked at the use of standing orders as a medical control device in advanced cardiac life support. The study compares the outcome of cardiac arrest victims who were treated initially using standing orders only with victims who were treated with direct physician orders only. No statistical difference was found between the two groups in the number of arrest victims with a palpable pulse on arrival in the emergency department. Paramedics reported a subjective improvement in the efficiency of care with the use of standing orders. Medical control of emergency medical services: An overview for emergency physicians. Page JR, Krentz MJ, Aranosian RD, et al. Dallas, TX, EMS Committee of the American College of Emergency Physicians, 1984 This off-line control, section views.
overview outlines the role of the medical director, (administrative) medical control, on-line medical and qualifications of medical directors. It also has a on review and audit, including individual case re-
Medical control of prehospital care. McSwain NJ. J Trauma 1984;24: 172. Dr McSwain’s editorial emphasizes the necessity of physician involvement in prehospital care, with the discussion centering around the treatment of trauma patients. The author places the burden of responsibility for an effective EMS system on the physicians involved in medical control. Rx for medical control. 1984;9(4):39-41.
Latessa
EM. J Emerg Med Serv
This is a brief article on medical control which incorporates Dr Norman McSwain’s components of prospective, immediate, and retrospective control. It incorporates a quality assurance design which demonstrates that prospective and immediate medical control is much simpler than retrospective control. The article also includes two forms, employee performance appraisal and crew performance evaluation, which are helpful for on-line evaluation. The emergency physicians and medical control ln advanced life support. Ponter JE. J Emerg Med 1985;3:31-35. This article is a description on how a large urban EMS district in California set certification, recertification, and continuing education standards for advanced life support physician medical radio operators (MROs). At the time of publication they had certified nearly 50 physician MROs and felt that they had achieved a high level of ongoing medical control. Medical control+nality assurance ln prehospital care. Holroyd BR, Knopp R, Kallsen G. JAMA 1986;256:10271031. The authors provide a very good overview of medical control aspects of prehospital care. They include historical and 113
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legislative background, organization of medical control (prospective, immediate, and retrospective), and types of medical control. Current trends concerning medical control also are included in the article. Role of the physician in the prehospital setting. Pepe PE, Stewart RD. Ann Emerg Med 1986;15:1480-1483. This article outlines the critical role physicians must play in assuring adequate medical control of the activities of prehospital care providers. As outlined, physicians should be involved in initial training of personnel, field supervision, policy decisions, system assessment, quality assurance, and research. The need for dedicated, competent physicians as leaders in insuring the credibility of prehospital care is discussed. This is an excellent article addressing medical control issues. Medical direction in emergency medical services: the role of the physician. Stewart RD. Emerg Med Clin North Am 1987;5:119-132. Dr Stewart begins this discussion with historical considerations of emergency medical services. After presenting the philosophy of prehospital care, he outlines the role of the physician by expanding the role and responsibilities of the EMS physician as outlined by ACEP to include system planning and design, protocol development, personnel education, medical control, quality assurance, research, and field care. Finally, the qualifications of an EMS medical director are discussed. This article provides an excellent overview of the components of physician involvement in EMS.
