Patients initially refusing care (PIRC) place their health in jeopardy and consume paramedic and base-station physician time. This study quantifies the time spent on-scene related to PIRC cases.

A retrospective analysis of 128 PIRC cases was performed in the Multomah County EMS system.

The PIRC cases had a significantly longer mean on-scene time than did non-refusal cases (30.3 vs 14.6 min; p<.001). Medication administration by paramedics (14% of patients) significantly increased the on-scene time. Overall, the mean time on-scene was not affected by age, gender, vital signs (pulse, blood pressure, respiratory rate), police involvement, and whether the patient was transported. The type of call had limited influence on on-scene time, although mean on-scene time was significantly longer for altered mental status cases than for trauma related cases (35.6 vs 22.4 min; p<.03).

PIRC cases create a burden on the EMS system by consuming paramedic and base-station physician time and by preventing these personnel from responding to other calls.

To investigate the relationship between age and Advanced Life Support (ALS) utilization.

All patients from 1 January 1987 to 31 December 1988 transported by ALS ambulances within Lebanon County, a rural/urban county of 112,000.

All runs resulting in patient treatment by ALS personnel were tallied at five-year age intervals and sub-grouped by trauma- and non-trauma-related calls. Utilization rates for each age group were obtained by dividing the calls by the population of each group. Correlation with age was tested by Spearman's rank correlation. Treatment rates for age groups were calculated for the six most frequent medical etiologies. To illustrate the effect of age distributions, age rates were applied to projected state and national population distributions.

There was a significant correlation with age for all transports (p < .01; r=.93) and for those not related to trauma (p<.01; r=.98). Correlation was not detected for trauma-related responses (p>.10; r=.19). Non-trauma-related case incidence varied among age groups, ranging from 1.1/1,000 for age five through nine years to 89/1,000 for age 80–84 years. Congestive heart failure, cardiac ischemia, syncope, myocardial infarction, and cardiac arrest evidenced increased incidence with age. Seizure did not. Older populations had a higher projected utilization of ALS services than did the younger age groups.

Non-trauma ALS utilization is highly dependent on the age of the patient. Due to projected aging of the population and increased utilization of ALS by the elderly, projected utilization will increase at a rate faster than will the population. Age:rate data can be combined with population projections to estimate future need.

Pediatric Emergency Air Transports (PEATs) at Massachusetts General Hospital, Boston, Massachusetts, were reviewed between November 1986 and December 1987. Severity of illness, complications, and outcome of PEATs were compared with ground transports. Factors associated with PEAT survival were identified.

Severity of illness was measured using a modified Denver Patient Status Category (DPSC) method and the Therapeutic Intervention Scoring System (TISS). There were 35 PEATs (30 helicopter, five fixed-wing) and 96 ground transports.

Mean severity of illness for patients was greater in PEAT than for the ground transport (PEAT DPSC score=4.23±1.06 versus ground DPSC=3.57±0.89 [SD], p=.0005). The PEAT mortality was associated with a greater mean severity of illness (TISS survivors=19.1±11.4 versus non-survivors=44.3±9.5, p=.0001), but not with: the presence of an in-flight physician; transport delay; transport duration; age; sex; history of chronic illness; or intra-transport medical complication.

Compared to ground transports, PEATs were used for higher risk patients.

The use of written decision rules will improve agreement between paramedics abstracting data from records of prehospital cardiac arrest.

Sixty-three ambulance reports were selected by a random sample of all out-of-hospital cardiac arrests. Four paramedic abstractors each were given a set of definitions for use in abstracting data and one pair, randomly assigned, also was given a set of decision rules. Abstractors recorded whether there was: (1) underlying cardiovascular disease; (2) a witnessed arrest; (3) bystander CPR; and (4) the presenting rhythm. Agreement between pairs of abstractors was determined by computing kappa values.

Kappa values for each variable, for abstractors without and with decision rules were: (1) 0.23, 0.33; (2) 0.39, 0.41; (3) 0.43, 0.66; and (4) 0.65, 0.80. Kappa values consistently were higher for the pair of abstractors using decision rules. The degree of improvement varied with the difficulty of the decision required.

The addition of decision rules to variable definitions is worthwhile but does not ensure good or excellent levels of agreement in data abstracted from records by paramedics.

The risk of exposure to the Hepatitis B Virus (HBV) is a known occupational health risk in medical personnel. The specific risk in emergency medical services (EMS) personnel in the United States (U.S.) is not known. Estimates have ranged from 0.6 to 30.0% The purpose of this investigation was to provide an estimate of the prevalence of this exposure, to determine if this risk is homogeneous throughout the U.S., and to provide an estimate of relative risk. The study hypothesis was that the risk of exposure to HBV is not homogeneous throughout the U.S.

All articles containing HBV studies of non-immunized EMS personnel (physicians, nurses, and emergency medical service technicians [EMTs]) were considered, provided they reported at least two of the following seromarkers: hepatitis B (HB) surface antigen; HB surface antibody; and/or HB core antibody. A computerized literature search of a database (MEDLARS) from 1980–1989 was performed. Reference sections of relevant articles and texts also were searched. The chi-square test of homogeneity of proportion was used, assuming binomial distribution. The alpha error rate was set at 0.05.

Seven articles from 1982 to 1989 qualified for inclusion. The average rate of prevalence for all studies was 14.04% (160/1,140), with a 95% confidence interval of 11.40 to 16.68%. The chi-square test was statistically significant (chi-square=12.59, 6 df, p<.01), suggesting that the risk of exposure is not homogeneous throughout the U.S., and may not be homogeneous within a city, nor between prehospital and hospital personnel. When compared to CDC estimates for the general population in the U.S., this analysis suggests that the EMS personnel tested run three times (2.8) greater risk of HBV exposure than does the general population.

EMS personnel run a great risk of exposure to HBV with a nationwide prevalence of 14.04%, but this risk is not spread homogeneously throughout the country.

Fully and semi-automatic defibrillator use by EMTs in neighboring communities was compared.

Both programs had similar response times, age and gender distribution, proportion of witnessed arrests, and proportion of patients found initially with ventricular fibrillation (VF). The time-to-shock from proper lead placement was shorter when the fully automatic defibrillator was used (16.6 vs. 44.3 seconds; p<.001) and the survival to hospital discharge rate was greater (26% vs. 0%; p=.O4). The semi-automatic defibrillators were more sensitive in detecting VF than were the fully automatic devices.

These data support the need for further comparison of the efficacy and effectiveness of semi- and fully automatic, external defibrillators.