Airway management is the most critical and potentially life-saving intervention performed by emergency medical service (EMS) providers. Invasive airway management often is required in non-cardiac-arrest patients who are combative or otherwise uncooperative. The success of prehospital invasive airway management in this patient population was evaluated.

A retrospective review was undertaken of the records of all such patients requiring endotracheal intubation over a three-year period (1987–1989). The study population included 278 patients enrolled by five advanced life support (ALS) units serving a suburban population of 425,000. Field trip sheets were reviewed for diagnosis, intubation method and success, number of intubation attempts, provider experience, reasons for unsuccessful intubations, and complications.

A total of 394 invasive airway management attempts were performed on 278 patients. The overall successful intubation rate was 75% (41 % orotracheal, 52% nasotracheal, 7% other or unknown). The most common diagnoses were COPD and pulmonary edema (30%) and trauma (24%). Experienced providers were successful on the first attempt in 57% of cases compared to 50% by inexperienced providers (p=.24). Multiple intubation attempts were required in 33% of the patients. There was no statistically significant difference in success rates between the orotracheal and nasotracheal methods (p=.51). The most common reason for unsuccessful intubation was altered level of consciousness. Complications occurred with 7% of successful attempts and in 18% of unsuccessful attempts (p<.001). Forty-six percent of the patients who were not intubated successfully in the field and required intubation in the emergency department (ED) received a neuromuscular blocking agent prior to successful intubation.

Prehospital providers can intubate a high but improvable proportion of non-cardiac-arrested patients by both the orotracheal and nasotracheal routes. The use of pharmacologic adjuncts to facilitate the prehospital intubation of selected, non-cardiac-arrested patients is a promising adjunct that needs further evaluation.

The initial Glasgow Coma Score (GCS) obtained by prehospital personnel on seizure victims is associated with the likelihood of treatment and transport.

Prehospital data were collected prospectively for all patients presenting with seizures to a mid-sized emergency medical services system during a five-month period. A total of 419 cases occurred (62.8% male, 37.2% female). Seizure frequency was highest in infants under the age of three years and in adults in their late 20s. A GCS was recorded in 378 cases (90.2%, study group). The GCS was >10 in 304 patients (80.4%) and ≤10 in 74 (19.6%). Patients with GCS≤10 were more likely to receive: oxygen (50.0% vs. 20.1%, p<.0001); IV (35.1% vs. 8.9%, p<.0001); intravenous (IV) medications (16.2% vs. 1.0%, p<.0001); and transport (97.3% vs. 76.3%, p<.0001).

Seizure patients with a GCS of ≤10 were more likely to receive a variety of prehospital treatments and to be transported than were patients with GCS >10. However, the clinical indicators that were used to make the decision that it was “safe” not to transport nearly one-third of the patients are unclear. Essentially no data exist regarding the parameters impacting treatment and transport of seizure patients. Future investigations with outcome data, are needed to determine whether low risk criteria can be developed to identify those patients (if any) that do not require treatment or transport. A GCS may provide an objective, reproducible parameter upon which to begin formulating such criteria.

The “log-roll” maneuver is a common method of moving patients with suspected spinal injuries despite the fact that there is very little published information concerning its effectiveness.

Lateral thoraco-lumbar motion and rotation during five variations of the log-roll maneuver were examined radiographically in fourteen healthy adults. Variations included the addition of axial traction and alterations in subject arm position.

While no rotational differences were noted between variations, substantial differences in lateral displacement were identified between individual subjects and techniques. This variability seemed to be due to differences in individual body habitus, particularly the shoulder/thorax to pelvis proportions and the amount of periabdominal fat. The addition of traction decreased motion in 59% of attempts but increased motion in 18%. While definitive recommendations cannot be made based upon these data, only one variation of the log-roll techniques examined consistently minimized lateral spinal motion in subjects tested. This variation involved positioning the subject with arms fully extended at their sides with palms resting on the lateral portion of their thighs and maintaining this position throughout the procedure.

Pending further studies, it may be advisable to utilize this variation in patients with suspected thoraco-lumbar trauma.

Suicidal patients who refuse prehospital transport pose a difficult problem for emergency medical services. A survey was conducted in an attempt to assess the current strategies for involuntary transport of such patients.

The medical directors of 135 of the largest EMS systems in the United States were mailed a questionnaire requesting descriptions of the operating procedures for dealing with suicidal patients who refuse transport.