EVALUATION/QUALITYASSURANCE Recurrent themes in ambulance critique review sessions over eight years. Pilcher DB, Gettinger CE, Seligson D. J Trauma 1979;19:324-328. This article outlines a quality assurance program involving biweekly ambulance critique review sessions used over an eight year period at the University of Vermont College of Medicine. It points out common problems of the system which can be avoided through prehospital personnel education. An additional benefit of the program is the good relations that develop between prehospital providers and ED personnel participating in the review sessions. Evaluation of an EMS regional referral system using a tracer methodology. Egges J, Turnock BJ. Ann Emerg Med 1980;9:918-923. This study followed five tracer conditions (multiple trauma, head trauma, spinal cord injury, bums, and low birth weight infants) in one region of the Illinois EMS system to determine whether the patients were treated in the appropriate regional center designated for the condition. It showed that only about half of the patients were moved to the appropriate center. An analysis of some of the transfer patterns is provided. The conclusions of the article are interesting but are too specific to be readily applicable to the general problem of EMS regionalization. 114
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JEMS staff report: Standardized skills testing: A new program for evaluating EMT’s, paramedics and medical radio operators. J Emerg Med Serv 1980;6(12):36-39. This article is a moderately in-depth review of skills testing for EMTs and radio resource personnel. An overview of a comprehensive testing process is provided. Resources for more detailed information and standardized testing materials are included. A method for reviewing radio-telemetry paramedic calls. Rottman SJ, Fitzgerald-Westby K. Ann Emerg Med 1981;10:36-38. The authors describe a method used at Los Angeles County/University of Southern California base station for reviewing taped paramedic telemetry calls. Emergency medicine residents who are rotating on a 2-week prehospital care rotation review the tapes of all telemetry paramedic calls. Using a specific review form, the residents critique the prehospital and ED physician assessments and treatments. Communication techniques are also evaluated. Using this review process, specific problems or exemplary runs are identified for presentation at tape review conferences. This program is felt to be very beneficial in the education of residents in telemetry protocol and communications procedures. Measuring your system. 1983;9(1):84-91.
Stout
JL. J Emerg
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Mr Stout presents a method by which an EMS system can be objectively evaluated on performance. Ten areas of importance to EMS function are outlined: clinical performance; medical accountability; dispatching and system status management; access, first responder, and citizen CPR; disaster capability; personnel management practices; stability, reliability, and fail-safes; pricing policies, billing, and collection practices; response time performance; and public accountability. The method allows for the calculation of a numerical score to judge performance. It helps identify problem areas in the EMS system and suggests possible solutions. A computer-assisted quality assurance system for an emergency medical service. Stewart RD, Burgman J, Cannon GM, et al. Ann Emerg Med 1985;14:25-29. This article describes the effectiveness of using a full-time quality assurance officer and a computer program designed for error detection to significantly improve the identification of documentation and performance errors that occur in a busy urban EMS system. The core of information necessary for developing a realistic, meaningful, quality assurance program essential for the prehospital phase of all local or regional EMS systems is contained in the article. The field instructor program: Quality control of prehoapital care, the Grst step. Pons PT, Dinerman N, Rosen P, et al. J Emerg Med 1985;2:421-427. The authors present the system used in the Denver paramedic system to orient new paramedics to their program and
KROHMER
evaluate the quality of care provided by these new personnel. The bulk of the orientation, training, and evaluation is done by paramedic field instructors while they are providing actual patient care. The successes, assets, and liabilities of the system as discussed. Prehospital assessment and scoring. Ramzy AI, Warren GT. Trauma Q 1986;3:1-13. This is a nice review of the current status of prehospital trauma scoring. The authors also describe the use of trauma scoring in the Maryland EMS system.
COMMUNICATION Telemetry-Medical command ln coronary and other mobile emergency care systems. Nagel EL, Hirschman JC, Nussenfeld SR, et al. JAMA 1970;214:332-338. This article is of historical interest. It describes one of the first large-scale EMS experiences with telemetry, in the city of Miami. The conclusion from the 2-year experience was that telemetry provided a mechanism for delivery of advanced care in the streets by paramedical personnel. The EMTs in the city were trained to defibrillate but were not using any other advanced life support skills, including IV or drug therapy. The authors conclude “telemetry of electrocardiograms is not new; and the use of paramedics to carry out a physician’s advise is not new. What is novel and exciting for the future of mobile emergency medical care is the combining of these techniques into one diagnostic treatment system with great economy of the physician’s time and utilization of strategically located and specially trained rescue squads to minimize the time lag between the receipt of the alarm and the actual delivery of medical services on the spot.” Prehospital care telemetry--How essential? Hitt JM, Sanders AB. J Emerg Med 1984;1:417-420. The authors examine the pilot use of ECG telemetry in Tucson, Arizona. A cost and use analysis suggests performance standards outlining situations in which telemetry may be helpful. The authors also suggest the value of intangibles that telemetry may provide a system: improved esprit de corps, in-service training and evaluation, and increased performance security when new personnel are introduced. They acknowledge that each EMS system must decide the value of telemetry in its system. A survey of prehospital care paramedic/physician communication for Multnomah County (Portland), Oregon. Thompson SJ, Schriver JA. J Emerg Med 1984;1:421-428. The authors review a trial implementation of a radio communications system between field paramedics and emergency physicians over a 6month period. The survey demonstrated that 16% of the calls involved requests for physician consultation, 1% involved physician-initiated advice, and 83% were for information only. The relative importance (concerning patient care) of physician radio intervention is discussed.