Fifty-nine of 130 questionnaires (45%) were returned. Seventeen emergency medical services (EMS) systems (29%) serve populations of less the 250,000, while 41 (69%) serve populations greater than 250,000. Cumulatively, respondents represent an excess of 2.1-million EMS responses per year, of which 0.5%-10.0% involve behavioral emergencies. Eleven of the 59 responding systems (19%) have urritten, explicit policies guiding the management of suicidal patients who refuse to be transported. Involuntary commitment proceedings are initiated in the prehospital setting in 25 of the 59 services (42%). Of these 25, the initiation of commitment proceedings is performed by the following (more than one may apply to a given system): 11 (44%) by base-station physicians, six (24%) by the emergency medical technician (EMT), 23 (92%) by a police officer, and five (20%) by family or friends. Ten of the 59 systems (17%) require a mental health delegate to authorize commitment. Two physicians can mandate involuntary commitment in one of the responding systems. Of the 25 systems that actually perform involuntary commitment in the prehospital setting, seven (28%) have established policies. Of the 34 systems which do not perform involuntary prehospital commitment, four (12%) have policies to guide the care of suicidal patients who refuse care.

Suicidal patients commonly confront emergency medical services, yet many systems lack explicit policies for dealing with such patients. Widely varied strategies are used to authorize transport of patients who are suicidal and refuse to be transported.

A national survey was conducted to determine the sponsorship of emergency medical services (EMS) projects, composition of EMS advanced life support (ALS) teams, types of medications and equipment carried, and procedures approved for use by EMS systems in the United States.

A mail survey was sent to 211 training supervisors of EMS services across the United States in 1989. The survey requested demographic and service-related information, including types of EMS sponsorship, composition of ALS teams, medications and equipment carried, and procedures which personnel have been trained to use. Medications carried were correlated with advanced cardiac life support (ACLS), the American College of Emergency Physicians (ACEP) recommended drug lists, and with the sponsoring agency.

One-hundred seventy (70%) survey forms were returned. The major providers of ALS in the United States are fire departments (36%), followed by private providers (26%), hospitals (22%), and local governments (16%). The most common ALS team composition was two paramedics followed by one paramedic and one emergency medical technician (EMT). Most ALS services carry all of the recommended ACLS medications; a much smaller percentage carry all of the drugs recommended by ACEP. Fire department based ALS units carried the least number of medications; hospital-based ALS units carried the highest number of medications. Combined, over 80 different medications were carried by the services responding to the survey.

The use of ACLS drugs and procedures are well-established nation-wide; less accepted are the medications recommended by ACEP. While over 80 different medications are carried by the EMS systems that responded to this survey, only a small fraction have been investigated in the prehospital setting.

This study describes the epidemiology of hazardous materials (hazmat) incidents in Fresno County, California, and analyzes the emergency medical services (EMS) response to these incidents.

The study area has a population of 635,000 people living in an area of 6,004 square miles.

All Hazmat Emergency Response Team (HERT) reports and related prehospital, emergency department, and inpatient records from ljuly 1988 through 30 June 1989 were reviewed retrospectively.

There were 107 hazmat incidents involving 156 materials consisting of pesticides (24.4%), miscellaneous chemicals (17.3%), corrosives (16.7%), petroleum products (13.5%), airborne toxins (10.2%), organic solvents (7.7%), unidentified chemicals (5.1%), infectious medical waste (1.9%), empty containers with radioactive warning symbols but without detectable radiation (1.3%), heavy metals (1.3%), and alkali metals (0.6%). In ten (9%) of the 107 incidents, 68 patients required on-scene evaluation and 26 patients were transported to emergency departments. Four of these patients required admission, three because of injuries due to vehicular accidents, and one because of a coincidental cere-brovascular accident. Five incidents produced multiple victims from exposures to airborne toxins, accounting for 63 (93%) of 68 patients. Spills of solid or liquid pesticides occurred in four incidents involving patients. Ambulance personnel and/or equipment became contaminated in three of these four incidents.

1) Ambulances should be dispatched selectively to hazmat incidents because only 9% of incidents involved patients. 2) training should emphasize personnel protection and proper patient decontamination to help prevent contamination of EMS personnel and equipment. 3) Preparation of EMS personnel should emphasize exposure to airborne toxins because these produced 93% of patients.

The effectiveness of using supplemental teaching sessions with animals and cadavers on the acquisition of technical skills of endotracheal intubation was studied.

Paramedic students were evaluated for early endotracheal skill acquisition in the operating room and by questionnaire.

Supplemental practice skills using either sheep or cadavers did not produce a statistically significant improvement in the percentage of successful clinical operating room intubations as compared to a group trained solely using intubation mannequins. More paramedics, certified and in practice, reported a statistically significant psychological benefit to supplemental cadaver training compared to supplemental animal (p<.05) and mannequin (p<.05) training.

Adjunctive teaching sessions using animals or cadavers do not improve the acquisition of initial technical success in clinical intubation over the use of the mannequin alone.