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Development and Implementation of emergency CPR lnstruction via telephone. Carter WB, Eisenberg MS, Hallstrom AP, et al. Ann Emerg Med 1984;13:695-700. In King County, Washington a CPR telephone message to be delivered to bystanders of cardiac arrest was developed based on review of taped cardiac arrest calls and the observation of the CPR performance of 60 community volunteers undergoing CPR training. It was then tested using 143 volunteers (without prior CPR training) in simulated cardiac arrest. The quality of CPR was comparable to CPR performed by individuals with formal CPR training. The wording of the message directly determined the adequacy of performance. Specific telephone CPR instructions are included in the article. Emergency CPR instruction via telephone. Eisenberg MS, Hallstrom AP, Carter WB, et al. Am J Public Health 1985;75:47-50. This study reports the results of a program conducted in suburban King County, Washington in which the emergency dispatcher provided bystander instruction in CPR. The study concludes that the telephone CPR program increased the percentage of cases in which bystander CPR was initiated (from 45% to 56% of cardiac arrests) and that such CPR was safe, increased survival, and was positively received by those involved. The small number of patients studied make significant statistical analysis difficult and, therefore, make sweeping conclusions impossible.
DISASTERMANAGEMENT Revising the rural hospital disaster plan: A role for the EMS system in managing the multiple casualty Incident. Melton RJ, Riner RM. Ann Emerg Med 1981;10:39-44. These authors believe that many rural communities use a military/civil defense model for disaster planning, which is inappropriate for the most probable types of disasters. The civil defense model involves large numbers of victims treated for long periods of time in the field setting. The authors propose that an EMS system model that relies on an EMS system working closely with the local hospitals is more effective and realistic. The EMS model is described in detail with lists of important responsibilities of various components of the system. Disaster medicine training in France. Feldstein B, Dufeu N, Handal K, et al. Ann Emerg Med 1983;12:49-51. This article describes the curriculum of a disaster medicine training program developed and conducted in France. The course is a 71-hour comprehensive didactic program that is followed by field experience lasting two days to 1 week. The curriculum is outlined. Disaster training for emergency physicians ln the United States: A systems approach. Feldstein BD, Gallery ME, Sanner PH, et al. Ann Emerg Med 1985;14:91-95. This is a description of the course, “Disaster Management in Planning for Emergency Physicians,” that was designed jointly by ACEP and the Federal Emergency Management 115
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Agency (FEMA). The 16-hour course was first conducted in September 1983. Topics covered include disaster elements, general planning and organization, victim flow, communication, evacuation modalities, field and hospital management, documentation, public relations, and applications to the local community. The psychological impact of disaster on rescue personnel. Durham TW, McCammon SL, Allison EJ. Ann Emerg Med 1985;14:73-77. This was a study of 79 health care workers involved in the care of victims of an apartment building explosion. A questionnaire was administered to all healthcare workers to assess the incidence of posttraumatic stress disorder (PTSD). Eighty percent of the interviewees were found to have at least one symptom of PTSD. These data support the need for a plan to address the emotional sequelae occurring in disaster careworkers. Disaster Medical Services. Disaster Committee, American College of Emergency Physicians. Ann Emerg Med 1985;14: 1026. The roles of emergency physicians in the medical aspects of disaster planning, management, and patient care are described in this document developed by the disaster committee and approved by the board of directors of ACEP on June 24, 1985. A prehospital approach to multiple-victim incidents. Haynes BE, Dahlen RD, Pratt FD, et al. Ann Emerg Med 1986;15:458-462. This article reviews an EMS system’s experience with multiple-casualty incidents, defined as four or more patients per incident. Forty-seven incidents were reviewed. Little tabulated data and no statistical analysis are provided. Identified as major problems in such incidents were field management, paramedic assessment, radio communications, and base hospital management. This article is an important review for physicians who train and supervise paramedics. The national disaster medical system: A concept ln large-scale emergency medical care. Moritsugu KP, Reutershan TP. Ann Emerg Med 1986;15:1496-1498. This is a description of the background and purpose of the National Disaster Medical System (NDMS), including rapid response, patient evacuation, and definitive medical care. This comprehensive program is designed to involve federal, state and community resources. The article describes how local communities may participate. SPECIAL EVENTS Emergency medical services at the 1984 Democratic national convention. (letter). Auerbach PS, Gelb AM, Turns JE. Ann Emerg Med 1985;14:709-711. This letter provides a description of the medical care system that was developed for the convention. It addresses security considerations, provides an overview of the responses during the convention, and makes recommendations for those involved in future similar activities. 116
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Special event medical care: The 1984 Los Angeles Summer Olympics experience. Baker WM, Simone BM, Niemann JT, et al. Ann Emerg Med 1986;15:185-190. A review of the medical care rendered on scene at the 1984 Summer Olympics, which was attended by 3.5 million people, is detailed. Care was provided for 5,516 patients. Medical problems were most frequently musculoskeletal, cutaneous, or environmental problems. Only 91 patients were transferred to a hospital for further care. The authors’ review would be helpful for physicians planning medical care for special events.
MEDICOLEGAL The ten-year malpractice experience of a large urban EMS system. Solar JM, Montes MF, Ego1 AB, et al. Ann Emerg Med 1985;14:87-90. The Dade County (Miami) area of Florida has 339 certified paramedics serving a population of 1.7 million persons and handling 265,060 incidents during the decade of 1972 to 1982. Sixteen malpractice claims from 11 incidents (1 per 24,096 incidents) were filed; 87% occurred in the second 5-year period. The average annual rate of claims per 100 paramedics increased from 0.38 in the first 5 years to 1.68 in the second 5 years. Cases are presented to demonstrate that inadequate record keeping and “gray zone” patients who do not fit any particular protocol present the greatest risk.
TRAUMA Utilization of medical care in Orange County: The impact of implementation of a regional trauma system. Cales RH, Anderson PG, Heilf RW. Ann Emerg Med 1985;14:853858. This article attempts to catalogue the impact of a countywide prehospital and hospital trauma system, based on mortality statistics, ambulance runs, and ED visits/hospital days. Data collected before and after implementation of the system are examined. The authors draw some useful, pragmatic conclusions and suggest some areas for improvement. Prehospital management of trauma: A tale of three cities. Pepe PE, Stewart RD, Copass MK. Ann Emerg Med 1986;15: 1484-1490. This is a survey of three major cities referable to the prehospital management of trauma victims. The section on categorization of trauma patients includes penetrating injuries, blunt trauma, major bums, and isolated extremity and head injuries. Rural EMS care is considered a unique entity, deserving of special consideration. The authors call for closer scrutiny of the role of aeromedical evacuation. Direct inacademically oriented physivolvement of “street-wise,” cians is obligatory to provide leadership, management, and research of field trauma. Other issues covered are trauma center referrals, high-risk patients, the continuum of medical care, outcome data, and pain relief. Note: The comments and opinions in these annotations are those of the reviewers (committee members) and not necessarily those of the STEM Board of Directors.